Persistent tinnitus often, though not always, indicates the presence of sensory hearing loss
Intermittent periods of mild, high-pitched tinnitus lasting seconds to minutes are common in nor- mal-hearing persons
General Considerations
Tinnitus is defined as the sensation of sound in the absence of an exogenous sound source Tinnitus can accompany any form of hearing loss, and its presence provides no diagnostic value in determining the cause of a hearing loss Approximately 15% of the general population experiences some type of tinnitus, with prevalence beyond 20% in aging populations
Clinical Findings
Symptoms and Signs Though tinnitus is commonly associated with hearing loss, tinnitus severity correlates poorly with the degree of hearing loss About one in seven tinnitus sufferers experiences severe annoyance, and 4% are severely disabled When severe and persistent, tinnitus may interfere with sleep and ability to concentrate, resulting in considerable psychological distress Pulsatile tinnitus—often described by the patient as listening to one’s own heartbeat—should be distinguished from tonal tinnitus Although often ascribed to conductive hearing loss, pulsatile tinnitus may be far more serious and may indicate a vascular abnormality, such as glomus tumor, venous sinus stenosis, carotid vaso-occlusive disease, arteriovenous malformation, or aneurysm In contrast, a staccato “clicking” tinnitus may result from middle ear muscle spasm, sometimes associated with palatal myoclonus The patient typically perceives a rapid series of popping noises, lasting seconds to a few minutes, accompanied by a fluttering feeling in the ear Diagnostic Testing For routine, nonpulsatile tinnitus, audiometry should be ordered to rule out an associated hearing loss For unilateral tinnitus, particularly associated with hearing loss in the absence of an obvious causative factor (ie, noise trauma), an MRI should be obtained to rule out a retrocochlear lesion, such as vestibular schwannoma MRA and MRV and temporal bone computed tomography (CT) should be considered for patients who have pulsatile tinnitus to exclude a causative vascular lesion or sigmoid sinus abnormality
Treatment
The most important treatment of tinnitus is avoidance of exposure to excessive noise, ototoxic agents, and other factors that may cause cochlear damage Masking the tinnitus with music or through amplification of normal sounds with a hearing aid may also bring some relief Among the numerous drugs that have been tried, oral anti- depressants (eg, nortriptyline at an initial dosage of 50 mg orally at bedtime) have proved to be the most effective Habituation techniques, such as tinnitus retraining therapy, and masking techniques may prove beneficial in those with refractory symptoms Transcranial magnetic stimulation of the central auditory system has been shown to improve symptoms in some patients