Tinnitus

Probability diagnosis

Ear wax or debris

Sensorineural hearing loss (esp. noise induced)

Otosclerosis

Ageing

Ear infection (e.g. viral cochleitis)

Meniere syndrome

Serious disorders not to be missed

Vascular:

• arteriovenous malformation

• carotidovenous fistula

• arterial bruits (esp. carotid)

• venous hum (jugular)

Infection:

• suppurative otitis media

Cancer/tumour:

• acoustic neuroma (unilateral)

Other:

• head injury

Pitfalls (often missed)

Impacted wisdom tooth

Temporomandibular injury/dysfunction

Alcoholism

Rarities:

• superior canal dehiscence

• glomus jugulare tumour

• syphilis

Masquerades checklist

Anaemia (severe)

Depression

Drugs (aspirin, NSAIDs, loop diuretics, marijuana, quinine, aminoglycosides)

Spinal dysfunction

Is the patient trying to tell me something?

Consider if subjective tinnitus.

Key history

• Recent onset or longstanding

• Pulsating or non-pulsating

• Head injury

• Exposure to loud noise

• Upper respiratory infection

• Otitis externa

Key examination

• Otoscope of ear

• Cardiovascular (esp. auscultation neck)

Key investigations

• Audiogram

• Tympanogram (middle ear function)

• FBE

• MRI or CT scan (esp. if head injury)

Diagnostic tips

• Think otosclerosis in young.

• Tinnitus may precede other symptoms of Meniere syndrome by months.

• Non-pulsative and continuous → inner ear.

• Venous hum → jugular vein.

• Vascular symptoms → organic disorder.

• Stress and anxiety exacerbate tinnitus.

• Associated depression may lead to suicide.