TINNITUS

TINNITUS: Excerpt from Algorithmic Diagnosis of Symptoms and Signs

Ask the Following Questions:

1. Is it subjective or objective? Objective tinnitus is unusual, but it may indicate glomus tumors, arteriovenous malformations, carotid stenosis, aneurysms, anemia, a patent eustachian tube, or myoclonus. Objective tinnitus means that both the patient and the examiner can hear the noises.
2. If it is subjective, is it unilateral or bilateral? Unilateral subjective tinnitus is more likely to be associated with a more serious disorder such as Ménière's disease, acoustic neuroma, cholesteatoma, or vascular disease.
3. Is there a history of trauma? A history of trauma would suggest that the tinnitus is due to whiplash, concussion, or trauma to the middle or inner ear.
4. Is there a history of the use of ototoxic drugs? Drugs that may cause tinnitus include aminoglycosides, tetracyclines, clindamycin, caffeine, and the tricyclic antidepressants. Aspirin and quinine may also be associated with tinnitus.
5. Are there abnormalities found on the ear examination? Abnormalities on the ear examination include cerumen, otitis externa, otitis media, mastoiditis, and cholesteatomas. The tympanic membrane may be red in cases of glomus tumors.
6. Is there vertigo and deafness? The presence of vertigo with deafness should suggest Ménière's disease, acoustic neuroma, and cholesteatoma, as well as multiple sclerosis, basilar artery insufficiency, and brain stem tumors.
7. Are there other neurologic signs? The presence of other neurologic signs along with vertigo and deafness would suggest multiple sclerosis, advanced acoustic neuroma, basilar artery occlusion or insufficiency, brain stem tumors, and central nervous system syphilis.

DIAGNOSTIC WORKUP

The basic workup includes a CBC, sedimentation rate, urinalysis, chemistry panel, thyroid profile, VDRL test, audiometry, caloric tests (electronystagmography), and x-rays of the mastoids and petrous bones. Specialized audiometry may be performed, such as impedance audiometry, Békésy audiometry, and BSEP studies.

If an acoustic neuroma is strongly suspected, CT scans with iodine infusion or instillation of 4 cc of oxygen in the subarachnoid space would be indicated. Gadolinium-enhanced MRI may also diagnose an early acoustic neuroma. Angiography and venography may help diagnose objective tinnitus. A spinal tap may be helpful in diagnosing multiple sclerosis and central nervous system syphilis. A glucose tolerance test may be indicated to rule out diabetes mellitus.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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