What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) is the only treatment proven to improve quality of life in patients with persistent, bothersome tinnitus and should be your primary therapeutic intervention. 1

Initial Evaluation and Classification

Before initiating treatment, you must classify the tinnitus to identify potentially treatable underlying causes:

• Perform otoscopic examination immediately to exclude cerumen impaction, retrotympanic vascular masses (paragangliomas), acute otitis externa, or middle ear infection 2
• Determine if tinnitus is pulsatile or non-pulsatile, as pulsatile tinnitus almost always requires imaging evaluation (unlike bilateral non-pulsatile tinnitus) and may indicate life-threatening vascular abnormalities including dural arteriovenous fistulas, arterial dissection, or atherosclerotic carotid disease 1, 3
• Assess laterality (unilateral vs bilateral), since unilateral tinnitus has higher likelihood of identifiable structural cause and warrants imaging 1, 3
• Order comprehensive audiologic examination for any patient with unilateral tinnitus, persistent tinnitus (≥6 months), or associated hearing difficulties 1

Evidence-Based Treatment Algorithm

First-Line Treatments (Strong Evidence)

1. Cognitive Behavioral Therapy (CBT)

• CBT has the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus 1, 4
• This should be your primary therapeutic recommendation for patients whose tinnitus significantly impacts daily functioning 1

2. Hearing Aids

• Recommend hearing aid evaluation for ANY degree of hearing loss, even if mild or unilateral 1, 4
• Hearing aids provide significant relief for patients with associated hearing loss and are strongly recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1

3. Education and Counseling

• Provide education and counseling about tinnitus management strategies to all patients with persistent, bothersome tinnitus 1
• Supportive counseling should begin during initial evaluation to help patients cope and improve chances of successful subsequent treatment 5

Second-Line Treatment (Moderate Evidence)

Sound Therapy

• May be recommended as a management option for persistent tinnitus, providing symptomatic relief 1
• The evidence base is strongest for combination of sound therapy with CBT-based counseling 4

Treatments NOT Recommended (Avoid These)

The American Academy of Otolaryngology-Head and Neck Surgery explicitly advises against the following due to insufficient evidence and potential side effects:

• Antidepressants, anticonvulsants, or anxiolytics for primary treatment of persistent tinnitus 1
• Intratympanic medications for routine tinnitus management 1
• Dietary supplements including Ginkgo biloba, melatonin, or zinc due to lack of consistent benefit 1

Special Populations and Considerations

Pulsatile Tinnitus

• Order CT angiography (CTA) of head and neck with contrast as first-line imaging when suspecting dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease, or arteriovenous malformations 3
• Alternatively, order high-resolution CT temporal bone (non-contrast) for suspected paragangliomas, glomus tumors, jugular bulb abnormalities, or superior semicircular canal dehiscence 3

Psychiatric Comorbidities

• Immediately refer patients with severe anxiety or depression for psychiatric intervention due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1, 2

Chemotherapy-Induced Tinnitus

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

Imaging Indications

Order imaging studies ONLY when:

• Tinnitus is pulsatile 1, 2
• Tinnitus is unilateral or asymmetric 1, 2
• Focal neurological abnormalities are present 1, 2
• Asymmetric hearing loss is documented 1, 2

Do NOT order imaging for bilateral, non-pulsatile, symmetric tinnitus without neurological deficits 2

Critical Pitfalls to Avoid

• Never dismiss pulsatile tinnitus as benign—it requires imaging evaluation due to identifiable causes in >70% of cases, including life-threatening conditions like dural AVF that can present with isolated pulsatile tinnitus before catastrophic hemorrhage 3
• Never prescribe medications without clear evidence of benefit that may cause side effects or worsen tinnitus 1
• Never overlook mild hearing loss—even mild or unilateral hearing loss can benefit from hearing aid intervention 1, 2
• Never fail to perform otoscopy before ordering expensive imaging studies—simple treatable causes like cerumen impaction must be excluded first 2
• Never tell patients "there is nothing that can be done"—this statement is inappropriate and should be strongly condemned, as multiple evidence-based treatments exist 6