Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Tinnitus


Related Terms

  • Ringing in the Ears
  • Tinnitus Aurium

Differential Diagnosis

  • Anxiety
  • Depression
  • Head noise from intracranial aneurysm or glomus tumor
  • Hypertension
  • Ménière's disease
  • Multiple sclerosis
  • Muscle spasms in middle ear (stapedius muscle and tensor tympani muscle)
  • Occlusive carotid artery disease
  • Otosclerosis
  • Presbycusis (age-related ear or head noise)
  • TMJ syndrome
  • Vascular noise from arteriovenous malformation or arteriovenous shunt

Specialists

  • Neurologist
  • Otolaryngologist

Comorbid Conditions

Factors Influencing Duration

Factors influencing length of disability for tinnitus include the general health and fitness of the individual before onset of the condition; response to rehabilitation; severity of the condition; evidence of pre-existing diseases that might interfere with the healing process; individual's general ability to heal and cope; degree to which the workplace can be modified to accommodate the individual's needs; and compliance and success with a treatment plan.

Medical Codes

ICD-9-CM:
388.30 - Tinnitus, Unspecified
388.31 - Tinnitus, Subjective
388.32 - Tinnitus, Objective

Overview

Tinnitus is a sensation of noise that seems to be in the ear or head when no external sound is actually present. Tinnitus aurium literally means ringing in the ears although the affected individual may experience swishing, clicking, or other noise patterns. Head noise occurs in nearly everyone, but is usually masked by outside sounds. Wax or a foreign body blocking the ear may cause an individual to become more aware of normal head sounds. Occasional periods of high-pitched tinnitus lasting several minutes are common in normal-hearing individuals. Tinnitus can arise in the outer or inner ear, middle ear, or in the head. It is not a disease in itself, but a symptom of an underlying condition. Tinnitus is usually associated with hearing loss, and a direct cause is not always found.

The two types of tinnitus are objective (less common) and subjective (most common). If, by listening to the sounds within the individual’s ear (auscultation), the health practitioner can hear noise in the affected individual's ear or detect pulsating motion from surrounding structures, the condition is called objective tinnitus. If only the affected individual can hear the sounds, the condition is called subjective tinnitus.

Underlying causes of objective tinnitus include abnormalities in the blood vessels within the brain or in front of the ear (arteriovenous malformation or glomus jugulare tumor), spasms of the muscles within the middle ear (stapedius muscle and tensor tympani muscle), temporomandibular joint syndrome (TMJ), and certain dysfunctions of the auditory tube that connects the middle ear with the back of the throat (eustachian tube).

Causes of subjective tinnitus include aging (presbycusis), exposure to loud environmental noise over a period of time or during an extreme incident (noise trauma), stiffening of the middle ear bones (otosclerosis), balance disorders of the inner ear (Ménière's syndrome and labyrinthitis), inflammation and infection of the middle ear (otitis media and mastoiditis), wax or dirt build-up in the ear canal, tumors of the nerves involved in hearing (acoustic neuromas), exposure to drugs such as aspirin that may damage the hearing mechanism (ototoxic drugs), metabolic dysfunction (hyper- or hypothyroidism, hyperlipidemia, zinc deficiency, or vitamin A and/or B deficiency), high blood pressure (hypertension) or high cholesterol and other cardiovascular diseases, skull fracture or closed head trauma, whiplash injury, brain infection (meningitis), multiple sclerosis, Lyme disease, psychological conditions (depression, anxiety), and possibly excessive use of caffeine or other food substances such as aspartame.

Persistent tinnitus can interfere with an individual's ability to perform usual daily activities and can prevent individuals from getting enough sleep. Tinnitus can cause considerable psychological distress and can be incapacitating for some individuals.

Incidence and Prevalence: An estimated 1 of every 5 individuals experiences some degree of tinnitus and 36 million individuals in the US experience persistent tinnitus. Nine million individuals are affected so severely they cannot live normal lives. Tinnitus is most prevalent between the ages of 40 and 70, affecting women and men equally. Seventy-five percent of individuals with tinnitus have some degree of permanent damage to the hearing mechanism in the inner ear (sensorineural hearing loss).

