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Tinnitus--Current Concepts in Diagnosis and Management.

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Title: Tinnitus--Current Concepts in Diagnosis and Management.
Language: English
Authors: Epstein, Stephen
Source: Volta Review. 1997 99(5):119-127.
Peer Reviewed: Y
Page Count: 9
Publication Date: 1997
Document Type: Journal Articles
Descriptors: Adults, Children, Classification, Clinical Diagnosis, Disability Identification, Hearing Impairments, Intervention, Medical Evaluation, Outcomes of Treatment
ISSN: 0042-8639
Abstract: This article discusses the causes of tinnitus, sound or noise in the ears or head without any external stimulation. Classification of tinnitus, the essentials of medical evaluation of a patient with tinnitus, essential test procedures, and current concepts in the management of tinnitus are addressed. (CR)
Entry Date: 2000
Accession Number: EJ603410
Database: ERIC
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  Value: <anid>AN0002653863;VLT01NOV.97;2000Jan07.20:41;v4.1</anid> <title id="AN0002653863-1">TINNITUS -- CURRENT CONCEPTS IN DIAGNOSIS AND MANAGEMENT </title> <p>Tinnitus is defined as the perception of sound or noise in the ears or head without any external stimulation. It can present itself in many forms, such as a ringing, a hissing, a jetstream, crickets chirping, or even the sound of the ocean. A pulsating type of tinnitus is unique in the sense that it may represent a muscle spasm or an abnormality of the blood vessels within the ear or head and neck area. Tinnitus can be continuous or intermittent, and may be aggravated by loud noises, certain medications, stress, and changing positions of the head and neck. It is usually more noticeable to people in a relatively quiet environment. Although tinnitus in one ear is less common than complaints of tinnitus in both ears, it may be suggestive of an inner ear tumor, vascular abnormality, or spasm of palatal, face, or neck muscles. </p> <p>Subjective tinnitus is heard by the affected person only and is usually related to some form of hearing loss. Objective tinnitus is heard by both the affected person and the examiner and is generally caused by a blood vessel abnormality, muscle spasm, or joint clicking within the head or neck area. Currently, there are 40 million Americans who have tinnitus; about 10 million of them have tinnitus that is troublesome enough for these people to seek medical attention. </p> <hd id="AN0002653863-2">Current Philosophy</hd> <p>It is important to recognize that tinnitus is not a disease but rather a symptom reflective of underlying pathology involving the ear, related blood vessels, joints, and muscular structures of the head and neck area. It is a symptom that evokes both mystery and frustration on the part of the professionals involved with the diagnosis and management, as well as the patients. Being a subjective symptom, tinnitus has not been effectively and accurately measured despite the use of various tinnitus matching techniques. We don't even fully understand the exact mechanism of tinnitus from a physiological point of view, nor do we know the exact site of origin of tinnitus within the human body. Common sense would tell us that the origin lies within the inner ear or surrounding structures. Recent studies using position emission tomography (PET) and single photon emission computed tomography (SPECT) indicate that the origin of tinnitus in certain patients may be within the auditory center of the temporal lobe of the brain. Scientists have created animal models in which tinnitus can be produced and investigated in the cochlea or inner ear. It is possible that tinnitus may have a multicentric origin and may occur anywhere within the auditory system--from the hair cells within the cochlea or inner ear to the auditory center within the brain. In certain cases, tinnitus may originate outside the auditory system itself. With the creation of animal models that can duplicate tinnitus along with advanced technology such as the PET and SPECT, scientists have just begun to scratch the surface in regard to the exact physiological basis and site of origin of tinnitus. The National Institute on Deafness and Other Communication Disorders (NIDCD) has provided millions of dollars toward scientific research related to tinnitus, and the Tinnitus Research Consortium has been created to accelerate progress in basic and clinical research on tinnitus. The International Tinnitus Seminar sponsored by the American Tinnitus Association is held every five years, providing an opportunity for scientists from all over the world to gather to discuss and compare their research regarding the latest developments in the diagnosis and management of tinnitus. These are just a few examples of the increasing scientific research and programs dedicated to the study of tinnitus. </p> <hd id="AN0002653863-3">Causes