Tinnitus
Tinnitus is the perception of sound, such as ringing, buzzing, or hissing, in the ears or head without an external acoustic stimulus.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Noise-induced hearing loss | History of occupational/recreational noise exposure | 「平時有冇接觸好嘈嘅環境？」 | ~25% |
| Presbycusis (age-related SNHL with tinnitus) | Bilateral, gradual, older age, high-frequency hearing loss | 「兩邊耳仔都差咗，高音聽唔到？」(bilateral high-frequency loss in elderly) | ~20% | |
| Cerumen impaction / OME | Unilateral, conductive hearing loss, fullness; visible on otoscopy | 「耳仔有冇塞住嘅感覺？」; otoscopy: wax occlusion or dull TM | ~10% | |
| Serious Not To Miss | Sudden sensorineural hearing loss | Acute onset (<72h), unilateral, ENT emergency | 「突然聽唔到？幾時開始？」; urgent audiometry + ENT referral | ~1% |
| Ménière's disease [3] | Episodic vertigo (hours) + fluctuating hearing loss + tinnitus + aural fullness | 「有冇一陣陣天旋地轉，每次幾個鐘？」 | ~1% | |
| Acoustic neuroma (vestibular schwannoma) [1] | Unilateral progressive SNHL + tinnitus ± unsteadiness; CPA lesion on MRI | 「一邊耳仔聽力慢慢差咗？行路有冇唔穩？」; Weber lateralises to contralateral ear | <1% | |
| Nasopharyngeal carcinoma (NPC) [2] | Unilateral conductive hearing loss, epistaxis/blood-stained postnasal drip, neck mass; Southern Chinese | 「痰有冇帶血？頸有冇腫？」; otoscopy: middle ear effusion | <1% | |
| Pitfalls | Eustachian tube dysfunction / sinusitis | History of URTI, nasal congestion, ear fullness; conductive loss [5] | 「最近有冇傷風感冒鼻塞？」; otoscopy: retracted TM | ~5% |
| TMJ dysfunction | Clicking jaw, tinnitus exacerbated by jaw movement | 「開口食嘢有冇「卡卡」聲或者痛？」; TMJ tenderness on palpation | ~3% | |
| Cholesteatoma / CSOM | Foul-smelling ear discharge, conductive hearing loss | 「耳仔有冇流膿或者臭嘅嘢？」; otoscopy: retraction pocket/pearly mass | ~2% | |
| Masquerades | Depression / anxiety | Low mood, insomnia, somatic amplification of tinnitus | 「心情點？有冇成日唔開心或者緊張？」 | ~10% |
| Drug-induced (ototoxic medications) | Temporal correlation with medication; aminoglycosides, aspirin, cisplatin, loop diuretics [4] | 「最近有冇開始食新藥？」 | ~3% | |
| Thyrotoxicosis | Palpitations, weight loss, heat intolerance – can cause pulsatile tinnitus | 「有冇心跳好快、消瘦、怕熱？」 | ~1% | |
| Trying to Tell Me Something? | Stress / anxiety / insomnia | Tinnitus worsened by stress; sleep disturbance; fear of serious disease | 「最近壓力大唔大？瞓得好唔好？最擔心啲咩？」 | ~15% |
Tinnitus – Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce self, set agenda | 「你好，我係X醫生，今日會同你傾下你嘅情況，大概傾六分鐘，有咩唔明可以隨時問我。」 | Builds rapport; interpersonal marks for greeting, agenda-setting |
| 0:30–2:00 | Open question → HPI (SOCRATES for tinnitus) | 「可唔可以用你自己嘅說話講下你耳仔有咩唔舒服？」→ follow with 「幾時開始？一邊定兩邊？咩聲嚟㗎？持續定陣陣嚟？有冇咩嘢令到佢差啲或者好啲？」 | Chief complaint & HPI – marks for completeness, open-to-focused approach |
| 2:00–3:00 | Red flags & associated symptoms | 「有冇覺得聽嘢差咗？有冇頭暈或者天旋地轉？有冇耳仔流嘢或者痛？有冇頭痛、面麻痺、視嘢有問題？有冇頸嗰度摸到腫嘢？」 | Screens for acoustic neuroma, NPC, Ménière's; avoids missing serious Dx |
| 3:00–3:45 | PMH / Drug Hx / Family Hx / Social Hx | 「之前有冇長期病患？食緊咩藥？有冇食過消炎止痛藥或者抗生素？屋企人有冇類似問題？你做咩工作？平時有冇接觸好大噪音？有冇飲酒、食煙？」 | Drugs (aspirin, aminoglycosides), noise exposure, NPC family history – all differentiators |
| 3:45–4:30 | ICE – uncover hidden agenda | 「你自己覺得係咩原因？」→「你最擔心啲咩？」→「你今日嚟最想我幫到你咩？」 | ICE marks; hidden agenda (e.g., fear of brain tumour / cancer) |
| 4:30–5:15 | Signpost → brief focused exam plan / safety net | 「我想幫你檢查下耳仔同聽力，可以嗎？」→「如果之後有突然聽唔到、頭好暈或者面歪，要即刻返嚟或者去急症室。」 | Permission-seeking; safety-netting scores interpersonal + clinical marks |
| 5:15–6:00 | Summarise, check understanding, close | 「我總結返：你耳仔響咗X個月，一邊多啲，聽力差咗…我嘅計劃係幫你安排聽力測試同進一步檢查。有冇嘢想問？」 | Summarising and closing score dedicated marks |
