12-phase flow (12)

1. 1FRAME
   Frame as a CHRONIC outpatient engine for ADULT primary bothersome tinnitus per AAO-HNSF 2014 (Tunkel OHNS PMID 25273878). Two jobs: (A) screen out secondary / red-flag causes (vestibular schwannoma, vascular pulsatile, sudden SNHL, intracranial / vascular pathology) — recognise and route OUT; (B) run the evidence-based ladder — education + audiometry + hearing-aid trial + CBT first-line for chronic bothersome + sound therapy adjunct — AGAINST routine pharmacotherapy for primary tinnitus.
   advance: primary-tinnitus scope confirmed; secondary / red-flag causes routed OUT by engine_id
2. 2ENTRY
   Capture duration (≥6 months chronic), laterality (unilateral = red flag), bothersome burden, and pulsatile vs subjective character — the fastest triage in primary tinnitus (Tunkel OHNS 2014 PMID 25273878). Recent-onset (<6 mo) prioritises spontaneous-resolution counselling.
   inputs: tinnitus_duration, tinnitus_laterality_uni_or_bilateral
   advance: duration / laterality / bothersome status / pulsatility recorded
3. 3CONTEXT
   Capture context: coexisting hearing loss (age / noise / occupational), ototoxic medications (aminoglycosides, loops, platinum, high-dose ASA/NSAIDs), comorbid depression / anxiety / insomnia (CBT target), TMD / cervical somatosensory features, noise-exposure history. Most chronic tinnitus is co-morbid with hearing loss and emotional/sleep distress.
   inputs: hearing_loss_history_age_or_noise_exposure, ototoxic_medication_exposure_aminoglycoside_loop_platinum_salicylate_NSAID, comorbid_depression_anxiety_insomnia, noise_exposure_occupational_recreational
   actions: panel.cbc, panel.thyroid
   advance: hearing-loss + ototoxin + comorbid-distress + somatosensory context captured
4. 4RED_FLAGS
   Recognise can't-miss secondary causes and DO NOT manage them here. Pulsatile / objective tinnitus → MRA/MRV head + ENT (dural AVF, glomus, venous sinus stenosis, dehiscent jugular bulb). UNILATERAL tinnitus with asymmetric SNHL → MRI IAC (vestibular schwannoma). Tinnitus with focal neuro / severe headache / papilloedema / new asymmetric SNHL → urgent imaging. SUDDEN tinnitus + sudden SNHL → ent.sudden-sensorineural-hearing-loss.core.v1 within the steroid window. These are recognised here and ROUTED OUT.
   inputs: tinnitus_pulsatile_or_subjective, focal_neuro_signs_or_severe_headache
   advance: red-flag pulsatile / unilateral-asymmetric / focal-neuro / sudden-SNHL features screened and routed by engine_id if positive
5. 5INITIAL_WORKUP
   Comprehensive AUDIOMETRIC EXAMINATION (pure-tone + speech) — the AAO-HNSF 2014 recommendation for tinnitus that is unilateral, persistent ≥6 mo, or associated with hearing difficulties. Quantify bothersome burden with THI or TFI. Routine bloods (CBC, TFTs, vitamin B12) only when clinically suggested — AAO-HNSF 2014 does NOT mandate routine lab work-up for idiopathic primary tinnitus (Tunkel PMID 25273878).
   inputs: audiometric_examination_pta_speech, tinnitus_bothersome_burden_THI_or_TFI
   actions: panel.cbc, panel.thyroid
   advance: audiometry obtained; THI/TFI baseline recorded; lab work-up driven by clinical suspicion only
6. 6BRANCHING_WORKUP
   Branch on findings: asymmetric SNHL or unilateral persistent tinnitus → MRI IAC (vestibular schwannoma); pulsatile → MRA/MRV head; somatosensory modulation (jaw/neck movement changes volume) → TMD / cervical pathway (route to ent.tmd.core.v1 / cervical PT); fluctuating SNHL + episodic vertigo + aural fullness → ent.meniere-disease.core.v1; chronic noise / age-related symmetric SNHL + bilateral tinnitus → primary-tinnitus pathway here
   inputs: mri_iac_when_indicated, tmd_jaw_or_neck_somatosensory_modulation, vestibular_or_meniere_features
   advance: imaging if indicated; secondary cause confirmed or excluded; subtype assigned
7. 7DIFFERENTIAL
   Terminal differential: primary (idiopathic) bothersome tinnitus (most common — typically bilateral + symmetric SNHL + non-pulsatile pivot) vs vestibular schwannoma (unilateral + asymmetric SNHL + MRI IAC pivot — route to neuro-otology) vs vascular pulsatile tinnitus (objective / pulsatile + MRA pivot — route ENT/neuro-otology) vs Meniere disease (episodic vertigo + fluctuating low/mid SNHL + aural fullness pivot — route to ent.meniere-disease.core.v1) vs ototoxicity (drug exposure + temporal pivot — discontinue offending agent) vs somatosensory tinnitus (jaw / neck modulation pivot — TMD / cervical PT pathway) vs sudden SNHL (sudden onset + audiometric documentation pivot — route to ent.sudden-sensorineural-hearing-loss.core.v1)
   advance: single best subtype assigned; secondary causes routed OUT; primary chronic bothersome tinnitus stays here
8. 8RISK_STRATIFICATION
   Stratify by AAO-HNSF 2014 axis: bothersome vs non-bothersome (the management focus); chronic (≥6 mo) vs recent-onset; bothersome + hearing loss (hearing-aid trial candidate) vs bothersome + no hearing loss (CBT + sound therapy candidate); comorbid mood / sleep / occupational disability (CBT priority + integrated mental-health care). Layer suicide risk in severely bothered patients (rare but documented).
