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ULY CLINIC

19 Septemba 2025, 04:01:54

Tinnitus

Tinnitus refers to the perception of sound in the absence of an external source. Patients may describe it as ringing, buzzing, humming, roaring, sizzling, or musical tones, and it can be unilateral or bilateral, constant or intermittent. While the brain can sometimes suppress or adapt to tinnitus, severe cases may cause significant distress or even suicidal ideation.

Classification:

Subjective tinnitus: Heard only by the patient.
Objective tinnitus: Audible to an observer using a stethoscope.
Tinnitus aurium: Noise perceived in the ears.
Tinnitus cerebri: Noise perceived in the head.

Pathophysiology

Auditory pathway dysfunction: Neural injury or aberrant spontaneous firing of auditory sensory neurons produces abnormal sound perception.

Cochlear damage: Hair cell injury due to noise, ototoxic drugs, or aging (presbycusis) alters sensory input.

Vascular causes: Turbulent blood flow or vascular compression (e.g., carotid atherosclerosis, glomus tumors) produces pulsatile tinnitus.

Systemic and neurological factors: Hypertension, Ménière’s disease, labyrinthitis, or tumors can affect auditory perception.

Drug-induced: Salicylates, aminoglycosides, quinine, vancomycin, and other ototoxic drugs can produce reversible or irreversible tinnitus.

History and Physical Examination

History:

Characterize sound: type, pitch, intensity, location, onset, duration, pattern
Associated symptoms: vertigo, headache, hearing loss, nausea, fullness in the ear
Past history: drug use, noise exposure, cardiovascular or systemic disorders

Physical Examination:

Otoscopy: Examine external canal and tympanic membrane
Hearing tests: Weber and Rinne tuning fork tests
Vascular assessment: Auscultate for bruits in the neck; compress carotid/jugular to test pulsatile tinnitus
Cervical and nasopharyngeal exam: Evaluate for masses affecting eustachian tube or vertebral arteries

Medical causes

Cause	Onset	Key Features	Associated Signs	Pathophysiology	Management
Acoustic neuroma	Gradual	Unilateral tinnitus	Unilateral sensorineural hearing loss, vertigo, facial weakness, headache	Tumor of 8th cranial nerve	MRI, surgical removal, radiotherapy if indicated
Carotid atherosclerosis	Gradual	Pulsatile tinnitus, can be suppressed by carotid compression	Weak carotid pulse, bruit	Turbulent blood flow from stenosis	Vascular evaluation, lifestyle, antiplatelets, surgery if critical
Cervical spondylosis	Gradual	Tinnitus aggravated by neck movement	Neck stiffness, vertigo, nystagmus, arm pain	Osteophytes compress vertebral arteries	Physical therapy, NSAIDs, surgery if severe
Eustachian tube patency	Gradual	Audible breath/voice sounds, fullness	Tympanic membrane movement with respiration	Persistent patency → altered sound conduction	Myringotomy, nasal decongestants, autoinflation techniques
Glomus jugulare tumor	Gradual	Pulsatile tinnitus	Reddish-blue mass behind TM, progressive conductive hearing loss, dizziness, otorrhagia	Vascular tumor of middle ear	Surgical excision, radiotherapy
Hypertension	Acute or chronic	Bilateral high-pitched tinnitus	Headache, nausea, vomiting, blurred vision, seizures	Vascular pressure changes affecting cochlear perfusion	Blood pressure control, antihypertensives
Labyrinthitis	Acute	Tinnitus with vertigo	Sensorineural hearing loss, nystagmus, dizziness	Infection/inflammation of labyrinth	Antibiotics if bacterial, supportive care
Ménière’s disease	Intermittent	Tinnitus, vertigo, ear fullness	Fluctuating sensorineural hearing loss, nausea, diaphoresis, nystagmus	Endolymphatic hydrops in inner ear	Salt restriction, diuretics, vestibular suppressants, surgery in refractory cases
Ossicle dislocation	Acute	Tinnitus post-trauma	Hearing loss, possible middle ear bleeding	Disruption of ossicular chain	Surgical repair
Otitis externa/media	Acute	Tinnitus secondary to ear canal/tympanic inflammation	Ear pain, discharge, fever (media)	Conductive interference	Antibiotics, analgesics, ear hygiene
Otosclerosis	Gradual	Ringing, roaring, whistling	Progressive hearing loss, vertigo	Stapes fixation	Hearing aids, stapedectomy
Presbycusis	Gradual	High-frequency tinnitus	Symmetric bilateral sensorineural hearing loss	Age-related hair cell degeneration	Hearing aids, counseling
Tympanic membrane perforation	Acute	Tinnitus	Hearing loss, fullness, possible pain, vertigo	Disruption of TM	Observation, surgical repair if needed
Drugs/alcohol	Acute or chronic	Reversible or irreversible tinnitus	Often dose-related	Ototoxic effects on cochlea	Avoid offending agent, monitor hearing
Noise exposure	Acute or chronic	Bilateral tinnitus	Progressive hearing loss	Hair cell damage	Hearing protection, avoidance of loud sounds

Emergency interventions

Acute tinnitus with sudden hearing loss or vertigo: urgent ENT referral
Pulsatile tinnitus with bruit or neurologic deficit: evaluate for vascular lesions

Special considerations

Tinnitus is often difficult to cure, especially if chronic or sensorineural.
Adaptive strategies include masking devices, hearing aids, sound therapy, cognitive behavioral therapy, and biofeedback.
Identify and remove reversible causes whenever possible.

Patient counseling

Avoid loud noise, ototoxic drugs, and excessive alcohol
Educate on masking and coping strategies
Reassure patients that complete elimination may not be possible, but symptoms can often be managed
Emphasize regular hearing assessments and ENT follow-up

Pediatric pointers

Third-trimester maternal use of ototoxic drugs can cause fetal labyrinthine injury, leading to tinnitus
Children may develop tinnitus due to otitis media, noise exposure, or congenital cochlear malformations
Early recognition and management are important to prevent hearing loss and developmental delays

References

Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. Mosby Elsevier; 2008.
Lehne RA. Pharmacology for Nursing Care. 7th ed. Saunders Elsevier; 2010.
Sommers MS, Brunner LS. Pocket Diseases. F.A. Davis; 2012.
Sataloff RT. Tinnitus: Clinical and Research Perspectives. 2nd ed. San Diego: Plural Publishing; 2017.