Tinnitus: Difference between revisions

(Created page with "==Background== *Perception of sound without external stimulation *Can be constant or pulsatile, high or low pitched, hissing, clicking, or ringing ==Causes/Differential Diagn...")
 
(Add verified PubMed references (PMIDs 34060792, 29621860))
 
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==Background==
==Background==
*Perception of sound without external stimulation
*Perception of sound without external stimulation<ref>Dalrymple SN, Lewis SH, Philman S. Tinnitus: Diagnosis and Management. Am Fam Physician. 2021 Jun 1;103(11):663-671. PMID 34060792</ref><ref>Esmaili AA, Renton J. A review of tinnitus. Aust J Gen Pract. 2018 Apr;47(4):205-208. PMID 29621860</ref>
*Can be constant or pulsatile, high or low pitched, hissing, clicking, or ringing
*Can be constant or pulsatile, high or low pitched, hissing, clicking, or ringing
*Most ED presentations are benign, but key EM role is to identify dangerous causes:
**Pulsatile tinnitus → vascular lesion (carotid dissection, AVM, dural AV fistula)
**'''Acute tinnitus with hearing loss''' → sudden sensorineural hearing loss (ENT emergency)
**Tinnitus after medication change → ototoxicity (especially [[salicylate toxicity]])
==Clinical Features==
*Subjective (only patient hears) vs. objective (examiner can hear — think vascular or mechanical cause)
*Pulsatile vs. non-pulsatile
*Unilateral vs. bilateral
*Associated hearing loss, vertigo, fullness ([[Meniere's disease]])
*Associated headache, visual changes, papilledema ([[idiopathic intracranial hypertension]])
*Medication review for ototoxic agents
===Red Flags===
*Pulsatile tinnitus (vascular cause until proven otherwise)
*Unilateral tinnitus with hearing loss (acoustic neuroma, sudden SNHL)
*Associated neurologic deficits (stroke, dissection)
*Recent head trauma
*Suicidal ideation (severe tinnitus is a risk factor)
==Differential Diagnosis==
===Objective (May Be Heard by Examiner)===
*Vascular (often pulsatile): AVM, aneurysm, arterial bruits, [[carotid stenosis]] or [[vertebral and carotid artery dissection|dissection]], dural AV fistula
*Mechanical: enlarged eustachian tube, palatal myoclonus, stapedial muscle spasm


==Causes/Differential Diagnosis==
===Objective===
''May be heard by examiner. Less common''
*Mechanical: Enlarged eustachian tube, palatal myoclonus, stapedial muscle spasm
*Vascular: often pulsatile
**[[AVM]], aneurysm
**Arterial bruits
**[[Carotid stenosis]] or [[vertebral and carotid artery dissection|dissection]]
===Subjective===
===Subjective===
*Excessive noise exposure and/or any cause of sensory hearing loss
*Noise-induced hearing loss (most common cause overall)
*[[Otitis media]], [[otomycosis]], [[herpes zoster oticus]]
*[[Otitis media]], [[otomycosis]], [[herpes zoster oticus]]
*[[Meniere's disease]]
*[[Meniere's disease]]
*[[Labyrinthitis]]
*[[Labyrinthitis]]
*[[Head trauma]], [[otic barotrauma]], [[decompression sickness]]
*[[Head trauma]], [[otic barotrauma]], [[decompression sickness]]
*[[Hypertension]],
*[[TMJ]] dysfunction
*[[TMJ]]
*[[Acoustic neuroma]] (vestibular schwannoma)
*[[MS]]
*[[Idiopathic intracranial hypertension]]
*Acoustic neuroma
*[[MS]], [[stroke]]
*[[Abducens nerve palsy]]
 
*[[Leukostasis and hyperleukocytosis]]
===Ototoxic Medications===
*[[Benign intracranial hypertension]]
*[[Salicylate toxicity]]: tinnitus is an early symptom — check salicylate level
*Ototoxicity/medication effect:
*Loop [[diuretics]] ([[furosemide]], [[bumetanide]], ethacrynic acid)
**[[Salicylate toxicity]]: tinnitus is an early symptom
*[[Aminoglycosides]], [[erythromycin]], [[vancomycin]]
**[[Hydrocarbons]]
*Chemotherapeutics: cisplatin, carboplatin
**[[Caffeine toxicity]]
*[[NSAIDs]], [[quinine]], [[bupropion]]
**[[Oxygen toxicity]]
*[[Caffeine]], [[hydrocarbons]]
**[[NSAIDs]]
**Loop [[diuretics]] ([[furosemide]], [[bumetanide]], ethacrynic acid)
**Antibiotics: [[aminoglycosides]], [[erythromycin]], [[vancomycin]]
**Chemotherapeutics: cisplatin, carboplatin, vinblastine, vincristine
**[[Quinine]]
**[[Fosphenytoin]]
**[[Bupropion]]


