What is the appropriate workup and treatment for a patient presenting with tinnitus?

Tinnitus Workup and Treatment

Initial Classification and Risk Stratification

The first critical step is determining whether the tinnitus is pulsatile or non-pulsatile, as this fundamentally changes your diagnostic approach and urgency. 1

Pulsatile Tinnitus (Synchronous with Heartbeat)

• Order imaging immediately—pulsatile tinnitus has an identifiable structural or vascular cause in over 70% of cases, and missing life-threatening conditions like dural arteriovenous fistula or arterial dissection can result in catastrophic hemorrhage or stroke. 2
• Perform otoscopy to look for vascular retrotympanic masses (paragangliomas appear as red pulsatile masses behind the tympanic membrane). 1, 2
• Test for carotid/jugular compression relief: if tinnitus diminishes with gentle compression, this suggests venous etiology (sigmoid sinus abnormalities) or arterial dissection. 2
• First-line imaging: Order CT angiography (CTA) of head and neck with contrast when suspecting dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease, or arteriovenous malformations. 1, 2
• Alternative first-line: Order high-resolution CT temporal bone (non-contrast) when otoscopy suggests paragangliomas, glomus tumors, or you suspect jugular bulb abnormalities or superior semicircular canal dehiscence. 1, 2
• If initial imaging is negative but clinical suspicion remains high, proceed to MRI with MR angiography (MRA) and MR venography (MRV). 2

Non-Pulsatile Tinnitus

Determine laterality and associated symptoms:

Unilateral or asymmetric hearing loss:

• Order MRI of internal auditory canals with contrast—this is the most appropriate test to evaluate for retrocochlear pathology like vestibular schwannoma. 1
• Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) promptly, ideally within 4 weeks. 1

Bilateral, symmetric, no focal neurologic deficits:

• Do NOT order imaging—imaging is not indicated and represents low-yield, expensive testing with potential harms. 1
• Obtain audiologic examination if tinnitus is persistent (≥6 months) or patient reports hearing difficulties, even if they don't perceive hearing loss. 1
• If tinnitus is recent onset (<6 months) and non-bothersome, audiologic testing may be deferred but should be obtained if symptoms persist. 1

Red Flags Requiring Immediate Imaging or Specialist Referral

Order imaging (MRI or CTA depending on presentation) if ANY of the following are present: 1

• Unilateral or lateralizing tinnitus
• Pulsatile tinnitus
• Asymmetric hearing loss on audiometry
• Focal neurologic abnormalities (cranial nerve deficits, ataxia, weakness)
• Head trauma history
• Objective tinnitus (examiner can hear it with stethoscope)

Special consideration: Young overweight women with pulsatile tinnitus, headaches, and vision changes require urgent evaluation for idiopathic intracranial hypertension—this is the second most common cause of pulsatile tinnitus and can cause permanent vision loss if missed. 2

Treatment Algorithm

Step 1: Address Treatable Underlying Causes

• Remove impacted cerumen if present on otoscopy. 1
• Treat middle ear infection or effusion. 1
• Review medications for ototoxic agents (aminoglycosides, loop diuretics, high-dose aspirin, chemotherapy agents). 3
• Refer for surgical evaluation if imaging reveals paragangliomas, superior semicircular canal dehiscence, or vascular malformations amenable to intervention. 2, 3

Step 2: Audiologic Intervention

• If hearing loss is present (even mild or unilateral), recommend hearing aid evaluation—hearing aids provide significant relief and have strong evidence for benefit. 1, 3, 4
• Sound therapy (white noise machines, masking devices) may provide symptomatic relief for persistent tinnitus. 3

Step 3: Evidence-Based Behavioral Therapy

• Cognitive Behavioral Therapy (CBT) is the ONLY treatment proven to improve quality of life in patients with persistent, bothersome tinnitus—this should be your primary therapeutic recommendation. 3, 5, 4
• Provide education and counseling about tinnitus mechanisms, natural history, and management strategies for all patients with persistent, bothersome tinnitus. 1, 3

Step 4: What NOT to Recommend

Do NOT routinely prescribe the following due to insufficient evidence and potential harms: 1, 3

• Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment
• Intratympanic medications (steroids, gentamicin)
• Dietary supplements (Ginkgo biloba, melatonin, zinc, magnesium)

Exception: Consider treating comorbid depression or anxiety with appropriate medications if these conditions exist independently and are severe, but do not expect tinnitus improvement. Screen for suicide risk in patients with severe psychiatric comorbidity, as this population has increased risk. 3

Common Pitfalls to Avoid

• Dismissing pulsatile tinnitus as benign without imaging—this is a dangerous error as treatable and life-threatening causes are common. 2
• Ordering imaging for bilateral, symmetric, non-pulsatile tinnitus without localizing features—this represents inappropriate resource utilization with no benefit. 1
• Missing mild hearing loss that could benefit from amplification—obtain audiometry even when patients don't report hearing difficulties. 1
• Prescribing medications or supplements without evidence—this exposes patients to side effects without benefit and may worsen tinnitus. 3
• Inadequate otoscopic examination before ordering imaging—vascular retrotympanic masses can be identified on physical exam, guiding appropriate imaging selection. 1, 2
• Delaying audiologic testing for 6 months—obtain testing promptly (within 4 weeks) for unilateral tinnitus or when clinically indicated, rather than waiting arbitrarily. 1