Download PDF
Semin Neurol 2013; 33(03): 256-269
DOI: 10.1055/s-0033-1354603
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Tinnitus: Diagnostic Approach Leading to Treatment

Robert Aaron Levine
1   Department of Otolaryngology, Tel Aviv Sourasky (Ichilov) Medical Center, Tel Aviv, Israel
› Author Affiliations
Further Information

Publication History

Publication Date:
21 September 2013 (online)

    Permissions and Reprints

Abstract

Optimal care for a patient with tinnitus begins with identifying the cause of the tinnitus. Once the cause has been identified then an appropriate treatment plan can be initiated. In this article, the author reviews how to identify the tinnitus etiology and its treatment.

The workup begins with the patient's description of the percept because in some cases, the quality of the tinnitus will make the diagnosis (e.g., clicking, which is readily suppressed pharmacologically); in other cases, it will give direction in the diagnostic evaluation (e.g., pulsatile). With the exception of a small dural arteriovenous malformation, the source of objective pulsatile tinnitus can be determined without conventional cerebral angiography. If the diagnostic workup is unrevealing and the pulsations are not suppressed with somatic testing, then eighth nerve vascular compression becomes the likely etiology, especially if there is some clicking also heard, no matter how minor.

The two major causes of tinnitus are hearing loss and myofascial disorders of the head and neck. Moreover, the two can combine and cause tinnitus even though either condition alone would not have caused tinnitus. Although the tinnitus of hearing loss is not easily treatable, the tinnitus from myofascial disorders is often responsive to an optimized myofascial treatment program. Hyperacusis, a frequent accompaniment of tinnitus, and its treatment are discussed.

Keywords

tinnitus - somatic - eighth nerve - craniocervical - dorsal cochlear nucleus - vascular compression - stress - hyperacusis
 

