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{{CMG}}; {{AE}} {{KS}} {{SAI}}


==Overview==
==Overview==
Tinnitus ([[International Phonetic Alphabet|IPA pronunciation]]: {{IPA|[tɪ'naɪtəs]}} or {{IPA|['tɪnɪtəs]}},<ref name="ata">[http://www.ata.org American Tinnitus Association | Home | Help For Ringing In The Ears]</ref> from the Latin word for "ringing"<ref name="m-w">[http://m-w.com/cgi-bin/dictionary?book=Dictionary&va=tinnitus Dictionary of tinnitus - Merriam-Webster Online Dictionary]</ref>) is the perception of sound in the [[human]] [[ear]] in the absence of corresponding external sound(s).  
[[Tinnitus]] is derived from the Latin word ''tinnire,'' meaning to ring. Tinnitus can be classified as subjective and objective.  This classification not only explains the underlying etiology but also directs the management of tinnitus. In the normal functioning auditory pathway, there is ordered tonotopic frequency mapping from the [[cochlea]] to the [[auditory cortex]] via [[midbrain]].  Conditions associated with [[Cochlear nucleus|cochlear]] damage result in altered tonotopic organization and ultimately tinnitus. The pathophysiology of tinnitus can be explained by the tinnitus model. Common causes of tinnitus include [[Ototoxicity]], [[Presbycusis]], noise induced [[hearing loss]], late onset congenital [[hearing loss]], [[Ménière's disease|meniere's disease]], and [[Loop diuretics]]. The [[incidence rate]] of tinnitus increases with age and is more prevalent in older people. Tinnitus is more prevalent in men compared to women and [[Smoking|smokers]] compared to non-smokers. If left untreated, patients may progress to functional impairment, [[insomnia]], [[anxiety]], and [[depression]]. TSI is used to rank the patient's based upon their severity. The score ranges from 0-45. Symptoms and history include sounds such as ringing, buzzing, pulsatile, roaring and humming and progressive hearing loss.  An extensive neurological examination may rule out underlying brainstem damage or hearing loss. The Weber and Rinne test are done to establish sensorineural or conductive hearing loss. They are usually abnormal.  MRI with contrast is followed by CT/CTA and ultimately interventional angiography, if needed. Initial audiometric tests are done to identify asymmetries between the ears and to locate the site of abnormality such as middle ear, cochlea, and brainstem.  These tests include: pure-tone audiogram, tympanometry, auditory reflex testing, determination of speech discrimination abilities, otoacoustic emissions testing and auditory brainstem response testing (ABR).  Tinnitus is a symptom and not a disease itself.  It is a chronic condition that can be managed by treating the underlying etiology. The treatment of tinnitus is usually directed towards improvement in the quality of life by decreasing awareness or desensitizing towards tinnitus.  It is usually achieved by identifying the underlying pathology or the associated disease. It is recommended to treat underlying [[insomnia]] and depression (Grade 1B). [[Cochlear implants]] may be considered for tinnitus associated with severe [[sensorineural hearing loss]]. Other therapies include: [[tinnitus retraining therapy]] (TRT) (Grade 1C), [[biofeedback]] (Grade 2C), and  [[Cognitive behavioral therapy|cognitive behavioral therapy (CBT)]] as an adjunct to TRT (Grade 2C). [[Acupuncture]] and electrical stimulation are considered equally effective as placebo, no significant role established so far.
 
<br />
==Historical Perspective==
 
*In the early 19th century, Frenchman and Jean Marie Gaspard Itard introduced the concept of masking.  They were the first ones to differentiate between subjective and objective [[tinnitus]].
*Later in the 19th Century, with the introduction of germ theory and [[anesthesia]], surgical therapy such as incudectomy was established.
*[[Tinnitus]] is derived from the Latin word ''tinnire,'' meaning to ring.
*
 
==Classification==
Tinnitus can be classified as subjective and objective.  This classification not only explains the underlying etiology but also directs the management of tinnitus.
 
===Subjective tinnitus:===
 
*It is only experienced by the affected individual in the absence of any [[auditory]] stimulation
*More common, usually described as continuous ringing, high pitch sound
 
===Objective tinnitus:===
 
*It is experienced not only by the affected individual but also by anyone else
*Relative rare, usually described as intermittent [[venous hum]], low pitch sound
*It has an underlying [[vascular]] (abnormality of the [[carotid artery]], jugular bulb or [[jugular vein]]) or [[muscular]] etiology (degenerative conditions such as [[Amyotrophic lateral sclerosis diagnostic evaluation|amyotrophic lateral sclerosis]]) and usually caused by sound produced in ear, head or neck.<br />


==Pathophysiology==
==Pathophysiology==


===Pathophysiology of Subjective Tinnitus===
In the normal functioning auditory pathway, there is ordered tonotopic frequency mapping from the [[cochlea]] to the [[auditory cortex]] via [[midbrain]].<ref name="pmid24744443">{{cite journal |vauthors=Minen MT, Camprodon J, Nehme R, Chemali Z |title=The neuropsychiatry of tinnitus: a circuit-based approach to the causes and treatments available |journal=J. Neurol. Neurosurg. Psychiatry |volume=85 |issue=10 |pages=1138–44 |date=October 2014 |pmid=24744443 |doi=10.1136/jnnp-2013-307339 |url=}}</ref><ref name="pmid10601720">{{cite journal |vauthors=Qiu C, Salvi R, Ding D, Burkard R |title=Inner hair cell loss leads to enhanced response amplitudes in auditory cortex of unanesthetized chinchillas: evidence for increased system gain |journal=Hear. Res. |volume=139 |issue=1-2 |pages=153–71 |date=January 2000 |pmid=10601720 |doi=10.1016/s0378-5955(99)00171-9 |url=}}</ref>  Conditions associated with [[Cochlear nucleus|cochlear]] damage result in altered tonotopic organization and ultimately tinnitus. The pathophysiology of tinnitus can be explained by the tinnitus model.<ref name="pmid10669517">{{cite journal |vauthors=Melcher JR, Sigalovsky IS, Guinan JJ, Levine RA |title=Lateralized tinnitus studied with functional magnetic resonance imaging: abnormal inferior colliculus activation |journal=J. Neurophysiol. |volume=83 |issue=2 |pages=1058–72 |date=February 2000 |pmid=10669517 |doi=10.1152/jn.2000.83.2.1058 |url=}}</ref><ref name="pmid9443467">{{cite journal |vauthors=Lockwood AH, Salvi RJ, Coad ML, Towsley ML, Wack DS, Murphy BW |title=The functional neuroanatomy of tinnitus: evidence for limbic system links and neural plasticity |journal=Neurology |volume=50 |issue=1 |pages=114–20 |date=January 1998 |pmid=9443467 |doi=10.1212/wnl.50.1.114 |url=}}</ref>
One of the possible mechanisms relies in the otoacustic emissions. The [[inner ear|inner]] [[ear]] contains thousands of minute hairs which vibrate in response to sound waves and cells which convert neural signals back into acoustical vibrations. The sensing cells are connected with the vibratory cells through a neural feedback loop, whose gain is regulated by the brain. This loop is normally adjusted just below onset of self-oscillation, which gains the ear spectacular sensitivity and selectivity. If something changes, it's easy for the delicate adjustment to cross the barrier of oscillation and tinnitus results. This can actually be measured by a very sensitive microphone outside the ear.
 
