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Tinnitus
Description/Etiology
Tinnitus is a common auditory condition defined as the perception of noise or a ringing in the ears, whether or not external noise is present. Tinnitus is usually medically harmless, but can cause much anxiety and affect concentration. Most people with tinnitus report minimal distress; however, in others, the condition causes fatigue, stress, sleep problems, difficulty concentrating, memory deficits, depression, anxiety, irritability, and can affect balance. In rare cases, tinnitus may occur with hearing loss,which does not cause tinnitus but may make it more noticeable to the patient,or be associated with an aneurysm or a brain tumor. Tinnitus is classified in several ways, including by the level of ringing or noise volume. The perceived ringing may be soft or loud. Acute tinnitus lasts days to weeks, while chronic tinnitus persists for more than 6 months. Tinnitus may be unilateral or bilateral and may be pulsatile, with the noise occurring in rhythm with the patients heartbeat, or nonpulsatile. Finally, tinnitus is classified as subjective or objective. Subjective tinnitus is heard only by the person affected, and may be associated with underlying conditions including acoustic neuroma, Mnires disease, otitis media, impacted cerumen, head injury, whiplash, multiple sclerosis, the use of ototoxic drugs (e.g., loop diuretics, chemotherapy agents, salicylates, NSAIDs), certain metabolic disorders (e.g., hypertension, anemia, thyroid disorders, diabetes mellitus), and temporomandibular joint disorders. Objective tinnitus, which is heard not just by the affected individual but also by others in close proximity, is extremely rare and may be caused by arteriovenous malformations (AVM), vascular tumors, heart valve disease, or carotid stenosis. There is no known cure for tinnitus other than determining and eliminating the causes of the symptoms, if possible. Treatment options include irrigation for cerumen impaction and antibiotics for acute otitis media. Pharmacologic therapy is effective in some patients. Acoustic therapy provided through background music, white noise machines, or noise-making devices similar in appearance to hearing aids helps the patient to tolerate the tinnitus-related noise. Hearing aids or cochlear implants may also be used to improve hearing in patients with hearing loss. Electrical stimulation, in which external electrodes around the ear deliver a low-frequency current, may provide symptomatic relief to some patients. Tinnitus retraining therapy, a counseling method that uses cognitive strategies (e.g., patient education about tinnitus etiology) to reduce the patients reaction to tinnitus, is effective in some cases. (For more information, see Quick Lesson AboutTinnitus and Retraining Therapy .) Successful treatment often includes psychological interventions (e.g., cognitive behavioral therapy; CBT) to help the patient cope with the condition.

ICD-9
388.3

ICD-10
H93.1

Facts and Figures

The lifetime prevalence of tinnitus is as high as 16%. In the United States, an estimated 50 million people have tinnitus. Tinnitus can occur at any age, but it is more common in those with age-related hearing loss. Most cases occur in patients between the ages of 40 and 70 years; chronic tinnitus affects 2530% of the U.S. population over the age of 65 years. The prevalence of tinnitus is higher in patients with impaired hearing compared with normal hearing; in fact, ~ 90% of cases of chronic tinnitus are associated with sensorineural hearing loss. Tinnitus is rare in children with normal hearing, but affects 3364% of children with severe hearing loss. Up to 40% of people with tinnitus report experiencing impaired social and occupational performance and life enjoyment as a result of the condition. Major depression is diagnosed in 4860% of patients with chronic tinnitus, and anxiety disorders are diagnosed in 45%.

Authors
Karen Dente, MD, MA Cinahl Information Systems, Glendale, CA Tanja Schub, BS Cinahl Information Systems, Glendale, CA

Reviewers
Rosalyn McFarland, DNP, RN, APNP, FNP-BC Darlene Strayer, RN, MBA Cinahl Information Systems, Glendale, CA Nursing Practice Council Glendale Adventist Medical Center, Glendale, CA

Risk Factors
Risk factors for development of tinnitus include hearing loss, ongoing exposure to loud noise without ear protection, age > 65 years, and post-traumatic stress disorder (PTSD). Males are at increased risk of developing tinnitus, likely due to increased noise exposure (e.g., in military, occupational, and recreational activities). Additional risk factors include pregnancy, use of ototoxic medications (for details, see Red Flags , below), and renal and hepatic impairment.

Editor
Diane Pravikoff, RN, PhD, FAAN Cinahl Information Systems, Glendale, CA

Signs and Symptoms/Clinical Presentation

Symptoms vary widely and are subjective except in those with the objective form of tinnitus. Symptoms include hearing whistling, hissing, humming, roaring, sizzling, buzzing, and ringing in the ears.