  • References

  • 1 Oron Y, Roth Y, Levine RA. Sudden brief unilateral tapering tinnitus: prevalence and properties. Otol Neurotol 2011; 32 (9) 1409-1414
    CrossrefPubMedGoogle Scholar
  • 2 Marchiando A, Per-Lee JH, Jackson RT. Tinnitus due to idiopathic stapedial muscle spasm. Ear Nose Throat J 1983; 62 (1) 8-13
    PubMedGoogle Scholar
  • 3 Palikh GM, Vaughn BV. Topiramate responsive exploding head syndrome. J Clin Sleep Med 2010; 6 (4) 382-383
    PubMedGoogle Scholar
  • 4 Pearce JM. Clinical features of the exploding head syndrome. J Neurol Neurosurg Psychiatry 1989; 52 (7) 907-910
    CrossrefPubMedGoogle Scholar
  • 5 Brantberg K. Paroxysmal staccato tinnitus: a carbamazepine responsive hyperactivity dysfunction symptom of the eighth cranial nerve. J Neurol Neurosurg Psychiatry 2010; 81 (4) 451-455
    CrossrefPubMedGoogle Scholar
  • 6 Levine RA. Typewriter tinnitus: a carbamazepine-responsive syndrome related to auditory nerve vascular compression. ORL J Otorhinolaryngol Relat Spec 2006; 68 (1) 43-46 , discussion 46–47
    CrossrefPubMedGoogle Scholar
  • 7 Nam EC, Handzel O, Levine RA. Carbamazepine responsive typewriter tinnitus from basilar invagination. J Neurol Neurosurg Psychiatry 2010; 81 (4) 456-458
    CrossrefPubMedGoogle Scholar
  • 8 Russell D, Baloh RW. Gabapentin responsive audiovestibular paroxysmia. J Neurol Sci 2009; 281 (1-2) 99-100
    CrossrefPubMedGoogle Scholar
  • 9 Levine RA, Nam EC, Melcher J. Somatosensory pulsatile tinnitus syndrome: somatic testing identifies a pulsatile tinnitus subtype that implicates the somatosensory system. Trends Amplif 2008; 12 (3) 242-253
    CrossrefPubMedGoogle Scholar
  • 10 Cardarelli F, Melcher JR, Szeles JC , et al. Continuous auricular electrical stimulation quiets the tinnitus of the somatosensory pulsatile tinnitus syndrome. In Fourth International TRI Tinnitus Conference: Frontiers in Tinnitus Research. Regensburg, Germany: Tinnitus Research Initiative; 2010: 61
    Google Scholar
  • 11 Sismanis A. Pulsatile tinnitus: contemporary assessment and management. Curr Opin Otolaryngol Head Neck Surg 2011; 19 (5) 348-357
    Google Scholar
  • 12 Madani G, Connor SE. Imaging in pulsatile tinnitus. Clin Radiol 2009; 64 (3) 319-328
    Google Scholar
  • 13 Ryu H, Yamamoto S, Sugiyama K, Uemura K, Nozue M. Neurovascular decompression of the eighth cranial nerve in patients with hemifacial spasm and incidental tinnitus: an alternative way to study tinnitus. J Neurosurg 1998; 88 (2) 232-236
    CrossrefPubMedGoogle Scholar
  • 14 De Ridder D, Vanneste S, Adriaenssens I , et al. Microvascular decompression for tinnitus: significant improvement for tinnitus intensity without improvement for distress. A 4-year limit. Neurosurgery 2010; 66 (4) 656-660
    CrossrefPubMedGoogle Scholar
  • 15 Baurier VO, Tuca JO. Auditory hallucinosis in brainstem lesions and musical hallucination in deafness. Analogies and differences. Eur J Neurol 1996; 3 (3) 203-211
    CrossrefPubMedGoogle Scholar
  • 16 Heller MF, Bergman M. Tinnitus aurium in normally hearing persons. Ann Otol Rhinol Laryngol 1953; 62 (1) 73-83
    PubMedGoogle Scholar
  • 17 Del Bo L, Forti S, Ambrosetti U , et al. Tinnitus aurium in persons with normal hearing: 55 years later. Otolaryngol Head Neck Surg 2008; 139 (3) 391-394
    CrossrefPubMedGoogle Scholar
  • 18 Knobel KA, Sanchez TG. Influence of silence and attention on tinnitus perception. Otolaryngol Head Neck Surg 2008; 138 (1) 18-22
    CrossrefPubMedGoogle Scholar
  • 19 Levine RA, Abel M, Cheng H. CNS somatosensory-auditory interactions elicit or modulate tinnitus. Exp Brain Res 2003; 153 (4) 643-648
