Tinnitus: Difference between revisions
(Expanded with concise EM-focused content: red flags for pulsatile tinnitus, ototoxic meds, sudden SNHL urgency, evaluation, disposition) |
(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 | *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) | **'''Acute tinnitus with hearing loss''' → sudden sensorineural hearing loss (ENT emergency) | ||
** | **Tinnitus after medication change → ototoxicity (especially [[salicylate toxicity]]) | ||
==Clinical Features== | ==Clinical Features== | ||
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===Ototoxic Medications=== | ===Ototoxic Medications=== | ||
* | *[[Salicylate toxicity]]: tinnitus is an early symptom — check salicylate level | ||
*Loop [[diuretics]] ([[furosemide]], [[bumetanide]], ethacrynic acid) | *Loop [[diuretics]] ([[furosemide]], [[bumetanide]], ethacrynic acid) | ||
*[[Aminoglycosides]], [[erythromycin]], [[vancomycin]] | *[[Aminoglycosides]], [[erythromycin]], [[vancomycin]] | ||
| Line 50: | Line 50: | ||
*Auscultate over periauricular area, orbits, and neck for bruits (objective tinnitus) | *Auscultate over periauricular area, orbits, and neck for bruits (objective tinnitus) | ||
*Cranial nerve exam, hearing (Weber/Rinne), cerebellar function | *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) | *Other workup guided by history (BMP, TSH, CBC, head CT if trauma or neurologic deficits) | ||
| Line 58: | Line 58: | ||
*Identify and treat reversible causes | *Identify and treat reversible causes | ||
*Stop/minimize ototoxic agents | *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 | *Outpatient: masking techniques (white noise), habituation therapy, consider antidepressants for severe cases | ||
*Reassurance for most patients | *Reassurance for most patients | ||
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
- Noise-induced hearing loss (most common cause overall)
- Otitis media, otomycosis, herpes zoster oticus
- Meniere's disease
- Labyrinthitis
- Head trauma, otic barotrauma, decompression sickness
- TMJ dysfunction
- Acoustic neuroma (vestibular schwannoma)
- Idiopathic intracranial hypertension
- MS, stroke
Ototoxic Medications
- Salicylate toxicity: tinnitus is an early symptom — check salicylate level
- Loop diuretics (furosemide, bumetanide, ethacrynic acid)
- Aminoglycosides, erythromycin, vancomycin
- Chemotherapeutics: cisplatin, carboplatin
- NSAIDs, quinine, bupropion
- Caffeine, hydrocarbons
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