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Tinnitus: History Taking and Differential Diagnoses

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Overview

Tinnitus is the perception of sound in the absence of an external source. It is a symptom and not a disease. It is often described as ringing, buzzing, hissing, or humming. Tinnitus can be unilateral or bilateral. In bilateral tinnitus, it may be asymmetric – one side may be worse than the other.

Tinnitus can be divided into:

  • Subjective tinnitus – where there is no sound source – more common
  • Objective – rare and there is a noise heard that is generated in the head, can be heard by others (e.g. arterial bruits)

Causes

Subjective tinnitus

Objective tinnitus

History Taking

Overview

With each symptom, always (if relevant) ask about:

  • When did it start?
  • Did it come on suddenly or gradually?
  • Is it continuous or intermittent?
  • Has this ever happened before?
  • Is this in one or both ears?
    • Unilateral tinnitus can suggest vestibular schwannoma, impacted earwax, otitis externa, or otitis media
    • Bilateral tinnitus may have associated hearing loss

Tinnitus

  • What do they hear?
    • Roaring and aural fullness may suggest Ménière’s disease
    • Clicking and pulsatile sounds suggest causes of objective tinnitus such as idiopathic intracranial hypertension and arteriovenous malformations
  • Are there any scenarios where it is worse?
    • For example, when the environment is quiet

Review of systems

Screen for red flags:

  • Any fever?
  • Any night sweats?
  • Any unexplained weight loss?
  • Any symptoms associated with a stroke? Examples are:
    • Problems with balance?
    • Problems with speech?
    • Weakness or numbness?

Screen for ear symptoms:

  • Hearing loss?
  • Dizziness? – does the room spin?
  • Ear pains?
    • Use SOCRATES
  • Ear discharge?
  • Do they hear any clicking or popping?
  • Do their ears ever feel full?
  • Has anything been inserted into the ear?

Screen for nose symptoms:

Screen for neurological symptoms:

Past Medical History

Questions include:

  • Do they have any other medical conditions?
  • Have they ever had any previous surgery?
  • Do they take any regular medications?
  • Do they take any over-the-counter medications, herbal remedies, or supplements?
  • Have they had a recent infection such as a cold or the flu?
  • Do they take eardrops? – some patients forget these count as regular medications

Family History

  • Is there any family history of anything similar?

Allergy History

  • Are they allergic to anything?
    • What happens during the allergic reaction?

Social History

  • Do they smoke?
    • If so, how much and how long?
  • Do they drink alcohol?
    • If so, how much and how long?
  • Do they use any illicit drugs?
    • If so, how much and how long?
  • What is their occupation?
    • Does their job include loud sounds?
  • Who’s at home?
    • What support do they have?
  • How has this impacted their activities of daily living?
  • Has there been any recent foreign travel?

Physical Examinations

Overview

An ear examination and cranial nerve exam should be performed, including using Weber and Rinne tuning fork tests. Some signs that may be present include:

  • Otoscopy may show:
    • Impacted earwax
    • External ear canal erythema
    • Cholesteatoma
    • Problems with the tympanic membrane (e.g. erythema, perforation, or effusion)
  • Arterial bruits (e.g. carotid bruit) which may suggest a cause of objective tinnitus
  • Weber and Rinne tests may help with identifying the type of any hearing loss present
  • A vestibular schwannoma may lead to cranial nerve involvement:
    • Vestibulocochlear nerve (CN VIII) – hearing loss, tinnitus, and vertigo
    • Trigeminal nerve (CN V) – absent corneal reflex, facial numbness
    • Facial nerve (CN VII) – facial nerve palsy

Investigations

  • Audiometry:
    • Identifies any associated hearing loss
  • Offer an MRI of the head and neck, temporal bone, and internal auditory meatus if:
    • Pulsatile tinnitus is present or
    • No pulsatile tinnitus is present, but there are:
      • Associated neurological, otological, or head and neck signs/symptoms or
      • The non-pulsatile tinnitus is unilateral or asymmetrical
  • Magnetic resonance angiography (MRA):
    • Often performed in pulsatile tinnitus as it can be caused by vascular pathology

