Tinnitus Workup and Treatment
Initial Workup
All patients presenting with tinnitus require a targeted history, physical examination, and audiologic evaluation to identify treatable underlying conditions and guide management. 1
Step 1: Targeted History and Physical Examination
Obtain specific tinnitus characteristics to identify potentially treatable pathology:
- Laterality: Unilateral tinnitus requires more aggressive workup including imaging 2, 1
- Quality: Distinguish pulsatile from non-pulsatile tinnitus, as pulsatile tinnitus almost always requires imaging to evaluate for vascular abnormalities 3, 4
- Duration: Differentiate recent onset (<6 months) from persistent tinnitus (≥6 months) to prioritize intervention 1, 5
- Associated symptoms: Assess for hearing loss, vertigo, otalgia, otorrhea, or focal neurological symptoms 1, 6
- Impact on quality of life: Distinguish bothersome from non-bothersome tinnitus, as this classification guides treatment decisions 2, 5
Physical examination must include:
- Otoscopic examination to identify cerumen impaction, tympanic membrane abnormalities, or middle ear pathology 1
- Cranial nerve examination, particularly CN VIII (hearing) 1
- Auscultation of the neck, periauricular region, and temporal area for bruits if pulsatile tinnitus is present 1, 4
Step 2: Audiologic Evaluation
Obtain a comprehensive audiologic examination (pure tone audiometry, speech audiometry, and acoustic reflex testing) for all patients with unilateral tinnitus, persistent tinnitus (≥6 months), or hearing difficulties. 2, 1, 5
The guideline also provides an option to obtain audiologic testing in all tinnitus patients regardless of laterality, duration, or perceived hearing status, as hearing loss is frequently unrecognized by patients and commonly associated with tinnitus. 2, 1 This approach is reasonable given that detecting mild hearing loss can identify candidates for hearing aid intervention, which is an evidence-based treatment. 3
For patients with sound tolerance problems (hyperacusis), measure loudness discomfort levels at audiometric frequencies. 1
Step 3: Imaging Studies
Do NOT obtain imaging studies unless one or more of the following red flags are present: 2, 1, 5
- Unilateral or asymmetric tinnitus
- Pulsatile tinnitus
- Focal neurological abnormalities
- Asymmetric hearing loss
This strong recommendation against routine imaging is based on the low yield in patients without these features and avoids unnecessary costs, radiation exposure, and detection of incidental findings. 2 For bilateral, non-pulsatile tinnitus without neurological symptoms, imaging is not indicated. 3
When imaging is indicated, consider CT temporal bone for suspected bony abnormalities or MRI with contrast for suspected vestibular schwannoma or vascular anomalies. 4
Treatment Approach
Cognitive behavioral therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus and should be recommended. 3, 5, 7
Evidence-Based Treatment Algorithm
For ALL patients with persistent, bothersome tinnitus:
Education and counseling about tinnitus management strategies, natural history, and realistic expectations 1, 3, 5
Cognitive behavioral therapy (CBT) to reduce tinnitus-related distress and improve quality of life 3, 5, 8
For patients with documented hearing loss (even mild or unilateral):
- Hearing aid evaluation and fitting - this provides significant relief and is recommended even for mild or unilateral hearing loss 1, 3, 5
Additional treatment option:
- Sound therapy may be offered as a management option for symptomatic relief through auditory masking 1, 3, 5
Special Considerations
For pulsatile tinnitus: Obtain appropriate vascular imaging (CTA or MRA) to identify potentially treatable vascular causes such as sigmoid sinus abnormalities or carotid artery pathology. 3, 4 Surgical repair or embolization may be indicated in severe cases. 4
For patients with severe anxiety or depression: Prompt identification and intervention is critical due to increased suicide risk in tinnitus patients with psychiatric comorbidities. 3, 4
For TMJ-related tinnitus: Consider TMJ dysfunction if tinnitus is unilateral and worsens with jaw movements, particularly if accompanied by neck pain. 4
Treatments NOT Recommended
The following interventions should NOT be routinely recommended due to insufficient evidence of benefit and potential for harm: 2, 3, 5
- Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary treatment of persistent tinnitus 3, 5
- Dietary supplements including Ginkgo biloba, melatonin, or zinc 3, 5
- Transcranial magnetic stimulation for routine treatment 5
These recommendations are strong because prescribing medications without clear evidence may cause side effects or worsen tinnitus, and dietary supplements lack consistent evidence of efficacy. 3
Common Pitfalls to Avoid
- Overlooking mild hearing loss that could benefit from hearing aid intervention - even mild or unilateral hearing loss warrants hearing aid evaluation 3
- Ordering unnecessary imaging for bilateral, non-pulsatile tinnitus without neurological symptoms 2, 3
- Recommending unproven treatments such as dietary supplements that lack evidence 1, 3
- Delaying audiologic assessment - testing should be completed promptly, preferably within 4 weeks of initial assessment 2
- Failing to assess psychiatric comorbidities - screen for anxiety, depression, and suicidal ideation given increased risk in tinnitus patients 3, 4