Uncovering the hidden agenda: Ask explicitly 「你今日點解決定嚟睇醫生？」(Why did you decide to come today?) – tinnitus patients often present because of a specific fear (brain tumour, NPC, going deaf) or functional impact (insomnia, anxiety, work difficulty) rather than the symptom itself.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Duration | When did it start? Sudden or gradual? | 「幾時開始？突然定慢慢嚟？」 | Sudden onset → sudden SNHL, vascular cause; gradual → presbycusis, Ménière's | Sudden SNHL (emergency), acoustic neuroma |
| Laterality | One ear or both? | 「一邊定兩邊？邊邊多啲？」 | Unilateral tinnitus with hearing loss → must exclude acoustic neuroma and NPC [1][2] | Acoustic neuroma, NPC, cerumen impaction |
| Character | What does it sound like? Ringing, pulsatile, clicking? | 「咩聲嚟㗎？嗡嗡聲、脈搏聲、定其他？」 | Pulsatile → vascular (AVM, carotid stenosis, glomus tumour); non-pulsatile → sensorineural | Pulsatile tinnitus DDx |
| Hearing loss | Any hearing difficulty? | 「有冇覺得聽嘢差咗？」 | Ménière's: triad of vertigo, hearing loss, tinnitus, aural fullness [3]; acoustic neuroma: SNHL [1] | Ménière's, acoustic neuroma, presbycusis |
| Vertigo | Any spinning sensation? | 「有冇天旋地轉嘅感覺？」 | Vertigo + tinnitus + hearing loss = Ménière's triad [3] | Ménière's disease, BPPV, labyrinthitis |
| Aural fullness/discharge | Ear fullness? Any discharge? | 「耳仔有冇塞住嘅感覺？有冇流嘢出嚟？」 | Fullness → Ménière's, OME; discharge → CSOM, cholesteatoma | Ménière's, CSOM, cholesteatoma |
| Nasal/NPC symptoms | Nose blocked? Blood in spit/postnasal drip? Neck lump? | 「鼻塞唔塞？有冇痰帶血或者鼻水帶血？頸有冇摸到腫嘢？」 | Blood in postnasal drip is significant in early NPC diagnosis [2] | NPC – urgent ENT referral |
| Neurological | Facial numbness, weakness, diplopia, headache? | 「面有冇痺或者歪？有冇睇嘢重影？頭痛？」 | CN V/VII/VI involvement → CPA tumour, NPC skull base invasion [1][2] | Acoustic neuroma, NPC, brain tumour |
| Drug history | Any medications? Aspirin, antibiotics, diuretics, chemo? | 「食緊咩藥？有冇食阿士匹靈、抗生素、去水丸？」 | Aminoglycosides → ototoxicity [4]; aspirin, loop diuretics, cisplatin, quinine | Drug-induced tinnitus |
| Noise exposure | Occupation? Loud noise at work or leisure? | 「做咩工作？有冇接觸好嘈嘅環境？有冇戴耳機聽好大聲嘅嘢？」 | Noise-induced hearing loss – most common cause in younger adults | Noise-induced hearing loss/tinnitus |
| PMH | Any hypertension, DM, heart disease, thyroid problems? | 「有冇高血壓、糖尿、心臟病、甲狀腺問題？」 | CVS disease → pulsatile tinnitus; thyroid → masquerade | Pulsatile tinnitus, thyrotoxicosis |
| Family Hx | Family history of hearing loss or NPC? | 「屋企人有冇聽力問題或者鼻咽癌？」 | NPC endemic in Southern China; Ménière's has 20% family history [3] | NPC, familial SNHL, Ménière's |
| Psych impact | Does it affect sleep, mood, concentration, work? | 「有冇影響瞓覺？心情點？做嘢集唔集中到？」 | Functional impact = biopsychosocial problem; screens depression/anxiety | Anxiety, depression, insomnia |
| ICE | What do you think is causing it? What worries you most? What do you hope I can do? | 「你自己覺得係咩事？最擔心咩？想我點幫你？」 | Directly scores ICE marks | Fear of cancer, deafness, desire for referral/reassurance |
Case Report Form Answer Builder
- CC: Tinnitus × [duration], [unilateral/bilateral]
- HPI points to capture:
- Onset, duration, laterality, character (ringing vs pulsatile), constant vs intermittent
- Associated: hearing loss (type), vertigo, aural fullness, otalgia, otorrhoea
- Nasal symptoms: epistaxis, blood-stained postnasal drip, nasal obstruction (NPC screen)
- Neurological: facial numbness/weakness, diplopia, headache
- Drug exposure: ototoxic medications
- Noise exposure history
- Functional impact: sleep, concentration, mood, work
