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James A. Henry, PhD; A triage guide for Tara L. Zaugg, AuD; Paula J. Myers, PhD; Caroline J. Kendall, PhD; Ringing in the may be symptomatic of a serious Elias M. Michaelides, MD Veterans Affairs RR&D condition—or it may be benign. Th is guide can help you National Center for Rehabilitative tell the diff erence. Auditory , VA Medical Center, Portland, Ore (Drs. Henry and Zaugg); Department of Otolaryngology/Head and Neck Surgery, Oregon & Science “Doctor, I have this ringing in my ears.” University, Portland (Dr. Henry); James A. Haley PRACTICE VA Hospital, Tampa, Fla RECOMMENDATIONS ith an estimated 10% to 15% of adults experi- (Dr. Myers); › Let patients know that they encing chronic tinnitus,1 most primary care VA Connecticut Healthcare System, West Haven (Drs. can learn to manage their W are familiar with this complaint. Th e Kendall and Michaelides); reactions to tinnitus with prevalence of tinnitus increases with age and with exposure Department of methods that include stress to high levels of —the most commonly reported cause.1 (Dr. Kendall) and reduction, therapeutic sound, Department of Surgery- With people living longer and such “toxic” noise levels on the Otolaryngology (Dr. A and coping skills. rise, tinnitus is a condition you can expect to encounter even Michaelides), Yale School › Refer patients with tinnitus more frequently. of Medicine, New Haven, Conn to an audiologist for a hear- Despite the prevalence of tinnitus, however, there are no ing evaluation, assessment of clinical standards or best practice guidelines for managing it. [email protected] the tinnitus, and, if indicated, Th us, many physicians are uncertain about what to tell pa- support in learning to man- The authors reported no tients with this distressing disorder, and when (or whether) to potential confl ict of interest age reactions to tinnitus. A relevant to this article. refer them to specialists. So patients are sometimes told that › Give patients with suicidal “nothing can be done” and that they simply must “learn to ideation or extreme live with” tinnitus. or depression in response Such negative messages from a trusted can have to tinnitus a same-day a detrimental eff ect, causing some patients to stop seeking referral to a mental health help and to become increasingly disturbed by tinnitus.2 What’s professional. A more, these messages are untrue. Some conditions that result › Provide an urgent refer- in tinnitus can be treated. And, although tinnitus itself cannot ral to an otolaryngologist or normally be cured, there are numerous interventions and edu- emergency care if you suspect cational strategies that can help patients change their reactions sudden sensorineural to—and learn to cope with—the ringing in their ears. We de- loss or another urgent medi- cal condition. A veloped this evidence-based review and tinnitus triage guide (TABLE 1) to help family physicians respond appropriately to Strength of recommendation (SOR) this distressing, but common, condition. A Good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence Is it transient noise, or tinnitus? C Consensus, usual practice, Virtually everyone experiences “transient noise,” which opinion, -oriented evidence, case series is usually described as a whistling sound accompanied by a sensation of sudden temporary .3,4 Th ese idio- pathic episodes are usually unilateral, and often accompa- nied by a feeling of ear blockage. CONTINUED

JFPONLINE.COM VOL 59, NO 7 | JULY 2010 | THE JOURNAL OF FAMILY PRACTICE 389 TABLE 1 Tinnitus triage guide27

If the patient Refer to Status/considerations

Has neural defi cits such as facial Otolaryngology or ED Emergency weakness, head trauma, or other urgent medical condition

Has unexplained sudden and otolaryngology Emergency; must see hearing loss audiologist prior to otolaryngologist on same day

Expresses or Mental health or ED May be emergency; manifests obvious mental illness report suicide ideation; provide escort, if necessary

Has any of the following: Otolaryngology and audiology Urgent; schedule • symptoms suggestive of otolaryngology exam as soon somatic origin of tinnitus as possible (eg, tinnitus that with heartbeat) • persistent otalgia or otorrhea There is no • vestibular symptoms (eg, /) prescription drug specifi cally Has symptoms that suggest Audiology and otolaryngology Nonurgent; schedule audiology for tinnitus, but a neurophysiologic origin of exam before patient sees tinnitus without: otolaryngologist • ear , drainage, or or anxiolytics malodor may relieve • vestibular symptoms associated • sudden hearing loss symptoms of • facial weakness or paralysis psychological ED, emergency department. distress.

