A 75-year-old man comes to the physician because of 'a noise in his head.' He describes the noise as a high-pitched ringing which is always present. The sound does not pulsate and does not vary with position. He states that it is interfering with his ability to fall asleep. He denies any changes in balance, falls, or muscle weakness. He denies any problems with hearing or vision.
He has a history of hypertension, hyperlipidemia, benign prostatic hyperplasia, and degenerative joint disease of both knees and his right hip. His medications include ibuprofen, lovastatin, and enalapril. He drinks 1-2 alcoholic beverages on the weekends. He states he feels somewhat depressed a couple of days per week.
His blood pressure is 130/72 mm Hg and pulse is 78/min. There are no abnormalities of his head, ears, eyes, nose, or throat. There are no carotid or head bruits and cervical spine motion is normal. Cardiovascular examination is unremarkable.
Which of the following is the most appropriate next step in managing his tinnitus?

Question

A 75-year-old man comes to the physician because of 'a noise in his head.'  He describes the noise as a high-pitched ringing which is always present.  The sound does not pulsate and does not vary with position.  He states that it is interfering with his ability to fall asleep.  He denies any changes in balance, falls, or muscle weakness.  He denies any problems with hearing or vision.
He has a history of hypertension, hyperlipidemia, benign prostatic hyperplasia, and degenerative joint disease of both knees and his right hip.  His medications include ibuprofen, lovastatin, and enalapril.  He drinks 1-2 alcoholic beverages on the weekends.  He states he feels somewhat depressed a couple of days per week.
His blood pressure is 130/72 mm Hg and pulse is 78/min.  There are no abnormalities of his head, ears, eyes, nose, or throat.  There are no carotid or head bruits and cervical spine motion is normal.  Cardiovascular examination is unremarkable.
Which of the following is the most appropriate next step in managing his tinnitus?

Quizplus · Accepted Answer

11ec193a_9798_96e1_853d_c1003431b010_MD0002_00 Tinnitus is defined as a sound perception within the head or ears that can be buzzing, ringing, or hissing. Pulsatile tinnitus usually implies a significant underlying vascular pathology, while non-pulsatile tinnitus tends to be non-vascular (causes listed in the above table). Pulsatile tinnitus usually requires a thorough investigation with an ENT consult and brain imaging. Non-pulsatile tinnitus is usually due to dysfunction within the auditory system (cochlear end-organ, cochlear nerve, brainstem, and auditory cortex). Tinnitus is often a sign of sensorineural hearing loss, although most patients do not complain of hearing loss. This patient's tinnitus (high-pitched ringing, non-pulsatile, continuous, not affected by position) suggests an origin within the auditory system. Patients with non-pulsatile tinnitus believed to originate from the auditory pathways require initial audiometric testing to detect asymmetry between the two ears and abnormalities in the middle ear, cochlea, or brainstem. Further work-up and treatment is based upon these findings. (Choice B) Both nonsteroidal anti-inflammatory drugs and angiotensin converting enzyme inhibitors have been linked to tinnitus, but the association is unclear. Pending the results of the audiometric evaluation, a trial of discontinuation of ibuprofen and substitution for enalapril may be indicated. (Choice C) Magnetic resonance angiography would be indicated in patients who present with a vascular origin of the tinnitus such as history of pulsatile, intermittent, or position-dependent tinnitus; or a bruit in the head and neck region. (Choice D) Non-contrast CT helps evaluate for intracranial hemorrhage and many cortical lesions, but contrast head CT is required to evaluate patients with pulsatile tinnitus for tumors such as paraganglioma. This patient has non-pulsatile tinnitus with a benign examination and would not require head CT. (Choice E) Antidepressant therapy is not effective in treating tinnitus. However, this patient may benefit from further evaluation for symptoms of depression and possible anti-depressant therapy afterwards. Educational objective: Tinnitus is a perception of sound inside the ear that can be pulsatile (usually vascular etiology) or non-pulsatile (usually non-vascular etiology). Non-pulsatile tinnitus usually originates in the auditory pathways and is frequently a sign of sensorineural hearing loss (although many patients do not complain about hearing loss) and requires initial audiometry testing. __________ References: Prevalence and characteristics of tinnitus among US adults. (http://www.ncbi.nlm.nih.gov/pubmed/20670725) Tinnitus in the older adult: epidemiology, pathophysiology and treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/15040757) An otoneurosurgical approach to non-pulsatile and pulsatile tinnitus. (http://www.ncbi.nlm.nih.gov/pubmed/18225613)

A 75-Year-Old Man Comes to the Physician Because of 'A