What are the management strategies for patients with tinnitus?

Management of Tinnitus

Cognitive Behavioral Therapy (CBT) is the only treatment with strong evidence for improving quality of life in patients with persistent, bothersome tinnitus and should be the cornerstone of management. 1, 2

Initial Evaluation Framework

Targeted History and Physical Examination

Perform a systematic assessment to identify secondary causes that require specific treatment 3, 4:

• Tinnitus characteristics: Document laterality (unilateral vs bilateral), duration, quality (ringing, buzzing, clicking, pulsatile), and whether it's bothersome or non-bothersome 3, 1
• Associated symptoms: Specifically ask about hearing loss, vertigo, otalgia, otorrhea, and focal neurological deficits 4, 5
• Otoscopic examination: Look for cerumen impaction, tympanic membrane abnormalities, or middle ear pathology 4
• Vascular assessment: Auscultate the neck, periauricular region, and temporal area for bruits if pulsatile tinnitus is present 4, 6
• Cranial nerve examination: Focus on CN VIII function 4

Audiologic Testing Strategy

Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for patients with: 3, 1, 4

• Unilateral tinnitus
• Persistent tinnitus ≥6 months
• Associated hearing difficulties
• Consider for all tinnitus patients regardless of presentation 3

Imaging Decision Algorithm

Do NOT obtain imaging studies unless one or more of the following are present: 3, 1, 4

• Unilateral or asymmetric tinnitus
• Pulsatile tinnitus
• Focal neurological abnormalities
• Asymmetric hearing loss

For pulsatile tinnitus specifically, imaging (CTA or MRA) is almost always required to identify vascular abnormalities 1, 6

Evidence-Based Treatment Hierarchy

First-Line Interventions

1. Education and Counseling (for all patients with persistent, bothersome tinnitus) 1, 4

• Explain that tinnitus is a symptom, not a disease
• Reassure that most tinnitus is benign
• Discuss natural progression and management strategies

2. Hearing Aids (for patients with any degree of hearing loss) 1, 4

• Recommend hearing aid evaluation even if hearing loss is mild or unilateral 1
• Hearing aids provide significant relief for tinnitus patients with associated hearing loss 1

3. Cognitive Behavioral Therapy 1, 4, 2

• CBT has the strongest evidence base for improving quality of life
• Should be offered to patients with persistent, bothersome tinnitus

4. Sound Therapy 1, 4

• May provide symptomatic relief for persistent tinnitus
• Options include ear-level noise generators, combination devices, or personal listening devices 7

Treatments to AVOID

Do NOT recommend the following due to insufficient evidence and potential harm: 1, 4

• Medications: Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary tinnitus treatment 1, 4
• Dietary supplements: Ginkgo biloba, melatonin, zinc, or other supplements lack consistent benefit 1, 4

Special Considerations

Psychiatric Comorbidity 3, 1

• Promptly identify and intervene for patients with severe anxiety or depression
• Suicide risk is increased in tinnitus patients with coexisting psychiatric illness
• These patients require urgent mental health referral

Chemotherapy-Induced Tinnitus 1

• No causative treatment exists for established platinum-based chemotherapy ototoxicity
• Hearing aids remain beneficial
• CBT strategies can be offered with moderate evidence

Common Pitfalls to Avoid

• Overlooking mild hearing loss: Even mild or unilateral hearing loss may benefit from amplification 1, 4
• Ordering unnecessary imaging: Bilateral, non-pulsatile tinnitus without neurological symptoms does not require imaging 4
• Prescribing unproven medications: Avoid medications without clear evidence that may cause side effects or worsen tinnitus 1
• Dismissive statements: Never tell patients "nothing can be done" - this is inappropriate and harmful 8
• Ignoring sound tolerance problems: If hyperacusis is present, measure loudness discomfort levels at audiometric frequencies 4, 7

Clinical Algorithm Summary

1. Distinguish bothersome from non-bothersome tinnitus - this guides treatment intensity 3, 1, 4
2. Rule out secondary causes through targeted history, physical exam, and selective audiologic testing 3, 4
3. Reserve imaging for unilateral, pulsatile, or neurologically concerning presentations 3, 1, 4
4. Implement evidence-based treatments: CBT, hearing aids (if hearing loss present), education/counseling, and sound therapy 1, 4
5. Avoid ineffective treatments: medications and supplements without evidence 1, 4
6. Screen for psychiatric comorbidity and intervene urgently when present 3, 1