What is the initial workup and recommended history for a 47-year-old female (YOF) with non-pulsatile tinnitus and normal hearing testing?

Initial Workup and Recommended History for Non-Pulsatile Tinnitus in a 47-Year-Old Female with Normal Hearing

For a 47-year-old female with non-pulsatile tinnitus and normal hearing testing, a targeted history and physical examination should be performed to identify potentially treatable underlying conditions, with no imaging studies indicated unless specific red flags are present. 1, 2

Targeted History Components

• Obtain detailed tinnitus characteristics:

  • Onset (sudden vs. gradual) 1, 2
  • Duration (recent vs. persistent ≥6 months) 1, 2
  • Quality (ringing, buzzing, hissing, etc.) 2
  • Pitch (high vs. low) 2
  • Loudness and pattern (constant vs. intermittent) 2
  • Laterality (unilateral vs. bilateral) 1, 2

• Assess for associated symptoms:

  • Vertigo or dizziness 2, 3
  • Otalgia (ear pain) 2
  • Otorrhea (ear discharge) 2
  • Neurological symptoms (headache, facial weakness, etc.) 2, 3

• Review medical history:

  • Noise exposure history 1, 3
  • Medication review (including over-the-counter) for ototoxic drugs 1
  • History of ear infections or ear surgery 4
  • Cardiovascular risk factors 1
  • Psychiatric history (especially anxiety and depression) 1

Physical Examination

• Comprehensive otologic examination:

  • Otoscopy to identify cerumen impaction, tympanic membrane abnormalities, or middle ear pathology 1, 2
  • Examination of external auditory canal 1
  • Assessment for retrotympanic masses 1

• Neurological examination:

  • Cranial nerve examination, especially CN VIII 2
  • Assessment for focal neurological deficits 1

• Head and neck examination:

  • Auscultation of periauricular region, neck, and temporal area (even though tinnitus is non-pulsatile) 2
  • Temporomandibular joint assessment 4

Assessment of Tinnitus Impact

• Determine if tinnitus is bothersome or non-bothersome 1, 2
• Assess impact on:
  • Sleep 2, 3
  • Concentration 2
  • Emotional well-being 1
  • Daily activities 2

Further Evaluation

• Since the patient already has normal hearing testing, no additional audiologic testing is indicated at this time 1, 2

• No imaging studies are recommended for non-pulsatile tinnitus with normal hearing and without:

  • Unilateral tinnitus 1
  • Focal neurological abnormalities 1
  • Pulsatile quality 1

Management Considerations

• Distinguish between recent onset and persistent tinnitus (≥6 months) to guide management approach 1, 2
• For persistent, bothersome tinnitus, consider:
  • Education and counseling about management strategies 1, 2
  • Cognitive behavioral therapy 1, 2
  • Sound therapy options 1, 2

Important Caveats

• Be vigilant for red flags that would warrant imaging or specialist referral:

  • Development of unilateral tinnitus 1
  • New neurological symptoms 1, 3
  • Change in tinnitus character (especially if becomes pulsatile) 1
  • Development of hearing loss 1, 3

• Avoid recommending unproven treatments such as dietary supplements (Ginkgo biloba, melatonin, zinc) 2, 3

• Screen for psychiatric comorbidities, as patients with tinnitus and severe anxiety or depression require prompt identification and intervention 1