What is the recommended evaluation and treatment approach for a patient presenting with tinnitus, considering their age, occupation, and history of noise exposure?

Tinnitus Evaluation

Begin with a targeted history and physical examination to identify treatable causes, obtain comprehensive audiologic testing for any unilateral or persistent tinnitus, and reserve imaging exclusively for red flags: pulsatile tinnitus, unilateral/asymmetric presentation, focal neurological deficits, or asymmetric hearing loss. 1, 2

Initial Clinical Assessment

Critical History Elements to Obtain

• Tinnitus characteristics: Document onset, duration, laterality (unilateral vs bilateral), quality (pulsatile vs non-pulsatile), pitch, loudness, and temporal pattern 1
• Associated symptoms: Specifically ask about hearing loss, vertigo, otalgia, otorrhea, headaches, vision changes, and any neurological symptoms 1, 2
• Occupational and noise exposure history: This is particularly relevant given the patient's occupation and helps identify preventable causes 3
• Impact assessment: Determine if the tinnitus is bothersome vs non-bothersome, as this fundamentally changes management strategy 1, 2

Physical Examination Components

• Otoscopic examination: Look for cerumen impaction, tympanic membrane abnormalities, middle ear pathology, or vascular retrotympanic masses (suggests paragangliomas) 1, 4
• Cranial nerve examination: Focus on CN VIII (hearing) and other focal neurological deficits 1, 2
• Auscultation: If pulsatile tinnitus is reported, auscultate the neck, periauricular region, and temporal area for bruits 1
• Jugular/carotid compression test: For pulsatile tinnitus, compression that relieves symptoms suggests venous etiology (sigmoid sinus abnormalities) or arterial dissection 4

Audiologic Testing

Order comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for any patient with unilateral tinnitus, persistent tinnitus (≥6 months), or hearing difficulties. 1, 2, 5

• Consider routine audiologic examination for ALL tinnitus patients regardless of laterality or duration, as subclinical hearing loss may be revealed even when patients don't perceive hearing problems 1, 2
• Sensorineural hearing loss is the most common identifiable cause of non-pulsatile tinnitus 3, 6
• For patients with sound tolerance problems (hyperacusis), measure loudness discomfort levels at audiometric frequencies 1

Imaging Decision Algorithm

When Imaging is REQUIRED

Order imaging studies ONLY when one or more of the following red flags are present: 1, 2, 5

1. Pulsatile tinnitus: This has an identifiable structural or vascular cause in >70% of cases and can indicate life-threatening conditions like dural arteriovenous fistula or arterial dissection 4
2. Unilateral or asymmetric tinnitus: Higher risk of underlying pathology including vestibular schwannoma 2
3. Focal neurological abnormalities: Requires immediate imaging to rule out stroke, hemorrhage, or mass lesions 1, 2, 4
4. Asymmetric hearing loss on audiometry: Raises concern for retrocochlear pathology 2, 4

Imaging Selection Based on Clinical Presentation

For pulsatile tinnitus:

• First-line: CT angiography (CTA) of head and neck with contrast when suspecting dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease, sigmoid sinus abnormalities, or arteriovenous malformations 4
• Alternative first-line: High-resolution CT temporal bone (non-contrast) when suspecting paragangliomas, glomus tumors, jugular bulb abnormalities, superior semicircular canal dehiscence, or aberrant vascular anatomy 4
• Second-line: MRI with contrast and MR angiography if CT/CTA negative but clinical suspicion remains high 4

For unilateral/asymmetric hearing loss:

• MRI of internal auditory canals with contrast to evaluate for vestibular schwannoma 4

When Imaging is NOT Indicated

Do NOT order imaging for bilateral, symmetric, non-pulsatile tinnitus without focal neurological abnormalities or asymmetric hearing loss—this represents inappropriate resource utilization with no benefit. 1, 2, 5

Age and Occupation Considerations

• Noise exposure history: Adults age 40-70 are most commonly affected, and occupational noise exposure is a significant risk factor 3, 7
• Prevention counseling: Advise avoidance of further noise exposure to prevent progression 3
• Young overweight women: If presenting with pulsatile tinnitus, headaches, and vision changes, strongly suspect idiopathic intracranial hypertension (second most common cause of pulsatile tinnitus) 4

Common Pitfalls to Avoid

• Missing life-threatening causes: Dural arteriovenous fistula can present with isolated pulsatile tinnitus before catastrophic hemorrhage—maintain high index of suspicion 4
• Dismissing pulsatile tinnitus as benign: Nearly all cases of pulsatile tinnitus require imaging evaluation 4
• Overlooking mild hearing loss: Obtain audiometry even when patients don't report hearing difficulties, as amplification can provide significant relief 1, 4
• Ordering unnecessary imaging: Resist pressure to image bilateral, symmetric, non-pulsatile tinnitus without red flags 1, 2, 5
• Inadequate otoscopic examination: Can lead to delayed diagnosis of vascular retrotympanic masses (paragangliomas) 4

Management Framework

For Non-Bothersome Tinnitus

• Provide reassurance and education about natural history 1, 2
• No specific treatment required 2

For Bothersome, Persistent Tinnitus (≥6 months)

Mandatory interventions:

• Education and counseling: Discuss natural history, management strategies, and realistic expectations 1, 2
• Hearing aid evaluation: If any degree of hearing loss is documented on audiometry, even mild or unilateral 1, 2, 5
• Cognitive behavioral therapy: The ONLY treatment proven to improve quality of life in tinnitus patients 2, 3, 5

Optional interventions:

• Sound therapy for auditory masking (evidence less robust than CBT) 2, 5

Avoid these interventions:

• Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for routine treatment 2, 5
• Ginkgo biloba, melatonin, zinc, or other dietary supplements 2, 5
• Transcranial magnetic stimulation 5

Red Flags Requiring Urgent Evaluation

Immediate escalation needed for: 2

• Sudden onset unilateral tinnitus with hearing loss
• Focal neurological deficits
• Severe anxiety or depression
• History of malignancy or recent trauma
• Pulsatile tinnitus (may indicate vascular emergency)