Tinnitus

Author Credentials 

Syed Ahsan, MD, FACS
Otology/Neurotology, Clinical Asst Professor
Head and Neck Surgery
Kaiser Permanente, Southern California and UC Irvine
Irvine, CA and Orange, CA respectively

 

Module Summary

Tinnitus is a phantom perception of sound that is primarily due to hearing loss or noise exposure.  However, multiple etiologies exist (TBI, somatic tinnitus, concussions) which can also trigger tinnitus and / or modulate tinnitus perception and distress.  Both central and peripheral lesions can lead to chronic tinnitus. Tinnitus can persist despite resolution of a hearing loss or loss of cochlear nerve function because it is generated in the central auditory pathways. A thorough physical exam and good history are crucial to determining the etiology of tinnitus. Pulsatile tinnitus should be worked up for vascular lesions including imaging.  No one treatment is effective for all tinnitus patients.  Treatment should be pursued when tinnitus has a significant impact on the patient’s quality of life.  A multidisciplinary approach is often needed for patients who suffer significantly from tinnitus.

Module Learning Objectives 
  1. Identify the different causal mechanisms of tinnitus.
  2. Know the various etiologies and the exacerbating factors underlying the perception of tinnitus. 
  3. Be familiar with the signs and symptoms associated with tinnitus that may suggest a treatable pathology.
  4. Cite the principles of treatment of tinnitus.
  5. Recognize the signs and symptoms associated with tinnitus that should trigger further investigations.

 

Embryology

Learning Objectives 
  1. Recognize the auditory pathway and the generators of tinnitus.
  2. Be familiar with the concept of non auditory pathway interaction with the auditory pathway and the modulation of tinnitus.
  • Cochlea: inner and outer hair cells, spiral ganglion neurons, endolymph physiology, vascular supply
  • Auditory nerve: conditions affecting the cochlear nerve and its projections in the brainstem 
  • Brainstem (Dorsal cochlear nucleus)
  • Auditory cortex, temporal lobe projections
  • Presumptive role of non-auditory pathway (Basal Ganglia, somatosensory regions) in tinnitus modulation
  • Vascular structures (Jugular vein, carotid artery, Transverse and sigmoid sinus)

 

 

References 
  1. Lockwood AH et al.: The functional neuroanatomy of tinnitus: Evidence for limbic system links and neural plasticity. Neurology 1998; 50:114.
  2. JK Moore: The human brainstem auditory pathway. in Neurotology; RK Jackler, DE Brackmann eds. Mosby, 1994, pp.1-17.
  3.  AR Moller: Physiology of the ear and the auditory nervous system. in Neurotology; RK Jackler, DE Brackmann eds. Mosby, 1994, pp.21-32.
  4. A.J. Heller. Classification and epidemiology of tinnitus. Otolaryngol Clin North Am. 2003; 36: 239-248.
  5. Snow JB, ed. Tinnitus: Theory and Management. Lewiston, NY; BC Decker; 2004: 16-41.

 

Pathogenesis

Learning Objectives 
  1. State how somatosensory system can generate and/or modulate tinnitus.
  2. Differentiate tinnitus into primary and secondary tinnitus based on etiology.
  3. Define the role of psychiatric disorders in patients suffering from tinnitus.
  4. Identify the mechanisms of tinnitus generation and understand the role of neurosynchrony in the generation of tinnitus.
References 
  1. Ralli M, et al. Somatosensory tinnitus: Current evidence  and future perspectives. J Int Med Res. 2017; 45: 933-947.
  2. Michiels S, et al. Diagnostic Criteria for Somatosensory Tinnitus: A Delphi Process and Face to Face Meeting to Establish Consensus. Trends Hear. 2018 Jan-Dec; 22.
  3. Tunkel, et al. Clinical practice Guidelines; Tinnitus. Otolaryngol Head Neck Surg. 2014; Oct;151(2 Suppl):S1-S40.
  4. Henry J, Dennis K, Schecter M. General review of tinnitus: prevalence, mechanisms, effects and management. J Speech Lang Hear Res. 2005; 48: 1204-1235.
  5. Zoger S, Svedlund J, Holgers K. Relationship between tinnitus severity and psychiatric disorders. Psychosomatics. 2006; 47: 282-288.
  6. Nondahl, D, Cruckshanks K, Huang G. Tinnitus and its risk factors in the Beaver Dam Offspring Study. Int J Audiol. 2011; 50: 313-320.
  7. Haider H, et al.  Pathophysiology of Subjective tinnitus; Triggers and Maintenance. Front Neurosci. 2018; 12: 866.