To distinguish between tinnitus—the (somatic) processes.6 of sound that is produced inter- Th e ringing may be relatively soft; in nally, rather than by an external stimulus— some cases, it can be heard only in quiet en- and transient ear noise, consider the duration vironments or while the patient is trying to and frequency. Transient ear noise generally sleep. In others, the tinnitus may be constant, disappears within seconds (and does not re- interfering with concentration and daily ac- quire diagnostic testing or treatment). Tin- tivities, as well as sleep. In the most severe nitus, which can have a variety of underlying cases, tinnitus may be associated with severe pathologies, is defi ned as ear or head noise depression and anxiety, even to the point of that lasts at least 5 minutes and occurs at least suicidal ideation.7 twice a week.5 Notably, however, the loudness or other perceptual characteristics of tinnitus do not necessarily indicate the degree to which it is Neurophysiologic tinnitus a problem for the patient.7 Although patients is most common often report that tinnitus interferes with Neurophysiologic (sensorineural) tinnitus, their hearing, they usually also have hear- which originates within the auditory nervous ing loss, which an audiologic evaluation will system, accounts for the vast majority of cas- reveal.7-9 es. Th e pathology exists anywhere between Certain medications can trigger or exac- the and the auditory cortex, and ex- erbate tinnitus, including , nonsteroi- cludes any sounds generated by mechanical dal anti-infl ammatory drugs, loop diuretics,

390 THE JOURNAL OF FAMILY PRACTICE | JULY 2010 | VOL 59, NO 7 TRIAGE GUIDE FOR TINNITUS

and .2 Fairly high doses are usually TABLE 2 required to cause tinnitus, however, and the Managing neurophysiologic tinnitus: eff ects are typically temporary. Patients have 2,5,25-27 also reported exacerbation of tinnitus due to A range of options alcohol, salt, and caff eine intake. Cognitive-behavioral therapy from aminoglycosides and platinum-con- taining chemotherapeutic drugs is a well- Elimination of tinnitus-inducing medications (eg, NSAIDs, loop diuretics, known cause of hearing loss and tinnitus, and quinine) but these eff ects are often irreversible.10,11 Hearing aids, sound generators, or other sound devices Neurophysiologic tinnitus is gener- Lifestyle modifi cations (eg, improve sleep hygiene, exercise regularly, limit ally not serious from a medical standpoint. salt intake) While all patients with this condition should undergo an audiologic exam and hearing Medication (antidepressants or anxiolytics) evaluation, only about 20% of adults who Patient education that stresses that there are numerous techniques that experience tinnitus require intervention.12-14 can be used to manage reactions to tinnitus Although there is no cure, patients with clini- Stress reduction techniques (eg, imagery, meditation, and deep breathing cally signifi cant tinnitus can be taught stress techniques) management and therapeutic use of sound techniques, as well as lifestyle modifi cations Therapeutic sound (eg, using interesting sound to direct attention away from tinnitus, low-level background sound to reduce auditory contrast, (TABLE 2) to minimize its detrimental eff ects. and soothing sound for relief)