====Lesion projection zone (LPZ):====
This zone is defined as the area in the [[auditory cortex]] that represents the damaged [[Cochlear nerve|cochlear]] input.  The [[neurons]] in the LPZ zone show 2 main changes:
 
*Accelerated spontaneous firing rate
*Increased representation of [[neurons]] that represent the damaged [[Cochlear nerve|cochlear]] region also known as lesion edge frequencies in the LPZ
 
===Tinnitus model:===
This model explains 2 major phenomena in the [[auditory cortex]] caused by lack of [[sensory]] [[Peripheral Nervous System|peripheral]] auditory input ([[cochlea]])


Other possible mechanisms of how things can change in the ear is damage to the receptor cells. Although receptor cells can be regenerated from the adjacent supporting Deiters cells after injury in birds, reptiles, and amphibians, in mammals it is believed that they can be produced only during [[embryogenesis]].  Although mammalian Deiters cells reproduce and position themselves appropriately for regeneration, they have not been observed to [[transdifferentiation|transdifferentiate]] into receptor cells except in tissue culture experiments.<ref name="nih-16525832">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16525832 Supporting cell proliferation after hair cell injury in mature guinea pig cochlea in vivo]</ref><ref name="nih-16791196">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16791196 Mammalian cochlear supporting cells can divide and trans-differentiate into hair cells]</ref> Therefore, if these hairs become damaged, through prolonged exposure to excessive decibel levels, for instance, then deafness to certain frequencies occurs.  In tinnitus, they may falsely relay information at a certain frequency that an externally audible sound is present, when it is not.
*Hyperactivity in the lesion projections zone (LPZ)
*Increased [[Cortical area|cortical]] representation of the lesion-edge frequencies in the LPZ


The mechanisms of subjective tinnitus are often obscure. While it is not surprising that direct trauma to the inner ear can cause tinnitus, other apparent causes (e.g., [[temporomandibular joint disorder]] (TMJ) and dental disorders) are difficult to explain. Recent research has proposed that there are two distinct categories of subjective tinnitus: '''Otic''' tinnitus, caused by disorders of the inner ear or the acoustic nerve, and '''somatic''' tinnitus, caused by disorders outside the ear and nerve but still within the head or neck. It is further hypothesized that somatic tinnitus may be due to "central crosstalk" within the brain, as certain head and neck nerves enter the brain near regions known to be involved in hearing.
==Causes of subjective tinnitus==
====Sensorineural hearing loss:====


While most discussions of tinnitus tend to stress physical mechanisms, there is strong evidence that the level of an individual's awareness of their tinnitus can be stress-related, and so should be addressed by improving the state of the nervous system generally, using gradual, unobtrusive, long-term treatments. [http://www.paralumun.com/healthtinn.htm]
*[[Ototoxicity]]
*[[Presbycusis]]
*Noise induced [[hearing loss]]
*Late onset congenital [[hearing loss]]
*[[Idiopathic]]


===Pathophysiology of Objective Tinnitus===
====Cochlear injury:====
In a minority of cases, a clinician can perceive an actual sound (''e.g.'', a [[bruit]]) emanating from the patient's ears.  This is called  '''objective tinnitus'''.  Objective tinnitus can arise from muscle spasms that cause clicks or crackling around the middle ear.<ref name="entnet-hearing">[http://www.entnet.org/healthinfo/hearing/tinnitus.cfm ENT Health Information > Hearing > Tinnitus]</ref>  Some people experience a sound that beats in time with the pulse ('''pulsatile tinnitus'''<ref name="rnid-290661">[http://www.rnid.org.uk/information_resources/factsheets/tinnitus/factsheets_leaflets/?ciid=290661 RNID.org.uk: Information and resources: Our factsheets and leaflets: Tinnitus: Factsheets and leaflets]</ref>).  Pulsatile tinnitus is usually objective in nature, resulting from altered blood flow or increased blood turbulence near the ear (such as from [[atherosclerosis]] or venous hum<ref name="nih-6865626">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=6865626&dopt=Abstract Diagnosis and cure of venous hum tinnitus]</ref>), but it can also arise as a subjective phenomenon from an increased awareness of blood flow in the ear.<ref name="rnid-290661" /> Rarely, pulsatile tinnitus may be a symptom of potentially life-threatening conditions such as [[carotid artery]] [[aneurysm]]<ref name="nih-15956490">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15956490 Otologic manifestations of petrous carotid aneurysms]</ref> or [[carotid artery dissection]].<ref name="nih-15096317">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15096317 Carotid Artery Dissection]</ref>


== Causes of subjective tinnitus ==
*[[Ménière's disease|Meniere's disease]]
Tinnitus can have many different causes, but most commonly results from otologic disorders - the same conditions that cause hearing loss.  The most common cause is noise-induced hearing loss, resulting from exposure to excessive or loud noises. [[Ototoxicity|Ototoxic]] drugs can cause tinnitus either secondary to hearing loss or without hearing loss, and may increase the damage done by exposure to loud noise, even at doses that are not in themselves ototoxic.<ref name="nih-7035098">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=7035098 Ototoxic drugs and noise]</ref>
*[[Loop diuretics]]
*Platinum based [[chemotherapy]]
*[[Antibiotics]]
*[[Salicylate]]
*[[Trauma]]


==Common Causes of Tinnitus<ref name="nih-14727828">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=14727828 Diagnostic approach to tinnitus]</ref>==
====Vascular causes:====
*Otologic problems and [[hearing loss]]:
** Conductive hearing loss
*** External [[ear infection]]
*** Acoustic shock
*** Cerumen ([[earwax]]) impaction
*** Middle ear effusion
** [[Sensorineural hearing loss]]
*** Excessive or loud noise
*** [[Presbycusis]] (age-associated hearing loss)
*** [[Ménière's disease]]
*** [[Acoustic neuroma]]
*** [[Mercury (element)|mercury]] or [[lead]] [[poison]]ing
*** [[Ototoxic]] medications
**** [[Analgesics]]:
***** [[Aspirin]]
***** [[Nonsteroidal anti-inflammatory drugs]]
***** [[Diflunisal]]
***** [[Sulindac]]
**** [[Antibiotics]]:
***** [[Aminoglycosides]]  e.g. [[gentamicin]]
***** [[Chloramphenicol]]
***** [[Erythromycin]]
***** [[Rifaximin]]
***** [[Tetracycline]]
***** [[Vancomycin]]
**** [[Chemotherapy]] and [[antiviral]] drugs:
***** [[Bleomycin]]
***** [[Interferon]]
***** Pegylated interferon-alpha-2b
***** [[Cisplatin]]
***** [[Mechlorethamine]]
***** [[Methotrexate]]
***** [[Vincristine]]
**** Loop [[diuretics]]:
***** [[Bumetanide]]
***** [[Ethacrynic acid]]
***** [[Furosemide]]
**** Others:
***** [[Chloroquine]]
***** [[Clomifene]]
***** [[Febuxostat]]
***** [[Quinine]]
***** [[Hydroxychloroquine]]
***** [[Naltrexone]]
***** [[Oxcarbazepine]]
***** [[Rizatriptan]]
***** [[Thalidomide]]


*[[Neurologic]] disorders:
*[[Systemic hypertension]]
**[[Multiple sclerosis]]
*[[Sickle cell anemia]]
**[[Head injury]]
*[[Small-sized vessel vasculitis|Small vessel disease]]<ref name="pmid9927967">{{cite journal |vauthors=Fortune DS, Haynes DS, Hall JW |title=Tinnitus. Current evaluation and management |journal=Med. Clin. North Am. |volume=83 |issue=1 |pages=153–62, x |date=January 1999 |pmid=9927967 |doi=10.1016/s0025-7125(05)70094-8 |url=}}</ref><ref name="pmid10609479">{{cite journal |vauthors=Levine RA |title=Somatic (craniocervical) tinnitus and the dorsal cochlear nucleus hypothesis |journal=Am J Otolaryngol |volume=20 |issue=6 |pages=351–62 |date=1999 |pmid=10609479 |doi=10.1016/s0196-0709(99)90074-1 |url=}}</ref>
***[[Skull]] fracture
*[[Hypercholesterolemia]]
***Closed head injury
*[[Hypercoagulable state]]
***[[Whiplash (medicine)|Whiplash]] injury
*[[Diabetic vascular disease|Diabetic vasculopathy]]
***[[Temporomandibular joint disorder]]


*[[Metabolic]] disorders:
====CNS causes:====
**[[Thyroid]] disorder
**[[Hyperlipidemia]]
**[[Vitamin B12]] deficiency


