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++

Probability diagnosis

++

Ear wax or debris

++

Sensorineural hearing loss (esp. noise induced)

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Otosclerosis

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Ageing

++

Ear infection (e.g. viral cochleitis)

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Meniere syndrome

++

Serious disorders not to be missed

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Vascular:

++

  • arteriovenous malformation

  • carotidovenous fistula

  • arterial bruits (esp. carotid)

  • venous hum (jugular)

++

Infection:

++

  • suppurative otitis media

++

Cancer/tumour:

++

  • acoustic neuroma (unilateral)

++

Other:

++

  • head injury

++

Pitfalls (often missed)

++

Impacted wisdom tooth

++

Temporomandibular injury/dysfunction

++

Alcoholism

++

Rarities:

++

  • superior canal dehiscence

  • glomus jugulare tumour

  • syphilis

++

Masquerades checklist

++

Anaemia (severe)

++

Depression

++

Drugs (aspirin, NSAIDs, loop diuretics, marijuana, quinine, aminoglycosides)

++

Spinal dysfunction

++

Is the patient trying to tell me something?

++

Consider if subjective tinnitus.

++

Key history

++

  • Recent onset or longstanding

  • Pulsating or non-pulsating

  • Head injury

  • Exposure to loud noise

  • Upper respiratory infection

  • Otitis externa

++

Key examination

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  • Otoscope of ear

  • Cardiovascular (esp. auscultation neck)

++

Key investigations

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  • Audiogram

  • Tympanogram (middle ear function)

  • FBE

  • MRI or CT scan (esp. if head injury)

++

Diagnostic tips

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  • Think otosclerosis in young.

  • Tinnitus may precede other symptoms of Meniere syndrome by months.

  • Non-pulsative and continuous → inner ear.

  • Venous hum → jugular vein.

  • Vascular symptoms → organic disorder.

  • Stress and anxiety exacerbate tinnitus.

  • Associated depression may lead to suicide.

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