- Tinnitus is a perceived sensation of sound in the absence of an external acoustic stimulus; often described as a ringing, hissing, buzzing, clicking, or whooshing
- Derived from the Latin word tinnire, meaning “to ring”
- May be heard in one or both ears or centrally within the head
- Two types: subjective (most common) and objective tinnitus
- Subjective tinnitus: perceived only by the patient; can be continuous, intermittent, or pulsatile
- Objective tinnitus: audible to the examiner; rare
- Primary tinnitus: idiopathic with or without sensorineural hearing loss (SNHL) (1)
- Secondary tinnitus: associated with a specific cause (other than SNHL)
- Incidence increasing in association with excessive noise exposure
- Higher rates of tinnitus in smokers, hypertensives, diabetics, and obese patients
- Tinnitus reported by 35 to 50 million adults in the United States; although underreported, 12 million seek medical care.
- Affects 10–15% of adults (2)
- Prevalence increases with age and peaks in 6th decade of life; estimated 8% prevalence reported post–COVID-19 infection
- Prevalence of 13–53% in general pediatric population
- Ethnic: whites > blacks and Hispanics
- Gender: males > females
Etiology and Pathophysiology
- Precise pathophysiology is unknown; numerous theories have been proposed. Ototoxic agents or noise exposure damage hair cells so that there is abnormal neural activity in the auditory cortex. Inflammation may play a role.
- Causes of secondary tinnitus (2):
- Otologic: cholesteatoma, cerumen impaction, foreign body, middle ear effusion, otosclerosis, Ménière disease, vestibular schwannoma, patulous eustachian tube
- Medications: anti-inflammatory agents (aspirin, NSAIDs); antimalarial agents, antimicrobial drugs (aminoglycosides, macrolides); antineoplastic agents, loop diuretics, miscellaneous drugs (antiarrhythmics, antiulcer, anticonvulsants, antihypertensives); anesthetics
- Somatic: temporomandibular joint (TMJ) dysfunction, head or neck injury
- Neurologic: multiple sclerosis, spontaneous intracranial hypertension, vestibular migraine, type I Chiari malformation, palatal myoclonus, idiopathic stapedial muscle spasm
- Infectious: viral (impact of COVID-19 on tinnitus is unknown) bacterial, fungal
- Metabolic: diabetes mellitus, dyslipidemia, vitamin B12 deficiency
- Vascular: aortic or carotid stenosis, venous hum, arteriovenous fistula or malformation, vascular tumors, high cardiac output state (anemia)
Limited evidence to support a genetic component
- Hearing loss (but can have tinnitus with normal hearing)
- High-level noise exposure
- Advanced age
- Use of ototoxic medications (some are irreversible)
- Otologic disease (otosclerosis, Ménière disease, cerumen impaction)
- Depression and anxiety associated with increased odds of tinnitus
- Avoid loud noise exposure and wear appropriate ear protection to prevent hearing loss.
- Monitor ototoxic medications and avoid prescribing more than one ototoxic agent concurrently.
Commonly Associated Conditions
- SNHL caused by presbycusis (age-associated hearing loss) or prolonged loud noise exposure
- Conductive hearing loss due to cerumen, otosclerosis, cholesteatoma
- Psychological disorders: depression, anxiety, insomnia, suicidal ideation
- Despair, frustration, interference with concentration and social interactions, work hindrance
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