Tinnitus: Diagnosis and Management

Tinnitus is the sensation of hearing a sound in the absence of an internal or external source and is a common problem encountered in primary care. Most cases of tinnitus are benign and idiopathic and are strongly associated with sensorineural hearing loss. A standard workup begins with a targeted history and physical examination to identify treatable causes and associated symptoms that may improve with treatment. Less common but potentially dangerous causes such as vascular tumors and vestibular schwannoma should be ruled out. A comprehensive audiologic evaluation should be performed for patients who experience unilateral tinnitus, tinnitus that has been present for six months or longer, or that is accompanied by hearing problems. Neuroimaging is not part of the standard workup unless the tinnitus is asymmetric or unilateral, pulsatile, associated with focal neurologic abnormalities, or associated with asymmetric hearing loss. Cognitive behavior therapy is the only treatment that has been shown to improve quality of life in patients with tinnitus. Sound therapy and tinnitus retraining therapy are treatment options, but evidence is inconclusive. Melatonin, antidepressants, and cognitive training may help with sleep disturbance, mood disorders, and cognitive impairments, respectively. Avoidance of noise exposure may help prevent the development or progression of tinnitus. Providing information about the natural progression of tinnitus and being familiar with the causes that warrant additional evaluation, imaging, and specialist involvement are essential to comprehensive care.