From the Guidelines
The initial workup for tinnitus should begin with a comprehensive history and physical examination, focusing on onset, duration, character, and associated symptoms, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery Foundation 1.
Key Components of the Initial Workup
- Obtain a detailed medication history as some drugs (aspirin, NSAIDs, aminoglycosides, loop diuretics) can cause or worsen tinnitus.
- Perform a complete otologic examination including otoscopy to assess for cerumen impaction, foreign bodies, or middle ear pathology.
- Audiometric testing is essential to evaluate hearing loss, which commonly accompanies tinnitus.
Additional Testing and Management
- Additional testing may include tympanometry, acoustic reflex testing, and in selected cases, imaging studies like MRI to rule out retrocochlear pathology such as vestibular schwannoma, especially with unilateral tinnitus or asymmetric hearing loss, as suggested by the ACR Appropriateness Criteria 1.
- Management begins with addressing any underlying causes such as cerumen removal or discontinuing ototoxic medications when possible.
- For persistent tinnitus, sound therapy using white noise machines, hearing aids (if hearing loss is present), or tinnitus maskers can help reduce awareness of the tinnitus.
- Cognitive behavioral therapy is effective for managing the psychological impact of tinnitus, as recommended by the clinical practice guideline: tinnitus executive summary 1.
Considerations for Quality of Life
- Patient education about tinnitus and reassurance are crucial components of management, as understanding that tinnitus is rarely associated with serious pathology can significantly reduce anxiety and improve coping.
- While no medications are FDA-approved specifically for tinnitus, antidepressants like nortriptyline may help patients with concomitant depression or anxiety, but their use should be guided by the clinical practice guideline: tinnitus executive summary 1.
From the Research
Initial Workup for Tinnitus
The initial workup for a patient presenting with tinnitus involves a thorough history, head and neck examination, and audiometric testing to identify an underlying etiology 2, 3. This evaluation is crucial in determining the cause of tinnitus, which can be subjective or objective.
Key Components of the Initial Evaluation
- A comprehensive history to identify potential causes of tinnitus, such as exposure to loud noise, ototoxic medications, or Meniere's disease 2, 3
- A physical examination of the head, eyes, ears, nose, throat, neck, and neurologic system to guide subsequent evaluation 3
- Audiometry with tympanometry to assess hearing loss and middle ear function 3, 4
- Classification of the type, quality, and intensity of tinnitus to help guide treatment 4
Specialized Testing and Referral
- Unilateral or pulsatile tinnitus may require specialized audiometric testing and radiologic studies to rule out more serious pathology, such as acoustic neuroma or vascular abnormalities 2, 3
- Patients with persistent, bothersome tinnitus may benefit from referral to a specialist, such as an otolaryngologist or an audiologist, for further evaluation and management 5
Management Strategies
- Supportive counseling to help patients cope with tinnitus and improve the chances of successful treatment 3
- Treatment modalities, such as cognitive behavioral therapy, tinnitus retraining therapy, sound therapy, hearing aids, and pharmacotherapy, may be recommended based on the underlying cause and severity of tinnitus 4, 5