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Chapter 19. Tinnitus

Malathi Srinivasan, MD

A 75-year-old man is brought in by his daughter for progressive mainly unilateral tinnitus, hearing loss, and dizziness for the past year. About 3 weeks ago, he began experiencing unsteadiness and sustained a fall while walking up the stairs.

  • What additional questions would you ask to further characterize the tinnitus?
  • How do you classify tinnitus?
  • What are the alarm symptoms or signs that warrant a rapid assessment, including possible central nervous system (CNS) imaging?
  • What maneuvers can help distinguish between different types of tinnitus?
  • Can you make the diagnosis of tinnitus purely from the history?

Tinnitus is a common symptom in primary care, with great heterogeneity in terms of presentation, severity, and etiology. The term “tinnitus” originates from the Latin word tinnire, which means “to ring.” Although commonly defined as ringing in the ears, a better definition is that “tinnitus is the conscious expression of a sound that originates in an involuntary manner.”1 Tinnitus may be reported by patients as ringing, hissing, buzzing, pulsing, humming, or whistling.2 Tinnitus may cause insomnia; difficulty hearing in social situations; anxiety; annoyance; frustration; and feelings of inadequacy, social anxiety, or loss of control. Only 4% to 8% of patients with tinnitus report moderate to severe tinnitus that interferes with their daily life.3 Tinnitus must be distinguished from auditory hallucinations (see Key Terms).

A truly evidence-based approach to tinnitus is handicapped by lack of epidemiologic and observational data. Thus, likelihood ratios for associated tinnitus symptoms cannot be generated. Most studies have included very small numbers of patients.

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TinnitusA person's perception of a simple involuntary sound that is usually not audible to the observer. The monotonous sound may range in pitch, tone, and amplitude. Often described as hissing, buzzing, ringing, whizzing, pulsing, whooshing, or “steam escaping.” It may be caused by normal body functions or by dysfunction of the peripheral or central auditory systems. The perception of tinnitus and degree of disability are often influenced by psychological factors. Serious pathology may cause either loud or muted tinnitus.
Auditory hallucinationA person's perception of an involuntary sound, often a complex sound, which may be noisy, musical, or voices. Generally indicates psychiatric disturbance (eg, psychosis).
HyperacusisSound and noise intolerance, usually causing discomfort from sounds that would not bother a healthy individual. Sometimes associated with tinnitus.
Subjective tinnitusTinnitus, usually continuous, that only the patient can hear. A “phantom sound” caused by peripheral (middle/inner ear) or central (auditory track to cortex) damage and subsequent reorganization with loss of suppression of neural activity. Ninety-five percent of all tinnitus patients have this form. As in phantom limb pain, symptom control is difficult, but patients often feel better in noisy environments (self-masking).
Objective tinnitusTinnitus that is caused by the body and perceived by a normal healthy ear. The physician can often hear this sound. Fewer than 5% of tinnitus patients have ...

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