What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) is the only treatment with strong evidence for improving quality of life in patients with persistent, bothersome tinnitus, and should be your primary therapeutic recommendation. 1

Initial Classification and Evaluation

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

• Determine if tinnitus is pulsatile or non-pulsatile - pulsatile tinnitus almost always requires imaging evaluation (CT or MR angiography) as it indicates underlying vascular abnormalities in over 70% of cases 1, 2
• Assess laterality - unilateral tinnitus requires comprehensive audiologic examination and may warrant imaging to exclude vestibular schwannoma 1, 3
• Perform otoscopic examination to identify vascular retrotympanic masses (paragangliomas), cerumen impaction, or middle ear pathology 1, 3
• Obtain comprehensive audiometry for any patient with unilateral tinnitus, persistent tinnitus (≥6 months), or associated hearing difficulties 1

Evidence-Based Treatment Algorithm

For All Patients with Persistent, Bothersome Tinnitus:

• Provide education and counseling about tinnitus management strategies as an essential first step 1
• Screen for severe anxiety or depression and provide immediate psychiatric intervention if present, as tinnitus patients with psychiatric comorbidities have increased suicide risk 1, 3

For Patients with Hearing Loss (Even Mild or Unilateral):

• Recommend hearing aid evaluation - hearing aids provide significant relief and are indicated even for mild or unilateral hearing loss 1, 4
• This is a critical intervention that is frequently overlooked in clinical practice 1

For Persistent, Bothersome Tinnitus Without Hearing Loss:

• Refer for Cognitive Behavioral Therapy (CBT) - this has the strongest evidence base for improving quality of life 1, 5
• Consider sound therapy as a management option for symptomatic relief, though evidence is less robust than for CBT 1

Treatments You Should NOT Recommend

The American Academy of Otolaryngology-Head and Neck Surgery provides clear guidance on ineffective treatments:

• Do not prescribe antidepressants, anticonvulsants, or anxiolytics for primary treatment of tinnitus due to insufficient evidence and potential side effects 1
• Do not recommend intratympanic medications for persistent tinnitus 1
• Do not recommend dietary supplements including Ginkgo biloba, melatonin, or zinc due to lack of consistent benefit 1

Exception for Psychiatric Comorbidity:

• Antidepressants may be appropriate for treating comorbid depression or anxiety disorders, but not for tinnitus itself 5

Special Clinical Scenarios

Pulsatile Tinnitus:

• Order CT angiography (CTA) of head and neck as first-line imaging to evaluate for dural arteriovenous fistulas, arterial dissection, atherosclerotic disease, or sigmoid sinus abnormalities 2
• Alternative: high-resolution CT temporal bone if suspecting paragangliomas, glomus tumors, or jugular bulb abnormalities 2
• Missing dural arteriovenous fistula is life-threatening - it can present with isolated pulsatile tinnitus before catastrophic hemorrhage 2

Unilateral Tinnitus:

• Order MRI of internal auditory canals with contrast to exclude vestibular schwannoma 3

Bilateral, Non-Pulsatile Tinnitus:

• Do not order imaging studies unless focal neurological deficits or asymmetric hearing loss are present 1, 3

Common Pitfalls to Avoid

• Failing to identify mild hearing loss that could benefit from hearing aids - even mild or unilateral hearing loss warrants hearing aid evaluation 1
• Dismissing pulsatile tinnitus as benign - this requires imaging in nearly all cases due to identifiable structural causes in >70% of cases 2
• Prescribing medications without evidence that may worsen tinnitus or cause side effects 1
• Ordering brain imaging for bilateral, symmetric, non-pulsatile tinnitus without neurological deficits - this is unnecessary and costly 3
• Overlooking psychiatric comorbidities - severe anxiety or depression requires immediate intervention due to suicide risk 1, 3

Treatment for Chemotherapy-Induced Tinnitus

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