EN4.19 | Tinnitus — Summary & Reflection

KEY TAKEAWAYS

Tinnitus is the perception of sound without an external source, affecting 10–15% of adults:

• Classification: subjective (most common — cochlear/central) vs objective (rare — audible to examiner, vascular/muscular); pulsatile (vascular, urgent imaging) vs non-pulsatile.
• Red flags: unilateral tinnitus (MRI to exclude acoustic neuroma); pulsatile tinnitus (vascular imaging); sudden-onset with hearing loss (SSNHL emergency).
• Pathophysiology: cochlear hair cell loss → reduced afferent input → central auditory hyperactivity (maladaptive plasticity) → phantom sound perception.
• Investigation: audiometry all patients; MRI (unilateral or unexplained); CT angiography/MRA (pulsatile).
• Management: treat underlying cause; counselling/education (correct misconceptions); TRT (directive counselling + sound therapy); CBT; hearing aids (if SNHL); no proven pharmacological cure.
• Note: tinnitus loudness typically only 5–10 dB above threshold — explaining this is therapeutically important.

REFLECT

The retired factory worker has bilateral NIHL-related tinnitus — he needs audiometry, explanation, TRT, and likely hearing aids; there is no cure but substantial symptom improvement is possible. The teacher with pulsatile tinnitus needs vascular imaging — MRI and MRA/CT angiography. Reflect on what you would say to the factory worker when he asks: 'Is there any tablet I can take?' How do you communicate honestly that there is no proven medication while still offering hope through non-pharmacological management? Consider also the occupational medicine dimension — what industrial noise exposure contributed to his tinnitus, and what could have been done 20 years ago to prevent it?