View source for Tinnitus

==Background==
*Perception of sound without external stimulation<ref>Dalrymple SN, Lewis SH, Philman S. Tinnitus: Diagnosis and Management. Am Fam Physician. 2021 Jun 1;103(11):663-671. PMID 34060792</ref><ref>Esmaili AA, Renton J. A review of tinnitus. Aust J Gen Pract. 2018 Apr;47(4):205-208. PMID 29621860</ref>
*Can be constant or pulsatile, high or low pitched, hissing, clicking, or ringing
*Most ED presentations are benign, but key EM role is to identify dangerous causes:
**Pulsatile tinnitus → vascular lesion (carotid dissection, AVM, dural AV fistula)
**'''Acute tinnitus with hearing loss''' → sudden sensorineural hearing loss (ENT emergency)
**Tinnitus after medication change → ototoxicity (especially [[salicylate toxicity]])

==Clinical Features==
*Subjective (only patient hears) vs. objective (examiner can hear — think vascular or mechanical cause)
*Pulsatile vs. non-pulsatile
*Unilateral vs. bilateral
*Associated hearing loss, vertigo, fullness ([[Meniere's disease]])
*Associated headache, visual changes, papilledema ([[idiopathic intracranial hypertension]])
*Medication review for ototoxic agents

===Red Flags===
*Pulsatile tinnitus (vascular cause until proven otherwise)
*Unilateral tinnitus with hearing loss (acoustic neuroma, sudden SNHL)
*Associated neurologic deficits (stroke, dissection)
*Recent head trauma
*Suicidal ideation (severe tinnitus is a risk factor)

==Differential Diagnosis==
===Objective (May Be Heard by Examiner)===
*Vascular (often pulsatile): AVM, aneurysm, arterial bruits, [[carotid stenosis]] or [[vertebral and carotid artery dissection|dissection]], dural AV fistula
*Mechanical: enlarged eustachian tube, palatal myoclonus, stapedial muscle spasm

===Subjective===
*Noise-induced hearing loss (most common cause overall)
*[[Otitis media]], [[otomycosis]], [[herpes zoster oticus]]
*[[Meniere's disease]]
*[[Labyrinthitis]]
*[[Head trauma]], [[otic barotrauma]], [[decompression sickness]]
*[[TMJ]] dysfunction
*[[Acoustic neuroma]] (vestibular schwannoma)
*[[Idiopathic intracranial hypertension]]
*[[MS]], [[stroke]]

===Ototoxic Medications===
*[[Salicylate toxicity]]: tinnitus is an early symptom — check salicylate level
*Loop [[diuretics]] ([[furosemide]], [[bumetanide]], ethacrynic acid)
*[[Aminoglycosides]], [[erythromycin]], [[vancomycin]]
*Chemotherapeutics: cisplatin, carboplatin
*[[NSAIDs]], [[quinine]], [[bupropion]]
*[[Caffeine]], [[hydrocarbons]]

==Evaluation==
*Otoscopic exam (cerumen impaction, otitis media, TM perforation)
*Auscultate over periauricular area, orbits, and neck for bruits (objective tinnitus)
*Cranial nerve exam, hearing (Weber/Rinne), cerebellar function
*Pulsatile tinnitus: CT/CTA or MRI/MRA to evaluate for vascular cause
*Acute unilateral hearing loss + tinnitus: audiometry referral urgently (sudden SNHL)
*Salicylate level if aspirin use or toxicity suspected
*Other workup guided by history (BMP, TSH, CBC, head CT if trauma or neurologic deficits)

==Management==
*Identify and treat reversible causes
*Stop/minimize ototoxic agents
*Salicylate toxicity: treat per [[salicylate toxicity]] protocol
*Sudden sensorineural hearing loss: urgent ENT referral (may benefit from systemic or intratympanic steroids if started within 2 weeks)
*Cerumen impaction: removal often provides relief
*Outpatient: masking techniques (white noise), habituation therapy, consider antidepressants for severe cases
*Reassurance for most patients

==Disposition==
*Discharge unless underlying condition requires admission
*Urgent ENT referral for: sudden hearing loss, pulsatile tinnitus, unilateral tinnitus concerning for acoustic neuroma
*Return precautions: hearing loss, new neurologic symptoms, vertigo, worsening

==See Also==
*[[Hearing loss]]
*[[Meniere's disease]]
*[[Salicylate toxicity]]
*[[Focal neurologic deficits]]

==References==
<references/>

[[Category:Symptoms]]
[[Category:ENT]]