Tinnitus

Question 1

Approach

Answer 1

I want to exclude central causes

1. Central – CNS (sensorineural)
   a. Head trauma, stroke, MS,
2. Peripheral – Auditory:
   a. Meniere’s disease (vertigo)
   b. Conductive: OE/OM, wax, otosclerosis , TM perforation, trauma. Eustachian tube dysfunction
3. Peripheral – Blood vessels (sensorineural)
   a. Vascular: arterial bruits, HTN, DM,
   b. Drugs (ototoxic): NSAIDs/aspirin, antibiotics (aminoglycosides)
   c. Other: thyrotoxicosis

Question 2

History

Answer 2

1) Tinnitus – onset, duration, unilateral/bilateral, type of sound, timing (after loud concert, quiet when at night), High-pitch vs low-pitch (Meniere disease)
Non-pulsatile vs. pulsatile (arterial bruits, tympanic paraganglionomas)

Associated symptoms: hearing loss, vertigo,
Red flags: neurological deficits, unilateral & pulsatile tinnitus.
Functional impact
2) Screen DDX
3) General medical history, GP screening

Question 3

Examination

Answer 3

Vital signs, complete head and neck examination, full cranial nerve examination (Weber’s + Rinne’s), otoscopy
Cardiovascular exam – carotid bruit, venous hum,

Question 4

Investigations

Answer 4

Suspected vascular cause- CT angiography
Suspected auditory cause- audiometric tests, consider formal audiology evaluation (>6 months, constant)
audiogram & tympanometry

Question 5

Management

Answer 5

Appropriate referral if serious underlying cause (unilateral tinnitus or hearing loss)
Constant >6 months, formal audiology evaluation
Treat Cause

Supportive treatment

• optimise medications
• Avoid loud sounds, masking (background music), self-help groups
• Behavioural therapies (CBT)
• Treat underlying cause
• Drugs, but includes misoprostol (PGE1 analogue),
• Opportunistic GP screening and management