Tinnitus

What is tinnitus?

Tinnitus is the perception of sound in the ears or head, where no external source of the sound exists.

Tinnitus can be divided into two main types:

Subjective

This is by far the most common type of tinnitus, where there is no acoustic stimulus.

Many doctors are concerned that their patient with tinnitus could have an acoustic neuroma (also known as a vestibular schwannoma) but in fact acoustic neuromata are rare, with an incidence of just 1 per 100,000 people per year. They also tend to present with unilateral sensorineural hearing loss, not necessarily with tinnitus alone. Overall, only 2% of patients with unilateral tinnitus and sensorineural hearing loss will prove to have a vestibular schwannoma.¹

Objective

This is rare and occurs when there is an audible noise generated within the head.

Causes of tinnitus (aetiology)

Subjective

Common causes are:

• Otological: any cause of hearing loss; particularly presbyacusis. Also, noise-induced hearing loss, otosclerosis, impacted cerumen, otitis media, Ménière's disease.

• Psychological: anxiety, depression and experience of psychological trauma have been linked to tinnitus. Although it is not always clear whether these factors specifically cause the onset of tinnitus, or if they are contributing factors, tinnitus often arises during or after periods of intense stress. It is also common for perception of pre-existing tinnitus to increase during periods of high stress.

• Jaw disorders: temporomandibular joint dysfunction.

• Neurological: head injury, multiple sclerosis, acoustic neuroma and other similar tumours.

• Infectious: meningitis, syphilis.

• Drug-related: salicylates, non-steroidal anti-inflammatory drugs (NSAIDs), aminoglycosides, loop diuretics, cytotoxicity.

Many cases of tinnitus have no identifiable cause.

Objective

Noises generated within the head can be:

• Pulsatile: due to movement of blood - eg, carotid stenosis, vascular anomalies or tumours, valvular heart disease, high cardiac output states.

• Muscular or anatomical: palatal myoclonus, spasm of tympanic muscles, patulous Eustachian tube.

• Spontaneous: otoacoustic emissions.

How common is tinnitus? (Epidemiology)

Tinnitus is a common complaint. NHS England's Joint Strategic Needs Assessment Guidance estimates that 10% of the adult population will have tinnitus at some point in their lifetime. It will be moderately intrusive in 2.8% of the population, severely intrusive in 1.6% and can disrupt a person's ability to live a normal life in 0.5%.² The prevalence in children is similar (although children are less likely to spontaneously report tinnitus than adults).³

The presence of tinnitus has been reported to increase progressively with age, affecting 5% of people aged 20-30 years and 12% of people over 60 years of age.⁴

The link between depression and tinnitus has been queried in the past but a large comprehensive systematic review reported a prevalence of 33% in people who had tinnitus.⁵

The link between tinnitus and suicide is controversial. The guidance from the National Institute for Care and Health Excellence (NICE) specifically recommends referring people with tinnitus to a crisis mental health management team if they have a high risk of suicide.⁶ However, a large literature review failed to draw any definitive conclusion about a link between suicide and tinnitus.⁷

Symptoms of tinnitus (presentation)

Symptoms

Patients can sometimes delay seeking medical attention for tinnitus.

Most commonly reported sounds are:

• Ringing.

• Buzzing.

• Cricket-like.

• Hissing.

• Whistling.

• Humming.

The tinnitus may be unilateral or bilateral. If bilateral, it may be equal on both sides or perceived to be louder in one ear over the other.⁸

Examination and investigations⁶

• Assess the effect that tinnitus is having on the person's function, mental health, quality of life and sleep. A number of formal questionnaires and scoring systems are available. NICE guidance refers to the Tinnitus Functional Index (TFI) and the tinnitus questionnaire (TQ).

• Thorough examination of the head, neck, ears and jaw should be made. Although most patients with tinnitus will have a normal clinical examination, it is important to check for:

  • Impacted earwax (which can sometimes cause tinnitus and is easily rectified).

  • Carotid bruit (in the case of pulsatile tinnitus).

  • Cranial nerve defects (which can signify a neoplasm in the brain stem or posterior nasopharynx).

  • Otitis media.

  • Masses or lymphadenopathy in the neck, or behind the ear (which can signify a neoplasm).

• A formal hearing test (audiogram and assessment of middle ear function via tympanometry is recommended). This is because hearing loss is commonly associated with tinnitus and may be the cause of it. Rehabilitation with a hearing aid may be recommended as a tinnitus management strategy.

Non-pulsatile tinnitus

• MRI of the internal auditory meatus should be offered to people with non-pulsatile tinnitus who have associated neurological, otological or head and neck signs and symptoms. If MRI is contra-indicated, contrast-enhanced CT is a suitable alternative.

• Consider offering MRI of internal auditory meatus to people with unilateral or asymmetrical non-pulsatile tinnitus who have no associated neurological, audiological, otological or head and neck signs and symptoms, particularly if unilateral hearing loss affecting the same side is also identified. Contrast-enhanced CT is an alternative.

