What are the treatment options for tinnitus?

Tinnitus Treatment

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

Initial Evaluation and Risk Stratification

Perform immediate otoscopic examination to identify treatable causes such as cerumen impaction, retrotympanic vascular masses (paragangliomas), acute otitis externa, or middle ear infection before ordering expensive imaging studies. 1, 2

Classify tinnitus characteristics to guide workup:

• Pulsatile vs. non-pulsatile: Pulsatile tinnitus almost always requires imaging evaluation (CT angiography or high-resolution CT temporal bone) due to identifiable vascular or structural causes in >70% of cases, including life-threatening conditions like dural arteriovenous fistulas or arterial dissection. 1, 3
• Unilateral vs. bilateral: Unilateral tinnitus has higher likelihood of structural pathology requiring imaging. 4, 1
• Associated hearing loss: Asymmetric hearing loss mandates imaging to exclude vestibular schwannoma. 4, 1

Screen for psychiatric emergencies: Patients with severe anxiety or depression related to tinnitus require immediate psychiatric intervention due to increased suicide risk. 1, 2

Audiologic Assessment

Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for:

• Unilateral tinnitus (regardless of duration) 1
• Persistent tinnitus (≥6 months) 1
• Any perceived hearing difficulties 1
• Even when patient denies hearing loss, as audiometry frequently detects unrecognized sensorineural hearing loss 4

This testing should be completed promptly, preferably within 4 weeks of initial assessment. 4

Imaging Indications

DO NOT obtain imaging for bilateral, non-pulsatile, symmetric tinnitus without focal neurological deficits. 4, 1, 2

DO obtain imaging for:

• Pulsatile tinnitus: Order CT angiography (CTA) of head/neck with contrast as first-line to evaluate for dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease, sigmoid sinus abnormalities, or arteriovenous malformations. 1, 3
• Unilateral tinnitus: Order MRI internal auditory canals with contrast to exclude vestibular schwannoma. 1, 2
• Asymmetric hearing loss: Follow appropriate imaging protocol for hearing loss evaluation. 4, 1
• Focal neurological abnormalities: Obtain appropriate neuroimaging. 4, 1
• Suspected middle ear vascular masses on otoscopy: Order high-resolution CT temporal bone (non-contrast) for paragangliomas, glomus tumors, jugular bulb abnormalities, or superior semicircular canal dehiscence. 1, 3

Evidence-Based Treatment Algorithm

For All Patients with Persistent, Bothersome Tinnitus:

1. Education and Counseling (mandatory first step):

• Explain tinnitus mechanisms and natural history 1
• Provide reassurance when serious pathology is excluded 1
• Discuss realistic treatment expectations 1

2. Cognitive Behavioral Therapy (CBT):

• This is the ONLY treatment with strong evidence for improving quality of life and should be recommended for all patients with persistent, bothersome tinnitus. 1, 5, 6
• CBT addresses the psychological distress and maladaptive reactions to tinnitus rather than eliminating the sound itself. 6, 7

3. Hearing Aid Evaluation:

• Recommend hearing aids for ANY degree of hearing loss, even if mild or unilateral, as hearing aids provide significant relief and are strongly evidence-based. 1, 8
• Hearing aids work by amplifying environmental sounds that mask tinnitus and by addressing the auditory deprivation that contributes to tinnitus generation. 1

4. Sound Therapy:

• May provide symptomatic relief through environmental sound enrichment, white noise generators, or smartphone apps. 1
• Evidence is less robust than for CBT or hearing aids but represents a reasonable adjunctive option. 7

Treatments NOT Recommended

DO NOT routinely prescribe the following due to insufficient evidence and potential harm:

• Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment (may be appropriate for comorbid psychiatric conditions, but not for tinnitus itself). 1
• Intratympanic medications (lack of efficacy data). 1
• Dietary supplements including Ginkgo biloba, melatonin, or zinc (no consistent benefit demonstrated). 1

Common Pitfalls to Avoid

• Failing to perform otoscopy before ordering imaging: Simple treatable causes like cerumen impaction or otitis externa are frequently missed. 2
• Ordering brain imaging for bilateral, symmetric, non-pulsatile tinnitus: This represents low-yield, expensive testing with potential for incidental findings and unnecessary anxiety. 4, 2
• Dismissing pulsatile tinnitus as benign: This is a critical error, as pulsatile tinnitus requires imaging to exclude life-threatening vascular pathology. 1, 3
• Missing dural arteriovenous fistulas: These can present with isolated pulsatile tinnitus before catastrophic hemorrhage and require high index of suspicion. 3
• Overlooking mild hearing loss: Even mild or unilateral hearing loss benefits from hearing aid intervention. 1, 2
• Prescribing unproven medications: Avoid medications without clear evidence that may cause side effects or worsen tinnitus. 1, 2
• Failing to screen for psychiatric comorbidities: Depression and anxiety significantly impact tinnitus burden and require concurrent treatment. 1

Special Populations

Chemotherapy-induced tinnitus (platinum-based agents):

• No causative treatment exists for established ototoxicity. 1
• Hearing aids remain beneficial. 1
• CBT strategies can be offered with moderate supporting evidence. 1
• Sodium thiosulfate may prevent ototoxicity in children receiving cisplatin, but adult use is uncertain due to tumor protection concerns. 1