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

Initial Workup and Management of Tinnitus

Clinicians should perform a targeted history and physical examination at the initial evaluation of a patient with tinnitus, followed by a comprehensive audiologic examination, particularly for patients with unilateral tinnitus, tinnitus present for ≥6 months, or tinnitus associated with hearing difficulties. 1, 2

Initial Assessment

History and Physical Examination

• Key history elements to document:

  • Tinnitus characteristics: onset, duration, location (unilateral vs bilateral), quality (pulsatile vs non-pulsatile), pitch, loudness, variability
  • Associated symptoms: hearing loss, vertigo, dizziness, ear fullness
  • Exacerbating/alleviating factors
  • Impact on quality of life, sleep, concentration
  • Medical history: head/neck trauma, noise exposure, ototoxic medications
  • Psychiatric history: anxiety, depression

• Physical examination:

  • Otoscopic examination to visualize ear canals and tympanic membranes 1
  • Look for cerumen impaction, middle ear fluid, tympanic membrane perforation
  • Tuning fork tests (Weber and Rinne) to differentiate conductive from sensorineural hearing loss 1
  • Cranial nerve examination
  • Auscultation of neck, periauricular region, and skull for bruits (if pulsatile tinnitus)

Diagnostic Testing

Audiologic Evaluation

• Prompt comprehensive audiologic examination is strongly recommended for:

  • Unilateral tinnitus
  • Persistent tinnitus (≥6 months)
  • Tinnitus associated with hearing difficulties 2, 1, 3

• Components of audiologic evaluation:

  • Pure tone audiometry
  • Speech audiometry
  • Tympanometry
  • Acoustic reflex testing 1

The American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend audiologic testing even in patients without perceived hearing difficulties, as hearing loss is frequently unrecognized by patients but commonly associated with tinnitus 2, 4.

Imaging Studies

• Imaging is NOT recommended routinely for tinnitus evaluation 2, 3

• Imaging is indicated ONLY for patients with:

  • Unilateral tinnitus
  • Pulsatile tinnitus
  • Focal neurological abnormalities
  • Asymmetric hearing loss 2, 1, 3

• Appropriate imaging based on presentation:

  • 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

Management Approach

Education and Counseling

• Explain the natural history of tinnitus
• Provide information about management strategies
• Reassure patients about benign nature of most tinnitus 1, 4

Hearing Aid Evaluation

• Recommend hearing aid evaluation for patients with documented hearing loss and persistent, bothersome tinnitus 1, 4
• Hearing aids can improve tinnitus by amplifying external sounds and reducing auditory deprivation 1

Sound Therapy

• Consider sound therapy options (white noise machines, smartphone apps)
• May be offered as an option for patients with persistent, bothersome tinnitus 1, 4

Cognitive Behavioral Therapy (CBT)

• CBT is the strongest evidence-based treatment for persistent, bothersome tinnitus 1, 3, 5, 4
• Improves quality of life and coping strategies
• Should be recommended for all patients with persistent, bothersome tinnitus 1

Pharmacologic Management

• Avoid routine use of:
  • Antidepressants
  • Anticonvulsants
  • Anxiolytics
  • Intratympanic medications
  • Dietary supplements (Ginkgo biloba, melatonin, zinc) 4
• Limited course of vestibular suppressants (e.g., meclizine) may be considered for symptomatic relief if vertigo is present 1

Follow-up and Referral

• Document resolution, improvement, or worsening of symptoms
• Schedule follow-up within 4-6 weeks to assess response to initial management
• Consider referral to specialized tinnitus/hyperacusis clinic for persistent or worsening symptoms 1

Common Pitfalls to Avoid

• Failing to remove cerumen before assessment
• Overlooking non-otologic causes
• Not performing comprehensive audiologic evaluation for unilateral or persistent tinnitus
• Using unproven medications or supplements
• Ordering unnecessary imaging for non-concerning tinnitus presentations 1
• Prolonged use of vestibular suppressants 1

By following this structured approach to tinnitus evaluation and management, clinicians can effectively identify potentially serious underlying causes while providing evidence-based interventions to improve quality of life for patients with persistent, bothersome tinnitus.