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 comprehensive audiologic examination within 4 weeks, regardless of laterality, duration, or perceived hearing status. 1

History and Physical Examination

The targeted history should assess:

• Tinnitus characteristics:

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

• Associated symptoms:

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

• Physical examination:

  • Otoscopic examination
  • Cranial nerve assessment
  • Auscultation for bruits (if pulsatile tinnitus)
  • Temporomandibular joint examination

Audiologic Testing

• All patients with tinnitus should undergo comprehensive audiologic testing 1, which includes:

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

• This testing is particularly crucial for patients with:

  • Unilateral tinnitus
  • Tinnitus persisting ≥6 months
  • Tinnitus accompanied by hearing difficulties 2

• If dizziness is present, video- or electronystagmography (VNG/ENG) should be added 1

• Electrocochleography is indicated if fluctuating hearing loss is identified during audiometry 1

Imaging Studies

Imaging studies should NOT be routinely obtained unless one or more of the following are present:

• Unilateral tinnitus
• Pulsatile tinnitus
• Focal neurological abnormalities
• Asymmetric hearing loss 1

When imaging is indicated, the appropriate studies include:

• Pulsatile tinnitus: CT angiography or MR angiography
• Unilateral tinnitus with asymmetric hearing loss: MRI with contrast of internal auditory canals
• Focal neurological findings: MRI brain with contrast 1

Psychological Assessment

• Screen for depression and anxiety, particularly in patients with severe psychological distress 1
• Assess suicide risk in patients with severe tinnitus-related distress 1

Common Pitfalls to Avoid

1. Ordering unnecessary imaging for bilateral, non-pulsatile tinnitus without asymmetric hearing loss or focal neurological findings 1

2. Delaying audiologic evaluation in patients with unilateral tinnitus 1

3. Ordering imaging before completing audiometric testing 1

4. Failing to distinguish between different types of dizziness (vertigo, lightheadedness, imbalance) 1

5. Telling patients "nothing can be done" when multiple management strategies exist 1

Follow-up and Referral

• Schedule follow-up within 4-6 weeks to assess response to initial management
• If symptoms persist or worsen, consider referral to a specialized tinnitus/hyperacusis clinic 1

Treatment Considerations

• Cognitive behavioral therapy is strongly recommended as first-line treatment for persistent, bothersome tinnitus 1, 3
• Sound therapy options (white noise machines, environmental sound generators, smartphone apps) can be beneficial 1
• Hearing aids are recommended for patients with hearing loss-associated tinnitus 1
• Avoid routine use of antidepressants, anticonvulsants, anxiolytics, intratympanic medications, or dietary supplements for treating persistent tinnitus due to lack of evidence 1, 3