Tinnitus

Educational Objectives

The goal of this program is to improve diagnosis and management of tinnitus. After hearing and assimilating this program, the clinician will be better able to:

1. Utilize patient history and physical examination to identify etiology of tinnitus.

2. Perform diagnostic workup and imaging for pulsatile and nonpulsatile tinnitus.

3. Select management strategies for tinnitus based on underlying cause.

Summary

Moderator: Michael S. Harris, MD, Assistant Professor, Department of Otolaryngology & Communication Sciences, Division of Otology, Neurotology, & Skull Base Surgery, Medical College of Wisconsin, Milwaukee, WI

David R. Friedland, MD, PhD, Professor and Vice Chair, Chief of the Division of Otology and Neuro-otologic Skull Base Surgery, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI

Steven A. Harvey, MD, Associate Professor, Dept. of Otolaryngology & Communication Sciences, Medical College of Wisconsin, Milwaukee, WI

Nonpulsatile Tinnitus

Questions on patient history: history of noise exposure, triggering factors, otologic history, history and characteristics of tinnitus, occupational and recreational exposure, symmetry of tinnitus, caffeine intake, and medications; loss of sleep and effect of tinnitus on concentration during the day help assess degree to which tinnitus is bothering the patient and may influence aggressiveness of workup and treatment

Examination: includes tuning fork, binocular microscopy, ear examination, palpation of temporomandibular joint (TMJ), and evaluation for tension in neck muscles and jaw; placement of tuning fork up to each ear is used to assess for diplacusis (sign of cochlear pathology)

Diagnostic testing for unilateral tinnitus: pure tone phonetic audiometry and word recognition performance are recommended; 5% to 10% of patients with subjective tinnitus have normal audiogram, and ultra-high frequency range should also be tested; measurement of otoacoustic emissions (OAE) provides frequency-specific information, and if OAE is intact across all ranges with moderate hearing loss on audiogram, additional testing should be performed to check for malingering; audiogram should be repeated in 6 to 12 mo to evaluate changes

Magnetic resonance imaging (MRI): used to examine ear structures, internal acoustic canal (IAC), and blood vessels; anterior inferior cerebellar artery (AICA) vascular loop into the IAC is commonly observed on MRI but does not usually cause pathology; prolongation between wave 1 and 3 on auditory brainstem response suggests compression of the nerve in symptomatic patient with AICA vascular loop

Patient with normal audiometry

Counseling: physician should explain that patient may become conscious of electrical sound in inner ear produced by auditory pathway if cortical inhibitory pathways are affected and that tinnitus, ear pain, and high levels of muscle tension are common; physical or massage therapy, acupuncture, and bite guards may be recommended

Treatment: conventional — masking strategies are particularly useful for patients with difficulty sleeping; hearing aids may be recommended for sensorineural hearing loss; quiet environments should be avoided; relaxation or sound therapy may be considered; cognitive behavioral therapy (CBT) is useful and can be performed with guidance from websites or phone apps or with a professional; Holmes-Rahe Life Stress Inventory is a questionnaire used to correlate life stress with odds for somatic issues (eg, pain, fatigue, insomnia); unconventional — transcranial magnetic stimulation of the temporalis muscles has minimal efficacy, is expensive and uncomfortable, and is generally avoided; acupuncture may be considered; healthy diet is recommended; studies show natural bioflavonoid product (eg, Lipo-Flavonoid) is not effective, but some patients may observe benefit

2014 guidelines for management: workup — includes targeted physical examination, detailed history, and audiometry to assess degree of sensorineural hearing loss; strong recommendation against routine reflexive MRI or computed tomography (CT), with exception of unilateral or pulsatile tinnitus or if other focal neurologic abnormalities or asymmetric sensorineural hearing loss are present; questionnaires are recommended to differentiate between bothersome and mild tinnitus and between transient and persistent tinnitus; patient education on presumed mechanism and natural history is recommended; treatment — hearing aids are recommended for hearing loss; sound therapy is optional; CBT is recommended; medical therapy and dietary supplements are not recommended

Follow-up testing: imaging — recommended for patients with unilateral tinnitus and 2 normal audiograms within 6 to 12 mo; word recognition — consider difference between ears; acoustic reflexes — unreliable and not recommended; vestibular evoked myogenic potentials — may be used to evaluate for isolated superior vs inferior nerve dysfunction; retrocochlear pathology — FIESTA noncontrast MRI provides information on structure and can identify small acoustic neuromas

Pulsatile Tinnitus

Description: pulse-synchronous tinnitus occurs in synchrony with the heartbeat; regular, regularly irregular, or irregularly irregular pattern identifies whether tinnitus is related to pulsations of vascular system or myoclonic muscle spasm

Etiology: vascular causes are most common; other causes include middle ear neoplasia, myoclonus, otosclerosis, or patulous Eustachian tube; physiologic changes to blood flow include anemia, thyroid dysregulation, and atherosclerosis (most common cause in patients >65 yr of age)

Questions to ask patient: if tinnitus changes with position; when turning, flexing, or extending head; with placement of pressure over side of the neck; or with intrathoracic pressure; if patient can hear their breathing, voice, chewing, and eye movements to distinguish from superior canal dehiscence or patulous Eustachian tube; venous or arterial etiology, patient age, headaches, and vision changes should also be considered in workup of patient

Examination: patient should be asked if tinnitus is present during examination; auscultation over carotid, preauricular, orbit, and behind mastoid is recommended; undiluted fundoscopy is used to measure spontaneous venous pulsations on retina, and patients without these (≈20%) may have increased intracranial pressure; as patient turns their head to each side, placement of pressure on neck and behind mastoid, and palpation behind ear is recommended to assess if tinnitus changes; inquire about anemia or thyroid disease (but laboratory testing is usually unnecessary)