• Do not offer imaging to people with symmetrical non-pulsatile tinnitus who have no associated neurological, audiological, otological or head and neck signs and symptoms.

Pulsatile tinnitus

People with persistent pulsatile tinnitus are typically referred to secondary care for assessment. Baseline blood tests are undertaken to identify a treatable cause of hyperdynamic circulation (eg, full blood count, thyroid profile to consider anaemia or hyperthyroidism for example). Imaging is also performed:

• For people with synchronous pulsatile tinnitus:

  • Magnetic resonance angiogram or MRI of head, neck, temporal bone and internal auditory meatus if clinical examination and audiological assessment are normal, or contrast-enhanced CT of head, neck, temporal bone and internal auditory meatus if these modalities are contra-indicated. Contrast-enhanced CT of temporal bone can be performed if an osseous or middle-ear abnormality is suspected (for example, glomus tumour), followed by MRI if further investigation of soft tissue is required.

• For people with non-synchronous pulsatile tinnitus (for example, caused by palatal myoclonus), consider:

  • MRI of the head, or if they cannot have MRI, contrast-enhanced CT of the head.
    

Management of tinnitus⁶

General measures

• Tinnitus support or counselling (sometimes known as 'hearing therapy'): this is a formal description NICE uses for a consultation in which information between the patient (and if necessary their carer or family) and doctor or audiologist is passed in a two-way process. It enables the doctor to understand the impact that tinnitus is having on the person's life (tinnitus-related distress) and to give them information. It is important to give the patient an explanation about the condition and reassurance that it will not progress and that there are no sinister findings. A management plan can jointly be agreed at the end of the session.

• There is a strong association between tinnitus and stress; relaxation techniques or relaxing background music can distract or mask some tinnitus. Cognitive behavioural therapy often works well to reshape negative thought patterns and behaviours associated with tinnitus-induced distress. Acceptance and commitment therapy is typically used.

• If tinnitus-related distress does not respond to tinnitus support, consider referral - in the following order - for:

  • Digital-related cognitive behaviour therapy (dCBT). This is a form of CBT delivered using digital technology, such as a computer, tablet or phone, and overseen by a psychologist. The actual therapy is similar to that used in face-to-face CBT (for example, positive imagery and learning to identify and challenge unhelpful thoughts).

  • Group-based cognitive therapy delivered by appropriately trained and supervised practitioners or psychologists.

  • Individual tinnitus-related CBT delivered by psychologists.

• Tinnitus-retraining therapy is no longer recommended. NICE considers that the evidence base is limited.

• Recommend amplification devices for people with tinnitus and hearing loss.

• Masking devices (termed 'sound therapy' by NICE) have traditionally been advocated, but NICE feels this treatment modality requires further research. However, given that white-noise and sound enrichment devices are accessible (eg, free white noise apps), and are safe when used intermittently, many people continue to use sound therapy as a tinnitus management strategy.

Pharmacological

Patients who experience tinnitus are occasionally desperate for a treatment to help alleviate the noise if they have not naturally habituated to its presence over time. However, NICE has not found sufficient evidence to recommend any particular pharmacological therapy. Several therapies have been tried in the past, including:

• Anti-vertigo drugs - eg, prochlorperazine.

• Anti-convulsants.

• Intratympanic medication.

• Ginkgo biloba.

• Melatonin.

• Zinc.

Surgical

Surgical treatment is almost never used, unless a surgically treatable underlying cause has been identified (eg, an acoustic neuroma).⁸

When to refer

• Refer immediately (same day) to a crisis mental health management team for people who have tinnitus associated with a high risk of suicide.

• Refer immediately (same day via A&E), people with tinnitus associated with:

  • Sudden onset of significant neurological symptoms or signs (for example, facial weakness); or

  • Acute uncontrolled vestibular symptoms (for example, vertigo); or

  • Suspected stroke.

• Refer people to be seen within 24 hours, usually via discussion with the local on-call ENT service, if they have tinnitus and sudden hearing loss (developed over a period of three days or less) in the previous 30 days.

• Refer people urgently for assessment and management if they have tinnitus associated with either of the following:

  • Distress affecting mental well-being even after receiving tinnitus support.

  • Hearing loss that developed suddenly more than 30 days previously or rapidly worsening hearing loss (over a period of 4 to 90 days).

• Refer people for tinnitus assessment and management in line with local pathways if they have any of the following:

  • Tinnitus that bothers them despite having received tinnitus support.

  • Persistent objective tinnitus.

  • Tinnitus associated with unilateral or asymmetric hearing loss.

• Consider referring people for tinnitus assessment and management in line with local pathways if they have any of the following:

  • Persistent pulsatile tinnitus

  • Persistent unilateral tinnitus