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Points from history and examination

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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  • 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
      • contrast-enhanced computed tomography (CT)
      • magnetic resonance imaging (MRI) of the brain

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