Medical Minute: Tinnitus Pearls

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September 11, 2014 by dailybolusoflr

By: Marrissa Baker, MD

Subjective (perception of sound in absence of real acoustic stimulus) vs. objective (real sounds that can be heard by physician with stethoscope or Doppler)
Type

Causes
Subjective tinnitus

Otologic
Presbycusis, otitis, impacted cerumen, Ménière disease
Neurologic
Head injury, MS, vestibular schwannoma
Infectious
AOM, meningitis, neurosyphilis
Drug-related
Aspirin, NSAIDs, aminoglycosides, loop diuretics, chemotherapy
Objective tinnitus

Pulsatile
Carotid artery stenosis, anemia, AVM, vascular tumors,
carotid dissection, atherosclerosis, valvular heart disease (AS)
Muscular
Palatal myoclonus, stapedius or tensor tympani spasm,
patulous eustachian tube
Most important causes for ED are aspirin overdose and pulsatile tinnitus (pulsing sensation concurrent with cardiac cycle)

 History and Physical
  • Characterize the sound the patient hears and ask about onset, duration, associated symptoms, and medications
  • Perform thorough head and neck exam
  • Full neuro exam to search for a central source (ischemic event along the auditory pathway has not been clearly shown to appear suddenly in isolation without other neuro symptoms))

 Labs

  • Consider are salicylate levels, CBC (for anemia), and TSH (hyper or hypothyroid)

Imaging



  • If the patient has tinnitus and other neuro findings that are concerning for possible CVA, neuroimaging is indicated. CTA head/neck is the test of choice for pulsatile tinnitus.
  • In up to 40% of cases, CT identified the diagnosis for pulsatile tinnitus
Treatment
  • Emergency department management is needed only in cases of life-threatening conditions such as aspirin overdose, carotid artery dissection, and anemia
  • Treat the underlying cause if identified. Otherwise, refer patients to outpatient otolaryngologic and audiologic testing
  • No good symptomatic treatment of tinnitus from the EDs

References:
  1. Siegelman J, Kazda G, and Lindberg D. Evaluation and treatment of common ear complaints in the emergency department. Emergency Medicine Practice. 2010 July; 12:7 
  2. Welsh KJ, Nath AR, and Lewin MR. (2011) Evaluation of tinnitus in the emergency department. Up to date on Tinnitus. Bahmad F (Ed.)

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