==Evaluation==
==Evaluation==
*Evaluate for emergent causes
*Otoscopic exam (cerumen impaction, otitis media, TM perforation)
*Accurate/definitive diagnosis often involves referral to otolaryngology/audiometry  
*Auscultate over periauricular area, orbits, and neck for bruits (objective tinnitus)
*Cranial nerve exam, hearing (Weber/Rinne), cerebellar function
*Pulsatile tinnitus: CT/CTA or MRI/MRA to evaluate for vascular cause
*Acute unilateral hearing loss + tinnitus: audiometry referral urgently (sudden SNHL)
*Salicylate level if aspirin use or toxicity suspected
*Other workup guided by history (BMP, TSH, CBC, head CT if trauma or neurologic deficits)


==Management==
==Management==
*Stop/minimize exposure to excessive noise and ototoxic agents
*Identify and treat reversible causes
*Outpatient management may include masking the tinnitus (e.g. with music or white noise), habituation techniques, or antidepressants  
*Stop/minimize ototoxic agents
*Salicylate toxicity: treat per [[salicylate toxicity]] protocol
*Sudden sensorineural hearing loss: urgent ENT referral (may benefit from systemic or intratympanic steroids if started within 2 weeks)
*Cerumen impaction: removal often provides relief
*Outpatient: masking techniques (white noise), habituation therapy, consider antidepressants for severe cases
*Reassurance for most patients


==Disposition==
==Disposition==
*Discharge unless underlying condition requires admission
*Discharge unless underlying condition requires admission
*Urgent ENT referral for: sudden hearing loss, pulsatile tinnitus, unilateral tinnitus concerning for acoustic neuroma
*Return precautions: hearing loss, new neurologic symptoms, vertigo, worsening


==See Also==
==See Also==
*[[Hearing loss]]
*[[Meniere's disease]]
*[[Salicylate toxicity]]
*[[Focal neurologic deficits]]
*[[Focal neurologic deficits]]
==External Links==


==References==
==References==
<references/>
<references/>


[[Category:Symptoms]] [[Category:ENT]]
[[Category:Symptoms]]
[[Category:ENT]]

Latest revision as of 10:53, 22 March 2026

Background

  • Perception of sound without external stimulation[1][2]
  • Can be constant or pulsatile, high or low pitched, hissing, clicking, or ringing
  • Most ED presentations are benign, but key EM role is to identify dangerous causes:
    • Pulsatile tinnitus → vascular lesion (carotid dissection, AVM, dural AV fistula)
    • Acute tinnitus with hearing loss → sudden sensorineural hearing loss (ENT emergency)
    • Tinnitus after medication change → ototoxicity (especially salicylate toxicity)

Clinical Features

  • Subjective (only patient hears) vs. objective (examiner can hear — think vascular or mechanical cause)
  • Pulsatile vs. non-pulsatile
  • Unilateral vs. bilateral
  • Associated hearing loss, vertigo, fullness (Meniere's disease)
  • Associated headache, visual changes, papilledema (idiopathic intracranial hypertension)
  • Medication review for ototoxic agents

Red Flags

  • Pulsatile tinnitus (vascular cause until proven otherwise)
  • Unilateral tinnitus with hearing loss (acoustic neuroma, sudden SNHL)
  • Associated neurologic deficits (stroke, dissection)
  • Recent head trauma
  • Suicidal ideation (severe tinnitus is a risk factor)

Differential Diagnosis

Objective (May Be Heard by Examiner)

  • Vascular (often pulsatile): AVM, aneurysm, arterial bruits, carotid stenosis or dissection, dural AV fistula
  • Mechanical: enlarged eustachian tube, palatal myoclonus, stapedial muscle spasm

Subjective

Ototoxic Medications

Evaluation

  • Otoscopic exam (cerumen impaction, otitis media, TM perforation)
  • Auscultate over periauricular area, orbits, and neck for bruits (objective tinnitus)
  • Cranial nerve exam, hearing (Weber/Rinne), cerebellar function
  • Pulsatile tinnitus: CT/CTA or MRI/MRA to evaluate for vascular cause
  • Acute unilateral hearing loss + tinnitus: audiometry referral urgently (sudden SNHL)
  • Salicylate level if aspirin use or toxicity suspected
  • Other workup guided by history (BMP, TSH, CBC, head CT if trauma or neurologic deficits)

Management

  • Identify and treat reversible causes
  • Stop/minimize ototoxic agents
  • Salicylate toxicity: treat per salicylate toxicity protocol
  • Sudden sensorineural hearing loss: urgent ENT referral (may benefit from systemic or intratympanic steroids if started within 2 weeks)
  • Cerumen impaction: removal often provides relief
  • Outpatient: masking techniques (white noise), habituation therapy, consider antidepressants for severe cases
  • Reassurance for most patients

Disposition

  • Discharge unless underlying condition requires admission
  • Urgent ENT referral for: sudden hearing loss, pulsatile tinnitus, unilateral tinnitus concerning for acoustic neuroma
  • Return precautions: hearing loss, new neurologic symptoms, vertigo, worsening

See Also

References

  1. ↑ Dalrymple SN, Lewis SH, Philman S. Tinnitus: Diagnosis and Management. Am Fam Physician. 2021 Jun 1;103(11):663-671. PMID 34060792
  2. ↑ Esmaili AA, Renton J. A review of tinnitus. Aust J Gen Pract. 2018 Apr;47(4):205-208. PMID 29621860
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