What are the treatment options for tinnitus?

Tinnitus Treatment

For patients with persistent, bothersome tinnitus, cognitive behavioral therapy (CBT) is the only treatment proven to improve quality of life and should be the cornerstone of management, combined with hearing aids for any degree of hearing loss and patient education/counseling. 1

Initial Evaluation and Risk Stratification

Immediate Assessment Required

• Perform otoscopic examination to identify treatable causes: cerumen impaction, retrotympanic masses (paragangliomas), acute otitis externa, or middle ear infection 1, 2
• Classify tinnitus as pulsatile vs. non-pulsatile and unilateral vs. bilateral - this fundamentally determines the diagnostic pathway 1
• Screen for severe anxiety or depression immediately, as tinnitus patients with psychiatric comorbidities have increased suicide risk requiring urgent psychiatric intervention 1, 2

When to Order Imaging (Critical Decision Point)

Order imaging studies ONLY if one or more of the following are present: 3, 1

• Pulsatile tinnitus (almost always requires imaging - over 70% have identifiable vascular/structural causes) 1, 4
• Unilateral tinnitus 3, 1
• Focal neurological abnormalities 3, 1
• Asymmetric hearing loss 3, 1

Do NOT order imaging for bilateral, non-pulsatile, symmetric tinnitus without neurological deficits - this represents overuse of low-yield, expensive testing 3, 2

Audiologic Testing

• Obtain comprehensive audiologic examination for patients with unilateral tinnitus, persistent tinnitus (≥6 months), or any perceived hearing difficulties 3, 1
• Consider audiologic testing even in patients without perceived hearing loss, as hearing loss is frequently unrecognized and commonly associated with tinnitus 3
• Testing should be performed promptly, preferably within 4 weeks of initial assessment 3

Evidence-Based Treatment Algorithm

First-Line Treatments (Strong Evidence)

1. Cognitive Behavioral Therapy (CBT) 1

• Strongest evidence for improving quality of life in persistent, bothersome tinnitus 1
• Should be recommended for all patients with persistent, bothersome tinnitus 1
• Tinnitus-specific CBT combined with sound therapy has the strongest evidence base 5

2. Hearing Aids 1

• Recommend hearing aid evaluation for any degree of hearing loss, even if mild or unilateral 1
• Hearing aids provide significant relief for patients with associated hearing loss 1
• This is a commonly overlooked intervention - do not dismiss mild hearing loss as insignificant 1, 2

3. Education and Counseling 1

• Essential component for all patients with persistent tinnitus 1
• Reassure patients that tinnitus is not life-threatening once serious causes are excluded 6
• Explain natural progression and management strategies 7

Second-Line Treatment Options (Moderate Evidence)

Sound Therapy 1

• May be recommended for symptomatic relief in persistent tinnitus 1
• Evidence is inconclusive as monotherapy, but combination with CBT-based counseling shows stronger evidence 5

Treatments NOT Recommended (Strong Evidence Against)

Medications - Do Not Prescribe

The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends AGAINST: 1

• Antidepressants for primary tinnitus treatment 1
• Anticonvulsants 1
• Anxiolytics 1
• Intratympanic medications 1

Rationale: Insufficient evidence of benefit with potential for side effects or worsening tinnitus 1, 2

Exception: Antidepressants may be appropriate for treating comorbid depression, not the tinnitus itself 7

Dietary Supplements - Do Not Recommend

Do not recommend any dietary supplements, including: 1

• Ginkgo biloba 1
• Melatonin 1
• Zinc 1
• Other supplements 1

Rationale: Lack of consistent evidence of efficacy 1

Special Populations and Considerations

Pulsatile Tinnitus (Requires Different Approach)

• Nearly always requires imaging evaluation - identifiable causes in >70% of cases 1, 4
• Life-threatening causes include dural arteriovenous fistulas (can cause hemorrhagic stroke) and arterial dissection 4
• First-line imaging: CT angiography (CTA) of head/neck with contrast OR high-resolution CT temporal bone, depending on suspected etiology 4
• Common causes: atherosclerotic carotid disease (17.5%), paragangliomas (16%), idiopathic intracranial hypertension (second most common) 4

Chemotherapy-Induced Tinnitus

• No causative treatment exists for established platinum-based chemotherapy ototoxicity 1
• Hearing aids remain beneficial 1
• CBT strategies can be offered with moderate evidence 1

Common Pitfalls to Avoid

1. Prescribing medications without evidence - antidepressants, anticonvulsants, and anxiolytics lack efficacy for primary tinnitus treatment and may cause harm 1, 2

2. Recommending unproven supplements - Ginkgo biloba, zinc, and melatonin lack consistent evidence 1, 2

3. Overlooking mild hearing loss - even mild or unilateral hearing loss benefits from hearing aid intervention 1, 2

4. Ordering imaging for bilateral non-pulsatile tinnitus - this is low-yield and expensive without red flag features 3, 2

5. Missing pulsatile tinnitus red flags - dismissing pulsatile tinnitus as benign can miss life-threatening vascular causes 1, 4

6. Inadequate otoscopic examination - failing to identify simple treatable causes like cerumen or vascular retrotympanic masses 1, 2

7. Missing psychiatric comorbidities - failing to screen for severe anxiety/depression misses increased suicide risk 1, 2