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

Initial Workup for Tinnitus

The initial workup for tinnitus should include a targeted history, physical examination, and audiologic evaluation, with imaging studies only indicated for patients with unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss. 1, 2

Step 1: Targeted History

• Obtain detailed tinnitus characteristics including onset, duration, laterality, quality (ringing, buzzing, hissing, pulsatile), pitch, loudness, and pattern to identify potentially treatable underlying conditions 1
• Assess for associated symptoms such as hearing loss, vertigo, otalgia, otorrhea, or neurological symptoms 1
• Determine if tinnitus is bothersome or non-bothersome to guide management strategy 1
• Distinguish between recent onset and persistent tinnitus (≥6 months) 1
• Evaluate for risk factors including age, noise exposure, head trauma, and use of ototoxic medications 3

Step 2: Physical Examination

• 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
• Check for vascular retrotympanic masses that may indicate underlying vascular abnormalities 5, 4

Step 3: Classify Tinnitus Type

• Determine if tinnitus is pulsatile or non-pulsatile 6, 5
• Identify if tinnitus is subjective (heard only by patient) or objective (audible to examiner) 5, 7
• Determine if tinnitus is unilateral or bilateral 1
• Assess if tinnitus is associated with hearing loss 1

Step 4: Audiologic Evaluation

• A comprehensive audiologic examination is recommended for patients with:
  • Unilateral tinnitus 1, 2
  • Persistent tinnitus (≥6 months) 1, 2
  • Tinnitus associated with hearing difficulty 1
• Audiologic testing should include pure tone audiometry, speech audiometry, and acoustic reflex testing 1
• Consider measuring loudness discomfort levels for patients with hyperacusis 1

Step 5: Imaging Studies

• Imaging studies should NOT be obtained for tinnitus evaluation unless one or more of the following are present:
  • Focal neurological abnormalities 1, 2
  • Asymmetric hearing loss 1, 2
  • Pulsatile tinnitus 1, 5, 2
  • Unilateral tinnitus 2
• For pulsatile tinnitus without visible retrotympanic lesion, CT angiography (CTA) of the head and neck is recommended as first-line imaging 4
• For pulsatile tinnitus with visible retrotympanic lesion, high-resolution temporal bone CT without IV contrast is recommended 4
• MRI is indicated when acoustic neuroma is suspected (unilateral tinnitus with sensorineural hearing loss) 2, 7

Common Pitfalls to Avoid

• Obtaining unnecessary imaging studies for non-pulsatile, bilateral tinnitus without neurological symptoms 1, 2
• Overlooking mild hearing loss that may benefit from amplification 1, 5
• Recommending unproven treatments such as dietary supplements without evidence of efficacy 5
• Failing to identify potentially serious causes such as vascular abnormalities or vestibular schwannoma 2, 8
• Not providing education and counseling about management strategies, which should begin during the initial evaluation 1, 8

Next Steps in Management

• For patients with hearing loss, recommend hearing aid evaluation 1, 5
• Consider cognitive behavioral therapy for persistent, bothersome tinnitus (strongest evidence-based treatment) 5, 2, 3
• Provide education and counseling about tinnitus management strategies 1, 5
• Consider sound therapy options for symptomatic relief 1, 5
• Address any underlying treatable conditions identified during workup 5