Source: Medical Disability Advisor



Diagnosis

History: The individual with tinnitus relates a history of hearing noises (ringing, buzzing, roaring, clicking, chirping, or hissing) in one or both ears when noise is not actually present in the environment. These noises can be high-pitched or low-pitched, intermittent or constant, with one tone or many tones. Seventy-five percent of individuals with tinnitus report some degree of hearing loss. Thirty-five percent of individuals with tinnitus report feeling dizzy part of the time and some complain of constant dizziness.

Individuals with tinnitus may relate a history of ear infections or balance disorders, previous ear surgery, exposure to excessive noise, high blood pressure, meningitis, head trauma, a whiplash injury, or depression before and/or since the onset of tinnitus. Some individuals may report sudden onset of tinnitus after taking certain prescription or over-the-counter drugs. An understanding of the individual's work and living environments and activities is necessary to determine exposure to noise trauma.

Physical exam: A thorough medical evaluation is conducted. Careful assessment of the individual's general mood may reveal signs of depression or anxiety. Examination of the ear through an otoscope or microscope may reveal signs of current or treated ear disease.

Tests: Audiometric evaluation (air and bone transmission, as well as speech discrimination) is performed to identify hearing loss and other diseases and conditions of the hearing mechanism. Brain stem auditory evoked response (BAER) helps evaluate the auditory nerve that may be affected in structural causes of tinnitus associated with sensorineural hearing loss. If a clear-cut diagnosis of ear disease or sensorineural hearing loss cannot be made, other tests and consultations may be ordered to rule out underlying cardiovascular, metabolic, neurological, pharmacological, dental, and psychological abnormalities that might be causing tinnitus. Brain MRI, CT focused on the middle ear, or a type of x-ray called a tomogram of the ear canal may reveal structural causes of tinnitus.

Source: Medical Disability Advisor



Treatment

Treatment of tinnitus focuses first on medically or surgically treating the underlying cause of the condition, including treating depression with non-ototoxic antidepressants, anti-anxiety drugs, and muscle relaxants or psychotherapy, if deemed necessary. Medications taken by the individual are re-evaluated and ototoxic drugs are avoided, if possible (aspirin compounds, aminoglycoside antibiotics, nonsteroidal anti-inflammatory drugs, and heterocycline antidepressants). Surgery may be needed for tinnitus caused by neuromas, vascular abnormalities, and TMJ syndrome. If the cause of tinnitus cannot be found or treated, the focus of treatment changes to helping the individual stop progression of tinnitus and learn how to cope with the condition.

The individual should be instructed to avoid caffeine-containing beverages and food. Excessive noise should be avoided with the use of ear protection, if necessary. The individual is taught to use masking techniques at home and work. Masking is the provision of a low-level noise to block out or "mask" the head noise heard by the individual. This can be accomplished by playing soft music or a tape of nature sounds while resting or sleeping, providing white noise in the workplace, using a hearing aid to amplify sound from the outside and overcome head noise, and wearing a special tinnitus instrument that is a combination hearing aid and tinnitus masker for individuals with both hearing loss and tinnitus.

Source: Medical Disability Advisor



Prognosis

In many instances, tinnitus resists all types of therapy. About 25% of individuals with tinnitus improve significantly, 50% improve to some degree, and 25% remain unchanged. In some cases, tinnitus may progress in severity as the underlying disease progresses. Improvement usually results from the successful reversal of underlying hearing or medical disorders or the individual's successful use of antidepressants, masking techniques, or special tinnitus instruments. The sensorineural hearing loss associated with tinnitus may be permanent and irreversible.

Source: Medical Disability Advisor



Rehabilitation

Biofeedback can be useful for individuals whose tinnitus appears related to emotional stress, anxiety, or hysteria. Through visual or auditory signals, the individual learns to relax and exert some degree of control over the nerves. This can lower blood pressure, pulse rate, and relax tense muscles.