    CrossrefPubMedGoogle Scholar
  • 20 Tucker DA, Phillips SL, Ruth RA, Clayton WA, Royster E, Todd AD. The effect of silence on tinnitus perception. Otolaryngol Head Neck Surg 2005; 132 (1) 20-24
    CrossrefPubMedGoogle Scholar
  • 21 Abel MD, Levine RA. Muscle contractions and auditory perception in tinnitus patients and nonclinical subjects. Cranio 2004; 22 (3) 181-191
    PubMedGoogle Scholar
  • 22 Levine RA. Somatic (craniocervical) tinnitus and the dorsal cochlear nucleus hypothesis. Am J Otolaryngol 1999; 20 (6) 351-362
    CrossrefPubMedGoogle Scholar
  • 23 Huy PT, Sauvaget E. Idiopathic sudden sensorineural hearing loss is not an otologic emergency. Otol Neurotol 2005; 26 (5) 896-902
    CrossrefPubMedGoogle Scholar
  • 24 Coles RR. Tinnitus. In: Stephens D, , ed. Adult Audiology. Guilford, UK: Butterworth Heinemann; 1996
    Google Scholar
  • 25 Fowler EP. Control of head noises: their illusions of loudness and timbre. Arch Otolaryngol 1943; 37: 391-398
    CrossrefPubMedGoogle Scholar
  • 26 Chung DY, Gannon RP, Mason K. Factors affecting the prevalence of tinnitus. Audiology 1984; 23 (5) 441-452
    CrossrefPubMedGoogle Scholar
  • 27 Häusler R, Levine RA. Auditory dysfunction in stroke. Acta Otolaryngol 2000; 120 (6) 689-703
    CrossrefPubMedGoogle Scholar
  • 28 Larson PS, Cheung SW. A stroke of silence: tinnitus suppression following placement of a deep brain stimulation electrode with infarction in area LC. J Neurosurg 2013; 118 (1) 192-194
    CrossrefPubMedGoogle Scholar
  • 29 Lowry LD, Eisenman LM, Saunders JC. An absence of tinnitus. Otol Neurotol 2004; 25 (4) 474-478
    CrossrefPubMedGoogle Scholar
  • 30 Ashton H. Protracted withdrawal syndromes from benzodiazepines. J Subst Abuse Treat 1991; 8 (1-2) 19-28
    CrossrefPubMedGoogle Scholar
  • 31 McConnell JG. Benzodiazepine tolerance, dependency, and withdrawal syndromes and interactions with fluoroquinolone antimicrobials. Br J Gen Pract 2008; 58 (550) 365-366
    PubMedGoogle Scholar
  • 32 Penner MJ. Linking spontaneous otoacoustic emissions and tinnitus. Br J Audiol 1992; 26 (2) 115-123
    CrossrefPubMedGoogle Scholar
  • 33 Penner MJ, Coles RR. Indications for aspirin as a palliative for tinnitus caused by SOAEs: a case study. Br J Audiol 1992; 26 (2) 91-96
    CrossrefPubMedGoogle Scholar
  • 34 Yuen HW, Eikelboom RH, Atlas MD. Auditory manifestations of superior semicircular canal dehiscence. Otol Neurotol 2009; 30 (3) 280-285
    CrossrefPubMedGoogle Scholar
  • 35 Dornhoffer JL, Helms J, Hoehmann DH. Presentation and diagnosis of small acoustic tumors. Otolaryngol Head Neck Surg 1994; 111 (3 Pt 1) 232-235
    CrossrefPubMedGoogle Scholar
  • 36 Morrison GA, Sterkers JM. Unusual presentations of acoustic tumours. Clin Otolaryngol Allied Sci 1996; 21 (1) 80-83
    PubMedGoogle Scholar
  • 37 Curtin HD. Rule out eighth nerve tumor: contrast-enhanced T1-weighted or high-resolution T2-weighted MR?. AJNR Am J Neuroradiol 1997; 18 (10) 1834-1838
    PubMedGoogle Scholar
  • 38 Fortnum H, O'Neill C, Taylor R , et al. The role of magnetic resonance imaging in the identification of suspected acoustic neuroma: a systematic review of clinical and cost effectiveness and natural history. Health Technol Assess 2009; 13 (18) iii –iv, ix–xi, 1–154
    PubMedGoogle Scholar
  • 39 Dawes PJ, Basiouny HE. Outcome of using magnetic resonance imaging as an initial screen to exclude vestibular schwannoma in patients presenting with unilateral tinnitus. J Laryngol Otol 1999; 113 (9) 818-822