of Tinnitus</hd> <p>There are many ways to classify the various causes of tinnitus. I find that the simplest approach and one that is very helpful to me when evaluating a patient is to distinguish those causes related to the ear as otological and those cases not related to the ear as non-otological. I then subclassify the otological causes into external ear, middle ear, and inner ear. I subclassify the non-otological causes into systemic, neurological, vascular, and musculoskeletal. The following are some of the more common causes of tinnitus using the classifications I have described. </p> <hd id="AN0002653863-4">Classification of Tinnitus</hd> <hd id="AN0002653863-5">Otological Causes</hd> <p>In this category, any condition that interferes with the transmission of sound or causes a defect within the hearing system may result in the production of tinnitus. </p> <hd1 id="AN0002653863-6"> External Ear </hd1> <p>1. Obstruction or narrowing of the ear canals </p> <p>2. Impacted cerumen, or wax, in the ear canals </p> <hd1 id="AN0002653863-7"> Middle Ear </hd1> <p>1. Serous otitis media with fluid in the middle ear </p> <ulist> <item>2. Perforation of the ear drum </item> <item>3. Fixation or dissociation of the ossicular chain (the bones in the middle ear) </item> <item>4. Cholesteatoma (a pocket of the eardrum growing in the middle ear as a result of chronic ear infections) 5. Glomus tumor (a vascular tumor arising in the middle ear space) </item> </ulist> <p>The hearing loss produced by conditions involving the external ear and middle ear is a conductive hearing loss that can be associated with tinnitus. These conditions are treatable by medical and surgical procedures and generally result in improvement of the hearing and resolution of the tinnitus. </p> <hd1 id="AN0002653863-8"> Inner Ear </hd1> <p>Inner ear causes of tinnitus usually are a result of deterioration or destruction of the inner ear hair cells as a result of the following. </p> <p>1. Presbycusis </p> <ulist> <item>2. Noise exposure/acoustic trauma </item> <item>3. Ototoxic medications </item> <item>4. Sudden hearing loss syndrome </item> <item>5. Meniere's disease </item> <item>6. Perilymphatic fistula </item> <item>7. Autoimmune inner ear disease </item> <item>8. Acoustic neuroma </item> </ulist> <p>These conditions result in a sensorineural hearing loss and are commonly associated with tinnitus. Unless the hearing loss is successfully alleviated in Meniere's disease, sudden hearing loss syndrome, acoustic trauma, and perilymphatic fistula, the hearing loss and tinnitus remain permanent. </p> <hd id="AN0002653863-9">Non-Otological Causes of Tinnitus</hd> <hd1 id="AN0002653863-10"> Systemic Disorders </hd1> <p>These disorders may affect physiology within the inner ear resulting in a sensorineural hearing loss and tinnitus. The hearing loss and tinnitus may be reversible depending on time factors and successful rate of treatment. </p> <p>1. Anemia </p> <ulist> <item>2. Elevated blood cholesterol </item> <item>3. Elevated blood fats </item> <item>4. Underactive thyroid condition </item> <item>5. Diabetes mellitus 6. Zinc, iron, and vitamin B12 deficiency </item> </ulist> <p>The following disorders are generally associated with a normal examination of the ear and a normal hearing evaluation; however, they can cause tinnitus. </p> <hd1 id="AN0002653863-11"> Neurological Disorders </hd1> <p>1. Benign intracranial hypertension </p> <ulist> <item>2. Migraine headaches </item> <item>3. Multiple sclerosis </item> <item>4. Brain tumors involving the base of the brain, temporal bone, and auditory centers in the temporal lobe </item> </ulist> <hd1 id="AN0002653863-12"> Vascular Disorders </hd1> <p>1. Aneurysms involving the blood vessels of the head and neck area </p> <ulist> <item>2. Malformations between arteries and veins </item> <item>3. Abnormal vascular loops in the head and neck </item> <item>4. Blood vessel narrowing from arteriosclerosis within the head and neck </item> </ulist> <hd1 id="AN0002653863-13"> Musculoskeletal Disorders </hd1> <p>1. Temperomandibular joint (TMJ) disorders and related spasm of the face and neck muscles </p> <ulist> <item>2. Arthritis of cervical spine </item> <item>3. Spasms of the palate, eustachean tube, and middle ear muscles </item> </ulist> <hd id="AN0002653863-14">The Essentials of Medical Evaluation of a Patient with Tinnitus</hd> <p>The primary objective of the medical evaluation of a patient with tinnitus is to determine the cause of the tinnitus so that appropriate management can be implemented. Using the classification of the causes of tinnitus outlined in this chapter, it would be appropriate to determine whether or not the tinnitus is of otological or non-otological origin. Once this distinction is made, further evaluation can be taken to determine the more specific cause of the tinnitus. A complete medical evaluation including history and physical