 

Basic Science

Learning Objectives 
  1. Describe the possible neural and chemical mechanisms that are currently thought to underlie the tinnitus phenomenon.
  2. Identify how doe CNS disease impact tinnitus development.
  3. Cite what types of lesions cause tinnitus due to proximity.

 

References 
  1. Jastreboff, PJ. Phantom auditory perception (tinnitus): mechanisms of generation and perception. Neurosci Res. 1990; 8: 221-254.
  2. Miller AR. Pathophysiology of tinnitus. Ann Otol Rhinol Laryngol 1984; 93: 39-44.
  3. Haider H, et al. Pathophysiology of Subjective tinnitus; Triggers and Maintenance. Front Neurosci. 2018; 12:  866.
  4. Shore S, Roberts L, Langguth B. Maladaptive plasticity in tinnitus triggers, mechanisms and treatment. Nat Rev Neurotol. 2016; 12: 150-160.

Incidence

Learning Objectives 
  1. Recognize the incidence and prevalence of tinnitus in modern society. 
  2. Identify the economic impact of tinnitus on society.
  3. Describe the effect of tinnitus on health related quality of life.

 

References 
  1. Nondahl, D, Cruckshanks K, Huang G. Tinnitus and its risk factors in the Beaver Dam Offspring Study. Int J Audiol. 2011; 50: 313-320.
  2. Heller A.J. Classification and epidemiology of tinnitus. Otolaryngol Clin North Am. 2003; 36: 239-248.
  3. Smith G, et al. Complementary and integrative treatment of tinnitus. Otolaryngol Clin North Am; 2013; 46: 389-408.
  4. Tyler R, Baker L. Difficulties experienced by tinnitus sufferers. J Speech Hear Disord. 1983; 48: 150-154.
  5. Negrila- Mezei A et al. Tinnitus in elderly population: clinic correlations and impact upon QOL. J Med Life. 2011; 4: 412-416. 

 

Genetics

Learning Objectives 
  1. Recognize that the mechanisms of tinnitus have been so far elusive, and that the effects of genetic and epigenetic factors are unknown.
References 
  1. Vona B, et al. Genetics of Tinnitus: Still in its infancy. Front Neurosci. 2017;11: 236.

Patient Evaluation

Learning Objectives 
  1. Recognize the importance of history in diagnosing the cause of tinnitus.
  2. Cite the appropriate physical exams in helping to determine diagnosis of tinnitus and realize that findings on PE can help direct the need for further testing.
  3. Identify when to use audiometric tests such as audiogram, otoacoustic emissions, and ABR in helping evaluate patients with tinnitus.
  4. Identify that the patients with unilateral or pulsatile tinnitus should have prompt audiogram.
  5. Describe the effects of TMJ disorder, medications, and psychiatric factors in development of tinnitus and/or patient reactivity to tinnitus.

 

References 
  1. Tunkel et al. Clinical Practice Guideline: Tinnitus. Otolaryngol Head Neck Surg. 2014; 151: S1-40.
  2. Chole R and Parker W. Tinnitus and Vertigo in patients with TMJ disorder. Arch Otolaryngol Head Neck Surg. 1992; 118: 817-821.
  3. Chari  D, Limb C. Tinnitus. Med Clin North Am. 2018; 102: 1081-1093.

Measurement of Functional Status

Learning Objectives 
  1. Recognize the importance of distinguishing bothersome tinnitus from non bothersome tinnitus.
  2. Review the definition of bothersome tinnitus is one which affects quality of life and or functional health status.
  3. Appreciate the need for intervention when the tinnitus is bothersome.
  4. Be familiar with various validated questionnaires /surveys on effect of tinnitus on QOL / functional status (Tinnitus Handicap Inventory, Visual analogue scales, Tinnitus Functional Index).
References 
  1. Tunkel et al. Clinical Practice Guideline: Tinnitus. Otolaryngol Head Neck Surg. 2014; 151: S1-40.
  2. Newman C, Jacobson G, Spitzer B. Development of the Tinnitus Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1996; 122: 143-148.
  3. Meikle M, Henry J, Griest S, et al. The tinnitus functional index: development of a new clinical measure for chronic intrusive tinnitus. Ear Hear. 2012; 32s: 153-176.
  4. Noble W. Tinnitus self-assessment scales: domains of coverage and psychometric properties. The Hearing J. 2001; 54: 20-26.

Imaging

Learning Objectives 
  1. Imaging is not routinely necessary in evaluating tinnitus patients except in certain specific circumstances (unilateral tinnitus, unilateral hearing loss, pulsatile tinnitus, and cranial neuropathies).
  • Cite when it is appropriate to order imaging
  • Explain which imaging modality to order depending on patients tinnitus description (CT, MRI, MRA, CT angio)
    • No imaging is recommended for primary tinnitus without hearing loss or cranial neuropathies
References 
  1. Tunkel et al. Clinical Practice Guideline: Tinnitus. Otolaryngol Head Neck Surg. 2014;151: S1-40.
  2. Vattoth S, Shah R, Cure J. A compartment-based approach for the imaging evaluation of tinnitus. AJNR Am J Neuroradiol. 2010; 31: 211-218.

