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Tinnitus

Surgery > Ear, nose & throat

Differential Diagnosis Schema 🧠

Sensorineural Causes

  • Noise-induced hearing loss: Prolonged exposure to loud noise leading to cochlear damage and tinnitus, often high-pitched.
  • Presbycusis: Age-related hearing loss associated with tinnitus, typically bilateral and high-pitched.
  • Meniere’s disease: Characterized by episodic vertigo, fluctuating hearing loss, and tinnitus (often low-pitched and unilateral).
  • Acoustic neuroma: Benign tumor on the vestibulocochlear nerve causing unilateral tinnitus, hearing loss, and sometimes vertigo.
  • Ototoxic medications: Drugs such as aminoglycosides, loop diuretics, or high-dose aspirin that can cause tinnitus as a side effect.
  • Sudden sensorineural hearing loss: Rapid onset hearing loss often accompanied by tinnitus, requiring urgent evaluation.
  • Multiple sclerosis: Can present with tinnitus as part of central nervous system involvement.
  • Trauma: Head or neck injury leading to tinnitus due to damage to the auditory pathways.

Conductive Causes

  • Earwax impaction: Can cause conductive hearing loss and associated tinnitus, often described as a ringing or buzzing.
  • Otitis media: Middle ear infection causing conductive hearing loss and tinnitus, often with a feeling of fullness in the ear.
  • Otosclerosis: Abnormal bone growth in the middle ear leading to progressive conductive hearing loss and tinnitus.
  • Eustachian tube dysfunction: Can cause a sensation of fullness, muffled hearing, and associated tinnitus.
  • Cholesteatoma: Abnormal skin growth in the middle ear that can lead to hearing loss, discharge, and tinnitus.
  • Barotrauma: Damage to the ear due to pressure changes, leading to tinnitus and hearing loss, often related to flying or diving.
  • Glomus tumor: Vascular tumor in the middle ear that can cause pulsatile tinnitus.

Vascular Causes

  • Carotid artery stenosis: Narrowing of the carotid artery can lead to turbulent blood flow, causing pulsatile tinnitus.
  • Arteriovenous malformations: Abnormal connections between arteries and veins in the brain or ear can cause pulsatile tinnitus.
  • Hypertension: Elevated blood pressure can exacerbate tinnitus, particularly pulsatile tinnitus.
  • Atherosclerosis: Hardening of the arteries can lead to turbulent blood flow and associated pulsatile tinnitus.
  • Venous hum: Turbulent blood flow in the jugular vein can be transmitted to the ear, causing a whooshing sound.
  • Vascular tumors: Tumors like glomus tumors can produce pulsatile tinnitus due to their vascular nature.

Key Points in History 🥼

Onset and Duration

  • Sudden vs. gradual onset: Sudden onset may indicate acoustic trauma, sudden sensorineural hearing loss, or acute otitis media. Gradual onset suggests age-related hearing loss or chronic conditions like Meniere’s disease.
  • Duration: Persistent tinnitus over weeks or months is more concerning for chronic conditions, whereas transient tinnitus may be related to temporary factors like noise exposure or acute infections.
  • Fluctuating vs. constant: Fluctuating tinnitus is characteristic of Meniere’s disease, while constant tinnitus is often seen in chronic sensorineural hearing loss or ototoxicity.
  • Pulsatile vs. non-pulsatile: Pulsatile tinnitus suggests a vascular cause, while non-pulsatile tinnitus is more likely due to auditory system issues.
  • Unilateral vs. bilateral: Unilateral tinnitus is concerning for focal lesions such as acoustic neuroma or vascular anomalies, while bilateral tinnitus is often seen in systemic or age-related conditions.
  • Associated events: Recent exposure to loud noise, head trauma, or new medications may help identify the cause of tinnitus.

