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Diagnosing Tinnitus
A hearing test should be the first step in an audiological evaluation of tinnitus, since about 90 percent of tinnitus cases occur with hearing loss.
 
Starting with a thorough medical exam, the proper diagnosis and evaluation of tinnitus are both critical for successful tinnitus management.
A small number of people with tinnitus are severely affected by it and often show signs of mood disturbances, sleep difficulties, and cognitive dysfunction. Timely and appropriate tinnitus evaluation is critical for adequate tinnitus management so that these patients, who represent about 0.5 percent of the population, can improve and regain functionality and quality of life.
 
Patients usually first complain about their tinnitus to their primary care providers, either to a physician or nurse practitioner. However, you may be told by a well-meaning (if ill-informed) physician during a routine office visit that there is nothing you can do for your tinnitus. This is incorrect.
 
If your tinnitus is persistent and problematic, ask to be referred to a specialist: an ear, nose, and throat doctor (ENT or otolaryngologist) or an audiologist. Both are able to conduct additional evaluations focused on the auditory and related systems.
Remember that tinnitus is a symptom, not a condition itself. Here is what to expect during a comprehensive evaluation.

Establishing Medical Causes
 
The focus of medical evaluation of tinnitus should be to identify any active and treatable medical conditions you may have that are causing or contributing to tinnitus. Medical conditions involving the auditory system, especially those causing hearing loss, can frequently lead to tinnitus. These range from simple cerumen (earwax) impaction in the ear canal to complex conditions that involve the inner ear or auditory neural pathways.
 
Common auditory conditions that can lead to tinnitus include otitis media (a middle ear infection); otosclerosis (an abnormal bone growth in the middle ear); sudden sensorineural hearing loss (sudden deafness); Ménière’s disease; noise-induced hearing loss; presbycusis (age-related hearing loss); acoustic neuroma (a benign, slow-growing tumor on the auditory nerve); and some brain diseases that involve the auditory system.
 
Vascular system disorders in the head and neck area can cause tinnitus that pulses in time with the heartbeat. Head and neck injuries including whiplash are frequently associated with tinnitus. Severe temporomandibular (jaw) joint disorders can sometimes result in tinnitus. Tinnitus can also occur with systemic diseases such as severe anemia, hypertension, hypothyroidism, and syphilis.
 
Your medical evaluation should also include discovering concurrent conditions such as tinnitus-related anxiety, depression, and insomnia, as these can affect your prognosis and treatment plan.

Audiological Tests
Your medical evaluation will start with a thorough medical history, followed by a careful physical examination and diagnostic testing. These can provide important clues leading to the identification of the underlying cause of your tinnitus.
 
Laboratory and imaging studies are sometimes required to obtain the correct diagnosis or to rule out potentially serious diseases underlying tinnitus. Prompt identification and management of causal and concurrent conditions in tinnitus may not only reduce their potentially detrimental consequences, but may also resolve or improve the tinnitus when the conditions are addressed.
 
Audiological evaluation is an inseparable and important part of tinnitus assessment. A hearing test is almost always needed to identify any condition that involves the auditory system. This should be the first step in an audiological evaluation of tinnitus, since about 90 percent of cases occur with hearing loss.
 
In addition to routine pure tone and speech audiometry, a range of audiological tests can help assess the health and function of your middle ear, inner ear, and auditory pathway. They may include tympanometry, otoacoustic emissions, electrocochleography, auditory brainstem responses, and vestibular evoked myogenic potentials.
 
The audiological evaluation should also include tinnitus test protocols that can help determine the pitch and loudness of your tinnitus and how it interacts with an external sound, or what is termed maskability and residual inhibition.
 
When documentation for claims or litigation is needed—if your tinnitus arose as a result of an accident or was related to workplace injury or hazards exposure—tinnitus testing must be geared toward establishing certain levels of objectivity and severity. This is often achieved through assessment of test-retest reliability and the use of one of many tinnitus severity indices.
 
The impact of tinnitus on an individual’s life cannot always be determined based upon simple measures of tinnitus itself. A comprehensive tinnitus assessment should always include measures of the impact of tinnitus on your quality of life and ability to function.
 
A number of tinnitus evaluation questionnaires have been developed and reported in tinnitus studies. These usually contain multiple-choice questions covering various aspects of essential daily activities, sleep, communication, interpersonal interactions, cognitive functions, and emotional well-being as well as tinnitus characteristics that can be used to generate an overall index score. This score reflects how severely tinnitus affects a patient.
 
While these questionnaires all demonstrate certain levels of usefulness in determining the severity of tinnitus, their differences make comparison among studies complicated. There is a need to unify the tools used in measurement of tinnitus severity.
 
The Tinnitus Handicap Index and the Tinnitus Severity Index are typically used most frequently. Recently published, the Tinnitus Function Index has been developed as an effort by experts from multiple tinnitus centers based upon existing tinnitus questionnaires.
 
Consultation with other healthcare specialists can be an important part of your tinnitus evaluation. Tinnitus can be a very complex condition and appropriate management often requires knowledge and expertise beyond the scope of any particular medical specialty.
 
Although you may be under the care of a primary care provider, otolaryngologist, or audiologist, they may refer you to a psychologist, psychiatrist, neurologist, dentist, or any number of other specialists if there are signs that indicate the presence of conditions that are best managed by these specialists.
 
A team approach to evaluate your tinnitus will not only ensure an accurate diagnosis, but will often yield the best possible management outcomes.   

Yongbing Shi, M.D., Ph.D., is an assistant professor of otolaryngology in the Department of Otolaryngology–Head and Neck Surgery at the Oregon Health & Science University (OHSU) in Portland, where he is also a member of the OHSU Tinnitus Clinic care team.
 
William H. Martin, Ph.D., is the director of the OHSU Tinnitus Clinic. He is also a professor of Otolaryngology–Head and Neck Surgery and a professor of Public Health and Preventive Medicine at OHSU.
 
 
 
 
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