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THE BULLETIN
a possible cause of ipsilateral hearing loss and tinnitus. If posi-
tive ABR results are obtained, MRI evaluation of the cerebello-
pontine angle with contrast material (such as gadolinium) should
be performed. Low-pitched roaring, ringing, or hissing tinnitus;
hearing loss, which may be temporary or permanent; vertigo; and
a feeling of pressure or fullness in the ear can indicate endolym-
phatic hydrops or Meniere’s Disease. Symptoms usually occur in
the form of “attacks” that increase in frequency during the first
few years of the disease, then decrease in frequency as hearing
thresholds stabilize. Electrocochleography testing is one way to
diagnose endolymphatic hydrops. Patients who exhibit vestibular
disorders should undergo electronystagmography testing to assess
the severity and characteristics of their symptoms. Pulsatile tinnitus
associated with abnormalities of blood vessels in the neck can be
evaluated with sonography, conventional angiography, or magnetic
resonance angiography. Conditions such as a dehiscent jugular
bulb or stenosis of carotid arteries can sometimes be treated surgi-
cally. However, many forms of pulsatile tinnitus are not caused
by these conditions. Pulsatile tinnitus is often a consequence of
hearing loss; arteriosclerosis; weight loss or weight gain. These
physiologic changes can cause patients to hear blood pulsing or
“swishing” in vessels—sounds they did not perceive previously.
Surgery is not recommended for most cases of pulsatile tinnitus.
Sudden hearing loss, especially if bilateral, might indicate auto-
immune inner ear disease. Diagnostic tests for this include the
Western blot immunoassay.
Treatment of active disease processes
Treatment of the following contributors to tinnitus can help to
mitigate the symptom.
Otitis media.
Successful treatment of the infection with oral anti-
biotics usually resolves auditory symptoms.
Allergies, sinus congestion, or infection.
When inflammation
subsides, tinnitus associated with these conditions usually resolves.
Otosclerosis.
Abnormal accumulations of calcium on middle-ear
ossicles (especially the stapes) or the cochlea can result in slowly
progressing conductive or sensorineural hearing loss, tinnitus, and
vestibular disturbances. Stapedectomy surgery—including implan-
tation of ossicular prostheses—is often successful for advanced
cases associated with significant hearing loss. Hearing aids also
benefit some patients with ototsclerosis + tinnitus.
Meniere’s Disease or other forms of endolymphatic hydrops.
Meniere’s Disease, characterized by abnormally high fluid pres-
sure within the cochlea, has an estimated prevalence of one
percent in the U.S. Management includes meclizine, antiemetics
and diuretics, and a low-sodium diet. If patients do not respond to
meclizine, benzodiazepines can be prescribed to reduce the severity
of vertigo attacks. Surgical intervention—including installation of
an endolymphatic shunt, labyrinthectomy, or vestibular neurec-
tomy—or transtympanic injections of gentamicin are options in
severe cases.
Autoimmune inner ear disease.
This disease has an estimated
prevalence of 0.1 percent in the U.S. Symptoms include sudden
hearing loss in one ear that usually progresses to the second ear.
Patients may also feel fullness in the ear and experience vertigo
as well as ringing, hissing, or roaring tinnitus. Most patients with
autoimmune inner ear disease respond to initial treatment with
oral prednisone.
Auditory neoplasms.
Growths such as acoustic neuroma or
cholesteatoma can cause tinnitus. Acoustic neuroma (or vestibular
schwannoma) is a benign neoplasm that arises from the vestib-
ular division of the eighth cranial nerve. Symptoms include unilat-
eral hearing loss, tinnitus, and vestibular disturbances. Surgical
resection or radiation treatment of the tumor can resolve these
symptoms, especially if the neoplasm is detected while it is small.
Cholesteatoma is a benign epithelial cell mass that grows in the
middle-ear cavity. Over time, cholesteatomas can enlarge and
damage middle ear ossicles. Hearing loss, tinnitus, dizziness, and
facial muscle paralysis can result from continued cholesteatoma
growth. Early detection and surgical resection of auditory neoplasms
can reduce the likelihood or severity of residual symptoms.
Hyper- or hypotension.
Of these two disorders, hypertension is
more likely to contribute to tinnitus. Maintenance of blood pres-
sure within the optimum range can decrease or resolve tinnitus
for some patients.
Metabolic disorders.
Disorders such as diabetes mellitus, hyper-
thyroidism, or hypothyroidism can contribute to tinnitus. Successful
management of these conditions can reduce or resolve the patient’s
tinnitus.
Managing persistent tinnitus
Successful treatment of the disorders discussed above can resolve
or reduce tinnitus. However, if tinnitus continues to bother the
patient after other conditions have been treated, the clinical focus
should shift from “treatment” to “management” of the symptom.
Like other neurologic symptoms, tinnitus can be considered chronic
if it persists for 6 months or more. Approximately 90 percent of
cases of chronic tinnitus are associated with some degree of
sensorineural hearing loss. Because sensorineural hearing loss
is irreversible, most cases of chronic tinnitus cannot be “cured.”
Duckro et al.
9
wrote: “As with chronic pain, the treatment of
chronic tinnitus is more accurately described in terms of manage-
ment rather than cure.” The goal of management is not
neces-
sarily
to mask or remove the patient’s perception of tinnitus. In
many cases, this is not possible. Successful management enables
TINNITUS, CONT.
