Management of Tinnitus
Immediate Clinical Characterization
The first and most critical step is to determine whether the tinnitus is pulsatile or non-pulsatile, as this single distinction fundamentally changes the entire diagnostic and management pathway. 1
For Pulsatile Tinnitus (synchronous with heartbeat):
Urgent imaging is mandatory because over 70% of pulsatile tinnitus cases have an identifiable structural or vascular cause, including life-threatening conditions such as dural arteriovenous fistula, arterial dissection, or arteriovenous malformations that can lead to catastrophic hemorrhage or stroke if missed. 1, 2
Perform otoscopic examination immediately to identify vascular retrotympanic masses (paragangliomas appear as red pulsatile lesions behind the tympanic membrane). 1, 2
Order CT angiography (CTA) of head and neck with contrast using a mixed arterial-venous phase (20-25 seconds post-contrast) as the first-line imaging study—this captures both arterial causes (atherosclerotic carotid disease, arterial dissection, dural AVF) and venous causes (sigmoid sinus abnormalities, jugular bulb variants) in a single acquisition. 1, 2
If otoscopy reveals a vascular retrotympanic mass, order high-resolution CT temporal bone (non-contrast) instead to evaluate for paragangliomas, glomus tumors, jugular bulb abnormalities, or superior semicircular canal dehiscence. 1, 2
If CTA is negative but clinical suspicion remains high, proceed to MRI brain with contrast plus MR angiography/venography to detect subtle vascular malformations or cerebellopontine angle lesions. 1
For Non-Pulsatile Tinnitus:
Imaging is NOT indicated for bilateral, symmetric, non-pulsatile tinnitus without localizing features—this represents low-value care with no benefit. 1, 3
However, imaging IS required if the non-pulsatile tinnitus is: 1, 4
- Unilateral or asymmetric
- Associated with asymmetric hearing loss
- Associated with focal neurological deficits
- Persistent beyond 6 months with bothersome symptoms
Audiologic Evaluation
Obtain comprehensive audiologic examination (pure-tone audiometry, speech audiometry, acoustic reflex testing) within 4 weeks for any patient with unilateral tinnitus, persistent tinnitus (≥6 months), or tinnitus accompanied by hearing difficulties. 1, 3
This testing is essential even when patients don't report hearing difficulties, because mild hearing loss amenable to amplification is frequently missed without formal testing. 1
For unilateral or asymmetric hearing loss detected on audiometry, order MRI of internal auditory canals with contrast to exclude vestibular schwannoma (acoustic neuroma). 3
First-Line Treatment Interventions
When Hearing Loss is Documented:
Refer for hearing aid evaluation immediately—hearing aids are the first-line audiologic therapy with the strongest evidence for tinnitus symptom improvement. 1, 5
Hearing aids provide benefit even for mild or unilateral hearing loss. 1, 5
The mechanism is that amplification reduces the auditory deprivation that drives central nervous system hyperactivity underlying tinnitus perception. 6
For Bothersome Tinnitus Without Hearing Loss:
Cognitive behavioral therapy (CBT) is the only treatment proven in large randomized controlled trials to definitively improve quality of life in tinnitus patients. 6, 4, 5
CBT addresses the psychological distress, anxiety, and catastrophic thinking patterns that amplify tinnitus perception. 6, 4
Sound therapy (wide-band noise, masking devices) can be offered as adjunctive treatment, though evidence is less robust than for CBT. 5, 7
Tinnitus retraining therapy combines sound therapy with directive counseling, but evidence remains inconclusive. 4, 7
Mandatory Psychosocial Screening
Screen all patients with bothersome tinnitus for anxiety and depression using validated instruments, because these conditions frequently coexist and patients with severe psychiatric comorbidity carry increased suicide risk requiring urgent intervention. 1, 3
Approximately 20% of adults with tinnitus require clinical intervention, though most adapt over time. 3, 6
Melatonin may help with sleep disturbance, and antidepressants may address mood disorders, though neither treats tinnitus directly. 4
Patient Education and Counseling
Provide education at the initial visit about tinnitus mechanisms (central nervous system hyperactivity from auditory deprivation), natural history (most patients habituate over time), and realistic expectations about available treatments. 1, 4
Emphasize that tinnitus is a symptom, not a disease, and that identifying and treating underlying causes (when present) is the priority. 8
Counsel on noise avoidance to prevent progression, particularly for patients with occupational or recreational noise exposure. 3, 4
Common Pitfalls to Avoid
Never dismiss pulsatile tinnitus without imaging—treatable and life-threatening vascular causes are common, and missing dural AVF can result in catastrophic hemorrhage. 1, 2
Do not order imaging for bilateral, symmetric, non-pulsatile tinnitus—this represents inappropriate resource utilization with extremely low diagnostic yield. 1, 4
Do not delay audiometry—testing should occur within 4 weeks for persistent or unilateral tinnitus to avoid missing treatable hearing loss. 1
Do not overlook inadequate otoscopic examination—vascular retrotympanic masses (paragangliomas) can be identified on otoscopy and change the imaging algorithm entirely. 1, 2
Do not miss intracranial hypertension, particularly in young, overweight women with headaches and pulsatile tinnitus—this can cause vision loss if untreated. 1
Pharmacologic Considerations
No effective drug treatments exist for primary tinnitus—multiple well-designed studies have failed to identify medications that consistently eliminate tinnitus symptoms. 6, 5, 7
Medications should target comorbid conditions (antidepressants for depression, melatonin for insomnia) rather than tinnitus itself. 4
Avoid ototoxic medications when possible, as these can worsen tinnitus. 3, 6
Specific Etiologies Requiring Targeted Treatment
Atherosclerotic Carotid Stenosis (17.5% of pulsatile tinnitus):
- Medical management with antiplatelet therapy, statin, and blood pressure control. 2
- Carotid endarterectomy or stenting for hemodynamically significant stenosis. 2
Dural Arteriovenous Fistula (8% of pulsatile tinnitus):
- Endovascular embolization or surgical treatment urgently. 2
Arterial Dissection:
- Immediate anticoagulation or antiplatelet therapy. 2
Idiopathic Intracranial Hypertension (second most common cause of pulsatile tinnitus):
- Treatment of IIH results in dramatic resolution of pulsatile tinnitus in nearly 100% of cases. 1
Paragangliomas/Glomus Tumors (16% of pulsatile tinnitus):
- Surgical resection, radiation therapy, or observation depending on size and symptoms. 1
Superior Semicircular Canal Dehiscence:
- Surgical repair if symptoms are debilitating. 1
Cerumen Impaction:
- Simple removal provides immediate relief. 3