History
Pain Location, quality, course, aggrevating/relieving factors |
Discharge (frequency, colour, consistency, odour) |
Feeling of fullness/pressure |
Hearing loss (uni/bilateral/partial/complete |
Tinnitus |
Vertigo |
Loud noise exposure |
Injury to the ear |
Recent swimming/air travel |
Infection |
Past Ear surgery/treatment |
Past serious illness |
Family history of hearing problems/ ear conditions |
Cold water sports |
Hearing Loss
Types |
Age |
Congenital |
Infant - Young children |
Serous Otitis Media |
Infant - Young children |
Postinfective |
Young children - Teenagers/adolescents |
Noise Induced |
Teenagers/adolescents - Over 60 |
Otosclerosis |
20-60yo |
Acoustic Neuroma |
20-60+yo |
Meniere's Disease |
20-60 yo |
Early Prebycusis |
40-60 yo |
Prebycusis |
60+ |
Tinnitus Classfications
Subjective |
Objective |
Most common |
Can be heard by patient and examiner - Rare |
Sound can only be heard by patient - caused by abnormal activity in inner ear/CNS |
Vascular Abnormalities, muscle related |
Primary |
Secondary |
Idiopathic + sensorineural Hearing loss |
Underlying cause - not sensorineural |
Constant/intermittent/unilateral/bilateral:
Buzzing, Whistling, Hissing, Ringing, Roaring, Clicking, Pulsing (vascular), Whooshing, Humming
Causes of Subjective Tinnitus
Infections |
Ear wax |
Inner ear noise damage |
Meniere's disease |
Otosclerosis |
Acoustic Neuroma |
MS |
Ototoxic drugs |
Metabolic disorder |
Psychological disorders |
Mechanical disorders |
If unilateral + sensorineural hearing loss consider:
Meniere's disease + Acoustic Neuroma
If Bilateral consider:
Age related hearing loss
Noise induced hearing loss
Drug induced ototoxicity
Subjective tinnitus + conductive hearing loss consider:
Disorders of middle/outer ear
Otosclerosis(family hx)
Examination
External Ear |
Auscultate periauricular area, temporal bone, orbit, vascular structures of the neck |
Otoscopy |
TMD Exam |
CN Exam (VII, VIII) |
Check for anaemia, thyroid, hyperlipidemia +diabetes |
Assess for other causes of pain, tinnitus/hearing loss |
Regional lymphnodes |
If Tinnitus is pulsatile - head, neck exam, blood pressure + CV system (Murmurs, carotid + temporal artery bruits |
Red Flags
EMERGENCY REFERRAL |
Sudden onset pulsatile tinnitus |
Tinnitus with associated significant neuro symptoms |
Tinnitus Secondary to head trauma |
Tinnitus associated with sudden hearing loss |
All patients with tinnitus should be referred to their GP - non-emergencies only
Referred to ENT - audiological assessment
URGENT REFERRAL - Same day to GP
Objective/pulsatile tinnitus |
Unilateral tinnitus |
Tinnitus with unilateral/asymmetric hearing loss |
Tinnitus with persistent otalgia/otorrhoea that does not resolve with treatment |
Tinnitus with vestibular symptoms -dizziness, vertigo |
LESS URGENT
Tinnitus of unknown cause - not associated with hearing loss, ear pain, drainage or malodour, vestibular symptoms or facial weakness or hearing loss that cannot be distinguished |
Tinnitus that is causing distress - despite primary care management |
Otoscopy
Before inserting Otoscope, observe the outside of the ear - hearing aid, shape, discharge, deformities, skin |
Pull the pinna up and back for adults, up for children |
Slowly insert no more than 0.5cm in |
Ear disorders
Acute Otitis media |
S&S |
Otoscopy Findings |
| |
Fullness in the ear |
Retracted, pink/red tympanic membrane |
| |
Fever |
Pus and membrane can bulge |
| |
Vomiting |
| |
Headache |
| |
Hearing loss |
| |
Fluid coming from the ear |
| |
Diarrhoea |
Serous Otitis media |
| |
Fullness, pressure, popping in the ear |
Retracted Tympanic membrane - yellowish/blueish in colour |
| |
Hearing loss |
Bubbles/ air/fluid level can be seen |
| |
Pain |
Chronic suppurative otitis media |
Painless otorrhea |
Defects in tympanic membrane |
| |
Bacterial or fungal |
Ear full of pus |
Perforated Eardrum |
Painful |
| |
Hearing loss |
Hole in eardrum with redness |
| |
Caused by: Repeated infections + trauma |
Exostosis |
Surfer's ear - cold water |
Nodular bony outgrowths covered with skin |
| |
Can occlude ear canal |
Tympanosclerosis |
Hearing loss if affects ossicles |
White plaques in tympanic membrane /middle ear cavity |
|
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