Should a patient (Px) with tinnitus be referred to a specialist?

From the Guidelines

Patients with tinnitus should be referred to a specialist if certain red flags are present or if the tinnitus significantly impacts their quality of life despite initial management, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery Foundation 1. The decision to refer a patient with tinnitus to a specialist depends on several factors, including the presence of red flags, the impact of tinnitus on quality of life, and the effectiveness of initial management.

• Red flags that warrant initial referral to a specialist include pulsatile tinnitus, unilateral tinnitus, sudden onset tinnitus, tinnitus associated with hearing loss, vertigo, or neurological symptoms, as these may indicate underlying vascular abnormalities, acoustic neuroma, or other serious conditions requiring specialized evaluation 1.
• Primary care providers should first conduct a thorough history, physical examination including otoscopy, and basic audiometric testing, as recommended by the American College of Radiology Appropriateness Criteria 1.
• Initial management can include reassurance, sound therapy (white noise machines, smartphone apps), and addressing modifiable factors like reducing caffeine, alcohol, and stress, as suggested by the clinical practice guideline for tinnitus 1.
• If tinnitus persists and causes significant distress despite these measures for 3-6 months, referral to an ENT specialist or audiologist is appropriate, as they can provide comprehensive audiological assessment, tinnitus retraining therapy, cognitive behavioral therapy, or consider medications like low-dose antidepressants for tinnitus-related distress 1.
• Early referral is particularly important for patients with suicidal ideation related to tinnitus or those with severe sleep disturbance or anxiety that significantly impairs functioning, as emphasized by the American Academy of Otolaryngology-Head and Neck Surgery Foundation 1.

From the Research

Referral to Specialist for Tinnitus

• Patients with tinnitus should be referred to a specialist in certain cases, as indicated by the studies 2, 3, 4.
• The decision to refer a patient to a specialist depends on the characteristics of the tinnitus, such as:
  • Unilateral or pulsatile tinnitus, which may be associated with more serious underlying conditions 4.
  • Tinnitus that is persistent (lasting 6 months or longer) or associated with hearing difficulties 2, 3.
• Referral to an otolaryngologist is recommended for patients with pulsatile or unilateral tinnitus, as these qualities may be associated with more serious underlying conditions 4.
• A comprehensive audiologic evaluation should be performed for patients who experience unilateral tinnitus, tinnitus that has been present for six months or longer, or that is accompanied by hearing problems 2, 3.
• Neuroimaging is not part of the standard workup unless the tinnitus is asymmetric or unilateral, pulsatile, associated with focal neurologic abnormalities, or associated with asymmetric hearing loss 2, 3.

Evaluation and Management of Tinnitus

• A targeted history and physical examination should be performed at the initial evaluation of a patient with presumed primary tinnitus to identify conditions that may relieve tinnitus 2.
• Clinicians should distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus and prioritize intervention accordingly 2.
• Cognitive behavioral therapy is recommended for patients with persistent, bothersome tinnitus, as it has been shown to improve quality of life 2, 3.
• Sound therapy and tinnitus retraining therapy are treatment options, but evidence is inconclusive 3, 5.