Tinnitus

Tinnitus is a common symptom in which sound (whistling, hissing, buzzing, ringing, pulsating) is perceived in the absence of an external source. Tinnitus can be unilateral or bilateral, acute or chronic, intermittent or constant, and is often but not always associated with hearing loss. Primary tinnitus is idiopathic, while secondary tinnitus results from an underlying cause such as noise exposure, infection, trauma, turbulent vascular flow, ototoxicity, or tumor. Clinical evaluation for tinnitus includes assessment of tinnitus characteristics, associated symptoms, and risk factors for tinnitus, as well as an ENT, neck, cardiac, and neurological examination. Patients with tinnitus red flag features require prompt further evaluation. Audiological examination is recommended for most patients who require testing, while imaging is reserved for patients with unilateral tinnitus, asymmetric hearing loss, pulsatile tinnitus, and/or focal neurological deficits. The management of secondary tinnitus focuses on treating the underlying cause. Symptomatic therapy for tinnitus is typically indicated for persistent bothersome tinnitus, while patient education is usually sufficient for nonbothersome tinnitus. Symptomatic therapy includes cognitive behavioral therapy (CBT), hearing aids for concomitant hearing loss, and sound therapy. Management may also involve treating risk factors and comorbidities, including addressing the effects of tinnitus on sleep, mental health, and cognition. Prognosis depends on the underlying etiology. Tinnitus is more likely to be self-limited in younger patients with a short duration of symptoms.

• Tinnitus: perceived sound (e.g., whistling, hissing, buzzing, ringing, pulsating) without an external source
• Subjective tinnitus: only heard by the affected individual
• Objective tinnitus: can be heard by an examiner

Objective tinnitus is caused by sounds originating from within the body such as carotid bruits, cervical venous hum, heart murmurs, or musculoskeletal sounds (e.g., due to stapedial myoclonus). ^[1]

• Prevalence: approx. 1 in 10 adults in the US ^[2]
• Risk factors for tinnitus ^[1][2]
  • Male sex
  • Increasing age (peak 50–59 years)
  • Occupational or environmental noise exposure
  • Military service
  • History of head injury
  • Hypertension
  • Smoking
  • Arthritis

Epidemiological data refers to the US, unless otherwise specified.

Primary tinnitus is idiopathic and may be associated with sensorineural hearing loss (SNHL). The following are causes of secondary tinnitus, i.e., tinnitus provoked by an identifiable underlying condition. ^[1][3][4]

Otologic

• Infectious or inflammatory
  • Acute otitis media (AOM)
  • Labyrinthitis
  • Chronic suppurative otitis media
  • Otitis media with effusion
• Traumatic
  • Perforated tympanic membrane
  • Ear barotrauma
  • Acoustic trauma
• Structural
  • Cerumen impaction
  • Foreign body in the ear
  • Cholesteatoma
  • Eustachian tube dysfunction
• Idiopathic or degenerative
  • Meniere disease
  • Sudden sensorineural hearing loss (SSNHL)
  • Presbycusis
  • Otosclerosis

Neurologic

• Infectious
  • Meningitis
  • Syphilis
  • Lyme disease
• Inflammatory
  • Multiple sclerosis
  • Systemic lupus erythematosus
  • Sarcoidosis
• Other
  • Stroke
  • Elevated intracranial pressure
  • Muscular myoclonus or spasm (e.g., of the stapedius muscle, tensor tympani muscle, muscles of the palate)
  • Chiari I malformation
  • Vestibular migraine

Neoplastic

• Acoustic neuroma
• Meningioma
• Vascular tumors, e.g., hemangioma, paraganglioma of the middle ear

Vascular

• Carotid artery stenosis
• Arteriovenous malformation
• Cervical venous hum
• High-output heart failure
• Heart murmurs

Musculoskeletal

• Temporomandibular joint disorder (TMJD)
• Paget disease of bone
• Head injuries, e.g., temporal bone fracture

Metabolic ^[3]

• Vitamin B₁₂ deficiency
• Hyperlipidemia
• Diabetes mellitus
• Thyroid disease

Ototoxic substances ^[3]

Examples of common ototoxic substances are listed below.

