Maura K.

Cosetti

Tinnitus, or the perception of sound in the absence of an

external auditory source, is a common patient complaint
in otolaryngologic practices. Recent studies estimate that
tinnitus may affect up to 50 million adults in the United
States, with 16 million experiencing frequent or chronic
tinnitus in the prior 12 months (1,2). The distinction
between nonpulsatile and pulsatile tinnitus and subjec
tive and objective tinnitus are critical in the appropriate
diagnosis and management of these patients. This chapter
discusses the theories of pathophysiology, epidemiology,
assessment tools, and diagnostic and therapeutic
consider ations associated with each type of tinnitus. As
hyperacusis frequently presents in conjunction with
nonpulsatile sub jective tinnitus, we include a discussion
of this condition along with that form of tinnitus.
Unfortunately, tinnitus, particularly the more common
nonpulsatile subjective form, is frequently dismissed
due to the mistaken belief that there is no available
therapy for these patients; tinni tus patients are instructed
that there is Hno pill or surgery to help them and
subsequently discharged. In this chapter, we discuss the
various forms of tinnitus, and rational guidelines for
their diagnosis and management.

HISTORY
EXAMINATION

AN D

PHYSICAL

Classification
Although a variety of tinnitus classification systems have
been proposed, there is no currently accepted system in
widespread use. At present, the most clinically relevant dis
tinction for the general otolaryngologist is the character
ization of subjective versus objective and pulsatile versus
nonpulsatile tinnitus. Classification of a patient's tinnitus
into these different categories can aid in appropriate diag
nosis and management of his or her complaint, and so
the patient's history and physical examination should be
structured to first determine the answers to these critical
questions.

Pamela C. Roehm

The distinction between pulsatile and nonpulsatile

tinnitus is based on the patient's description of the sound
that he or she perceives. Further discrimination of
pulsatile sounds into arterial (pulsations following the
heartbeat) or venous ("whooshing" sounds) can also be
based on the patient's description. The distinction
between subjec tive (heard only by the patient) and
objective (able to be heard by patient and examiner) is
also critical in diagnosis and treatment of tinnitus and is
made during the physi cal examination (3). Objective
tinnitus can occasionally be heard without other
instrumentation by the clinician (as in patients with
tinnitus resulting from mechanical car diac valves).
More commonly, the sound is perceived on auscultation
of the periauricular region, ear canal, neck, or chest.
Patient confirmation that the sound in question is
identical to their tinnitus is required for definite
identifica tion. Objective tinnitus is rare and suggests an
identifiable source for the acoustic stimulus underlying
the tinnitus, such as a vascular bruit. vascular tumor, and
palatal or ten sor tympani myoclonus (4).
Pulsatile tinnitus can be either subjective or objective,
while nonpulsatile tinnitus is almost exclusively
subjective. Patients' descriptions of both pulsatile and
nonpulsatile tinnitus can vary significantly, so clinical
acumen is often required to effectively characterize the
type of tinnitus. Typically, nonpulsatile tinnitus is
described as "ringing. "hissing." "buzzing." or "roaring."
In contrast, sounds char acterized as rhythmic, concordant
with the patient's pulse, modified by external
movements, or altered by changes in position should be
classified as "pulsatile" tinnitus.

History
A careful and accurate history of the present illness is cru
cial for tinnitus characterization and has important impli
cations in both diagnosis and therapeutic management.
In addition to differentiating pulsatile from nonpulsatile

