What are the treatment options for an adult patient with no prior history of ear problems experiencing tinnitus (ringing in the ears)?

Treatment of Tinnitus (Ringing in the Ears)

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

Initial Evaluation Steps

Before initiating treatment, perform a targeted assessment to identify treatable underlying conditions:

• Otoscopic examination to exclude cerumen impaction, retrotympanic mass, acute otitis externa, or middle ear infection 2
• Classify the tinnitus type: pulsatile vs. non-pulsatile, unilateral vs. bilateral 1
• Screen for psychiatric comorbidities: patients with severe anxiety or depression require immediate psychiatric intervention due to increased suicide risk 1, 3
• Obtain comprehensive audiologic examination if tinnitus is unilateral, persistent (≥6 months), or associated with hearing difficulties 1

When to Order Imaging

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

DO order imaging when:

• Pulsatile tinnitus is present (requires CTA or MRA to evaluate vascular abnormalities) 1, 2
• Unilateral or asymmetric tinnitus (requires MRI of internal auditory canals with contrast to exclude vestibular schwannoma) 1, 2
• Focal neurological abnormalities are present 1

Evidence-Based Treatment Algorithm

First-Line Treatments

1. Education and counseling for all patients with persistent tinnitus about management strategies and natural progression 1

2. Hearing aids if ANY degree of hearing loss is present, even if mild or unilateral—this is a common pitfall where providers overlook mild hearing loss that could benefit from amplification 1, 4

3. Cognitive Behavioral Therapy (CBT) for persistent, bothersome tinnitus—this has the strongest evidence for improving quality of life 1, 5, 4

4. Sound therapy may provide symptomatic relief and can be combined with CBT-based counseling 1, 4

Treatments to AVOID

Do NOT recommend the following due to insufficient evidence and potential side effects:

• Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment 1
• Intratympanic medications 1
• Dietary supplements including Ginkgo biloba, melatonin, or zinc 1

The American Academy of Otolaryngology-Head and Neck Surgery explicitly advises against these interventions due to lack of consistent benefit 1

Special Clinical Scenarios

Pulsatile Tinnitus

• Almost always requires imaging evaluation to identify vascular causes (arterial dissection, dural arteriovenous fistulas, paragangliomas, sigmoid sinus abnormalities) 1, 3
• Consider vascular tumors and obtain appropriate CTA or MRA 1

Chemotherapy-Induced Tinnitus

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

Ménière's Disease-Associated Tinnitus

• Manage by controlling the underlying vestibular disorder rather than treating tinnitus specifically 1

Critical Safety Considerations

Immediate psychiatric referral is mandatory for patients with tinnitus accompanied by severe anxiety or depression due to documented increased suicide risk in this population 1, 3, 2

Common Clinical Pitfalls to Avoid

• Ordering expensive brain imaging for bilateral, symmetric, non-pulsatile tinnitus without neurological deficits 2
• Prescribing medications without clear evidence of benefit 1, 2
• Failing to evaluate for mild hearing loss that could benefit from hearing aids 1, 2
• Missing simple treatable causes like cerumen impaction during initial otoscopy 2
• Recommending dietary supplements that lack efficacy evidence 1