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

Initial Workup and Management of Tinnitus

Clinicians should perform a targeted history and physical examination at the initial evaluation of a patient with tinnitus to identify conditions that if promptly identified and managed may relieve tinnitus. 1

Initial Assessment

Targeted History

• Determine if tinnitus is:
  • Unilateral or bilateral
  • Pulsatile or non-pulsatile
  • Constant or intermittent
  • Recent onset (<6 months) or persistent (≥6 months)
  • Bothersome or non-bothersome (critical distinction for management) 1, 2
• Associated symptoms:
  • Hearing loss
  • Vertigo/dizziness
  • Headache
  • Focal neurological symptoms
• Potential causes:
  • Noise exposure
  • Ototoxic medications
  • Head trauma
  • TMJ disorders
  • Vestibular migraine
  • Somatic tinnitus (modulated by body movements) 2

Physical Examination

• Otoscopic examination
• Cranial nerve examination
• TMJ examination
• Auscultation for bruits (if pulsatile tinnitus)
• Examination of neck and periauricular region

Diagnostic Testing

Audiologic Evaluation

• Prompt comprehensive audiologic examination is mandatory for patients with:
  • Unilateral tinnitus
  • Persistent tinnitus (≥6 months)
  • Tinnitus associated with hearing difficulties 1, 2
• Consider routine audiologic examination for all tinnitus patients regardless of laterality, duration, or perceived hearing status 1

Imaging Studies

• Do not obtain imaging studies for tinnitus unless patient has one or more of:
  • Unilateral tinnitus
  • Pulsatile tinnitus
  • Focal neurological abnormalities
  • Asymmetric hearing loss 1, 3
• When indicated, appropriate imaging may include MRI with contrast of internal auditory canals or CT angiography for pulsatile tinnitus 3

Management Approach

Step 1: Identify and Treat Underlying Causes

• Cerumen impaction
• Otitis media
• Ototoxic medications (modify or discontinue if possible)
• TMJ disorders
• Vestibular migraine

Step 2: Assess Impact and Classify Tinnitus

• Distinguish between bothersome and non-bothersome tinnitus 1, 2
• Determine if recent onset (<6 months) or persistent (≥6 months) 1
• Screen for anxiety, depression, and sleep disturbance
• Assess impact on quality of life

Step 3: Management of Persistent, Bothersome Tinnitus

First-line Interventions:

1. Education and counseling about tinnitus mechanisms and management strategies 1, 2
2. Cognitive Behavioral Therapy (CBT) - the only intervention proven to improve quality of life in tinnitus patients 1, 2, 3
3. Hearing aid evaluation for patients with documented hearing loss 1, 2
4. Sound therapy options:
   • White noise machines
   • Tabletop sound generators
   • Ear-level masking devices
   • Environmental sound enrichment 1, 2

Interventions NOT Recommended:

• Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for routine treatment 1, 2
• Dietary supplements (Ginkgo biloba, melatonin, zinc) 1, 2
• Transcranial magnetic stimulation 1

Special Considerations

Pulsatile Tinnitus

• Requires more urgent evaluation due to potential vascular causes
• Consider vascular imaging studies (CT angiography or MRA)
• May require referral to otolaryngology, neurology, or vascular surgery

Severe Psychological Impact

• Patients with severe anxiety or depression related to tinnitus require prompt identification and intervention due to increased suicide risk 2
• Consider referral to mental health professional

Pitfalls and Caveats

• Failure to distinguish between bothersome and non-bothersome tinnitus can lead to unnecessary interventions
• Overlooking unilateral tinnitus may delay diagnosis of potentially serious conditions like vestibular schwannoma
• Setting unrealistic expectations - emphasize that primary tinnitus is typically idiopathic with no cure, but symptoms can be mitigated 2
• Speech comprehension difficulties are common in tinnitus patients and may be underrecognized, especially in noisy environments 4
• Avoid promising complete resolution of symptoms, as this may lead to patient disappointment and decreased adherence to management strategies