Tinnitus Evaluation¶
VERSION: 1.1 CREATED: February 2, 2026 REVISED: February 2, 2026 STATUS: Approved
DIAGNOSIS: Tinnitus Evaluation
ICD-10: H93.19 (Tinnitus, unspecified ear), H93.11 (Tinnitus, right ear), H93.12 (Tinnitus, left ear), H93.A9 (Pulsatile tinnitus, unspecified ear), H93.A1 (Pulsatile tinnitus, right ear), H93.A2 (Pulsatile tinnitus, left ear), H93.A3 (Pulsatile tinnitus, bilateral), H93.19 (Tinnitus, unspecified), R42 (Dizziness and giddiness — when co-occurring), H90.5 (Unspecified sensorineural hearing loss), D33.3 (Benign neoplasm of cranial nerves — vestibular schwannoma)
CPT CODES: 92557 (comprehensive audiometry), 92550 (tympanometry), 92587 (distortion product OAE), 70553 (MRI brain with/without contrast), 70551 (MRI brain without contrast), 70544 (MRA head / MR venography), 70547 (MRA neck), 70496 (CTA head), 70498 (CTA neck), 93880 (carotid duplex ultrasound), 70450 (CT head without contrast), 70480 (CT temporal bones), 92540 (VNG/ENG), 92517 (VEMP), 92585 (ABR), 62270 (lumbar puncture), 95816 (EEG routine), 92134 (OCT posterior segment), 36224 (cerebral angiography), 86596 (anti-neuronal antibody), 86235 (extractable nuclear antigen antibody), 85300 (antithrombin III), 85303 (protein C), 85306 (protein S), 81241 (Factor V Leiden), 81240 (prothrombin G20210A), 86147 (anticardiolipin antibody)
SYNONYMS: Tinnitus, ringing in ears, ringing in the ears, pulsatile tinnitus, pulse-synchronous tinnitus, ear ringing, buzzing in ears, humming in ears, whooshing in ear, heartbeat in ear, subjective tinnitus, objective tinnitus, non-pulsatile tinnitus, sensorineural tinnitus, somatic tinnitus, tinnitus aurium, vascular tinnitus, venous hum
SCOPE: Neurological evaluation and management of tinnitus in adults. Covers classification (pulsatile vs. non-pulsatile, subjective vs. objective), identification of red flags (unilateral tinnitus, pulsatile tinnitus, associated hearing loss, focal neurological deficits), evaluation for vascular causes (dural arteriovenous fistula, carotid stenosis/dissection, IIH, glomus tumors), cerebellopontine angle tumors (vestibular schwannoma/acoustic neuroma), audiometric evaluation, MRI/MRA indications, and management including CBT for tinnitus, sound therapy, and pharmacotherapy. Excludes primary otologic management of cerumen impaction, otitis media, otosclerosis, and cochlear implant evaluation (ENT-managed). Excludes tinnitus in pediatric populations.
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════
1. LABORATORY WORKUP¶
1A. Essential/Core Labs¶
| Test | ED | HOSP | OPD | ICU | Rationale | Target Finding |
|---|---|---|---|---|---|---|
| CBC (CPT 85025) | STAT | STAT | ROUTINE | - | Anemia can cause pulsatile tinnitus (high-output state); polycythemia (hyperviscosity); infection if otitis suspected | Normal; anemia (Hgb <10) — correct and reassess; elevated WBC — infection |
| CMP (CPT 80053) | STAT | STAT | ROUTINE | - | Electrolyte abnormalities; renal dysfunction (uremia can cause tinnitus); baseline metabolic assessment | Normal; BUN/Cr elevation — renal evaluation; hyponatremia |
| TSH (CPT 84443) | - | ROUTINE | ROUTINE | - | Hyperthyroidism causes pulsatile tinnitus (high-output state); hypothyroidism associated with sensorineural hearing loss | Normal; hyperthyroidism — endocrine referral; hypothyroidism — treat and reassess hearing |
| Blood glucose / HbA1c (CPT 82947 / 83036) | ROUTINE | ROUTINE | ROUTINE | - | Diabetes is risk factor for sensorineural hearing loss and small vessel disease; diabetic neuropathy affecting cochlear nerve; relevant for sudden SNHL workup | Fasting glucose 70-100; HbA1c <7.0% |
| Lipid panel (CPT 80061) | - | ROUTINE | ROUTINE | - | Vascular risk factor assessment if pulsatile tinnitus or vascular cause suspected; dyslipidemia associated with sensorineural hearing loss | LDL <100; total cholesterol <200; dyslipidemia — treatment |
1B. Extended Workup (Second-line)¶
| Test | ED | HOSP | OPD | ICU | Rationale | Target Finding |
|---|---|---|---|---|---|---|
| ESR (CPT 85652) / CRP (CPT 86140) | - | ROUTINE | ROUTINE | - | Temporal arteritis (pulsatile tinnitus in elderly); vasculitis; autoimmune inner ear disease | Normal; elevated — evaluate for GCA in >50 yo, autoimmune SNHL |
| ANA (CPT 86235) | - | - | ROUTINE | - | Autoimmune inner ear disease (AIED); systemic lupus; vasculitis affecting cochlea | Negative; positive — autoimmune workup |
| RPR / VDRL (CPT 86592) | - | - | ROUTINE | - | Otosyphilis can present as tinnitus and hearing loss; especially if bilateral asymmetric SNHL | Negative; reactive — FTA-ABS confirmation, treatment |
| Vitamin B12 (CPT 82607) | - | ROUTINE | ROUTINE | - | B12 deficiency associated with tinnitus and sensorineural hearing loss | >300 pg/mL; low — supplementation |
| Ferritin / Iron studies (CPT 82728 / 83540) | - | ROUTINE | ROUTINE | - | Iron deficiency anemia is common cause of pulsatile tinnitus (high-output state); even without frank anemia | Ferritin >50; iron-deficient — supplementation; pulsatile tinnitus may resolve |
| Zinc level (CPT 84630) | - | - | ROUTINE | - | Zinc deficiency has been associated with tinnitus in some studies; cochlear function | Normal; low — supplementation trial |
| Coagulation studies (PT/INR, PTT) (CPT 85610 / 85730) | STAT | ROUTINE | - | - | If cerebral venous sinus thrombosis suspected (pulsatile tinnitus, headache, papilledema) | Normal; prolonged — evaluate coagulopathy |
1C. Rare/Specialized (Refractory or Atypical)¶
| Test | ED | HOSP | OPD | ICU | Rationale | Target Finding |
|---|---|---|---|---|---|---|
| FTA-ABS (CPT 86780) | - | - | ROUTINE | - | Confirmatory for syphilis if RPR positive; otosyphilis diagnosis | Negative; positive — penicillin treatment |
| Lyme serology (CPT 86618) | - | - | ROUTINE | - | Lyme neuroborreliosis can cause cranial neuropathies and hearing loss in endemic areas | Negative; positive — Western blot confirmation |
| Anti-cochlear antibodies / HSP-70 antibodies (CPT 86235) | - | - | EXT | - | Autoimmune inner ear disease if bilateral progressive SNHL with tinnitus; responds to steroids | Negative; positive — steroid trial for AIED |
| Paraneoplastic antibody panel (CPT 86596) | - | - | EXT | - | Rare; paraneoplastic cochlear/vestibular degeneration; anti-Hu, anti-CRMP5 | Negative; positive — malignancy search |
| CSF analysis (CPT 89050, 89051) | - | EXT | EXT | - | If IIH suspected (opening pressure); infectious/inflammatory cause; leptomeningeal disease; neurosyphilis confirmation | Opening pressure >25 cm H2O — IIH; pleocytosis — infection/inflammation; positive VDRL — neurosyphilis |
| Hypercoagulability panel (CPT 85300, 85303, 85306, 81241, 81240, 86147) | - | - | EXT | - | If cerebral venous thrombosis suspected as cause of pulsatile tinnitus | Normal; abnormal — anticoagulation; CVT workup |
2. DIAGNOSTIC IMAGING & STUDIES¶
2A. Essential/First-line¶
| Study | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications |
|---|---|---|---|---|---|---|---|
