Diagnosis of Tinnitus

Tinnitus Diagnosis: Book Excerpts

• Ask the Following Questions - TINNITUS
• Differential Diagnosis - Tinnitus
• Differential Diagnosis - Tinnitus
• Approach to the Diagnosis - TINNITUS AND DEAFNESS
• History and physical examination - Tinnitus
• History and physical examination - Tinnitus
• History - Tinnitus
• Differential Overview - Tinnitus
• History - Tinnitus
• History and physical examination - Tinnitus
• Approach to the Diagnosis - TINNITUS AND DEAFNESS

Diagnostic Tests for Tinnitus: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Tinnitus.

TINNITUS: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

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.

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Tinnitus: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Acute or chronic otitis media
• Impacted cerumen
• Eustachian tube dysfunction
  –“Ocean roar” that may wax and wane with respiration
• Dysfunctional hearing aid
• Presbycusis (high pitch)
• Idiopathic (low pitch)
• Noise-induced hearing loss (high pitch)
• Meniere's disease
  –Triad of tinnitus, hearing loss, and vertigo
• Ototoxicity secondary to drugs
  –High pitch
  –May persist after medication (e.g., aminoglycosides)
  –May be dose-related (e.g., aspirin)
• Trauma
  –Commonly associated with airbag, whiplash, barotrauma
  –May have ruptured tympanic membrane
• TMJ syndrome
  –Nonpulsatile tinnitus (Costen's syndrome)
  –Associated jaw symptoms (e.g., pain, clicking)
• Migraine headache
• Vascular disease (e.g., atherosclerosis, diabetic vasculopathy, arteriovenous malformation, small vessel disease, hypertension)
• Stroke
• Otosclerosis
  –Associated with chronic otitis media or tympanic membrane trauma
• Pseudotumor cerebri
• Tumor
  –Glomus tympanicum or jugulare: Pulsatile tinnitus with hearing loss
  –Acoustic neuroma: Unilateral hearing loss and tinnitus, headache
• Infections (e.g., meningitis, Lyme disease, rubella)
• Less common etiologies (“zebras”) include thyroid disease, Paget's disease, myoclonus of palatal muscles, fetal insults (infections, toxins), sickle cell disease, osteogenesis imperfecta, neurosyphilis, symptomatic Chiari malformation, late onset congenital hearing loss, dissecting aneurysm, carotid cancer, and multiple sclerosis

Workup and Diagnosis

• History and physical exam, including medication history and complete head and neck examination
  –Include neurologic and/or systemic exam if indicated by history
  –Evaluate temporomandibular joint for clicking, popping, and dislocation
• Tympanometry to diagnose otitis media and eustachian tube dysfunction
• Full audiology evaluation if possible sensorineural etiology
• Consider CBC (anemia) and glucose tolerance test (occult diabetes mellitus)
• Head CT scan is indicated if glomus tumor is suspected (delineates base of skull involvement)
• MRI (with enhancement) if possible Chiari malformation, multiple sclerosis, pseudotumor cerebri, or acoustic neuroma
• Angiography
• MRA if CT and MRI are negative but vascular etiology is suspected
• Consider referral to otolaryngologist or neurologist
• Consider screening for secondary depression or insomnia, because this is common in patients with tinnitus

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Tinnitus: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Impacted cerumen
• Eustachian tube dysfunction
  –“Ocean roar” that may wax and wane with respiration
• Acute otitis media
  –Red TM with poor movement, ±fluid
• Chronic otitis media
  –Persistent otitis with poor TM movement
• Noise-induced hearing loss
  –High pitch
• Trauma
  –Airbag, whiplash, barotrauma, etc.
• Temporal-mandibular joint disorder
  –Nonpulsatile tinnitus
• Migraine
• Ototoxicity
  –High pitch
  –Many drugs, including salicylates and aminoglycosides
• Otosclerosis
• Pseudotumor cerebri
• Infections (meningitis, Lyme disease, rubella)
• Acquired AVM, arterial bruit, venous hum (positional change of tinnitus)
• Tumor
  –Glomus tympanicum or jugulare (pulsatile tinnitus with hearing loss)
  –Acoustic neuroma
• Thyroid disease
• Autoimmune inner ear disease
• Idiopathic
  –Low pitch
• Fetal insults
  –Infections, toxins, etc.
• Sickle cell disease, anemia
• Osteogenesis imperfecta
• Symptomatic Chiari malformation
• Late-onset congenital hearing loss
• Less common causes are
  –Hypertension
  –Myoclonus of palatal muscles
  –Multiple sclerosis
  –Small vessel disease
  –Presbycusis (high pitch)

