From the Guidelines
The workup for tinnitus should begin with a comprehensive history and physical examination, focusing on the characteristics of the tinnitus, associated symptoms, and potential causes, as recommended by the American Academy of Otolaryngology and Head and Neck Surgery Foundation (AAO-HNS) guidelines 1.
Initial Evaluation
The initial evaluation includes a detailed otologic examination, audiometric testing to assess hearing loss, and tympanometry to evaluate middle ear function.
- Laboratory tests may include complete blood count, thyroid function tests, and lipid profile to identify systemic causes.
- A thorough history and physical examination are helpful for elucidating a cause, especially in cases of nonpulsatile tinnitus (NPT) 1.
Imaging Studies
Imaging studies such as MRI of the brain and temporal bones are indicated when there are asymmetric symptoms, unilateral hearing loss, or neurological abnormalities to rule out structural lesions like acoustic neuroma or vascular abnormalities 1.
- The American College of Radiology (ACR) Appropriateness Criteria recommend against any imaging studies of the head and neck for the subset of patients in whom tinnitus does not localize to 1 ear, is nonpulsatile, and is not associated with focal neurological abnormalities or an asymmetric hearing loss 1.
Specialized Tests
Additional specialized tests may include:
- Auditory brainstem response testing
- Otoacoustic emissions
- Vestibular testing if balance issues are present
Referral and Treatment
Referral to an otolaryngologist is recommended for persistent tinnitus, especially when accompanied by hearing loss, vertigo, or when symptoms significantly impact quality of life 1.
- Treatment options depend on the underlying cause and may include addressing hearing loss with hearing aids, sound therapy, cognitive behavioral therapy, or medications like antidepressants for associated psychological distress.
- The AAO-HNS guidelines recommend a prompt and comprehensive audiological examination in patients with hearing problems or with unilateral persistent tinnitus 1.
From the Research
Workup for Tinnitus
The workup for tinnitus typically involves a combination of the following steps:
- A targeted history and physical examination to identify treatable causes and associated symptoms that may improve with treatment 2, 3, 4, 5, 6
- A comprehensive audiologic evaluation for patients who experience unilateral tinnitus, tinnitus that has been present for six months or longer, or that is accompanied by hearing problems 2, 3, 5
- Neuroimaging is not part of the standard workup unless the tinnitus is asymmetric or unilateral, pulsatile, associated with focal neurologic abnormalities, or associated with asymmetric hearing loss 2, 3
- Blood profile analysis may be included in the stepwise workup of tinnitus 4
- Referral to a specialist when necessary 4
Diagnostic Tests
The following diagnostic tests may be used to evaluate patients with tinnitus:
- Audiologic examination to measure hearing function 3, 5, 6
- Otoscopic and tuning fork examination to evaluate the ears and hearing 5
- Formal hearing testing to assess hearing loss 5
- Neuroimaging studies such as MRI or CT scans to rule out underlying conditions such as vascular tumors or vestibular schwannoma 2, 3
Treatment Options
The following treatment options may be considered for patients with tinnitus:
- Cognitive behavioral therapy to improve quality of life 2, 3, 6
- Sound therapy to help manage symptoms 3
- Tinnitus retraining therapy to help patients habituate to the sound 2
- Hearing aids to improve hearing and reduce tinnitus symptoms 4, 5
- Masking devices to help mask the sound of tinnitus 4
- Drugs such as melatonin, antidepressants, and cognitive training to help with sleep disturbance, mood disorders, and cognitive impairments 2