What are the treatments for tinnitus (ringing in the ears)?

Treatment of Tinnitus (Ringing in the Ears)

Cognitive behavioral therapy (CBT) is the single most effective treatment for improving quality of life in patients with persistent, bothersome tinnitus, and should be your primary therapeutic recommendation. 1

Initial Assessment and Treatable Causes

Before initiating symptomatic treatment, perform an otoscopic examination to identify simple, reversible causes:

• Check for cerumen impaction – this is easily treatable and often overlooked 2
• Examine for retrotympanic masses or middle ear pathology 2
• Rule out acute otitis externa 2

Determine tinnitus characteristics to guide further workup:

• Pulsatile tinnitus requires imaging (CT or MR angiography) to evaluate for vascular abnormalities 1, 2
• Unilateral tinnitus requires MRI of internal auditory canals with contrast to exclude vestibular schwannoma 2
• Bilateral, non-pulsatile tinnitus without neurological deficits does NOT require imaging 2

Evidence-Based Treatment Algorithm

First-Line Interventions

1. Hearing Aid Evaluation (Even for Mild or Unilateral Hearing Loss)

• Recommend hearing aids for ANY degree of hearing loss, even if mild or unilateral 1, 2
• This is often overlooked but provides significant relief 1
• Obtain comprehensive audiometry for unilateral or persistent tinnitus (≥6 months) 1

2. Cognitive Behavioral Therapy

• CBT has the strongest evidence for improving quality of life 1, 3
• Should be recommended for all patients with persistent, bothersome tinnitus 1
• More effective than any pharmacological intervention 4

3. Education and Counseling

• Provide education about tinnitus management strategies to all patients with persistent symptoms 1
• Explain natural progression and set realistic expectations 4

Second-Line Options

Sound Therapy

• May provide symptomatic relief for persistent tinnitus 5
• Evidence is less robust than for CBT, but can be offered as adjunctive treatment 3

Treatments to AVOID

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

• Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment 1
• Intratympanic medications 1
• Dietary supplements (Ginkgo biloba, melatonin, zinc) – these lack consistent benefit 1

Exception: Antidepressants may be appropriate for treating comorbid depression, not the tinnitus itself 4

Critical Safety Considerations

Psychiatric Emergency Screening

• Patients with severe anxiety or depression require immediate psychiatric intervention due to documented suicide risk in tinnitus patients with psychiatric comorbidities 5, 1, 2
• This is a medical emergency and should not be delayed 5

Common Clinical Pitfalls

Avoid these frequent errors:

• Failing to perform otoscopy before ordering expensive imaging 2
• Ordering brain imaging for bilateral, symmetric, non-pulsatile tinnitus without neurological findings 2
• Overlooking mild hearing loss that could benefit from amplification 2
• Prescribing medications without evidence that may worsen symptoms 1, 2
• Telling patients "nothing can be done" – CBT and hearing aids ARE effective 6

Special Population: Chemotherapy-Induced Tinnitus

For platinum-based chemotherapy-related tinnitus:

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