The Clinical Approach to a 67-Year-Old Man With Worsening Tinnitus
Ronald N. Rubin, MD—Series Editor
Rubin RN. The clinical approach to a 67-year-old man with worsening tinnitus. Consultant. 2019;59(1):20-21.
A 67-year-old man noticed a worsening of tinnitus, which he characterized as roaring sounds bilaterally. He had had mild symptoms for some time, but the severity had worsened in recent months. He was not sure about whether he had sustained any hearing loss, but he said that those around him suspected that there had been some hearing loss, such as when there is conversation around him rather than directed at him.
He reported having no pain in the ears, no headaches, no vertigo, and no balance disorder symptoms. He was otherwise extremely healthy, without major medical diagnoses such as diabetes mellitus. He said that the tinnitus is most noticeable when going to sleep but that he is able to do so without major difficulty.
He was now retired but had spent a career in factory work, during which he had had significant exposure to loud machinery noise. Although ear protection eventually became routine in the workplace, this was much less the case early in his career. He also had served 3 years of active duty in the Navy during the Vietnam War, including significant time on deck duty on an aircraft carrier with the attendant extreme noise exposure.
Physical examination revealed a strongly built man appearing younger than his stated chronological age. All vital signs were normal. Gross tuning fork testing seemed to demonstrate somewhat diminished hearing bilaterally compared with the examiner. There was no nystagmus, and the ear canals and tympanic membranes are patent, noninflamed, and otherwise normal.
Answer: A, obtain audiometry to detect the presence and degree of coexisting hearing loss.
The patient presented here has the very common symptom of tinnitus (approximately 5% overall, with most predominance in people older than 60), which is the perception of sounds in the absence of external sources. Although tinnitus traditionally is described as ringing, the sounds can vary from ringing to buzzing and even roaring, which was this patient’s perception.
The initial evaluation of tinnitus involves good old-fashioned physician-to-patient careful history-taking and examination, which will quickly identify several key issues that will direct further workup and which if any therapeutic strategies need to be considered.
First, is the patient’s tinnitus objective? Can the sound (however it is described) be correlated with sounds arising within the body, such as clicks from auditory muscle or swallowing muscle contractions, or pulsatile or flowlike sounds from blood flow? Or is the tinnitus subjective—a sound without any of these correlations? The latter is by far the more common.
Second, are there history or physical examination findings related to the presence of pathology in the ears or even more centrally, such as ear pain, ear drainage, nystagmus, vertigo, and dizziness? Any of these findings may point to a middle ear, cochlear, or even retrocochlear etiology. If and when these findings are present, then imaging of the area (Answer B) is indicated. Otherwise, imaging is not indicated.1
And third, back to the patient’s history, how bothersome is the subjective tinnitus? And, does he have a significant background of long-term exposure to loud noises, which is the situation in most cases?1
Our patient’s history is consistent with subjective tinnitus that is clearly associated with a lifetime of exposure to loud noise levels. And since he has brought it to medical attention, at presentation it is somewhere between trivial and bothersome in qualitative assessment. The tinnitus is not acute and has been present for more than 6 months.
The next steps in the workup have an accepted guideline. Almost always (97% of the time),1 a comprehensive audiologic examination will find significant, symmetric hearing loss in the 500 to 4000 Hz range and will uncover unilaterality or other findings indicating a cochlear or retrocochlear abnormality that might steer the evaluation back to imaging or other studies to determine the etiology and diagnosis.1,2
If we have diagnosed subjective, uncomplicated tinnitus associated with bilateral hearing loss, such as in our patient’s case, the focus turns to the best management options and prognosis. Thus, Answer A is the optimal and indicated next step in the presented case.
Once the initial clinical and audiometric evaluation has been completed, and the firm diagnosis is that of primary tinnitus, and management is indicated (eg, if the patient characterizes the tinnitus as “persistent” or “bothersome”), two interrelated strategies have a good track record of efficacy: the use of hearing aids to amplify speech and environmental sound, and the use of broadband sound generators.
Both of these approaches involve acoustic stimulation, which is thought to reverse a maladaptive increase in central auditory activity that is compensating for the loss of auditory neural input associated with the usual ongoing hearing loss in these patients. The best results have been reported in the patient groups with demonstrated hearing loss using both modalities in combination.1,2 This usually involves the use of modern hearing aid devices that increase auditory speech input as well as increase input of background sounds such as broadband noises.1,2
Answers C and D, both incorrect and not appropriate, address management schemes other than or in addition to the useful therapies discussed above. As can be so typical when assessing a variable and subjective symptom such as tinnitus, the use of a myriad of psychological and tangential medications have been evaluated. Suffice it to say that in a large quantity of trials, there is no evidence of efficacy for either antidepressant and antiepileptic drugs (Answer C) or forms of psychologic therapy, and neither are part of published guidelines.
Answer D, firm reassurance with later follow-up, is an overstatement. Many patients with tinnitus are quite concerned that perhaps they are going deaf. The primary care provider at the start and the specialist in detail later on must educate the patient that the ultimate prognosis most often is quite good, that certain maneuvers will help now as well as later on if needed for both the tinnitus symptoms and any related hearing loss. It is not enough to quickly dismiss the concern as trivial, to not arrive at a firm diagnosis, and to not discuss the current extent of hearing loss and what interventions might improve the patient’s symptoms now and/or later as needed.
Audiometry was arranged for the patient, and the results showed symmetric moderate hearing impairment in the 500 to 4000 Hz range. He was evaluated for hearing aids and is in the early phases of adjusting to their use, but he already notes significant improvement in tinnitus when they are in place.
Bothersome and persistent tinnitus is common and has varying characteristics such as ringing, buzzing, or roaring in the ears. A history of significant exposure to loud noises will almost always be present. There will very frequently also be either clinically apparent or audiometry-documented concomitant hearing loss in the 500 to 4000 Hz range. Initial evaluation includes excluding objective forms of tinnitus (eg, pulsation related) and the presence of coincident neurological findings such as nausea, emesis, vertigo, and nystagmus, which suggest a cochlear or retrocochlear etiology. If these are absent, little is gained from imaging, and the indicated next step is audiometry, which usually detects the presence of hearing loss. Management principles include patient education about the process and the use of hearing aids, which improve both hearing and tinnitus in most cases. No medications are currently available that have been shown to be effective in ameliorating tinnitus.
Ronald N. Rubin, MD, is a professor of medicine at the Lewis Katz School of Medicine at Temple University and is chief of clinical hematology in the Department of Medicine at Temple University Hospital in Philadelphia, Pennsylvania.
- Bauer CA. Tinnitus. N Engl J Med. 2018;378(13):1224-1231.
- Shargorodsky J, Curhan GC, Farwell WR. Prevalence and characteristics of tinnitus among US adults. Am J Med. 2010;123(8):711-718.