Differential Diagnoses

Presbycusis

  • A history may reveal:
    • More common in older patients (>50 years)
    • Slow, gradual, high-frequency bilateral hearing loss that is worse in louder environments
    • Difficulty with understanding consonants such as ch, f, k, p, and s, and this makes understanding speech difficult
  • A physical exam may reveal:
    • Weber and Rinne’s tests show sensorineural hearing loss
  • Investigations may reveal:
    • Audiometry – bilateral high-frequency sensorineural hearing loss

Otosclerosis

  • A history may reveal:
    • Hearing loss in a relatively young patient (~20s)
    • Most commonly bilateral but can be unilateral
    • There is usually a family history
  • A physical exam may reveal:
    • Weber and Rinne’s tests show conductive hearing loss
  • Investigations may reveal:
    • Audiometry – conductive hearing loss

Impacted earwax

  • A history may reveal:
    • The use of cotton buds in the ear or hearing aids
  • A physical exam may reveal:
    • Otoscopy usually identifies impacted earwax
  • Diagnosis is clinical

Otitis media

  • A history may reveal:
    • More common in children
    • Associated earache and fever
    • May perforate leading to foul discharge release from the ear 
  • A physical exam may reveal:
    • A red, bulging, tympanic membrane
  • Diagnosis is clinical

Ménière’s disease

  • A history may reveal:
    • 15-minute to 24-hour episodes of vertigo, tinnitus, hearing loss, and aural fullness
    • Aural fullness may precede the attack
  • Investigations may reveal:
    • Diagnosis is clinical
    • Audiometry – unilateral sensorineural hearing loss

Vestibular schwannoma (acoustic neuroma)

  • A history may reveal:
    • Hearing loss, tinnitus, vertigo
    • Cranial nerve involvement (e.g. the trigeminal nerve and facial numbness)
    • May present with sudden sensorineural hearing loss (<72 hours)
  • A physical exam may reveal:
    • Signs of trigeminal nerve (CN V) or facial nerve (CN VII) palsy
  • Investigations may reveal:
    • MRI of the cerebellopontine angle – investigation of choice
    • Audiometry – helps determine the degree of hearing loss

Multiple sclerosis

  • A history may reveal:
    • A history of optic neuritis, fatigue, sensory disturbances (e.g. pins and needles or numbness), spasticity, urinary dysfunction
    • Tinnitus may occur in the absence of hearing loss
  • Investigations may reveal:
    • MRI of the brain and spinal cord with gadolinium contrast – shows white matter lesions

Patulous eustachian tube

  • A history may reveal:
    • An adenoidectomy or weight loss
    • Clicking sounds when swallowing, autophony (the unusually loud hearing of a person’s own voice)
  • A physical exam may reveal:
    • Otoscopy may show the movement of the tympanic membrane with respiration

Idiopathic intracranial hypertension

  • A history may reveal:
    • An overweight, white, female patient
    • The use of drugs including tetracyclines or the combined oral contraceptive pill
    • Headaches suggestive of elevated intracranial pressure (e.g. worse in the morning, worse on bending forward)
    • Associated blurred vision
  • A physical exam may reveal:
  • Investigations may reveal:
    • MRI brain – rules out mass lesions
    • Lumbar puncture – increased opening pressure

Salicylate overdose

  • A history may reveal:
    • Ingestion of a large amount of a salicylate
    • In the early stages, patients have tachypnoea and tachycardia
  • Investigations may reveal:
    • Venous/arterial blood gas:
      • Early stages – respiratory alkalosis
      • Later stages – may show mixed respiratory alkalosis and metabolic acidosis
    • Serum salicylate – elevated

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