 

Pathology

Learning Objectives 
  1. Identify how cochlear and central lesions can lead to tinnitus.
  2. Cite the role of somatic cause of tinnitus.
  3. Recognize the various non audiological causes of tinnitus (medications).
  4. Describe the role non audiometric central areas (limbic system, ventral intermediate thalamus, and ventral and basal ganglia) may play a role in the modulation of tinnitus loudness and distress.
References 
  1. Norena AJ. An integrative model of tinnitus based on a central gain controlling neural sensitivity. Neurosci Biobehav Rev. 2011;35(5):1089-1109.
  2. Norena AJ, Mulders WH, Robertson D. Suppression of putative tinnitus-related activity by extra-cochlear electrical stimulation. J Neurophysiol. 2015;113(1):132-143.
  3. Muhlnickel W, Elbert T, Taub E, Flor H. Reorganization of auditory cortex in tinnitus. Proc Natl Acad Sci U S A. 1998;95(17):10340-10343.
  4. Salvi RJ, Wang J, Ding D. Auditory plasticity and hyperactivity following cochlear damage. Hear Res. 2000;147(1-2):261-274.

Treatment

Learning Objectives 
  1. Describe the approach to treating the patient with tinnitus using a holistic approach.
  2. Explain the use of hearing aids and tinnitus maskers in the treatment of tinnitus.
  3. Review the common medications that may be helpful in helping the emotional and psychological impact of tinnitus.
  4. Describe the basic principles behind tinnitus retraining therapy.
  5. Define the role of Cognitive behavioral therapy in tinnitus management.
  6. Compare some of the surgical procedures that may help with tinnitus.
  7. Appreciate of some of the research into electrical modulation of tinnitus (vagal nerve stimulation, deep brain stimulation, repetitive transcranial magnetic stimulation, and sound and somatic therapy for certain etiologies of tinnitus).
  8. Review the available alternatives in management of tinnitus using supplements and their limitations.
References 
  1. Seidman M and Ahsan S. Contemporary management of tinnitus. Curr Opin Otolaryngol Head neck Surg. 2015; 23: 376-381.
  2. Dobie RA. A review of randomized clinical trials in tinnitus. Laryngoscope. 1999; 109: 1202.
  3. Andersson G, Lyttkens L: A meta-analytic review of psychological treatments for tinnitus. Br. J Audiol 1999; 33: 201.
  4. Park J, White A, Ernst E. Efficacy of acupuncture as a treatment for tinnitus: a systematic review. Arch Otolaryngol Head Neck Surg. 2000; 126: 489.
  5. Jastreboff P, Gray W, Gold S. Neurophysiological approach to tinnitus patients. Am J Otol. 1996; 17: 236.
  6. Drew S, Davies E. Effectiveness of ginkgo biloba in treating tinnitus: double blind placebo controlled trial. BMJ. 2001; 322: 73.
  7. Seidman M, Standring R, Dornhoffer J. Tinnitus: current understanding and contemporary management. Curr Opin Otolaryngol Head Neck Surg. 2010; 18:363-368.
  8. Blasco M and Redleaf M. Cochlear implantation in unilateral sudden deafness improves tinnitus and speech comprehension: meta-analysis and systematic review. Otol Neurotol. 2014; 35:1426-1432.
  9. Nash B, Carlon M, and Van Gompel J. Microvascular decompression for tinnitus: systematic review. J Neurosurg. 2017; 126: 1148-1157.
  10. Soleymani T, Pieton D, Pezeshkian P, Miller P, et al. Surgical approaches to tinnitus treatment: A review and novel approaches. Surg Neurol Int. 2011. 2; 154.

Medical Therapies

Learning Objectives 
  1. Identify the common medications that may be helpful in helping the emotional and psychological impact of tinnitus.
  2. Report that clinicians should not routinely use anxiolytics, antidepressants, and intratympanic injections for the primary treatment of bothersome tinnitus.
  3. Be aware of the alternative therapies, such as supplements, for treatment of tinnitus is controversial and there is still debate on their efficacy.
  4. Recognize that medications can be used to relieve the distress associated with primary tinnitus (sleep disturbance, increased anxiety and stress, problems relaxing, and concentration).
References 
  1. Tunkel et al. Clinical Practice Guideline: Tinnitus. Otolaryngol Head Neck Surg. 2014; 151: S1-40.
  2. Seidman M and Ahsan S. Contemporary management of tinnitus. Curr Opin Otolaryngol Head neck Surg. 2015; 23: 376-381.
  3. Seidman M, Standring R, Dornhoffer J. Tinnitus: current understanding and contemporary management. Curr Opin Otolaryngol Head Neck Surg. 2010; 18:363-368.

