Evaluation and Management of Tinnitus
Initial Evaluation: History and Physical Examination
Begin with a targeted history and physical examination to identify treatable underlying conditions that may relieve tinnitus. 1, 2
Key History Elements to Obtain:
- Tinnitus characteristics: onset, duration, laterality (unilateral vs bilateral), quality, pitch, loudness, and pattern 2
- Pulsatile vs non-pulsatile: pulsatile tinnitus synchronous with heartbeat requires different workup 3
- Associated symptoms: hearing loss, vertigo, otalgia, otorrhea, neurological symptoms 2
- Medication history: identify ototoxic drugs 4, 5
Physical Examination Components:
- Otoscopic examination: identify cerumen impaction, tympanic membrane abnormalities, middle ear pathology 2
- Cranial nerve examination: focus on CN VIII (hearing) 2
- Auscultation: neck, periauricular region, temporal area for bruits if pulsatile tinnitus reported 2
Audiologic Testing Strategy
Obtain a comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) promptly—preferably within 4 weeks—for patients with tinnitus that is unilateral, persistent (≥6 months), or associated with hearing difficulties. 1, 2
- You may also obtain audiologic examination for all tinnitus patients regardless of laterality, duration, or perceived hearing status, as hearing loss is frequently present even when not perceived by the patient 1
- Audiologic testing identifies sensorineural hearing loss (the most common identifiable cause of tinnitus) and guides treatment decisions 4, 5
Imaging Decision Algorithm
Do NOT obtain imaging studies unless one or more of the following "red flags" are present: 1, 2
Indications for Imaging:
- Unilateral/asymmetric tinnitus 1
- Pulsatile tinnitus 1, 3
- Focal neurological abnormalities 1
- Asymmetric hearing loss 1
Imaging Selection for Pulsatile Tinnitus:
- First-line: High-resolution CT temporal bone (non-contrast) OR CT angiography (CTA) head/neck with contrast, depending on suspected etiology 3
- CT temporal bone for: paragangliomas, glomus tumors, jugular bulb abnormalities, superior semicircular canal dehiscence 3
- CTA for: dural arteriovenous fistulas, arterial dissection, atherosclerotic disease, sigmoid sinus abnormalities, arteriovenous malformations 3
- MRI/MRA with contrast: reserved for cerebellopontine angle lesions or when CT/CTA negative but suspicion remains high 3
Critical pitfall: Pulsatile tinnitus has identifiable causes in >70% of cases and can indicate life-threatening conditions like dural arteriovenous fistula or arterial dissection—never dismiss it as benign 3
Classification for Treatment Planning
Step 1: Bothersome vs Non-Bothersome
Distinguish patients with bothersome tinnitus from those with non-bothersome tinnitus, as this determines treatment intensity. 1, 2
Step 2: Duration Assessment
Differentiate recent onset from persistent tinnitus (≥6 months) to prioritize intervention and discuss natural history. 1, 2
Treatment Algorithm for Persistent, Bothersome Tinnitus
First-Line Interventions:
1. Education and Counseling (All Patients)
- Educate about management strategies, natural history, and realistic expectations 1, 2
- Begin supportive counseling during initial evaluation 5
2. Hearing Aid Evaluation (If Hearing Loss Present)
- Recommend hearing aid evaluation for all patients with documented hearing loss and persistent, bothersome tinnitus, even if mild or unilateral 1, 2, 6
- Hearing aids address the most common underlying cause and provide symptom relief 4, 6
3. Cognitive Behavioral Therapy (CBT)
- Recommend CBT for patients with persistent, bothersome tinnitus—this is the only treatment proven to improve quality of life 1, 2, 4, 7
- CBT has the strongest evidence base for tinnitus management 6
4. Sound Therapy (Optional)
- May recommend sound therapy (wide-band noise, environmental sounds, masking devices) for symptomatic relief 1, 2, 6
- Evidence is inconclusive but clinical experience supports use 4, 7
Treatments to AVOID
Do NOT routinely recommend the following, as they lack evidence and may cause harm: 1, 2, 7
Medications (Strong Recommendation Against):
- Antidepressants (unless treating comorbid depression) 1, 2
- Anticonvulsants 1, 2
- Anxiolytics (unless treating comorbid anxiety) 1, 2
- Intratympanic medications 1, 2
Dietary Supplements (Strong Recommendation Against):
Other Interventions:
- Transcranial magnetic stimulation (TMS): do not recommend for routine treatment 1, 2
- Acupuncture: insufficient evidence to make recommendation 1, 2
Common Pitfalls to Avoid
- Over-imaging: Avoid imaging for bilateral, non-pulsatile tinnitus without neurological symptoms or asymmetric hearing loss 1, 2
- Missing pulsatile tinnitus: Always ask if tinnitus is synchronous with heartbeat—this requires imaging evaluation 3
- Overlooking mild hearing loss: Even mild or unilateral hearing loss may benefit from amplification 2, 6
- Dismissing psychological impact: Screen for anxiety and depression, as these significantly affect quality of life 8, 6
- Delaying audiologic testing: Obtain audiometry within 4 weeks for high-risk presentations (unilateral, persistent, hearing difficulties) 1