Tinnitus
Background
- Perception of sound without external stimulation[1][2]
- 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