Tinnitus
This means noises heard (nearly always subjectively) in the ears or head. They are often described as being like a whistling kettle, an engine, or in time with the heartbeat. As a short-lived phenomenon, it is very common (often with URTIs) – such cases do not usually present to the general practice. More serious, persistent tinnitus occurs in up to 2% of the population. It is very distressing and can cause secondary depression and insomnia. Objective tinnitus is very rare.
Differential diagnosis
Common Diagnoses
- Earwax
- Hearing Loss (20% of Cases: Chronic Noise Damage and Presbyacusis)
- Suppurative Otitis Media (Also Chronic Infection and Serous OM)
- Otosclerosis
- Ménière’s Disease
Occasional Diagnoses
- After a Sudden Loud Noise (e.g. Gunfire)
- Head Injury (Especially Basal Skull Fracture)
- Impacted Wisdom Teeth and TMJ Dysfunction
- Drugs: Aspirin Overdose, Loop Diuretics, Aminoglycosides, Quinine
- Hypertension and Atherosclerosis
Rare Diagnoses
- Acoustic Neuroma
- Palatal Myoclonus (Objectively Detectable)
- Arteriovenous Fistulae and Arterial Bruits (Objectively Detectable)
- Severe Anaemia and Renal Failure
- Glomus Jugulare Tumours (Objectively Detectable)
Ready reckoner
Key distinguishing features of the most common diagnoses
| Earwax | Hearing Loss | Otitis Media | Otosclerosis | Ménière’s Disease | |
|---|---|---|---|---|---|
| Sudden Onset | Yes | No | Yes | No | Possible |
| Pain in Ear | Possible | No | Yes | No | No |
| Rinne’s Test Positive | No | Yes | Possible | No | Yes |
| Vertigo | Possible | No | Possible | No | Yes |
| High-Pitched | No | Possible | No | No | Yes |
Possible investigations
Likely: None.
Possible: Tympanogram, audiogram, MRI scan (all usually in secondary care).
Small Print: FBC, U&E, skull X-ray, angiography (the latter two in secondary care).
- FBC and U&E: If anaemia or renal failure suspected.
- Tympanogram for middle-ear function and stapedial reflex threshold. Audiogram to assess hearing loss objectively
- Cerebral angiography: If vascular pathology suspected.
- MRI scan: The most sensitive way to examine the inner ear and skull for structural lesions.
- Skull X-ray: If associated with significant head injury.
Top Tips
- Most patients are afraid of the diagnosis of tinnitus because of its potentially debilitating nature. If the cause is clearly self-limiting or remediable, take time to reassure the patient.
- Have a low threshold for referral in persistent tinnitus. While no specific treatment may be available, this shows that you are taking the problem seriously, ensures that remediable problems won’t be missed and may give the patient access to masking devices.
- Be prepared to reassess ongoing tinnitus, as new symptoms may develop. For example, tinnitus may precede other symptoms in Ménière’s disease by months or even years.
Red Flags
- Depression in tinnitus has been severe enough to cause suicide. Make a thorough psychological assessment and consider a trial of antidepressants.
- Think of otosclerosis in younger patients (15–30) with persistent conductive deafness – especially if there is a family history. Early diagnosis is important.
- Progressive unilateral deafness with tinnitus could be caused by an acoustic neuroma. Exclude by referring for an MRI scan.