What is the recommended stepwise evaluation and management approach for an adult presenting with tinnitus, including assessment for reversible causes, red‑flag signs, and treatment options?

Stepwise Evaluation and Management of Adult Tinnitus

Immediate Clinical Characterization

The first critical step is determining whether the tinnitus is pulsatile (synchronous with heartbeat) or non-pulsatile, as this single distinction fundamentally changes the diagnostic urgency and imaging strategy. 1

• Pulsatile tinnitus requires urgent imaging evaluation because it has an identifiable structural or vascular cause in over 70% of cases, including life-threatening conditions such as arterial dissection, dural arteriovenous fistulas (which can cause catastrophic hemorrhage), and atherosclerotic carotid disease. 1

• Non-pulsatile tinnitus that is bilateral, symmetric, and without localizing features does not require imaging and represents inappropriate resource utilization. 1, 2

Red-Flag Assessment Requiring Immediate Imaging

Obtain urgent imaging (high-resolution CT temporal bone or CT angiography head/neck) if any of the following are present: 1, 2

• Pulsatile quality (even if bilateral)
• Unilateral presentation (even if non-pulsatile)
• Focal neurological deficits (shift to stroke/mass protocol, not tinnitus-specific)
• Asymmetric hearing loss on audiometry
• Objective tinnitus (audible to examiner—strongly suggests vascular pathology)
• Vision changes (especially in young overweight women with headaches—suspect idiopathic intracranial hypertension, the second most common cause of pulsatile tinnitus)

Otoscopic Examination Priorities

Perform comprehensive otoscopy to identify: 1

• Vascular retrotympanic masses (paragangliomas appear as pulsatile red masses behind tympanic membrane—16% of pulsatile tinnitus cases)
• Cerumen impaction (simple reversible cause)
• Middle ear effusion or infection

Missing paragangliomas on otoscopy leads to delayed diagnosis and inappropriate imaging selection. 1

Audiometric Testing Algorithm

Order comprehensive audiologic examination within 4 weeks (pure tone audiometry, speech audiometry, acoustic reflex testing) for: 1, 2

• Any unilateral tinnitus
• Persistent tinnitus (≥6 months duration)
• Any patient reporting hearing difficulties

Critical pitfall: Patients often don't report mild hearing loss, yet hearing aids provide significant relief even for mild or unilateral hearing loss. 2

Imaging Decision Tree for Pulsatile Tinnitus

First-Line Imaging Choice:

Option A: High-resolution CT temporal bone (non-contrast) when suspecting: 1

• Paragangliomas or glomus tumors
• Jugular bulb abnormalities (high-riding or dehiscent)
• Superior semicircular canal dehiscence
• Sigmoid sinus diverticulum/dehiscence
• Aberrant venous anatomy

Option B: CT angiography head/neck with contrast (mixed arterial-venous phase at 20-25 seconds) when suspecting: 1

• Dural arteriovenous fistulas (8% of cases—life-threatening if missed)
• Arterial dissection (urgent identification required)
• Atherosclerotic carotid disease (most common cause at 17.5%)
• Arteriovenous malformations

Second-Line Imaging:

Reserve MRI with contrast and MR angiography/venography for: 1

• Cerebellopontine angle lesions (vestibular schwannoma)
• Negative CT/CTA but high clinical suspicion persists
• Contraindications to iodinated contrast

Physical Examination Maneuvers

• Jugular/carotid compression test: Relief of pulsatile tinnitus with gentle compression suggests venous etiology (sigmoid sinus abnormalities) or arterial dissection. 1

• Auscultation: Listen over neck, periauricular area, and mastoid for objective tinnitus (bruits suggest vascular pathology). 3

Assessment of Reversible Causes

Systematically evaluate for: 2, 3

• Cerumen impaction (remove and reassess)
• Ototoxic medications (aspirin, NSAIDs, aminoglycosides, loop diuretics, platinum chemotherapy)
• Middle ear pathology (effusion, infection, otosclerosis)
• Menière's disease (episodic vertigo, fluctuating hearing loss, aural fullness)
• Sudden sensorineural hearing loss (requires urgent corticosteroid treatment)

Evidence-Based Treatment for Non-Pulsatile Tinnitus

First-Line Interventions:

1. Hearing aids (strongest recommendation): 2, 4

• Indicated for any degree of hearing loss, even mild or unilateral
• Provide significant relief by amplifying ambient sound and reducing tinnitus perception
• Should be offered immediately after audiometry confirms hearing loss

2. Education and counseling (mandatory for all patients): 2

• Explain tinnitus mechanisms, natural history, and realistic expectations
• Reassure that tinnitus is not life-threatening (once serious causes excluded)
• Discuss habituation—most patients adapt over time

3. Cognitive Behavioral Therapy (CBT): 2, 4

• Strongest evidence for improving quality of life in persistent, bothersome tinnitus
• Combination of sound therapy and CBT-based counseling has best evidence base
• Addresses catastrophic thinking and maladaptive coping

4. Sound therapy: 2, 4

• Wide-band sound generators or environmental sound enrichment
• Reduces contrast between tinnitus and silence
• Most effective when combined with counseling

Treatments NOT Recommended:

Do not prescribe the following due to insufficient evidence and potential harm: 2

• Antidepressants, anticonvulsants, or anxiolytics (unless treating comorbid psychiatric condition)
• Intratympanic medications
• Dietary supplements (Ginkgo biloba, melatonin, zinc)

Psychiatric Comorbidity Screening

Immediately screen for severe anxiety and depression in all tinnitus patients: 2, 3

• Tinnitus patients with severe psychiatric comorbidity have increased suicide risk
• Requires prompt mental health referral and intervention
• Anxiety/depression can be both cause and consequence of tinnitus

Special Population Considerations

Idiopathic Intracranial Hypertension (IIH):

• High-risk demographic: Young, overweight women with headaches and pulsatile tinnitus 1
• Urgent ophthalmology referral required—can cause permanent vision loss if missed
• Treatment of IIH resolves pulsatile tinnitus in nearly 100% of cases 1

Chemotherapy-Induced Tinnitus:

• No causative treatment exists for established platinum-based ototoxicity 2
• Hearing aids and CBT remain beneficial for symptom management 2
• Sodium thiosulfate may prevent ototoxicity in children receiving cisplatin (adult use uncertain) 2

Common Diagnostic Pitfalls

1. Dismissing pulsatile tinnitus as benign without imaging—treatable and life-threatening causes are common (>70% have identifiable cause). 1

2. Missing dural arteriovenous fistulas—can present with isolated pulsatile tinnitus before catastrophic hemorrhage. 1

3. Inadequate otoscopic examination—leads to delayed diagnosis of paragangliomas and inappropriate imaging selection. 1

4. Overlooking mild hearing loss—patients don't always report it, yet hearing aids provide significant benefit even for mild/unilateral loss. 2

5. Ordering imaging for bilateral, symmetric, non-pulsatile tinnitus—represents low-yield, expensive testing with no benefit. 1, 2

6. Prescribing medications without evidence—antidepressants, anticonvulsants, and supplements lack efficacy data and may cause harm. 2

Long-Term Management Strategy

• Team approach involving otolaryngology, audiology, and mental health professionals optimizes outcomes. 2

• Long-term follow-up is necessary—10-15% of bilateral tinnitus cases have underlying causes identified only after extended observation. 2

• No cure exists—treatment focuses on symptom management, habituation, and quality of life improvement. 2, 4

• Approximately 20% of adults with tinnitus require clinical intervention, while most adapt spontaneously. 3