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
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
Pathophysiology
Causes of subjective tinnitus
Common Causes
Sensorineural hearing loss:
- Ototoxicity
- Presbycusis
- Noise induced hearing loss
- Late onset congenital hearing loss
- Idiopathic
Cochlear injury:
- Ménière disease
- Loop diuretics
- Platinum based chemotherapy
- Antibiotics
- Salicylate
- Trauma
Vascular causes:
- Systemic hypertension
- Sickle cell anemia
- Small vessel disease
- Hypercholesterolemia
- Hypercoagulable state
- Diabetic vasculopathy
CNS causes:
- Pseudotumor cerebri
- Stroke
- Vascular malformations
- Tumor
- Sarcoid
- Multiple sclerosis
Infections:
- Rubella
- Cytomegalovirus
- Chronic otitis media
- Neurosyphilis
- Measles
- Lyme disease
- Meningitis
Bone disease:
- Otosclerosis
- Fibrous dysplasia
- Osteogenesis imperfecta
- Paget disease
Metabolic disorders:
- Hyperparathyroidism
- Chronic renal failure
- Diabetes mellitus
- Thyroid disease
Autoimmune diseases:
- Autoimmune inner ear disease
- SLE
- Rheumatoid arthritis
Medications:
- ACE inhibitors
- Antimalarial medications
- Aminoglycosides
- Dapsone
- Doxazosin
- Calcium channel blockers
- Benzodiazepines
- Cisplatin
- Clarithromycin
- COX-2 inhibitors
- Loop diuretics
- Tricyclic antidepressant
Differential Diagnosis of Tinnitus
Epidemiology and Demographics
Risk Factors
Natural History, Complications and Prognosis
- Early clinical features include
- If left untreated, patients may progress to
- Common complications of
Diagnosis
History and Symptoms:
Physical Examination:
Laboratory Findings:
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.
Other Diagnostic Testing:
- 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
- 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.