What are the treatment pathways for patients with tinnitus?

Treatment Pathways for Tinnitus

For patients with tinnitus, the treatment pathway begins with distinguishing pulsatile from non-pulsatile tinnitus and bothersome from non-bothersome presentations, as these classifications fundamentally determine the diagnostic and therapeutic approach. 1

Initial Evaluation and Risk Stratification

Step 1: Targeted History and Physical Examination

• Perform a focused otologic examination to identify treatable underlying conditions, including assessment for vascular retrotympanic masses (paragangliomas), asymmetric hearing loss, and neurological deficits 2, 1
• Determine laterality (unilateral vs bilateral), duration (acute vs persistent ≥6 months), and whether the tinnitus is pulsatile or non-pulsatile 2, 1
• Assess for "bothersome" tinnitus—defined as tinnitus that significantly impacts quality of life—as this determines treatment intensity 2, 1

Step 2: Audiologic Testing

• Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for all patients with unilateral tinnitus, persistent tinnitus ≥6 months, or any hearing difficulties 2, 1
• Even mild or unilateral hearing loss warrants audiologic evaluation, as hearing aids provide significant benefit in this population 1

Step 3: Imaging Decision

• Obtain imaging (CT temporal bone or CTA head/neck) for patients with: unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss 2, 1, 3
• Do not obtain imaging for bilateral, non-pulsatile tinnitus without localizing features 2, 1, 3
• Pulsatile tinnitus requires imaging in nearly all cases, as identifiable causes exist in >70% of patients, including life-threatening conditions like dural arteriovenous fistulas and arterial dissection 3

Evidence-Based Treatment Algorithm

For Patients with Hearing Loss and Tinnitus

• Recommend hearing aid evaluation as first-line treatment, even for mild or unilateral hearing loss 1
• Hearing aids provide dual benefit: amplification of environmental sounds and masking of tinnitus 1, 4

For Patients with Persistent, Bothersome Tinnitus (Primary Tinnitus)

First-Line Interventions:

• Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life and should be recommended for all patients with bothersome tinnitus 1, 5, 4
• Provide education and counseling about tinnitus mechanisms, natural history, and management strategies 1
• Consider sound therapy (white noise, nature sounds, specialized tinnitus masking devices) for symptomatic relief 1, 4

Treatments NOT Recommended:

• Do not prescribe antidepressants, anticonvulsants, or anxiolytics specifically for tinnitus treatment, as evidence is insufficient and side effects may worsen symptoms 1
• Do not recommend dietary supplements (Ginkgo biloba, melatonin, zinc) due to lack of consistent benefit 1
• Do not use intratympanic medications for routine tinnitus management 1

For Pulsatile Tinnitus with Identified Cause

• Atherosclerotic carotid disease (most common cause, 17.5% of cases): vascular risk factor modification 3
• Paragangliomas/glomus tumors (16% of cases): surgical resection, radiation therapy, or observation depending on size and symptoms 3
• Idiopathic intracranial hypertension (second most common cause): weight loss, acetazolamide, or surgical intervention for vision-threatening cases 3
• Dural arteriovenous fistulas (8% of cases): urgent neurosurgical/endovascular intervention due to stroke risk 3
• Superior semicircular canal dehiscence: surgical repair if symptoms are debilitating 3

Special Populations and Considerations

Psychiatric Comorbidities

• Screen for severe anxiety and depression, as tinnitus patients with psychiatric comorbidities have increased suicide risk requiring prompt intervention 1
• While antidepressants are not recommended for tinnitus itself, they should be prescribed when clinically indicated for comorbid depression 1, 4

Chemotherapy-Induced Tinnitus

• No causative treatment exists for established platinum-based chemotherapy ototoxicity 1
• Offer hearing aids for associated hearing loss and CBT strategies for symptom management 1

Common Pitfalls to Avoid

• Missing life-threatening causes: Dismissing pulsatile tinnitus as benign without imaging can miss dural AVF, arterial dissection, or intracranial hypertension 3
• Inadequate otoscopic examination: Failing to visualize vascular retrotympanic masses delays diagnosis of paragangliomas 3
• Overlooking mild hearing loss: Not offering hearing aid evaluation for mild or unilateral hearing loss misses a highly effective intervention 1
• Prescribing unproven medications: Recommending supplements or medications without evidence exposes patients to unnecessary costs and side effects 1
• Telling patients "nothing can be done": This statement is inappropriate and harmful; multiple evidence-based interventions exist for symptom management 6