Certain medications can trigger or exacerbate tinnitus, including aspirin, nonsteroidal anti-inflammatory drugs, loop diuretics, and quinine.2 Fairly high doses are usually required to cause tinnitus, however, and the effects are typically temporary. Patients have also reported exacerbation of tinnitus due to alcohol, salt, and caffeine intake. Ototoxicity from aminoglycosides and platinum-containing chemotherapeutic drugs is a well-known cause of hearing loss and tinnitus, but these effects are often irreversible.10,11
Neurophysiologic tinnitus is generally not serious from a medical standpoint. While all patients with this condition should undergo an audiologic exam and hearing evaluation, only about 20% of adults who experience tinnitus require intervention.12-14 Although there is no cure, patients with clinically significant tinnitus can be taught stress management and therapeutic use of sound techniques, as well as lifestyle modifications (TABLE 2) to minimize its detrimental effects.
TABLE 2
Managing neurophysiologic tinnitus: A range of options2,5,25-27
| Cognitive-behavioral therapy |
| Elimination of tinnitus-inducing medications (eg, NSAIDs, loop diuretics, and quinine) |
| Hearing aids, sound generators, or other sound devices |
| Lifestyle modifications (eg, improve sleep hygiene, exercise regularly, limit salt intake) |
| Medication (antidepressants or anxiolytics) |
| Patient education that stresses that there are numerous techniques that can be used to manage reactions to tinnitus |
| Stress reduction techniques (eg, imagery, meditation, and deep breathing techniques) |
| Therapeutic sound (eg, using interesting sound to direct attention away from tinnitus, low-level background sound to reduce auditory contrast, and soothing sound for relief) |
| NSAIDs, nonsteroidal anti-inflammatory drugs. |
Somatic tinnitus may be serious
Somatic tinnitus, also known as somato-sound, refers to the perception of sound that originates within the body—in vascular, muscular, skeletal, or respiratory structures, or in the temporomandibular joint.4 These “body sounds” have an internal acoustic source.9
Pulsatile tinnitus, which pulses in synchrony with the heartbeat, is the most common somatosound.15,16 Most patients with pulsatile tinnitus have benign venous “hums,” but serious conditions such as arteriovenous malformations, glomus tumors, and carotid stenosis must be considered. Auscultation over the neck and temporal bone may reveal bruits that can help localize the lesion. We recommend either magnetic resonance imaging (MRI) of the head or computed tomography (CT) angiography, accompanied by timely referral to an otolaryngologist for a focused evaluation.15,17,18
Somatosounds can also be nonpulsatile, indicating a nonvascular source. Examples of nonvascular somatosounds include middle-ear muscle spasms and eustachian tube dysfunction. Nonpulsatile somatic tinnitus is rarely progressive or dangerous. It is reasonable to offer reassurance to patients with nonpulsatile tinnitus, followed by a referral to an otolaryngologist if the symptoms interfere with daily activities.
Unilateral tinnitus is a red flag
In most cases, tinnitus is bilateral. Unilateral tinnitus may indicate a more serious medical condition. It is a common presenting sign of both vestibular schwannoma (also known as acoustic neuroma) and Meniere’s disease.
Patients with unilateral tinnitus should receive a hearing test as soon as possible; if asymmetric hearing loss is found, MRI is indicated, both with and without contrast of the internal auditory canal, to rule out vestibular schwannoma.
Idiopathic sudden sensorineural hearing loss (ISSNHL), which may be associated with new onset unilateral tinnitus, should be considered an otologic emergency. When you suspect ISSNHL, you’ll need to make a same-day referral for an otologic examination.
If left untreated, the ISSNHL and associated tinnitus will resolve partially or completely at least 50% of the time. This recovery rate may be improved with glucocorticoid treatments.19 Prompt initiation of corticosteroid therapy can be a factor in the chances of recovery—the more rapidly such patients are seen and treated, the better their prognosis.20
Tinnitus triage: Key points
Following our triage guide (TABLE 1) should result in appropriate care in most cases. Here are some considerations to keep in mind:
Urgent medical referral. Any patient with tinnitus and symptoms suggestive of serious underlying treatable pathology requires an urgent otolaryngology referral. That includes ISSNHL, which you should suspect whenever a patient reports an unexplained decrease in hearing, as well as pulsatile tinnitus, vestibular symptoms, and long-standing ear pain, drainage, or malodor that does not resolve with routine treatment. If possible, such patients should undergo an audiologic assessment prior to the otolaryngology visit; however, the otolaryngology exam is the primary concern.
Facial paralysis, severe vertigo, or sudden onset pulsatile tinnitus can indicate a serious intracranial condition. These symptoms may point to cerebrovascular disease or neoplasm, and should be treated as an otologic emergency.
Mental health referral. Some tinnitus patients require a mental health assessment, either because of obvious manifestations of a mental illness or because of expressed suicidal ideation. If there’s a question about the patient’s mental health, consider consulting with a mental health provider or using basic screening tools for anxiety and depression to help determine the need for referral, as well as the urgency.12