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 to identify potentially treatable underlying conditions, followed by a comprehensive audiologic examination, particularly for unilateral, persistent (≥6 months), or hearing difficulty-associated tinnitus. 1

Step 1: Targeted History and Physical Examination

• Obtain detailed tinnitus characteristics: onset, duration, laterality (unilateral vs bilateral), quality (pulsatile vs non-pulsatile), pitch, loudness, and pattern (constant vs intermittent) 1, 2
• Assess for associated symptoms: hearing loss, vertigo, otalgia, otorrhea, or neurological symptoms 1
• Review medical history for risk factors: noise exposure, ototoxic medications, head trauma, otologic disorders, cardiovascular disease, and psychiatric conditions 3
• Evaluate impact on quality of life and determine if tinnitus is bothersome or non-bothersome 1
• Perform otoscopic examination to identify cerumen impaction, tympanic membrane abnormalities, or middle ear pathology 1
• Conduct cranial nerve examination, especially focusing on hearing (CN VIII) 1
• Auscultate the neck, periauricular region, and temporal area for bruits if pulsatile tinnitus is reported 1, 4

Step 2: Audiologic Evaluation

• Prompt comprehensive audiologic examination is required for patients with:

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

• Consider routine audiologic examination for all tinnitus patients regardless of laterality, duration, or perceived hearing status 1, 5

• Audiologic assessment should include:

  • Pure tone audiometry
  • Speech audiometry
  • Tympanometry
  • Acoustic reflex testing
  • Otoacoustic emissions when appropriate 6
  • Tinnitus matching (pitch and loudness) and minimum masking levels 6

Step 3: Specialized Testing Based on Findings

• Imaging studies should NOT be obtained for tinnitus evaluation unless one or more of the following are present:

  • Tinnitus localizing to one ear
  • Pulsatile tinnitus
  • Focal neurological abnormalities
  • Asymmetric hearing loss 1

• For patients with sound tolerance problems (hyperacusis), measure loudness discomfort levels at audiometric frequencies 6

• For pulsatile tinnitus, consider vascular imaging studies (CT angiography, MR angiography, or conventional angiography) 4

Step 4: Classification and Further Management

• Distinguish between bothersome and non-bothersome tinnitus 1, 5
• Differentiate recent onset from persistent tinnitus (≥6 months) 1, 5
• Categorize as primary (idiopathic) or secondary (identifiable cause) tinnitus 2, 7
• For persistent, bothersome tinnitus:
  • Provide education and counseling about management strategies 1, 5
  • Recommend hearing aid evaluation if hearing loss is present 1, 5
  • Consider cognitive behavioral therapy 1, 5
  • Consider sound therapy options 1, 5

Common Pitfalls to Avoid

• Failing to distinguish between objective (can be heard by examiner) and subjective tinnitus (heard only by patient) 4
• Ordering unnecessary imaging studies for non-pulsatile, bilateral tinnitus without neurological symptoms 1
• Overlooking mild hearing loss that may benefit from amplification 5, 3
• Recommending unproven treatments such as dietary supplements (Ginkgo biloba, melatonin, zinc) 2
• Routinely prescribing medications (antidepressants, anticonvulsants, anxiolytics) specifically for tinnitus treatment 5, 2
• Underestimating the psychological impact of tinnitus on quality of life 3