Points from history and examination

• a diagnostic approach to identify an underlying etiology of tinnitus should include:
  • a detailed history
  • examination of the head and neck
  • audiometric testing
• points from the history:
  • onset (1)
    • in old age progressive hearing loss with tinnitus is associated with presbycusis
    • precipitous onset may suggest loud noise exposure or head injury
  • character of sound
  • a low-pitched rumbling sound suggests Meniere's disease
  • a high-pitched sound may indicate sensorineural hearing loss
  • if the tinnitus is made up of "voices" then this requires psychiatric referral
  • pattern (1)
    • pulsatile tinnitus
      • may indicate anxiety or acute inflammatory ear conditions
      • vascular aetiologies may cause pulsatile tinnitus
      • including tumours (glomus, carotid body), carotid stenosis, arteriovenous malformations, intracranial aneurysms, high cardiac output states
    • continuous tinnitus is associated with hearing loss (1)
    • episodic tinnitus is associated with Meniere's disease (1)
  • localization (1)
    • bilateral tinnitus is usually benign
    • causes of unilateral tinnitus include
      • cerumen impaction
      • otitis externa
      • otitis media
    • when tinitus is associated with unilateral sensorineural hearing loss acoustic neuroma should be suspected (1)
  • intrusion
    • not all patients suffer intrusion from their tinnitus
    • if the tinnitus is intrusive then this raises patients' concern about serious intracranial disease, reinforcing tinnitus. There may be a deterioration in sleep, mood, and concentration. Intrusion dictates whether and how much treatment is needed (2)
  • otological history
    • tinnitus may result from almost any ear problem
      • particularly causes of deafness, such as audiovestibular symptoms, exposure to noise, head injury, and ear surgery
    • when aural fullness, hearing loss and vertigoare associated, Meniere's disease should be suspected (1)
  • aggravating and inhibitory factors
    • tinnitus experienced in patulous eustachian tube subsides when lying down (1)
  • other causes to consider:
    • tinnitus may be associated with:
      • fever
      • cardiovascular disease e.g. hypertension, cardiac failure
• also tinnitus may be associated with high cardiac output states (anaemia, thyrotoxicosis, pregnancy)
• neurological disease e.g.multiple sclerosis, neuropathy, alcoholism
• physical immobility
  • tinnitus may be associated with mental stress and depression (therefore it is important to obtain a psychosocial history)
  • drugs may rarely cause or exacerbate tinnitus e.g. salicylates, aminoglycosides, quinine, loop diuretics, and beta blockers
  • other potential contributing causes include
    
    • hyperlipidemia, vitamin B12 deficiency, thyroid disorder (1)
• examination of the head and neck:
  • examine ears:
• for meatal wax or foreign bodies and signs of middle ear disease (effusion, infection, perforation, glomus).
• free-field speech tests detect deafness
• Rinne's test and Weber's test differentiate conductive and sensorineural losses
• note that audiometry is better for defining and documenting deafness
  • examine cranial nerves:
• particularly trigeminal and facial. Points from the history will indicate the need for further neurological or general examinations
• auscultate over the neck, periauricular area, mastoid, orbits (1)
• when tinnitus is of venous origin, it can be suppressed by pressing on the ipsilateral jugular vein (1)
• audiometric tests (1)
  • an audiometric assessment should be done on all patients with tinnitus
  • diagnostic testing should include the following
    • audiography
    • tests for speech discrimination
    • tympanometry
• further investigations (1)
  • if the patient has an abnormal medical history the following tests should be obtained (1)
    • thyroid function tests, hematocrit, complete blood chemistry, lipid profile
  • following tests help to identify the underlying disease
    • contrast-enhanced computed tomography (CT)
    • magnetic resonance imaging (MRI) of the brain

Reference:

• (1) Crummer RW et al.Diagnostic Approach to Tinnitus. American Family Physician 2004; 69(1)
• (2) Hannan A et al. BMJ, 2005;330(7485):237