What is the recommended treatment for a patient presenting with tinnitus?

Recommended Treatment for Tinnitus

Cognitive Behavioral Therapy (CBT) is the only treatment with strong evidence from randomized controlled trials demonstrating improved quality of life in patients with persistent, bothersome tinnitus and should be recommended as first-line therapy. 1, 2

Initial Evaluation and Risk Stratification

Mandatory Audiologic Testing

• Obtain a comprehensive audiologic examination promptly for all patients with tinnitus that is unilateral, persistent (≥6 months), or associated with hearing difficulties 3, 4
• Even patients without perceived hearing problems should be considered for audiologic testing, as hearing loss is frequently present and treatable 3

Imaging Indications (Red Flags)

Do NOT obtain imaging studies unless one or more of the following are present: 3, 1, 4

• Unilateral tinnitus
• Pulsatile tinnitus
• Focal neurological abnormalities
• Asymmetric hearing loss

When imaging is indicated, MRI with contrast is the preferred modality to rule out vestibular schwannoma or vascular abnormalities 5

Evidence-Based Treatment Algorithm

Step 1: Distinguish Bothersome from Non-Bothersome Tinnitus

• Use validated questionnaires (Tinnitus Handicap Inventory or Tinnitus Functional Index) to determine if active treatment is needed 5
• Patients with non-bothersome tinnitus require reassurance and education only 1, 4

Step 2: Address Hearing Loss (If Present)

Recommend hearing aid evaluation immediately for ALL patients with any degree of hearing loss and tinnitus, even if hearing loss is mild or unilateral. 1, 2, 4

• Hearing aids provide significant relief by addressing auditory deprivation that often underlies tinnitus 2, 6
• This intervention should not be delayed or dismissed based on severity of hearing loss 5

Step 3: Provide Education and Counseling

• All patients with persistent, bothersome tinnitus should receive education about management strategies and natural history 1, 2, 4
• This foundational intervention helps set realistic expectations for management 2

Step 4: Initiate Cognitive Behavioral Therapy

CBT is the ONLY treatment with Grade B evidence from RCTs showing preponderance of benefit for improving quality of life. 1, 2, 4

• CBT should be offered to all patients with persistent, bothersome tinnitus 4
• The combination of sound therapy and CBT-based counseling has the strongest evidence base 6

Step 5: Consider Sound Therapy

• Sound therapy may be recommended as an option for symptomatic relief in patients with persistent, bothersome tinnitus 1, 4
• Evidence is less conclusive than for CBT, but it can provide benefit when combined with counseling 6

Treatments to AVOID

Medications - Strong Recommendation AGAINST

Do NOT routinely prescribe the following due to insufficient evidence and potential harm: 1, 2, 4

• Antidepressants
• Anticonvulsants
• Anxiolytics (including benzodiazepines)
• Intratympanic medications

Dietary Supplements - Recommendation AGAINST

Do NOT recommend the following due to lack of consistent benefit: 1, 2, 4

• Ginkgo biloba
• Melatonin
• Zinc
• Other dietary supplements

Other Interventions

• Transcranial magnetic stimulation should not be used for routine treatment 4

Special Clinical Scenarios

Unilateral Tinnitus

• Imaging is mandatory to rule out vestibular schwannoma (10-15% of cases have identifiable underlying cause) 5
• If sudden hearing loss accompanies unilateral tinnitus, initiate urgent corticosteroid therapy 5

Pulsatile Tinnitus

• Almost always requires imaging evaluation (CTA or MRA) to identify vascular causes 1
• Consider vascular abnormalities and potentially treatable conditions 1

Psychiatric Comorbidities

Screen ALL patients with bothersome tinnitus for anxiety and depression, as psychiatric comorbidities increase suicide risk and require prompt intervention. 1, 5, 2

Chemotherapy-Induced Tinnitus

• No causative treatment exists for established platinum-based chemotherapy ototoxicity 1
• Hearing aids and CBT remain beneficial for symptom management 1

Common Pitfalls to Avoid

• Do not overlook mild hearing loss - even minimal hearing loss warrants hearing aid evaluation 5, 2
• Do not prescribe medications without clear evidence - this may cause side effects or worsen tinnitus 1, 2
• Do not defer treatment indefinitely - patients with persistent symptoms are unlikely to resolve spontaneously and benefit from active intervention 2
• Do not recommend supplements lacking efficacy evidence - this wastes resources and delays effective treatment 1, 2