*[[Psychogenic]] disorders:
*[[Pseudotumor cerebri]]
**[[Clinical depression|Depression]]
*[[Stroke]]
**[[Anxiety]]
*[[Vascular malformations]]
*[[Tumor]]
*[[Sarcoid]]
*[[Multiple sclerosis]]


*Other causes:
====Infections:====
**[[Fibromyalgia]]
**[[Hypertonia]] (Muscle Tension)
**[[Thoracic outlet syndrome]]
**[[Lyme disease]]
**Hypnogogia
**[[Sleep paralysis]]


== Complete Differential Diagnosis of Tinnitus==
*[[Rubella]]
*[[Acoustic neuroma]]
*[[Cytomegalovirus]]
*Acute or chronic [[otitis media]]
*[[Chronic otitis media]]
*[[Alcohol]]
*[[Neurosyphilis]]
*[[Aminoglycosides]]
*[[Measles]]
*[[Anemia]]
*[[Lyme disease]]
*[[Antidepressant]]s
*[[Anxiety]]
*Arterial [[bruit]]s
:*Abberant [[carotid artery]]
:*[[Carotid stenosis]]
:*Persistant stapedial artery
*[[Arteriovenous malformation]]
*[[Aspirin]]
*AV shunts
*[[Bruxism]]
*Cardiac [[arrhythmias]]
*[[Cerumen]]
*Cervival osteochondrosis
*[[Depression]]
*[[Diabetes mellitus]]
*[[Diuretics]]
*[[Drugs]]- [[Piroxicam]]
*[[Epilepsy]]
*Eustation tube dysfunction
*External auditory canal obstruction
*Faulty jaw position
*Foreign body against [[tympanic membrane]]
*Glomus tympanicum
*Hallucinations
*Heavy metals
*Heavy [[smoking]]
*High jugular bulb
*[[Hypertension]]
*[[Hyperthyroidism]]
*[[Hypertension]]
*[[Hypothyroidism]]
*[[Indomethacin]]
*Inner ear disease
*[[Meniere Disease]]
*[[Meningitis]]
*[[Meningitis]]
*Middle ear disease
 
*[[Multiple Sclerosis]]
====Bone disease:====
*[[Nasopharyngeal carcinoma]]
 
*Noise induced [[hearing loss]]
*[[Omeprazole]]
*[[Otosclerosis]]
*[[Otosclerosis]]
*Palatial [[myoclonus]]
*[[Fibrous dysplasia]]
*[[Pregnancy]]
*[[Osteogenesis imperfecta]]
*[[Presbycusis]] (age related hearing loss)
*[[Paget's disease]]
*[[Pseudotumor cerebri]]
 
*[[Quinine]]
====Metabolic disorders:====
*[[Sorafenib]]
 
*[[Stapedius]] spasm
*[[Hyperparathyroidism]]
*Tooth abnormalities
*[[Chronic renal failure]]
*Tooth extractions
*[[Diabetes mellitus]]
*Temporal lobe [[tumor]]
*[[Thyroid diseases|Thyroid disease]]
*[[Venous hum]]s
 
*[[Vitamin A]] deficency
====Autoimmune diseases:====
*[[Vitamin B]] deficency
 
*[[Autoimmune disease|Autoimmune]] inner ear disease
*[[SLE]]
*[[Rheumatoid arthritis]]
 
====Medications:====
 
*[[ACE inhibitor|ACE inhibitors]]
*[[Antimalarial medication|Antimalarial]] medications
*[[Aminoglycosides]]
*[[Dapsone]]
*[[Doxazosin]]
*[[Calcium channel blockers]]
*[[Benzodiazepines]]
*[[Cisplatin]]
*[[Clarithromycin]]
*[[COX-2 inhibitor|COX-2 inhibitors]]
*[[Loop diuretics]]
*[[Tricyclic antidepressant]]<br />
 
==Differential Diagnosis of Tinnitus==
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Diseases
| colspan="5" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Clinical manifestations'''
! colspan="2" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Para-clinical findings
| colspan="1" rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Gold standard'''
! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Additional findings
|-
| colspan="4" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Symptoms'''
! rowspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Physical examination
|-
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Lab Findings
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Imaging
|-
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Acute onset
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Recurrency
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Nystagmus
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Hearing problems, tinnitus
|-
| colspan="10" style="background: #7d7d7d; color: #FFFFFF; text-align: center;" |'''Peripheral'''
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Ramsay Hunt syndrome type II|HSV oticus]]<br>
 
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px;" |
*loss of tastein the front two-thirds of the [[tongue]]
*[[Acute facial nerve paralysis]]
*[[Vesicles]] in the [[ear canal]], the [[tongue]], and/or [[hard palate]]
 
| style="background: #F5F5F5; padding: 5px; text-align: center;" | + [[Varicella zoster virus|VZV]] antibody titres
| style="background: #F5F5F5; padding: 5px;" |
*[[Magnetic resonance imaging|MRI]] with [[gadolinium]] contrast may show enhancement of the [[facial nerve]] and [[vestibulocochlear nerve]]
| style="background: #F5F5F5; padding: 5px;" |
*[[History and Physical examination|History/ Physical exam]]
| style="background: #F5F5F5; padding: 5px;" |
*May be associated with [[otalgia]], [[dry mouth]] and [[dry eyes]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Ménière's disease|Meniere disease]]<br>
 
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | + (Progressive)
| style="background: #F5F5F5; padding: 5px;" |
*[[Sensorineural hearing loss]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*[[CT scan]] may show small or invisible [[vestibular aqueduct]]
| style="background: #F5F5F5; padding: 5px;" |
*[[History and Physical examination|History/ Physical exam]]
*Ruling out other CNS and ear pathologies.
| style="background: #F5F5F5; padding: 5px;" |
*May be associated with [[Nausea and vomiting|nausea]], [[Nausea and vomiting|vomiting]], and [[tinnitus]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Labyrinthine concussion<br>
 
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[[high frequency hearing loss]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*[[CT scan]] may show evidence of [[head trauma]] or [[temporal bone]] [[fracture]]
| style="background: #F5F5F5; padding: 5px;" |
*[[History and Physical examination|History/ Physical exam]]
| style="background: #F5F5F5; padding: 5px;" |
*Follows blunt [[head trauma]]
*May be associated with [[dizziness]] or [[tinnitus]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Perilymphatic fistula]]<br>
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[[Tullio phenomenon]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*[[CT scan]] may show fluid around the round window recess
| style="background: #F5F5F5; padding: 5px;" |
*[[History and Physical examination|History/ Physical exam]]/[[Imaging]]
| style="background: #F5F5F5; padding: 5px;" |
*Complication of  [[stapedectomy]], [[head injury]], or heavy lifting
*It may be provoked by activities such as [[Sneeze|sneezing]], lifting, straining, [[Cough|coughing]], and loud sounds.        (Tullio phenomenon)
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Semicircular canal
dehiscence syndrome<br>
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
 
