PANCE Blueprint EENT (7%)


Patient will present as→ a 70-year-old female who states that her children and grandchildren have asked her to seek medical attention as she seems to be losing her hearing.  She also describes an occasional ringing, buzzing, and hissing sound. She is in generally good health and her only medications are a multivitamin along with calcium and vitamin D. You examine her ears and find the external auditory canals to be free of cerumen and the tympanic membranes to be normal in appearance.

Tinnitus is a noise in the ears. It is experienced by 10 to 15% of the population; often described as a ringing, hissing, buzzing, or whooshing.

  • You have to understand the underlying cause:
    • 90% is associated with sensorineural hearing loss: caused by loud noise, presbycusis (as in the patient case presentation), medications (aspirin, antibiotics, aminoglycosides, loop diuretics, and CCBs), Meniere's disease, and acoustic neuroma
    • 5% vascular: Carotid stenosis
    • 5% mechanical abnormalities: TMJ
  • Continuous tinnitus: presbycusis or long-term hearing loss
  • Episodic, low-pitched, rumbling tinnitus: Meniere disease
  • Pulsatile tinnitus: vascular cause

All patients with significant tinnitus should be referred for comprehensive audiologic evaluation to determine the presence, degree, and type of hearing loss.

  • In patients with unilateral tinnitus and hearing loss, acoustic neuroma should be ruled out by gadolinium-enhanced MRI
  • In patients with unilateral tinnitus and normal hearing and physical examination, MRI is not necessary unless tinnitus persists > 6 mo

No pharmacologic agent has been shown to cure or consistently alleviate tinnitus

  • The goal is to try to identify the cause, i.e remove ototoxic medications, hearing aids
    • Correcting hearing loss (eg, with a hearing aid) relieves tinnitus in about 50% of patients

Question 1
A 68-year-old female is brought to the clinic by her husband with complaints of severe episodes of vertigo. This is her fourth attack this week. She is nauseous but has not vomited. She also reports fullness in her left ear accompanied by a low-tone blowing tinnitus and sensation of “fullness.” Which of the following represents an appropriate treatment for this patient?  
oral steroids on an as-needed basis
Ménière disease is a disorder associated with an increased endolymph within the cochlea and labyrinth. The precise pathogenesis is unknown, but evidence suggests an inability to regulate the volume, flow, and composition of endolymph. Oral steroids are of no benefit, but intratympanic steroid injections performed by an otolaryngologist may provide relief.
symptomatic care with antihistamines and diuretics
topical antibiotic drops for 7 days
The etiology of Ménière disease is not infectious, and there is no role for antimicrobial therapy orally or topically.
vestibular suppressant medication until symptoms subside
Vestibular suppressant medication is indicated for labyrinthitis or benign positional vertigo, not Ménière disease.
Question 1 Explanation: 
Antihistamines and diuretics (acetazolamide) in addition to a low-salt diet are the mainstays of treatment for Ménière disease
Question 2
The most common cause of tinnitus is
Infection (otitis media)
Chronic use of salicylates
Sensorineural hearing loss
Acoustic neuroma
Question 2 Explanation: 
Tinnitus is a common condition that is characterized by a ringing, roaring, rushing, buzzing, or whistling sound in the ears. The condition may be continuous or pulsatile with each heartbeat. In most cases, there is an associated hearing loss. In fact, the major cause of tinnitus is a sensorineural hearing loss. The list of associated conditions is extensive and includes obstruction of the canals, eustachian tube dysfunction, otosclerosis, Meniere’s disease, aminoglycoside toxicity, chronic use of salicylates, anemia, hypertension, hypothyroidism, hyperlipidemia, noise-induced hearing loss, and tumors associated with the inner ear (e.g., acoustic neuroma). The evaluation of a patient with tinnitus includes an audiogram and CT scan or MRI of the head, with special emphasis given to the temporal area. Pulsatile tinnitus may require vascular studies to rule out aneurysm formation. Treatment depends on the diagnosis, but in most cases if the underlying disease is controlled, the tinnitus disappears. If no underlying disease process is present, background music or amplification may help to relieve symptoms.
Question 3
Recurrent vertigo, tinnitus, and hearing loss are hallmark findings of
Meniere’s disease
Vestibular neuronitis
Benign positional vertigo
Acoustic neuroma
Question 3 Explanation: 
Meniere’s disease is a peripheral cause of vertigo. Symptoms include the hallmark findings of recurrent vertigo, tinnitus, and hearing loss. The cause is thought to arise from endolymphatic hydrops. In most cases, the vertigo lasts for several hours, up to an entire day. Although at first hearing may be little affected, over time it deteriorates. Tinnitus is usually constant and may become worse during the acute attacks. Vertigo may be severe and accompanied by nausea and vomiting. Treatment consists of salt restriction (i.e., no more than 2 g per day) and the use of hydrochlorothiazide, anticholinergics, antihistamines, and antiemetics. Resistant cases may require referral to an ear– nose– throat specialist.
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References: Merck Manual · UpToDate

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