What to do for tinnitus (ringing in the ears) after a head injury?

Management of Tinnitus After Head Injury

For tinnitus following head injury, immediate medical evaluation is recommended to identify underlying causes, with imaging studies indicated for unilateral, persistent, or pulsatile tinnitus to rule out serious pathology.

Initial Assessment

When evaluating tinnitus after head trauma, consider:

• Timing of onset: Tinnitus that begins immediately after head trauma suggests a direct relationship
• Characteristics: Determine if the tinnitus is:
  • Unilateral or bilateral
  • Pulsatile or non-pulsatile
  • Constant or intermittent
• Associated symptoms: Check for:
  • Hearing loss
  • Dizziness/vertigo
  • Headache
  • Cognitive difficulties (memory, concentration)
  • Neurological deficits

Diagnostic Approach

Imaging Studies

• CT scan is indicated for:

  • Unilateral tinnitus
  • Pulsatile tinnitus
  • Tinnitus with focal neurological abnormalities
  • Asymmetric hearing loss 1, 2

• Temporal bone CT is recommended as first-line imaging for pulsatile tinnitus to evaluate for:

  • Vascular anomalies
  • Paraganglioma
  • Middle ear tumors
  • Semicircular canal dehiscence 1

• MRI with internal auditory canal protocol should be considered for:

  • Persistent unilateral tinnitus
  • Tinnitus with asymmetric hearing loss
  • Neurological symptoms 1

Audiological Assessment

• Comprehensive audiological examination is recommended for all patients with:
  • Unilateral tinnitus
  • Persistent tinnitus (≥6 months)
  • Tinnitus associated with hearing difficulties 2

Treatment Approaches

Immediate Management

1. Rule out serious pathology:

   • Pulsatile tinnitus may indicate vascular abnormalities requiring urgent evaluation 1, 2
   • Tinnitus with sudden hearing loss requires immediate medical attention 1

2. Address modifiable factors:

   • Check for cerumen impaction, which can cause or exacerbate tinnitus 1
   • Review medications that may cause or worsen tinnitus (including ibuprofen) 3

Evidence-Based Interventions

1. Sound Therapy:

   • Provides relief from tinnitus-associated stress
   • Offers passive distraction from tinnitus perception 2
   • Can be delivered through various devices (white noise machines, smartphone apps)

2. Hearing Aids (if hearing loss is present):

   • Recommended even for mild or unilateral hearing loss
   • Improves auditory input and reduces contrast between tinnitus and background sound 2

3. Cognitive Behavioral Therapy (CBT):

   • Has the strongest evidence base among all interventions for tinnitus
   • Particularly effective for managing emotional response to tinnitus 2, 4
   • Acceptance and Commitment Therapy (ACT) appears particularly effective 2

4. Combined Approach:

   • Evidence is strongest for combining sound therapy with CBT-based counseling 4

Important Cautions

• Avoid unproven treatments:

  • Supplements like Ginkgo biloba lack evidence and may have drug interactions 2
  • Medications such as antidepressants, anticonvulsants, and anxiolytics should not be routinely prescribed specifically for tinnitus 2

• Monitor for complications:

  • Post-traumatic tinnitus patients often experience more severe symptoms and additional co-symptoms compared to non-traumatic tinnitus 5
  • Higher rates of depression, concentration difficulties, and memory problems occur in trauma-associated tinnitus 6, 5

• Watch for red flags requiring immediate attention:

  • Worsening headache
  • Focal neurological deficits
  • Confusion or memory problems
  • Increased sleepiness 1

Special Considerations for Post-Traumatic Tinnitus

• Tinnitus after head injury may result from reduced central efferent suppression of cochlear mechanics 7
• Up to 53% of individuals with traumatic brain injuries develop tinnitus 6
• Post-traumatic tinnitus is often associated with hyperacusis (increased sensitivity to sound) and difficulty hearing in background noise 7
• Auditory symptoms are often overlooked in concussion management protocols despite their significant impact on quality of life 8

Follow-up Recommendations

• Regular follow-up to monitor tinnitus severity and impact on quality of life
• Reassessment if symptoms worsen or new symptoms develop
• Consider referral to tinnitus specialist if symptoms persist despite initial management