Ringing in the Ear

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of tinnitus

Described as ‍pulsatilenon-pulsatile ‍ringingbuzzinghummingroaringhissingwhistling

Rated at ‍012345678910 / 10 ‍

Pattern ‍persistentintermittent

Worsening factors: ‍nonequiet environments

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍hearing loss

‍vertigo

‍ear pain

‍ear fullness

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍nausea

‍difficulty concentrating

‍difficulty sleeping

‍anxiety

‍depression



Contributing factors:

‍loud noise exposure

‍smoking

‍alcohol

‍high caffeine intake

‍stress

no history of: ‍tinnitus, ‍noise-induced hearing loss, ‍age-related hearing loss, ‍Meniere's disease, ‍otitis media, ‍otitis externa, ‍temporomandibular joint disorder, ‍vascular disorders, ‍anxiety, ‍depression

no use of: ‍aspirin, ‍chemotherapy drugs, ‍new medication





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought ‍organized, ‍suicidal ideation, judgment ‍good





ASSESSMENT:

‍Benigh tinnitus ‍likelysuspectedpossible

DDx: sensorineural hearing loss, Meniere's disease, acoustic neuroma, earwax impaction, ototoxic medications, eustachian tube dysfunction, temporomandibular joint disorder, head or neck injuries, hypertension, neck artery stenosis, aortic valve stenosis, anemia, hyperthyroidism, anxiety, depression, sleep disorders, benign intracranial hypertension, foreign body in the ear, vestibular schwannoma, neurological disorders





PLAN:

Investigations:

- Audiogram

- MRI of the brain and internal auditory canals if unilateral with hearing loss

- CT scan of the temporal bones

Treatments:

- Reassured that most cases are benign

- Sound therapy

- Cognitive behavioral therapy

- Avoidance of loud noises

- Limit caffeine and alcohol

- Hearing aids

- ‍Steroids

Further care:

- Referral to otolaryngologist if sudden onset, pulsatile, unilateral, hearing loss, or if persistent

- Referral to audiologist

- Referral to psychologist

- Referral to tinnitus support group

- Follow-up in ‍ ‍weeksmonths

- Return if tinnitus worsens, if new symptoms develop such as hearing loss, dizziness, or if symptoms do not improve with treatment