Ear, Nose, and Throat – Tinnitus: By Carol Bauer M.D.

Tinnitus is the awareness of sound without
an obvious external source. New onset tinnitus can be very disturbing
and cause significant distress and anxiety. Chronic tinnitus, defined as being present
for longer than 6 months, is less intrusive and bothersome, primarily because most people
with chronic tinnitus adapt through natural habituation. The two most common causes of tinnitus are
age-related hearing loss and hearing loss secondary to noise damage to the inner ear. Rarely does tinnitus signify a serious medical
condition but this should be considered under specific conditions and clinical presentations. Signs and symptoms of a possible serious medical
condition causing tinnitus are: unilateral tinnitus
pulsatile tinnitus tinnitus temporally related to sudden hearing
loss tinnitus associated with vertigo or other
neurological deficits A thorough otoscopic examination is important
to identify serious conditions causing unilateral tinnitus, such as chronic mastoiditis and
cholesteatoma. If there are no signs of acute or chronic
ear infection, consider a retrocochlear cause, such as vestibular schwannoma, and vascular
lesions such as glomus tumor, arterio-venous malformation, arteriovenous fistula causing
tinnitus synchronous with the pulse, or asynchronous pulsatile tinnitus related to spasm of the
tensor tympani or stapedius muscles. Tinnitus almost universally occurs with sudden
sensorineural hearing loss. This is a medical emergency since prompt treatment
may reverse the hearing loss and eliminate the tinnitus. Tinnitus that occurs as part of a symptom
complex of neurologic deficits can require urgent or emergent evaluation. Episodic tinnitus occurring in conjunction
with vertigo and fluctuating hearing loss may be the presenting symptoms of endolymphatic
hydrops or Meniere’s disease, migraine vertigo, or perilymphatic fistula. These are uncommon conditions but should be
referred for evaluation and management by an Otolaryngologist. More serious conditions requiring emergent
evaluation would include tinnitus and prolonged vertigo with ataxia, dysphagia, and dysarthria
suggesting central cerebrovascular events. A hearing evaluation is the most important
element in the tinnitus work-up, after the history and physical exam. Rarely is imaging a necessary or beneficial
part of the evaluation, except in the case of suspected retrocochlear, neurologic, or
infectious causes of tinnitus, which would be evident from the history and physical examination.

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