History and exam
Key diagnostic factors
common
presence of risk factors
Risk factors include older age, hearing loss, loud noise exposure, vestibular schwannoma.
medication history
Aspirin, non-steroidal anti-inflammatory drugs, aminoglycosides, furosemide, ethacrynic acid, chloroquine, quinine, and cisplatin are associated with tinnitus.[9]
history of noise exposure
People who work in noisy environments are 1.6 times more likely to have tinnitus than people who work in quiet environments.[31]
episodic sounds
Episodic ringing tinnitus, aural fullness, fluctuating hearing loss, and episodic vertigo suggests Meniere's disease.
hearing loss
Most common cause of tinnitus. Presbycusis, noise-induced hearing loss, Meniere's disease, vestibular schwannoma, glomus tumour, ototoxic medicine, otosclerosis, or cerumen impaction may be the underlying cause.
vertigo
Associated with tinnitus in Meniere's disease, ototoxic medicines, and vestibular schwannoma.
uncommon
pulsatile sounds
May be noted in arteriovenous malformation, severe anaemia, thyrotoxicosis, middle ear inflammation, glomus tumour, benign intracranial hypertension, partial stenosis of a carotid artery, or a persistent stapedial artery.[34]
clicking sounds
May be noted in repetitive contraction of tensor veli palatini, tensor tympani, and temporomandibular joint syndrome, and palatal myoclonus.[8]
visual changes
History of visual changes, especially when these are accompanied by headaches, can lead to a diagnosis of arteriovenous fistula (AVF). Visual changes are present in 25% of patients with AVF.[7]
presence of bruits or hums
Associated with low-pitch pulsatile tinnitus. Tinnitus can be reduced by turning the head to the opposite side or by pressure over the ipsilateral internal jugular vein. Reduction in perception of tinnitus by this method is considered as diagnostic factor for venous hum.[7]
cranial nerve palsies
Cranial nerves V, VIII, IX, X, or XI can be affected by large vestibular schwannomas.
cerumen (ear wax)
Cerumen impaction can cause conductive hearing loss with or without tinnitus. Otoscopy is required in all patients with tinnitus to rule out the presence of wax. Sometimes a small hair on the tympanic membrane can cause a vibratory, tinny-like sound and removing the hair can resolve the symptom.
abnormal otoscopy
Erythema, perforation, an obstructing mass, cholesteatoma, or effusion may be seen.
abnormal Weber's test
This test in combination with the Rinne's test will differentiate sensorineural from conductive hearing loss.
When the Weber's test lateralises to the affected ear and the Rinne's test demonstrates bone conduction greater than air conduction, one can usually assume a conductive hearing loss in that ear.
If significant asymmetrical sensorineural hearing loss is present, the Weber's test often lateralises to the unaffected ear and the Rinne's test demonstrates air conduction greater than bone conduction.
abnormal Rinne's test
This test in combination with the Weber's test will differentiate sensorineural from conductive hearing loss.
When the Weber's test lateralises to the affected ear and the Rinne's test demonstrates bone conduction greater than air conduction, one can usually assume a conductive hearing loss in that ear.
If significant asymmetrical sensorineural hearing loss is present, the Weber's test often lateralises to the unaffected ear and the Rinne's test demonstrates air conduction greater than bone conduction.
Other diagnostic factors
common
slow-onset progressive hearing loss
Progressive hearing loss with tinnitus and advancing age suggests presbycusis.
high pitch
Noise-induced hearing loss and presbycusis may produce high-pitched tinnitus.[3]
low pitch
Venous hum, Meniere's disease, or cerumen impaction may produce low-pitched tinnitus.
A venous hum may be heard in patients with a history of hypertension and with an anatomically high jugular bulb. The quality of the sound changes with head position and pressure over the jugular vein.[39]
unilateral
May be noted with vestibular schwannoma, unilateral cerumen impaction, otitis media, and otitis externa. Unilateral, constant tinnitus may be associated with a cerebellopontine angle tumour or a glomus tumour.
bilateral
May be noted in patients with bilateral hearing loss.
uncommon
worse with chewing
Palatal myoclonus is a type of objective tinnitus that occurs with repetitive rapid contraction of soft palate muscles. The patient notices the noise while chewing and swallowing.
polyuria/polydipsia
History of these two symptoms demonstrates possible presence of diabetes mellitus as a cause of tinnitus.[7]
diarrhoea
May be present in thyrotoxicosis.[7]
palpitations
May be present in thyrotoxicosis; secreting glomus tumour is occasionally accompanied by these symptoms.[7]
foreign body
Such as a hair on the tympanic membrane.
Risk factors
strong
older age
More common in people aged between 40 and 70 years.
hearing loss
One study found an 11% increase in the likelihood of reporting tinnitus for each 10 dB increase in pure-tone average (PTA).[31]
PTA is the average of the sensitivity levels typically measured at 500, 1000, and 2000 Hz (three-frequency average).
loud noise exposure
People who work in noisy environments are 1.6 times more likely to have tinnitus than people who work in quiet environments.[31]
vestibular schwannoma
Causes sensorineural hearing loss.
weak
ototoxic medicines
Aspirin, non-steroidal anti-inflammatory drugs, aminoglycosides, furosemide, ethacrynic acid, chloroquine, quinine, cisplatin, some narcotics, and many other medicines may be associated with tinnitus.[9]
heavy metal exposure
Exposure to arsenic, lead, and mercury.[32]
history of cerebrovascular disease
Arteriovenous malformations, arteriovenous fistulas, carotid abnormalities, and high-riding jugular bulb cause tinnitus.[7]
history of multiple sclerosis
Tinnitus has been reported in a minority of patients with multiple sclerosis.[33]
history of head trauma
Labyrinthine concussion may result in tinnitus.
history of depression
Tinnitus is more prevalent in patients with depression.[7]
It is not completely understood whether the chronic nature of tinnitus causes depression or whether tinnitus occurs more in patients with depression because of psychological vulnerability.
history of anxiety
Anxiety may exacerbate tinnitus.
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