| Comprehensive audiometry (CPT 92557) with tympanometry (CPT 92550) | - | URGENT | ROUTINE | - | First-line for ALL tinnitus patients; pure tone audiometry, speech discrimination, tympanometry; identifies type and degree of hearing loss; essential for determining etiology | Sensorineural hearing loss (SNHL) — cochlear vs. retrocochlear; conductive hearing loss (CHL) — middle ear pathology; asymmetric SNHL — MRI for vestibular schwannoma; normal — reassuring but does not exclude pathology | Patient cooperation required |
| MRI brain and IACs (internal auditory canals) with gadolinium (CPT 70553) | - | URGENT | ROUTINE | - | Essential if: Unilateral or asymmetric tinnitus; unilateral or asymmetric SNHL; pulsatile tinnitus (to evaluate for vascular malformation or CPA mass); focal neurological deficits; Gold standard for vestibular schwannoma, CPA tumors, meningioma, demyelination | Vestibular schwannoma (enhancing mass in IAC/CPA); meningioma; dural AVF; brainstem lesion; MS plaque; cholesteatoma; leptomeningeal disease | MRI-incompatible implants; severe claustrophobia; GFR <30 (gadolinium contraindication) |
| Otoscopic examination | STAT | STAT | ROUTINE | - | Bedside exam for ALL patients; evaluate for cerumen impaction, tympanic membrane perforation, middle ear effusion, glomus tumor (visible as red/blue mass behind TM), cholesteatoma | Cerumen impaction — removal; retrotympanic mass (glomus tumor, aberrant carotid, high jugular bulb); TM perforation; middle ear effusion | None |
| Auscultation of head, neck, periauricular region | STAT | STAT | ROUTINE | - | Critical for pulsatile tinnitus; listen over mastoid, periauricular, orbits, and neck for bruit; detect objective tinnitus from vascular lesion (dural AVF, carotid stenosis, glomus tumor) | Bruit present — vascular imaging (MRA/CTA); no bruit does NOT exclude vascular cause | None |
2B. Extended¶
| Study | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications |
|---|---|---|---|---|---|---|---|
| MRA head (CPT 70544) and neck (CPT 70547) | URGENT | URGENT | ROUTINE | - | Pulsatile tinnitus workup; evaluates for dural AVF, arterial stenosis/dissection, fibromuscular dysplasia, vertebral/carotid stenosis, aneurysm; use CTA if MRA not available | Dural AVF (early venous filling); carotid stenosis; carotid/vertebral dissection; fibromuscular dysplasia; aneurysm; aberrant vasculature | MRA: same as MRI; CTA (CPT 70496/70498): contrast allergy, renal impairment |
| CT temporal bones (CPT 70480) without contrast | - | ROUTINE | ROUTINE | - | Evaluate bony anatomy; superior semicircular canal dehiscence (can cause pulsatile tinnitus); glomus jugulare/tympanicum; otosclerosis; cholesteatoma; aberrant carotid artery; high jugular bulb; tegmen defect | Glomus tumor (permeative bone destruction); canal dehiscence; otosclerosis; temporal bone fracture; aberrant carotid | Radiation exposure (low) |
| CTA head and neck (CPT 70496 / 70498) | URGENT | URGENT | ROUTINE | - | Alternative or complement to MRA for pulsatile tinnitus; better spatial resolution for some vascular lesions; faster acquisition in ED; evaluates for dural AVF, carotid stenosis, dissection, glomus tumor | Dural AVF; stenosis; dissection; glomus tumor vascularity; fibromuscular dysplasia | Contrast allergy; renal impairment; radiation |
| Carotid duplex ultrasound (CPT 93880) | - | ROUTINE | ROUTINE | - | Non-invasive screening for carotid stenosis if pulsatile tinnitus; can detect FMD in some cases; identifies high-flow states | Carotid stenosis; plaque; FMD (string of beads); flow abnormalities | None |
| Fundoscopic exam / OCT (CPT 92134) | STAT | STAT | ROUTINE | - | Evaluate for papilledema if pulsatile tinnitus (IIH); bilateral papilledema in young obese female with pulsatile tinnitus — IIH until proven otherwise | Papilledema — measure opening pressure (LP); IIH; venous sinus thrombosis | Pupillary dilation for detailed exam |
| MR venography (MRV) (CPT 70544) | - | URGENT | ROUTINE | - | If IIH or cerebral venous sinus thrombosis suspected; evaluates venous sinus patency; transverse sinus stenosis (common in IIH and common cause of pulsatile tinnitus) | Venous sinus thrombosis; transverse sinus stenosis (bilateral or unilateral); venous outflow obstruction | Same as MRI |
2C. Rare/Advanced¶
| Study | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications |
|---|---|---|---|---|---|---|---|
| Cerebral angiography (DSA) (CPT 36224) | - | URGENT | ROUTINE | - | Gold standard for dural AVF; obtain when MRA/CTA suggestive but inconclusive; preoperative planning for AVF embolization or glomus tumor; evaluates venous drainage patterns | Dural AVF (early venous filling, fistula site, venous drainage pattern); glomus tumor blood supply; vascular anatomy for embolization planning | Invasive (stroke risk ~0.5%); contrast allergy; renal impairment; coagulopathy |
| Videonystagmography (VNG) (CPT 92540) | - | - | ROUTINE | - | If vestibular symptoms accompany tinnitus; evaluate vestibular function; caloric testing for unilateral vestibular hypofunction | Unilateral weakness (peripheral vestibular lesion); central patterns | Perforated TM (water calorics) |
| Auditory brainstem response (ABR) (CPT 92585) | - | - | ROUTINE | - | If retrocochlear pathology suspected and MRI contraindicated; screening for vestibular schwannoma when MRI not possible; interaural latency differences | Prolonged wave I-III or I-V interpeak latency (retrocochlear lesion); absent waves | Requires patient cooperation; less sensitive than MRI |
| VEMP (vestibular evoked myogenic potentials) (CPT 92517) | - | - | ROUTINE | - | If superior semicircular canal dehiscence suspected (pulsatile tinnitus, autophony, bone conduction hyperacusis); tests saccule/utricle | Reduced threshold on cVEMP/oVEMP — canal dehiscence | Hearing loss affects testing |
| OAE (otoacoustic emissions) (CPT 92587) | - | - | ROUTINE | - | Assess outer hair cell function; normal OAEs with abnormal audiogram suggest retrocochlear pathology; helps differentiate cochlear vs. neural | Present OAEs with abnormal ABR — auditory neuropathy/retrocochlear; absent OAEs — cochlear damage | Middle ear pathology affects results |
| Temporal bone CT angiography (CPT 70496) | - | - | EXT | - | Specialized for aberrant carotid artery, dehiscent jugular bulb, or persistent stapedial artery causing pulsatile tinnitus | Aberrant vascular anatomy; dehiscent jugular bulb; persistent stapedial artery | Radiation; contrast |
Lumbar Puncture¶
| Study | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications |
|---|---|---|---|---|---|---|---|
| LP with opening pressure (CPT 62270) | URGENT | URGENT | ROUTINE | - | Indicated if IIH suspected: Pulsatile tinnitus + headache + papilledema (especially in young obese female); also if CSF infection or leptomeningeal disease suspected; Measure opening pressure in lateral decubitus position | Opening pressure >25 cm H2O — IIH; normal CSF composition in IIH; pleocytosis — infection; positive cytology — leptomeningeal disease; elevated protein — inflammation | Mass lesion on imaging (perform MRI first); coagulopathy; anticoagulation; skin infection at LP site |
3. TREATMENT PROTOCOLS¶
3A. Acute/Emergent Treatment¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Treat underlying cause | - | All tinnitus with identifiable etiology | - :: - :: - :: Priority is identifying and treating the underlying cause: Cerumen removal (impaction); antibiotics for otitis; correct anemia; treat hyperthyroidism; discontinue ototoxic medications; manage IIH; refer for vascular intervention (dural AVF embolization, carotid endarterectomy) | - | Tinnitus is a symptom, not a diagnosis; treatment of underlying cause resolves tinnitus completely in many cases | STAT | STAT | ROUTINE | - |