   inputs: tinnitus_bothersome_burden_THI_or_TFI, comorbid_depression_anxiety_insomnia
   advance: bothersome-burden band + comorbidity-driven CBT priority + hearing-aid candidacy assigned
9. 9TREATMENT
   AAO-HNSF 2014 evidence-based ladder for CHRONIC BOTHERSOME PRIMARY tinnitus (Tunkel OHNS PMID 25273878): (1) STRONG recommendation: educate patient + distinguish bothersome from non-bothersome; (2) RECOMMENDATION: hearing-aid trial if documented hearing loss + bothersome tinnitus; (3) RECOMMENDATION: CBT — Cima Lancet 2012 (PMID 22633033) showed CBT-based stepped care improved THI -7.5 + tinnitus questionnaire score -8.1 vs usual care at 12 months; Beukes Int J Audiol 2018 (PMID 30295113) showed internet-based CBT acceptable and effective; (4) OPTION: SOUND THERAPY (masker / white-noise / hearing-aid amplifier with masking) — adjunct, especially nocturnal. EMERGING: bimodal trigeminal-acoustic stimulation (Lenire device, Conlon Sci Transl Med 2020 PMID 33028707) THI Cohen-d -0.87 to -0.92 / TFI -0.77 to -0.87, both p<0.001 — encoded as add-on adjunct given lack of CPG endorsement yet. AGAINST: AAO-HNSF 2014 STRONG RECOMMENDATIONS AGAINST routine antidepressants, anticonvulsants, anxiolytics, intratympanic medications, Ginkgo biloba, melatonin, zinc, dietary supplements, and transcranial magnetic stimulation for PRIMARY tinnitus. Co-morbid depression / anxiety is treated on its own pathway with shared decision-making — counsel that any tinnitus effect of antidepressants is small and is not the indication.
   inputs: audiometric_examination_pta_speech, tinnitus_bothersome_burden_THI_or_TFI
   advance: evidence-based ladder step started; pharmacotherapy correctly NOT initiated for primary tinnitus; comorbid mood/anxiety treated separately if present
10. 10DISPOSITION
    OUTPATIENT longitudinal management is the default for primary tinnitus. Specialist neuro-otology / ENT referral for: pulsatile / objective tinnitus, unilateral with asymmetric SNHL, sudden SNHL, somatosensory features refractory to PT, severe disability despite ladder. Psychology / mental-health referral for severe bothersome burden, comorbid depression, suicidal ideation.
    inputs: focal_neuro_signs_or_severe_headache
    advance: outpatient longitudinal plan documented; specialist referrals queued where indicated
11. 11MONITORING
    Track at each 3-6-month visit: THI / TFI trend, hearing-aid acoustic adherence + benefit, CBT engagement and module completion, sleep / mood comorbidity, ototoxin exposure changes, hearing-protection adherence. Long-term improvement is gradual — counsel realistic expectations (Cima Lancet 2012 PMID 22633033 — Cohen d ~0.45 for tinnitus impairment at 12 months).
    inputs: tinnitus_bothersome_burden_THI_or_TFI
    advance: structured THI/TFI + CBT + hearing-aid + comorbidity review completed each visit
12. 12FOLLOWUP
    Longitudinal chronic-disease arc: 3-6 monthly stable; sooner for sleep / mood / suicidal-ideation flares. Maintain hearing protection (concert/work). Reassess audiometry annually if hearing loss; sooner if change. Re-screen for ototoxic medication updates at every visit (DM aminoglycosides, oncology platinum, vancomycin courses). Re-counsel that AAO-HNSF 2014 is AGAINST routine pharmacotherapy — many patients will be offered gabapentin / sertraline by other clinicians and ask for it; reinforce evidence
    inputs: noise_exposure_occupational_recreational
    advance: structured longitudinal + hearing-protection + ototoxin re-screen + pharmacotherapy-counter-counselling completed