What is the best treatment approach for a patient with bilateral tinnitus?

Treatment of Bilateral Tinnitus

For bilateral, nonpulsatile tinnitus without asymmetric hearing loss or neurologic deficits, cognitive behavioral therapy (CBT) is the only treatment proven to improve quality of life, and hearing aids should be offered when any degree of hearing loss is documented. 1, 2

Initial Evaluation: Rule Out Imaging Indications

Before proceeding with treatment, confirm that imaging is not indicated by verifying the absence of red flags 3, 1:

• Do not order imaging for bilateral, symmetric, nonpulsatile tinnitus—this represents inappropriate resource utilization with no benefit 1, 2
• Imaging is only indicated if tinnitus is unilateral, pulsatile, associated with focal neurologic abnormalities, or accompanied by asymmetric hearing loss 3, 1

Mandatory Audiologic Assessment

Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for any persistent tinnitus (≥6 months), even when patients deny hearing difficulties 3, 2:

• This identifies mild or unilateral hearing loss that patients often underreport but benefits significantly from amplification 2, 4
• Audiometry should be completed within 4 weeks of presentation 3

Evidence-Based Treatment Algorithm

First-Line Interventions

1. Hearing aids (if any hearing loss documented, even mild or unilateral):

   • Strong recommendation with significant quality of life improvement 1, 2, 4
   • Amplification reduces psychosocial and emotional manifestations of tinnitus 1
   • Do not withhold hearing aids based on severity of hearing loss—even mild loss benefits from treatment 2, 4

2. Cognitive Behavioral Therapy (CBT):

   • Strongest evidence base for improving quality of life in persistent, bothersome tinnitus 1, 5, 2
   • The combination of sound therapy and CBT-based counseling has the most robust evidence 5, 4
   • CBT specifically targets the psychosocial impact and habituation to tinnitus 2, 6

3. Education and Counseling (for all patients):

   • Provide information about tinnitus mechanisms, natural history, and management strategies 1, 5, 2
   • Essential component of comprehensive care regardless of other interventions 5, 2

4. Sound Therapy (optional adjunct):

   • May provide symptomatic relief as a management option 5, 2
   • Best evidence when combined with CBT-based counseling 5, 4

Treatments to Avoid

Do not routinely prescribe the following due to insufficient evidence and potential harms 1, 5, 2:

• Antidepressants, anticonvulsants, or anxiolytics for tinnitus itself (unless treating comorbid psychiatric conditions) 1, 5, 2
• Intratympanic medications 1, 5, 2
• Dietary supplements (Ginkgo biloba, melatonin, zinc) 1, 5, 2
• Transcranial magnetic stimulation 2

Special Considerations and Pitfalls

When Bilateral Tinnitus Requires Imaging Despite Presentation

Order imaging if any of the following develop 1:

• Asymmetric hearing loss on audiometry
• Focal neurologic deficits
• Pulsatile quality (synchronous with heartbeat)
• History of head trauma

Common Clinical Errors

• Missing mild hearing loss: Always obtain audiometry even when patients report normal hearing—mild loss is frequently underreported but highly treatable 2, 4
• Prescribing medications without evidence: Antidepressants and anticonvulsants lack efficacy for tinnitus itself and may cause side effects 1, 5, 2
• Ordering unnecessary imaging: Bilateral, symmetric, nonpulsatile tinnitus without localizing features does not warrant imaging 1, 2
• Overlooking psychiatric comorbidities: Screen for severe anxiety or depression, which increase suicide risk and require prompt intervention 5

Distinguishing Bothersome from Non-Bothersome Tinnitus

Prioritize intervention for patients with bothersome tinnitus (impacts quality of life, sleep, concentration, or emotional well-being) 3, 2:

• Bothersome tinnitus warrants active treatment with CBT and hearing aids
• Non-bothersome tinnitus may only require education and reassurance 2

Treatment Efficacy Expectations

• CBT: Strongest evidence for quality of life improvement, though does not eliminate tinnitus perception 1, 5, 2
• Hearing aids: Significant relief when hearing loss present, even if mild 1, 2, 4
• Sound therapy: Provides symptomatic relief but evidence is less robust than CBT 5, 2
• Natural history: Many patients habituate over time with education and counseling alone 6