What is the recommended treatment for unilateral tinnitus without hearing loss?

Management of Unilateral Tinnitus Without Hearing Loss

For unilateral tinnitus without documented hearing loss, you must obtain imaging studies to rule out serious underlying pathology, particularly vestibular schwannoma and vascular abnormalities, as unilateral localization is a red flag requiring investigation regardless of hearing status. 1

Immediate Diagnostic Workup

Audiologic Testing

• Obtain a comprehensive audiologic examination promptly (within 4 weeks) even though the patient reports no hearing difficulties, as hearing loss may be subclinical or unrecognized by the patient 1
• This testing is critical because it will determine whether asymmetric hearing loss exists, which would further strengthen the indication for imaging 1
• The audiogram characterizes the nature of any hearing loss (conductive, sensorineural, or mixed) and helps identify patients who may benefit from sound therapy 1

Targeted History and Physical Examination

• Perform otoscopic examination to identify cerumen impaction, middle ear effusion, tympanic membrane perforation, cholesteatoma, or vascular retrotympanic masses (glomus tumors, aberrant internal carotid artery, dehiscent jugular bulb) 2
• Determine if the tinnitus is pulsatile or non-pulsatile, as this dictates the imaging approach 1, 2, 3
• Assess for focal neurologic abnormalities that would indicate central pathology 1

Imaging Requirements

For Non-Pulsatile Unilateral Tinnitus

MRI with contrast of the internal auditory canals is the most appropriate imaging test to exclude retrocochlear pathology, particularly vestibular schwannoma (acoustic neuroma), which commonly presents with unilateral tinnitus. 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery provides a strong recommendation against imaging for bilateral tinnitus, but explicitly states that imaging should be obtained when tinnitus localizes to one ear, even without other symptoms. 1 This is a critical distinction—unilateral presentation alone is sufficient indication for imaging.

For Pulsatile Unilateral Tinnitus

• First-line imaging includes CT temporal bone without contrast plus CT angiography (CTA) of head and neck with contrast to identify vascular abnormalities (arteriovenous fistulas, sigmoid sinus diverticulum, arterial dissection) and bony dehiscences 1, 2, 3
• MRI with MR angiography/venography may be considered as an alternative to screen for intracranial vascular malformations 1, 3

Treatment Based on Findings

If Imaging and Audiometry Are Normal

• Educate the patient about the benign nature of their tinnitus and natural history 1, 4
• Distinguish whether the tinnitus is bothersome or non-bothersome, as this determines the intensity of intervention 1, 2, 4
• For persistent, bothersome tinnitus (≥6 months), recommend cognitive behavioral therapy (CBT), which is the only treatment proven to improve quality of life 1, 2, 4
• Consider sound therapy (white noise generators, hearing assistive technology) as an option, though evidence is less robust than for CBT 1, 2, 4

If Hearing Loss Is Detected on Audiometry

• Recommend hearing aid evaluation, as amplification improves quality of life by reducing psychosocial and emotional manifestations of tinnitus 2, 4
• For unilateral hearing loss, consider CROS (contralateral routing of signal) hearing aids that transmit sound from the affected ear to the better ear 2
• Consider BiCROS hearing aids if the better ear also has hearing loss 2
• Evaluate osseointegrated bone conductive devices as surgical options for single-sided deafness 2

If Pathology Is Identified on Imaging

• Treatment depends on the specific etiology (surgical resection for vestibular schwannoma, embolization or surgical repair for vascular abnormalities, etc.) 2, 3

Critical Pitfalls to Avoid

• Do not skip imaging for unilateral tinnitus—it has higher risk of underlying pathology compared to bilateral tinnitus, and the American Academy of Otolaryngology explicitly includes "tinnitus that localizes to one ear" as an indication for imaging 1, 2
• Do not routinely prescribe antidepressants, anticonvulsants, anxiolytics, or intratympanic medications as primary treatment without addressing underlying cause 1, 2, 4
• Do not recommend Ginkgo biloba, melatonin, zinc, or other dietary supplements as primary treatment 1, 2, 4
• Do not delay audiologic evaluation, as early identification of hearing loss improves treatment outcomes 1, 2