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

Initial Workup for Tinnitus

The initial workup for a patient presenting with tinnitus should include a targeted history and physical examination, comprehensive audiologic evaluation within 14 days of symptom onset, and classification of tinnitus as pulsatile vs. non-pulsatile, unilateral vs. bilateral, recent vs. persistent, and bothersome vs. non-bothersome to guide management decisions. 1

Initial Assessment

History and Physical Examination

• Characterize tinnitus by:

  • Duration (recent onset vs. persistent ≥6 months)
  • Quality (pitch, loudness, constant vs. intermittent)
  • Associated symptoms (hearing loss, vertigo, headache)
  • Impact on quality of life and sleep
  • Fluctuations in hearing 1

• Assess for potential causes:

  • Noise exposure history
  • Ototoxic medication use (antibiotics, salicylates, NSAIDs, loop diuretics, chemotherapy)
  • Head trauma
  • Systemic conditions (hypertension, diabetes, thyroid disorders)
  • Psychiatric conditions (depression, anxiety) 1, 2

Physical Examination

• Perform otoscopic examination to identify visible abnormalities
• Conduct tuning fork tests (Weber and Rinne) to differentiate conductive from sensorineural hearing loss
• Complete focused neurological examination to assess for focal deficits 1

Audiologic Evaluation

• All patients with unilateral tinnitus, persistent tinnitus (≥6 months), or tinnitus associated with hearing difficulties should undergo comprehensive audiologic evaluation 1, 3
• The American Academy of Otolaryngology-Head and Neck Surgery recommends this evaluation within 14 days of symptom onset 1
• Audiologic testing should include:
  • Pure tone audiometry
  • Speech audiometry
  • Tympanometry
  • Acoustic reflex testing 1

Red Flags Requiring Immediate Investigation

• Sudden onset of bilateral hearing loss
• Focal neurological findings
• Severe headaches
• Concurrent severe bilateral vestibular loss
• Pulsatile tinnitus
• Visible abnormality on otoscopic examination
• Unilateral tinnitus with asymmetric hearing loss 1

Imaging and Advanced Testing

Imaging is not part of standard workup unless specific indications are present 2, 3:

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 with sudden hearing loss	MRI with contrast of internal auditory canals

Specialist Referral

• ENT referral is indicated for:

  • Pulsatile tinnitus
  • Unilateral tinnitus
  • Tinnitus with sudden hearing loss
  • Tinnitus with focal neurological symptoms
  • Tinnitus with visible abnormality on otoscopic examination 1

• Audiology referral is recommended for:

  • Comprehensive audiologic examination for patients with unilateral tinnitus
  • Persistent tinnitus
  • Tinnitus associated with hearing difficulties 1

Common Pitfalls to Avoid

• Failing to remove cerumen before assessment
• Overlooking non-otologic causes
• Not performing comprehensive audiologic evaluation
• Using unproven medications or supplements
• Ordering unnecessary imaging for non-concerning tinnitus presentations
• Delayed referral for unilateral tinnitus
• Missing red flags that warrant urgent evaluation 1

Tinnitus Classification for Management

After initial workup, tinnitus should be classified to guide management:

1. Pulsatile vs. non-pulsatile
2. Unilateral vs. bilateral
3. Recent onset vs. persistent
4. Associated with hearing loss or neurological symptoms
5. Bothersome vs. non-bothersome 1

This structured approach ensures thorough evaluation while avoiding unnecessary testing, facilitating appropriate management decisions based on the specific characteristics of each patient's tinnitus.