Associated Symptoms

  • Hearing loss: Accompanying hearing loss is common in tinnitus, especially in noise-induced hearing loss, presbycusis, and Meniere’s disease.
  • Vertigo: The presence of vertigo suggests Meniere’s disease, vestibular migraine, or labyrinthitis.
  • Ear fullness or pain: May indicate middle ear pathology such as otitis media or Eustachian tube dysfunction.
  • Neurological symptoms: Facial weakness, numbness, or ataxia along with tinnitus may suggest an acoustic neuroma or central causes.
  • Cardiovascular symptoms: Pulsatile tinnitus with headaches or syncope may suggest a vascular cause such as carotid artery stenosis or arteriovenous malformations.
  • Medication history: Noting the use of ototoxic drugs such as aminoglycosides, loop diuretics, or NSAIDs.
  • Psychological impact: Assess for anxiety, depression, or sleep disturbances due to chronic tinnitus.
  • Trauma: History of recent head or neck trauma can lead to tinnitus due to damage to the auditory system.
  • Infections: Recent upper respiratory infections may lead to middle ear effusion and tinnitus.
  • Occupational history: Exposure to loud noises in the workplace is a significant risk factor for tinnitus.

Background

  • Past medical history: Chronic conditions such as hypertension, diabetes, or hyperlipidemia that could contribute to vascular causes of tinnitus.
  • Medication history: Document current and past use of ototoxic medications, including over-the-counter drugs like aspirin.
  • Family history: Genetic predispositions to conditions like Meniere’s disease, otosclerosis, or early-onset hearing loss.
  • Social history: Lifestyle factors including smoking, alcohol use, and occupation-related noise exposure.
  • Psychological history: Anxiety, depression, or other mental health conditions that may exacerbate the perception of tinnitus.
  • Surgical history: Previous ear surgeries or head and neck surgeries that may affect hearing and contribute to tinnitus.
  • Exposure history: Any recent exposure to loud noise, ototoxic chemicals, or infections that could precipitate tinnitus.
  • Recent illnesses: Upper respiratory infections or sinusitis that may contribute to middle ear effusion and tinnitus.
  • Trauma history: Any incidents of head or neck trauma that could affect the auditory pathways.

Possible Investigations 🌡️

Audiological Tests

  • Pure tone audiometry: Assesses hearing levels across different frequencies, helping to distinguish between conductive and sensorineural hearing loss.
  • Tympanometry: Evaluates middle ear function and helps diagnose conditions like otitis media or Eustachian tube dysfunction.
  • Speech audiometry: Measures the ability to hear and understand speech, providing additional information on the functional impact of hearing loss.
  • Otoacoustic emissions (OAE): Tests cochlear (outer hair cell) function, often used in screening for sensorineural hearing loss.
  • Auditory brainstem response (ABR): Assesses the auditory nerve and brainstem pathways, useful in diagnosing retrocochlear pathology such as acoustic neuroma.
  • High-frequency audiometry: Useful for detecting early ototoxic damage not identified by standard audiometry.
  • Tinnitus matching: Used to determine the pitch and loudness of tinnitus, aiding in diagnosis and management.
  • Electrocochleography: May be indicated in cases of suspected Meniere’s disease to assess inner ear fluid pressure.
  • Vestibular testing: If vertigo is present, tests like videonystagmography (VNG) can help diagnose associated vestibular disorders.

Imaging Studies

  • MRI brain and internal auditory canals: Gold standard for evaluating retrocochlear pathology, such as acoustic neuroma or multiple sclerosis.
  • CT scan of the temporal bones: Useful for assessing bony structures, particularly in cases of conductive hearing loss due to otosclerosis or trauma.
  • Carotid Doppler ultrasound: To assess for carotid artery stenosis or other vascular causes of pulsatile tinnitus.
  • Magnetic resonance angiography (MRA): Evaluates vascular structures in the brain, particularly in cases of suspected arteriovenous malformations or aneurysms causing pulsatile tinnitus.
  • CT angiography: May be used in cases where detailed evaluation of vascular anatomy is needed, particularly for surgical planning.
  • Chest X-ray: If vascular causes of tinnitus are suspected, such as aortic aneurysm with mediastinal involvement.
  • Echocardiography: In cases where cardiovascular causes of tinnitus are suspected, such as valvular heart disease.

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Ear, nose & throat