Workup and Diagnosis

• History
  –Pitch of noise, duration, noise exposure, etc.
  –Complete history including problems during
• pregnancy
  –Birth history
  –PMH, medication use
• Physical exam
  –Complete head/neck exam looking for abnormalities
  –Neurologic/systemic exam if indicated by history
• Labs
  –CBC if infectious origin suspected
  –Consider TFTs (occult thyroid disease)
• Studies
  –Tympanometry: OM, eustachian tube dysfunction
  –Full audiology evaluation if suspect sensorineural etiology
• Radiology
  –Head CT if suspect glomus tumor (delineates base of skull involvement)
  –MRI (with enhancement): Chiari malformation, MS, pseudotumor cerebri, acoustic neuroma
  –Angiography: Constant pulsatile tinnitus if no specific vascular or musculoskeletal source
  –MRA if CT and MRI negative and suspect vascular etiology

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

TINNITUS AND DEAFNESS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

When a patient complains of tinnitus and deafness, a good occupational history is essential. Gradual onset of unilateral deafness should be considered an acoustic neuroma until proven otherwise. The combination of other symptoms and signs is the key to a clinical diagnosis. Thus tinnitus, deafness, and vertigo suggest Ménière disease. Almost total unilateral deafness (sudden in onset in a diabetic) suggests diabetic neuritis. A similar episode can occur in syphilis, but vertigo is also often present. Tinnitus and vertigo following a head injury suggest either traumatic myringitis, labyrinthitis, or postconcussion syndrome. If there is total deafness with the tinnitus and vertigo, a basilar skull fracture should be considered. Tinnitus and headache suggest migraine.

Diagnostic studies that should be done in all cases are audiograms, caloric tests, and x-rays of the skull, petrous bones, and mastoids. If an acoustic neuroma is suspected, tomography of the petrous bones, a CT scan or MRI, and basilar myelography may be indicated. Syphilis and multiple sclerosis require a spinal tap to assist in diagnosis. Angiography and EEGs may be required in selected cases.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Tinnitus: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient to describe the sound he hears, including its onset, pattern, pitch,
location, and intensity. Ask whether it’s accompanied by other symptoms, such as vertigo, headache, or hearing loss. Next, take a health history, including a complete drug history.

Using an otoscope, inspect the patient’s ears and examine the tympanic membrane. To check for hearing loss, perform the Weber and Rinne tuning fork tests. (See Differentiating conductive from sensorineural hearing loss, page 316.)

Also, auscultate for bruits in the neck. Then compress the jugular or carotid artery to see if this affects the tinnitus. Finally, examine the nasopharynx for masses that might cause eustachian tube dysfunction and tinnitus.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Tinnitus: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient to describe the sound he hears, including its onset, pattern, pitch, location, and intensity. Ask whether it’s accompanied by other symptoms, such as vertigo, headache, or hearing loss. Next, take a health history, including a complete drug history.

Using an otoscope, inspect the patient’s ears and examine the tympanic membrane. To check for hearing loss, perform the Weber and Rinne tuning fork tests. (See Differentiating conductive from sensorineural hearing loss, page 396.)

Also, auscultate for bruits in the neck. Then compress the jugular vein or carotid artery to see if this affects the tinnitus. Finally, examine the nasopharynx for masses that might cause eustachian tube dysfunction and tinnitus.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Tinnitus: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Important features of the history should include:

A. Date of tinnitus onset, particularly any relation to an illness or change in drug regimen.

 B. A description of the tinnitus may help subdivide into vibratory and nonvibratory sources. Are there any exacerbating or ameliorating factors? An association with respirations or pulse points to a vibratory source. Positional change (such as lowering the head between the knees causing venous engorgement), variation with respirations, or distortion of one’s own voice can point toward a patulous eustachian tube as the mechanism for tinnitus.

 C. Fluctuation of symptoms. This is commonly associated with Ménière’s disease.

 D. History of noise exposure or hearing loss. Noise-induced hearing loss usually causes high-pitched tinnitus, whereas Ménière’s disease usually produces a lower-pitched sound. Conductive hearing loss from cerumen impaction, otitis media, or otosclerosis can heighten the awareness of internal vibratory sounds such as a venous hum or myoclonus. Presbycusis, or degeneration within the organ of Corti, is frequently seen in the elderly. It is associated with high-frequency hearing loss and high-pitched tinnitus (Chapter 6.2).

