What is the recommended evaluation and management approach for a patient presenting with tinnitus?

Tinnitus Evaluation and Management

Clinicians should perform a comprehensive audiologic evaluation for patients with tinnitus, particularly when it is unilateral, persistent (≥6 months), or associated with hearing difficulties, and recommend cognitive behavioral therapy (CBT) as the first-line treatment for persistent, bothersome tinnitus. 1, 2

Diagnostic Evaluation

Initial Assessment

1. Targeted history and physical examination:

   • Identify potential underlying causes (vascular tumors, vestibular schwannoma)
   • Assess tinnitus characteristics:
     • Unilateral vs. bilateral
     • Pulsatile vs. non-pulsatile
     • Duration (recent onset vs. persistent ≥6 months)
     • Associated symptoms (hearing loss, vertigo, neurological symptoms)
   • Evaluate impact on quality of life 1, 2

2. Audiologic testing:

   • Pure tone audiometry - gold standard to measure hearing sensitivity and differentiate between conductive and sensorineural hearing loss
   • Speech audiometry - assess speech recognition abilities
   • Tympanometry - evaluate middle ear function
   • Acoustic reflex testing - help differentiate conductive from sensorineural pathology 2

When to Order Imaging

• Neuroimaging is NOT routinely recommended for tinnitus evaluation 1
• Imaging is indicated only for:
  • Unilateral or asymmetric tinnitus
  • Pulsatile tinnitus (CT angiography or MR angiography)
  • Tinnitus with focal neurological abnormalities
  • Tinnitus with asymmetric hearing loss (MRI with contrast of internal auditory canals) 1, 2, 3

Management Approach

First-Line Treatments

1. Cognitive Behavioral Therapy (CBT):

   • Strongest evidence-based treatment for persistent, bothersome tinnitus
   • Improves quality of life and coping strategies
   • Should be recommended for all patients with persistent, bothersome tinnitus 1, 2

2. Hearing Aid Evaluation:

   • Recommended for patients with hearing loss and persistent, bothersome tinnitus
   • Beneficial even with mild or unilateral hearing loss
   • Improves tinnitus by amplifying external sounds and reducing auditory deprivation 1, 2

3. Education and Counseling:

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

Second-Line Treatments

1. Sound Therapy:
   • May be recommended for persistent, bothersome tinnitus
   • Options include white noise machines, environmental sound generators, smartphone apps
   • Evidence is less robust than for CBT 1, 2

Treatments to AVOID

1. Medications NOT routinely recommended:

   • Antidepressants
   • Anticonvulsants
   • Anxiolytics
   • Intratympanic medications 1

2. Supplements NOT recommended:

   • Ginkgo biloba
   • Melatonin
   • Zinc
   • Other dietary supplements 1

3. Other interventions NOT recommended:

   • Transcranial magnetic stimulation (TMS) 1
   • No recommendation can be made regarding acupuncture 1

Follow-Up Care

• 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 2
• Distinguish patients with bothersome tinnitus of recent onset from those with persistent symptoms (≥6 months) to prioritize intervention 1

Common Pitfalls to Avoid

• Failing to remove cerumen before assessment, which can prevent accurate diagnosis
• Overlooking non-otologic causes (TMJ dysfunction, migraine, anxiety)
• Not performing comprehensive audiologic evaluation for unilateral or persistent tinnitus
• Using unproven medications or supplements that may have side effects without benefit
• Ordering unnecessary imaging for non-concerning tinnitus presentations 1, 2

Special Considerations

• Patients with sleep disturbance may benefit from addressing this specific symptom
• Mood disorders associated with tinnitus may require separate treatment
• Noise exposure avoidance may help prevent development or progression of tinnitus 3, 4