From the Guidelines
A tinnitus workup should begin with a comprehensive medical history and physical examination, focusing on the onset, duration, and characteristics of the tinnitus, as well as associated symptoms like hearing loss or vertigo, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guideline for tinnitus 1. The evaluation should include a complete ear examination, audiometric testing (pure tone audiometry, speech audiometry, and tympanometry), and specialized tests like otoacoustic emissions and auditory brainstem responses to assess hearing function. Some key points to consider in the workup include:
- Classification of tinnitus as pulsatile or nonpulsatile to optimize the imaging workup, given different diagnostic considerations for each 1
- Identification of underlying causes such as noise exposure, ototoxic medications, ear pathologies, vascular abnormalities, or neurological disorders
- Assessment of the impact on quality of life using questionnaires like the Tinnitus Handicap Inventory
- Consideration of cognitive-behavioral therapy (CBT) for patients with persistent, bothersome tinnitus, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guideline for tinnitus 1
- Education and counseling for patients with persistent, bothersome tinnitus, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guideline for tinnitus 1 Imaging studies such as MRI or CT scans are recommended when asymmetric hearing loss, focal neurological findings, or pulsatile tinnitus are present to rule out structural abnormalities, as suggested by the ACR Appropriateness Criteria for tinnitus 1. Additional assessments include tinnitus matching (pitch and loudness), masking level measurements, and questionnaires like the Tinnitus Handicap Inventory to evaluate the impact on quality of life. This comprehensive approach helps identify potential causes and allows for targeted treatment strategies, which is crucial as tinnitus can significantly affect a patient's psychological well-being and daily functioning 1.
From the Research
Tinnitus Workup
- A standard workup for tinnitus begins with a targeted history and physical examination to identify treatable causes and associated symptoms that may improve with treatment 2.
- The workup should also include 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.
- 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.
Diagnostic Testing
- A prompt, comprehensive audiologic examination should be performed in patients with tinnitus that is unilateral, persistent (≥ 6 months), or associated with hearing difficulties 3.
- Clinicians should distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus 3.
- The development group made a strong recommendation against obtaining imaging studies of the head and neck in patients with tinnitus, specifically to evaluate tinnitus that does not localize to 1 ear, is nonpulsatile, and is not associated with focal neurologic abnormalities or an asymmetric hearing loss 3.
Evaluation and Treatment
- Clinicians should perform a targeted history and physical examination at the initial evaluation of a patient with presumed primary tinnitus to identify conditions that if promptly identified and managed may relieve tinnitus 3.
- Clinicians should educate patients with persistent, bothersome tinnitus about management strategies 3.
- Cognitive behavioral therapy is the only treatment that has been shown to improve quality of life in patients with tinnitus 2.
- Sound therapy and tinnitus retraining therapy are treatment options, but evidence is inconclusive 2.