What is the initial management approach for patients with tinnitus?

Initial Management of Tinnitus

Begin with a targeted history focusing on tinnitus characteristics (onset, duration, laterality, quality, pitch, loudness, pattern) and perform otoscopic examination to identify treatable causes like cerumen impaction or middle ear pathology, followed by comprehensive audiologic testing for all patients with unilateral, persistent (≥6 months), or hearing-associated tinnitus. 1

Step 1: Obtain Critical History Elements

• Document laterality (unilateral vs bilateral), duration (recent onset vs persistent ≥6 months), and quality (pulsatile vs non-pulsatile) as these determine imaging needs and urgency 1, 2
• Assess for associated symptoms: hearing loss, vertigo, otalgia, otorrhea, or neurological symptoms that suggest specific etiologies 1
• For pulsatile tinnitus, this almost always requires imaging evaluation to identify vascular abnormalities 2
• Screen for severe anxiety, depression, or suicidal ideation as tinnitus patients with psychiatric comorbidities have increased suicide risk requiring prompt intervention 2, 3

Step 2: Perform Focused Physical Examination

• Conduct otoscopic examination to identify cerumen impaction, tympanic membrane abnormalities, or middle ear pathology—these are treatable causes 1
• Perform cranial nerve examination with emphasis on CN VIII (hearing) 1
• Auscultate the neck, periauricular region, and temporal area for bruits if pulsatile tinnitus is reported 1
• Evaluate for TMJ dysfunction by assessing if tinnitus worsens with jaw movements, which can cause unilateral tinnitus 3

Step 3: Order Audiologic Testing

• Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for patients with unilateral, persistent, or hearing difficulty-associated tinnitus 1
• Consider routine audiologic examination for all tinnitus patients regardless of laterality, duration, or perceived hearing status for accurate diagnosis 1
• For patients with sound tolerance problems (hyperacusis), measure loudness discomfort levels at audiometric frequencies 1

Step 4: Determine Imaging Needs

Do NOT obtain imaging studies unless one or more of the following are present: 1, 2

• Unilateral tinnitus

• Pulsatile tinnitus

• Focal neurological abnormalities

• Asymmetric hearing loss

• Avoid unnecessary imaging for non-pulsatile, bilateral tinnitus without neurological symptoms 1

• For pulsatile tinnitus, obtain CTA or MRA to identify potentially treatable vascular conditions 2

Step 5: Classify and Initiate Management

• Distinguish between bothersome vs non-bothersome tinnitus as this guides treatment intensity 1, 2
• Differentiate recent onset from persistent tinnitus (≥6 months) to determine treatment approach 1

For All Patients with Persistent, Bothersome Tinnitus:

• Provide education and counseling about tinnitus management strategies—this is essential for all patients 1, 2
• Recommend hearing aid evaluation if hearing loss is present, even if mild or unilateral—hearing aids have significant evidence for relief 2
• Consider Cognitive Behavioral Therapy (CBT) as it has the strongest evidence for improving quality of life in tinnitus patients 2
• Consider sound therapy as a management option for symptomatic relief 2

Critical Pitfalls to Avoid

• Do NOT recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary treatment due to insufficient evidence and potential side effects 2
• Do NOT recommend dietary supplements (Ginkgo biloba, melatonin, zinc) due to lack of consistent benefit 2
• Do NOT overlook mild hearing loss that could benefit from hearing aid intervention 1, 2
• Do NOT prescribe medications without clear evidence of benefit that may cause side effects or worsen tinnitus 2