Basic Assessment of Tinnitus - #31Take Quiz
Initial diagnosis of tinnitus by history and physical exam.
|Objective Tinnitus||Subjective Tinnitus|
|Can be heard by an observer -- either overtly, with a stethoscope or with a microphone||Cannot be heard externally -- hearing loss, somatic or staccato "typewriter" ty|
- Synchronous with the pulse and can derive from either arterial or venous sources.
- Asynchronous causes have a neuromuscular cause usually involving oropharyngeal or ear muscles.
- Functional problems include spontaneous emissions or patulous eustachian tubes.
- 90% have sensorineural hearing loss, 5% have conductive loss and 5% have normal hearing â€“
- cerumen impaction, ear infection, otosclerosis, Meniereâ€™s syndrome, medication effects, trauma, tumor and systemic diseases.
History is critical:
- Onset, duration, periodicity, location (one ear or both), pitch (high or low), subjective loudness, fluctuance, exacerbating/alleviating factors (caffeine, medicine, noise, yawning), associated vertigo, otalgia or otorrhea.
- Exposure to noise or barotrauma, head or neck injuries, temporomandibular joint disease.
- History of ototoxic drugs (ASA, NSAIDS, antibiotics, loop diuretics, and cytotoxic drugs).
- Subjective factors: level of intrusiveness, and impact on activities and sleep.
- Otoscope exam: look for external auditory canal abnormalities, including cerumen, infection or inflammation, or structural anomalies
- Stethoscope exam: auscultating if tinnitus is objective, and assessment of the neck vasculature for bruits or aberrant sounds. Stethoscope placement is close to the meatus and the skull behind the ear.
- Vascular exam: cardiac and carotid auscultation
- Sinus exam: look for disease or infection
- Neurological exam: assessment of cranial nerves II – XII and balance
- Depression screen
- Rinne and Weber tests
512 Hz tuning fork is placed against the mastoid until the patient can no longer hear it, then it is placed 1-2 cm from the auditory canal to determine if they can hear it.
256 Hz fork is placed on the bony middle forehead.
Normal should be air conduction > bone conduction
|Normal is equal sound in each ear|
Conductive loss: bone > air
Conductive loss: lateralization toward affected side
Sensorineural loss: equally poor conduction
Sensorineural loss: lateralization opposite deficit
Labs/Diagnostic tests: CBC, TSH, and BMP, RPR or FTA-ABS, autoimmune panel (ANA, ESR, CRP, and RF). MRI/MRA of the head and neck for pulsatile tinnitus.
Referral: Referral of cases, particularly those with significant functional impact, should be to an Otolaryngologist or Audiologist for further assessments. Patients should be prepared for a comprehensive audiology evaluation, and prepared by cerumen removal prior to the assessments.
DIAGRAM: An evidence based approach to differential diagnosis Figure 19.2 Access Medicine
Geriatric Patient Visit
Provide initial assessment of tinnitus.
Tinnitus is the either subjective or objective perception of sound without an identifiable external source. Tinnitus can be described as ringing, buzzing, clicking, roaring, or other sounds and can be either unilateral or bilateral.
37 million Americans are thought to have tinnitus, of which the majority is subjective (Marion and Cevette).
1.Understand differences between objective and subjective tinnitus.
2.Understand how to properly assess and examine a patient presenting with tinnitus.
3.Understand how to manage a patient with tinnitus and when to refer to a specialist.
Review of Systems (ROS)
- Henry JA, Dennis KC, Schechter MA. General review of tinnitus: prevalence, mechanisms, effects, and management. J Speech Lang Hear Res. 48(5):1204-35, 2005 Oct. http://www.ncbi.nlm.nih.gov/pubmed/16411806
- Marion MS and Cevette MJ. Tinnitus. Mayo Clin Proc. 66(6): 614-20, 1991 June. http://www.ncbi.nlm.nih.gov/pubmed/?term=tinnitus+marion+cevette
- Henderson MC, Lawrence MT and Smetana GW. (2012) The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e. New York, NY: McGraw-Hill Companies.
Users are free to download and distribute Geriatric Fast Facts for informational, educational, and research purposes only. Citation: Steven Denson MD, Yana Thaker, Thomas Kidder MD. Fast Fact #31: Basic Assessment of Tinnitus, April 2013.
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