| Discontinue/reduce ototoxic medications | - | All tinnitus patients on ototoxic drugs | - :: - :: - :: Review medication list: High-dose aspirin (>2g/day), aminoglycosides, loop diuretics (furosemide), cisplatin, quinine, vancomycin, erythromycin; reduce dose or substitute when possible | When medication is essential and no alternative exists | Ototoxic medications are a common reversible cause; Cianfrone et al. (2011): medication review is first step | STAT | STAT | ROUTINE | - |
| IV dexamethasone (sudden SNHL with tinnitus) | IV | Sudden sensorineural hearing loss with tinnitus | 10 mg :: IV :: once :: Sudden SNHL is otologic emergency: Dexamethasone 10 mg IV then transition to oral prednisone 1 mg/kg/day (max 60 mg) x 14 days with taper; OR methylprednisolone 48 mg daily x 14 days; start within 72 hours for best outcomes; ENT urgent referral | Active infection (relative); uncontrolled diabetes; GI bleed | Blood glucose monitoring every 6 hours while on steroids; Chandrasekhar et al. (2019): AAO-HNS guideline recommends steroids within 2 weeks of sudden SNHL onset; earlier is better | STAT | STAT | URGENT | - |
| Acetazolamide (IIH-related pulsatile tinnitus) | PO | Pulsatile tinnitus due to IIH | 500 mg :: PO :: BID :: Acetazolamide 250-500 mg PO BID, titrate up to 1g BID as tolerated; monitor electrolytes; reduces CSF production; can dramatically improve pulsatile tinnitus in IIH | Sulfa allergy; hepatic insufficiency; hypokalemia; metabolic acidosis | Electrolytes (potassium, bicarbonate) weekly x 4 weeks, then monthly; renal function; paresthesias (common, benign); NORDIC Idiopathic Intracranial Hypertension Study Group (2014): acetazolamide effective for IIH | URGENT | URGENT | ROUTINE | - |
3B. Disease-Specific Treatment¶
NON-PULSATILE TINNITUS — Behavioral and Sound-Based Therapies¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Cognitive behavioral therapy (CBT) for tinnitus | - | Non-pulsatile tinnitus with distress, anxiety, insomnia, or functional impairment | - :: - :: 8-20 sessions :: First-line evidence-based therapy: 8-20 sessions of CBT adapted for tinnitus; addresses catastrophic thinking, hypervigilance, emotional response to tinnitus; reduces tinnitus distress, improves sleep and function; does NOT eliminate tinnitus but reduces impact | None | Track TFI/THI scores every 4-6 sessions; Cima et al. (2012): RCT demonstrated CBT significantly reduces tinnitus severity and improves quality of life; Cochrane review (2020): CBT is most evidence-supported therapy | - | - | ROUTINE | - |
| Sound therapy / masking | - | All bothersome non-pulsatile tinnitus | - :: - :: continuous :: Options: Background sound enrichment (fan, white noise, nature sounds); ear-level sound generators; combination hearing aid + sound generator; Notch therapy (tailor-made notched music); smartphone apps (e.g., Oto, ReSound Relief); avoid silence | None | Partial or complete masking reduces tinnitus perception; Hobson et al. (2012): Cochrane review — limited evidence but widely recommended as adjunct; safe and well tolerated | - | ROUTINE | ROUTINE | - |
| Tinnitus retraining therapy (TRT) | - | Chronic bothersome non-pulsatile tinnitus | - :: - :: 12-24 months :: Combined counseling + sound therapy: Directive counseling (neurophysiological model) + low-level broadband sound generators worn 6-8h/day; goal is habituation (tinnitus perceived but not bothersome); requires 12-24 months | Requires patient commitment and trained provider | Clinical improvement in 70-80%; Jastreboff & Jastreboff (2000): established protocol; evidence is moderate | - | - | ROUTINE | - |
| Hearing aids | - | Tinnitus with coexisting hearing loss | - :: - :: daily use :: If hearing loss present: Amplification reduces tinnitus perception by enriching auditory input; modern hearing aids include tinnitus masking programs; bilateral fitting preferred for bilateral loss; trial period recommended | Profound hearing loss (cochlear implant evaluation instead) | Shekhawat et al. (2013): hearing aids improve tinnitus in majority of patients with hearing loss; offer to all eligible patients | - | - | ROUTINE | - |
| Acceptance and commitment therapy (ACT) | - | Alternative to CBT; tinnitus-related distress | - :: - :: 8-12 sessions :: Mindfulness-based approach; acceptance of tinnitus rather than control; values-driven action; emerging evidence supports efficacy | None | Track TFI/THI scores; Westin et al. (2011): ACT comparable to CBT for tinnitus distress reduction | - | - | ROUTINE | - |
NON-PULSATILE TINNITUS — Pharmacotherapy¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Amitriptyline | PO | Tinnitus with comorbid insomnia, depression, or anxiety | 10 mg :: PO :: QHS :: Start 10 mg QHS, titrate by 10 mg every 1-2 weeks to 50 mg; low-dose TCA; reduces tinnitus perception in subset of patients; stronger evidence for comorbid conditions | Cardiac arrhythmia; urinary retention; narrow-angle glaucoma; elderly (anticholinergic risk) | ECG at baseline; anticholinergic side effects; limited direct evidence for tinnitus; Sullivan et al. (1993): modest benefit in severe tinnitus | - | - | ROUTINE | - |
| Nortriptyline | PO | Tinnitus with comorbid depression; alternative to amitriptyline with fewer anticholinergic effects | 25 mg :: PO :: QHS :: Start 25 mg QHS, titrate to 50-75 mg; less sedating than amitriptyline | Cardiac conduction abnormality; recent MI; urinary retention; narrow-angle glaucoma; elderly (anticholinergic risk) | ECG at baseline if dose >75 mg; monitor for anticholinergic side effects; Sullivan et al. (1993): RCT showed nortriptyline reduced tinnitus loudness and depression scores | - | - | ROUTINE | - |
| Melatonin | PO | Tinnitus with insomnia | 3 mg :: PO :: QHS :: 3-5 mg at bedtime; improves sleep in tinnitus patients; modest direct effect on tinnitus | None significant | Hurtuk et al. (2011): melatonin improved tinnitus scores in patients with sleep disturbance; safe; low side effect profile | - | - | ROUTINE | - |
| Sertraline | PO | Tinnitus with comorbid anxiety/depression | 50 mg :: PO :: daily :: Start 25-50 mg daily, titrate to 100-200 mg; SSRI; treats comorbid anxiety and depression that amplify tinnitus distress | Concurrent MAOI; QTc prolongation (high doses) | Monitor mood; GI side effects initially; Zoger et al. (2006): sertraline reduced tinnitus severity in patients with anxiety/depression | - | - | ROUTINE | - |
| Gabapentin | PO | Tinnitus associated with acoustic trauma or comorbid neuropathic pain | 300 mg :: PO :: TID :: Start 300 mg QHS, titrate by 300 mg every 3-5 days to 300-600 mg TID; limited evidence for tinnitus alone; helps subset with noise-induced tinnitus | Renal impairment (adjust dose) | Bauer & Brozoski (2006): some benefit in trauma-related tinnitus; negative in other populations; use if comorbid neuropathic pain | - | - | ROUTINE | - |