NSAIDs, nonsteroidal anti-infl ammatory drugs. Somatic tinnitus may be serious Somatic tinnitus, also known as somato- sound, refers to the perception of sound that Unilateral tinnitus is a red fl ag originates within the body—in vascular, mus- In most cases, tinnitus is bilateral. Unilateral cular, skeletal, or respiratory structures, or in tinnitus may indicate a more serious medi- the temporomandibular joint.4 Th ese “body cal condition. It is a common presenting sounds” have an internal acoustic source.9 sign of both vestibular (also ❚ Pulsatile tinnitus, which pulses in syn- known as acoustic ) and Meniere’s chrony with the heartbeat, is the most common disease. somatosound.15,16 Most patients with pulsatile Patients with unilateral tinnitus should tinnitus have benign venous “hums,” but seri- receive a as soon as possible; ous conditions such as arteriovenous malfor- if asymmetric hearing loss is found, MRI is mations, glomus tumors, and carotid stenosis indicated, both with and without contrast of must be considered. over the neck the internal auditory canal, to rule out ves- and temporal bone may reveal that can tibular schwannoma. help localize the lesion. We recommend either ❚ Idiopathic sudden sensorineural hear- magnetic resonance imaging (MRI) of the head ing loss (ISSNHL), which may be associated or computed tomography (CT) angiography, with new onset unilateral tinnitus, should be accompanied by timely referral to an otolaryn- considered an otologic emergency. When you gologist for a focused evaluation.15,17,18 suspect ISSNHL, you’ll need to make a same- ❚ Somatosounds can also be non- day referral for an otologic examination. pulsatile, indicating a nonvascular source. If left untreated, the ISSNHL and as- Examples of nonvascular somatosounds in- sociated tinnitus will resolve partially or clude middle-ear muscle spasms and eusta- completely at least 50% of the time. Th is chian tube dysfunction. Nonpulsatile somatic recovery rate may be improved with gluco- tinnitus is rarely progressive or dangerous. It corticoid treatments.19 Prompt initiation of is reasonable to off er reassurance to patients therapy can be a factor in the with nonpulsatile tinnitus, followed by a re- chances of recovery—the more rapidly such ferral to an otolaryngologist if the symptoms patients are seen and treated, the better their interfere with daily activities. prognosis. 20 CONTINUED

JFPONLINE.COM VOL 59, NO 7 | JULY 2010 | THE JOURNAL OF FAMILY PRACTICE 391 Tinnitus triage: Key points using a validated questionnaire such as the Following our triage guide (TABLE 1) should Tinnitus Handicap Inventory, for the initial result in appropriate care in most cases. Here assessment and to monitor changes in the se- are some considerations to keep in mind: verity of the tinnitus as an outcome measure ❚ Urgent medical referral. Any patient of therapy.24 with tinnitus and symptoms suggestive of serious underlying treatable pathology re- quires an urgent otolaryngology referral. Th at Enlist an interdisciplinary team includes ISSNHL, which you should suspect For patients with somatic tinnitus, the treat- whenever a patient reports an unexplained ment—and the specialist who provides it— decrease in hearing, as well as pulsatile tinni- depends on the underlying cause. A patient tus, vestibular symptoms, and long-standing who has unilateral tinnitus may be referred , drainage, or malodor that does not by an audiologist or otolaryngologist to a resolve with routine treatment. If possible, neurologist, for example, if he or she is found such patients should undergo an audiologic to have Meniere’s disease; a patient with pul- assessment prior to the otolaryngology visit; satile tinnitus may be sent back to his or her however, the otolaryngology exam is the pri- primary care physician after diagnostic test- mary concern. ing has ruled out serious causes. Facial paralysis, severe vertigo, or sudden For patients with neurophysiologic tinni- Idiopathic onset pulsatile tinnitus can indicate a seri- tus (and any patient with untreatable somatic sudden ous intracranial condition. Th ese symptoms tinnitus), a well-organized interdisciplinary sensorineural may point to cerebrovascular disease or neo- team that includes the family physician, an hearing loss plasm, and should be treated as an otologic audiologist, and a psychologist is the best should be emergency. approach. Th e variety of available manage- treated as ❚ Mental health referral. Some tinnitus ment options (TABLE 2) incorporate medical an otologic patients require a mental health assessment, approaches, complementary and alterna- emergency. either because of obvious manifestations of tive treatments, psychological interventions, a mental illness or because of expressed sui- and sound-based methods. Lifestyle modi- cidal ideation. If there’s a question about the fi cations, such as improved sleep hygiene, patient’s mental health, consider consulting regular exercise, and dietary modifi cations, with a mental health provider or using basic may help, as well.25-27 First-line strategies screening tools for anxiety and depression to include: help determine the need for referral, as well ❚ Adjusting medications. Eliminating as the urgency.12 tinnitus-inducing medications, if medically Some patients experience extreme anxi- safe, is a common starting point. No prescrip- ety or depression in response to tinnitus tion drug has been developed specifi cally for and should be referred to a mental health tinnitus. But some antidepressants or anx- professional on the day they present with iolytics (eg, amitriptyline or lorazepam) are symptoms. Suicidal ideation warrants special commonly used to address coexisting sleep attention, of course—possibly including the and mental health disorders—primarily de- need to escort the patient to the emergency pression and anxiety—that may be associated department or to a behavioral specialist.21-23 with, or exacerbated by, tinnitus.28-30 ❚ Nonurgent medical referral. Ideally, ❚ Addressing hearing problems. Pa- all patients who present with tinnitus should tients should undergo a hearing evaluation see an audiologist and an otolaryngologist, and receive help in managing a hearing prob- but those who have no serious symptoms lem, if necessary. Hearing aids improve hear- should be referred on a nonurgent basis. Such ing and reduce the perception of tinnitus.31 patients need to have a comprehensive hear- ❚ Using therapeutic sound. Some audiol- ing evaluation—ideally, before they see the ogists are trained to implement various forms otolaryngologist so the test results are avail- of sound-based therapy. Tinnitus retraining able at the time of the exam. Th e audiologist therapy involves the use of background sound should also assess the severity of the tinnitus, to facilitate habituation to tinnitus; tinnitus