- Examples: "Worried about hearing getting worse"; "Afraid of brain tumour/cancer"; "Cannot sleep due to tinnitus"; "Wants referral for hearing test"
- Phrasing: Choose the single most important reason the patient came today – often a concern (fear of NPC/tumour) or functional impact (insomnia/work difficulty), not just the symptom itself.
| Likely Content | Example Wording | |
|---|---|---|
| Ideas | Patient thinks it could be from stress, ear infection, ageing, or brain tumour | "Patient thinks the ringing may be caused by a brain tumour." |
| Concerns | Fear of cancer (NPC/acoustic neuroma), fear of going deaf, fear of "something serious in the brain" | "Patient is worried the tinnitus means she has cancer." |
| Expectations | Wants hearing test, specialist referral, reassurance, or treatment to stop the noise | "Patient hopes to be referred for a hearing test and to an ENT specialist." |
- In a typical FM exam station: Most likely = Presbycusis with tinnitus (if older patient, bilateral, gradual) OR Noise-induced hearing loss (if younger with noise exposure) OR Cerumen impaction (if exam suggests conductive cause)
- Minimum supporting evidence: Age, bilateral gradual hearing loss, high-frequency loss pattern, no red flags
- If the stem gives unilateral SNHL + tinnitus → consider acoustic neuroma as most likely / serious DDx
- If the stem gives vertigo attacks + hearing loss + tinnitus → Ménière's disease [3]
| DDx | Key Discriminator |
|---|---|
| Acoustic neuroma | Unilateral progressive SNHL + tinnitus; MRI shows CPA mass [1] |
| Ménière's disease | Episodic vertigo lasting hours + fluctuating hearing loss + tinnitus + aural fullness [3] |
| Drug-induced ototoxicity | Temporal correlation with ototoxic drug; bilateral SNHL [4] |
(Adjust based on the specific stem: if nasal symptoms/neck mass → include NPC; if pulsatile → include vascular causes)
| Domain | Problem |
|---|---|
| Biological | Sensorineural hearing loss (or underlying ear pathology causing tinnitus) |
| Psychological | Anxiety about serious underlying cause (e.g., cancer/brain tumour); insomnia or depression secondary to tinnitus |
| Social/Functional | Impaired work performance or social communication due to hearing difficulty and tinnitus; noise-restricted occupation at risk |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Presbycusis | Bilateral SNHL on Rinne/Weber | Weber: midline (bilateral SNHL) or lateralises to better ear; Rinne: positive bilaterally (AC > BC) | Confirms sensorineural pattern; consistent with age-related hearing loss |
| Cerumen impaction | Occluding wax on otoscopy | Otoscopy of external auditory canal | Visible cause of conductive hearing loss and tinnitus; easily treatable |
| Acoustic neuroma | Weber lateralises to contralateral (unaffected) ear + ipsilateral Rinne positive | Tuning fork tests (512 Hz) | Confirms unilateral SNHL; warrants MRI IAM [1] |
| Ménière's disease | Low-frequency SNHL on audiometry; no reliable brief-exam physical sign in FM station | Audiometry (investigation, not bedside sign); during attack: spontaneous horizontal nystagmus beating away from affected ear | Fluctuating low-frequency SNHL is characteristic [3] |
| NPC | Unilateral middle ear effusion on otoscopy ± cervical lymphadenopathy | Otoscopy (dull TM, fluid level); palpate posterior triangle lymph nodes | Unilateral OME in Southern Chinese adult without URTI → NPC until proven otherwise [2] |
| Drug-induced | No specific physical sign; bilateral SNHL on audiometry | Review drug chart; audiometry | Temporal correlation is the key clue; bilateral symmetric SNHL [4] |
Must-Not-Miss Red Flags – When to Refer Urgently
