Last reviewed: 28 Dec 2021
Last updated: 16 Oct 2018



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

Other diagnostic factors

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

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

Diagnostic investigations

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

Emerging tests

  • otoacoustic emissions
  • functional MRI
  • PET scan
  • magnetoencephalographic

Treatment algorithm



Michael D. Seidman, MD, FACS

Medical Director Otologic/Neurotologic/Skull Base Surgery

Medical Director Wellness

Florida Hospital Celebration Health

Professort of Otolaryngology-Head and Neck Surgery

University of Central Florida

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.

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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