PULSATILE TINNITUS — Etiology-Directed Treatment¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Dural AVF embolization | Endovascular | Dural arteriovenous fistula confirmed on angiography | - :: endovascular :: - :: Endovascular embolization is primary treatment; transarterial or transvenous approach; goal is complete obliteration of fistula; staged procedures if needed; curative in majority; high-risk AVFs (cortical venous drainage, Cognard type IIb-V) require urgent treatment | Coagulopathy; contrast allergy (premedicate); renal insufficiency | Awad et al. (1990): endovascular embolization is effective; complete obliteration cures pulsatile tinnitus; monitor for recurrence | - | URGENT | ROUTINE | - |
| Carotid endarterectomy or stenting | Surgical/Endovascular | Carotid stenosis causing pulsatile tinnitus (typically >70% stenosis) | - :: surgical/endovascular :: - :: Per stroke prevention guidelines; tinnitus resolves after revascularization in many cases; surgical decision based on stenosis degree and stroke risk, not tinnitus alone | High surgical risk; complete occlusion (endarterectomy futile) | Standard carotid intervention monitoring; tinnitus resolution variable; treat per vascular guidelines | - | URGENT | ROUTINE | - |
| Acetazolamide (IIH-related pulsatile tinnitus) | PO | IIH-related pulsatile tinnitus | 500 mg :: PO :: BID :: Acetazolamide 250-500 mg PO BID, titrate up to 1g BID as tolerated; first-line medical therapy for IIH; weight loss is critical adjunct; reduces CSF production | Sulfa allergy; severe hepatic/renal disease; hypokalemia; metabolic acidosis | Electrolytes (potassium, bicarbonate) weekly x 4 weeks, then monthly; renal function; visual fields every 3-6 months | - | URGENT | ROUTINE | - |
| Venous sinus stenting | Endovascular | IIH with venous sinus stenosis causing refractory pulsatile tinnitus | - :: endovascular :: - :: Stenting of stenotic transverse sinus; emerging procedure for IIH refractory to medical therapy; resolves pulsatile tinnitus and headache in majority; requires pressure gradient >8 mmHg across stenosis | Venous sinus thrombosis; no gradient across stenosis | Ahmed et al. (2011): venous sinus stenting improved symptoms in majority of IIH patients; long-term data emerging | - | ROUTINE | ROUTINE | - |
| Glomus tumor resection or embolization | Surgical/Endovascular | Glomus jugulare or tympanicum causing pulsatile tinnitus | - :: surgical/endovascular :: - :: Surgical resection (often with preoperative embolization); radiosurgery for poor surgical candidates; observation for small, asymptomatic lesions in elderly; multidisciplinary skull base team | Major surgery risks (cranial nerve damage, especially CN VII, IX, X, XI); bleeding | Preoperative embolization reduces intraoperative bleeding; monitor cranial nerve function; hearing preservation when possible | - | ROUTINE | ROUTINE | - |
| Weight loss (IIH) | - | IIH-related pulsatile tinnitus | - :: - :: - :: 5-10% body weight loss significantly reduces ICP; bariatric surgery referral for BMI >40 or BMI >35 with comorbidities; dietary counseling | None | Sinclair et al. (2010): weight loss reduces ICP and improves IIH symptoms including pulsatile tinnitus | - | ROUTINE | ROUTINE | - |
VESTIBULAR SCHWANNOMA (Acoustic Neuroma) with Tinnitus¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Observation / serial MRI (watch and wait) | - | Small vestibular schwannoma (<1.5 cm) without significant growth or symptoms | - :: - :: - :: Serial MRI with contrast every 6-12 months for first 3 years, then annually if stable; majority of small tumors grow <2 mm/year; intervention if growth, hearing deterioration, or new symptoms | Not appropriate for rapidly growing tumors or large tumors with brainstem compression | Stangerup et al. (2006): majority of small VS show no significant growth; conservative management appropriate for small tumors | - | - | ROUTINE | - |
| Stereotactic radiosurgery (SRS) (Gamma Knife, CyberKnife) | - | Vestibular schwannoma <3 cm; growth on serial MRI; patient preference or poor surgical candidate | - :: - :: single session :: Tumor margin dose typically 12-13 Gy; high tumor control rate (>90%); hearing preservation 50-70% at 5 years; tinnitus outcome variable (improve, stabilize, or worsen) | Very large tumors (>3 cm); brainstem compression requiring decompression | Lunsford et al. (2005): long-term tumor control >97%; hearing preservation achievable | - | - | ROUTINE | - |
| Microsurgical resection | Surgical | Large vestibular schwannoma (>2.5-3 cm); brainstem compression; cystic tumors; failed radiosurgery | - :: surgical :: - :: Approaches: retrosigmoid (hearing preservation), translabyrinthine (no hearing preservation), middle fossa (small tumors, hearing preservation); choice depends on tumor size, hearing status, and surgeon expertise | Poor surgical candidate; small non-growing tumor | Intraoperative facial nerve monitoring (CN VII); postoperative cranial nerve assessment; MRI surveillance for recurrence | - | URGENT | ROUTINE | - |
3C. Medications to AVOID or Use with Caution¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Aminoglycosides (gentamicin, tobramycin, amikacin) | IV/IM | Ototoxic; dose-dependent cochlear and vestibular toxicity; can worsen tinnitus permanently | - :: IV/IM :: - :: AVOID in tinnitus patients unless no alternative exists; if essential, use once-daily dosing to reduce ototoxicity | Tinnitus or pre-existing hearing loss (relative); renal impairment increases risk | Drug levels (trough <1 for gentamicin); serial audiometry if prolonged course | - | ROUTINE | ROUTINE | - |
| High-dose aspirin (>2 g/day) | PO | Dose-dependent tinnitus; reversible with dose reduction; salicylate toxicity | - :: PO :: - :: AVOID doses >2 g/day; tinnitus usually resolves within 24-48h of dose reduction; low-dose aspirin (81-325 mg) is safe | Pre-existing tinnitus at high doses | Salicylate level if toxicity suspected; reduce dose if tinnitus develops | ROUTINE | ROUTINE | ROUTINE | - |
| Loop diuretics (furosemide, ethacrynic acid) | IV/PO | Ototoxic, especially IV high-dose or in renal impairment; usually reversible | - :: IV/PO :: - :: Use lowest effective dose; avoid rapid IV bolus; ethacrynic acid more ototoxic than furosemide | Pre-existing hearing loss with high doses (relative) | Monitor hearing; use lowest effective dose; avoid IV bolus | ROUTINE | ROUTINE | ROUTINE | - |
| Cisplatin and carboplatin | IV | Dose-dependent irreversible cochlear toxicity; high-frequency SNHL and tinnitus | - :: IV :: - :: Irreversible ototoxicity; no proven otoprotectant; cisplatin more ototoxic than carboplatin | Pre-existing hearing loss (dose modification) | Baseline and serial audiometry during treatment; monitor cumulative dose | - | ROUTINE | ROUTINE | - |
| Quinine and chloroquine | PO | Cinchonism (tinnitus, hearing loss, vertigo); usually reversible | - :: PO :: - :: Reversible ototoxicity; reduce dose if tinnitus develops; hydroxychloroquine lower risk | Pre-existing tinnitus at therapeutic doses | Monitor for tinnitus onset; reduce dose if symptoms develop | - | ROUTINE | ROUTINE | - |
