Last reviewed: 1 May 2023
Last updated: 10 Feb 2022



History and exam

Key diagnostic factors

  • presence of risk factors
  • medication history
  • episodic sounds
  • hearing loss
  • vertigo
  • pulsatile sounds
  • clicking sounds
  • visual changes
  • presence of bruits or hums
  • cranial nerve palsies
  • cerumen (ear wax)
  • abnormal otoscopy
  • abnormal Weber's test
  • abnormal Rinne's test
More key diagnostic factors

Other diagnostic factors

  • slow-onset progressive hearing loss
  • high pitch
  • low pitch
  • unilateral
  • bilateral
  • worse with chewing
  • polyuria/polydipsia
  • diarrhoea
  • palpitations
  • foreign body
Other diagnostic factors

Risk factors

  • older age
  • hearing loss
  • loud noise exposure
  • vestibular schwannoma
  • ototoxic medicines
  • heavy metal exposure
  • history of cerebrovascular disease
  • history of multiple sclerosis
  • history of head trauma
  • history of depression
  • history of anxiety
More risk factors

Diagnostic investigations

1st investigations to order

  • audiometry
More 1st investigations to order

Investigations to consider

  • FBC
  • thyroid function tests
  • lipid profile
  • fasting glucose
  • fluorescent treponemal antibody absorption assay
  • MRI head
  • CT temporal bones
  • MR angiography or CT angiography
  • carotid angiography
  • auditory brainstem response (ABR)
  • minimal masking level
  • residual inhibition
  • loudness and pitch matching
  • loudness discomfort level testing
More investigations to consider

Emerging tests

  • otoacoustic emissions
  • functional MRI
  • PET scan
  • magnetoencephalographic

Treatment algorithm


known aetiology

troublesome tinnitus


hearing loss on audiogram

normal hearing



Michael D. Seidman, MD, FACS

Medical Director Otologic/Neurotologic/Skull Base Surgery

Medical Director Wellness

Advent Health Medical Group

Professor of Otolaryngology-Head and Neck Surgery

University of Central Florida

Collaborative Prof of Oto-HNS University of South FLa

Past Board of Directors American Academy of Otolaryngology-Head and Neck Surgery




MDS is a consultant for Acclarent; is the owner of Body Language Vitamins; and is involved in post-market studies for Envoy (non-compensated) and research for MicroTransponder, Inc (non-compensated), Auris Medical, and the National Institutes of Health. He receives royalties from 7 patents. He is an author of a number of references cited in this topic.


Dr Michael D. Seidman would like to gratefully acknowledge Dr Hamid Djalilian, Dr Alice Lee, Dr Vanessa Rothholtz, and Dr Sanaz Hamidi, the previous contributors to this topic. HD, AL, VR, and SH declare that they have no competing interests.


HD, AL, VR, and SH declared that they had no competing interests.

Peer reviewers

Aaron Benson, MD

Clinical Adjunct Professor

Division of Neurotology

Department of Otolaryngology Head and Neck Surgery

University of Michigan

Ann Arbor


Consulting Staff

Toledo ENT




AB declares that he has no competing interests.

Andrew McCombe, MD, FRCS(ORL)

Consultant ENT Surgeon

Frimley Park Hospital

Portsmouth Road





AM declares that he has no competing interests.

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