a diagnostic approach to identify an underlying aetiology 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 tinnitus 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 audio-vestibular symptoms, exposure to noise, head injury, and ear surgery
when aural fullness, hearing loss and vertigo are 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
tinnitus may also be associated with high cardiac output states such as anaemia, thyrotoxicosis, and 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 hyperlipidaemia, vitamin B12 deficiency, and thyroid disorders (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, haematocrit, complete blood chemistry, lipid profile
following tests help to identify the underlying disease
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