Initial Recommendations for Treating Tinnitus in ENT Patients
The initial management of tinnitus should include a targeted history and physical examination, comprehensive audiologic evaluation, patient education/counseling, and consideration of sound therapy and cognitive behavioral therapy as first-line interventions. 1
Initial Evaluation
History and Physical Examination
- Obtain a targeted history focusing on:
- Tinnitus characteristics (unilateral vs. bilateral, pulsatile vs. non-pulsatile)
- Duration of symptoms (recent onset vs. persistent ≥6 months)
- Associated symptoms (hearing loss, vertigo, headache)
- Medication history (ototoxic medications)
- Noise exposure history
- Impact on quality of life and sleep 1
Physical Examination
- Perform otoscopic examination to visualize ear canals and tympanic membranes
- Look for cerumen impaction, middle ear fluid, tympanic membrane perforation
- Failure to remove cerumen before assessment is a common pitfall 1
Audiologic Testing
- Comprehensive audiologic examination is recommended for:
- Unilateral tinnitus
- Persistent tinnitus (≥6 months)
- Tinnitus associated with hearing difficulties 1
- Even patients without perceived hearing loss should undergo audiologic testing as hearing loss is frequently unrecognized but commonly associated with tinnitus 1
Initial Management Recommendations
1. Education and Counseling
- Provide clear explanation about the natural history of tinnitus
- Reassure patients that tinnitus is not life-threatening when appropriate
- Discuss coping strategies 1
2. Hearing Aids
- Recommend hearing aid evaluation for patients with documented hearing loss and persistent, bothersome tinnitus
- Hearing aids improve tinnitus by amplifying external sounds and reducing auditory deprivation 1
3. Sound Therapy
- Consider white noise machines, smartphone apps, and tinnitus masking devices
- Sound therapy can help reduce the perception of tinnitus 1, 2
4. Cognitive Behavioral Therapy (CBT)
- CBT is the only treatment shown to improve quality of life in patients with tinnitus
- Should be considered for patients with bothersome tinnitus 1, 2
5. Tinnitus Retraining Therapy
- Combination of sound therapy and counseling
- Has supportive but not conclusive evidence 1
When to Consider Imaging
Imaging is NOT recommended routinely for tinnitus evaluation but is indicated for specific presentations:
| Clinical Presentation | Recommended Imaging |
|---|---|
| Pulsatile tinnitus | CT angiography or MR angiography |
| Unilateral tinnitus with asymmetric hearing loss | MRI with contrast of internal auditory canals |
| Focal neurological findings | MRI brain with contrast |
| Tinnitus localizing to one ear | Appropriate imaging based on clinical findings |
Treatments to Avoid
- Antidepressants, anticonvulsants, and anxiolytics are not recommended for routine treatment of persistent tinnitus 3
- Dietary supplements such as Ginkgo biloba, melatonin, and zinc lack sufficient evidence 3
- Transcranial magnetic stimulation is not recommended for routine treatment 3
Follow-up and Referral
- Schedule follow-up within 4-6 weeks to assess response to initial management
- Consider referral to specialized care if:
- Symptoms persist or worsen
- Imaging reveals a vascular abnormality requiring intervention 1
Common Pitfalls to Avoid
- Failing to remove cerumen before assessment
- Overlooking non-otologic causes
- Not performing comprehensive audiologic evaluation for unilateral or persistent tinnitus
- Using unproven medications or supplements
- Ordering unnecessary imaging for non-concerning tinnitus presentations 1
- Missing pulsatile tinnitus, which can indicate serious underlying vascular pathology 1