Tinnitus CKS | A4 Medicine

1. TINNITUS CKS a4medicine.co.uk

2. FromLatintinnire ( toringortinkle )- asensationofanysoundperceived intheheadorintheearswithoutanevidentexternalstimulus. Atanypointintimearound10 % ofthepopulationexperiencestinnitus ( BTA ) Thereisnostandarddiagnosticcriterionfortinnitusandisnormally determinedbyself -reporttypicallyinreponsetoasinglequestion Tinnitushasareportedprevalenceofabout8-25.3 % intheUSAsystemic review ( AbbyMcCormacketal2016 ) reportedarangefrom5.1to42.7 % NogenderdiscriminationinincidenceHigherincidenceamong- militarypersonnel, stageworkers , drummersandthosewhoperformin frontofloudspeakers Subjectivetinnituscks –Occursinabsenceofanyphysicalsoundreaching theear – audibleonlytothepatient. Causes- waxinexternalear . Middleearcauses – otosclerosis , middleeareffusion

3. Innerearcauses –Noise-inducedhearinglossPresbyacusisMeniere’sdis Trauma ( surgery , headinjury ) OtotoxicdrugsLabyrinthitisAcoustic neuroma Two-thirdsofpeoplewithtinnitushaveadisordercausinghearing impairmentMostcommonlytinnitusisassociatedwithdisorderscausing sensorineuralhearingloss- includes
○agerelated
○noiserelated ( lesscommon )
○Meniere’sdis ( uncommon ) Lesscommonlytinnitusis associatedwithdisorderscausingconductivehearingloss
○wax
○ otosclerosis ( rare ) Ototoxicdrugs ( uncommonly ) Earinfections – including
○otitismedia
○otitismediawitheffusion
○chronic suppurativeotitismediaNeurologicaldisorders
○acousticneuroma
○ multiplesclerosisMetabolicdisorder – thyroiddiseaseanddiabetes Psychological→anxietyanddepressionTraumaoftheheadorneck


4. ObjectiveTinnitus –Generatedinthebodyandreachestheearthrough conductioninbodytissuesandisaudibletothepatientaswellasthe clinician ( alsocalledsomatosounds ).Highcardiacoutput
○treatment ofhypertensionwithACEi’sorCCB’sBenignintracranialhypertension DuralorextracranialAVfistulaCarotidorvertebralarterystenosis , tortuosity , dissectionoraneurysmAorticdissectionandmitral regurgitationDuralorcervcalAVM ( arteriovenousmalformation ) High jugularbulbVestibularschwannomaTemporomandibularjointsyndrome HaemangiomaGlomustumourOtosclerosisPaget’sdisease. Hasa vibratory , clickingorpulsatilecharacterAudiblewithastethoscope
○ placethestethoscopeclosetoexternalauditorymeatusoverthecarotid arteries , andontheskullinfrontandbehindthear. Ifpatientc/o pulsatiletinnitus – clinicianshouldconductextensivesearchforaskull basetumourNumerousvascularcausesofpulsatiletinnitus
mostcommon being○arteriovenousmalformations ( AVM ) and○fistulasBenign intracranialhypertensionhasbeenreportedasamajorcauseofpulsatile tinnitusintoungwomen
 


5. History–Noknownobjectiveteststhatcandeterminetheseverityof subjectivetinnitusunilateralorbilateralconstantorintermittenttriggers aroundonsetwhendiditstartbecomeannoyingassociatedsymptoms
○ deafness
○dizziness
○hyperacusis
○otalgiah/osignoiseexposure drughistory ( ototoxicdruguse ) familyh/ohearinglossfromotosclerosis Otosclersosis→bonearoundthebaseofstapesbecomesthickenedand eventuallyfuseswiththeboneofcochlea→reducesnormalsound transmissionleadingtoconductivehearinglosseffectonlifepsychological Examination –Otoscopy
○wax
○infectionsTuningforktests ( conductive orsensoryhearingloss ) BedsidehearingtestGeneralneurological assessment
○acoustincneuroma
○multiplesclerosisCheckblood pressureBloodtests
○hypoandhyperthyroidism
○FBC
○randomor fastingBMAuscultateears , headandneckifpulsatiletinnitus
○exclude bruitFundoscopy ( benignintracranialhypertension ) Referforformal hearingtest
○puretoneaudiometrywithassessmentofairandbone conductionMRI- forvestibularschwannoma ( acousticneuroma ) RedflagsSuddenonsetpulsatiletinnitusTinnitusinassociationwith significant/severevertigoUnilateraltinnitusTinnitusinassociationwith asymmetrichearinglossortinnituswithunexplainedsuddenhearingloss Tinnitusinassociationwithsignificantneurologicalsymptomandorsigns TinnitusfollowingheadtraumaTinnituscausingpsychologicaldistress 


