Management of Tinnitus
For a patient presenting with tinnitus, immediately classify it as pulsatile versus non-pulsatile and unilateral versus bilateral, as this determines whether imaging is required and guides all subsequent management decisions. 1, 2
Initial Clinical Assessment
Obtain specific tinnitus characteristics including onset, duration, laterality (which ear), quality (ringing, buzzing, hissing), whether it's synchronous with heartbeat (pulsatile), and whether it's bothersome enough to affect quality of life 2. Check for associated symptoms: hearing loss, vertigo, headaches, vision changes, or focal neurological deficits 1, 2.
Perform otoscopic examination to identify vascular retrotympanic masses (appear as red pulsatile masses behind tympanic membrane, suggesting paraganglioma), cerumen impaction, or tympanic membrane abnormalities 3, 1. If pulsatile tinnitus is reported, auscultate the neck, periauricular region, and temporal area for bruits 2.
Audiologic Testing
Order comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) promptly—ideally within 4 weeks—for any patient with unilateral tinnitus, persistent tinnitus (≥6 months), or hearing difficulties. 3, 4 You may obtain audiometry for all tinnitus patients regardless of laterality or duration, as hearing loss is frequently present even when patients don't report it 3, 1.
Imaging Decision Algorithm
DO NOT order imaging for:
- Bilateral, symmetric, non-pulsatile tinnitus without focal neurological abnormalities or asymmetric hearing loss 3, 1, 4
DO order imaging for:
- Pulsatile tinnitus (any laterality) - has identifiable structural/vascular cause in >70% of cases 1, 5
- Unilateral tinnitus 3, 4
- Asymmetric hearing loss on audiometry 3, 1
- Focal neurological abnormalities 3, 4
Imaging Selection:
For pulsatile tinnitus or suspected vascular causes: Order CT angiography (CTA) of head and neck with contrast using mixed arterial-venous phase (20-25 seconds post-contrast) to capture both arterial causes (atherosclerotic carotid disease 17.5% of cases, arterial dissection, dural arteriovenous fistulas 8% of cases) and venous causes (idiopathic intracranial hypertension, sigmoid sinus abnormalities, jugular bulb variants) 1, 5. This is life-threatening—dural AVF can cause hemorrhagic stroke if missed 5.
For suspected middle ear masses or bony abnormalities: Order high-resolution CT temporal bone (non-contrast) when otoscopy shows retrotympanic mass or when suspecting paragangliomas (16% of pulsatile tinnitus), superior semicircular canal dehiscence, or jugular bulb abnormalities 1, 5.
For unilateral non-pulsatile tinnitus with asymmetric hearing loss: Order MRI internal auditory canals with contrast to evaluate for vestibular schwannoma (acoustic neuroma) 1, 5.
Treatment for Persistent, Bothersome Tinnitus
Evidence-Based Interventions:
Cognitive Behavioral Therapy (CBT) is the only treatment proven to improve quality of life in tinnitus patients and should be recommended. 1, 6, 4 This has the strongest evidence base for symptom management 1, 7.
Recommend hearing aid evaluation for any patient with documented hearing loss and tinnitus, even if hearing loss is mild or unilateral. 1, 4, 7 Hearing aids provide significant relief and address the underlying sensorineural hearing loss present in most tinnitus cases 1.
Provide education and counseling about tinnitus mechanisms, natural history (many patients improve over time), and management strategies for all patients with persistent, bothersome tinnitus 1, 4.
Consider sound therapy (white noise, nature sounds, specialized tinnitus masking devices) as a management option, though evidence is less robust than for CBT 1, 4.
DO NOT Recommend:
Do not prescribe antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for routine tinnitus treatment due to insufficient evidence and potential side effects 1, 4.
Do not recommend dietary supplements (Ginkgo biloba, melatonin, zinc) as they lack consistent evidence of benefit 1, 4.
Special Populations and Red Flags
Young overweight women with pulsatile tinnitus, headaches, and vision changes: Suspect idiopathic intracranial hypertension (second most common cause of pulsatile tinnitus)—this can cause permanent vision loss if missed 1, 5. Order CTA head/neck urgently 5.
Patients with severe anxiety or depression: Require prompt identification and intervention due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1.
Tinnitus with focal neurological deficits: This shifts evaluation away from tinnitus-specific protocols to urgent stroke/mass lesion workup—order CTA head/neck emergently 5.
Common Pitfalls to Avoid
- Missing dural arteriovenous fistula in pulsatile tinnitus—this is life-threatening and can present with isolated tinnitus before catastrophic hemorrhage 5
- Dismissing pulsatile tinnitus as benign without imaging 1, 5
- Ordering MRI/CT for bilateral, symmetric, non-pulsatile tinnitus (inappropriate resource utilization) 1, 5
- Overlooking mild hearing loss that could benefit from hearing aid amplification 1
- Waiting 6 months to obtain audiometry when clinically indicated—order promptly within 4 weeks 3, 2
- Inadequate otoscopic examination missing vascular retrotympanic masses (paragangliomas) 1, 5