Patient will present as → a 70-year-old female who states that her children and grandchildren have asked her to seek medical attention as she seems to be losing her hearing. She also describes an occasional ringing, buzzing, and hissing sound. She is in generally good health, and her only medications are a multivitamin along with calcium and vitamin D. You examine her ears and find the external auditory canals to be free of cerumen and the tympanic membranes to be normal in appearance.
Tinnitus is a noise in the ears. It is experienced by 10 to 15% of the population, often described as a ringing, hissing, buzzing, or whooshing.
- You have to understand the underlying cause:
- 90% is associated with sensorineural hearing loss caused by loud noise, presbycusis (as in the patient's case presentation), medications (aspirin, antibiotics, aminoglycosides, loop diuretics, and CCBs), Meniere's disease, and acoustic neuroma
- 5% vascular: Carotid stenosis
- 5% mechanical abnormalities: TMJ
- Continuous tinnitus: presbycusis or long-term hearing loss
- Episodic, low-pitched, rumbling tinnitus: Meniere disease
- Pulsatile tinnitus: vascular cause
All patients with significant tinnitus should be referred for comprehensive audiologic evaluation to determine the presence, degree, and type of hearing loss.
- In patients with unilateral tinnitus and hearing loss, acoustic neuroma should be ruled out by gadolinium-enhanced MRI
- In patients with unilateral tinnitus and normal hearing and physical examination, MRI is not necessary unless tinnitus persists > 6 mo
No pharmacologic agent has been shown to cure or consistently alleviate tinnitus
- The goal is to try to identify the cause, i.e. remove ototoxic medications, hearing aids
- Correcting hearing loss (e.g., with a hearing aid) relieves tinnitus in about 50% of patients
Question 1 |
Recurrent vertigo, tinnitus, and hearing loss are hallmark findings of
Meniere’s disease | |
Cholesteatoma | |
Vestibular neuronitis | |
Benign positional vertigo | |
Acoustic neuroma |
Question 1 Explanation:
Meniere’s disease is a peripheral cause of vertigo. Symptoms include the hallmark findings of recurrent vertigo, tinnitus, and hearing loss. The cause is thought to arise from endolymphatic hydrops. In most cases, the vertigo lasts for several hours, up to an entire day. Although at first hearing may be little affected, over time it deteriorates. Tinnitus is usually constant and may become worse during the acute attacks. Vertigo may be severe and accompanied by nausea and vomiting. Treatment consists of salt restriction (i.e., no more than 2 g per day) and the use of hydrochlorothiazide, anticholinergics, antihistamines, and antiemetics. Resistant cases may require referral to an ear– nose– throat specialist.
Question 2 |
A 62-year-old man presents to his primary care provider with a six-month history of bothersome ringing in both ears. He worked in a manufacturing plant for 30 years and reports some difficulty hearing. Which of the following factors in this patient's history is the most likely cause of his tinnitus?
Otosclerosis Hint: Primarily causes conductive hearing loss, and less likely to be associated with tinnitus unless severe. | |
Exposure to loud noise | |
Recent use of non-steroidal anti-inflammatory drugs (NSAIDs Hint: While tinnitus can sometimes be a side effect of NSAIDs and salicylates (aspirin), this is usually transient and less likely in the setting of chronic symptoms without a direct correlation to medication use. | |
Meniere's disease Hint: Meniere's typically presents with episodic tinnitus accompanied by vertigo and fluctuating hearing loss. | |
Hypertension Hint: While hypertension can contribute to pulsatile tinnitus in some cases, this presentation with concurrent hearing loss strongly suggests noise-induced damage as the leading cause. |
Question 2 Explanation:
Noise-induced hearing loss is a significant risk factor for tinnitus. Long-term exposure to loud environments often damages structures in the inner ear, leading to both hearing loss and tinnitus.
Question 3 |
A 35-year-old woman presents with constant, unilateral (left sided) high-pitched ringing in her ear for the past month. She has no hearing loss, ear pain, or vertigo. In addition to a routine otoscopic exam, which of the following is the most appropriate initial diagnostic study in this patient?
Tympanometry Hint: Evaluates middle ear function and is mostly helpful with conductive hearing loss or Eustachian tube issues. | |
Audiometry | |
Vestibular testing Hint: Useful for vertigo assessment (e.g., Meniere's), but in a tinnitus-only case, audiometry is more targeted. | |
CT scan of temporal bones Hint: Imaging like CT isn't primarily indicated for typical tinnitus but is reserved for cases raising concern for structural pathologies. | |
MRI of the brain with and without contrast Hint: Used to rule out central causes of tinnitus when audiometric evaluation suggests a neural anomaly or when other symptoms indicate a potential central nervous system issue. |
Question 3 Explanation:
Pure-tone audiometry is the most appropriate initial diagnostic test for a patient presenting with tinnitus, especially with a history suggestive of noise-induced hearing loss. This test assesses the patient's hearing levels across a range of frequencies and can help identify hearing loss patterns associated with tinnitus.
Question 4 |
A 72-year-old man presents with 5 months of continuous ringing in both ears. It occurs day and night. He finds it very irritating. Audiometry confirms sensorineural hearing loss bilaterally. Tinnitus is negatively impacting his quality of life. Which of the following is the most appropriate management?
Gabapentin therapy Hint: Variable efficacy and side effects. | |
Hearing aids | |
Intratympanic steroid injection Hint: Side effects may outweigh benefits.
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Transcranial magnetic stimulation Hint: Still investigational. | |
Zinc supplementation Hint: No better than placebo in trials. |
Question 4 Explanation:
The patient has chronic, bothersome tinnitus caused by sensorineural hearing loss as confirmed by audiometry. The most appropriate management is hearing aids to help amplify external sounds and mask the internal phantom noise perceptions. Oral and intratympanic agents have variable efficacy and side effects. Transcranial magnetic stimulation is still investigational. Zinc is no better than placebo.
There are 4 questions to complete.
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References: Merck Manual · UpToDate