Applied Evidence

A triage guide for tinnitus

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Ringing in the ears may be symptomatic of a serious condition—or it may be benign. This guide can help you tell the difference.


 

References

PRACTICE RECOMMENDATIONS

Let patients know that they can learn to manage their reactions to tinnitus with methods that include stress reduction, therapeutic sound, and coping skills. A

Refer patients with tinnitus to an audiologist for a hearing evaluation, assessment of the tinnitus, and, if indicated, support in learning to manage reactions to tinnitus. A

Give patients with suicidal ideation or extreme anxiety or depression in response to tinnitus a same-day referral to a mental health professional. A

Provide an urgent referral to an otolaryngologist or emergency care if you suspect sudden sensorineural hearing loss or another urgent medical condition. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

“Doctor, I have this ringing in my ears.”

With an estimated 10% to 15% of adults experiencing chronic tinnitus,1 most primary care physicians are familiar with this complaint. The prevalence of tinnitus increases with age and with exposure to high levels of noise—the most commonly reported cause.1 With people living longer and such “toxic” noise levels on the rise, tinnitus is a condition you can expect to encounter even more frequently.

Despite the prevalence of tinnitus, however, there are no clinical standards or best practice guidelines for managing it. Thus, many physicians are uncertain about what to tell patients with this distressing disorder, and when (or whether) to refer them to specialists. So patients are sometimes told that “nothing can be done” and that they simply must “learn to live with” tinnitus.

Such negative messages from a trusted physician can have a detrimental effect, causing some patients to stop seeking help and to become increasingly disturbed by tinnitus.2 What’s more, these messages are untrue. Some conditions that result in tinnitus can be treated. And, although tinnitus itself cannot normally be cured, there are numerous interventions and educational strategies that can help patients change their reactions to—and learn to cope with—the ringing in their ears. We developed this evidence-based review and tinnitus triage guide (TABLE 1) to help family physicians respond appropriately to this distressing, but common, condition.

TABLE 1
Tinnitus triage guide27

If the patientRefer toStatus/considerations
Has neural deficits such as facial weakness, head trauma, or other urgent medical conditionOtolaryngology or EDEmergency
Has unexplained sudden hearing lossAudiology and otolaryngologyEmergency; must see audiologist prior to otolaryngologist on same day
Expresses suicidal ideation or manifests obvious mental illnessMental health or EDMay be emergency; report suicide ideation; provide escort, if necessary
Has any of the following:
  • symptoms suggestive of somatic origin of tinnitus (eg, tinnitus that pulses with heartbeat)
  • persistent otalgia or otorrhea
  • vestibular symptoms (eg, dizziness/vertigo)
Otolaryngology and audiologyUrgent; schedule otolaryngology exam as soon as possible
Has symptoms that suggest a neurophysiologic origin of tinnitus without:
  • ear pain, drainage, or malodor
  • vestibular symptoms
  • sudden hearing loss
  • facial weakness or paralysis
Audiology and otolaryngologyNonurgent; schedule audiology exam before patient sees otolaryngologist
ED, emergency department.

Is it transient noise, or tinnitus?

Virtually everyone experiences “transient ear noise,” which is usually described as a whistling sound accompanied by a sensation of sudden temporary hearing loss.3,4 These idiopathic episodes are usually unilateral, and often accompanied by a feeling of ear blockage.

To distinguish between tinnitus—the perception of sound that is produced internally, rather than by an external stimulus—and transient ear noise, consider the duration and frequency. Transient ear noise generally disappears within seconds (and does not require diagnostic testing or treatment). Tinnitus, which can have a variety of underlying pathologies, is defined as ear or head noise that lasts at least 5 minutes and occurs at least twice a week.5

Neurophysiologic tinnitus is most common

Neurophysiologic (sensorineural) tinnitus, which originates within the auditory nervous system, accounts for the vast majority of cases. The pathology exists anywhere between the cochlea and the auditory cortex, and excludes any sounds generated by mechanical (somatic) processes.6

The ringing may be relatively soft; in some cases, it can be heard only in quiet environments or while the patient is trying to sleep. In others, the tinnitus may be constant, interfering with concentration and daily activities, as well as sleep. In the most severe cases, tinnitus may be associated with severe depression and anxiety, even to the point of suicidal ideation.7

Notably, however, the loudness or other perceptual characteristics of tinnitus do not necessarily indicate the degree to which it is a problem for the patient.7 Although patients often report that tinnitus interferes with their hearing, they usually also have hearing loss, which an audiologic evaluation will reveal.7-9

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