(air-bone gaps on audiometry)
| style="background: #F5F5F5; padding: 5px;" |
*[[Tullio phenomenon]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*[[CT scan]] may show defect in the arcuate eminence of the [[superior semicircular canal]]
| style="background: #F5F5F5; padding: 5px;" |
*[[History and Physical examination|History/ Physical exam]]/[[Imaging]]
| style="background: #F5F5F5; padding: 5px;" |
*It may be provoked by [[Valsalva maneuver]], [[Cough|coughing]], and [[Sneeze|sneezing]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Cogan syndrome]]<br>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[[Interstitial keratitis]]
*[[Oscillopsia]]
*Absent [[vestibular function]] on [[Caloric reflex test|caloric test]]
*[[Systemic vasculitis]] ([[Aortitis]])
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Increased [[ESR]] and  [[cryoglobulins]]
| style="background: #F5F5F5; padding: 5px;" |
*[[CT scan]] may show  [[calcification]] or soft tissue attenuation obliterating the intralabyrinthine fluid spaces
| style="background: #F5F5F5; padding: 5px;" |
*[[History and Physical examination|History/ Physical exam]]
| style="background: #F5F5F5; padding: 5px;" |
*It may cause [[Ménière's disease|Ménière]]-like attacks
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Vestibular schwannoma]]<br>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[[Sensorineural hearing loss]]
*+ [[Rinne test]]
*Lateralization of [[Weber test]] to the normal [[ear]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*[[CT scan]] we may show  erosion, and widening of the [[Internal auditory meatus|internal acoustic meatus]]
*T1-weighted [[MRI]] may show a hypointense mass lesion where as T-2 weighted MRI  shows a hyperintense [[mass]] lesion
| style="background: #F5F5F5; padding: 5px;" |
*[[Imaging]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Gadolinium]]-enhanced [[MRI]] scan is the definitive diagnostic test for  [[Vestibular schwannoma|acoutic neuroma]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Otitis media]]<br>
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px;" |
*Fever
*Presence of effusion in the [[middle ear]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Increased [[Acute phase reactant|acute phase reactants]]
| style="background: #F5F5F5; padding: 5px;" |
*Opacification of the [[middle ear]]
| style="background: #F5F5F5; padding: 5px;" |
*[[History and Physical examination|History/ Physical exam]]
| style="background: #F5F5F5; padding: 5px;" |
*Patient may show other [[signs]] and [[symptoms]] of [[upper respiratory infection]] such as [[cough]], [[nasal discharge]], and [[fever]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Aminoglycoside toxicity<br>
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[[Oscillopsia]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*[[History and Physical examination|History/ Physical exam]]
| style="background: #F5F5F5; padding: 5px;" |
*May be associated with [[nausea]], [[vomiting]], and [[ataxia]]
*possibly irreversible
*[[Gentamicin]] is the most common one
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! colspan="10" style="background: #7d7d7d; color: #FFFFFF; text-align: center;" |Central
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Vestibular migraine<br>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px;" |
*History of [[migraine headaches]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*[[MRI]] may show [[White matter|white-matter]] hyper-intensities (WMHs)
| style="background: #F5F5F5; padding: 5px;" |
*ICHD-3 criteria
| style="background: #F5F5F5; padding: 5px;" |
*It may be associated with [[anxiety]] and [[depression]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Multiple sclerosis]]<br>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px;" |
*[[Lhermitte's sign]]
*[[Spasticity]]
*[[Hyperreflexia]]
*[[Internuclear ophthalmoplegia]]
*[[Optic neuritis]]
*[[Gait disturbance]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Elevated concentration of [[CSF]] [[oligoclonal bands]]
| style="background: #F5F5F5; padding: 5px;" |
*[[CT scan]] shows brain atrophy and contrast enhanced demyelinating plaques
*[[MRI scan|MRI]] showing cerebral plaques disseminating in time and space.
| style="background: #F5F5F5; padding: 5px;" |
*[[History and Physical examination|History and physical examination]]
*[[Imaging]]
*[[CSF analysis]]
| style="background: #F5F5F5; padding: 5px;" |
*[[MS]] is twice as prevalent in women as compared to men
*The onset of [[symptoms]] is mostly between the age of fifteen to forty years and  rarely before the  age of fifteen or after the age of sixty years
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Brain tumor|Brain tumors]]<br>
 
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[[Papilledema]]
*[[Focal neurological deficits]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Cerebral spinal fluid ([[CSF]]) may show cancerous cells
| style="background: #F5F5F5; padding: 5px;" |
*On [[CT scan]] most of the [[brain tumors]] appears as a hypodense mass lesions
*On T1- weighted [[MRI scan|MRI]] most of the [[brain tumors]] appears as a hypointense or Isointense whereas on T2-weighted [[MRI contrast agent|MRI]] they  appear as hyperintense lesions
| style="background: #F5F5F5; padding: 5px;" |
*[[Imaging]]
 
*[[Biopsy forceps|Biopsy]]
| style="background: #F5F5F5; padding: 5px;" |
*May experience  [[headache]], [[seizures]], [[Visual disturbance|visual changes]] and changes in [[personality]], [[mood]] and [[concentration]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Cerebellar infarction]]/hemorrhage
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | ++/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px;" |
*[[Limb]] [[ataxia]]
*[[Gait abnormality|Gait disturbance]]
*[[Dysarthria]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*Based on the time interval lapsed  between the onset of  [[stroke]] and [[imaging]] performed there may be different presentations
| style="background: #F5F5F5; padding: 5px;" |
*[[Imaging]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Posterior inferior cerebellar artery]] is the most common artery that causes [[vertigo]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Brain stem ischemia
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px;" |
*Contralateral body [[Muscle weakness|weakness]]
*[[Visual field]] deficits
*[[Oculomotor nerve|Oculomotor]] abnormalities
*[[Bulbar]] findings
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*Based on the time interval lapsed  between the onset of  [[stroke]] and [[imaging]] performed there may be different presentations
*For more information [[Ischemic stroke CT|click here]]
 
| style="background: #F5F5F5; padding: 5px;" |
*[[Imaging]]
| style="background: #F5F5F5; padding: 5px;" |
*It may be associated with [[subclavian steal syndrome]]
|}
'''ABBREVIATIONS'''
 
[[VZV]]= [[Varicella zoster virus]], [[MRI]]= [[Magnetic resonance imaging]], [[ESR]]= [[Erythrocyte sedimentation rate]], [[EEG]]= [[Electroencephalogram]], [[CSF]]= [[Cerebrospinal fluid]], GPe= [[Globus pallidus|Globus pallidus externa]], ICHD=  International Classification of Headache Disorders
 
==Epidemiology and Demographics==
 
*[[Tinnitus]] affects 10 to 15% of the population.
*85% of the population presenting with ear symptoms/disorders report tinnitus as an associated [[symptom]].<ref name="pmid20670725">{{cite journal |vauthors=Shargorodsky J, Curhan GC, Farwell WR |title=Prevalence and characteristics of tinnitus among US adults |journal=Am. J. Med. |volume=123 |issue=8 |pages=711–8 |date=August 2010 |pmid=20670725 |doi=10.1016/j.amjmed.2010.02.015 |url=}}</ref>
*The [[incidence rate]] of tinnitus increases with age and is more prevalent in older people.<ref name="pmid20371585">{{cite journal |vauthors=Shetye A, Kennedy V |title=Tinnitus in children: an uncommon symptom? |journal=Arch. Dis. Child. |volume=95 |issue=8 |pages=645–8 |date=August 2010 |pmid=20371585 |doi=10.1136/adc.2009.168252 |url=}}</ref>
*Tinnitus is more prevalent in men compared to women and [[Smoking|smokers]] compared to non-smokers.<ref name="pmid15782448">{{cite journal |vauthors=Adams PF, Hendershot GE, Marano MA |title=Current estimates from the National Health Interview Survey, 1996 |journal=Vital Health Stat 10 |volume= |issue=200 |pages=1–203 |date=October 1999 |pmid=15782448 |doi= |url=}}</ref><ref name="pmid15040757">{{cite journal |vauthors=Ahmad N, Seidman M |title=Tinnitus in the older adult: epidemiology, pathophysiology and treatment options |journal=Drugs Aging |volume=21 |issue=5 |pages=297–305 |date=2004 |pmid=15040757 |doi=10.2165/00002512-200421050-00002 |url=}}</ref>
 
==Risk Factors==
Common risk factors of tinnitus include
*Age
*[[Sensorineural hearing loss]]
*Loud noise exposure
*[[Vestibular schwannoma]]
*[[Ototoxic|Ototoxic medication]]
*History of [[anxiety]] and [[depression]]
*History of [[head trauma]]
*History of [[multiple sclerosis]]
 
