B-QuiCK: Tinnitus

B-QuiCK: Tinnitus

Assessment

• Determine tinnitus characteristics)

^* In patients with asymmetric hearing loss consider both bilateral and unilateral causes

^† Patients with vestibular schwannoma do not always have vertigo and focal neurological features

Diagnostic algorithm for patients presenting with tinnitus.

• Also perform:

• A medicines review for potential ototoxic causes of tinnitus
• An otoscopic examination and tympanometry to investigate possible external or middle ear pathology
• A focused neurological examination including cranial nerves and cerebellar function
• Assessment of the temporomandibular joint, jaw and neck in patients

• Assess hearing loss:

• Refer to an audiologist for a full diagnostic hearing assessment if possible
• A brief check can be performed by rubbing your fingers together behind the patient's ear or using a soft whisper and assessing whether they can hear the noise
• Use the Weber and Rinne tuning fork tests to help differentiate conductive hearing loss from sensorineural hearing loss

Interpretation of Weber and Rinne test results.

^*Side the tuning fork is heard best

^†Positive Rinne test – air conduction better than bone conduction; negative Rinne test – bone conduction better than air conduction

• Evaluate the impact of tinnitus on the patient’s quality of life:

• Ask about the effect tinnitus has on sleep, employment, study, leisure activities and relationships with family and friends
• Assess for symptoms of depression and anxiety

Management

• Address treatable causes of secondary tinnitus
• Improve hearing loss if there is a modifiable cause, e.g. refer for aural microsuction, hearing aids
• Address lifestyle factors, e.g stress reduction, sleep, diet, exercise, and provide education and reassurance for patients and their family/whānau
• Sound enrichment (neutral noises at a volume just quieter than the perceived tinnitus) can relieve symptoms and promote habituation
• Pharmacological treatments are not recommended for the management of tinnitus; only prescribe medicines to treat concomitant conditions
• For patients with tinnitus-related distress, encourage lifestyle changes to reduce stress and good sleep hygiene
  • Cognitive behavioural therapy (CBT) can be effective for alleviating distress in patients with tinnitus but tinnitus-focused CBT is not widely available in New Zealand; discuss with an audiologist who specialises in tinnitus
• Consider discussion with an audiologist or otolaryngologist for patients with primary tinnitus that still causes significant distress after management in primary care