 E. Medication history. Drugs can be a major contributor to tinnitus (e.g., salicylates, caffeine, aminoglycosides, alcohol, quinidine, nonsteroidals, carbamazepine, levodopa, propranolol (Inderal), and aminophylline) (3). Some hormonal preparations have also been implicated as has the postpartum state.

 F. Significant weight loss can be associated with a patulous eustachian tube (Chapter 2.13).

G. Concurrent medical conditions to be considered include hypertension, diabetes mellitus, thyroid disorders, hyperlipidemia, and infection. Arteriovenous sounds will be heightened by increased cardiac output. Vascular disease can cause ischemia of the auditory organs, including the cortex. Neural impulses can be affected by diabetes or MS.

H. Psychiatric disturbances can affect sound perception. Ask about anxiety or depression, which can heighten awareness of internal auditory sounds. In turn, tinnitus can exacerbate these underlying conditions. Auditory hallucinations can be assessed by mental status testing.

I. Psychological effects. Ask about impact on sleep, concentration, hearing, memory, irritability, and sense of well-being.

Physical examination

 Focus on the head, ears, eyes, nose, throat, and neck as well as the cardiovascular and neurologic systems. Assess vital signs and perform a complete ear examination, including evaluation for obstruction of the external auditory canal. Look for tympanic membrane landmarks, tympanic pulsations, or signs of tumor. Auscultate the external auditory canal for transmitted sounds and use tuning forks to assess air and bone conduction. Observe the neck for thyroid masses and auscultate for thyroid or carotid bruits. Evaluate extraocular movements, speech discrimination, and the integrity of the central nervous system (gait, equilibrium, sensation). If appropriate, include evaluation of mood, affect, and perception (e.g., hallucinations).

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Tinnitus: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Impacted cerumen

❑ Otitis media

❑ Eustachian dysfunction

❑ Presbyacusis

❑ Hypertension

❑ Drugs

❑ Ménière

❑ Arterial bruit

❑ Acoustic neuroma

❑ Vascular aneurysm

❑ Arteriovenous malformation

❑ Functional

❑ Glomus tumor

Diagnostic Approach

A high-pitched continuous tone is the most common type, due to a sensorineural hearing loss or cochlear injury. Low-pitched tinnitus is seen with Meniere disease. Vascular tinnitus is most often pulsatile and occurs with hypertension, berry aneurysm, arteriovenous malformation, internal carotid stenosis, a tortuous carotid within the temporal bone, increased intracranial pressure or glomus tumor. A clicking noise, or irregular or rapid pulsations that do not follow the pulse originate in myoclonus of the palatal, stapedial, or tensor tympani muscles. Tinnitus that can be heard with a stethoscope is usually a result of a tumor, aneurysm, or arteriovenous malformation.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Tinnitus: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient to describe the sound he hears, including its onset, pattern, pitch, location, and intensity. Ask whether the sound is accompanied by other symptoms, such as vertigo, headache, or hearing loss. Next, take a health history, including a complete drug history.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Tinnitus: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient to describe the sound he hears, including its onset, pattern, pitch, location, and intensity. Ask whether it's accompanied by other symptoms, such as vertigo, headache, or hearing loss. Next, take a health history, including a complete drug history.

Inspect the patient's ears and examine the tympanic membrane. To check for hearing loss, perform the Weber and Rinne tuning fork tests.

Also, auscultate for bruits in the neck. Then compress the jugular or carotid artery to see if this affects the tinnitus. Finally, examine the nasopharynx for masses that might cause eustachian tube dysfunction and tinnitus.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

TINNITUS AND DEAFNESS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

When a patient complains of tinnitus and deafness, a good occupational history is essential. Gradual onset of unilateral deafness should be considered an acoustic neuroma until proven otherwise. The combination of other symptoms and signs is the key to a clinical diagnosis. Thus tinnitus, deafness, and vertigo suggest Ménière disease. Almost total unilateral deafness (sudden in onset in a diabetic) suggests diabetic neuritis. A similar episode can occur in syphilis, but vertigo is also often present. Tinnitus and vertigo following a head injury suggest traumatic myringitis, labyrinthitis, or postconcussion syndrome. If there is total deafness with the tinnitus and vertigo, a basilar skull fracture should be considered. Tinnitus and headache suggest migraine. Diagnostic studies that should be done in all cases are audiograms, caloric tests, and x-rays of the skull, petrous bones, and mastoids. If an acoustic neuroma is suspected, tomography of the petrous bones, a CT scan or magnetic resonance imaging (MRI), and basilar myelography may be indicated. Syphilis and multiple sclerosis require a spinal tap to assist in diagnosis. Angiography and EEGs may be required in selected cases.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

 » Next page: Signs of Tinnitus

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