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Section IX: Otology

tinnitus, the history should clarify the location, that is,

unilateral or bilateral, onset, duration, intensity, and other
elements of the quality of the perceived sound.
Modifying factors, such as external movements or
position changes, should be identified. Patients
complaining of pulsatile tinnitus should be directly
asked if the pulsations of their tinnitus concords with
their pulse (5). Review of systems should include
questioning regarding the patient's mood and sleep
patterns, particularly for patients complaining of
subjective nonpulsatile tinnitus.
A complete otologic history should be obtained from
every tinnitus patient, including associated symptoms of
hearing loss, otalgia, otorrhea, autophony. vertigo, imbal
ance, disequilibrium, and other neurologic symptoms.
Past medical history should include prior history of otitis
media. otologic or neurosurgical procedures, head
trauma. meningitis, exposure to ototoxic medications
(including antibiotics, chemotherapeutic agents, and
nonsteroidal anti-inflammatory medications), history of
autoimmune diseases, and current or prior psychiatric
disorders. A list of current medications, including
vitamins, herbal supple ments, and over-the-counter
medications, is necessary. Finally. the clinician should
inquire about pertinent fam ily history. such as
paragangliomas. Social history should include tobacco,
alcohol, illicit drug usage, and intake of caffeine, all of
which can cause or increase nonpulsatile tinnitus. Levels
of previous noise exposure should be deter mined.
Physical Examination
A complete head and neck exam should be performed,
including otoscopy (by binocular microscopy), pneu
matic otoscopy, and tuning fork exam (both the Weber
and Rinne). The tympanic membrane should be closely
observed for medial and lateral excursions associated
with breathing. Patients should be monitored for
torsional nys tagmus during pneumatic otoscopy (fistula
test), prefer ably with Frenzel lenses in place. The
patient should be questioned for vertigo induced during
pneumatic insuffla tion of the ear canal (Hennebert
symptom). Cranial nerves should be tested. Additional
elements of a neurotologic examination, including
cerebellar function, gait evalua tion, Romberg and
Fukuda testing. and positional testing. should be
performed when appropriate.
For patients complaining of pulsatile tinnitus, palpa
tion of the postauricular region, mastoid, and neck should
note any thrills or vascular cords. Auscultation of periau
ricular region, neck, and chest should note the presence
of objective tinnitus as well as the presence of any bruits,
vascular hums, or murmurs. Light ipsilateral and bilateral
neck compression should be performed to assess the
effect of decreased jugular venous flow on presence or
intensity of the pulsatile tinnitus. In young patients,
carotid artery compression can also be attempted with the
goal of differ entiating venous from arterial causes of

pulsatile tinnitus.

Careful exam of the temporomandibular joint and ipsi

lateral pterygoid muscles should note any tenderness,
dicking. or inflammation. Palpation of the pre- and supra
auricular regions should assess for parotid abnormalities
or masses. Flexible fiberoptic nasopharyngoscopy should
be performed when examination of the eustachian tube
(ET) orifice is warranted or when palatal myodonus is
sus pected.
Diagnostic Evaluation
The initial evaluation of a patient presenting with
tinnitus should include a complete audiogram,
including pure tone and spondee thresholds, word
recognition scores, and tympanometry. Often it is
useful to perform this test prior to evaluation in the
otolaryngologist's office, as it is critical in the
determination of the etiology of tinnitus and
appropriate therapy. Other audiologic tests, includ ing
immittance testing, auditory brainstem responses,
otoacoustic emissions, and high-frequency
audiograms, may be useful in evaluation of select
patients with tin nitus. Testing for vestibular function,
(vestibular evoked myogenic potentials [VEMPs],
videonystagmography [VNG], and rotational chair
testing) may be warranted in the evaluation of patients
with specific complaints and
:findings on physical examination, as discussed below.
Similarly. imaging studies may be indicated for

certain patients who present with tinnitus, but are not

required for all.

SUBJECTIVE NONPULSATILE TINNITUS

Etiology
A variety of clinical entities may underlie nonpulsatile
tinnitus. Most often, these conditions cause hearing loss,
which is thought to be the initial step in the generation of
tinnitus in these patients. Noise-induced hearing loss, pres
byacusis, ototoxic medications, labyrinthitis, herpes zoster
oticus, Meniere's disease, and genetic hearing losses cause
inner ear hair cell damage resulting in hearing loss, which
can lead to nonpulsatile tinnitus. Chronic otitis media,
cholesteatoma, canal occlusion, and otosclerosis can cause
a conductive hearing loss that ultimately may result in tin
nitus. Lesions that affect the cochlear nerve and central
nervous system (CNS) such as acoustic neuroma, meningi
oma, multiple sclerosis, and Charcot-Marie-Tooth disease
can also induce tinnitus, typically along with a coincident
hearing loss (Fig. 161.1, Table 161.1).
However, not every patient with a hearing loss will
have tinnitus. Additionally. patients without a discern
able hearing loss (including evaluation with a high-fre
quency audiogram) or other identifiable pathology may
suffer from tinnitus as well. Other primary causes of tin
nitus include pharmacologic or dietary stimulants, head
trauma, and psychiatric disorders. Drugs or stimulants