| Benzodiazepines (chronic use) | PO | Temporary relief but dependence risk; does not address underlying cause; rebound tinnitus on withdrawal | - :: PO :: - :: Short-term use only if severe acute distress; transition to CBT/SSRI for long-term management; avoid chronic use | Dependence risk; respiratory depression; elderly (fall risk) | Limit to 2-4 weeks; plan transition to non-benzodiazepine therapy | ROUTINE | ROUTINE | ROUTINE | - |
4. OTHER RECOMMENDATIONS¶
4A. Referrals & Consults¶
| Recommendation | ED | HOSP | OPD | ICU |
|---|---|---|---|---|
| Classify tinnitus type (pulsatile vs. non-pulsatile) at initial encounter; pulsatile tinnitus requires vascular workup; ask if pulse-synchronous (check radial pulse simultaneously) | STAT | STAT | ROUTINE | - |
| Perform otoscopic exam on ALL patients; assess for cerumen impaction, TM abnormality, retrotympanic mass, cholesteatoma; low-cost, high-yield | STAT | STAT | ROUTINE | - |
| Audiology referral for comprehensive audiometry; ALL tinnitus patients require audiometry; asymmetric hearing loss triggers MRI | - | URGENT | ROUTINE | - |
| Review ALL medications for ototoxicity; aspirin, NSAIDs, aminoglycosides, loop diuretics, chemotherapeutics; discontinue or substitute when possible | STAT | STAT | ROUTINE | - |
| Neurology consultation if focal neurological deficits; pulsatile tinnitus with papilledema (IIH); suspected CPA mass; suspected dural AVF; diagnostic uncertainty | - | URGENT | ROUTINE | - |
| ENT / Otolaryngology referral for ALL patients with unilateral tinnitus; hearing loss; failed initial management; hearing aid evaluation; intratympanic therapy | - | ROUTINE | ROUTINE | - |
| Fundoscopic exam for pulsatile tinnitus to evaluate for papilledema; IIH presents with pulsatile tinnitus + headache + papilledema; tinnitus can be the presenting symptom | STAT | STAT | ROUTINE | - |
| Mental health screening (PHQ-9, GAD-7) for ALL tinnitus patients; tinnitus strongly associated with anxiety, depression, insomnia; tinnitus distress correlates more with psychological state than tinnitus loudness | - | ROUTINE | ROUTINE | - |
| Neurovascular surgery consultation if dural AVF, glomus tumor, or high-grade carotid stenosis identified; multidisciplinary treatment planning | - | URGENT | ROUTINE | - |
| Skull base surgery / neurotology referral if vestibular schwannoma identified; multidisciplinary discussion (observation vs. SRS vs. surgery) | - | ROUTINE | ROUTINE | - |
4B. Patient Instructions¶
| Recommendation | ED | HOSP | OPD |
|---|---|---|---|
| Use sound enrichment at all times, especially at bedtime: Use a fan, white noise machine, nature sounds, or smartphone app (Oto, ReSound Relief); avoid silence as it amplifies tinnitus perception | ROUTINE | ROUTINE | ROUTINE |
| Return to ED immediately if sudden hearing loss in one or both ears, new weakness or numbness, severe new headache, vision changes, or worsening pulsatile tinnitus with headache — these require urgent evaluation | STAT | STAT | ROUTINE |
| Protect hearing from noise exposure: Wear earplugs or noise-cancelling headphones in loud environments (concerts, power tools, machinery); avoid prolonged headphone use at high volumes; noise exposure worsens tinnitus permanently | - | ROUTINE | ROUTINE |
| Do NOT stop prescribed medications (aspirin, acetazolamide, antidepressants) without consulting your neurologist; abrupt discontinuation can worsen symptoms or cause withdrawal effects | - | ROUTINE | ROUTINE |
| Limit caffeine and alcohol as both can temporarily worsen tinnitus perception; monitor personal triggers and adjust intake accordingly | - | ROUTINE | ROUTINE |
| Report new symptoms promptly: New facial weakness or numbness, worsening hearing, new vertigo, or change in tinnitus character (non-pulsatile becoming pulsatile) warrants re-evaluation | ROUTINE | ROUTINE | ROUTINE |
| Engage with recommended therapy: CBT for tinnitus requires 8-20 sessions for full benefit; attend all scheduled appointments; practice techniques between sessions for best outcomes | - | - | ROUTINE |
4C. Lifestyle & Prevention¶
| Recommendation | ED | HOSP | OPD |
|---|---|---|---|
| Noise protection: Wear hearing protection in all environments >85 dB; use decibel-monitoring smartphone apps; limit headphone use to 60% volume for no more than 60 minutes at a time (60/60 rule) | - | ROUTINE | ROUTINE |
| Stress management: Chronic stress amplifies tinnitus perception; engage in regular mindfulness, meditation, or relaxation exercises; referral to psychologist or CBT therapist for tinnitus-specific coping strategies | - | - | ROUTINE |
| Sleep hygiene: Maintain consistent sleep-wake schedule; use sound enrichment at bedtime (white noise, nature sounds); avoid screens 1 hour before bed; melatonin 3-5 mg if persistent insomnia; CBT-I referral for chronic insomnia | - | ROUTINE | ROUTINE |
| Cardiovascular health: Regular moderate-intensity exercise (150 min/week); optimize blood pressure, lipids, glucose; vascular risk factors worsen both pulsatile and non-pulsatile tinnitus | - | - | ROUTINE |
| Avoid ototoxic substances: Read medication labels; ask pharmacist about ototoxicity with new prescriptions; avoid prolonged NSAID use; report any new tinnitus to prescribing physician | - | ROUTINE | ROUTINE |
═══════════════════════════════════════════════════════════════ SECTION B: SUPPORTING INFORMATION ═══════════════════════════════════════════════════════════════
5. DIFFERENTIAL DIAGNOSIS¶
Tinnitus Classification¶
| Type | Description | Common Causes |
|---|---|---|
| Subjective non-pulsatile | Perceived by patient only; continuous or intermittent ringing, buzzing, hissing; most common type (~85% of tinnitus) | Noise-induced hearing loss, presbycusis, ototoxic medications, Meniere's disease, vestibular schwannoma, idiopathic |
| Subjective pulsatile | Perceived by patient only; rhythmic, pulse-synchronous (heartbeat-like); ~5% of tinnitus but HIGH yield for treatable pathology | IIH, dural AVF, carotid stenosis/dissection, transverse sinus stenosis, anemia, hyperthyroidism, glomus tumor |
| Objective pulsatile | Audible to examiner (stethoscope over ear/mastoid); vascular or mechanical source | Dural AVF, glomus tumor, carotid stenosis, aberrant carotid artery, venous hum, arteriovenous malformation |
| Objective non-pulsatile | Audible clicking/crackling; rare | Palatal myoclonus, stapedial muscle spasm, patulous Eustachian tube, TMJ crepitus |
Pulsatile Tinnitus Differential (Neurological Focus)¶
| Category | Etiology | Key Features | Imaging |
|---|---|---|---|
| Dural arteriovenous fistula (dAVF) | Acquired arteriovenous shunt in dural sinuses; most common in transverse-sigmoid sinus region | Unilateral pulsatile tinnitus (most common presentation); cranial bruit possible; risk of intracranial hemorrhage if cortical venous drainage | MRA/CTA (screening); DSA (gold standard) |
| Idiopathic intracranial hypertension (IIH) | Elevated CSF pressure; often from transverse sinus stenosis | Bilateral pulsatile tinnitus; headache; papilledema; visual obscurations; young obese female; tinnitus is sole presenting symptom in some cases | MRI/MRV (empty sella, optic nerve sheath distension, transverse sinus stenosis); LP (opening pressure) |
| Carotid stenosis | Atherosclerotic narrowing of internal/common carotid | Ipsilateral pulsatile tinnitus; cervical bruit; vascular risk factors; presents with TIA/stroke in some cases | Carotid duplex; CTA/MRA neck |
