Evaluation and Management of Tinnitus
Immediate Red-Flag Assessment
Any patient with pulsatile tinnitus requires urgent imaging evaluation because this symptom indicates an underlying vascular or structural abnormality in over 70% of cases, and missing life-threatening causes like dural arteriovenous fistula or arterial dissection can result in catastrophic hemorrhage or stroke. 1
Critical Red Flags Requiring Urgent Imaging:
- Pulsatile tinnitus (synchronous with heartbeat) – identifiable pathology in 70-91% of cases 1
- Unilateral tinnitus – higher likelihood of structural cause 1
- Focal neurologic deficits – suggests intracranial pathology requiring immediate workup 1
- Asymmetric hearing loss (≥10 dB interaural difference at 2+ contiguous frequencies, or ≥15 dB at one frequency) – raises concern for retrocochlear pathology 2
- Objective tinnitus (audible to examiner) – strongly suggests vascular pathology 1
Physical Examination Essentials:
- Comprehensive otoscopic examination to identify vascular retrotympanic masses (paragangliomas appear as red pulsatile lesions), cerumen impaction, or middle ear effusion 1
- Jugular/carotid compression test – relief of pulsatile tinnitus suggests venous etiology (sigmoid sinus abnormalities) or arterial dissection 1
- Neurologic examination to identify focal deficits suggesting intracranial pathology 1
Imaging Indications and Protocols
When Imaging IS Required:
For Pulsatile Tinnitus:
- First-line: CT angiography (CTA) of head and neck with mixed arterial-venous phase (20-25 seconds post-contrast) captures both arterial and venous pathology in a single acquisition 1
- Evaluates for: dural arteriovenous fistulas (8% of cases), arterial dissection, atherosclerotic carotid disease (17.5% of cases), sigmoid sinus diverticulum, arteriovenous malformations 1
- Alternative first-line: High-resolution CT temporal bone (non-contrast) when otoscopy reveals vascular retrotympanic mass or suspecting paragangliomas (16% of cases), glomus tumors, jugular bulb abnormalities, superior semicircular canal dehiscence, aberrant vascular anatomy 1
- Second-line: MRI brain with contrast + MR angiography/venography if CTA negative but clinical suspicion remains high 1
For Unilateral Non-Pulsatile Tinnitus:
- MRI of internal auditory canals with contrast to evaluate for vestibular schwannoma, meningiomas, other retrocochlear pathology 2
- Note: Vestibular schwannomas can present with bilateral tinnitus even when tumor is unilateral (tinnitus occurs in 63-75% of cases) 2
For Asymmetric Hearing Loss (Regardless of Tinnitus Laterality):
- Imaging decisions should be guided by the hearing loss pattern, not the tinnitus pattern 2
- MRI of head and internal auditory canals without and with IV contrast is most appropriate 2
When Imaging is NOT Indicated:
The American College of Radiology recommends AGAINST imaging for bilateral, symmetric, non-pulsatile tinnitus without localizing features, as this represents low-yield, expensive testing with potential harms. 1, 3
Audiologic Evaluation
Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) within 4 weeks for: 1, 4
- Any unilateral tinnitus
- Persistent tinnitus (≥6 months)
- Tinnitus associated with hearing difficulties
- Any pulsatile tinnitus
Do not postpone audiometry – testing should be obtained promptly to avoid unnecessary delays in diagnosis 1
Treatment of Reversible Causes
Otologic Causes to Address:
- Cerumen impaction – removal provides immediate relief 5
- External ear infection – treat with appropriate antimicrobials 5
- Middle ear effusion – address underlying cause 5
- Ototoxic medications – discontinue or substitute when possible 5
- Idiopathic intracranial hypertension (second most common cause of pulsatile tinnitus) – treatment results in dramatic resolution of pulsatile tinnitus in nearly 100% of cases 1
Life-Threatening Vascular Causes Requiring Urgent Intervention:
- Dural arteriovenous fistulas – can lead to hemorrhagic or ischemic stroke if untreated 1
- Arterial dissection – requires urgent identification 1
- Arteriovenous malformations – carry 2-3% annual hemorrhage risk with 10-30% mortality from first hemorrhage 1
First-Line Therapies for Persistent, Bothersome Tinnitus
Evidence-Based Treatments:
1. Hearing Aids (When Hearing Loss is Present):
- The American Academy of Otolaryngology recommends hearing aid evaluation for patients with documented hearing loss and persistent bothersome tinnitus, as amplification improves quality of life 3, 4
- Strong evidence for benefit even with mild or unilateral hearing loss 6
2. Cognitive Behavioral Therapy (CBT):
- CBT is the ONLY treatment proven to improve quality of life in patients with persistent, bothersome tinnitus 3, 6
- Strongest evidence base for combination of sound therapy and CBT-based counseling 6
3. Education and Counseling:
- Provide at initial visit about tinnitus mechanisms, natural history, and management strategies 1, 4
- Helps set realistic expectations and empowers patients 4
Second-Line Therapies
Optional Treatments with Inconclusive Evidence:
Sound Therapy:
- May be recommended but evidence is inconclusive 7, 4
- Wide-band sound therapy and auditory masking may provide relief 5, 6
Tinnitus Retraining Therapy:
- Treatment option but evidence is inconclusive 7
Treatments NOT Recommended
The American Academy of Otolaryngology recommends AGAINST the following for routine treatment: 3, 4
- Antidepressants, anticonvulsants, or anxiolytics for tinnitus itself (may treat comorbid conditions)
- Intratympanic medications
- Ginkgo biloba, melatonin, zinc, or other dietary supplements
- Transcranial magnetic stimulation
Exception: Melatonin, antidepressants, and cognitive training may help with sleep disturbance, mood disorders, and cognitive impairments respectively, but not tinnitus itself 7
Psychosocial Screening
Screen patients with bothersome tinnitus for anxiety and depression using validated instruments, because these conditions frequently coexist and influence management decisions 1, 8
- Anxiety and depression can be both cause and consequence of tinnitus 1
- Patients with severe anxiety or depression require prompt identification 1
Common Pitfalls to Avoid
- Dismissing pulsatile tinnitus as benign without imaging – treatable and life-threatening causes are common 1
- Being falsely reassured by bilateral tinnitus when asymmetric hearing loss is present – the hearing loss drives imaging decisions, not tinnitus laterality 2
- Ordering imaging for bilateral, symmetric, non-pulsatile tinnitus – represents inappropriate resource utilization with no benefit 1, 3
- Inadequate otoscopic examination – can lead to delayed diagnosis of vascular retrotympanic masses (paragangliomas) 1
- Missing dural AVF – requires high index of suspicion as it can present with isolated pulsatile tinnitus before catastrophic hemorrhage 1
- Overlooking intracranial hypertension in young, overweight women with headaches – can lead to vision loss if missed 1
- Prescribing supplements or medications as primary treatment without addressing underlying causes 3