==Natural History, Complications and Prognosis==
 
*Early clinical features may include ear fullness, huming or ringing sensations in the ear
*If left untreated, patients may progress to functional impairment, [[insomnia]], [[anxiety]], and [[depression]].<ref name="pmid2381186">{{cite journal |vauthors=Stouffer JL, Tyler RS |title=Characterization of tinnitus by tinnitus patients |journal=J Speech Hear Disord |volume=55 |issue=3 |pages=439–53 |date=August 1990 |pmid=2381186 |doi=10.1044/jshd.5503.439 |url=}}</ref>


==Diagnosis==
==Diagnosis==
===Symptoms===
Tinnitus can be perceived in one or both ears or in the head. It is usually described as a ringing noise, but in some patients it takes the form of a high pitched whining, buzzing, hissing, humming, or whistling sound, or as ticking, clicking, roaring, "crickets" or "locusts", tunes, songs, or beeping.<ref name="rnid-about">[http://www.rnid.org.uk/information_resources/tinnitus/about_tinnitus/what_is_tinnitus/ RNID.org.uk: Information and resources: Tinnitus: About tinnitus: What is tinnitus]</ref> It has also been described as a "whooshing" sound, as of wind or waves.<ref name="nih-ency">[http://www.nlm.nih.gov/medlineplus/ency/article/003043.htm Medline Plus Medical Encyclopedia: Ear noises or buzzing]</ref>  Tinnitus is not itself a [[disease]] but a [[symptom]] resulting from a range of underlying causes, including ear infections, foreign objects or wax in the ear, and injury from loud noises. Tinnitus is also a side-effect of some oral medications, such as [[aspirin]], and may also result from an abnormally low level of [[serotonin]] activity.


The sound perceived may range from a quiet background noise to one that can be heard even over loud external sounds.  The term "tinnitus" usually refers to more severe cases.  Heller and Bergman (1953) conducted a study of 80 tinnitus-free university students placed in a soundproofed room found that 93% reported hearing a buzzing, pulsing or whistling sound.  Cohort studies have demonstrated that damage to hearing (among other [[noise health effects|health effects]]) from unnatural levels of noise exposure is very widespread in industrialized countries.<ref name="nih-16105247">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16105247 Noise exposure and subjective hearing symptoms among school children in Sweden]</ref>
===Diagnostic criteria:===
 
====Tinnitus severity index (TSI)====
 
*TSI is used to rank the patient's based upon their severity
*The score ranges from 0-45
 
====Tinnitus handicap questionnaire:====
 
*This questionnaire includes 27 questions and is used to estimate the social, physical and emotional handicap severity
 
====Tinnitus handicap inventory:====
 
*This questionnaire has 4 categories to classify severity
*None, mild,  moderate, and severe.
 
===History and Symptoms:===
 
*Sounds such as ringing, buzzing, pulsatile, roaring and humming
*Progressive hearing loss
*Recent exposure to excessive or loud noise or head trauma
*Poor hygiene leading to cerumen impaction
*Ear pain
*History of certain medication exposure


Because tinnitus is often defined as a subjective phenomenon, it is difficult to measure using objective tests, such as by comparison to noise of known frequency and intensity, as in an audiometric test.  The condition is often rated clinically on a simple scale from "slight" to "catastrophic" according to the practical difficulties it imposes, such as interference with sleep, quiet activities, or normal daily activities.<ref name="otohns-1030">[http://www.otohns.net/default.asp?id=1030 Guidelines for the Grading of Tinnitus Severity]</ref>  For research purposes, the more elaborate Tinnitus Handicap Inventory is often used.<ref name="nih-8630207">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8630207 Development of the Tinnitus Handicap Inventory]</ref>
===Physical Examination:===


===Physical examination===
*The ear examination may show signs of cerumen impaction, underlying infection or tympanic membrane perforation.
The ears should be examined for wax and a foreign body.
*Auscultation of neck, orbits and periauricular areas as helpful in establishing the diagnosis of vascular causes
*An extensive neurological examination may rule out underlying brainstem damage or hearing loss
*The Weber and Rinne test are done to establish sensorineural or conductive hearing loss. They are usually abnormal.


===Measuring tinnitus===
===Laboratory Findings:===
The basis of quantitative measurement of tinnitus relies on the brain’s tendency to select out only the loudest sounds heard. Based on this tendency, the amplitude of a patient's tinnitus can be measured by playing sample sounds of known amplitude and asking the patient which he or she hears. The tinnitus will always be equal to- or less than sample noises heard by the patient. This method works very well to gauge objective tinnitus (see above.) For example: if a patient has a pulsatile [[paraganglioma]] in his ear, he will not be able to hear the blood flow through the tumor when the sample noise is 5 decibels louder than the noise produced by the blood. As sound amplitude is gradually decreased, the tinnitus will become audible, and the level at which it does so provides an estimate of the amplitude of the objective tinnitus.


Objective tinnitus, however, is quite uncommon. Often patients with pulsatile tumors will report other coexistent sounds, distinct from the pulsatile noise, that will persist even after their tumor has been removed. This is generally subjective tinnitus, which, unlike the objective form, cannot be tested by comparative methods.
*There are no specific lab findings associated with tinnitis.


If a subject is focused on a sample noise, they can often detect it to levels below 5 decibels, which would indicate that their tinnitus would be almost impossible to hear. Conversely, if the same test subject is told to focus only on their tinnitus, they will report hearing the sound even when test noises exceed 70 decibels, making the tinnitus louder than a ringing phone. This quantification method suggests that subjective tinnitus relates only to what the patient is attempting to hear. Patients actively complaining about tinnitus could thus be assumed to be people who have become obsessed with the noise. This is only partially true. The problem is involuntary; generally complaining patients simply cannot override or ignore their tinnitus. The noise is often present in both quiet and noisy environments, and can become quite intrusive to their daily lives.
===Imaging:===


Subjective tinnitus may not always be correlated with ear malfunction or hearing loss. Even people with near-perfect hearing may still complain of it. Tinnitus may also have a connection to memory problems, anxiety, fatigue or a general state of poor health.
*MRA and CTA are the gold standard diagnostic tests for arteriovenous fistula related tinnitus.
*MRI with contrast is the initial preferred diagnostic test of choice for suspected vascular tinnitus.
*MRI with contrast is followed by CT/CTA and ultimately interventional angiography, if needed.<ref name="pmid8059655">{{cite journal |vauthors=Dietz RR, Davis WL, Harnsberger HR, Jacobs JM, Blatter DD |title=MR imaging and MR angiography in the evaluation of pulsatile tinnitus |journal=AJNR Am J Neuroradiol |volume=15 |issue=5 |pages=879–89 |date=May 1994 |pmid=8059655 |doi= |url=}}</ref>


==Prevention==
===Other Diagnostic Testing:===
Tinnitus and hearing loss can be permanent conditions, thus, precautionary measures are advisable. If a ringing in the ears is audible after exposure to a loud environment, such as a rock concert or a work place, it means that damage has been done.  Prolonged exposure to noise levels as low as 70 dB can result in damage to hearing ''(see [[noise health effects]])''.  If it is not possible to limit exposure, earplugs or ear defenders should be worn.  For musicians and DJs, special musicians' earplugs can lower the volume of the music without distorting the sound and can prevent tinnitus from developing in later years.