    PubMedGoogle Scholar
  • 40 Don M, Kwong B, Tanaka C. Interaural stacked auditory brainstem response measures for detecting small unilateral acoustic tumors. Audiol Neurootol 2012; 17 (1) 54-68
    PubMedGoogle Scholar
  • 41 Biesinger E. [C2 and C3 cervical nerve root syndrome: the influence of cervical spine dysfunction on ENT symptoms]. Manuelle Medizin 1997; 35: 12-19
    PubMedGoogle Scholar
  • 42 Chole RA, Parker WS. Tinnitus and vertigo in patients with temporomandibular disorder. Arch Otolaryngol Head Neck Surg 1992; 118 (8) 817-821
    CrossrefPubMedGoogle Scholar
  • 43 Tjell C, Tenenbaum A, Rosenhall U. Auditory function in whiplash-associated disorders. Scand Audiol 1999; 28 (4) 203-209
    CrossrefPubMedGoogle Scholar
  • 44 Tranter RM, Graham JR. A review of the otological aspects of whiplash injury. J Forensic Leg Med 2009; 16 (2) 53-55
    CrossrefPubMedGoogle Scholar
  • 45 Teachey WS, Wijtmans EH, Cardarelli F, Levine RA. Tinnitus of myofascial origin. Int Tinnitus J 2012; 17: 70-73
    PubMedGoogle Scholar
  • 46 Han SS, Nam EC, Won JY , et al. Clonazepam quiets tinnitus: a randomised crossover study with Ginkgo biloba. J Neurol Neurosurg Psychiatry 2012; 83 (8) 821-827
    CrossrefPubMedGoogle Scholar
  • 47 Jalali MM, Kousha A, Naghavi SE, Soleimani R, Banan R. The effects of alprazolam on tinnitus: a cross-over randomized clinical trial. Med Sci Monit 2009; 15 (11) PI55-PI60
    PubMedGoogle Scholar
  • 48 Johnson RM, Brummett R, Schleuning A. Use of alprazolam for relief of tinnitus. A double-blind study. Arch Otolaryngol Head Neck Surg 1993; 119 (8) 842-845
    CrossrefPubMedGoogle Scholar
  • 49 Attias J, Zwecker-Lazar I, Nageris B, Keren O, Groswasser Z. Dysfunction of the auditory efferent system in patients with traumatic brain injuries with tinnitus and hyperacusis. J Basic Clin Physiol Pharmacol 2005; 16 (2-3) 117-126
    PubMedGoogle Scholar
  • 50 Ceranic BJ, Prasher DK, Raglan E, Luxon LM. Tinnitus after head injury: evidence from otoacoustic emissions. J Neurol Neurosurg Psychiatry 1998; 65 (4) 523-529
    CrossrefPubMedGoogle Scholar
  • 51 Trotter MI, Donaldson I. Hearing aids and tinnitus therapy: a 25-year experience. J Laryngol Otol 2008; 122 (10) 1052-1056
    PubMedGoogle Scholar
  • 52 Peltier E, Peltier C, Tahar S, Alliot-Lugaz E, Cazals Y. Long-term tinnitus suppression with linear octave frequency transposition hearing AIDS. PLoS ONE 2012; 7 (12) e51915
    CrossrefPubMedGoogle Scholar
  • 53 Azevedo AA, Figueiredo RR. Tinnitus treatment with acamprosate: double-blind study. Braz J Otorhinolaryngol 2005; 71 (5) 618-623
    PubMedGoogle Scholar
  • 54 Sharma DK, Kaur S, Singh J, Kaur I. Role of acamprosate in sensorineural tinnitus. Indian J Pharmacol 2012; 44 (1) 93-96
    CrossrefPubMedGoogle Scholar
  • 55 Martin WH. Acamprosate trial for tinnitus. Parer presented at: 10th International Tinnitus Seminar; March 16–18, 2011; Florianopolis, Brazil
    PubMedGoogle Scholar
  • 56 Matsushima JI, Sakai N, Uemi N, Miyoshi S, Sakajiri M, Ifukube T. Evaluation of implanted tinnitus suppressor based on tinnitus stress test. Int Tinnitus J 1997; 3 (2) 123-131
    PubMedGoogle Scholar
  • 57 Van de Heyning P, Vermeire K, Diebl M, Nopp P, Anderson I, De Ridder D. Incapacitating unilateral tinnitus in single-sided deafness treated by cochlear implantation. Ann Otol Rhinol Laryngol 2008; 117 (9) 645-652
    CrossrefPubMedGoogle Scholar
  • 58 Sullivan M, Katon W, Russo J, Dobie R, Sakai C. A randomized trial of nortriptyline for severe chronic tinnitus. Effects on depression, disability, and tinnitus symptoms. Arch Intern Med 1993; 153 (19) 2251-2259
