Patient Presentation
An 8-year-old male came to clinic approximately 4 weeks after having left otitis media. His mother was concerned because he had said several times over the past week that he had sounds in his ears. He described the sounds as “popping” or sometimes “crunchy” like rice cereal. He said it wasn’t high pitched but was like a voice tone; it wasn’t too loud or soft. The sounds lasted only a few seconds but he wasn’t sure if it was associated with jaw movement or yawning. He denied ear pain, sore throat, or vertigo. He had normal balance and mentation. “It just sounds kind of weird for a few seconds and then goes away,” he described. He was not bothered by the sounds and denied having any similar problems in the past. He denied any trauma but did use headphones when he was playing videogames. The past medical history showed some upper respiratory tract infections including 2 otitis media infections in the past. He had not head trauma in the past. The family history was negative for any ear, nose or throat problems.
The pertinent physical exam showed a healthy boy with normal vital signs and growth parameters in the 75-90%. HEENT showed some clear fluid behind the left tympanic membrane with bubbles within the fluid. The tympanic membrane was in a normal position with normal landmarks. His right ear was normal. He had some very mild clear rhinorrhea. Yawning or other jaw movements did not reproduce the sounds. Neurological examination was normal including tests for balance. The diagnosis of a resolving middle ear effusion was made. The pediatrician counseled that it was most likely that the sounds were caused by the eustachian tube opening and closing causing air to move into the middle ear as the effusion was resolving. He recommended monitoring the problem and keeping a symptom diary with a followup appointment in 4 weeks if the problem was not resolving and sooner if it was becoming more frequent, painful or was affecting his activities including sleep or balance. He did not return for the followup appointment.
Discussion
Tinnitus is derived from the Latin word tinnire which means to ring but in general practice it means any perceived sound that is not generated externally. It is a common problem in adults. In children it is described as being commonly overlooked as children do not spontaneously report it. It is felt that children may consider the sound normal, or are easily distracted and therefore forget about it. Children can accurately describe the sounds they hear and use words such as buzz, ring, hum, swish, whish, blow or beep. Spontaneously reported tinnitus is ~6.5% and increases to 34% when children are specifically questioned in one study. Prevalence has been reported in up to 36% of children with normal hearing and rises to up to 66% in children with hearing loss. Constant tinnitus (43%) is reported more commonly than intermittent tinnitus (31.5%) and bilateral (69%) is more common than unilateral (31%). Tinnitus that affects quality of life is not reported in studies but studies in adults show ~33% will report tinnitus but only 0.4-1% report it affecting their quality of life. Reported problems in children with tinnitus include sensory perception problems, emotional/psychological problems, headache, dizziness and vertigo, fatigue, and sleep problems.
One study found no association between childhood hearing disorders and adult tinnitus after adjusting for adult hearing thresholds. Another study of adolescents found a high prevalence of tinnitus in those who had significant exposures to high sounds volume for long periods of time such as attending nightclubs or parties, headphone use for music or using cellphone headsets in the ear.
Learning Point
The cause of tinnitus is unclear but it has been associated with otitis media, myoclonus of the muscles of the palate or middle ear, acoustic trauma, arteriovenous malformations, and intracranial hypertension. Evaluation by an audiologist and otolaryngologist may uncover ear pathology. Treatment includes amplification if there is a hearing loss, sound generators (e.g. child who has increased problems in a quiet environment could listen to music while studying), and counseling. Counseling can validate the problem, discuss the natural history, identify aggravating and mitigating factors and help develop coping skills to address the tinnitus.
Questions for Further Discussion
1. What are indications for an audiogram?
2. How common is congenital hearing loss?
Related Cases
- Disease: Tinnitus
- Symptom/Presentation: Tinnitus
- Specialty: Otolaryngology
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Tinnitus
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Savastano M, Marioni G, de Filippis C. Tinnitus in children without hearing impairment. Int J Pediatr Otorhinolaryngol. 2009 Dec;73 Suppl 1:S13-5.
Shetye A, Kennedy V. Tinnitus in children: an uncommon symptom? Arch Dis Child. 2010 Aug;95(8):645-8.
Sanchez TG, Oliveira JC, Kii MA, Freire K, Cota J, Moraes FV. Tinnitus in adolescents: the start of the vulnerability of the auditory pathways. Codas. 2015 Jan-Feb;27(1):5-12.
Aarhus L, Engdahl B, Tambs K, Kvestad E, Hoffman HJ. Association Between Childhood Hearing Disorders and Tinnitus in Adulthood. JAMA Otolaryngol Head Neck Surg. 2015 Nov;141(11):983-9.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 