| Carotid/vertebral dissection | Arterial wall dissection; trauma, spontaneous, connective tissue disease | Acute onset pulsatile tinnitus + headache/neck pain; Horner syndrome (carotid); precedes stroke in some cases | CTA/MRA with fat-suppressed sequences |
| Glomus tumor (paraganglioma) | Glomus jugulare, glomus tympanicum | Pulsatile tinnitus (most common symptom); conductive hearing loss; red/blue mass behind TM (tympanicum); lower cranial nerve palsies (jugulare) | CT temporal bones; MRI; DSA preoperatively |
| Cerebral venous sinus thrombosis | Thrombosis of dural venous sinuses | Pulsatile tinnitus; headache; papilledema; seizures; focal deficits; hypercoagulable state | MRV or CT venogram |
| Transverse sinus stenosis (non-IIH) | Focal narrowing without elevated ICP; common anatomic variant | Unilateral pulsatile tinnitus; incidental finding in some cases; normal opening pressure on LP | MRV; catheter venography with pressure gradients |
| Fibromuscular dysplasia | Non-inflammatory, non-atherosclerotic arteriopathy | Pulsatile tinnitus; young/middle-aged female; involves carotid, vertebral, renal arteries | CTA/MRA (string of beads); DSA |
| High-output states | Anemia, pregnancy, thyrotoxicosis, Paget disease | Bilateral pulsatile tinnitus; resolves with treatment of underlying condition | Labs (CBC, TSH); clinical |
| Aberrant carotid artery | Carotid courses through middle ear; congenital | Pulsatile tinnitus; visible retrotympanic pulsating mass; DO NOT biopsy — risk of fatal hemorrhage | CT temporal bones |
Non-Pulsatile Tinnitus Differential (Neurological Focus)¶
| Etiology | Key Features | Workup |
|---|---|---|
| Vestibular schwannoma (acoustic neuroma) | Unilateral tinnitus (most common initial symptom in many cases); progressive unilateral SNHL; facial numbness (CN V); imbalance; facial weakness late | MRI with gadolinium (IACs) |
| Meniere's disease | Episodic tinnitus + fluctuating hearing loss + aural fullness + vertigo; low-frequency SNHL | Audiometry; clinical criteria |
| Noise-induced hearing loss | Chronic tinnitus following noise exposure; high-frequency SNHL; bilateral; 4 kHz notch on audiogram | Audiometry; history |
| Presbycusis | Age-related SNHL; bilateral high-frequency loss; gradual onset tinnitus | Audiometry; age >60 |
| Ototoxic medications | Temporal association with medication use; aminoglycosides, cisplatin, high-dose aspirin, loop diuretics | Medication history; serial audiometry |
| MS plaque (CPA/brainstem) | Tinnitus with other neurological symptoms; young adult; relapsing-remitting course | MRI brain with gadolinium |
| Otosclerosis | Low-frequency conductive hearing loss; tinnitus; family history; Carhart notch on audiogram | Audiometry; CT temporal bones |
| TMJ dysfunction (somatic tinnitus) | Tinnitus modulated by jaw movement, clenching; ipsilateral; TMJ pain/clicking | Clinical exam; dental referral |
| Cervical spine dysfunction (somatosensory tinnitus) | Tinnitus modulated by neck movement; cervical pathology | Cervical exam; imaging if needed |
Red Flags in Tinnitus Evaluation¶
| Red Flag | Concern | Action |
|---|---|---|
| Unilateral tinnitus | Vestibular schwannoma; CPA mass; asymmetric SNHL | MRI with gadolinium (IACs) |
| Pulsatile tinnitus | Vascular pathology (dural AVF, carotid stenosis, IIH, glomus tumor) | MRA/CTA; MRV; DSA if indicated |
| Pulsatile tinnitus + papilledema | IIH; cerebral venous sinus thrombosis | Urgent MRI/MRV; LP with opening pressure |
| Pulsatile tinnitus + cranial bruit | Dural AVF; carotid stenosis | Urgent vascular imaging; DSA |
| Sudden onset SNHL + tinnitus | Otologic emergency; vascular occlusion; viral cochleitis | Urgent audiometry; steroids within 72h; ENT |
| Focal neurological deficits | CPA mass (facial weakness, numbness); brainstem lesion; stroke | Urgent MRI; neurology consultation |
| Unilateral hearing loss (progressive) | Vestibular schwannoma; cholesteatoma; retrocochlear pathology | MRI IACs; audiometry |
| Tinnitus + suicidal ideation | Psychiatric emergency; tinnitus is independent risk factor for suicide | Immediate psychiatric evaluation; safety assessment |
| Retrotympanic mass | Glomus tumor; aberrant carotid; high jugular bulb; DO NOT biopsy | CT temporal bones; MRI; vascular imaging |
6. MONITORING PARAMETERS¶
ED / Acute Phase¶
| Parameter | ED | HOSP | OPD | ICU | Frequency | Target | Action if Abnormal |
|---|---|---|---|---|---|---|---|
| Neurologic exam (cranial nerves, fundoscopy, hearing) | STAT | STAT | ROUTINE | - | On presentation | No focal deficits; no papilledema | Papilledema — urgent MRI/MRV/LP; focal deficits — STAT MRI; cranial bruit — vascular imaging |
| Vital signs | STAT | ROUTINE | - | - | q4h (if admitted); on presentation (ED) | Stable; no hypertensive crisis | Hypertension — manage per guidelines; tachycardia — evaluate thyroid, anemia |
| Hearing assessment (bedside) | STAT | STAT | ROUTINE | - | On presentation | Weber/Rinne normal or lateralizes appropriately | Asymmetry — urgent audiometry; sudden SNHL — start steroids |
| Tinnitus characterization | STAT | STAT | ROUTINE | - | On presentation | Document pulsatile vs. non-pulsatile; unilateral vs. bilateral; quality; duration; modulating factors | Pulsatile — vascular imaging pathway; unilateral — MRI pathway |
| Blood glucose (if on steroids) | STAT | ROUTINE | ROUTINE | - | Every 6 hours while on steroids | Glucose <200 mg/dL | Glucose >200 — insulin per sliding scale; endocrine consultation if persistent |
Outpatient Follow-up¶
| Parameter | ED | HOSP | OPD | ICU | Frequency | Target | Action if Abnormal |
|---|---|---|---|---|---|---|---|
| Audiometry | - | ROUTINE | ROUTINE | - | Baseline, then annually (or sooner if change) | Stable hearing; no progression | Progressive hearing loss — repeat MRI; ENT; evaluate ototoxicity |
| Tinnitus severity (TFI or THI) | - | - | ROUTINE | - | Every 3-6 months | Decreasing score; <25 on TFI | Worsening — adjust therapy; add CBT; medication adjustment; re-evaluate etiology |
| MRI surveillance (if vestibular schwannoma) | - | - | ROUTINE | - | 6 months, 12 months, then annually x 5 years | No growth | Growth >2 mm/year — SRS or surgery discussion |
| Visual fields / fundoscopy (if IIH) | - | ROUTINE | ROUTINE | - | Every 3-6 months | No papilledema; stable visual fields | Visual field loss — escalate IIH treatment (increase acetazolamide, stent/shunt referral) |
| Mental health screening | - | ROUTINE | ROUTINE | - | Every visit | PHQ-9 <5; GAD-7 <5; no suicidality | Worsening — mental health referral; SSRI/CBT; safety plan if suicidal ideation |
| Medication review | - | ROUTINE | ROUTINE | - | Every visit | No new ototoxic medications | New ototoxic medication — discuss alternatives; baseline audiometry before starting |
| Acetazolamide labs (if on acetazolamide) | - | ROUTINE | ROUTINE | - | Weekly x 4 weeks, then monthly | Potassium >3.5; bicarbonate >18; creatinine stable | Hypokalemia — supplement; metabolic acidosis — dose reduction; renal impairment — discontinue |
7. DISPOSITION CRITERIA¶
Admission Criteria¶
| Level of Care | Criteria |
|---|---|
| ICU | Hemorrhagic complication of dural AVF (intracranial hemorrhage); acute stroke from carotid dissection; severe IIH with visual loss requiring emergent intervention |
