to the editor: We read with interest the article,¹ “Diagnostic Approach to Tinnitus,” by Drs. Crummer and Hassan in the January 1, 2004, issue of American Family Physician. It carefully and clearly presented the problem of tinnitus and can be a valuable source of information for family physicians and their patients. The authors¹ proposed their algorithm for a diagnostic approach to patients with tinnitus. We would like to present our experience in treating patients with this condition.

In the department of Otolaryngology at the Medical University in Gdansk, Poland, as in most centers that manage patients with tinnitus, one of the most important elements of diagnostics is history data.² Patients classify in a graphic way the pitch and loudness of tinnitus using a visual analog scale (see accompanying figure). Our patients receive questionnaires that assess how troublesome their tinnitus is and its influence on their daily activity and ability to function. We compare results of the visual analog scale and the questionnaires before and after treatment, which helps to objectively assess the therapy results.³

Perhaps the algorithm presented in the article¹ will result in the addition of some new elements of objective diagnostics of tinnitus, such as positron emission tomography (PET) or single photon emission computed tomography.^4–6 One study⁴ using PET in 10 patients with tinnitus found increased metabolic activity of the predominant auditorycortex. Although the patients complained of bilateral tinnitus, the brain metabolic activity was higher on the left side.⁴ Another study⁶ investigated four patients with continuous unilateral tinnitus, which could be altered by clenching their jaws. Using PET, the results showed that when the tinnitus was increased in this way the brain metabolic activity was increased on the opposite side.⁶ The study⁶ also found that the hippocampus was activated in these patients but not in the control subjects. Hippocampus activation could offer an explanation for the adverse psychologic effects that patients with tinnitus often experience. The new methods enable physicians to visualize what previously only had been heard and felt.

in reply: Tinnitus is a common symptom that can affect a patient’s quality of life. There are many measures to estimate the impact of tinnitus. The visual analogue scale is a reliable method, commonly used in studies to assess the results of therapy, including that of hyperbaric oxygen therapy.¹ Positron emission tomography (PET) is a nuclear medicine imaging study, used primarily for oncologic staging, which for a number of years also has been used to investigate tinnitus, along with other objective methods including auditory brainstem responses and auditory evoked magnetic field.² Our article³ was written from a primary care point of view. Sophisticated imaging such as PET and single photon emission computed tomography were not included in the algorithm in our article³ because their relevance in the diagnosis and treatment of tinnitus in the primary care setting is still undefined.