- Unilateral tinnitus with progressive hearing loss → acoustic neuroma until proven otherwise → MRI IAM [1]
- Sudden sensorineural hearing loss (onset < 72h) → ENT emergency → same-day referral, consider oral steroids
- Pulsatile tinnitus → vascular cause (AVM, glomus tumour, carotid stenosis) → imaging
- Blood-stained postnasal drip / unilateral OME / neck mass in Southern Chinese → NPC → urgent ENT + nasopharyngoscopy [2]
- Associated cranial nerve signs (facial numbness, diplopia, facial weakness) → CPA tumour or NPC skull base invasion → urgent imaging [1][2]
Top Traps That Lose Marks:
- Forgetting to ask about laterality – unilateral vs bilateral completely changes the DDx
- Not screening for NPC – Hong Kong endemic area; must ask about epistaxis, blood-stained postnasal drip, neck lumps, family history of NPC
- Not asking about ototoxic drugs – aminoglycosides, aspirin, loop diuretics, cisplatin [4]
- Missing the hidden agenda – patient often fears cancer or deafness; not eliciting ICE = lost marks
- Confusing conductive vs sensorineural hearing loss – determines the entire workup direction
- Not performing/describing tuning fork tests – Weber and Rinne are the expected physical exam for this complaint
- Forgetting functional/psychological impact – tinnitus causes significant distress; not asking about sleep/mood/work loses biopsychosocial marks
Shortest Safe Management / Safety-Net Line: 「我會幫你安排聽力測試，如果需要會轉介你去耳鼻喉專科。如果你突然聽唔到、頭好暈、面歪或者頸有新嘅腫塊，要即刻去急症室。」 (I'll arrange a hearing test and refer to ENT if needed. If you suddenly can't hear, feel very dizzy, get facial weakness, or find a new neck lump, go to A&E immediately.)
High Yield Summary
What to ASK: Laterality, character (pulsatile vs non-pulsatile), associated hearing loss & vertigo, NPC symptoms (blood in postnasal drip, neck lump), ototoxic drug history, noise exposure, functional impact (sleep/mood/work), and ICE (especially fear of cancer).
What to WRITE on CRF: Unilateral vs bilateral; hearing loss type (SNHL vs conductive); key DDx with discriminators; biopsychosocial problems including anxiety/insomnia/work impact; Weber/Rinne or otoscopy as physical sign.
What NOT to MISS: Unilateral SNHL + tinnitus = acoustic neuroma until proven otherwise. Unilateral OME in HK adult = NPC until proven otherwise. Sudden SNHL = ENT emergency. Always ask about ototoxic drugs. Always elicit ICE – the hidden agenda is usually fear of cancer or deafness.
Active Recall - Family Medicine Clinical Test
[1] GC 108. A mass in the brain brain tumours.pdf (p24 – Acoustic neuroma: sensorineural hearing loss, tinnitus, CPA angle, bilateral in NF2) [2] MBBS Final MB (Surgery) (Felix PY Lai).pdf (p251 – NPC clinical manifestation: unilateral tinnitus, hearing loss, blood in postnasal drip, neck mass) [3] GC 221. Vertigo Peripheral and central.pdf (p19 – Ménière's disease: idiopathic endolymphatic hydrops, triad of vertigo, hearing loss, tinnitus, aural fullness) [4] Block A - Drugs and the Kidney.pdf (p10 – Aminoglycosides: nephrotoxicity and ototoxicity) [5] MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (p112–113 – Eustachian tube dysfunction: ear pain, hearing loss, tinnitus as signs of sinusitis)
Suprapubic / Pelvic Pain
Suprapubic or pelvic pain is discomfort localized to the lower abdomen below the umbilicus, commonly arising from urinary, gynecological, gastrointestinal, or musculoskeletal pathology affecting the pelvic organs or structures.
Tiredness / Chronic Fatigue
Persistent, unexplained fatigue lasting six months or more that is not substantially relieved by rest and significantly impairs daily functioning.