It is also important to check medications for potential [[ototoxicity]].  [[Ototoxicity]] can be cumulative between medications, or can greatly increase the damage done by noise.  If ototoxic medications must be administered, close attention by the physician to prescription details, such as dose and dosage interval, can reduce the damage done.<ref name="ingenta-4">[http://www.ingentaconnect.com/content/tandf/soto/2001/00000121/00000005/art00004 IngentaConnect Drug-induced Otoxicity: Current Status]</ref>
*Initial audiometric tests<ref name="pmid25274374">{{cite journal |vauthors=Tunkel DE, Bauer CA, Sun GH, Rosenfeld RM, Chandrasekhar SS, Cunningham ER, Archer SM, Blakley BW, Carter JM, Granieri EC, Henry JA, Hollingsworth D, Khan FA, Mitchell S, Monfared A, Newman CW, Omole FS, Phillips CD, Robinson SK, Taw MB, Tyler RS, Waguespack R, Whamond EJ |title=Clinical practice guideline: tinnitus executive summary |journal=Otolaryngol Head Neck Surg |volume=151 |issue=4 |pages=533–41 |date=October 2014 |pmid=25274374 |doi=10.1177/0194599814547475 |url=}}</ref> are done to identify asymmetries between the ears and to locate the site of abnormality such as middle ear, cochlea, and brainstem.  These tests include:
**Pure-tone audiogram
**Tympanometry
**Auditory reflex testing
**Determination of speech discrimination abilities
**Otoacoustic emissions testing
**Auditory brainstem response testing (ABR)


==Treatment==
==Treatment==
There are many treatments that are effective for objective tinnitus. But there are no clear effective treatments for subjective tinnitus.  Conversely, tinnitus may resolve without any treatment. In the subjective tinnitus the treatment of the associated problems like fatigue, anxiety and a bad healthy status is essential to achieve success. Effective treatments include:


''Objective tinnitus:''
*Tinnitus is a symptom and not a disease itself.  It is a chronic condition that can be managed by treating the underlying etiology.
* Gamma knife radiosurgery ''(glomus jugulare)''<ref name="nih-16272947">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16272947 Treatment of glomus jugulare tumors in patients with advanced age: planned limited surgical resection followed by staged gamma knife radiosurgery: a preliminary report]</ref>
*The treatment of tinnitus is usually directed towards improvement in the quality of life by decreasing awareness or desensitizing towards tinnitus.  It is usually achieved by identifying the underlying pathology or the associated disease.
* Shielding of cochlea by teflon implant<ref name="nih-16331169">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16331169 Pulsatile tinnitus and the intrameatal vascular loop: why do we not hear our carotids?]</ref>
*It is recommended to treat underlying [[insomnia]] and depression. (Grade 1B)
* Botulinum toxin ''(palatal tremor)''<ref name="nih-16845571">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16845571 Botulinum toxin is effective and safe for palatal tremor: a report of five cases and a review of the literature]</ref>
 
* Propranolol and clonazepam ''(arterial anatomic variation)''<ref name="nih-16446904">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16446904 Pulsatile tinnitus: treatment with clonazepam and propranolol]</ref>
===Medical Therapy===
Following medications have minimal to modest role in relieving tinnitus.
 
*[[Misoprostol]]
*[[Lidocaine]] (intratympanic or intravenous)
*[[Benzodiazepine]] (alprazolam)
*[[Steroids]] such as [[dexamethasone]] (intratympanic)
*[[Carbamazepine]]
 
Following medications have been studied for tinnitus but are not found to be effective and have no role in the treatment of tinnitus
 
*[[Anticonvulsants]]
*[[Melatonin]]
*[[Ginkgo biloba]]
*[[Niacin]]


''Subjective tinnitus:''
===Surgery===
* Drugs and nutrients
** [[Lidocaine]], injection into the inner ear found to surpress the tinnitus for 20 minutes, according to a Swedish study. <ref>[http://www.lakemedelsvarlden.nu/article.asp?articleID=4893&articleCategoryID=2&issueID=113 Swedish website about tinnitus]</ref>
** Benzodiazepines (xanax, ativan, klonopin)
** Avoidance of caffeine, nicotine, salt<ref>Rogers, June: "Only When I Eat: Hope at Last". Ki Publishing Co-operative. UK ISBN 0951 0769 06</ref><ref name="nih-3374234">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=3374234 Vascular decompression of the cochlear nerve in tinnitus sufferers]</ref><ref name="nih-9092280">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=9092280 Meniere's disease: differential diagnosis and treatment]</ref>
** Avoidance of ''or'' consumption of alcohol<ref name="nih-8838550">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=8838550 Patients' reports of the effect of alcohol on tinnitus]</ref><ref name="nih-9092280" />
** Zinc supplementation ''(where serum zinc deficiency is present)''<ref name="nih-12544035">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12544035 The role of zinc in the treatment of tinnitus]</ref><ref name="nih-12393036">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12393036 The role of zinc in management of tinnitus]</ref><ref name="nih-1872515">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=1872515 Zinc in the management of tinnitus. Placebo-controlled trial]</ref>
** Acamprosate<ref name="nih-16612523">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16612523 Tinnitus treatment with acamprosate: double-blind study]</ref>
** Etidronate ''or'' sodium fluoride ''(otosclerosis)''<ref name="nih-9210803">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=9210803 Etidronate for the the neurotologic symptoms of otosclerosis: preliminary study] [sic]</ref>
** Lignocaine ''or'' anticonvulsants ''(usually in patients responsive to white noise masking)''<ref name="nih-6799263">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=6799263 Drugs in the treatment of tinnitus]</ref>
** Carbemazepine<ref name="nih-16514262">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16514262 Typewriter tinnitus: a carbamazepine-responsive syndrome related to auditory nerve vascular compression]</ref>
** Melatonin ''(especially for those with sleep disturbance)''<ref name="nih-16455366">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16455366 The effects of melatonin on tinnitus and sleep]</ref>
** Sertraline<ref name="nih-16415703">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16415703 The effects of sertraline on severe tinnitus suffering--a randomized, double-blind, placebo-controlled study]</ref>
** Vitamin combinations ''([[Lipo-Flavanoid|lipo-flavonoid]])''<ref>Williams HL, Maher FT, Corbin KB, et al: Eriodictyol glycoside in the treatment of Meniere’s disease. Ann Otol Rhinol Laryngol 72:1082, 1963.</ref>
* Electrical stimulation
** Transcranial magnetic stimulation or transcranial direct current stimulation<ref name="nih-16845596">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16845596 Transcranial magnetic stimulation for the treatment of tinnitus: a new coil positioning method and first results]</ref><ref name="nih-16930367">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16930367 Transient tinnitus suppression induced by repetitive transcranial magnetic stimulation and transcranial direct current stimulation]</ref>
** Transcutaneous electrical nerve stimulation<ref name="nih-16556347">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16556347 Treatment of tinnitus with transcutaneous electrical nerve stimulation improves patients' quality of life]</ref>
** Direct stimulation of auditory cortex by implanted electrodes<ref name="nih-16514263">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16514263 Primary and secondary auditory cortex stimulation for intractable tinnitus]</ref>
* Surgery
** Repair of perilymph fistula<ref name="nih-11137360">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11137360 Perilymph fistula--45 case analysis]</ref>
* External sound
** Low-pitched sound treatment has shown some positive, encouraging  results.[http://today.uci.edu/news/release_detail.asp?key=1570 (UC, Irvine press release)]
** Tinnitus masking<ref name="stanford-dattorro">[http://www.stanford.edu/~dattorro/Tin/tin.html Tinnitus masker - sonic designs by Jon Dattorro...]</ref> ([[white noise]])
** [[Tinnitus retraining therapy]]<ref name="nih-16274808">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16274808 Long-term clinical trial of tinnitus retraining therapy]</ref><ref name="nih-16640064">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16640064 Outcomes of clinical trial: tinnitus masking versus tinnitus retraining therapy]</ref>
** Auditive stimulation therapy (music therapy)<ref name="nih-16639917">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16639917 Auditive stimulation therapy as an intervention in subacute and chronic tinnitus: a prospective observational study]</ref>
** Compensation for lost frequencies by use of a hearing aid.<ref>[http://www.ohsu.edu/ohrc/tinnitusclinic/compTreatments.html OHSU Tinnitus Clinic: Comprehensive Treatment Programs including Tinnitus Retraining Therapy (TRT)]</ref>
** Ultrasonic bone-conduction external acoustic stimulation<ref name="nih-16639909">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16639909 Ultra-high-frequency ultrasonic external acoustic stimulation for tinnitus relief: a method for patient selection]</ref><ref name="nih-16419683">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16419683 Tinnitus improvement with ultra-high-frequency vibration therapy]</ref>
** Avoidance of outside noise ''(exogenous tinnitus)''<ref name="nih-16639912">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16639912 Subdividing tinnitus into bruits and endogenous, exogenous, and other forms]</ref>
* Psychological
** Cognitive behavior therapy<ref name="nih-16379495">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16379495 Treatment of tinnitus in the elderly: a controlled trial of cognitive behavior therapy]</ref>
* Light-based
** [[Photobiomodulation]] (a.k.a. Low Level Laser Therapy); efficacy is debated<ref>http://www.tinnitusformula.com/infocenter/articles/treatments/LLLT.aspx</ref>


