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 primary therapeutic intervention, combined with hearing aids if any degree of hearing loss is present. 1

Initial Diagnostic Evaluation

Essential Clinical Assessment

• Perform immediate otoscopic examination to identify treatable causes including cerumen impaction, retrotympanic masses, or middle ear pathology 1, 2
• Classify tinnitus as pulsatile versus non-pulsatile and unilateral versus bilateral, as this fundamentally determines the diagnostic pathway 1
• Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for any patient with unilateral tinnitus, persistent tinnitus ≥6 months, or associated hearing difficulties 3, 1

Imaging Decision Algorithm

Do NOT obtain imaging for: bilateral, non-pulsatile tinnitus without focal neurological deficits 3, 1

DO obtain imaging if ANY of the following are present:

• Pulsatile tinnitus (requires CT angiography or MR angiography) 3, 1
• Unilateral tinnitus (requires MRI internal auditory canals with contrast to exclude vestibular schwannoma) 3, 1
• Focal neurological abnormalities 3
• Asymmetric hearing loss 3, 1

Evidence-Based Treatment Algorithm

First-Line Interventions

• Provide education and counseling about tinnitus mechanisms and management strategies to all patients with persistent tinnitus 1
• Recommend hearing aids for any patient with documented hearing loss and tinnitus, even if hearing loss is mild or unilateral—this provides significant symptomatic relief 1
• Refer for cognitive behavioral therapy (CBT) as the strongest evidence-based treatment for improving quality of life in patients with persistent, bothersome tinnitus 1, 4, 5, 6

Sound Therapy Options

• Sound therapy may be offered as a management option for symptomatic relief in persistent tinnitus, though evidence is less robust than for CBT 1
• Tinnitus retraining therapy (TRT) can be considered, but evidence for effectiveness remains inconclusive 6

Psychiatric Comorbidity Management

• Immediately refer patients with severe anxiety or depression to psychiatric services due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1
• Address sleep disturbance, mood disorders, and cognitive impairments as separate clinical entities rather than treating tinnitus directly with medications 4

Treatments NOT Recommended

The following interventions lack evidence of benefit and should NOT be routinely recommended:

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

Important Caveat

While these medications are not recommended for treating tinnitus itself, antidepressants may be appropriate for treating comorbid depression as a separate diagnosis, and melatonin may help with associated sleep disturbance 4

Special Considerations for Pulsatile Tinnitus

Pulsatile tinnitus represents a distinct clinical entity requiring different management:

• Pulsatile tinnitus almost always requires imaging evaluation because identifiable structural or vascular causes are present in >70% of cases 7
• Life-threatening causes include dural arteriovenous fistulas (8% of cases, can cause hemorrhagic stroke), arterial dissection, and arteriovenous malformations 7
• First-line imaging: CT angiography (CTA) of head and neck with contrast for suspected vascular causes, or high-resolution CT temporal bone for suspected paragangliomas, glomus tumors, or jugular bulb abnormalities 7
• If CTA/CT negative but suspicion remains high, proceed to MRI with MR angiography 7

Common Clinical Pitfalls to Avoid

• Failing to perform otoscopy before ordering expensive imaging studies—simple causes like cerumen impaction are easily treatable 2
• Ordering brain imaging for bilateral, symmetric, non-pulsatile tinnitus without neurological deficits—this represents low-yield testing with unnecessary cost and radiation exposure 3, 2
• Prescribing medications without evidence of benefit—antidepressants and anticonvulsants for tinnitus itself cause side effects without improving tinnitus 1
• Overlooking mild hearing loss—even mild or unilateral hearing loss benefits from hearing aid intervention 1
• Dismissing pulsatile tinnitus as benign—this symptom mandates imaging evaluation due to potentially life-threatening causes 7
• Missing dural arteriovenous fistulas—these can present with isolated pulsatile tinnitus before catastrophic hemorrhage 7

Chemotherapy-Induced Tinnitus

• No causative treatment exists for established platinum-based chemotherapy ototoxicity 1
• Hearing aids remain beneficial for chemotherapy-induced hearing loss and tinnitus 1
• CBT strategies can be offered with moderate supporting evidence 1
• Sodium thiosulfate may prevent cisplatin ototoxicity in children, but adult use is uncertain due to tumor protection concerns 1