Management of Chronic Tinnitus
For patients with persistent, bothersome tinnitus, cognitive behavioral therapy (CBT) should be recommended as the primary intervention, as it has the strongest evidence for improving quality of life. 1, 2
Initial Evaluation Framework
Perform a targeted history and physical examination to identify potentially treatable underlying conditions that may relieve tinnitus: 1
- Determine laterality: Unilateral tinnitus is a red flag requiring imaging (MRI with contrast preferred) to exclude vestibular schwannoma or vascular abnormalities 1, 3
- Assess if pulsatile: Pulsatile tinnitus almost always requires vascular imaging (CTA or MRA) 2, 4
- Check for focal neurologic deficits or asymmetric hearing loss: These findings mandate imaging studies 1
- Perform otoscopy: Rule out simple treatable causes like cerumen impaction, otitis externa, or middle ear pathology 4
Obtain comprehensive audiologic examination promptly for patients with: 1
- Unilateral tinnitus
- Persistent tinnitus (≥6 months duration)
- Any associated hearing difficulties
Distinguish Bothersome from Non-Bothersome Tinnitus
Use validated questionnaires (Tinnitus Handicap Inventory or Tinnitus Functional Index) to quantify impact and guide treatment intensity 2, 3. This distinction is critical because only bothersome tinnitus requires active intervention. 1
Evidence-Based Treatment Algorithm
For Patients with Hearing Loss and Tinnitus:
Recommend hearing aid evaluation immediately, even if hearing loss is mild or unilateral 1, 2. Hearing aids provide significant relief and should be first-line for this population. 2, 3
For All Patients with Persistent, Bothersome Tinnitus:
Provide education and counseling about tinnitus management strategies, natural history, and realistic expectations 1, 2
Recommend cognitive behavioral therapy (CBT) as the primary therapeutic intervention with strongest evidence for improving quality of life 1, 2, 5
Consider sound therapy as an adjunctive option for symptomatic relief, though evidence is less robust than for CBT 1, 2
Screen for Psychiatric Comorbidities:
Assess for anxiety and depression in all patients with bothersome tinnitus, as psychiatric comorbidities increase suicide risk and require prompt intervention 2, 3, 4
Treatments to Explicitly AVOID
Do not routinely prescribe the following due to insufficient evidence and potential harm: 1, 2
- Antidepressants, anticonvulsants, or anxiolytics (including benzodiazepines) for primary tinnitus treatment 1, 3
- Intratympanic medications 1, 2
- Dietary supplements including Ginkgo biloba, melatonin, or zinc 1, 2, 3
- Transcranial magnetic stimulation (TMS) for routine treatment 1
These interventions lack consistent benefit and may cause adverse effects or worsen tinnitus. 2, 3
Imaging Decision Algorithm
Obtain imaging studies ONLY if one or more of the following are present: 1
- Unilateral tinnitus (MRI with contrast for internal auditory canals)
- Pulsatile tinnitus (CTA or MRA for vascular evaluation)
- Focal neurological abnormalities
- Asymmetric hearing loss
Do NOT obtain imaging for bilateral, non-pulsatile, symmetric tinnitus without neurological deficits. 2, 4 This represents unnecessary cost and does not change management.
Critical Pitfalls to Avoid
- Failing to perform otoscopy before ordering expensive imaging studies 4
- Ordering brain imaging for bilateral, symmetric, non-pulsatile tinnitus without red flags 4
- Overlooking mild hearing loss that could benefit from hearing aid intervention 2, 3
- Prescribing medications without evidence that may cause side effects 2, 3
- Missing psychiatric comorbidities that require urgent intervention due to suicide risk 2, 3, 4
Special Populations
For chemotherapy-induced tinnitus: No causative treatment exists for established ototoxicity, but hearing aids and CBT strategies remain beneficial 2
For sudden hearing loss with tinnitus: Initiate urgent corticosteroid therapy 3
If imaging reveals structural pathology (vestibular schwannoma, vascular abnormality): Refer to neurotology/neurosurgery for definitive management 3