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)
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