examination, appropriate hearing testing, blood tests, and x-rays can be quite extensive and will not be discussed in full detail in this chapter, except to highlight some of the important components of the evaluation. </p> <hd id="AN0002653863-15">The History</hd> <p>It is important at the onset to determine the description of the tinnitus and whether it is unilateral or bilateral and whether it is pulsatile, objective, or subjective in nature. It is essential to determine if there are any associated otological symptoms such as hearing loss, hyperacusis, described asincreased sensitivity to sounds, fullness in the ears, or vertigo. Is there a past history of ear infections, noise exposure, or surgery to the ear? Is there a history of ototoxic medication consumption such as aspirin and non-steroid anti-inflammatory agents, quinine, or ototoxic antibiotics? Other important aspects of the work-up include whether there is a history of high blood pressure, diabetes, or elevated cholesterol and triglycerides (blood fats). It is important to determine whether or not the patient has any associated neurological symptoms such as headaches, visual disturbances, memory loss, or muscle weakness. Other essential questions involve whether or not there is any history of arthritis, especially involving the head and neck area, and whether or not the patient has a history of major dental work or any temporomandibular joint (TMJ) problems. By obtaining a complete history one can determine at the onset whether the tinnitus is of otological or non-otological origin. </p> <hd id="AN0002653863-16">The Physical Examination</hd> <p>The most essential part of the examination is the evaluation of the ears to determine a possible otological origin of the tinnitus. A comprehensive examination of the ear can easily determine whether or not there are any abnormalities of the ear canal, eardrum, or middle ear cavity. When indicated, a cardiovascular examination including measurement of blood pressure and an examination for vascular, muscular, and joint pathology within the head and neck should be performed. A complete neurological examination may also be necessary. </p> <hd id="AN0002653863-17">The Essential Test Procedures</hd> <p>By the time the physician has completed the history and physical examination, many causes of tinnitus may be ruled out and the diagnosis can be narrowed to a few possible causes. The following tests will assist the physician in determining the final diagnosis. These test procedures should be included in the work-up depending on the working diagnosis. </p> <hd id="AN0002653863-18">Audiological Evaluation</hd> <p>Every patient with tinnitus should have a complete audiological evaluation, preferably in a soundproof room with a certified audiologist. A complete heating evaluation can determine the type of hearing loss (conductive or sensorineural), as well as the severity of the hearing loss. There are specific conditions causing hearing loss that can be diagnosed, such as a low-frequency sensorineural hearing loss similar to that found in Meniere's disease and acoustic neuroma patients, and a high-frequency sensorineural hearing loss found in presbycusis and noise-induced hearing loss patients. Special auditory testing can be used to diagnose an acoustic neuroma. It is quite possible for a patient with tinnitus to have normal hearing--therefore, non-otological causes of tinnitus must be ruled out. </p> <hd id="AN0002653863-19">Radiological Evaluation</hd> <hd1 id="AN0002653863-20"> CAT Scan of the Temporal Bones </hd1> <p>A CAT scan of the temporal bones may be necessary to confirm the presence of chronic middle ear and mastoid disease. </p> <hd1 id="AN0002653863-21"> Magnetic Resonance Imaging (MRI) of the Inner Ear with Central Dye </hd1> <p>This test may be performed to rule out the presence of an acoustic neuroma, especially if the audiological evaluation is suggestive of such a lesion. </p> <hd1 id="AN0002653863-22"> CAT Scan and/or MRI of the Head and Neck Area </hd1> <p>One or both of these tests may be performed to rule out any vascular, neurological (brain tumor or multiple sclerosis), or arthritic pathology within the head and neck area. </p> <hd id="AN0002653863-23">Blood Tests</hd> <p>Essential blood tests to determine the presence of anemia, diabetes mellitus (elevated blood sugar), elevated cholesterol and elevated blood fats, underactive thyroid condition, and the rare possibility of zinc and vitamin B12 deficiencies can also be useful. </p> <hd id="AN0002653863-24">Further Evaluation by Other Specialists</hd> <p>As the patient goes through the process of the history and physical examination and appropriate test battery (e.g., audiological evaluation and appropriate radiological evaluation), many of the possible causes of tinnitus can be eliminated, and it may be necessary for the patient to see a neurologist, cardiologist, vascular specialist, or someone who