    CrossrefPubMedGoogle Scholar
  • 59 Hoare DJ, Kowalkowski VL, Kang S, Hall DA. Systematic review and meta-analyses of randomized controlled trials examining tinnitus management. Laryngoscope 2011; 121 (7) 1555-1564
    CrossrefPubMedGoogle Scholar
  • 60 Attias J, Shemesh Z, Sohmer H, Gold S, Shoham C, Faraggi D. Comparison between self-hypnosis, masking and attentiveness for alleviation of chronic tinnitus. Audiology 1993; 32 (3) 205-212
    CrossrefPubMedGoogle Scholar
  • 61 Caffier PP, Haupt H, Scherer H, Mazurek B. Outcomes of long-term outpatient tinnitus-coping therapy: psychometric changes and value of tinnitus-control instruments. Ear Hear 2006; 27 (6) 619-627
    CrossrefPubMedGoogle Scholar
  • 62 David JB, Naftali A, Katz A. Tinntrain: a multifactorial treatment for tinnitus using binaural beats. Hearing J 2010; 63: 25-28
    PubMedGoogle Scholar
  • 63 Davis PB, Wilde RA, Steed LG, Hanley PJ. Treatment of tinnitus with a customized acoustic neural stimulus: a controlled clinical study. Ear Nose Throat J 2008; 87 (6) 330-339
    PubMedGoogle Scholar
  • 64 Hesser H, Weise C, Westin VZ, Andersson G. A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioral therapy for tinnitus distress. Clin Psychol Rev 2011; 31 (4) 545-553
    CrossrefPubMedGoogle Scholar
  • 65 Kreuzer PM, Goetz M, Holl M , et al. Mindfulness-and body-psychotherapy-based group treatment of chronic tinnitus: a randomized controlled pilot study. BMC Complement Altern Med 2012; 12: 235
    CrossrefPubMedGoogle Scholar
  • 66 Baguley DM. Hyperacusis. J R Soc Med 2003; 96 (12) 582-585
    CrossrefPubMedGoogle Scholar
  • 67 Blaesing L, Kroener-Herwig B. Self-reported and behavioral sound avoidance in tinnitus and hyperacusis subjects, and association with anxiety ratings. Int J Audiol 2012; 51 (8) 611-617
    CrossrefPubMedGoogle Scholar
  • 68 Florentine M. Relation between lateralization and loudness in asymmetrical hearing losses. J Am Audiol Soc 1976; 1 (6) 243-251
    PubMedGoogle Scholar
  • 69 Formby C, Sherlock LP, Gold SL. Adaptive plasticity of loudness induced by chronic attenuation and enhancement of the acoustic background. J Acoust Soc Am 2003; 114 (1) 55-58
    CrossrefPubMedGoogle Scholar
  • 70 Andersson G, Jüris L, Kaldo V, Baguley DM, Larsen HC, Ekselius L. [Hyperacusis—an unexplored field. Cognitive behavior therapy can relieve problems in auditory intolerance, a condition with many questions]. Lakartidningen 2005; 102 (44) 3210-3212
    PubMedGoogle Scholar
  • 71 Jastreboff PJ, Jastreboff MM. Tinnitus retraining therapy for patients with tinnitus and decreased sound tolerance. Otolaryngol Clin North Am 2003; 36 (2) 321-336
    CrossrefPubMedGoogle Scholar
  • 72 Noreña AJ, Chery-Croze S. Enriched acoustic environment rescales auditory sensitivity. Neuroreport 2007; 18 (12) 1251-1255
    CrossrefPubMedGoogle Scholar
  • 73 Vernon JA. Pathophysiology of tinnitus: a special case—hyperacusis and a proposed treatment. Am J Otol 1987; 8 (3) 201-202
    PubMedGoogle Scholar
  • 74 Sator-Katzenschlager SM, Szeles JC, Scharbert G , et al. Electrical stimulation of auricular acupuncture points is more effective than conventional manual auricular acupuncture in chronic cervical pain: a pilot study. Anesth Analg 2003; 97 (5) 1469-1473
    PubMedGoogle Scholar
  • 75 Kaltenbach JA, McCaslin DL. Increases in spontaneous activity of dorsal cochlear nucleus neurons following intense sound exposure. Aud Neurosci 1996; 3: 57-78
    PubMedGoogle Scholar