• Antibiotics: e.g., aminoglycosides, macrolides, tetracyclines, vancomycin
• NSAIDs: e.g., aspirin (salicylate toxicity), ibuprofen
• Chemotherapeutic agents: e.g., platinum-based chemotherapy, taxanes
• Loop diuretics: e.g., furosemide
• Anticonvulsants: e.g., carbamazepine, pregabalin
• Immunosuppressants: e.g., cyclosporin
• Other medications: atorvastatin, bupropion, hydroxychloroquine, PDE-5 inhibitors ^[5]
• Environmental or industrial toxins: mercury, arsenic, toluene, carbon monoxide
• Vaccinations: pneumococcal vaccine, HPV vaccine

Focused history ^[1][3]

• Onset, duration, and effect on quality of life: Consider using a validated tinnitus questionnaire to quantify symptom severity. ^[1]
  • Recent-onset tinnitus: < 6 months
  • Nonbothersome tinnitus: noticeable but tolerable; patients typically seek reassurance.
  • Bothersome tinnitus
    • Negatively impacts quality of life and/or functioning
    • Patients seek relief from tinnitus and associated sleep, mental health, or cognitive disturbances.
    • Considered persistent if present for ≥ 6 months
• Tinnitus characteristics: laterality, symmetry, pulsatility, sound frequency, quality (e.g., ringing, hissing, clicking)
  • Unilateral or asymmetric tinnitus suggests a focal auditory lesion, e.g., acoustic neuroma.
  • Pulsatile tinnitus suggests a vascular etiology, e.g., carotid bruits, heart murmurs.
  • Roaring tinnitus suggests Meniere disease.
  • Rhythmic clicking tinnitus suggests stapedial myoclonus or tensor tympani myoclonus.
  • Ringing, buzzing, or hissing tinnitus are characteristic of primary tinnitus.
• Related symptoms
  • Auditory or vestibular disturbances, e.g., hearing loss, vertigo
  • Infectious symptoms, e.g., fever, ear pain, congestion, otorrhea
  • Focal neurological symptoms, headaches
  • Auditory hallucinations (can mimic tinnitus)
• Exposures: ototoxic substances and other risk factors for tinnitus

Focused physical examination ^[1][3]

Identify abnormalities such as neurological deficits, vascular bruits, or head and neck lesions.

• HEENT examination
  • Ear examination including otoscopy
  • Focused hearing examination
  • Eye examination, e.g., fundoscopy, visual field testing
  • Examination of the TMJ
  • Red flag findings on head and neck examination, e.g., palpable masses
• Neurological examination
  • Cranial nerve examination
  • Cerebellar examination, e.g., Romberg test, nystagmus, gait assessment
  • Vestibular examination, e.g., HINTS examination
  • Mental status examination
• Cardiovascular examination: e.g., auscultation for bruits or murmurs, especially if tinnitus is pulsatile
• Cognitive assessment: if indicated

Red flags in tinnitus

Tinnitus with any of the following red flag features requires prompt workup for a potentially concerning underlying cause.

• Unilateral tinnitus
• Pulsatile tinnitus
• Sudden or unilateral hearing loss
• Focal neurological deficits

Approach ^[1][3]

• Perform a clinical evaluation for tinnitus.
• Prioritize prompt diagnostic workup in patients with red flags for tinnitus.
• Audiological examination is appropriate for most patients.
• Obtain imaging studies for patients with suspected focal or vascular causes.
• Consider additional diagnostics according to the suspected underlying cause (see “Common causes of tinnitus”).
• Routine laboratory testing is typically unnecessary.

Consider deferring diagnostics for patients with recent-onset tinnitus and no red flags for tinnitus. ^[1][3]

Audiological examination ^[1][3]

• Indications
  • Consider in all patients with tinnitus.
  • Obtain promptly for patients with unilateral or persistent tinnitus or hearing loss.
• Components
  • Evaluation by an audiologist
  • Otoscopy and cerumen removal
  • Audiometric testing
  • See also “Diagnostics for hearing loss.”

