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

Initial Workup and Management for Bilateral Constant Tinnitus

For patients with bilateral constant tinnitus, imaging studies are not indicated unless there are associated symptoms such as asymmetric hearing loss, neurologic deficits, or head trauma. 1

Step 1: Targeted History and Physical Examination

• Obtain detailed tinnitus characteristics including onset, duration, quality, pitch, loudness, and pattern to identify potentially treatable underlying conditions 2
• Assess for associated symptoms such as hearing loss, vertigo, otalgia, otorrhea, or neurological symptoms 2
• Perform otoscopic examination to identify cerumen impaction, tympanic membrane abnormalities, or middle ear pathology which may be causing tinnitus 2, 1
• Conduct cranial nerve examination, especially focusing on hearing (CN VIII) 2
• Determine if tinnitus is bothersome or non-bothersome to guide management strategy 2, 3

Step 2: Audiologic Evaluation

• Perform comprehensive audiologic examination, including pure tone audiometry, speech audiometry, and acoustic reflex testing 2, 3
• Consider high-frequency audiometry (8-16 kHz) as tinnitus may be an early indicator of high-frequency hearing loss 4
• Measure loudness discomfort levels if hyperacusis (sound sensitivity) is reported 2, 5
• If hearing loss is identified, even if mild or unilateral, recommend hearing aid evaluation 6, 3

Step 3: Management Approach

• Provide education and counseling about tinnitus and management strategies 2, 3
• Recommend cognitive behavioral therapy (CBT) for persistent, bothersome tinnitus as it has the strongest evidence base 6, 3
• Consider sound therapy options including wideband sound generators or combination devices 7, 3
• Avoid recommending unproven treatments such as:
  • Antidepressants, anticonvulsants, or anxiolytics for routine treatment 8, 3
  • Dietary supplements like Ginkgo biloba, melatonin, or zinc 8, 3

Special Considerations and Pitfalls

• Distinguish between pulsatile and non-pulsatile tinnitus, as pulsatile tinnitus almost always requires imaging evaluation 6, 1
• Avoid unnecessary imaging for bilateral non-pulsatile tinnitus without associated symptoms 1
• Do not overlook mild hearing loss that may benefit from amplification 6, 3
• Monitor for psychological impact as tinnitus can significantly affect quality of life and may be associated with anxiety and depression 6, 7
• Recognize that tinnitus classification (bothersome vs. non-bothersome, recent vs. persistent) guides appropriate management 2, 3

When to Consider Imaging

• Unilateral tinnitus 1
• Pulsatile tinnitus 1
• Asymmetric hearing loss 1
• Focal neurological abnormalities 1
• History of head trauma 1