The most important causes and the treatment of tinnitus

1. Big picture

Tinnitus is the perception of sound without an external sound source. Patients may describe it as ringing, buzzing, hissing, roaring, clicking, or pulsating. For the neurology exam, tinnitus is important because it can be a benign cochlear symptom, but it can also be the first clue to Ménière’s disease, vestibular schwannoma, vascular disease, posterior circulation pathology, ototoxicity, or sudden sensorineural hearing loss.

The examiner usually wants three things:

1. Is it pulsatile or non-pulsatile?

2. Is it unilateral/asymmetric or bilateral/symmetric?

3. Is it associated with hearing loss, vertigo, focal neurological signs, or severe distress?

Persistent bothersome tinnitus is not treated mainly with “circulation drugs” or random sedatives; the key modern approach is explain, assess hearing, treat the underlying cause, use hearing aids when hearing loss is present, and use tinnitus-focused psychological therapy such as cognitive behavioural therapy for distress. Guidelines emphasize targeted history/examination, audiological assessment, selective imaging, hearing aid evaluation when hearing loss is present, and cognitive behavioural therapy for persistent bothersome tinnitus.