Assessment
October 4, 2013

Patient History

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 Ask about history of infections, diseases, ototoxic drug use, and high levels of stress Assess the quality of the tinnitus, whether it is steady or pulsatile. Hemodynamic changes in the blood may cause a pulsatile tinnitus due to pregnancy, anemia, or hyperthyroidism Assess hearing, as central hearing loss may be the problem due to infarction, multiple sclerosis, neoplasm, or hematoma due to aneurysm rupture Physical Findings of Particular Interest Vertigo or nausea may indicate underlying inner ear (i.e., cochlea) problems Unilateral ringing may be a sign of an acoustic tumor Laboratory Tests That May Be Ordered CBC may indicate anemia, which can cause tinnitus Thyroid function tests may show hyperthyroidism as an underlying cause. Hyperthyroidism can lead to a hypermetabolic state and result in tinnitus due to increased blood flow near the cochlea Other Diagnostic Tests/Studies X-ray, MRI, or CT scan of the head may be indicated if a brain tumor is suspected Audiogram may be ordered to determine if there is hearing loss If Mnires disease is suspected, tests for nystagmus may provide a definitive diagnosis Blood vessel angiography study may be ordered if aneurysm or dural AVM are suspected

Treatment Goals
Provide Symptomatic Relief and Promote Improved Quality of Life Assess symptoms and individualized tolerance of tinnitus volume or level of impairment; assess fall risk if vertigo is present and maintain patient safety (e.g., airway, circulation, and prevention of injury) Administer prescribed medications for symptomatic relief Lidocaine may provide temporary relief; carBAMazepine may be ordered for tinnitus with an acoustic hallucinatory component Antidepressants (e.g., amitriptyline) and/or anti-anxiety agents (e.g., benzodiazepines) may be ordered for chronic tinnitus Antibiotics may be ordered for acute otitis media, if present Sedatives may be ordered for insomnia, if present Promote Emotional Well-Being and Educate Educate that relaxation and reduction of stress levels may reduce symptoms, and encourage trying meditation or yoga. If treatment offers no relief, reassure the patient that the condition is generally benign and not life threatening Assist the patient in learning how to mask the noise by using a white noise device at home or in the workplace, or a device called a tinnitus masker; which is placed behind the ear like a hearing aid, and emits low-pitched sounds to make tinnitus less irritating Request referral to a mental health clinician for supportive counseling on coping strategies if symptoms become intolerable

Food for Thought

Investigators who conducted a recent study of 492 patients with tinnitus found that, compared to usual therapy, cognitive behavioral therapy was associated with improved health-related quality of life and decreased tinnitus severity and tinnitus impairment (Cima et al., 2012) Authors of a recent systematic review of 5 trials including 160 participants found that repetitive transcranial magnetic stimulation can provide short-term improvements in symptoms of chronic tinnitus (Peng et al., 2012)

Red Flags
In some people, tinnitus is so incapacitating that they consider suicide Drugs that can cause tinnitus should be avoided; these include aspirin, quinine, and certain antibiotics

What Do I Need to Tell the Patient/Patients Family?

Reinforce, if indicated, that damage to the inner ear may be permanent but that many people can lessen the symptoms of tinnitus through behavioral adjustments Educate about factors that exacerbate tinnitus, including stress, inadequate sleep, and certain substances (e.g., alcohol); symptoms are often exacerbated at night when it is quiet and are reduced with white noise (e.g., a specialized white noise device or an air-conditioner) Explain that high blood pressure can cause tinnitus, so controlling high blood pressure with prescribed antihypertensive agents, regular exercise, proper diet, and a healthy body weight may prevent tinnitus or reduce its intensity Reinforce the importance of adherence to the prescribed medication regimen, as appropriate

References
1. Belli, H., Belli, S., Oktay, M. F., & Ural, C. (2012). Psychopathological dimensions of tinnitus and psychopharmacologic approaches in its treatment. General Hospital Psychiatry, 34(3), 282-289. 2. Cima, R. F., Maes, I. H., Joore, M. A., Scheyen, D. J., El Refaie, A., Baguley, D. M., & Vlaeyen, J. W. (2012). Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: A randomised controlled trial. Lancet, 379(9830), 1951-1959. 3. DynaMed. (2013, July 1). Tinnitus. Ipswich, MA: EBSCO Publishing. Retrieved September 20, 2013, from http://search.ebscohost.com/login.aspx?direct=true&db=dme&AN=116486&site=dynamed-live&scope=site

4. Holmes, D. M. (2013). Tinnitus. In F. J. Domino (Ed.), The 5-minute clinical consult 2013 (21th ed., pp. 1308-1309). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 5. Malouff, J. M., Schutte, N. S., & Zucker, L. A. (2011). Tinnitus-related distress: A review of recent findings. Current Psychiatry Reports, 13(1), 31-36. 6. Peng, Z., Chen, X. Q., & Gong, S. S. (2012). Effectiveness of repetitive transcranial magnetic stimulation for chronic tinnitus: A systematic review. OtolaryngologyHead and Neck Surgery, 147(5), 817-825. doi:10.1177/0194599812458771