HistoryPain 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 LossTypes | 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 ClassficationsSubjective | 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 TinnitusInfections | 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) ExaminationExternal 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 FlagsEMERGENCY 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 GPObjective/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 URGENTTinnitus 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 |
OtoscopyBefore 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 disordersAcute 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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