Diagnostic Approach for Tinnitus

Initial Assessment

The American Academy of Otolaryngology-Head and Neck Surgery recommends that clinicians perform a targeted history and physical examination at the initial evaluation of a patient with presumed primary tinnitus to identify conditions that if promptly identified and managed may relieve tinnitus 1, 2
Determine if tinnitus is subjective or objective, classify as pulsatile or non-pulsatile, determine if unilateral or bilateral, assess quality of sound, and determine if tinnitus is bothersome or non-bothersome to prioritize intervention 1, 2
Distinguish recent onset from persistent (≥6 months) tinnitus 1, 2
Associated hearing loss or difficulties should be assessed 2
Noise exposure, medications, exacerbating factors, psychological impact, and medical conditions should be evaluated 3, 4

A comprehensive audiologic examination is recommended for unilateral tinnitus, persistent tinnitus (≥6 months), and tinnitus associated with hearing difficulties 1, 2, 4
Imaging is not recommended for routine evaluation of tinnitus, but is indicated for tinnitus with unilateral or asymmetric presentation, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss 1, 2, 4
MRI with contrast or CT temporal bone may be used for suspected acoustic neuroma, retrocochlear pathology, or bony abnormalities 4

Pulsatile tinnitus may indicate a vascular abnormality and requires urgent evaluation 4, 3
Sudden onset unilateral tinnitus with hearing loss, tinnitus with severe anxiety or depression, and tinnitus with focal neurological deficits require urgent evaluation 3, 2
Common etiologies to consider include sensorineural hearing loss, noise exposure, age-related hearing loss, temporomandibular joint dysfunction, vascular abnormalities, ototoxic medications, and Eustachian tube dysfunction 3, 4