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Probability diagnosis

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Ear wax or debris

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Sensorineural hearing loss (esp. noise induced)

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Otosclerosis

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Ageing

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Ear infection (e.g. viral cochleitis)

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Meniere syndrome

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Serious disorders not to be missed

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Vascular:

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  • arteriovenous malformation

  • carotidovenous fistula

  • arterial bruits (esp. carotid)

  • venous hum (jugular)

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Infection:

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  • suppurative otitis media

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Cancer/tumour:

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  • acoustic neuroma (unilateral)

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Other:

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  • head injury

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Pitfalls (often missed)

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Impacted wisdom tooth

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Temporomandibular injury/dysfunction

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Alcoholism

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Rarities:

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  • superior canal dehiscence

  • glomus jugulare tumour

  • syphilis

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Masquerades checklist

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Anaemia (severe)

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Depression

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

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Spinal dysfunction

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Is the patient trying to tell me something?

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Consider if subjective tinnitus.

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Key history

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  • Recent onset or longstanding

  • Pulsating or non-pulsating

  • Head injury

  • Exposure to loud noise

  • Upper respiratory infection

  • Otitis externa

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Key examination

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  • Otoscope of ear

  • Cardiovascular (esp. auscultation neck)

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Key investigations

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  • Audiogram

  • Tympanogram (middle ear function)

  • FBE

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

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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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