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masking involves the use of soothing sound we have been successful in teaching patients to provide a of relief. Progressive tin- to manage their reactions to tinnitus—result- nitus management is a more recent method ing in a better quality of life—using a combi- that educates patients in the use of all types nation of educational counseling, therapeutic of therapeutic sound.32 Th ese sound-based sound, and CBT. JFP methods often include the use of hearing aids, sound generators, and other devices. ACKNOWLEDGMENTS Funding for this work was provided by Veterans Health Ad- ❚ Circling in a mental health profession- ministration, and Veterans Affairs Rehabilitation Research al. It is essential to involve psychologists or and Development (RR&D) Service (C4488R). Thanks to Robert Folmer, PhD, William Martin, PhD, Dennis Trune, PhD, and other mental health specialists in the care of Baker Shi, MD, PhD, for advice that contributed to this man- patients with clinically signifi cant tinnitus to uscript. Special thanks to Martin Schechter, PhD, for his sig- nifi cant contributions to our research. The authors also wish ensure that psychological and other barriers to thank Stephen Fausti, PhD, and Sara Ruth Oliver, AuD, for to successful management of the condition their consistent support of our research. are identifi ed and addressed. Cognitive- behavioral therapy (CBT) has been shown to CORRESPONDENCE James A. Henry, PhD, VA Medical Center (NCRAR), Post be helpful for patients with tinnitus.33 In fact, Offi ce Box 1034, Portland, OR 97207; [email protected]

References A good resource 1. Hoff man HJ, Reed GW. Epidemiology of tinnitus. In: Snow NY: BC Decker Inc; 2004:253-264. JB, ed. Tinnitus: Th eory and Management. Lewiston, NY: BC 16. Sismanis A. Pulsatile tinnitus. Otolaryngol Clin North Am. for patients Decker Inc; 2004:16-41. 2003;36:389-402. is the American 2. Jastreboff PJ, Hazell JWP.Tinnitus Retraining Th erapy: Imple- 17. Sismanis A. Pulsatile tinnitus. In: Vernon JA, ed. Tinnitus menting the Neurophysiological Model. New York: Cambridge Treatment and Relief. Needham Heights, Mass: Allyn & Ba- Tinnitus University Press; 2004. con; 1998:28-33. Association 3. Kiang NYS, Moxon EC, Levine RA. Auditory-nerve activity in 18. Wackym PA, Friedland DR. Otologic evaluation. In: Snow cats with normal and abnormal . In: Wolstenholme JB, ed. Tinnitus: Th eory and Management. Lewiston, NY: BC (www.ata.org). GEW, Knight J, eds. Sensorineural Hearing Loss. London: J. & Decker Inc; 2004:205-219. A. Churchill; 1970:241-273. 19. Hamid M, Trune D. 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JFPONLINE.COM VOL 59, NO 7 | JULY 2010 | THE JOURNAL OF FAMILY PRACTICE 393