TINNITUS

WHAT IS TINNITUS?
Tinnitus is the perception of sound in the head or the ears.
Derived from latin word tinnire, meaning to ring.
Typically an individual perceives a sound in the absence of
external sounds, and the perception is unrelated to any
external source.
It may be:
Objective type
Subjective type

PATHOPHYSIOLOGY
In terms of neurophysiology, tinnitus is the consequence
of brains response to input deprivation from the auditory
periphery.
In a healthy auditory system there is an ordered tonotopic
frequency mapping from auditory periphery(cochlea)
through the midbrain to the auditory cortex

When a region of cochlea is damaged ,the subcortical and

cortical projections adjust to this chronic lack of
output(plasticity) and the tonotopic organization is altered.
In the auditory cortex the region that corresponds to the
area of cochlear damage is termed as LESION PROJECTION
ZONE (LPZ).after cochlear damage the neurons in LPZ show
2 important changes
Increase in the spontaneous firing rate
Increase in the frequency representation of neurons that
border the region of damage(lesion edge frequencies)

Findings
Loss of central inhibition on the regions that are
damaged
Cortical plasticity of the neighbouring regions of
the cortex that are still active.
Hence tinnitus is detrimental cortical
adaptation to input deprivation from sensory
periphery

Additional data shows that tinnitus may also be associated

with neuronal hyperactivity at different levels of central
auditory pathways, including the dorsal cochlear nucleus
,the inferior colliculus. auditory cortex, and the straitum.

CAUSES OF TINNITUS

 SUBJECTIVE TINNITUS:
If the patient is suffering from subjective form of tinnitus(tinnitus aurium, non
vibratory or non auditory tinnitus), he complains of noises originating in his head or
ears.
In this case, a history of trauma, drug intake, exposure to loud noises has to be
taken.

OBJECTIVE TINNITUS:
If the patient is suffering from objective tinnitus(pseudo tinnitus or auditory
tinnitus), the noises can also be heard by the observer with a stethoscope or
simply by listening without any aid in close proximity to the ear.
Sometimes the sounds are pulsatile and synchronized with the patients heartbeat.
These occur because of disturbances In blood flow.
In this case, questions about muscular and vascular disorders need to be asked.

Causes of Objective Tinnitus

Vacular

AV shunts
Congenital AV malformations
Glomus tumour of middle ear
Arterial bruit
Carotid aneurysm
Carotid Stenosis
Vascular loop pressing on VIIIth nerve in internal auditory canal
Persistent stapedial artery
Venous hum
Dehiscent jugular bulb

Causes of Objective Tinnitus

Patulous Eustachian tube

Palatal Myoclonus
Idiopathic stapedial or tensor tympani myoclonus
Dental
Clicking of TMJ

Causes of Subjective Tinnitus

Otologic

Impacted wax
Fluid in middle ear
Acute or chronic otitis media
Menieres disease
Presbycusis
Noise induced hearing loss
Idiopathic sudden SNHL
Acoustic neuroma

Causes of Subjective Tinnitus

Metabolic

Hypothyroidism
Hyperthyroidism
Obesity
Hyperlipidemia
Vitamin deficiency e.g. B12

Causes of Subjective Tinnitus

Neurologic

Head injury(labyrinthine concussion)

Temporal bone fractures
Whiplash injury
Multiple sclerosis
Postmeningitic
Brain hemorrhage
Brain infarct

Causes of Subjective Tinnitus

Cardiovascular

Change in blood pressure

Anemia
Cardiac arrhythmias
Atherosclerosis

Causes of Subjective Tinnitus

Pharmacologic

Antibiotics: aminoglycosides, erythromycin, vancomycin

Chemotherapeutic drugs: vincristine, cisplatin
Diuretics: furosemide
Quinine medication for malaria
Anti depressants: heterocyclines
Aspirin and other NSAIDS in high doses

