Tinnitus CKS | A4 Medicine

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TINNITUS CKS
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From Latin tinnire ( to ring or tinkle )- a
sensation of any sound perceived in the head or
in the ears without an evident external
stimulus. At any point in time around 10 of
the population experiences tinnitus ( BTA )
There is no standard diagnostic criterion for
tinnitus and is normally determined by self
-report typically in reponse to a single question
Tinnitus has a reported prevalence of about
8-25.3 in the US A systemic review ( Abby
McCormack et al 2016 ) reported a range from 5.1
to 42.7 No gender discrimination in incidence
Higher incidence among- military personnel, stage
workers , drummers and those who perform in
front of loudspeakers Subjective tinnitus cks
Occurs in absence of any physical sound reaching
the ear audible only to the patient. Causes-
wax in external ear . Middle ear causes
otosclerosis , middle ear effusion
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Inner ear causes Noise-induced hearing loss
Presbyacusis Menieres dis Trauma ( surgery ,
head injury ) Ototoxic drugs Labyrinthitis
Acoustic neuroma Two-thirds of people with
tinnitus have a disorder causing
hearing impairment Most commonly tinnitus is
associated with disorders causing sensorineural
hearing loss- includes ? age related ? noise
related ( less common ) ? Menieres dis (
uncommon ) Less commonly tinnitus is associated
with disorders causing conductive hearing loss ?
wax ? otosclerosis ( rare ) Ototoxic drugs (
uncommonly ) Ear infections including ? otitis
media ? otitis media with effusion ? chronic
suppurative otitis media Neurological disorders ?
acoustic neuroma ? multiple sclerosis Metabolic
disorder thyroid disease and diabetes
Psychological ?anxiety and depression Trauma of
the head or neck
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Objective Tinnitus Generated in the body and
reaches the ear through conduction in body
tissues and is audible to the patient as well as
the clinician ( also called somatosounds ).High
cardiac output ? treatment of hypertension with
ACEis or CCBs Benign intracranial hypertension
Dural or extracranial AV fistula Carotid or
vertebral artery stenosis , tortuosity ,
dissection or aneurysm Aortic dissection and
mitral regurgitation Dural or cervcal AVM (
arteriovenous malformation ) High jugular bulb
Vestibular schwannoma Temporomandibular joint
syndrome Haemangioma Glomus tumour Otosclerosis
Pagets disease. Has a vibratory , clicking or
pulsatile character Audible with a stethoscope ?
place the stethoscope close to external auditory
meatus over the carotid arteries , and on the
skull in front and behind th ear. If patient c/o
pulsatile tinnitus clinician should conduct
extensive search for a skull base tumour
Numerous vascular causes of pulsatile
tinnitus most common being ? arteriovenous
malformations ( AVM ) and ? fistulas Benign
intracranial hypertension has been reported as a
major cause of pulsatile tinnitus in toung women
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HistoryNo known objective tests that can
determine the severity of subjective tinnitus
unilateral or bilateral constant or intermittent
triggers around onset when did it start become
annoying associated symptoms ? deafness ?
dizziness ? hyperacusis ? otalgia h/o sig noise
exposure drug history ( ototoxic drug use )
family h/o hearing loss from otosclerosis
Otosclersosis ? bone around the base of stapes
becomes thickened and eventually fuses with the
bone of cochlea ? reduces normal sound
transmission leading to conductive hearing loss
effect on life psychological Examination
Otoscopy ? wax ? infections Tuning fork tests (
conductive or sensory hearing loss ) Bedside
hearing test General neurological assessment ?
acoustinc neuroma ? multiple sclerosis Check
blood pressure Blood tests ? hypo and
hyperthyroidism ? FBC ? random or fasting BM
Auscultate ears , head and neck if pulsatile
tinnitus ? exclude bruit Fundoscopy ( benign
intracranial hypertension ) Refer for formal
hearing test ? pure tone audiometry with
assessment of air and bone conduction MRI- for
vestibular schwannoma ( acoustic neuroma ) Red
flags Sudden onset pulsatile tinnitus Tinnitus in
association with significant/severe vertigo
Unilateral tinnitus Tinnitus in association with
asymmetric hearing loss or tinnitus with
unexplained sudden hearing loss Tinnitus in
association with significant neurological symptom
and or signs Tinnitus following head trauma
Tinnitus causing psychological distress
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• Hearing test Arrange a hearing test for all
  patients with tinnitus- CKS advices an
  audiology referral if tinnitus persists for
  tinnitus that lasts 6 months or more Twenty
  percent of persons visiting tinnitus clinics have
  normal hearing
• discuss impact , concerns any recent assessment ,
  management plans
• reassure that tinnitus is common may resolve by
  itself commonly associated with hearing loss but
  not commonly associated with other underlying
  physical problems reassure that management
  strategies exist which may help people live well
  with tinnitus.
• Referral refer immediately -people with
  tinnitus who are at high risk of suicide to the
  crisis team refer immediately if tinnitus is
  associated with ? sudden onset of significant
  neurological symptoms or signs ( eg facial
  weakness ) or ? acute uncontrolled vestibular
  symptoms ( e,g vertigo ) or
• suspected stroke refer to be seen within 24 hrs
  if they have tinnitus and
• have hearing loss that has developed suddenly - (
  ie over a period of 3 days or less ) in the past
  30 days refer to be seen within 2 weeks if
  tinnitus ? distress affecting mental well
  being ( even if they have received tinnitus
  support at first point of contact ) ? hearing
  loss that developed suddenly more than 30 days
  ago or rapidly worsening hearing loss ( over a
  period of 4 -90 days ) refer for tinnitus
  assessment if ? continues to be bothersome ?
  persistent objective tinnitus ? associated with
  asymmetric or unilateral hearing loss consider a
  referral if ? persistent pulsatile tinnitus ?
  persistent unilateral tinnitus

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NICE recommends using questionnaires to assess
the impact of tinnitus Tinnitus Functional Index
how tinnitus affects them Visual analogue scale
if questionnaire cannot be used Discuss how
this affects their QoL Insomnia Severity Index
if it impacts sleep Tinnitus questionnaire ( TQ )
or mini- TQ alongside Tinnitus Functional Index
to assess psychological impact Assess for
depression and anxiety using a questionnaire or
an ability appropriate measure and agree on a
management plan in line with current guidance
Investigations some recommendations may relate
to specialists investigations can include ?
audiological assessment ( follow NICE guidance
) ? psychoacoustic tests ? imaging offer MRI of
internal auditory meati ( IAM ) ? those with
non-pulsatile tinnitus with associated
neurological , otological or head neck signs
and symptoms ? contrast enhanced CT ( IAM ) is
an alternative technique ? do not offer imaging
for people with symmetrical non-pulsatile
tinnitus with no associated neurological ,
audiological , otological or head neck signs
and symptoms synchronous pulsatile tinnitus
consider ? MRA or MRI of head , neck , temporal
bone and IAM if clinical examination
audiological assessment are normal OR ? contrast
enhanced CT of head , neck , temporal bone and
IAM if they cannot have MRA or MRI non-
synchronous pulsatile tinnitus ( for e,g if
caused by palatal myoclonus ) consider MRI of
head or contrast enhanced CT of head.
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Amplification device offer hearing aid if they
have a hearing loss that affects their ability
to communicate consider a hearing aid if they
have a hearing loss but do not have difficulties
communicating hearing aid is not indicated in
absence of hearing loss. Sound therapy NICE has
not made any recommendations for practice in this
area due to lack of evidence of these
interventions in isolation.