Treatment of Hissing in the Ears (Tinnitus)
For persistent, bothersome tinnitus (≥6 months), cognitive behavioral therapy (CBT) is the only treatment proven to improve quality of life and should be your primary recommendation, while hearing aids should be offered to any patient with associated hearing loss—even if mild or unilateral. 1, 2
Initial Evaluation and Classification
Before initiating treatment, you must distinguish between bothersome and non-bothersome tinnitus, as this fundamentally determines whether intervention is needed. 1, 2
Key evaluation steps:
Perform a targeted history focusing on: laterality (unilateral vs bilateral), duration (recent onset vs ≥6 months), quality (pulsatile vs non-pulsatile), associated hearing difficulties, and presence of severe anxiety or depression 1, 2
Obtain a comprehensive audiologic examination promptly if tinnitus is unilateral, persistent (≥6 months), or associated with hearing difficulties 1, 2
Critical red flag: Patients with severe anxiety or depression require immediate intervention due to increased suicide risk 2, 3
Imaging is NOT indicated for bilateral, non-pulsatile tinnitus without focal neurologic findings or asymmetric hearing loss 1, 4
Pulsatile tinnitus almost always requires imaging (CT angiography or high-resolution CT temporal bone) to identify potentially life-threatening vascular causes present in >70% of cases 2, 4
Evidence-Based Treatment Algorithm
For Persistent, Bothersome Tinnitus (≥6 months):
1. First-Line Interventions (ALWAYS offer these):
Cognitive Behavioral Therapy (CBT): This has the strongest evidence for improving quality of life and is the only treatment proven effective in randomized controlled trials 1, 2, 5
Education and counseling: Provide information about tinnitus mechanisms, natural history, and management strategies to all patients with persistent, bothersome tinnitus 1, 2
Hearing aid evaluation: Recommend for ANY patient with hearing loss and tinnitus, even if the hearing loss is only mild or unilateral 1, 2, 6
2. Second-Line Options (May offer):
- Sound therapy: Can provide symptomatic relief through auditory masking, though evidence is less robust than for CBT 1, 2
For Recent-Onset Tinnitus (<6 months):
Prioritize identifying and treating any underlying reversible causes (cerumen impaction, middle ear effusion, ototoxic medications) 1, 7
Defer aggressive intervention as many patients adapt naturally over time 1, 3
Provide reassurance and education about natural history 1
Treatments You Should NOT Recommend
The following have insufficient evidence and should NOT be routinely prescribed: 1, 2
Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment (may cause side effects without proven benefit)
Intratympanic medications
Dietary supplements including Ginkgo biloba, melatonin, or zinc
Transcranial magnetic stimulation (TMS)
Acupuncture (insufficient evidence to make recommendation)
Important caveat: While antidepressants should not be prescribed specifically for tinnitus, they remain appropriate for treating comorbid depression or anxiety disorders that commonly accompany tinnitus 1, 6
Common Clinical Pitfalls to Avoid
Missing hearing loss: Even mild or unilateral hearing loss warrants hearing aid evaluation, as this can significantly improve tinnitus 1, 2
Dismissing pulsatile tinnitus: This requires imaging evaluation due to identifiable—and sometimes life-threatening—causes in the majority of cases 2, 4
Overlooking psychiatric comorbidity: Screen for severe anxiety and depression, as these patients require urgent intervention due to suicide risk 2, 3
Prescribing unproven supplements: Patients often request these, but evidence does not support their use and may delay effective treatment 1, 2
Ordering unnecessary imaging: Bilateral, non-pulsatile tinnitus without localizing features does not require neuroimaging 1, 4
Special Populations
Chemotherapy-induced tinnitus: No causative treatment exists for established platinum-based chemotherapy ototoxicity, but hearing aids and CBT strategies remain beneficial 2