What is the recommended evaluation and management approach for patients presenting with tinnitus?

Evaluation of Tinnitus

Initial Clinical Assessment

Perform a targeted history and physical examination at the initial evaluation to identify treatable underlying conditions, focusing specifically on tinnitus characteristics (onset, duration, laterality, quality, pitch, loudness, pattern), associated symptoms (hearing loss, vertigo, otalgia, otorrhea, neurological symptoms), and otoscopic findings. 1, 2

Key History Elements to Obtain:

• Laterality: Unilateral tinnitus has higher risk of underlying pathology and warrants more aggressive investigation 2, 3
• Pulsatile vs. non-pulsatile: Pulsatile tinnitus requires imaging in nearly all cases due to identifiable vascular or structural causes in >70% of cases 4
• Duration: Distinguish recent onset (<6 months) from persistent (≥6 months) to prioritize intervention 1, 5
• Associated hearing difficulties: Guides timing and urgency of audiologic testing 1
• Neurological symptoms: Focal deficits mandate different evaluation pathway 2, 4

Physical Examination Components:

• Otoscopic examination: Identify cerumen impaction, tympanic membrane abnormalities, middle ear pathology, or vascular retrotympanic masses (paragangliomas) 2, 4
• Cranial nerve examination: Focus on CN VIII (hearing) 2
• Auscultation: Listen for bruits over neck, periauricular region, and temporal area if pulsatile tinnitus reported 2
• Temporomandibular joint assessment: TMJ dysfunction can cause unilateral tinnitus 3

Audiologic Testing

Obtain a comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) promptly for patients with unilateral tinnitus, persistent tinnitus (≥6 months), or associated hearing difficulties. 1, 2

• The term "prompt" means within 4 weeks of initial assessment 1
• For bilateral, non-bothersome, recent-onset tinnitus without hearing complaints, audiologic testing may be obtained but is optional 1
• Audiometry frequently reveals subclinical hearing loss even when patients do not perceive hearing difficulties 1, 3
• Asymmetric hearing loss on audiometry is a red flag requiring imaging evaluation 2, 3

Imaging Studies

Do NOT obtain imaging studies for bilateral, non-pulsatile tinnitus without focal neurological abnormalities or asymmetric hearing loss. 1, 2, 5

Imaging IS Required For:

• Unilateral or asymmetric tinnitus 2, 3, 5
• Pulsatile tinnitus (even if bilateral) 4, 3
• Focal neurological abnormalities 1, 2, 5
• Asymmetric hearing loss on audiometry 2, 3

Imaging Selection for Pulsatile Tinnitus:

• First-line: High-resolution CT temporal bone (non-contrast) for suspected paragangliomas, glomus tumors, jugular bulb abnormalities, superior semicircular canal dehiscence, or aberrant vascular anatomy 4
• Alternative first-line: CT angiography (CTA) of head and neck with contrast for suspected dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease, sigmoid sinus abnormalities, or arteriovenous malformations 4
• MRI with contrast and MRA: Reserved for cerebellopontine angle lesions (vestibular schwannoma), when CT/CTA negative but suspicion remains high, or contraindications to iodinated contrast 4

Classification and Management Pathway

Distinguish bothersome from non-bothersome tinnitus, as this determines the intensity of intervention required. 1, 5

For Persistent, Bothersome Tinnitus (≥6 months):

Mandatory Interventions:

• Education and counseling about management strategies, natural history, and realistic expectations 1, 3, 5
• Cognitive behavioral therapy (CBT): The only treatment proven to improve quality of life 1, 3, 5, 6
• Hearing aid evaluation if documented hearing loss present 1, 3, 5

Optional Interventions:

• Sound therapy for auditory masking (evidence less robust than CBT) 1, 3, 5

Interventions to AVOID:

• Do NOT routinely recommend: Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications 1, 5
• Do NOT recommend: Ginkgo biloba, melatonin, zinc, or other dietary supplements 1, 5
• Do NOT recommend: Transcranial magnetic stimulation 1, 5

Red Flags Requiring Urgent Evaluation

Immediate escalation is needed for the following presentations, as they may indicate life-threatening conditions such as dural arteriovenous fistula (risk of catastrophic hemorrhage), arterial dissection, or vestibular schwannoma: 4, 3

• Sudden onset unilateral tinnitus with hearing loss 3
• Pulsatile tinnitus (objective or subjective) 4, 3
• Focal neurological deficits 2, 3
• Severe anxiety or depression 3
• History of malignancy or recent trauma 3

Common Pitfalls to Avoid

• Missing dural arteriovenous fistula: Life-threatening cause that can present with isolated pulsatile tinnitus before catastrophic hemorrhage 4
• Dismissing pulsatile tinnitus as benign: Almost always requires imaging due to identifiable causes in >70% of cases 4
• Inadequate otoscopic examination: Can lead to delayed diagnosis of vascular retrotympanic masses (paragangliomas) 4
• Overlooking intracranial hypertension: Particularly in young, overweight women with headaches; can lead to vision loss if missed 4
• Ordering unnecessary imaging: For bilateral, non-pulsatile tinnitus without localizing features 2, 4, 5
• Recommending unproven treatments: Such as dietary supplements, which lack evidence and waste resources 1, 2, 5