What is the diagnostic approach for tinnitus?

Diagnostic Approach for Tinnitus

Clinicians should perform a targeted history and physical examination at the initial evaluation of a patient with presumed primary tinnitus to identify conditions that if promptly identified and managed may relieve tinnitus. 1

Initial Assessment

Classification of Tinnitus

• Determine if tinnitus is subjective (heard only by patient) or objective (audible to examiner) 2
• Classify as pulsatile (synchronous with heartbeat) or non-pulsatile 2
• Determine if unilateral or bilateral 2
• Assess quality of sound (ringing, buzzing, clicking, pulsations) 2
• Determine if tinnitus is bothersome or non-bothersome to prioritize intervention 1
• Distinguish recent onset from persistent (≥6 months) tinnitus 1

Key History Elements

• Duration of symptoms 3
• Associated hearing loss or difficulties 1
• Noise exposure (occupational or recreational) 2
• Medications (especially ototoxic drugs) 2
• Associated symptoms (vertigo, aural fullness, otorrhea) 3
• Exacerbating factors (jaw movement, position changes) 4
• Psychological impact (anxiety, depression, sleep disturbance) 2
• Medical conditions (hypertension, diabetes, TMJ disorders) 4, 2

Physical Examination

• Complete head and neck examination 1
• Otoscopic examination to identify cerumen impaction, tympanic membrane abnormalities, or retrotympanic masses 4
• Cranial nerve examination 3
• Auscultation of periauricular region, neck, and orbit for bruits 4
• Assessment of temporomandibular joint function 4
• Examination for focal neurological abnormalities 1

Diagnostic Testing

Audiologic Evaluation

• Comprehensive audiologic examination is recommended for:
  • Unilateral tinnitus 1, 4
  • Persistent tinnitus (≥6 months) 1
  • Tinnitus associated with hearing difficulties 1
• Audiologic testing should include:
  • Pure tone audiometry 3
  • Speech audiometry 3
  • Tympanometry 3
  • Acoustic reflex testing 5

Imaging Studies

• Imaging is NOT recommended for routine evaluation of tinnitus 1
• Imaging IS indicated for tinnitus with any of the following:
  • Unilateral or asymmetric tinnitus 1, 4
  • Pulsatile tinnitus 4, 2
  • Focal neurological abnormalities 1
  • Asymmetric hearing loss 1
• Appropriate imaging modalities:
  • MRI with contrast for suspected acoustic neuroma or retrocochlear pathology 4
  • CT temporal bone for suspected bony abnormalities or middle ear pathology 4

Additional Testing

• Vestibular testing (electronystagmography) for associated vertigo 6
• Tinnitus matching and loudness scaling may help characterize the tinnitus 5
• Tinnitus Handicap Inventory (THI) to assess impact on quality of life 5

Special Considerations

Red Flags Requiring Urgent Evaluation

• Pulsatile tinnitus (possible vascular abnormality) 4, 2
• Sudden onset unilateral tinnitus with hearing loss 2
• Tinnitus with severe anxiety or depression (increased suicide risk) 2
• Tinnitus with focal neurological deficits 1

Common Etiologies to Consider

• Sensorineural hearing loss (most common cause) 2
• Noise exposure (occupational or recreational) 2
• Age-related hearing loss (presbycusis) 2
• Temporomandibular joint dysfunction 4
• Vascular abnormalities (for pulsatile tinnitus) 4, 2
• Ototoxic medications 2
• Eustachian tube dysfunction 4

Diagnostic Algorithm

1. Perform targeted history and physical examination 1
2. Determine if tinnitus is bothersome or non-bothersome 1
3. Obtain prompt audiologic examination for unilateral, persistent, or hearing loss-associated tinnitus 1
4. Order imaging only for specific indications (unilateral, pulsatile, neurologic abnormalities, asymmetric hearing loss) 1, 4
5. Distinguish recent onset from persistent tinnitus to guide management 1
6. Provide education and counseling about tinnitus 1