Tinnitus: a stepwise workup to quiet the noise within

Patients with tinnitus--ringing in the ears or head--frequently present initially to their primary care physician. Tinnitus may be subjective (audible only by the patient) or objective (audible to the examiner). Subjective tinnitus is more common and may be due to peripheral or central auditory pathology, a metabolic abnormality, or anxiety/depression. Objective tinnitus is rare and is frequently due to a vascular or neuromuscular condition, intracranial or head/neck tumor, or some specific structural defect of the ear, cochlea, or retrocochlear area. The stepwise workup of tinnitus includes a comprehensive history and physical exam, audiologic evaluation, blood profile analysis, and referral when necessary. Treatments include hearing aids, masking devices, drugs, and biofeedback.