Treatment Plan for Tinnitus
Cognitive Behavioral Therapy (CBT) is the only treatment with strong evidence from randomized controlled trials demonstrating improved quality of life and should be recommended as first-line therapy for all patients with persistent, bothersome tinnitus. 1, 2, 3
Initial Assessment and Classification
Determine if tinnitus is persistent (≥6 months) versus recent onset, and whether it is bothersome versus non-bothersome, as this classification guides treatment intensity. 4, 2
Perform a targeted history and physical examination focusing on:
- Unilateral versus bilateral presentation (unilateral requires imaging to rule out vestibular schwannoma) 4, 3
- Pulsatile versus non-pulsatile (pulsatile almost always requires vascular imaging with CTA or MRA) 4, 3
- Associated hearing loss or difficulty (warrants comprehensive audiologic examination) 1, 2
- Psychiatric comorbidities, particularly severe anxiety or depression (increased suicide risk requires prompt intervention) 4, 3
Obtain comprehensive audiologic examination for any patient with unilateral tinnitus, persistent tinnitus (≥6 months), or associated hearing difficulties. 1, 2
Evidence-Based Treatment Algorithm
For ALL Patients with Persistent, Bothersome Tinnitus:
Provide education and counseling about tinnitus management strategies, including natural history and realistic expectations. 1, 4, 2, 3
Recommend CBT immediately - this has Grade B evidence from RCTs showing preponderance of benefit over harm and is the most evidence-based treatment available. 1, 2, 3, 5
For Patients with ANY Degree of Hearing Loss:
Recommend hearing aid evaluation immediately, even if hearing loss is mild or unilateral, as hearing aids provide significant relief by addressing auditory deprivation that often underlies tinnitus. 1, 4, 2, 3
Optional Adjunctive Therapy:
Sound therapy may be offered for symptomatic relief, though evidence is less robust than for CBT and hearing aids. 1, 4
Treatments to AVOID
Do NOT routinely prescribe antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary treatment of persistent, bothersome tinnitus due to low strength of evidence, significant potential side effects, and lack of proven benefit. 1, 2, 3 These medications should only be considered for treating comorbid conditions like depression or anxiety disorders, not tinnitus itself.
Do NOT recommend dietary supplements including Ginkgo biloba, melatonin, or zinc, as they lack consistent evidence of efficacy. 4, 2, 3
Do NOT recommend transcranial magnetic stimulation (TMS) for routine tinnitus treatment. 2
Common Clinical Pitfalls
Do not overlook mild hearing loss - even minimal hearing loss warrants hearing aid evaluation, as patients may benefit significantly. 4, 3
Do not defer treatment indefinitely - patients with persistent symptoms (≥6 months) are unlikely to resolve spontaneously and benefit from active intervention with CBT and hearing aids. 3
Do not prescribe medications without clear evidence that may cause side effects or paradoxically worsen tinnitus. 1, 3
Do not skip psychiatric screening - all patients with bothersome tinnitus should be screened for anxiety and depression due to increased suicide risk. 4, 3
Special Clinical Scenarios
For pulsatile tinnitus: Obtain vascular imaging (CTA or MRA) to identify potentially treatable vascular abnormalities or retrotympanic masses. 4, 3
For unilateral tinnitus: Obtain imaging studies to rule out vestibular schwannoma or other structural pathology. 3, 6
For medication-induced tinnitus (e.g., cisplatin): No treatment can reverse established ototoxicity, but hearing aids and CBT remain beneficial for symptom management. 4