What are the assessment and treatment options for tinnitus (ringing in the ears)?

Assessment and Treatment 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

• Targeted history should include:
  • Characteristics of tinnitus (unilateral vs. bilateral, duration, constant vs. intermittent)
  • Associated symptoms (hearing loss, vertigo, headache)
  • Pulsatile vs. non-pulsatile nature
  • Aggravating/alleviating factors
  • Medication history (ototoxic medications)
  • Noise exposure history
  • Impact on quality of life and sleep 2, 1

Physical Examination

• Otoscopic examination to visualize ear canals and tympanic membranes
• Look for cerumen impaction, middle ear fluid, tympanic membrane perforation
• Neurological examination to identify focal abnormalities
• Head and neck examination 1

Audiologic Testing

• Comprehensive audiologic examination is recommended for:
  • Unilateral tinnitus
  • Persistent tinnitus (≥6 months)
  • Tinnitus associated with hearing difficulties 2, 1
• Even patients without perceived hearing difficulties should undergo audiologic testing, as hearing loss is commonly associated with tinnitus but frequently unrecognized by patients 1

Imaging Studies

Imaging is NOT recommended routinely for tinnitus evaluation but is indicated for specific presentations:

Clinical Presentation	Recommended Imaging
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
Tinnitus localizing to one ear	Appropriate imaging based on clinical findings

2, 1

Management Approach

First-Line Interventions

1. Education and counseling

   • Explain the natural history of tinnitus
   • Provide coping strategies
   • Reassure that tinnitus is not life-threatening when appropriate 1

2. Hearing aids

   • Recommended for patients with hearing loss and persistent, bothersome tinnitus
   • Improves tinnitus by amplifying external sounds and reducing auditory deprivation 1

3. Sound therapy

   • White noise machines
   • Smartphone apps
   • Tinnitus masking devices 1, 3

Evidence-Based Treatments

• Cognitive Behavioral Therapy (CBT)

  • The only treatment shown to improve quality of life in patients with tinnitus 3
  • Should be considered for patients with bothersome tinnitus

• Tinnitus Retraining Therapy

  • Combination of sound therapy and counseling
  • Evidence is supportive but not conclusive 3, 4

Adjunctive Treatments

• Melatonin may help with sleep disturbance
• Antidepressants for associated mood disorders
• Cognitive training for cognitive impairments 3

Special Considerations

Pulsatile Tinnitus

• Requires thorough evaluation as it may indicate underlying vascular pathology:
  • Arteriovenous shunts or malformations
  • Carotid artery stenosis or dissection
  • Intracranial hypertension
  • Vascular tumors 1
• Initial management should include targeted history, physical examination, and appropriate vascular imaging 1

Follow-up

• Schedule follow-up within 4-6 weeks to assess response to initial management
• Consider referral to specialized care if symptoms persist or worsen 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

Treatment Algorithm

1. Identify and treat any underlying cause (cerumen impaction, medication side effect)
2. Assess impact on quality of life
3. For bothersome tinnitus:
   • Provide education and counseling
   • Recommend hearing aids if hearing loss is present
   • Initiate sound therapy
   • Refer for CBT if available
4. For non-bothersome tinnitus:
   • Provide education and reassurance
   • Consider follow-up as needed

Remember that while many treatments exist for tinnitus, none consistently eliminates symptoms completely, making a structured approach to management essential for improving patient quality of life 4, 5.