Surgical Therapies

Learning Objectives 
  1. Be aware of the lack of surgical treatment options for primary tinnitus.
  2. Recgnize that tinnitus due to sudden hearing loss, vascular compression, and Otosclerosis can be treated by surgical procedures aimed at correcting the primary problem causing the tinnitus.
  • rTMS, DBS, Transcranial direct stimulation, Direct auditory cortex stimulation , vagal nerve stimulation are investigational at this time.  Some (rTMS, Transcranial direct stimulation) have shown inconsistent results
References 
  1. Blasco M and Redleaf M. Cochlear implantation in unilateral sudden deafness improves tinnitus and speech comprehension: meta-analysis and systematic review. Otol Neurotol. 2014; 35:1426-1432.
  2. Nash B, Carlon M, and Van Gompel J. Microvascular decompression for tinnitus: systematic review. J Neurosurg. 2017; 126: 1148-1157.
  3. Soleymani T, Pieton D, Pezeshkian P, Miller P, et al. Surgical approaches to tinnitus treatment: A review and novel approaches. Surg Neurol Int. 2011. 2; 154.
  4. Ahsan S, Luo H, Zhang J et al. An Animal Model of Deep Brain Stimulation for Treating Tinnitus: A Proof of Concept Study. Laryngoscope. 2017. 

Staging

Learning Objectives 
  1. Understand there is no staging system for tinnitus.
  • Measurement of functional status / distress / QOL measures are available to assess patients.
References 
  1. Tunkel et al. Clinical Practice Guideline: Tinnitus. Otolaryngol Head Neck Surg. 2014; 151: S1-40.

Case Studies

  1. A 65 year old man present with unilateral tinnitus in the left ear.  He describes it as a high pitched non pulsatile sound.  It is continuous and has been present for over 6 months.  It is does not affect his sleep or daily activities.  Is a hearing test necessary in this patient?  If the hearing test came back showing ASNHL with decrease WRS in the left ear what would be your next recommendation?  Does this patient need anxiolytics or tinnitus retraining therapy.  Will a hearing aid help if his hearing in the affected ear is aidable?  How would you counsel this patient if there are no other abnormal findings besides the  ASNHL?
  2. A 45 year old woman present with tinnitus in her head.  It is a non pulsatile, hissing noise.  It has been present for more than 3 months and is affecting her life and sleep. Is an audiogram necessary?  How about an MRI?  If hearing test shows bilateral hearing loss will a Hearing aid be helpful.  Will tinnitus maskers be helpful in her management?  How about anxiolytics?  Along with hearing aids what other modalities of treatment would you recommend?  Is TRT helpful? Would you recommend cognitive behavioral therapy?

Review

Review Questions 
  1. What is the difference between primary and secondary tinnitus?
  2. Besides a good history and physical, what other tests/exams are necessary in evaluating patients with subjective non-pulsatile tinnitus?
  3. Which population/patients are at most risk of experiencing distressing tinnitus?
  4. What are some of the treatment options for tinnitus causing distress?
  5. Which treatment options are recommended by the most recent clinical practice guidelines for tinnitus?
  6. When are medical therapies best utilized in patients with tinnitus?
References 
  1. Tunkel et al. Clinical Practice Guideline: Tinnitus. Otolaryngol Head Neck Surg. 2014; 151: S1-40.
  2. Seidman M, Standring R, Dornhoffer J. Tinnitus: current understanding and contemporary management. Curr Opin Otolaryngol Head Neck Surg. 2010; 18:363-368.
  3. Seidman M and Ahsan S. Contemporary management of tinnitus. Curr Opin Otolaryngol Head neck Surg. 2015; 23: 376-381.
  4. Blasco M and Redleaf M. Cochlear implantation in unilateral sudden deafness improves tinnitus and speech comprehension: meta-analysis and systematic review. Otol Neurotol. 2014; 35:1426-1432.
  5. Vattoth S, Shah R, Cure J. A compartment-based approach for the imaging evaluation of tinnitus. AJNR Am J Neuroradiol. 2010; 31: 211-218.
  6. Chari  D, Limb C. Tinnitus. Med Clin North Am. 2018; 102: 1081-1093.
  7. Jastreboff, PJ. Phantom auditory perception (tinnitus): mechanisms of generation and perception. Neurosci Res. 1990; 8: 221-254.
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