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

Initial Workup for Tinnitus

The initial workup for a patient presenting with tinnitus should include a targeted history and physical examination, followed by a prompt comprehensive audiologic examination within 4 weeks, regardless of laterality, duration, or perceived hearing status. 1, 2

History and Physical Examination Components

• Tinnitus characteristics:

  • Laterality (unilateral vs. bilateral)
  • Duration (recent vs. persistent ≥6 months)
  • Quality (pulsatile vs. non-pulsatile)
  • Timing (constant vs. intermittent)
  • Severity and impact on quality of life

• Associated symptoms:

  • Hearing loss
  • Vertigo or dizziness
  • Aural fullness
  • Otorrhea
  • Otalgia
  • Neurological symptoms

• Risk factors:

  • Noise exposure
  • Ototoxic medications
  • Head trauma
  • Family history of hearing disorders
  • Cardiovascular disease
  • Hypertension

• Physical examination:

  • Otoscopic examination (to identify retrotympanic masses)
  • Cranial nerve examination
  • Auscultation of neck, periauricular region, and mastoid
  • Assessment for objective tinnitus (audible to examiner)

Audiologic Testing

• Comprehensive audiologic examination is recommended for all patients with tinnitus, particularly those with:

  • Unilateral tinnitus
  • Persistent tinnitus (≥6 months)
  • Associated hearing difficulties 1, 2
  • Tinnitus of any laterality or duration (optional but beneficial) 1

• Components of audiologic testing:

  • Pure tone audiometry
  • Speech audiometry
  • Tympanometry
  • Acoustic reflexes
  • Otoacoustic emissions (when indicated)

Imaging Studies

Imaging studies should NOT be obtained for tinnitus evaluation unless one or more of the following are present: 1, 2

• Unilateral tinnitus
• Pulsatile tinnitus
• Focal neurological abnormalities
• Asymmetric hearing loss

When imaging is indicated, the appropriate studies include:

• For pulsatile tinnitus: CT angiography or MR angiography
• For unilateral tinnitus with asymmetric hearing loss: MRI with contrast of internal auditory canals
• For focal neurological findings: MRI brain with contrast

Additional Testing Based on Clinical Presentation

• For patients with dizziness/vertigo:

  • Video- or electronystagmography (VNG/ENG) 2
  • Electrocochleography for fluctuating hearing loss 2

• For patients with severe psychological distress:

  • Depression and anxiety screening
  • Suicide risk assessment 1, 2

Common Pitfalls to Avoid

1. Delaying audiologic evaluation in patients with unilateral tinnitus 2
2. Ordering unnecessary imaging for bilateral, non-pulsatile tinnitus without asymmetric hearing loss or focal neurological findings 1, 2
3. Telling patients "nothing can be done" when multiple management strategies exist 2
4. Failing to recognize red flags requiring urgent evaluation:
   • Sudden onset unilateral tinnitus
   • Pulsatile tinnitus
   • Tinnitus with neurological deficits
   • Tinnitus following head trauma

By following this systematic approach to the initial workup of tinnitus, clinicians can identify potentially treatable causes, recognize patients requiring further specialized evaluation, and initiate appropriate management strategies to improve patient outcomes and quality of life.