Evaluation and Management of Tinnitus
Initial Clinical Assessment
Perform a targeted history and physical examination to identify treatable underlying conditions and classify the tinnitus as primary versus secondary. 1
Critical History Elements
- Document tinnitus characteristics: onset, duration, laterality (unilateral vs bilateral), quality (pulsatile vs non-pulsatile), pitch, loudness, and temporal pattern 2
- Assess associated symptoms: hearing loss (even subtle changes), vertigo, aural fullness, otalgia, otorrhea, headaches, or focal neurological deficits 2
- Screen for risk factors: noise exposure, ototoxic medications, head trauma, military service, depression, anxiety, and cardiovascular disease 3, 4
- Determine if tinnitus is bothersome: this distinction is mandatory as it drives management intensity 1, 5
Physical Examination Priorities
- Otoscopic examination: identify cerumen impaction, tympanic membrane abnormalities, middle ear pathology, or vascular retrotympanic masses 2
- Cranial nerve examination: focus on CN VIII (hearing) and other focal deficits 2
- Auscultation: listen over neck, periauricular region, and temporal area for bruits if pulsatile tinnitus is reported 2
Audiologic Testing
Obtain a comprehensive audiologic examination promptly for patients with unilateral tinnitus, persistent tinnitus (≥6 months), or any associated hearing difficulties. 1, 6
- Testing should include: pure tone audiometry, speech audiometry, and acoustic reflex testing 2, 5
- Consider routine audiologic examination for all tinnitus patients regardless of laterality, duration, or perceived hearing status, as mild hearing loss is often missed without formal testing 1, 7
- Asymmetric hearing loss (≥15 dB difference at two contiguous frequencies or ≥20 dB at a single frequency) raises suspicion for retrocochlear pathology 7
Imaging Decisions
Do NOT obtain imaging studies unless one or more of the following red flags are present: 1, 6
Indications for Imaging
| Clinical Feature | Imaging Modality | Rationale |
|---|---|---|
| Unilateral/asymmetric tinnitus | MRI internal auditory canals with gadolinium contrast | Rule out vestibular schwannoma, meningioma, or cerebellopontine angle lesions [1,7] |
| Pulsatile tinnitus | High-resolution CT temporal bone (non-contrast) OR CT angiography head/neck with contrast | Evaluate for vascular anomalies, paragangliomas, glomus tumors, dural arteriovenous fistulas, or arterial dissection (>70% have identifiable structural/vascular cause) [1,7,5] |
| Asymmetric hearing loss | MRI internal auditory canals with gadolinium contrast | Detect retrocochlear lesions [1,7] |
| Focal neurological abnormalities | MRI brain with contrast | Evaluate for central nervous system pathology [1] |
Common Pitfall
Avoid unnecessary imaging for bilateral, non-pulsatile tinnitus without neurological symptoms or asymmetric hearing loss—this represents the vast majority of primary tinnitus cases and imaging adds no value 1, 2, 6
Classification for Management
Step 1: Bothersome vs Non-Bothersome
Distinguish patients with bothersome tinnitus from those with non-bothersome tinnitus—this is a strong recommendation that determines intervention intensity. 1, 6
Step 2: Duration Assessment
Separate recent onset (<6 months) from persistent tinnitus (≥6 months) to prioritize intervention and facilitate discussions about natural history. 1, 5
Management of Persistent, Bothersome Tinnitus
Mandatory Interventions
Educate all patients with persistent, bothersome tinnitus about management strategies, natural history, and realistic expectations. 1, 6
Evidence-Based Treatment Recommendations
Cognitive Behavioral Therapy (CBT)
- Recommend CBT to patients with persistent, bothersome tinnitus—this is the only treatment proven to improve quality of life. 1, 3, 8, 6
- CBT addresses the emotional and psychological impact of tinnitus rather than eliminating the sound itself 8
Hearing Aids
- Recommend hearing aid evaluation for patients with documented hearing loss and persistent, bothersome tinnitus. 1, 6
- Even mild or unilateral hearing loss may benefit from amplification 8
Sound Therapy
- Clinicians may recommend sound therapy (wide-band noise, environmental sounds, or tinnitus maskers) to patients with persistent, bothersome tinnitus 1, 6
- Evidence is less robust than for CBT, but sound therapy combined with counseling shows benefit 8
Treatments to AVOID
Do NOT routinely prescribe the following for persistent, bothersome tinnitus: 1, 6
- Antidepressants, anticonvulsants, or anxiolytics (unless treating comorbid depression/anxiety independent of tinnitus)
- Intratympanic medications
- Ginkgo biloba, melatonin, zinc, or other dietary supplements
- Transcranial magnetic stimulation
These interventions lack evidence for improving tinnitus-specific outcomes 1, 6
Red Flags Requiring Urgent Specialist Referral
Immediately refer to otolaryngology or neurotology if any of the following are present: 7, 5
- Progressive unilateral hearing loss with tinnitus
- Pulsatile tinnitus (especially if objective/audible to examiner)
- Focal neurological deficits (facial weakness, numbness, ataxia, diplopia)
- Sudden onset unilateral tinnitus with hearing loss
- Severe anxiety or depression related to tinnitus
Special Considerations
Pulsatile Tinnitus
Pulsatile tinnitus has identifiable structural or vascular causes in over 70% of cases and requires urgent evaluation. 7, 5
- Arterial causes include atherosclerotic carotid disease (17.5% of pulsatile cases) and arterial dissection (life-threatening) 5
- Venous causes include idiopathic intracranial hypertension, particularly in young overweight women with headaches 5
- Dural arteriovenous fistulas (8% of cases) can lead to hemorrhagic or ischemic stroke if untreated 5
Hyperacusis
For patients with sound tolerance problems (hyperacusis), measure loudness discomfort levels at audiometric frequencies. 2
Algorithm Summary
- History & Physical → Identify red flags (unilateral, pulsatile, neurologic deficits, asymmetric hearing loss) 1, 2
- Audiologic Testing → Comprehensive audiometry for unilateral, persistent (≥6 months), or hearing-associated tinnitus 1, 6
- Imaging → ONLY if red flags present (see table above) 1, 6
- Classify → Bothersome vs non-bothersome; recent vs persistent 1, 5
- Treat Persistent Bothersome Tinnitus:
- Avoid unproven medications and supplements 1, 6
- Refer urgently if red flags present 7, 5