Although there are no specific cures for tinnitus, anything that brings the person out of the "fight or flight" stress response helps symptoms recede over a period of time. Calming body-based therapies, counseling and psychotherapy help restore well-being, which in turn allows tinnitus to settle. Chronic tinnitus can be quite stressful psychologically, as it distracts the affected individual from mental tasks and interferes with sleep, particularly when there is no external sound. Additional steps in reducing the impact of tinnitus on adverse health consequences include: a review of medications that may have tinnitus as a side effect; a physical exam to reveal possible underlying health conditions that may aggravate tinnitus; receiving adequate rest each day; and seeking a physician's advice concerning a sleep aid to allow for a better sleep pattern.
*[[Cochlear implants]] may be considered for tinnitus associated with severe [[sensorineural hearing loss]].


==Related Chapters==
===Other therapies:===
* [[Absolute threshold of hearing]]
* [[Auditory system]]
* [[Audiologist]]
* [[Ear]]
* [[Hearing impairment]]
* [[Hyperacusis]]
* [[Noise health effects]]


== External Links ==
*[[Tinnitus retraining therapy]] (TRT) (Grade 1C)
* {{DMOZ|Health/Conditions_and_Diseases/Ear,_Nose_and_Throat/Ear/Tinnitus/}}
*[[Biofeedback]] (Grade 2C)
*[[Cognitive behavioral therapy|Cognitive behavioral therapy (CBT)]] as  an adjunct to TRT (Grade 2C)
*[[Acupuncture]] and electrical stimulation are considered equally effective as placebo, no significant role established so far.
 
===Prevention===
 
*Tinnitus may be been prevented by limiting the exposure to loud noise.


==References==
==References==
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Latest revision as of 17:57, 6 October 2020

WikiDoc Resources for Tinnitus

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2] Sabeeh Islam, MBBS[3]

Overview

Tinnitus is derived from the Latin word tinnire, meaning to ring. Tinnitus can be classified as subjective and objective.  This classification not only explains the underlying etiology but also directs the management of tinnitus. In the normal functioning auditory pathway, there is ordered tonotopic frequency mapping from the cochlea to the auditory cortex via midbrain.  Conditions associated with cochlear damage result in altered tonotopic organization and ultimately tinnitus. The pathophysiology of tinnitus can be explained by the tinnitus model. Common causes of tinnitus include Ototoxicity, Presbycusis, noise induced hearing loss, late onset congenital hearing loss, meniere's disease, and Loop diuretics. The incidence rate of tinnitus increases with age and is more prevalent in older people. Tinnitus is more prevalent in men compared to women and smokers compared to non-smokers. If left untreated, patients may progress to functional impairment, insomnia, anxiety, and depression. TSI is used to rank the patient's based upon their severity. The score ranges from 0-45. Symptoms and history include sounds such as ringing, buzzing, pulsatile, roaring and humming and progressive hearing loss. An extensive neurological examination may rule out underlying brainstem damage or hearing loss. The Weber and Rinne test are done to establish sensorineural or conductive hearing loss. They are usually abnormal. MRI with contrast is followed by CT/CTA and ultimately interventional angiography, if needed. Initial audiometric tests are done to identify asymmetries between the ears and to locate the site of abnormality such as middle ear, cochlea, and brainstem.  These tests include: pure-tone audiogram, tympanometry, auditory reflex testing, determination of speech discrimination abilities, otoacoustic emissions testing and auditory brainstem response testing (ABR). Tinnitus is a symptom and not a disease itself.  It is a chronic condition that can be managed by treating the underlying etiology. The treatment of tinnitus is usually directed towards improvement in the quality of life by decreasing awareness or desensitizing towards tinnitus.  It is usually achieved by identifying the underlying pathology or the associated disease. It is recommended to treat underlying insomnia and depression (Grade 1B). Cochlear implants may be considered for tinnitus associated with severe sensorineural hearing loss. Other therapies include: tinnitus retraining therapy (TRT) (Grade 1C), biofeedback (Grade 2C), and cognitive behavioral therapy (CBT) as an adjunct to TRT (Grade 2C). Acupuncture and electrical stimulation are considered equally effective as placebo, no significant role established so far.


Historical Perspective

  • In the early 19th century, Frenchman and Jean Marie Gaspard Itard introduced the concept of masking.  They were the first ones to differentiate between subjective and objective tinnitus.
  • Later in the 19th Century, with the introduction of germ theory and anesthesia, surgical therapy such as incudectomy was established.
  • Tinnitus is derived from the Latin word tinnire, meaning to ring.

Classification

Tinnitus can be classified as subjective and objective.  This classification not only explains the underlying etiology but also directs the management of tinnitus.

Subjective tinnitus:

  • It is only experienced by the affected individual in the absence of any auditory stimulation
  • More common, usually described as continuous ringing, high pitch sound

Objective tinnitus:

Pathophysiology

In the normal functioning auditory pathway, there is ordered tonotopic frequency mapping from the cochlea to the auditory cortex via midbrain.[1][2]  Conditions associated with cochlear damage result in altered tonotopic organization and ultimately tinnitus. The pathophysiology of tinnitus can be explained by the tinnitus model.[3][4]

Lesion projection zone (LPZ):

This zone is defined as the area in the auditory cortex that represents the damaged cochlear input.  The neurons in the LPZ zone show 2 main changes:

  • Accelerated spontaneous firing rate
  • Increased representation of neurons that represent the damaged cochlear region also known as lesion edge frequencies in the LPZ

Tinnitus model:

This model explains 2 major phenomena in the auditory cortex caused by lack of sensory peripheral auditory input (cochlea)

  • Hyperactivity in the lesion projections zone (LPZ)
  • Increased cortical representation of the lesion-edge frequencies in the LPZ

Causes of subjective tinnitus

Sensorineural hearing loss:

Cochlear injury:

Vascular causes:

CNS causes:

Infections:

Bone disease:

Metabolic disorders:

Autoimmune diseases:

Medications:

Differential Diagnosis of Tinnitus

Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab Findings Imaging
Acute onset Recurrency Nystagmus Hearing problems, tinnitus
Peripheral
HSV oticus
 + +/− − +/− + VZV antibody titres
Meniere disease
 +/− + +/− + (Progressive) −
Labyrinthine concussion
 + − − + −
Perilymphatic fistula
 +/− + − + −
  • CT scan may show fluid around the round window recess
Semicircular canal

dehiscence syndrome

 +/− + − +

(air-bone gaps on audiometry)

−
Cogan syndrome
 − + +/− + Increased ESR and cryoglobulins
  • CT scan may show calcification or soft tissue attenuation obliterating the intralabyrinthine fluid spaces
Vestibular schwannoma
 − + +/− + −
Otitis media
 + − − +/− Increased acute phase reactants
Aminoglycoside toxicity
 + − − + − −
Central
Vestibular migraine
 – + +/− +/− −
  • ICHD-3 criteria
Multiple sclerosis
 − + +/− +/− Elevated concentration of CSF oligoclonal bands
  • CT scan shows brain atrophy and contrast enhanced demyelinating plaques
  • MRI showing cerebral plaques disseminating in time and space.
  • MS is twice as prevalent in women as compared to men
  • The onset of symptoms is mostly between the age of fifteen to forty years and rarely before the age of fifteen or after the age of sixty years
Brain tumors
 +/− + + + Cerebral spinal fluid (CSF) may show cancerous cells
  • On CT scan most of the brain tumors appears as a hypodense mass lesions
  • On T1- weighted MRI most of the brain tumors appears as a hypointense or Isointense whereas on T2-weighted MRI they appear as hyperintense lesions
Cerebellar infarction/hemorrhage + − ++/− +/− −
  • Based on the time interval lapsed between the onset of stroke and imaging performed there may be different presentations
Brain stem ischemia + − +/− +/− −
  • Based on the time interval lapsed between the onset of stroke and imaging performed there may be different presentations
  • For more information click here

