Tinnitus

Background

• Perception of sound without external stimulation
• 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 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