What are the treatment options for bilateral tinnitus?

Treatment of Bilateral Tinnitus

For bilateral, nonpulsatile tinnitus without asymmetric hearing loss or neurologic deficits, imaging is not indicated, and treatment focuses on cognitive behavioral therapy, sound therapy, and hearing aids when hearing loss is present. 1

Initial Diagnostic Approach

Determine if imaging is needed:

• Imaging is not routinely indicated for symmetric or bilateral, subjective, nonpulsatile tinnitus in the absence of other symptoms 1
• Imaging is typically unrevealing when tinnitus is related to medications, noise-induced hearing loss, presbycusis, or chronic bilateral hearing loss 1

Obtain comprehensive audiologic evaluation for:

• Any patient with tinnitus present for ≥6 months 2
• Any patient with accompanying hearing problems 2
• This identifies the most common underlying cause (sensorineural hearing loss) and guides amplification strategies 3, 2

Evidence-Based Treatment Options

First-Line Treatment: Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is the only treatment proven to improve quality of life in patients with persistent, bothersome tinnitus. 4, 2, 5

• CBT addresses the psychological and emotional impact of tinnitus 5
• The evidence base is strongest for a combination of sound therapy and CBT-based counseling 5

Hearing Amplification (When Hearing Loss Present)

Recommend hearing aids for patients with documented hearing loss and persistent bothersome tinnitus:

• Amplification improves quality of life by reducing psychosocial and emotional manifestations 4
• Hearing aids are indicated even for mild or unilateral hearing loss 5
• This addresses the most common identified cause of tinnitus (sensorineural hearing loss) 3

Sound Therapy Options

Consider sound therapy as an adjunctive treatment option:

• Wide-band sound therapy can provide relief 5
• Auditory masking may help patients with no remediable cause 6
• Hearing assistive technology and white noise generators are options, though evidence is less robust than for CBT 4
• Tinnitus retraining therapy is an option, but evidence remains inconclusive 2

Treatments NOT Recommended

Do not routinely prescribe the following as primary treatment:

• Antidepressants, anticonvulsants, or anxiolytics for tinnitus itself 4, 2
• Intratympanic medications 4
• Ginkgo biloba, melatonin, or zinc supplements 4, 2

Important caveat: Melatonin may help with sleep disturbance, and antidepressants may help with mood disorders that accompany tinnitus, but these do not treat the tinnitus itself 2

Supportive Counseling and Education

Provide counseling during initial evaluation:

• Supportive counseling should begin during the initial evaluation to help patients cope with tinnitus 3
• Provide information about the natural progression of tinnitus 2
• Reassurance and conservative measures often prove to have the best outcomes 7
• Counseling may improve the chances of successful subsequent treatment 3

When to Consider Imaging Despite Bilateral Presentation

Order imaging if any of the following are present:

• Concomitant asymmetric hearing loss (≥10 dB interaural difference at 2+ contiguous frequencies) 8
• Neurologic deficits 1
• Head trauma 1
• Pulsatile quality 1

In these scenarios, imaging should be guided by the ACR Appropriateness Criteria for the specific associated condition (hearing loss, cerebrovascular disease, or head trauma) rather than the tinnitus characteristics. 1, 8

Prevention Strategies

Counsel patients on noise exposure avoidance:

• Avoidance of noise exposure may help prevent the development or progression of tinnitus 2

Common Pitfalls to Avoid

• Do not order routine imaging for bilateral, symmetric, nonpulsatile tinnitus without other symptoms—this is explicitly not indicated and wastes resources 1
• Do not prescribe supplements or medications as primary treatment without addressing underlying causes 4, 2
• Do not dismiss the psychological impact—tinnitus can greatly affect physical and psychological quality of life and requires supportive management 7
• Do not delay audiologic evaluation—hearing loss is the most common identified cause and may be treatable with amplification 3, 2