Tinnitus: diagnostic approach leading to treatment.

Optimal care for a patient with tinnitus begins with identifying the cause of the tinnitus. Once the cause has been identified then an appropriate treatment plan can be initiated. In this article, the author reviews how to identify the tinnitus etiology and its treatment.The workup begins with the patient's description of the percept because in some cases, the quality of the tinnitus will make the diagnosis (e.g., clicking, which is readily suppressed pharmacologically); in other cases, it will give direction in the diagnostic evaluation (e.g., pulsatile). With the exception of a small dural arteriovenous malformation, the source of objective pulsatile tinnitus can be determined without conventional cerebral angiography. If the diagnostic workup is unrevealing and the pulsations are not suppressed with somatic testing, then eighth nerve vascular compression becomes the likely etiology, especially if there is some clicking also heard, no matter how minor.The two major causes of tinnitus are hearing loss and myofascial disorders of the head and neck. Moreover, the two can combine and cause tinnitus even though either condition alone would not have caused tinnitus. Although the tinnitus of hearing loss is not easily treatable, the tinnitus from myofascial disorders is often responsive to an optimized myofascial treatment program. Hyperacusis, a frequent accompaniment of tinnitus, and its treatment are discussed.