| General floor | Sudden sensorineural hearing loss requiring IV steroids and monitoring; newly diagnosed cerebral venous sinus thrombosis requiring anticoagulation initiation; newly diagnosed dural AVF requiring observation and planning for intervention; IIH with significant papilledema requiring serial visual field assessments and LP |
| Observation | Diagnostic uncertainty requiring urgent imaging (MRI/MRA not available as outpatient in timely fashion); intractable symptoms requiring symptomatic management |
Discharge Criteria¶
| Criterion | Details |
|---|---|
| Dangerous etiologies excluded or identified and managed | Vascular causes (dural AVF, carotid stenosis) either excluded or treatment plan in place; CPA mass excluded or identified with management plan; IIH diagnosed and treatment initiated |
| Hearing stable | No active sudden SNHL requiring emergent steroids; audiometry completed or scheduled |
| Follow-up arranged | Audiology within 2-4 weeks; ENT/neurology as indicated; mental health if needed |
| Safety assessment complete | No suicidal ideation (screen all patients); crisis resources provided if needed |
| Patient education provided | Tinnitus explained (benign in most cases); sound enrichment strategies discussed; avoid silence; hearing protection for noise exposure; when to return (sudden hearing loss, new neurological symptoms, severe distress) |
Discharge Prescriptions¶
| Medication | Indication | Instructions |
|---|---|---|
| Prednisone 60 mg (if sudden SNHL) | Sudden sensorineural hearing loss | 60 mg daily x 7-14 days then taper; start within 72h of onset; ENT follow-up within 1 week |
| Melatonin 3-5 mg | Tinnitus-associated insomnia | Take 30-60 minutes before bedtime; over-the-counter |
| Acetazolamide 250-500 mg BID (if IIH) | IIH-related pulsatile tinnitus | Take with meals; monitor for paresthesias (common side effect); labs in 1 week (electrolytes, bicarbonate) |
| Sound therapy app/device recommendation | All bothersome tinnitus | Use background sound enrichment, especially at bedtime; avoid silence; many free smartphone apps available |
| Sertraline 25-50 mg daily (if comorbid anxiety/depression) | Tinnitus with comorbid anxiety or depression | Start 25 mg daily, increase to 50 mg after 1 week if tolerated; follow up in 2-4 weeks; monitor for GI side effects |
8. EVIDENCE & REFERENCES¶
Key Guidelines¶
| Guideline | Source | Year | Key Recommendation |
|---|---|---|---|
| Clinical Practice Guideline: Tinnitus | AAO-HNS (Tunkel et al.) | 2014 | Comprehensive audiometry for all; targeted imaging for unilateral/pulsatile; against routine imaging for bilateral non-pulsatile; against routine pharmacotherapy; CBT recommended |
| Diagnostic Approach to Pulsatile Tinnitus | Defined diagnostic algorithm | 2013 | MRA/CTA for pulsatile tinnitus; DSA if high suspicion for dAVF; temporal bone CT for retrotympanic mass |
| Sudden Sensorineural Hearing Loss Practice Guideline | AAO-HNS (Chandrasekhar et al.) | 2019 | Steroids within 2 weeks of onset; intratympanic steroids as salvage; audiometry at baseline and follow-up |
| European Guideline on Tinnitus | European Academy of Otology and Neurotology | 2019 | CBT as first-line for distress; against routine pharmacotherapy for tinnitus alone; sound therapy as adjunct; structured assessment recommended |
Landmark Studies¶
| Study | Finding | Impact |
|---|---|---|
| Cima et al. (2012) | Stepped-care CBT for tinnitus significantly reduced tinnitus-related distress, improved quality of life in randomized controlled trial (n=492) | CBT is the most evidence-supported therapy for tinnitus; first-line for bothersome chronic tinnitus |
| Langguth et al. (2012) | Systematic review of rTMS for tinnitus; moderate short-term benefit on tinnitus severity; optimal stimulation parameters not established | TMS is promising but not yet standard; reserved for refractory cases in research settings |
| Mattox & Simmons (1977) | Natural history of vestibular schwannoma: tinnitus is presenting symptom in ~70% of patients; often precedes hearing loss | Unilateral tinnitus warrants MRI to rule out vestibular schwannoma |
| Sismanis (2003) | Comprehensive review of pulsatile tinnitus etiologies; defined diagnostic algorithm; dural AVF is most common surgically treatable vascular cause | Pulsatile tinnitus requires systematic vascular evaluation; high rate of identifiable and treatable pathology |
| Bauer & Brozoski (2006) | Gabapentin showed modest benefit for tinnitus related to acoustic trauma in RCT; no benefit in non-trauma tinnitus | Gabapentin helps trauma-related tinnitus but is not effective for non-traumatic tinnitus |
| Sullivan et al. (1993) | Nortriptyline reduced tinnitus loudness and depression in patients with severe tinnitus and comorbid depression | Tricyclic antidepressants benefit tinnitus patients with depression; treat comorbidity |
| NORDIC IIH Study Group (2014) | Acetazolamide with diet significantly improved papilledema, visual function, headache, pulsatile tinnitus, and quality of life in IIH (n=165) | Acetazolamide is first-line medical therapy for IIH; pulsatile tinnitus improves with ICP reduction |
| Chandrasekhar et al. (2019) | AAO-HNS guideline for sudden SNHL: steroids recommended within 2 weeks; intratympanic salvage if systemic fails; MRI to rule out retrocochlear | Standard of care for sudden hearing loss with tinnitus; early treatment improves outcomes |
Tinnitus Assessment Tools¶
| Tool | Scoring | Clinical Utility |
|---|---|---|
| Tinnitus Functional Index (TFI) | 0-100; <25 mild, 25-50 significant, >50 severe, >75 catastrophic | Most sensitive to treatment change; validated; tracks longitudinal response |
| Tinnitus Handicap Inventory (THI) | 0-100; Grade 1 (0-16) to Grade 5 (78-100) | Widely used; good test-retest reliability; validated in multiple languages |
| Visual Analogue Scale (VAS) for tinnitus | 0-10 for loudness and annoyance | Quick; useful for serial tracking; less comprehensive |
APPENDICES¶
Appendix A: Pulsatile Tinnitus Diagnostic Algorithm¶
Step 1: Is it pulse-synchronous? - Have patient tap finger with heartbeat while you listen to tinnitus description - Check radial pulse simultaneously with reported tinnitus rhythm - Pulse-synchronous — proceed to pulsatile tinnitus workup - Not pulse-synchronous — evaluate as non-pulsatile tinnitus
Step 2: Otoscopic exam - Retrotympanic mass (red/blue)? — CT temporal bones first (DO NOT biopsy); glomus tumor, aberrant carotid, high jugular bulb - Normal otoscopy — proceed to Step 3
Step 3: Is tinnitus objective (audible on auscultation)? - Listen with stethoscope over mastoid, periauricular, orbits, neck - Bruit present — high likelihood of vascular lesion; proceed to MRA/CTA - No bruit — still pursue vascular workup (many causes are not audible)
Step 4: Fundoscopic exam - Papilledema present — IIH or venous sinus thrombosis; MRI/MRV; LP with opening pressure - No papilledema — does not exclude IIH (6-10% lack papilledema)
Step 5: Imaging - MRI brain + MRA head/neck (first-line vascular screen) - CT temporal bones (if retrotympanic mass or bony pathology suspected) - MRV (if IIH or venous thrombosis suspected) - DSA (if MRA/CTA suggestive of dAVF or inconclusive with high suspicion)
