What is the best approach to managing tinnitus (ringing in the ears)?

Tinnitus Management Approach

Initial Evaluation: Identify Red Flags and Treatable Causes

Perform a targeted history and physical examination at the initial visit to identify potentially treatable underlying conditions and determine if imaging or urgent intervention is needed. 1, 2

Critical History Elements

• Laterality: Unilateral tinnitus is a red flag requiring imaging (MRI with contrast preferred) to rule out vestibular schwannoma or vascular abnormalities 2, 3
• Quality: Pulsatile tinnitus almost always requires vascular imaging (CTA or MRA) to identify treatable vascular causes 2, 4
• Duration: Distinguish recent onset (<6 months) from persistent (≥6 months) to guide urgency of intervention 1, 5
• Associated symptoms: Hearing loss, vertigo, focal neurological deficits, or sudden hearing loss requiring urgent corticosteroid therapy 4, 3

Physical Examination Essentials

• Otoscopic examination for cerumen impaction, tympanic membrane abnormalities, or middle ear pathology 4
• Cranial nerve examination focusing on CN VIII 4
• Auscultation of neck, periauricular region, and temporal area for bruits if pulsatile 4

Imaging Decision Algorithm

Do NOT obtain imaging unless one or more of the following are present: 1, 2, 5

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

This is a strong recommendation against routine imaging for bilateral, non-pulsatile tinnitus without neurological symptoms 1, 5

Audiologic Evaluation: Mandatory for Most Patients

Obtain a comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) promptly for patients with: 1, 4, 5

• Unilateral tinnitus (mandatory) 3
• Persistent tinnitus (≥6 months) 1, 5
• Associated hearing difficulties 1, 5

Consider routine audiologic examination for all tinnitus patients regardless of laterality, duration, or perceived hearing status, as even mild or subclinical hearing loss may be present and treatable 1, 4, 3

Classify Tinnitus Severity: Bothersome vs. Non-Bothersome

Distinguish bothersome from non-bothersome tinnitus using validated questionnaires (Tinnitus Handicap Inventory or Tinnitus Functional Index), as this classification determines whether active treatment is needed 1, 2, 3, 5. This is a strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery 1, 5.

Screen for Psychiatric Comorbidities

Promptly identify and intervene for severe anxiety or depression, as tinnitus patients with psychiatric comorbidities have increased suicide risk 2, 3

Evidence-Based Treatment Algorithm for Persistent, Bothersome Tinnitus

First-Line Interventions (Recommended)

1. Education and Counseling (for all patients)

   • Provide information about tinnitus management strategies, natural progression, and realistic expectations 1, 2, 5

2. Hearing Aid Evaluation (if any hearing loss present)

   • Recommend hearing aid evaluation even for mild or unilateral hearing loss 1, 2, 5
   • Hearing aids have significant evidence for relief when hearing loss is present 2, 6

3. Cognitive Behavioral Therapy (CBT)

   • CBT is the only treatment with strong evidence for improving quality of life in tinnitus patients 2, 3, 7, 5, 6
   • This is the strongest evidence-based intervention for persistent, bothersome tinnitus 2, 3

4. Sound Therapy (optional)

   • May be recommended as a management option for symptomatic relief 2, 5
   • Evidence is strongest when combined with CBT-based counseling 6

Treatments Explicitly NOT Recommended

The American Academy of Otolaryngology-Head and Neck Surgery recommends AGAINST the following due to insufficient evidence and potential harm: 1, 2, 5

• Antidepressants, anticonvulsants, anxiolytics (including benzodiazepines) for primary tinnitus treatment 2, 3, 5
• Intratympanic medications 1, 5
• Dietary supplements (Ginkgo biloba, melatonin, zinc) due to lack of consistent benefit 2, 3, 5
• Transcranial magnetic stimulation for routine treatment 5

Common Pitfalls to Avoid

• Do not overlook mild hearing loss that could benefit from hearing aid intervention 2, 4
• Do not prescribe medications without clear evidence that may cause side effects or worsen tinnitus 2
• Do not recommend unproven dietary supplements 4
• Do not obtain unnecessary imaging for bilateral, non-pulsatile tinnitus without neurological symptoms 4
• Do not miss unilateral tinnitus as a red flag requiring imaging 3

Special Considerations

Chemotherapy-Induced Tinnitus

• No causative treatment exists for established platinum-based chemotherapy ototoxicity 2
• Hearing aids and CBT strategies remain beneficial 2
• Sodium thiosulfate may be considered for prevention in children receiving cisplatin 2

If Imaging Reveals Pathology

• Refer to neurotology/neurosurgery for vestibular schwannoma or structural pathology 3
• Initiate urgent corticosteroid therapy if sudden hearing loss accompanies tinnitus 3