What is the differential diagnosis and management of tinnitus (ringing in the ears) without hearing loss?

Tinnitus Without Hearing Loss: Differential Diagnosis and Management

For tinnitus without documented hearing loss, perform a targeted history and physical examination to identify treatable causes, obtain comprehensive audiologic testing (which may reveal subclinical hearing loss), and prioritize cognitive behavioral therapy for persistent bothersome symptoms while avoiding routine pharmacologic interventions. 1

Differential Diagnosis

Primary Considerations

Unilateral tinnitus warrants more aggressive investigation due to higher risk of underlying pathology, even without apparent hearing loss 2, 3:

• Temporomandibular joint (TMJ) dysfunction - particularly if tinnitus worsens with jaw movements or yawning 2, 4
• Eustachian tube dysfunction - may present with ear fullness and positional changes 2
• Vascular abnormalities - consider if tinnitus is pulsatile or changes with position 2, 4:
  • Sigmoid sinus diverticulum or dehiscence
  • High jugular bulb or jugular bulb dehiscence
  • Arteriovenous malformations or fistulas
  • Carotid artery abnormalities
  • Paragangliomas (glomus tumors)
• Superior semicircular canal dehiscence - causes sound-induced or pressure-induced tinnitus 2
• Vestibular schwannoma (acoustic neuroma) - must be ruled out in unilateral cases 2, 3
• Subclinical hearing loss - audiometry may reveal hearing loss not perceived by the patient 1, 5

Bilateral Tinnitus Etiologies

• Noise exposure - even without measurable hearing loss on standard audiometry 3
• Ototoxic medications - assess current and recent medication history 3
• Cervical radiculopathy - can cause referred symptoms mimicking tinnitus with associated neck pain 4
• Idiopathic/primary tinnitus - diagnosis of exclusion after workup 1, 6

Diagnostic Workup

Initial Evaluation

Perform targeted history focusing on 1, 3:

• Laterality (unilateral vs bilateral) - unilateral requires imaging
• Duration (recent onset vs ≥6 months persistent)
• Quality (pulsatile vs non-pulsatile, pitch, loudness, temporal pattern)
• Exacerbating factors (jaw movements, position changes, yawning)
• Associated symptoms (ear fullness, vertigo, neurologic deficits)
• Medication history (ototoxic drugs)
• Noise exposure history
• Psychological impact (anxiety, depression, sleep disturbance, suicidal ideation)

Physical examination must include 1, 2:

• Comprehensive otologic examination for retrotympanic masses or vascular abnormalities
• TMJ assessment with jaw movement
• Neurologic examination for focal deficits
• Auscultation for objective tinnitus

Audiologic Testing

Obtain comprehensive audiologic examination promptly if tinnitus is 1, 3:

• Unilateral
• Persistent (≥6 months)
• Associated with any hearing difficulties (even if patient denies hearing loss)

Testing should include 3:

• Pure tone audiometry
• Speech audiometry
• Acoustic reflex testing
• Tinnitus matching (frequency and intensity)

Common pitfall: Many patients with "normal hearing" on screening actually have subclinical hearing loss on comprehensive audiometry 5

Imaging Studies

Obtain imaging ONLY if one or more of the following are present 1, 3:

• Unilateral or asymmetric tinnitus - MRI with contrast to rule out acoustic neuroma or retrocochlear pathology 2, 3
• Pulsatile tinnitus - CT temporal bone for bony abnormalities; MRI/MRA for vascular causes 2, 3
• Focal neurological abnormalities 1
• Asymmetric hearing loss (even if bilateral tinnitus) 1

Do NOT obtain routine imaging for bilateral, non-pulsatile tinnitus without red flags 1, 6

Management Algorithm

Step 1: Categorize Severity

Distinguish bothersome from non-bothersome tinnitus 1:

• Non-bothersome: reassurance, education about natural history, no active intervention needed
• Bothersome: proceed with management strategies below

Further categorize by duration 1:

• Recent onset (<6 months): education, monitoring, natural history discussion
• Persistent (≥6 months): active intervention warranted

Step 2: Address Underlying Causes

For TMJ-related tinnitus: dental/jaw therapies, physical therapy 2

For vascular abnormalities: surgical repair or embolization in severe cases 2, 4

For Eustachian tube dysfunction: treat underlying cause (allergies, reflux) 2

Step 3: Evidence-Based Interventions for Persistent, Bothersome Tinnitus

First-line: Cognitive Behavioral Therapy (CBT) 1, 7, 6:

• This is the ONLY treatment proven to improve quality of life
• Reduces tinnitus-related distress even without changing tinnitus perception
• Should be tinnitus-specific CBT when available

Second-line: Sound Therapy 1, 6:

• May be offered as an option for auditory masking
• Evidence is less robust than CBT but reasonable to try
• Can be combined with hearing aids if any hearing loss detected

Education and Counseling 1, 6:

• Mandatory for all patients with persistent, bothersome tinnitus
• Discuss natural history, management strategies, realistic expectations
• Address psychological impact (anxiety, depression, sleep disturbance)

Step 4: What NOT to Do

Do NOT routinely recommend 1, 6:

• Antidepressants, anticonvulsants, or anxiolytics for primary treatment of tinnitus (may address comorbid mood disorders separately)
• Intratympanic medications
• Ginkgo biloba, melatonin, zinc, or other dietary supplements
• Transcranial magnetic stimulation (TMS)
• Acupuncture (insufficient evidence)

Critical caveat: The word "routinely" acknowledges individual circumstances may warrant deviation, but these should NOT be first-line treatments 1

Red Flags Requiring Urgent Evaluation

Immediate escalation needed for 4, 3:

• Sudden onset unilateral tinnitus with hearing loss (consider sudden sensorineural hearing loss) 1
• Focal neurological deficits
• Severe anxiety, depression, or suicidal ideation
• History of malignancy or recent trauma
• Pulsatile tinnitus (vascular emergency potential)

Key Clinical Pitfalls

Delayed diagnosis: Patients and physicians often dismiss ear fullness/tinnitus as benign, delaying evaluation of potentially serious conditions 1

Assuming normal hearing: Even patients who deny hearing difficulties may have subclinical hearing loss on comprehensive audiometry that contributes to tinnitus 1, 5

Overuse of imaging: Bilateral, non-pulsatile tinnitus without red flags does NOT require imaging 1, 6

Inappropriate pharmacotherapy: No medications are effective for primary tinnitus treatment; avoid polypharmacy 1, 6

Underutilization of CBT: Despite being the only evidence-based treatment for quality of life improvement, CBT remains underutilized 7, 6