Causes of Subjective Tinnitus

Psychogenic
Anxiety
Depression

 Middle ear
infections
Otosclerosi
s
Pagets
disease

Inner Ear

Ear wax
Perforated
Ear drum

Middle Ear

External Ear

Broad outline of causes

Sensorine
ural
hearing
loss
Menieres
disease

 Antibiotics
Anti
depressants
Chemotherapeutic
drugs
Aspirin and
other NSAIDS
Sedatives

Non-auditory causes

Hypertension
Anemia
Thyroid
disorders
Vascular
disorders
Acoustic
tumors

Medicines

Systemic Disorders

Broad outline of causes

Head trauma
TMJ disorders
Neck
misalignment

INVESTIGATIONS FOR TINNITUS

A thorough clinical evaluation, including a complete patient

history and medication regimen, helps the doctor to determine if
tinnitus is present and what may be the cause of the condition.
Specialized tests are performed to diagnose tinnitus. Some of
these tests measure the specific features of the tinnitus itself.
These tests may include:

PHYSICAL EXAMINATION
It includes not just the ear but also the entire head, neck
and torso.
It also includes auscultation of the neck for bruits, which
can be transmitted along the carotid artery and for
venous hums, which can be transmitted along the
jugular vein.
Ausculatation should also be performed around the
cranium to check for arteriovenous malformations and
Pagets disease which can in rare cases contribute to
tinnitus.

OTOMICROSCOPIC EXAM

Red hue of Otosclerosis

Bluish tint of an uncovered Jugular vein.
Tympanic membrane exam for fluid infections.
Tumors of middle ear includimg glomus tumors can be
observed.
Toynbee tube(stethoscope with olive tip) or an electronic
stethoscope can be used to listen to the ear for objective
tinnitus.

 With glomus tumors, the pulsatile rush of blood in tumor

can be heard.
Tuning forks can be used to assess hearing, prior to
obtaining audiometric data.

Laboratory Tests
CBC (to rule out anemia as the cause of tinnitus)
X-Rays (to rule out any injury to the bones of head and neck
especially the whiplash injuries, TMJ related injuries , any
excessive bone growth or tumors etc.)
Thyroid function tests (to rule out Hypothyroidism or other
hormonal disorders.)
Radiological tests (CT scan , MRI)
Audiological tests
Blood tests for Syphylis (flourescent treponemal antibody
absorption (FTA-ABS), ANA, sedimentation rate etc.)

Radiological Imaging
For Pulsatile tinnitus, MRI with or without MR angiographic
scanning may be needed to look for a glomus tumor,
arteriovenous malformations, vascular anomalies, dural arterio
venous fistula and aneurysms of the carotid in the ear.
MRI of internal auditory canals is indicated to look for an acoustic
tumor in the case of unilateral hearing loss or tinnitus.
CT scan of the temporal bone will delineate a sigmoid sinus
diverticulum or bony dehiscence over the jugular bulb.
PET scan is done to identify areas of enhanced neural activity.
Used pretreatment and posttreatment to identify changes in
neural activity.

Audiological tests
A hearing test is almost always needed to identify any
condition that involves the auditory system. This should
be the first step in an audiological evaluation of tinnitus,
since about 90 percent of cases occur with hearing loss.
In addition to routine pure tone and speech
audiometry, a range of audiological tests can help
assess the health and function of your middle ear, inner
ear, and auditory pathway.
They may include:

Tympanometry
Otoacoustic emissions
Electrocochleography
Auditory brainstem responses
Vestibular evoked myogenic
potentials

TINNITUS TEST PROTOCOLS

This includes pitch and loudness matching of tinnitus
and how it interacts with an external sound, or what is
termed maskability and residual inhibition.
90% of patients with tinnitus match their tinnitus at 20dB
or less.
84% match their tinnitus at 9dB or less.
Minimum masking levels should also be obtained if
treatment with ear level devices is being considered.