Tinnitus Protocol

Intake, red flags, tests, and first-line management for adults with tinnitus.

Clinic quick guide Evidence-based

History & Red Flags

  • Unilateral, pulsatile, sudden hearing loss, neuro deficit, severe vertigo → urgent ENT/neurology imaging.
  • Onset, duration, triggers, noise exposure, ototoxic meds, sleep/stress, TMJ/neck pain.

Physical & Basic Tests

  • Otoscopy, tuning fork (Weber/Rinne), cranial nerves, TMJ/cervical exam.
  • Audiogram for almost all; tympanometry as needed.
  • If pulsatile: consider carotid/venous bruit, MRI/MRA/CT as indicated.

Common Causes

  • Sensorineural loss (presbycusis, noise-induced), otitis media with effusion, otosclerosis.
  • Medication: NSAIDs, aminoglycosides, loop diuretics, chemo, high-dose aspirin.
  • Somatic: TMJ disorder, cervical myofascial tension.
  • Vascular: AV malformation, carotid stenosis, idiopathic intracranial hypertension.

Management (initial)

  • Explain benign nature in most cases; set expectations.
  • Hearing loss: consider hearing aids/sound therapy.
  • Sleep/anxiety: CBT, mindfulness; short-term melatonin for sleep.
  • Somatic component: TMJ care, cervical stretching/physio.
  • Avoid loud noise; review and adjust ototoxic meds if feasible.

When to Refer

  • Unilateral or pulsatile tinnitus.
  • Asymmetric hearing loss or sudden hearing loss.
  • Neurologic signs, severe vertigo, or suspected vascular cause.