Tinnitus: Diagnosis and Management

 

Am Fam Physician. 2021 Jun 1;103(11):663-671.

  Patient information: See related handout on tinnitus, written by the authors of this article.

Related Curbside Consultation: Making Recommendations to Reduce Noise Exposure

Author disclosure: No relevant financial affiliations.

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.

Tinnitus is the perception of sound in the absence of an objective internal or external source. Tinnitus is a symptom, not a disease, and although it is typically not associated with a dangerous condition, it can significantly affect quality of life. Tinnitus is a common problem among adults in the United States, with an estimated prevalence of 10% to 15% and peak incidence between 60 and 69 years of age.13 At least 20% of people diagnosed with tinnitus will seek clinical intervention.4 The etiology of primary tinnitus is often unclear, but most cases are associated with sensorineural hearing loss (SNHL). Secondary tinnitus results from sound generated by a source near the ear or referred to the ear, and is rare, accounting for less than 1% of tinnitus cases.5,6 Vascular and neuromuscular etiologies are the more common causes of secondary tinnitus.5,7 Guidelines recommend a standard approach to history and physical examination that can begin the process of determining the etiology of the tinnitus, followed by audiometric testing and imaging, laboratory studies, and other testing as appropriate.8,9

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

RecommendationEvidence ratingComments

Patients with primary tinnitus that is not bothersome do not require further intervention.8

C

Guideline recommendation based on limited-quality studies of patient-oriented outcomes

A focused history and physical examination should be performed to identify tinnitus characteristics and examination findings that direct differential diagnosis, further evaluation, and treatment options.8

C

Guideline recommendation based on observational studies

Patients should be referred within four weeks for audiologic examination if tinnitus is chronic, bothersome, unilateral, or associated with hearing changes.8

C

Guideline recommendation based on observational studies

Imaging should be avoided unless tinnitus is unilateral, pulsatile, associated with asymmetric hearing loss, or with focal neurologic abnormalities.8,9

C

Patient-oriented recommendation from the American Academy of Otolaryngology–Head and Neck Surgery and European guidelines based on observational studies with significant benefit over harm

Patients should be referred to cognitive behavior therapy for chronic, bothersome primary tinnitus.8,9,25,44,45

B

Patient-oriented evidence based on systematic review of limited-quality randomized controlled trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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SARAH N. DALRYMPLE, MD, is an assistant professor in the Department of Family Medicine at the University of Virginia, Charlottesville....

SARAH H. LEWIS, DO, is an assistant professor in the Department of Family Medicine at the University of Virginia, Charlottesville.

SAMANTHA PHILMAN, MD, MPH, is a fellow in the Information Mastery and Faculty Development Fellowship and a clinical instructor in the Department of Family Medicine at the University of Virginia, Charlottesville.

Address correspondence to Sarah N. Dalrymple, MD, University of Virginia, 1221 Lee St., Box 800729, Charlottesville, VA 22908 (email: sdalrymple@virginia.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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