If SSNHL is suspected, refer to audiology as soon as possible (no later than 2 weeks). For most other patients, arrange examination within 4 weeks of symptom onset. ^[1]

Imaging ^[1][3][6]

• Indications
  • Unilateral or asymmetrical tinnitus
  • Pulsatile tinnitus
  • Focal neurological deficit
  • Asymmetrical hearing loss
• Options
  • Focal neurological deficit: CT head and/or MRI brain
  • Pulsatile tinnitus: CT temporal bones without contrast, CTA head and neck
  • Unilateral or asymmetrical tinnitus or hearing loss: MRI head and auditory canal with and without contrast

Avoid routine imaging for patients with bilateral tinnitus that is isolated (i.e., with normal hearing and neurological examination) or associated with symmetrical hearing loss. ^[1][3]

Consider tinnitus symptom management for secondary tinnitus if it is bothersome tinnitus and the underlying cause is irreversible. ^[1]

Approach ^[1][3][7]

• Identify and address causes of secondary tinnitus, e.g., discontinue ototoxic medications.
• Initiate treatment for underlying SSNHL within 2 weeks of symptom onset. ^[8]
• Provide patient education to all patients.
• Offer tinnitus symptom management to patients with persistent bothersome tinnitus. ^[1][3]
• Treat comorbidities and address reversible risk factors for tinnitus.

Avoid expensive or time-consuming interventions for recent-onset primary tinnitus (< 6 months), as the rates of spontaneous resolution are high. ^[1]

Patient education ^[1][7]

• Tinnitus causes and treatment options
• The natural history and prognosis of tinnitus
• Avoidance of loud noise exposure
• Management of individual risk factors for tinnitus
• See “Patient Education Discussion Points for Bothersome Tinnitus” in “Tips & Links” for details.

Symptomatic therapy for tinnitus ^[1][3][7]

• The following applies to patients with persistent bothersome tinnitus and may be appropriate for other patients on a case-by-case basis : ^[1]
  • Offer CBT to all patients. ^[9]
  • Refer patients with hearing loss for hearing-aid evaluation.
  • Consider sound therapy, e.g., acoustic stimulators, hearing aids, ambient sound generators. ^[10]
  • Consider tinnitus retraining therapy. ^[11]
• Avoid the following : ^[1][3]
  • Pharmacological therapy (e.g., antidepressants, anxiolytics, anticonvulsants, betahistine) ^[12]
  • Dietary supplements (e.g., zinc, Ginkgo biloba, melatonin) ^[13][14]
  • Transcranial magnetic stimulation
  • Transcutaneous electrical nerve stimulation
  • Hyperbaric oxygen therapy
  • Acupuncture

Treatment of comorbidities

• Treatment of depression
• Treatment of anxiety disorders
• Treatment of dementia
• Behavioral and cognitive therapies for insomnia and pharmacological therapy for insomnia

• Refer patients with acute focal neurological deficits and/or trauma to the emergency department.
• Consider otolaryngology referral for persistent bothersome tinnitus.
• Consider specialist referral for suspected secondary tinnitus.
  • Otolaryngology: e.g., for SSNHL, Meniere disease
  • Dental or maxillofacial surgery: e.g., for TMJD
  • Neurology: e.g., for suspected vestibular migraine, stroke
  • Neurosurgery: e.g., for intracranial neoplasms
  • Vascular surgery: e.g., for carotid artery stenosis
  • Toxicology: e.g., for salicylate poisoning

• Globally, tinnitus is either self-limited or improves significantly in 20–50% of patients within 5 years. ^[1]
• Favorable prognostic factors (e.g., higher likelihood of spontaneous resolution) include: ^[1]
  • Younger age
  • Short duration of symptoms (e.g., onset < 6 months ago)
• Symptom severity can fluctuate over time.

The prognosis of secondary tinnitus depends on the underlying cause and its degree of reversibility.