Individuals using amplification to improve tinnitus-related hearing loss may need instruction and practice in the use of hearing aids in various settings. Individuals wishing to learn speech reading (lip reading) also need instruction and practice. Occupational and vocational therapy may be needed to help individuals who have hearing loss adapt to their environments.

Physical therapy may be required for individuals with associated balance disorders. Individuals with persistent balance disorders may benefit from vestibular rehabilitation, an exercise program designed to take advantage of the brain's tendency to eventually adapt (habituate) to the repetition of a specific stimulus causing vertigo.

Traditional physical therapy addresses the secondary symptoms associated with the inactivity that accompanies persistent balance disorders. Secondary symptoms may include decreased strength, loss of range of motion, and increased tension particularly in the cervical and shoulder region that can lead to muscle fatigue and headaches. Physical therapists will teach the individual exercises that provide overall strengthening and help to restore muscles.

Source: Medical Disability Advisor



Complications

Tinnitus itself is not associated with complications although continuing to work or live with excessive environmental noise (i.e., loud music, machinery, tools, and equipment) will most likely increase the degree of sensorineural hearing loss and, in turn, increase the severity of tinnitus. The frustration of living with tinnitus may bring on or increase depression or anxiety and individual may have difficulty concentrating.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals with tinnitus must avoid working in excessively noisy environments that can cause additional sensorineural hearing loss and may need ear protection devices. Since many individuals with tinnitus experience some difficulty with balance, work restrictions and accommodations may be required to protect them and their co-workers (e.g., restrictions on use of certain equipment or working at heights). Phone system accommodations may be required for individuals with significant hearing loss. Provision of white noise in the individual's work area may help block out the inner noises.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual report ringing, buzzing, roaring, clicking, chirping, or hissing in one or both ears?
  • Does individual have arteriovenous malformation, glomus jugulare tumor, stapedius muscle, tensor tympani muscle spasms, TMJ syndrome, or eustachian tube dysfunction?
  • Has individual had exposure to loud environmental noise over a period of time or noise trauma?
  • Does individual have otosclerosis, Ménière's syndrome, labyrinthitis, otitis media, mastoiditis, wax or dirt build-up in the ear canal, acoustic neuromas, exposure to ototoxic drugs, hyper- or hypothyroidism, hyperlipidemia, zinc deficiency, vitamin A and/or B deficiency, hypertension, high cholesterol, other cardiovascular diseases, skull fracture, closed head trauma, whiplash injury, meningitis, multiple sclerosis, Lyme, depression, anxiety, and possibly excessive use of caffeine or other food substances such as aspartame?
  • Does individual's tinnitus interfere with daily activities or sleep?
  • Has the tinnitus caused psychological distress for individual? Is it incapacitating?
  • On exam, is there evidence of current or treated ear disease?
  • Does individual appear depressed?
  • Was blood pressure measured in both arms? Was a complete audiometric evaluation done? Has individual had a brain stem auditory evoked response (BAER)? Has individual had a brain MRI, CT focused on the middle ear, or a tomogram of the ear canal?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • What is the underlying cause of individual's tinnitus? Is it being treated?
  • Is surgery indicated? Is individual on appropriate medications?
  • If necessary, is individual seeing an appropriate mental health professional?
  • Has individual been instructed to avoid caffeine-containing beverages and food?
  • Does individual wear hearing protection when around any noise?
  • Does individual use any masking devices?

Regarding prognosis:

  • Is individual active in rehabilitation? Is a home exercise program in place?
  • Can individual's employer accommodate any necessary restrictions?
  • Does individual have any conditions that may affect ability to recover?

Source: Medical Disability Advisor



References

General

Noble, J., and H. L. Greene, eds. "Diagnosis of Hearing Loss." Textbook of Primary Care Medicine. 3rd ed. St. Louis: Mosby-Year Book, Inc., 2001. 1730.

Source: Medical Disability Advisor






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