Evaluation and Management of Chronic Non-Pulsatile Tinnitus
For a patient with chronic non-pulsatile tinnitus without red flags, order a comprehensive audiologic examination within 4 weeks and do NOT order imaging studies. 1, 2
Initial Clinical Assessment
The first priority is to determine whether the tinnitus is bothersome versus non-bothersome, as this fundamentally guides treatment intensity. 2 Bothersome tinnitus negatively impacts quality of life and warrants active intervention, while non-bothersome tinnitus requires only reassurance and education. 2
Key History Elements to Elicit
- Laterality: Confirm the tinnitus is bilateral or symmetric (unilateral tinnitus requires imaging for retrocochlear pathology like vestibular schwannoma). 1, 2
- Pulsatile quality: Verify the sound is NOT synchronous with heartbeat (pulsatile tinnitus has identifiable vascular causes in >70% of cases and mandates urgent imaging). 3
- Duration: Document that symptoms have persisted ≥6 months, defining this as "persistent" tinnitus. 2
- Associated symptoms: Rule out focal neurologic deficits, asymmetric hearing loss, vertigo, or recent head trauma—any of these red flags changes the diagnostic pathway entirely. 1, 2
- Medication review: Identify ototoxic drugs (aminoglycosides, loop diuretics, high-dose aspirin, chemotherapy agents). 4
- Noise exposure: Document occupational or recreational loud noise exposure. 5
Targeted Physical Examination
- Otoscopy: Examine for cerumen impaction, middle ear effusion, or vascular retrotympanic masses (which would appear as red pulsatile lesions and indicate paraganglioma). 3, 4
- Neurologic exam: Confirm absence of focal deficits, cranial nerve abnormalities, or nystagmus. 2
- Auscultation: Listen over the periauricular area, mastoid, orbit, and neck with a stethoscope to rule out objective tinnitus (audible bruits suggest vascular pathology). 4, 6
Diagnostic Testing
Audiologic Evaluation (First-Line, Mandatory)
Order a comprehensive audiologic examination within 4 weeks that includes: 2
- Pure-tone audiometry
- Speech audiometry
- Acoustic reflex testing
This testing serves multiple critical purposes: 2
- Identifies sensorineural hearing loss (the most common association with non-pulsatile tinnitus)
- Detects asymmetric hearing loss that would mandate imaging
- Establishes baseline for hearing aid candidacy
- Rules out sudden sensorineural hearing loss (which requires urgent corticosteroid treatment within 2 weeks)
Imaging Decision (Strong Recommendation AGAINST)
Do NOT order CT, MRI, or any neuroimaging for bilateral, symmetric, non-pulsatile tinnitus without localizing features. 1, 2 This represents low-value care with no diagnostic yield and potential patient harm from unnecessary radiation exposure and incidental findings. 1, 2
The only scenarios requiring imaging are: 1, 2
- Unilateral or asymmetric tinnitus → MRI internal auditory canals with contrast
- Pulsatile tinnitus → CT temporal bone or CTA head/neck
- Focal neurologic abnormalities → follow stroke/cerebrovascular protocols
- Asymmetric hearing loss on audiometry → MRI internal auditory canals with contrast
First-Line Management
Patient Education (Essential for All Patients)
Provide counseling about: 2
- Mechanism: Tinnitus represents aberrant neural activity in auditory pathways, often triggered by hearing loss
- Natural history: 10-15% of adults experience tinnitus, but only 20% require clinical intervention; many patients habituate over time
- Reassurance: In the absence of red flags, tinnitus does not indicate life-threatening disease
- Realistic expectations: Complete elimination is rarely achievable; management focuses on reducing distress and improving quality of life
Hearing Aid Evaluation (If Hearing Loss Present)
If audiometry documents hearing loss—even mild or unilateral—recommend hearing aid evaluation. 2 Hearing aids have the strongest evidence for tinnitus relief among all interventions, as amplification reduces the contrast between tinnitus and environmental sound. 2
Cognitive Behavioral Therapy (Evidence-Based Treatment)
Recommend cognitive behavioral therapy (CBT) for patients with persistent, bothersome tinnitus. 2 CBT is the only treatment proven to improve quality of life in randomized trials. 5, 2 It addresses maladaptive thought patterns, reduces emotional distress, and teaches coping strategies. 2
Sound Therapy (Optional Adjunct)
Clinicians may offer sound therapy using: 2
- Bedside sound machines (white noise, nature sounds)
- Smartphone apps
- Hearing aids with built-in sound generators
- Combination devices
Evidence for sound therapy is less robust than CBT, but it provides symptomatic relief for some patients by masking tinnitus or promoting habituation. 2
Psychosocial Screening
Screen for anxiety and depression using validated instruments (PHQ-9, GAD-7), as these conditions frequently coexist with bothersome tinnitus and influence treatment decisions. 1, 2 Patients with severe anxiety or depression require prompt mental health referral. 1
Treatments to AVOID
The following interventions lack evidence and should NOT be routinely recommended: 2
- Medications: Antidepressants, anticonvulsants, anxiolytics, or intratympanic injections (unless treating comorbid depression/anxiety)
- Dietary supplements: Ginkgo biloba, melatonin, zinc
- Transcranial magnetic stimulation: Insufficient evidence for routine use
Follow-Up Strategy
For patients with non-bothersome tinnitus: 2
- Provide reassurance and education
- No routine follow-up required unless symptoms worsen
For patients with bothersome tinnitus: 2
- Schedule follow-up in 4-6 weeks after audiometry results
- Reassess symptom severity and treatment response
- Consider specialty referral (otolaryngology, audiology) if symptoms persist despite initial management
Common Pitfalls to Avoid
Ordering imaging for bilateral symmetric non-pulsatile tinnitus: This wastes resources and exposes patients to unnecessary testing. 1, 2
Delaying audiometry: Waiting beyond 4 weeks risks missing sudden sensorineural hearing loss, which requires urgent corticosteroid treatment. 7, 2
Dismissing patient distress: Even when no structural cause exists, bothersome tinnitus significantly impairs quality of life and warrants active management with CBT and sound therapy. 2
Missing unilateral presentation: Always confirm true bilaterality, as unilateral tinnitus has higher likelihood of structural pathology (vestibular schwannoma) requiring MRI. 1, 2
Prescribing unproven supplements: Ginkgo biloba and other supplements lack evidence and create false hope. 2