Imaging: MRI or noncontrast CT recommended if venous origin is suspected, and examine jugular sigmoid system to look for diverticula, high riding jugular bulb, or dehiscence; analysis of MRI — examine for signs of encephalocele, cerebrospinal fluid (CSF) leakage into ear, or cochlear pathology; images of the sagittal plane are critical for evaluating potential retrocochlear issue (eg, vertigo, dizziness, or hearing loss) and can identify empty sella, if cerebellum is low riding (to identify Chiari malformation), and if atrophy is observed in cortex

Benign or idiopathic intracranial hypertension: presents with symptoms of increased intracranial pressure, eg, papilledema or headache, and diagnosis is based on symptoms because mechanism relating to pulsatile tinnitus is unclear; high opening pressure with normal CSF pressure on lumbar puncture is the most important diagnostic finding; patients do not have localizing findings on neurologic exam, evidence of other venous obstruction on neural imaging, or other cause of increased intracranial pressure; other signs and symptoms may include dizziness, headache, migraine, conductive hearing loss, and spontaneous encephaloceles and CSF leaks; strongly related to obesity and has become increasingly prevalent

Treatment: involves multidisciplinary approach; weight loss or bariatric surgery may be recommended; temporary use of acetazolamide (eg, Diamox) may be considered to reduce CSF production; optic nerve sheath fenestrations may be performed for visual impairment; permanent CSF diversion with ventriculoperitoneal shunt may be considered to treat CSF leak

Protocol for pulsatile tinnitus: otoscopy performed to evaluate for effusion or middle ear neoplasm and if normal, contrast-enhanced CT of temporal bone is performed; if CT is normal, MRI is performed to evaluate for empty sella and changes to posterior globe, followed by definitive diagnostic workup with lumbar puncture

Role of angiography: indicated after normal findings on CT and MRI for workup of pulsatile tinnitus, and formal arteriography performed by vascular neurosurgeon; if pseudoconductive hearing loss from masking is observed on audiogram, analysis of stapedial reflexes can rule out conductive hearing loss, otosclerosis, or superior canal dehiscence

Middle ear myoclonus or tensor tympani syndrome

Patient history: assesses level of anxiety, caffeine consumption, general life stress; frequency, effect on life, triggers, regularity, duration, onset and cessation, associated hearing loss, pain, drainage, surgery on ear; pulsatile tinnitus should be ruled out; identify whether sensation is heard or felt and whether it occurs at another location

Examination: microscopy may be used while patient makes facial movements to evaluate tympanic membrane; if patient experiences tinnitus in clinic, stethoscope can be used to listen over ear canal, and the bell portion is used to listen over mouth to hear moisture clicking in back of throat if tensor tympani myoclonus is present

Management: lifestyle modification — includes caffeine restriction and reduction of stress and anxiety using CBT; medications — muscle relaxants have variable results, but studies suggest combination of anticonvulsants and muscle relaxants may be effective; interventions — lifting tympanomeatal flap and placement of pledget of water-insoluble hemostatic device (eg, Gelfoam) and botulinum toxin (eg, Botox) on stapedius or tensor tympani muscle may be considered for temporary management; transfection of tendon may improve hemifacial spasm caused by middle ear myoclonus

Readings

Beebe Palumbo D et al. The management and outcomes of pharmacological treatments for tinnitus. Curr Neuropharmacol. 2015;13:692-700; Cunnane MB. Imaging of tinnitus. Neuroimaging Clin N Am. 2019;29:49-56; Ellenstein A et al. Middle ear myoclonus: two informative cases and a systematic discussion of myogenic tinnitus. Tremor Other Hyperkinet Mov (N Y). 2013;3:tre-03-103-3713-1; Esmaili AA, Renton J. A review of tinnitus. Aust J Gen Pract. 2018;47:205-208; Hofmann E et al. Pulsatile tinnitus: imaging and differential diagnosis. Dtsch Arztebl Int. 2013;110:451-458; Jensen RH et al. The diagnosis and management of idiopathic intracranial hypertension and the associated headache. Ther Adv Neurol Disord. 2016;9:317-326; Keppler H et al. The relationship between tinnitus pitch and parameters of audiometry and distortion product otoacoustic emissions. J Laryngol Otol. 2017;131:1017-1025; Langguth B et al. Tinnitus: causes and clinical management. Lancet Neurol. 2013;12:920-930; Langguth B et al. Efficacy of different protocols of transcranial magnetic stimulation for the treatment of tinnitus: pooled analysis of two randomized controlled studies. World J Bio Psychiat. 2014;15:276-285; Mattox DE, Hudgins P. Algorithm for evaluation of pulsatile tinnitus. Acta Otolaryngol. 2008;128:427-431; Nelson RF et al. The rising incidence of spontaneous cerebrospinal fluid leaks in the United States and the association with obesity and obstructive sleep apnea. Otol Neurotol. 2015;36:476-480; Tunkel DE et al. Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. 2014;151:S1-S40.

Disclosures

For this program, the following has been disclosed: Dr. Friedland reported that that he and his spouse have served on the clinical advisory board for Frequency Therapeutics and that his spouse received grant funding from Med El Corp. Dr. Harris reported nothing to disclose. Dr. Harvey reported nothing to disclose. The planning committees reported nothing to disclose. 

Acknowledgements

Dr. Harris, Dr. Friedland and Dr. Harvey were recorded at the 6th Annual Best Evidence ENT, presented by the Medical College of Wisconsin, Kohler, WI, and held August 8-11, 2019. For information on future CME activities from this sponsor, please visit mcw.edu. Audio Digest thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

OT540501

Qualifies for:

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.