Step 6: Laboratory - CBC (anemia), TSH (hyperthyroidism), metabolic panel - ESR/CRP (vasculitis), coagulation studies (CVT)
Step 7: Etiology identified? - YES — Treat underlying cause (see Section 3B) - NO — Evaluate for: venous hum (benign, increases in lateral head turn), sigmoid sinus wall dehiscence, benign intracranial hypertension variant; specialist referral
Appendix B: Non-Pulsatile Tinnitus Evaluation Pathway¶
Step 1: History - Duration, onset, laterality, quality (ringing, buzzing, hissing), severity (TFI/THI) - Associated hearing loss, vertigo, aural fullness, facial weakness/numbness - Noise exposure history; medication review (ototoxic drugs); head/neck trauma - TMJ symptoms (jaw pain, clicking, modulation of tinnitus with jaw movement) - Psychological impact: anxiety, depression, insomnia, concentration, suicidal ideation
Step 2: Physical Exam - Otoscopy (cerumen, TM, middle ear) - Cranial nerve exam (CN V, VII, VIII in particular) - Weber/Rinne tuning fork tests - TMJ exam (palpation, range of motion, crepitus) - Cervical spine exam
Step 3: Audiometry - ALL patients: comprehensive audiometry - Asymmetric SNHL (>10 dB at 2 frequencies or >15 dB at 1 frequency) — MRI IACs - Normal or symmetric — no routine MRI (per AAO-HNS guideline)
Step 4: MRI (if indicated) - Unilateral tinnitus — MRI brain with IACs with gadolinium - Asymmetric SNHL — MRI brain with IACs with gadolinium - If MRI contraindicated — ABR (less sensitive)
Step 5: Management - Treat underlying cause if identified - Hearing loss — hearing aids (with tinnitus masking program) - Bothersome tinnitus — CBT (first-line); sound therapy; TRT - Comorbid depression/anxiety — SSRI/CBT - Insomnia — melatonin; CBT-I; sound enrichment at bedtime - Refractory — specialty tinnitus clinic; TMS, neuromodulation
Appendix C: IIH-Tinnitus Connection¶
Why pulsatile tinnitus in IIH: - Elevated intracranial pressure — turbulent venous flow through compressed/stenotic transverse sinus - Transverse sinus stenosis (bilateral or unilateral) amplifies venous flow sounds - Tinnitus is the sole presenting symptom of IIH before headache or visual changes develop in some cases - Resolution of pulsatile tinnitus is a marker of treatment response
IIH diagnostic criteria (Modified Dandy): 1. Signs/symptoms of elevated ICP (headache, pulsatile tinnitus, visual obscurations, papilledema) 2. No localizing neurological signs (except CN VI palsy) 3. CSF opening pressure >25 cm H2O (lateral decubitus) 4. Normal CSF composition 5. No structural cause on imaging (MRI/MRV to exclude venous thrombosis, mass)
IIH treatment ladder: 1. Weight loss (5-10% body weight) 2. Acetazolamide 250 mg BID — titrate to 1 g BID 3. Topiramate 25-100 mg BID (adjunct; also promotes weight loss) 4. Lumbar puncture (therapeutic; temporary ICP reduction) 5. Venous sinus stenting (for stenosis with gradient >8 mmHg) 6. CSF diversion (VP shunt, LP shunt) for refractory cases with visual loss
Appendix D: Vestibular Schwannoma and Tinnitus¶
Key Facts: - Tinnitus is the presenting symptom in ~70% of vestibular schwannomas - Unilateral high-pitched tinnitus is the classic presentation - Tinnitus precedes hearing loss by months to years in some cases - ALL patients with unilateral tinnitus require audiometry; asymmetric SNHL triggers MRI - Small tumors (<1.5 cm) often managed conservatively with serial MRI - Tinnitus persists or worsens after treatment (surgery or SRS) even if tumor is controlled in some cases
When to suspect vestibular schwannoma: - Unilateral tinnitus (especially high-pitched continuous) - Progressive unilateral sensorineural hearing loss - Asymmetric speech discrimination scores - Unilateral vestibular hypofunction - Facial numbness (CN V involvement; larger tumors) - Facial weakness (CN VII; late finding)
Appendix E: Ototoxic Medications Reference¶
| Medication Class | Examples | Tinnitus Risk | Reversibility |
|---|---|---|---|
| Aminoglycosides | Gentamicin, tobramycin, amikacin, streptomycin | High (dose-dependent, cumulative) | Usually irreversible |
| Loop diuretics | Furosemide, ethacrynic acid, bumetanide | Moderate (IV, high dose, renal failure) | Usually reversible |
| Salicylates | High-dose aspirin (>2 g/day) | High (dose-dependent) | Reversible (24-72h after reduction) |
| Platinum chemotherapeutics | Cisplatin, carboplatin | High (cisplatin > carboplatin) | Irreversible |
| Quinine/Chloroquine | Quinine, chloroquine, hydroxychloroquine | Moderate | Usually reversible |
| Macrolide antibiotics | Erythromycin (IV high dose), azithromycin | Low-Moderate | Usually reversible |
| Vancomycin | Vancomycin (especially with aminoglycosides) | Moderate (synergistic with aminoglycosides) | Variable |
| NSAIDs | Ibuprofen, naproxen (high dose, chronic use) | Low-Moderate | Usually reversible |
CHANGE LOG¶
v1.1 (February 2, 2026) - Reformatted Section 4A to 5-column layout (Recommendation | ED | HOSP | OPD | ICU); merged Details content into Recommendation column - Added Section 4B (Patient Instructions) with 7 tinnitus-specific items: sound enrichment, return precautions, hearing protection, medication compliance, caffeine/alcohol, symptom reporting, therapy engagement - Added Section 4C (Lifestyle & Prevention) with 5 items: noise protection, stress management, sleep hygiene, cardiovascular health, ototoxic substance avoidance - Reformatted Section 4B/4C to 4-column layout (Recommendation | ED | HOSP | OPD) per template standard - Added venue columns (ED, HOSP, OPD, ICU) to Section 6 Monitoring tables - Added blood glucose monitoring parameter for steroid-treated patients (Section 6) - Added acetazolamide lab monitoring parameter (Section 6) - Made acetazolamide row in Section 3B pulsatile tinnitus self-contained (removed cross-reference to 3A) - Expanded nortriptyline contraindications to be self-contained (removed implicit cross-reference to amitriptyline) - Populated Section 3C (Medications to AVOID) with Route, structured content in Dosing, Contraindications, and Monitoring columns - Added blood glucose/HbA1c ED coverage as ROUTINE (previously "-") - Replaced non-directive language throughout ("consider" replaced with directive imperatives; "may" replaced with factual statements) - Added ICU to frontmatter setting field - Updated REVISED date and STATUS line - Updated discharge prescription for SSRI to specify sertraline with dosing - Added neurovascular surgery and skull base surgery referrals to Section 4A (moved from 4B Extended)
v1.0 (February 2, 2026) - Initial template creation - Comprehensive neurological tinnitus evaluation covering pulsatile and non-pulsatile etiologies - Vascular causes (dural AVF, carotid stenosis, IIH, glomus tumor), CPA tumors (vestibular schwannoma), and systemic causes - Treatment protocols for CBT, sound therapy, pharmacotherapy, and etiology-directed interventions - Structured dosing format for all medications - Five appendices: pulsatile algorithm, non-pulsatile pathway, IIH-tinnitus connection, vestibular schwannoma reference, ototoxic medications
This template has been validated through the checker/rebuilder pipeline (v1.1) and requires physician review before clinical deployment.