ABBREVIATIONS

VZV= Varicella zoster virus, MRI= Magnetic resonance imaging, ESR= Erythrocyte sedimentation rate, EEG= Electroencephalogram, CSF= Cerebrospinal fluid, GPe= Globus pallidus externa, ICHD= International Classification of Headache Disorders

Epidemiology and Demographics

  • Tinnitus affects 10 to 15% of the population.
  • 85% of the population presenting with ear symptoms/disorders report tinnitus as an associated symptom.[7]
  • The incidence rate of tinnitus increases with age and is more prevalent in older people.[8]
  • Tinnitus is more prevalent in men compared to women and smokers compared to non-smokers.[9][10]

Risk Factors

Common risk factors of tinnitus include

Natural History, Complications and Prognosis

  • Early clinical features may include ear fullness, huming or ringing sensations in the ear
  • If left untreated, patients may progress to functional impairment, insomnia, anxiety, and depression.[11]

Diagnosis

Diagnostic criteria:

Tinnitus severity index (TSI)

  • TSI is used to rank the patient's based upon their severity
  • The score ranges from 0-45

Tinnitus handicap questionnaire:

  • This questionnaire includes 27 questions and is used to estimate the social, physical and emotional handicap severity

Tinnitus handicap inventory:

  • This questionnaire has 4 categories to classify severity
  • None, mild,  moderate, and severe.

History and Symptoms:

  • Sounds such as ringing, buzzing, pulsatile, roaring and humming
  • Progressive hearing loss
  • Recent exposure to excessive or loud noise or head trauma
  • Poor hygiene leading to cerumen impaction
  • Ear pain
  • History of certain medication exposure

Physical Examination:

  • The ear examination may show signs of cerumen impaction, underlying infection or tympanic membrane perforation.
  • Auscultation of neck, orbits and periauricular areas as helpful in establishing the diagnosis of vascular causes
  • An extensive neurological examination may rule out underlying brainstem damage or hearing loss
  • The Weber and Rinne test are done to establish sensorineural or conductive hearing loss. They are usually abnormal.

Laboratory Findings:

  • There are no specific lab findings associated with tinnitis.

Imaging:

  • MRA and CTA are the gold standard diagnostic tests for arteriovenous fistula related tinnitus.
  • MRI with contrast is the initial preferred diagnostic test of choice for suspected vascular tinnitus.
  • MRI with contrast is followed by CT/CTA and ultimately interventional angiography, if needed.[12]

Other Diagnostic Testing:

  • Initial audiometric tests[13] are done to identify asymmetries between the ears and to locate the site of abnormality such as middle ear, cochlea, and brainstem.  These tests include:
    • Pure-tone audiogram
    • Tympanometry
    • Auditory reflex testing
    • Determination of speech discrimination abilities
    • Otoacoustic emissions testing
    • Auditory brainstem response testing (ABR)

Treatment

  • Tinnitus is a symptom and not a disease itself.  It is a chronic condition that can be managed by treating the underlying etiology.
  • The treatment of tinnitus is usually directed towards improvement in the quality of life by decreasing awareness or desensitizing towards tinnitus.  It is usually achieved by identifying the underlying pathology or the associated disease.
  • It is recommended to treat underlying insomnia and depression. (Grade 1B)

Medical Therapy

Following medications have minimal to modest role in relieving tinnitus.

Following medications have been studied for tinnitus but are not found to be effective and have no role in the treatment of tinnitus

Surgery

Other therapies:

Prevention

  • Tinnitus may be been prevented by limiting the exposure to loud noise.

References

  1. ↑ Minen MT, Camprodon J, Nehme R, Chemali Z (October 2014). "The neuropsychiatry of tinnitus: a circuit-based approach to the causes and treatments available". J. Neurol. Neurosurg. Psychiatry. 85 (10): 1138–44. doi:10.1136/jnnp-2013-307339. PMID 24744443.
  2. ↑ Qiu C, Salvi R, Ding D, Burkard R (January 2000). "Inner hair cell loss leads to enhanced response amplitudes in auditory cortex of unanesthetized chinchillas: evidence for increased system gain". Hear. Res. 139 (1–2): 153–71. doi:10.1016/s0378-5955(99)00171-9. PMID 10601720.
  3. ↑ Melcher JR, Sigalovsky IS, Guinan JJ, Levine RA (February 2000). "Lateralized tinnitus studied with functional magnetic resonance imaging: abnormal inferior colliculus activation". J. Neurophysiol. 83 (2): 1058–72. doi:10.1152/jn.2000.83.2.1058. PMID 10669517.
  4. ↑ Lockwood AH, Salvi RJ, Coad ML, Towsley ML, Wack DS, Murphy BW (January 1998). "The functional neuroanatomy of tinnitus: evidence for limbic system links and neural plasticity". Neurology. 50 (1): 114–20. doi:10.1212/wnl.50.1.114. PMID 9443467.
  5. ↑ Fortune DS, Haynes DS, Hall JW (January 1999). "Tinnitus. Current evaluation and management". Med. Clin. North Am. 83 (1): 153–62, x. doi:10.1016/s0025-7125(05)70094-8. PMID 9927967.
  6. ↑ Levine RA (1999). "Somatic (craniocervical) tinnitus and the dorsal cochlear nucleus hypothesis". Am J Otolaryngol. 20 (6): 351–62. doi:10.1016/s0196-0709(99)90074-1. PMID 10609479.
  7. ↑ Shargorodsky J, Curhan GC, Farwell WR (August 2010). "Prevalence and characteristics of tinnitus among US adults". Am. J. Med. 123 (8): 711–8. doi:10.1016/j.amjmed.2010.02.015. PMID 20670725.
  8. ↑ Shetye A, Kennedy V (August 2010). "Tinnitus in children: an uncommon symptom?". Arch. Dis. Child. 95 (8): 645–8. doi:10.1136/adc.2009.168252. PMID 20371585.
  9. ↑ Adams PF, Hendershot GE, Marano MA (October 1999). "Current estimates from the National Health Interview Survey, 1996". Vital Health Stat 10 (200): 1–203. PMID 15782448.
  10. ↑ Ahmad N, Seidman M (2004). "Tinnitus in the older adult: epidemiology, pathophysiology and treatment options". Drugs Aging. 21 (5): 297–305. doi:10.2165/00002512-200421050-00002. PMID 15040757.
  11. ↑ Stouffer JL, Tyler RS (August 1990). "Characterization of tinnitus by tinnitus patients". J Speech Hear Disord. 55 (3): 439–53. doi:10.1044/jshd.5503.439. PMID 2381186.
  12. ↑ Dietz RR, Davis WL, Harnsberger HR, Jacobs JM, Blatter DD (May 1994). "MR imaging and MR angiography in the evaluation of pulsatile tinnitus". AJNR Am J Neuroradiol. 15 (5): 879–89. PMID 8059655.
  13. ↑ Tunkel DE, Bauer CA, Sun GH, Rosenfeld RM, Chandrasekhar SS, Cunningham ER, Archer SM, Blakley BW, Carter JM, Granieri EC, Henry JA, Hollingsworth D, Khan FA, Mitchell S, Monfared A, Newman CW, Omole FS, Phillips CD, Robinson SK, Taw MB, Tyler RS, Waguespack R, Whamond EJ (October 2014). "Clinical practice guideline: tinnitus executive summary". Otolaryngol Head Neck Surg. 151 (4): 533–41. doi:10.1177/0194599814547475. PMID 25274374.

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