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

Related Curbside Consultation: Making Recommendations to Reduce Noise Exposure

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

This clinical content conforms to AAFP criteria for CME.

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

RecommendationEvidence ratingComments
Patients with primary tinnitus that is not bothersome do not require further intervention.8 CGuideline 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 CGuideline 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 CGuideline 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 CPatient-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 BPatient-oriented evidence based on systematic review of limited-quality randomized controlled trials
RecommendationSponsoring organization
Do not order imaging studies in patients with nonpulsatile bilateral tinnitus, symmetric hearing loss, and an otherwise normal history and physical examination.American Academy of Otolaryngology–Head and Neck Surgery Foundation


For this review, tinnitus is categorized as primary and secondary. Primary tinnitus is the more common of the two categories. It is idiopathic, and most cases are associated with SNHL, including presbycusis and noise-related hearing loss. The exact pathophysiology of primary tinnitus is often unclear and is likely multifactorial. It is thought to be a phantom sensation from abnormal neural activity in the ear, the auditory nerve, or central nervous system.10 Patients with primary tinnitus that is not bothersome do not require further intervention.8 Secondary tinnitus has an identifiable cause.8 Table 1 lists the causes of secondary tinnitus.6,1116 Many medications are associated with ototoxicity, resulting in tinnitus or hearing loss; the most commonly used are listed in Table 2.1719 Tinnitus is also a common accompanying symptom of Meniere disease and vestibular schwannoma, previously known as acoustic neuroma. Tinnitus is strongly associated with depression; the presence of tinnitus can worsen depressive symptoms and contribute to suicidal ideation.8,20

InfectiousBacterial (Lyme disease, syphilis), fungal, viral
MetabolicDiabetes mellitus, hyperlipidemia, vitamin B12 deficiency
NeurologicIdiopathic intracranial hypertension, idiopathic stapedial or tensor tympani muscle spasm, multiple sclerosis, palatal myoclonus, spontaneous intracranial hypotension, type I Chiari malformation, vestibular migraine
OtologicCerumen impaction, cholesteatoma, foreign body, Meniere disease, middle ear effusion, otitis, otosclerosis, patulous eustachian tube, tympanic membrane perforation, vestibular schwannoma
SomaticHead or neck injury, temporomandibular joint dysfunction
ToxicologicMedication or substance use
TraumaticCerumen removal
VascularArterial bruit; arteriovenous malformation; carotid atherosclerosis, dissection, or tortuosity; Paget disease; vascular tumors; venous hum
Bupivacaine (Marcaine), lidocaine
Carbamazepine (Tegretol), pregabalin (Lyrica)
Anti-inflammatory agents
Aspirin,* nonsteroidal anti-inflammatory drugs, sulfasalazine (Azulfidine)
Antimalarial agents
 Chloroquine (Aralen), quinine
Antimicrobial agents
 Amikacin, gentamicin, kanamycin, neomycin, tobramycin (Tobrex)
 Azithromycin (Zithromax), erythromycin
 Doxycycline, minocycline (Minocin)
Antineoplastic agents
Platinum compounds
 Carboplatin (Paraplatin), cisplatin
Protein kinase inhibitors
 Axitinib (Inlyta), dasatinib (Sprycel), imatinib (Gleevec), lapatinib (Tykerb), osimertinib (Tagrisso), ruxolitinib (Jakafi)
Pyrimidine analogues
 Capecitabine (Xeloda)
 Paclitaxel (Taxol)
Antivirals for treatment of hepatitis C virus infections
Ribavirin (Rebetol), sofosbuvir (Sovaldi), telaprevir (Incivek)
Calcineurin inhibitors
 Cyclosporine (Sandimmune)
Monoclonal antibodies
 Ipilimumab (Yervoy), nivolumab (Opdivo), trastuzumab (Herceptin)
Loop diuretics
Furosemide (Lasix), torsemide (Demadex)||
Paralytics (for anesthesia)
Quaternary ammonium compounds
Phosphodiesterase type 5 inhibitors
Sildenafil (Viagra), tadalafil (Cialis)
 Bivalent (HPV-16, HPV-18); quadrivalent (HPV-6, HPV-11, HPV-16, HPV-18)
Pneumococcal polysaccharide (Pneumovax)
Atorvastatin (Lipitor), bupropion (Wellbutrin), risedronate (Actonel), varenicline (Chantix)
Antiarrhythmics, dopamine agonists, hormone agents, proton pump inhibitors


When a patient presents with tinnitus, the clinician's main goal is to identify causes that can be treated, or that may be dangerous. Figure 1 outlines elements of the initial evaluation and management of tinnitus.5,8,9,13,1719,2126


A focused, detailed history and physical examination are the primary tools for diagnosing tinnitus, distinguishing benign from dangerous causes, and determining potential treatment options.8,9 Initial triage involves identifying characteristics of the patient's tinnitus that warrant urgent evaluation: pulsatile, associated with neurologic abnormalities, asymmetric or unilateral symptoms, and asymmetric hearing loss. Although it is much less common, pulsatile tinnitus should raise suspicion for underlying cardiovascular disease and intracranial vascular abnormality (e.g., vascular tumor), increased intracranial pressure, or neoplasm.11

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