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Probability diagnosis

Ear wax or debris

Sensorineural hearing loss (esp. noise induced)



Ear infection (e.g. viral cochleitis)

Meniere syndrome

Serious disorders not to be missed


  • arteriovenous malformation

  • carotidovenous fistula

  • arterial bruits (esp. carotid)

  • venous hum (jugular)


  • suppurative otitis media


  • acoustic neuroma (unilateral)


  • head injury

Pitfalls (often missed)

Impacted wisdom tooth

Temporomandibular injury/dysfunction



  • superior canal dehiscence

  • glomus jugulare tumour

  • syphilis

Masquerades checklist

Anaemia (severe)


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

  • Otoscope of ear

  • Cardiovascular (esp. auscultation neck)

Key investigations

  • Audiogram

  • Tympanogram (middle ear function)

  • FBE

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

Diagnostic tips

  • 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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