What is the initial evaluation and management approach for an adult with persistent tinnitus?

Persistent Tinnitus in Adults: Causes and Initial Evaluation

Begin with a targeted history and physical examination to identify secondary causes, then obtain a comprehensive audiologic examination within 4 weeks, as sensorineural hearing loss is the most common identifiable cause of persistent tinnitus. 1

Primary Causes of Persistent Tinnitus

Sensorineural hearing loss (SNHL) is the most frequently identified underlying cause of persistent tinnitus, occurring in the majority of patients with bothersome tinnitus and no obvious ear pathology. 1, 2 The key causative categories include:

Common Etiologies

• Age-related hearing loss (presbycusis) - the most prevalent cause in adults over 40 years 3, 4
• Noise-induced hearing loss from occupational or recreational exposure 3, 2
• Ototoxic medications including aminoglycosides, loop diuretics, chemotherapy agents, and high-dose aspirin 3, 2
• Idiopathic tinnitus - when no identifiable cause is found despite thorough evaluation 4, 2

Less Common but Important Causes

• Temporomandibular joint (TMJ) dysfunction 3
• Eustachian tube dysfunction 3
• Cerumen impaction or middle ear effusion 2

Critical Red Flags Requiring Urgent Evaluation

You must immediately escalate evaluation if any of these features are present:

• Pulsatile tinnitus - indicates vascular or structural abnormality in >70% of cases, with life-threatening causes including dural arteriovenous fistula (8% of cases) and arterial dissection 5, 6
• Unilateral or asymmetric tinnitus - raises concern for vestibular schwannoma or other retrocochlear pathology 1
• Focal neurological abnormalities - suggests central nervous system pathology 1
• Asymmetric hearing loss - requires different imaging protocol to exclude acoustic neuroma 1
• Sudden onset with hearing loss - may represent sudden sensorineural hearing loss requiring urgent treatment 3
• Severe anxiety or depression - suicide has been reported in tinnitus patients with coexisting psychiatric illness 1

Initial Evaluation Algorithm

Step 1: Targeted History

Obtain specific information about: 1, 3

• Laterality (unilateral vs bilateral)
• Quality (pulsatile vs non-pulsatile; ringing, buzzing, clicking)
• Duration (recent onset vs persistent ≥6 months)
• Severity (bothersome vs non-bothersome)
• Associated hearing difficulties
• Noise exposure history
• Medication review for ototoxic agents
• Exacerbating factors
• Psychological impact on quality of life

Step 2: Physical Examination

Perform focused otoscopic examination to identify: 1, 5

• Cerumen impaction or middle ear effusion
• Vascular retrotympanic masses (paragangliomas appear as pulsatile red masses behind tympanic membrane)
• Tympanic membrane abnormalities
• Auscultation over periauricular area, orbit, and neck for objective tinnitus

Step 3: Audiologic Testing

Obtain a prompt comprehensive audiologic examination (within 4 weeks) for all patients with persistent tinnitus (≥6 months), unilateral tinnitus, or associated hearing difficulties. 1 This should include:

• Pure tone audiometry
• Speech audiometry
• Acoustic reflex testing 6

The audiologic examination serves multiple purposes: identifies hearing loss (frequently associated with tinnitus), characterizes the nature of hearing loss (conductive, sensorineural, or mixed), detects unsuspected hearing loss, and initiates workup for serious disease causing unilateral tinnitus and hearing loss. 1

Step 4: Imaging Decision

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

• Tinnitus localizing to one ear
• Pulsatile tinnitus
• Focal neurological abnormalities
• Asymmetric hearing loss

If imaging is indicated, the choice depends on suspected etiology: 5

• High-resolution CT temporal bone (non-contrast) for suspected paragangliomas, glomus tumors, jugular bulb abnormalities, superior semicircular canal dehiscence, or aberrant vascular anatomy
• 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
• MRI with contrast and MRA reserved for cerebellopontine angle lesions, when CT/CTA are negative but suspicion remains high, or contraindications to iodinated contrast

Classification for Management Planning

Distinguish bothersome from non-bothersome tinnitus - this is mandatory as it determines intervention intensity. 1, 6 Patients with non-bothersome tinnitus require only reassurance and education.

Distinguish recent onset (<6 months) from persistent (≥6 months) tinnitus to prioritize intervention and facilitate discussions about natural history and follow-up care. 1, 6

Common Pitfalls to Avoid

• Missing pulsatile tinnitus - this almost always requires imaging evaluation due to identifiable causes in >70% of cases, including life-threatening dural AVF that can present with isolated pulsatile tinnitus before catastrophic hemorrhage 5
• Inadequate otoscopic examination - can lead to delayed diagnosis of vascular retrotympanic masses (paragangliomas) and inappropriate imaging selection 5
• Dismissing bilateral tinnitus as benign - while bilateral non-pulsatile tinnitus without localizing features typically does not require imaging, pulsatile tinnitus—even if bilateral—requires imaging evaluation 5, 6
• Overlooking intracranial hypertension - particularly in young, overweight women with headaches and pulsatile tinnitus, as this is the second most common cause of pulsatile tinnitus and can lead to vision loss if missed 5
• Ordering unnecessary imaging - imaging is not indicated for subjective, non-pulsatile, bilateral tinnitus without localizing features 5