Case Study: Ringing in Both Ears
SOAP Note
Subjective
Chief Complaint
45-year-old male presents with a 3-year history of bilateral "ringing" in the ears, more noticeable at bedtime. Also believes hearing has slightly worsened over the past 3 years.
History of Present Illness
No history of otologic trauma, surgery, noise exposure, or ear infections.
Medications
Denies any prescription medications or supplements.
Social History
Nonsmoker and nondrinker.
Review of Systems (ROS)
Denies otalgia, otorrhea, and vertigo.
Objective
Vital Signs
BP 124/78, Resp 16, Pulse 88, Temp. 97.6, Weight 188 pounds, Height 58, Pain 0.
Physical Exam
Patient is not in acute distress. Otoscopy: Normal external auditory canals, clear tympanic membranes with normal mobility. Facial nerve function is normal. Weber test lateralized to the left. Rinne test positive bilaterally. Unremarkable head, neck, and cardiac exam.
Assessment
Differential Diagnoses
1. Bilateral Sensorineural Hearing Loss (SNHL) - ICD-10: H90.3, CPT: 92557
2. Tinnitus - ICD-10: H93.13, CPT: 92568
3. Meniere's Disease (less likely given the absence of vertigo) - ICD-10: H81.0, CPT: 92567
Primary Diagnosis
Tinnitus (H93.13) due to its chronic nature and the patient's primary complaint.
Plan
Diagnostics
An audiogram is a primary diagnostic tool we should employ for this patient. Given his complaints of ringing and a perceived decrease in hearing ability, an audiogram will provide a comprehensive assessment of his hearing across various frequencies (Shapiro et al., 2021). This test will help determine the type and degree of hearing loss, if present, and can be used to guide subsequent interventions.
Treatment and Management
For symptom relief, pharmacologic interventions can be considered. Low-dose alprazolam or nortriptyline have shown efficacy in some patients with tinnitus, helping to alleviate the distress associated with the constant ringing (Kim et al., 2022). It is important, however, to monitor for potential side effects.
In terms of non-pharmacologic interventions, sound therapy stands out as a beneficial approach. The patient may use background noise or specific sounds to help mask or distract from the tinnitus effects (Wang et al., 2020). If the audiogram confirms hearing loss, hearing aids can be used as an intervention as they often come with tinnitus masking features.
Alternative therapies, such as Tinnitus Retraining Therapy (TRT), should also be considered. TRT combines sound therapy with educational counseling, aiming to habituate the patient to the tinnitus sound, making it less noticeable and bothersome over time (Ogawa et al., 2020).
Follow-up
The chronic nature of tinnitus and the potential for associated distress suggest a follow-up in 3 months would be in order. This will allow us to assess the effectiveness of the interventions and make any necessary adjustments. However, if...
…addressed in the treatment plan.4. Age-related hearing loss is a common underlying condition. Prolonged exposure to loud noises is another, as is earwax blockage, otosclerosis, and Meniere's disease.
5. First-line management would include Cognitive Behavioral Therapy (CBT) combined with sound therapy. CBT gives patients coping mechanisms to deal with the stress of tinnitus, and sound therapy can reduce the perception of the ringing.
6. I would consider CBT as it provides strategies to reframe negative thought patterns and reduce the emotional burden associated with the constant ringing.
7. Effects on QOL include sleep disturbances, making it hard for patients to fall or stay asleep. The constant ringing can also make concentration challenging and harm work performance. It can lead to emotional distress, frustration, and decreased efficiency in daily tasks.
8. If there is no improvement after trying initial interventions for 6 months, or if an audiogram indicates a more severe underlying issue, I would refer the patient to an otolaryngologist or audiologist.
9. I would want to empower the patient with knowledge and I would advise him to avoid loud noises so as to prevent further auditory damage. I would suggest limiting caffeine and alcohol to help, as these can exacerbate symptoms. I would also educate about…
References
Kim, H. G., Lee, H. Y., Park, E., Choi, J., Rah, Y. C., Song, J. J., ... & Im, G. J. (2022).
Clonazepam Usage Improves Chronic Tinnitus and Sleep Quality: A Prospective Cohort Study. Korean Journal of Otorhinolaryngology-Head and Neck Surgery, 65(12), 758-764.
Ogawa, K., Sato, H., Takahashi, M., Wada, T., Naito, Y., Kawase, T., ... & Kanzaki, S. (2020).
Clinical practice guidelines for diagnosis and treatment of chronic tinnitus in Japan. Auris Nasus Larynx, 47(1), 1-6.
Shapiro, S. B., Noij, K. S., Naples, J. G., & Samy, R. N. (2021). Hearing loss andtinnitus. Medical Clinics, 105(5), 799-811.
Trivedi, B., Ojha, T., Soni, N. K., Bansal, M., Sharma, K., & Chhabra, B. (2023). Evaluating theIncidence of Audiological Derangement in Cases of Thyroid Hormone Imbalance. Indian Journal of Otolaryngology and Head & Neck Surgery, 75(Suppl 1), 574-577.
Wang, H., Tang, D., Wu, Y., Zhou, L., & Sun, S. (2020). The state of the art of sound therapy forsubjective tinnitus in adults. Therapeutic Advances in Chronic Disease, 11, 2040622320956426.
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