specializes in disorders of the temperomandibular joint to obtain a definitive diagnosis of the cause of their tinnitus. </p> <hd id="AN0002653863-25">Current Concepts in the Management of Tinnitus</hd> <p>It is apparent from the previous section that many underlying conditions causing tinnitus can be successfully treated with medical or surgical intervention. I will therefore confine my discussion of the management of tinnitus for those patients who have an underlying sensorineural hearing loss secondary to presbycusis, noise exposure, acoustic trauma, or ototoxic medications. For simplicity, I will refer to this as Subjective Sensorineural Tinnitus (SST). These patients comprise the vast majority of the 40 million Americans who have tinnitus. We know so little about the exact physiology and site of origin of tinnitus related to a sensorineural hearing loss that we unfortunately do not have a "cure." At least 10 million Americans complain of tinnitus and require some form of intervention, and we have a responsibility to provide some sort of treatment plan to enable them to cope with this often stressful and debilitating condition. Once a patient has been completely worked up and all other conditions have been eliminated, I recommend taking these steps in managing the patient with SST. </p> <hd id="AN0002653863-26">Inform and Reassure the Patient</hd> <p>This is probably the most important aspect in the management of a patient with SST. Once you have eliminated all other possible causes, it is essential that you inform patients of the nature of their hearing loss and that the tinnitus is related to that hearing loss. It is equally essential that you assure patients that they do not have a brain tumor or Alzheimer's disease, nor have they had a stroke. It is amazing how many patients think of the worst possible scenarios with the symptoms of tinnitus. This approach will satisfy the vast majority of patients with SST who will then successfully cope with their tinnitus. For patients with SST who desire continuing support and inormation in regard to Tinnitus, I refer them to the American Tinnitus Association that has chapters all over the U.S. </p> <hd id="AN0002653863-27">Inform the Patient of the Conditions That May Aggravate or Accentuate Tinnitus</hd> <hd1 id="AN0002653863-28"> Diet </hd1> <p>Patients should avoid caffeine, nicotine and heavy salt intake. They should keep the diet low in sugar, cholesterol, and fats, and take appropriate medications for elevated cholesterol diabetes. </p> <hd1 id="AN0002653863-29"> Avoidance of Certain Medications </hd1> <p>Aspirin, non-steroidal anti-inflammatory drugs (NSAIDS) and ototoxic antibiotics should be avoided. If any medication causes increase in the tinnitus, it should be discontinued and the treating physician consulted. </p> <hd1 id="AN0002653863-30"> Loud Noise and Music </hd1> <p>Loud noise exposure from power tools and loud music exposure using headphones or attending concerts can aggravate tinnitus. It is important to keep music volume low and to use sound reduction ear plugs when exposed to power tools and loud music. </p> <hd id="AN0002653863-31">Encourage the Use of Background Music</hd> <p>A certain percentage of patients with SST will state that their tinnitus prevents them from falling asleep at night, or studying or reading in quiet environments. The simple solution of using background music in these situations usually solves the problem. </p> <hd id="AN0002653863-32">The Role of Amplification in the Management of Tinnitus</hd> <p>One of the earliest theories in regard to the etiology of tinnitus is that it is produced by the inner ear in response to diminished auditory stimulation. This may very well be true now that we are aware that the inner ear produces its own sounds, called otacoustic emissions. Amplification of sounds utilizing hearing aids, cochlear implants, and other acoustic listening devices, when indicated, usually reduces the awareness of SST. </p> <hd id="AN0002653863-33">The Use of Masking Devices</hd> <p>There are small hearing aid-like devices that present a continuous, more pleasant sound that matches the tinnitus in the hope of masking the more unpleasant sounds of the tinnitus. This approach has been met with only limited success and appears to contradict the more current approach to the management of tinnitus, habituation, or tinnitus retraining therapy. </p> <hd id="AN0002653863-34">The Role of Medication in the Management of Tinnitus</hd> <p>As of this writing, it is appropriate to conclude that there are no medications available that effectively cure or eliminate SST. The most effective medications are antidepressants recommended to patients who are severely distressed by SST. There are literally hundreds of medications that have been considered for the treatment of SST through experimental studies. The following are the major categories of drugs recommended for treatment