Who should a patient with tinnitus be referred to?

Referral Pathways for Patients with Tinnitus

Patients with tinnitus should be referred to an otolaryngologist (ENT specialist) as the primary specialist, with additional referrals to audiology for comprehensive hearing evaluation, particularly for persistent or unilateral tinnitus. 1, 2, 3

Initial Assessment and Referral Algorithm

Step 1: Primary Care Evaluation

• Determine if tinnitus is:
  • Pulsatile vs. non-pulsatile
  • Unilateral vs. bilateral
  • Recent onset (<6 months) vs. persistent (≥6 months)
  • Associated with hearing loss or neurological symptoms
  • Bothersome vs. non-bothersome

Step 2: Referral Decision

1. Immediate ENT referral for:

   • Pulsatile tinnitus (may indicate vascular abnormality)
   • Unilateral tinnitus
   • Tinnitus with sudden hearing loss
   • Tinnitus with focal neurological symptoms
   • Tinnitus with visible abnormality on otoscopic examination

2. Audiologist referral for:

   • Comprehensive audiologic examination for patients with:
     • Unilateral tinnitus
     • Persistent tinnitus (≥6 months)
     • Tinnitus associated with hearing difficulties 2, 3

3. Additional specialist referrals based on findings:

   • Neurology: For tinnitus associated with neurological symptoms 2
   • Vascular specialists: For confirmed vascular abnormalities causing pulsatile tinnitus 2

Evidence-Based Rationale

The American Academy of Otolaryngology-Head and Neck Surgery guidelines strongly recommend that patients with tinnitus receive a comprehensive evaluation by an otolaryngologist, particularly for unilateral, persistent, or hearing loss-associated tinnitus 1, 3. This is because ENT specialists are best positioned to:

1. Rule out treatable underlying pathologies
2. Coordinate multidisciplinary care
3. Recommend appropriate interventions based on tinnitus classification

For audiologic evaluation, the evidence supports comprehensive testing for patients with unilateral tinnitus, persistent tinnitus (≥6 months), or tinnitus with hearing difficulties 3. This is crucial as tinnitus is strongly associated with sensorineural hearing loss in many cases 4.

Special Considerations for Pulsatile Tinnitus

Pulsatile tinnitus requires a different diagnostic approach:

• CT angiography (CTA) of the head and neck with IV contrast is recommended as first-line imaging
• Referral to vascular specialists may be necessary if imaging reveals vascular abnormalities 2

Common Pitfalls to Avoid

1. Delayed referral: Unilateral tinnitus should prompt prompt referral to ENT, not watchful waiting
2. Incomplete evaluation: Failing to obtain comprehensive audiologic evaluation when indicated
3. Unnecessary imaging: Ordering neuroimaging for non-concerning tinnitus presentations (bilateral, non-pulsatile, without focal neurological findings) 2, 3
4. Missing red flags: Failing to recognize signs that warrant urgent evaluation (pulsatile tinnitus, focal neurological symptoms)

Treatment Coordination

While ENT specialists typically coordinate care, treatment often involves a multidisciplinary approach:

• Audiologists: For hearing evaluation and hearing aid fitting if indicated
• Psychologists/psychiatrists: For cognitive behavioral therapy, which is the only treatment shown to improve quality of life in tinnitus patients 4
• Neurologists: For cases with associated neurological symptoms 2, 5

The evidence shows that despite the availability of multiple specialists and treatment options, satisfaction with tinnitus management remains low 6, highlighting the importance of appropriate specialist referral and coordinated care.