What is the initial workup and management for a patient presenting with tinnitus?

Initial Workup and Management for Tinnitus

The initial workup for tinnitus should include a targeted history and physical examination followed by a prompt, comprehensive audiologic examination for patients with unilateral tinnitus, persistent tinnitus (≥6 months), or tinnitus associated with hearing difficulties. 1

Initial Evaluation

Targeted History

• Characteristics of tinnitus:
  • Unilateral vs bilateral
  • Duration (recent onset vs persistent ≥6 months)
  • Constant vs intermittent
  • Pulsatile vs non-pulsatile
  • Associated hearing loss or difficulty
  • Impact on quality of life (bothersome vs non-bothersome)

Physical Examination

• Otoscopic examination to identify:
  • Cerumen impaction
  • Foreign bodies
  • Tympanic membrane abnormalities
  • Middle ear pathology
• Head and neck examination to identify:
  • Temporomandibular joint dysfunction
  • Vascular abnormalities
  • Focal neurological deficits

Diagnostic Testing

Audiologic Evaluation

• Mandatory audiologic testing for:
  • Unilateral tinnitus
  • Persistent tinnitus (≥6 months)
  • Tinnitus with hearing difficulties 1
• Optional audiologic testing may be considered for all patients with tinnitus regardless of laterality, duration, or perceived hearing status 1
• Testing should be completed within 4 weeks of initial assessment 1

Imaging Studies

• Imaging is NOT recommended for routine evaluation of tinnitus 1
• Imaging IS indicated when tinnitus presents with:
  • Unilateral localization
  • Pulsatile quality
  • Focal neurological abnormalities
  • Asymmetric hearing loss 1

Management Approach

Step 1: Classify Tinnitus

• Determine if tinnitus is bothersome vs non-bothersome 1
• Determine if tinnitus is recent onset vs persistent (≥6 months) 1

Step 2: Management Based on Classification

• For non-bothersome tinnitus:

  • Reassurance
  • Education about natural history
  • Follow-up as needed

• For bothersome tinnitus:

  1. Education and counseling about management strategies 1
  2. Hearing aid evaluation if hearing loss is present 1
  3. Cognitive behavioral therapy (CBT) - the only treatment shown to improve quality of life 1, 2
  4. Sound therapy may be considered as an option 1

Treatments to AVOID

• Do NOT routinely prescribe:

  • Antidepressants
  • Anticonvulsants
  • Anxiolytics
  • Intratympanic medications 1

• Do NOT recommend dietary supplements:

  • Ginkgo biloba
  • Melatonin
  • Zinc
  • Other supplements 1

• Do NOT recommend transcranial magnetic stimulation (TMS) 1

Special Considerations

Red Flags Requiring Urgent Evaluation

• Pulsatile tinnitus (possible vascular abnormality)
• Sudden onset unilateral tinnitus with hearing loss
• Tinnitus with focal neurological deficits
• Tinnitus following head trauma

Common Pitfalls

1. Failure to identify underlying treatable causes - Always perform a thorough targeted history and physical examination
2. Unnecessary imaging - Only order imaging for specific indications
3. Delayed audiologic testing - Should be completed within 4 weeks for indicated cases
4. Prescribing ineffective medications - Avoid medications without proven benefit
5. Overlooking psychological impact - CBT is the most evidence-based treatment for bothersome tinnitus

Follow-up

• For persistent, bothersome tinnitus, regular follow-up is recommended to:
  • Reassess impact on quality of life
  • Adjust management strategies
  • Provide ongoing support and education

By following this algorithmic approach to tinnitus evaluation and management, clinicians can effectively identify potentially serious underlying causes, avoid unnecessary testing, and provide evidence-based interventions to improve patients' quality of life.