How should constant tinnitus be evaluated and managed?

Evaluation and Management of Constant Tinnitus

For constant tinnitus, immediately determine whether it is pulsatile or non-pulsatile and unilateral or bilateral, because pulsatile tinnitus requires urgent vascular imaging in nearly all cases to identify life-threatening causes like dural arteriovenous fistula or arterial dissection, while bilateral non-pulsatile tinnitus without hearing loss or neurologic deficits does not require imaging and should proceed directly to audiometry and cognitive behavioral therapy. 1, 2

Initial Clinical Characterization

Determine the exact quality of the tinnitus:

• Pulsatile (synchronous with heartbeat) versus non-pulsatile – this single distinction fundamentally changes your entire diagnostic pathway 1, 2
• Unilateral versus bilateral – unilateral disease has much higher likelihood of identifiable structural pathology 1, 2
• Duration – persistent tinnitus is defined as ≥6 months, which guides treatment intensity 3, 1
• Bothersome versus non-bothersome – only bothersome tinnitus warrants aggressive intervention 3, 1

Perform targeted otoscopic examination to identify vascular retrotympanic masses (appear as red pulsatile lesions suggesting paraganglioma), cerumen impaction, or middle ear effusion before any imaging decisions 1, 2

Screen for psychiatric comorbidity using validated instruments for anxiety and depression, because tinnitus patients with severe psychiatric symptoms have documented increased suicide risk requiring immediate intervention 1

Diagnostic Algorithm for Pulsatile Tinnitus

If the tinnitus is pulsatile, imaging is mandatory regardless of laterality because identifiable pathology exists in >70% of cases, including life-threatening conditions 1, 2:

First-Line Imaging for Pulsatile Tinnitus:

• If otoscopy reveals a vascular retrotympanic mass: Order high-resolution CT temporal bone (non-contrast) to evaluate for paragangliomas, glomus tumors, jugular bulb abnormalities, or superior semicircular canal dehiscence 1, 2

• If otoscopy is normal: Order CT angiography (CTA) of head and neck with contrast using mixed arterial-venous phase (20-25 seconds post-contrast) to capture both arterial causes (atherosclerotic disease, arterial dissection, dural arteriovenous fistula) and venous causes (sigmoid sinus diverticulum, transverse sinus stenosis, jugular bulb variants) in a single acquisition 1, 2

Second-Line Imaging:

• If CTA is negative but clinical suspicion remains high: Proceed to MRI brain with gadolinium contrast plus MR angiography/venography to identify cerebellopontine angle lesions, subtle vascular malformations, or signs of intracranial hypertension 1, 2

Critical Pulsatile Tinnitus Causes Not to Miss:

• Dural arteriovenous fistula (8% of cases) – can cause hemorrhagic or ischemic stroke if untreated 1, 2
• Arterial dissection – life-threatening emergency requiring urgent identification 1, 2
• Idiopathic intracranial hypertension – second most common cause, particularly in young overweight women with headaches; untreated cases cause permanent vision loss 1, 2
• Atherosclerotic carotid disease – most frequent cause at 17.5% of pulsatile tinnitus cases 2

Diagnostic Algorithm for Non-Pulsatile Tinnitus

Imaging Decision:

Do NOT order imaging if the tinnitus is bilateral, symmetric, and non-pulsatile without focal neurologic abnormalities or asymmetric hearing loss – this represents low-value care with no diagnostic yield 3, 1, 4

DO order imaging (MRI internal auditory canals with contrast) if ANY of the following are present: 3, 1, 4

• Unilateral tinnitus
• Asymmetric hearing loss on audiometry
• Focal neurologic abnormalities
• Pulsatile quality (already addressed above)

Audiologic Testing:

Order comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) within 4 weeks for: 3, 1, 4

• Any unilateral tinnitus
• Persistent tinnitus ≥6 months
• Any patient reporting hearing difficulties
• Even when patients deny hearing problems – mild hearing loss is frequently missed and highly treatable 1

Evidence-Based Treatment for Persistent, Bothersome Tinnitus

First-Line Interventions (Strong Evidence):

1. Cognitive Behavioral Therapy (CBT) – the ONLY treatment with proven benefit for improving quality of life in tinnitus patients; this should be your primary therapeutic recommendation 1, 4, 5, 6

2. Hearing aids for ANY degree of documented hearing loss – even mild or unilateral hearing loss benefits from amplification, with strong evidence for tinnitus relief 3, 1, 4, 5

3. Education and counseling – provide information about tinnitus mechanisms, natural history, and management strategies at the initial visit 3, 1, 4

Optional Interventions (Weaker Evidence):

• Sound therapy – may provide symptomatic relief but evidence is inconclusive 1, 4, 5

Treatments to AVOID (Strong Recommendations Against):

Do NOT prescribe the following due to lack of efficacy and potential harm: 3, 1, 4

• Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment
• Intratympanic medications
• Dietary supplements (Ginkgo biloba, melatonin, zinc)
• Transcranial magnetic stimulation

Exception: Treat comorbid depression or anxiety as separate conditions if present, but not as primary tinnitus therapy 1

Special Clinical Scenarios

Tinnitus with Dizziness/Vertigo:

If episodic vertigo lasting 20 minutes to 24 hours + fluctuating hearing loss + aural fullness: Suspect Ménière's disease; order audiometry and MRI internal auditory canals to exclude vestibular schwannoma 7

Critical distinction: BPPV causes vertigo lasting seconds, not the 20-minute to 24-hour episodes of Ménière's disease 7

Tinnitus with Focal Neurologic Deficits:

Immediately order CTA head and neck emergently – this shifts evaluation away from tinnitus protocols toward stroke/hemorrhage/mass lesion workup 1, 2

Chemotherapy-Induced Tinnitus:

No treatment reverses established platinum-based ototoxicity, but hearing aids and CBT remain beneficial for symptom management 1

Long-Term Management and Follow-Up

Establish multidisciplinary team involving otolaryngology (medical oversight), audiology (hearing aids and sound therapy devices), and mental health professionals (CBT delivery) 1

Schedule regular follow-up because underlying etiologies become apparent in 10-15% of bilateral tinnitus cases only after extended observation 1

Reassess patients whose symptoms do not improve to exclude delayed-presentation causes like Menière's disease, otosclerosis, or acoustic neuroma 1

Critical Pitfalls to Avoid

• Dismissing pulsatile tinnitus without imaging – treatable and life-threatening vascular causes are common 1, 2
• Ordering imaging for bilateral symmetric non-pulsatile tinnitus – this is inappropriate resource utilization 3, 1, 4
• Overlooking mild hearing loss – patients frequently deny hearing difficulties despite audiometric abnormalities that would benefit from amplification 1
• Neglecting psychiatric screening – missing severe anxiety or depression can result in failure to identify heightened suicide risk 1
• Prescribing medications without evidence – antidepressants, anticonvulsants, and supplements lack efficacy for primary tinnitus and may cause harm 3, 1, 4
• Missing dural arteriovenous fistula – this life-threatening cause can present as isolated pulsatile tinnitus before catastrophic hemorrhage 1, 2