What are the treatment options for a patient with constant tinnitus?

Treatment of Constant Tinnitus

For a patient with constant (persistent) tinnitus, cognitive behavioral therapy (CBT) is the only treatment proven to improve quality of life and should be recommended, while hearing aids should be offered if any degree of hearing loss is present—even if mild or unilateral. 1, 2

Initial Evaluation: Identify Treatable Causes

Before addressing persistent tinnitus management, perform a targeted assessment to exclude secondary causes that require specific treatment:

• Otoscopic examination to identify cerumen impaction, retrotympanic vascular masses (paragangliomas), or middle ear pathology 1, 3
• Determine if tinnitus is pulsatile (synchronous with heartbeat) versus non-pulsatile, as this fundamentally changes the diagnostic approach 2, 4
• Assess laterality: unilateral versus bilateral 1, 2
• Screen for severe anxiety or depression, as suicide risk is elevated in tinnitus patients with psychiatric comorbidity and requires immediate intervention 1, 3

Audiologic Testing

Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for any patient with:

• Unilateral tinnitus 1, 2
• Persistent tinnitus ≥6 months 1, 5
• Any perceived hearing difficulty 1, 2

This should be done promptly, ideally within 4 weeks, even if the patient denies hearing problems—mild hearing loss is frequently missed and highly treatable. 2, 4

Imaging: When to Order (and When NOT to Order)

Do NOT obtain imaging for bilateral, symmetric, non-pulsatile tinnitus without focal neurologic abnormalities or asymmetric hearing loss. 1, 2, 5 This represents inappropriate resource utilization with no benefit.

DO obtain imaging if any of the following are present:

• Pulsatile tinnitus (requires CT angiography or high-resolution CT temporal bone) 1, 2, 4
• Unilateral tinnitus (requires MRI internal auditory canals with contrast to exclude vestibular schwannoma) 2, 4
• Focal neurologic abnormalities 1, 5
• Asymmetric hearing loss 1, 2

Evidence-Based Treatment for Persistent, Bothersome Tinnitus

First-Line Interventions (RECOMMEND)

1. Cognitive Behavioral Therapy (CBT): The strongest evidence for improving quality of life in tinnitus patients. 1, 2, 6, 5 This is the only treatment with proven benefit for tinnitus-related distress.

2. Hearing Aids: Recommend evaluation for any patient with documented hearing loss, even if mild or unilateral. 1, 2, 6 Hearing aids provide significant relief and have strong evidence for benefit.

3. Education and Counseling: Provide information about tinnitus mechanisms, natural history (many patients improve over time), and management strategies. 1, 2, 5 This is essential for all patients with persistent, bothersome tinnitus.

Optional Interventions (MAY OFFER)

• Sound therapy: May provide symptomatic relief, though evidence is inconclusive. 1, 2, 5 This includes white noise machines, nature sounds, or other background sounds to mask tinnitus.

Treatments to AVOID (Do NOT Recommend)

The following have insufficient evidence and should NOT be routinely recommended:

• Medications: Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary tinnitus treatment 1, 2, 5
• Dietary supplements: Ginkgo biloba, melatonin, zinc, or other supplements 1, 2, 5
• Transcranial magnetic stimulation (TMS) 1, 5

Important caveat: While these medications should not be prescribed for tinnitus itself, antidepressants or anxiolytics may be appropriate if the patient has comorbid depression or anxiety disorder requiring treatment. 6

Common Pitfalls to Avoid

• Ordering brain imaging for bilateral, non-pulsatile tinnitus without localizing features—this is low-yield and expensive 2, 4, 3
• Missing mild hearing loss that could benefit from amplification because the patient doesn't complain of hearing difficulty 2, 4
• Dismissing pulsatile tinnitus as benign—over 70% have identifiable structural or vascular causes, some life-threatening (dural arteriovenous fistula, arterial dissection) 2, 4
• Prescribing medications or supplements without evidence, which may cause side effects without benefit 1, 2
• Failing to screen for psychiatric comorbidity, particularly severe depression with suicide risk 1, 3

Treatment Algorithm Summary

1. Exclude secondary causes: Otoscopy, determine if pulsatile, assess laterality, screen for psychiatric emergency 1, 2, 3
2. Obtain audiometry for unilateral, persistent (≥6 months), or hearing-related tinnitus 1, 2, 5
3. Image only if indicated: pulsatile, unilateral, focal neurologic signs, or asymmetric hearing loss 1, 2, 4
4. Recommend CBT for all patients with persistent, bothersome tinnitus 1, 2, 6, 5
5. Recommend hearing aid evaluation if any hearing loss documented 1, 2, 6
6. Provide education and counseling about natural history and coping strategies 1, 2, 5
7. Consider sound therapy as adjunctive symptomatic treatment 1, 2, 5
8. Avoid medications and supplements for primary tinnitus treatment 1, 2, 5