of SST. </p> <hd1 id="AN0002653863-35"> Medications That Have Been Recommended for Treatment of SST </hd1> <p> <bold> Anesthetic agents. </bold> Procaine and lidocaine, when given intravenously, eliminate tinnitus, probably functioning as inhibitors of neural impulses. Too risky to be given intravenously in patients with normal cardiac functions. </p> <p>Tocanide, an oral form of lidocaine, is not as effective in eliminating tinnitus and still has serious side effects. </p> <p> <bold> Anticonvulsive agents. </bold> Tegretol and Dilantin are sed primarily for the treatment of seizures and have serious side effects, precluding their use for treatment of SST. </p> <p> <bold> Antianxiety agents. </bold> Klonopin, Valium, and Serax are recommended for reducing the anxiety and stress related to SST. They may have some merit in generally preventing fatigue and drowsiness. </p> <p> <bold> Antidepressants. </bold> Antidepressants like Prozac, Zoloft, Wellbutrin, andElavil are extremely effective in reducing the anxiety and stress related to SST. These medications do not eliminate the tinnitus, but enable the patients to cope with the symptoms. </p> <p> <bold> Vasoactive Medications. </bold> These medications, which include niacin, histamines, and ginkgo biloba, generally cause dilation of inner ear blood vessels and surrounding structures, but have not been significantly effective in reducing tinnitus in most patients with SST. </p> <p>Many other classes of medications have been suggested for treating SST, such as antihistamines, calcium channel blockers, antihypertension medications, vitamins, and others, most of which have not demonstrated any significant reduction or elimination of SST. </p> <hd id="AN0002653863-36">Surgical Treatment for SST</hd> <p>Patients with severe debilitating SST who have no auditory function in the affected ear may be candidates for surgical treatment. Patients with debilitating SST who undergo complete section of the auditory nerve or destruction of the inner ear with streptomycin may have less than a 50% success rate in eliminating their SST. Patients with Meniere's disease with underlying endolymphatic sac decompression may actually have an acceleration of their tinnitus. </p> <hd id="AN0002653863-37">Habitulation or Tinnitus Retraining Therapy (TRT)</hd> <p>This is the most recent method of management for patients with SST. Working with the tinnitus models, it has been concluded that with the development of tinnitus, the central nervous system becomes the receptor of the tinnitus and thus is responsible for the "annoyance." Using a broad frequency, low-level noise generator in both ears, habitulation or Tinnitus Retraining Therapy (TRT), basically "distracts" the central nervous system so that the auditory system becomes "normalized" to the tinnitus, and therefore the tinnitus becomes less bothersome. This is not a form of masking, which attempts to block out the tinnitus. Proponents of TRT state that masking is actually contraindicated. TRT conditions patients with SST to habitulate, or cope, with the tinnitus, almost eliminating it from their conscious awareness even though it is always there. TRT is usually conducted by an individual who has been formally trained in the technique; it usually takes an average of 12-18 months to successfully acclimate to the tinnitus. Once completed, the low-level noise generator is no longer needed. There is an intense amount of counseling associated with tinnitus retraining therapy and its proponents report about an 80% success rate. </p> <hd id="AN0002653863-38">Conclusion</hd> <p>Tinnitus is a symptom that evokes a sense of mystery and frustration on the part of the professional and the patient. The vast majority of the 40 million patients with tinnitus have subjective sensorineural tinnitus (SST) related to a sensorineural hearing loss secondary to presbycusis, noise exposure, or ototoxic medications. Only 25% of these patients have tinnitus that is so stressful that it requires intervention. This article explores the mystique behind tinnitus, outlines the most common causes, and suggests a rational approach to the options for management of SST. It stresses the importance of a complete evaluation of every patient with tinnitus, resulting in an accurate diagram and appropriate management. This article discusses the latest approaches in the treatment options for the patient with SST. With advancing technology and scientific research in the field of tinnitus, it is hopeful that a better understanding of this symptom and more effective "cures" for tinnitus will be forthcoming. </p> <aug> <p>By Stephen Epstein, M.D. </p> <p>Adapted by M.D. </p> <p></p> <p>Dr. Epstein is an otologist, and associate clinical professor of otolaryngology-head and neck surgery and pediatrics at George Washington University School of Medicine, Washington, DC. </p> </aug>
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