Tinnitus: Differential Diagnosis and Management
Differential Diagnosis
The differential diagnosis of tinnitus must first distinguish between primary (idiopathic) tinnitus and secondary tinnitus with an identifiable underlying cause, with classification based on laterality (unilateral vs bilateral), temporal pattern (pulsatile vs non-pulsatile), and duration (recent onset vs persistent ≥6 months). 1
Common Etiologies to Consider:
Auditory/Otologic Causes:
- Sensorineural hearing loss (most common association) - age-related presbycusis or noise-induced hearing loss 1, 2
- Cerumen impaction - identified on otoscopic examination 3
- Tympanic membrane or middle ear pathology 3
- Ménière's disease - presents with episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness 4
- Acoustic neuroma/vestibular schwannoma - particularly with unilateral tinnitus and asymmetric hearing loss 1
- Eustachian tube dysfunction 1
Vascular Causes (Pulsatile Tinnitus):
- Sigmoid sinus diverticulum or dehiscence 4
- Carotid artery stenosis or atherosclerosis 5
- Glomus tumors 5
- Arteriovenous malformations or fistulas 5, 6
- Intracranial hypertension 5
Musculoskeletal Causes:
- Temporomandibular joint (TMJ) dysfunction - causes unilateral tinnitus worsening with jaw movements 4
- Myofascial disorders of head and neck - a major treatable cause 6
- Cervical radiculopathy - neck pain radiating to head/ear region with associated proprioceptive dysfunction 4
Medication-Related:
- Ototoxic medications - including aminoglycosides, loop diuretics, chemotherapy agents, high-dose aspirin 1, 2
Neurologic/Psychiatric:
- Eighth nerve vascular compression - especially if clicking component present 6
- Depression and anxiety - both risk factors and consequences 2
Initial Assessment
Perform a targeted history focusing on tinnitus characteristics: onset, duration, laterality (unilateral vs bilateral), quality (pulsatile vs non-pulsatile, clicking, ringing, buzzing), pitch, loudness, temporal pattern, and whether bothersome or non-bothersome. 7, 1, 3
Key History Elements:
- Associated symptoms: hearing loss, vertigo, otalgia, otorrhea, neurological symptoms 3
- Noise exposure history 1
- Current medications (assess for ototoxic agents) 1
- Exacerbating factors: jaw movements (TMJ), neck position, stress 1, 4
- Psychological impact: assess for anxiety, depression, suicidal ideation 4, 2
- Medical conditions: hypertension, diabetes, head trauma, prior neck surgery 4
Physical Examination Must Include:
- Otoscopic examination to identify cerumen, tympanic membrane abnormalities, or middle ear pathology 3
- Cranial nerve examination, especially CN VIII (hearing assessment) 3
- Auscultation of neck, periauricular region, and temporal area for bruits if pulsatile tinnitus reported 3, 5
- Palpation of cervical region and TMJ 5
- Head positioning test 5
Diagnostic Testing
Audiologic Evaluation:
Obtain a prompt comprehensive audiologic examination (within 4 weeks) for patients with unilateral tinnitus, persistent tinnitus (≥6 months), or tinnitus associated with hearing difficulties. 7, 1, 8
- Testing should include: pure tone audiometry, speech audiometry, and acoustic reflex testing 3
- Consider routine audiologic examination for all tinnitus patients regardless of laterality, duration, or perceived hearing status, as hearing loss may be unperceived by the patient 7, 3
- For hyperacusis: measure loudness discomfort levels at audiometric frequencies 3
Imaging Studies:
Do NOT obtain imaging studies for routine tinnitus evaluation. 7, 1, 8 This is a strong recommendation against unnecessary imaging in low-yield situations.
Imaging IS indicated only when one or more of the following are present: 7, 1, 8
- Unilateral or asymmetric hearing loss
- Pulsatile tinnitus
- Focal neurological abnormalities
- Tinnitus localizing to one ear
When imaging is indicated:
- MRI with contrast for suspected acoustic neuroma or retrocochlear pathology 1
- CT temporal bone for suspected bony abnormalities or middle ear pathology 1, 4
- MR angiography or conventional angiography for suspected vascular abnormalities in pulsatile tinnitus 5, 6
Red Flags Requiring Urgent Evaluation
Immediate escalation of care is required for: 4
- Focal neurological deficits
- Sudden onset unilateral tinnitus with hearing loss 1
- Pulsatile tinnitus (may indicate vascular abnormality) 1, 5
- History of malignancy
- Recent trauma
- Severe anxiety, depression, or suicidal ideation 4, 2
Management
Classification for Treatment Planning:
Distinguish bothersome from non-bothersome tinnitus to prioritize intervention. 7, 8 This is a strong recommendation.
Differentiate recent onset from persistent tinnitus (≥6 months) to facilitate discussions about natural history and follow-up care. 7, 8
Management of Primary Persistent Bothersome Tinnitus:
1. Education and Counseling (For All Patients):
- Provide education about tinnitus mechanisms and management strategies to all patients with persistent, bothersome tinnitus 7, 3, 8
- Reassure that tinnitus is not life-threatening once serious pathology excluded 9
2. Hearing Aids:
- Recommend hearing aid evaluation for patients with persistent, bothersome tinnitus and documented hearing loss (even mild or unilateral) 7, 3, 2, 8
3. Cognitive Behavioral Therapy (CBT):
- Recommend CBT to patients with persistent, bothersome tinnitus to reduce tinnitus-related distress and improve quality of life 7, 3, 4, 2, 8
- Evidence base is strongest for combination of sound therapy and CBT-based counseling 2
4. Sound Therapy:
- May offer sound therapy as an option to provide auditory masking and relief 7, 3, 8
- Wide-band sound therapy can be beneficial 2
Treatments NOT Recommended:
Do NOT routinely prescribe: 7, 8
- Antidepressants, anticonvulsants, or anxiolytics for routine treatment
- Intratympanic medications
- Ginkgo biloba, melatonin, zinc, or other dietary supplements
- Transcranial magnetic stimulation
No effective drug treatments are currently available. 2
Management of Specific Etiologies:
For TMJ/Myofascial Disorders:
- Optimized myofascial treatment program is often responsive 6
- Physical therapy and TMJ-specific interventions 4
For Pulsatile Tinnitus with Vascular Abnormalities:
- Surgical repair or embolization may be indicated in severe cases 4, 5
- Interventional radiology procedures 5
For Cerumen Impaction:
- Simple removal may relieve tinnitus 3
Common Pitfalls to Avoid:
- Do not obtain unnecessary imaging for non-pulsatile, bilateral tinnitus without neurological symptoms 3, 8
- Do not overlook mild hearing loss that may benefit from amplification 3
- Do not recommend unproven treatments such as dietary supplements 3, 8
- Do not delay audiologic examination beyond 4 weeks when indicated 7
- Do not miss pulsatile tinnitus requiring vascular workup 5, 6