What is the best course of treatment for a 54-year-old patient with tinnitus?

Treatment of Tinnitus in a 54-Year-Old Patient

Begin with targeted history and physical examination to classify the tinnitus as pulsatile versus non-pulsatile and unilateral versus bilateral, then obtain comprehensive audiometry, and implement cognitive behavioral therapy (CBT) with hearing aids if any hearing loss is present—these are the only interventions with strong evidence for improving quality of life. 1

Initial Classification and Evaluation

The first critical step is determining whether the tinnitus is pulsatile or non-pulsatile, as this fundamentally changes your diagnostic approach and imaging decisions. 2, 1

Key History Elements to Obtain:

• Laterality: Is it unilateral or bilateral? Unilateral tinnitus requires more extensive workup including imaging. 2, 1
• Quality: Pulsatile (rhythmic with heartbeat) versus continuous ringing/buzzing/hissing. 2, 1
• Duration: Has it been present for ≥6 months? This defines "persistent" tinnitus. 2, 1
• Associated symptoms: Hearing loss, vertigo, aural fullness, focal neurological deficits. 1, 3
• Impact on quality of life: Is it bothersome? Does it affect sleep, concentration, or cause anxiety/depression? 2

Physical Examination Priorities:

• Otoscopic examination to exclude cerumen impaction, retrotympanic masses, or middle ear pathology. 4
• Auscultation over the neck, periauricular area, and orbit to detect objective pulsatile tinnitus. 2
• Neurological examination to identify focal deficits that would mandate imaging. 1

Diagnostic Testing Algorithm

Audiometry (Required in Most Cases):

Obtain comprehensive audiologic examination for this 54-year-old patient if the tinnitus is unilateral, persistent (≥6 months), or associated with any hearing difficulties. 1 Given the patient's age and the high association between tinnitus and sensorineural hearing loss, audiometry is almost certainly indicated. 2

Imaging (Selective, Not Routine):

Do NOT order imaging if the tinnitus is bilateral, non-pulsatile, and without focal neurological abnormalities or asymmetric hearing loss. 2, 1 The AAO-HNS makes a strong recommendation against imaging in this scenario. 2

DO order imaging if any of the following are present:

• Pulsatile tinnitus: Requires CT angiography (CTA) or MR angiography (MRA) to evaluate for vascular abnormalities. 1, 4
• Unilateral tinnitus: Requires MRI of internal auditory canals with contrast to exclude vestibular schwannoma. 1, 3
• Asymmetric hearing loss on audiometry: Mandates MRI evaluation. 1
• Focal neurological deficits: Requires neuroimaging. 1

Evidence-Based Treatment Approach

First-Line Interventions (Strong Evidence):

1. Cognitive Behavioral Therapy (CBT)

• CBT has the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus. 1 This should be your primary therapeutic recommendation. 1
• CBT helps patients develop coping strategies and reduces the psychological distress associated with tinnitus. 5

2. Hearing Aids

• Recommend hearing aid evaluation for ANY degree of hearing loss, even if mild or unilateral. 1 This is critical—many clinicians mistakenly believe hearing aids are only for moderate-to-severe hearing loss. 1
• Hearing aids provide significant relief by amplifying ambient sounds that mask tinnitus and by addressing the underlying hearing loss that commonly accompanies tinnitus. 1

3. Education and Counseling

• Provide education about tinnitus mechanisms and reassurance that it is not life-threatening in most cases. 1 This alone can reduce anxiety and improve coping. 6
• Explain that tinnitus is a symptom, not a disease, and that habituation often occurs over time. 5

Sound Therapy (Optional):

• Sound therapy may provide symptomatic relief by masking tinnitus with background noise. 1 However, evidence is less robust than for CBT and hearing aids. 5

Treatments to AVOID (Strong Recommendations Against):

Do NOT routinely prescribe:

• Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment—insufficient evidence and potential for side effects. 1
• Intratympanic medications—lack of evidence for benefit. 1
• Dietary supplements (Ginkgo biloba, melatonin, zinc)—no consistent benefit demonstrated. 1

These medications may be appropriate for treating comorbid depression or anxiety, but not for tinnitus itself. 1

Critical Safety Considerations

Psychiatric Screening:

Screen for severe anxiety and depression in all tinnitus patients. 1 Patients with severe psychiatric symptoms require prompt psychiatric intervention due to documented increased suicide risk in tinnitus patients with coexisting psychiatric illness. 2, 1

Red Flags Requiring Urgent Evaluation:

• Pulsatile tinnitus: Almost always requires imaging to exclude treatable vascular abnormalities. 1, 4
• Unilateral tinnitus with asymmetric hearing loss: Raises concern for vestibular schwannoma. 1
• Associated vertigo with fluctuating hearing loss and aural fullness: Consider Ménière's disease. 3

Common Pitfalls to Avoid

• Ordering brain imaging for bilateral, symmetric, non-pulsatile tinnitus without neurological deficits—this is unnecessary, costly, and not recommended. 2, 1, 4
• Overlooking mild hearing loss—even mild or unilateral hearing loss warrants hearing aid evaluation. 1, 4
• Prescribing medications without evidence—avoid the temptation to prescribe supplements or medications that lack proven benefit. 1
• Failing to address psychiatric comorbidity—missing severe anxiety or depression can have serious consequences. 1
• Not performing otoscopy first—simple causes like cerumen impaction should be excluded before expensive workup. 4

Practical Treatment Algorithm for This 54-Year-Old:

1. Classify tinnitus: Determine if pulsatile/non-pulsatile, unilateral/bilateral. 2, 1
2. Perform otoscopy: Rule out simple treatable causes. 4
3. Order audiometry: Given age and likely persistent symptoms. 1
4. Determine imaging need: Only if pulsatile, unilateral, or asymmetric hearing loss present. 1
5. Refer for CBT: This is your primary therapeutic intervention. 1
6. Refer for hearing aid evaluation: If any hearing loss detected on audiometry. 1
7. Provide education and counseling: Essential for all patients. 1
8. Screen for psychiatric comorbidity: Intervene promptly if severe. 1
9. Avoid unproven treatments: No supplements, no routine medications. 1