What is the recommended referral and management approach for patients presenting with tinnitus?

Tinnitus Referral and Management Approach

Patients with tinnitus should be referred to an audiologist for comprehensive audiologic evaluation, particularly when tinnitus is unilateral, persistent (≥6 months), or associated with hearing difficulties. 1, 2

Initial Evaluation and Classification

Targeted History and Physical Examination

• Determine if tinnitus is:
  • Unilateral vs bilateral
  • Pulsatile vs non-pulsatile
  • Recent onset vs persistent (≥6 months)
  • Associated with hearing difficulties
  • Bothersome vs non-bothersome 1, 2

Red Flags Requiring Immediate Referral

• Pulsatile tinnitus
• Unilateral tinnitus
• Focal neurological abnormalities
• Asymmetric hearing loss 1, 2

Referral Algorithm

1. For pulsatile tinnitus:

   • Refer to ENT specialist and for contrast-enhanced CT angiography (CTA) of head and neck 2
   • Consider MR angiography as an alternative 2

2. For unilateral tinnitus or asymmetric hearing loss:

   • Refer to ENT specialist and for MRI with contrast of internal auditory canals 2

3. For persistent (≥6 months) or bothersome tinnitus:

   • Refer for comprehensive audiologic evaluation 1, 2
   • Consider referral to specialized tinnitus/hyperacusis clinic if symptoms persist despite initial management 2

4. For tinnitus with significant psychological distress:

   • Screen for depression, anxiety, and suicide risk
   • Consider referral to mental health professional 2

Management Approach

First-line Treatments

1. Cognitive Behavioral Therapy (CBT)

   • Strongest evidence-based treatment for persistent, bothersome tinnitus 2, 3
   • Improves quality of life and helps patients cope with tinnitus 3

2. Hearing Aids

   • Recommended for patients with hearing loss-associated tinnitus (even mild or unilateral) 2
   • Improves tinnitus by amplifying external sounds and reducing auditory deprivation 2

3. Sound Therapy

   • Options include white noise machines, environmental sound generators, smartphone apps
   • Helps mask tinnitus and reduce perception 2

4. Education and Counseling

   • Explain the natural history of tinnitus
   • Provide coping strategies and management options 1, 2

Treatments to Avoid

• Do not routinely recommend:
  • Antidepressants
  • Anticonvulsants
  • Anxiolytics
  • Intratympanic medications
  • Dietary supplements (including Ginkgo biloba, melatonin, zinc) 2, 3

Follow-up Care

• Schedule follow-up within 4-6 weeks to assess response to initial management 2
• If symptoms persist or worsen, consider referral to specialized tinnitus/hyperacusis clinic 2

Important Caveats

• Despite numerous treatment options, satisfaction rates with tinnitus treatments remain low 4
• Imaging studies should not be obtained unless tinnitus is unilateral, pulsatile, associated with focal neurological abnormalities, or asymmetric hearing loss 1, 3
• The combination of sound therapy and CBT-based counseling has the strongest evidence base, though clinical response varies due to the heterogeneity of tinnitus 5
• Noise exposure avoidance may help prevent development or progression of tinnitus 6