6. Hearingtest –Arrangeahearingtestforallpatientswithtinnitus- CKS advice’sanaudiologyreferraliftinnituspersistsfortinnitusthatlasts6 monthsormoreTwentypercentofpersonsvisitingtinnitusclinicshave normalhearing discussimpact , concernsanyrecentassessment , managementplans reassurethattinnitusiscommon & mayresolvebyitselfcommonly associatedwithhearinglossbutnotcommonlyassociatedwithother underlyingphysicalproblemsreassurethatmanagementstrategiesexist whichmayhelppeoplelivewellwithtinnitus. Referral – referimmediately -peoplewithtinnituswhoareathighriskof suicidetothecrisisteamreferimmediatelyiftinnitusisassociatedwith
○ suddenonsetofsignificantneurologicalsymptomsorsigns ( egfacial weakness ) or
○acuteuncontrolledvestibularsymptoms ( e,gvertigo ) or
 ○suspectedstrokerefertobeseenwithin24hrsiftheyhavetinnitusand havehearinglossthathasdevelopedsuddenly -
( ieoveraperiodof3 daysorless ) inthepast30daysrefertobeseenwithin2weeksiftinnitus &
○distressaffectingmentalwellbeing ( eveniftheyhavereceived tinnitussupportatfirstpointofcontact )
○hearinglossthatdeveloped suddenlymorethan30daysagoorrapidlyworseninghearingloss ( overa periodof4 -90days ) referfortinnitusassessmentif○continuestobe bothersome
○persistentobjectivetinnitus
○associatedwithasymmetric orunilateralhearinglossconsiderareferralif
○persistentpulsatile tinnitus
○persistentunilateraltinnitus

7. NICErecommendsusingquestionnairestoassesstheimpactoftinnitus TinnitusFunctionalIndex – howtinnitusaffectsthemVisualanaloguescale – ifquestionnairecannotbeusedDiscusshowthisaffectstheirQoLInsomnia SeverityIndex – ifitimpactssleepTinnitusquestionnaire ( TQ ) ormini- TQ alongsideTinnitusFunctionalIndextoassesspsychologicalimpactAssess fordepressionandanxietyusingaquestionnaireoranabilityappropriate measureandagreeonamanagementplaninlinewithcurrentguidance Investigations – somerecommendationsmayrelatetospecialists investigationscaninclude
○audiologicalassessment ( followNICE guidance )
○psychoacoustictests
○imagingofferMRIofinternal auditorymeati ( IAM )
○thosewithnon-pulsatiletinnituswithassociated neurological , otologicalorhead & necksignsandsymptoms
○contrast enhancedCT ( IAM ) isanalternativetechnique
○donotofferimaging forpeoplewithsymmetricalnon-pulsatiletinnituswithnoassociated neurological , audiological , otologicalorhead & necksignsandsymptoms synchronouspulsatiletinnitusconsider
○MRAorMRIofhead , neck , temporalboneandIAMifclinicalexamination & audiologicalassessment arenormalOR
○contrastenhancedCTofhead , neck , temporalbone andIAMiftheycannothaveMRAorMRInon- synchronouspulsatiletinnitus ( fore,gifcausedbypalatalmyoclonus ) considerMRIofheadorcontrast enhancedCTofhead.

8. Amplificationdevice – offerhearingaidiftheyhaveahearinglossthat affectstheirabilitytocommunicateconsiderahearingaidiftheyhavea hearinglossbutdonothavedifficultiescommunicatinghearingaidisnot indicatedinabsenceofhearingloss. Soundtherapy – NICEhasnotmadeanyrecommendationsforpracticein thisareaduetolackofevidenceoftheseinterventionsinisolation.