Tinnitus Evaluation and Management
Immediate Clinical Triage: Determine If Imaging Is Required
The first critical decision is whether the tinnitus is pulsatile, unilateral, or associated with focal neurologic deficits or asymmetric hearing loss—any of these features mandates urgent imaging to exclude life-threatening vascular or structural causes. 1
Red Flags Requiring Immediate Imaging
Pulsatile tinnitus (synchronous with heartbeat) has an identifiable structural or vascular cause in >70% of cases, including arterial dissection, dural arteriovenous fistula, atherosclerotic carotid disease, sigmoid sinus abnormalities, and paragangliomas—missing these can result in catastrophic hemorrhage or stroke. 1
Unilateral tinnitus has a higher likelihood of identifiable pathology (vestibular schwannoma, vascular lesions, or temporal bone abnormalities) compared to bilateral presentation. 1
Focal neurologic deficits shift the evaluation away from tinnitus protocols toward acute stroke/hemorrhage workup. 1
Asymmetric hearing loss raises suspicion for retrocochlear pathology (acoustic neuroma) and requires MRI of the internal auditory canals with contrast. 1
Imaging Algorithm for High-Risk Tinnitus
First-line for pulsatile tinnitus with normal otoscopy: Order CT angiography (CTA) of head and neck with mixed arterial-venous phase (20–25 seconds post-contrast) to simultaneously evaluate arterial causes (dissection, atherosclerotic disease, dural AVF, AVM) and venous causes (sigmoid sinus diverticulum, transverse sinus stenosis, jugular bulb abnormalities). 1
First-line when otoscopy reveals a vascular retrotympanic mass: Order high-resolution non-contrast CT of the temporal bone to assess for paragangliomas, glomus tumors, jugular bulb anomalies, or superior semicircular canal dehiscence. 1
Second-line when CTA is negative but suspicion remains high: Proceed to MRI brain with gadolinium plus MR angiography/venography to detect cerebellopontine angle lesions, subtle vascular malformations, or signs of intracranial hypertension. 1
Reserve catheter angiography for objective tinnitus (audible to examiner), inconclusive noninvasive imaging, or definitive characterization of dural AVF identified on CTA/MRA. 1
Low-Risk Tinnitus: When Imaging Is NOT Indicated
Bilateral, symmetric, non-pulsatile tinnitus without localizing features does not require imaging—this represents low-value care with no diagnostic yield. 1, 2
Mandatory Audiologic Testing
Order comprehensive audiologic examination (pure-tone audiometry, speech audiometry, acoustic reflex testing) within 4 weeks for any persistent tinnitus (≥6 months), unilateral tinnitus, or tinnitus with hearing difficulties—this identifies asymmetric hearing loss that changes the imaging algorithm and documents baseline hearing for treatment planning. 1, 2
Do not postpone audiometry even when patients deny hearing difficulties, because mild hearing loss amenable to hearing aid intervention is frequently missed. 1
Essential Physical Examination Maneuvers
Perform otoscopic examination before any treatment to exclude cerumen impaction, middle ear effusion, or vascular retrotympanic masses (paragangliomas appear as red pulsatile lesions behind the tympanic membrane). 1, 2
Auscultate over the neck, periauricular area, and mastoid with a stethoscope to detect objective tinnitus—if audible to the examiner, this strongly suggests vascular pathology requiring immediate vascular imaging. 1
Test jugular/carotid compression: Relief of pulsatile tinnitus upon gentle compression suggests venous etiology (sigmoid sinus abnormalities, jugular bulb variants) or arterial dissection. 1
Screen for severe anxiety or depression using validated instruments, because tinnitus patients with psychiatric comorbidities have documented increased suicide risk and require immediate psychiatric intervention. 1, 2
Evidence-Based Treatment Algorithm
Step 1: Address Treatable Underlying Causes
Remove cerumen impaction if present on otoscopy. 3
Treat middle ear effusion or infection causing conductive hearing loss. 3
Refer for surgical evaluation if imaging identifies paragangliomas, sigmoid sinus diverticulum, superior semicircular canal dehiscence, or dural AVF—these structural lesions may be amenable to resection, stenting, or surgical repair. 1
Manage idiopathic intracranial hypertension (the second most common cause of pulsatile tinnitus, especially in young overweight women with headaches)—treatment dramatically resolves pulsatile tinnitus in nearly 100% of cases when truly pulsatile. 1
Step 2: First-Line Audiologic Intervention
Recommend hearing aid evaluation for any documented hearing loss—even mild or unilateral—because hearing aids provide significant tinnitus relief and have the strongest evidence for benefit among audiologic interventions. 2
Hearing aids are effective even when patients do not report subjective hearing difficulty. 2
Sound therapy (masking devices, hearing-assistive technology) may provide symptomatic relief for persistent tinnitus. 2
Step 3: Cognitive Behavioral Therapy
Cognitive Behavioral Therapy (CBT) is the only treatment proven in large randomized controlled trials to improve quality of life in patients with persistent, bothersome tinnitus. 2, 4, 5, 6
CBT targets tinnitus tolerance and addresses associated anxiety, depression, insomnia, and concentration difficulties. 2, 4
Specialized CBT for tinnitus should be delivered by clinicians familiar with tinnitus management strategies. 2
Step 4: Education and Counseling
Provide education at the initial visit about tinnitus mechanisms, natural history (most patients adapt over time), and realistic expectations—counseling is an essential component for all patients with persistent tinnitus. 2
Explain that approximately 80% of tinnitus sufferers adapt to the phantom sound without requiring intensive intervention, but 20% will need clinical management. 3, 4
Treatments NOT Recommended (Avoiding Common Pitfalls)
Do not prescribe antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary tinnitus treatment—insufficient evidence exists for benefit, and these carry potential side effects. 2
Do not recommend dietary supplements (Ginkgo biloba, melatonin, zinc) due to lack of consistent benefit in clinical trials. 2
Do not dismiss pulsatile tinnitus as benign without imaging—treatable and life-threatening causes are common, and failure to detect dural AVF or arterial dissection can result in catastrophic outcomes. 1
Do not order imaging for bilateral, symmetric, non-pulsatile tinnitus—this represents inappropriate resource utilization with no diagnostic yield. 1, 2
Special Populations and Situations
Tinnitus with Severe Psychiatric Comorbidity
- Immediately refer patients with severe anxiety or depression for psychiatric intervention, because tinnitus patients with active psychiatric illness have documented increased suicide risk. 1, 2, 3
Ototoxic Medication-Induced Tinnitus
No causative treatment exists for established ototoxicity from platinum-based chemotherapy (cisplatin), but hearing aids and CBT remain beneficial for symptom management. 2
Sodium thiosulfate may prevent ototoxicity in children receiving cisplatin, but its use in adults is uncertain due to concerns about tumor protection. 2
Tinnitus as Part of Menière's Disease
- Manage the underlying vestibular disorder rather than treating tinnitus specifically—tinnitus control follows disease control. 2
Long-Term Follow-Up and Multidisciplinary Care
Arrange regular follow-up visits because underlying etiologies are identified in 10–15% of bilateral tinnitus cases only after extended observation. 2
Coordinate care among otolaryngology, audiology, and mental health professionals—otolaryngology provides medical oversight, audiology fits hearing aids and sound-therapy devices, and mental health delivers CBT and psychiatric support. 2
Reassess patients whose tinnitus does not improve to exclude delayed-presentation causes such as Menière's disease, otosclerosis, or acoustic neuroma. 2
Consider implantable hearing solutions (cochlear implants, bone-anchored hearing aids) for individuals with severe hearing loss and persistent bothersome tinnitus. 2