Describe tinnitus with its causes and management.

Nature and Classification

• Tinnitus is the perception of sound in the absence of an external acoustic stimulus.
• It is a symptom, not a disease, and is extremely common, affecting some 10 to 15% of adults, of whom a small minority are severely troubled.
• Subjective tinnitus — heard only by the patient. This is the great majority

Management

• The first and most important intervention IS explanation and reassurance — that tinnitus is common, that it is not a sign of a brain tumour or of impending deafness, and that it does not damage the ear. A great many patients need nothing further once the fear is removed, and fear is what drives the distress
• Treat any treatable cause — remove wax; treat middle ear disease, Meniere disease and otosclerosis; stop or substitute ototoxic drugs; and correct anaemia or thyroid disease
• Hearing AIDS are the single most effective treatment where there is a hearing loss.
• Sound therapy and masking — environmental sound, bedside sound generators, and wearable maskers, which break the silence in which tinnitus is loudest
• Tinnitus retraining therapy (TRT) combines directive counselling with sound enrichment to achieve habituation — the aim being not to abolish the sound but to make it no longer noticed or distressing, in the way one ceases to notice a refrigerator
• Cognitive behavioural therapy has the best evidence of any intervention for reducing tinnitus-related distress, and should be offered to the significantly troubled patient
• NO drug is licensed or reliably effective for tinnitus itself.
• Treat the sleep disturbance, which is frequently the most disabling consequence, with sleep hygiene and bedside sound
• Screen for depression and ask about suicidal ideation; severe tinnitus carries a real risk and the question is rarely asked
• Advise against silence and against over-protection of the ears, both of which make tinnitus more prominent; but advise hearing protection against genuine noise exposure
• Cochlear implantation frequently improves tinnitus in the profoundly deaf, and is a recognised secondary benefit
• Support groups and patient organisations help many, and the knowledge that others live with it successfully is itself therapeutic
• Tinnitus is a symptom, not a disease, and the search is always for the underlying cause of the hearing loss
• Pulsatile tinnitus always warrants investigation, being the one form with a reliably organic and sometimes serious cause
• Auscultate the ear, mastoid, neck and orbit in pulsatile tinnitus before ordering any imaging