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

Tinnitus Treatment

For patients with persistent, bothersome tinnitus, cognitive behavioral therapy (CBT) is the only treatment proven to improve quality of life and should be the cornerstone of management, combined with hearing aids for those with any degree of hearing loss. 1

Initial Evaluation and Risk Stratification

Perform immediate otoscopic examination to identify treatable causes such as cerumen impaction, retrotympanic vascular masses (paragangliomas), acute otitis externa, or middle ear infection before ordering expensive diagnostic studies. 2

Classify tinnitus characteristics to guide subsequent workup: 1

• Pulsatile vs. non-pulsatile: Pulsatile tinnitus (synchronous with heartbeat) requires imaging in nearly all cases, as it has an identifiable structural or vascular cause in >70% of cases 3
• Unilateral vs. bilateral: Unilateral tinnitus warrants audiologic testing and potential imaging 4
• Associated symptoms: Presence of hearing loss, focal neurological deficits, or severe psychiatric symptoms changes management urgency 1

Audiologic Assessment

Obtain comprehensive audiologic examination promptly (within 4 weeks) for patients with: 4

• Unilateral tinnitus
• Persistent tinnitus (≥6 months duration)
• Any associated hearing difficulties
• Pulsatile tinnitus

This testing should include pure tone audiometry, speech audiometry, and acoustic reflex testing to detect hearing loss (present in the majority of tinnitus patients), characterize its nature (conductive, sensorineural, or mixed), and identify candidates for hearing aid intervention. 4

Imaging Decisions

Do NOT obtain imaging for bilateral, symmetric, non-pulsatile tinnitus without focal neurological abnormalities or asymmetric hearing loss—this represents low-yield, expensive testing with potential harms from radiation, contrast, and incidental findings. 4, 1

DO obtain imaging when tinnitus has any of these features: 4, 1

• Pulsatile (any laterality)
• Unilateral/asymmetric
• Focal neurological abnormalities
• Asymmetric hearing loss

Imaging Selection Algorithm:

For pulsatile tinnitus: 3

• First-line: CT angiography (CTA) head and neck with contrast when suspecting dural arteriovenous fistulas (8% of cases, life-threatening if missed), arterial dissection, atherosclerotic carotid disease (17.5% of cases), or sigmoid sinus abnormalities
• Alternative first-line: High-resolution CT temporal bone (non-contrast) when otoscopy reveals retrotympanic mass or when suspecting paragangliomas (16% of cases), jugular bulb abnormalities, superior semicircular canal dehiscence, or aberrant venous anatomy
• Second-line: MRI/MRA with contrast if CT/CTA negative but clinical suspicion remains high, or for cerebellopontine angle lesions

For unilateral non-pulsatile tinnitus with asymmetric hearing loss: 2

• MRI internal auditory canals with contrast to exclude vestibular schwannoma

Evidence-Based Treatment Options

First-Line Interventions

1. Cognitive Behavioral Therapy (CBT) 1

• Strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus
• Reshapes negative thought patterns and behaviors associated with tinnitus-induced distress
• Should be recommended for all patients with bothersome tinnitus

2. Hearing Aids 1

• Recommend hearing aid evaluation for ANY degree of hearing loss, even if mild or unilateral
• Provides significant symptomatic relief by amplifying ambient sounds and reducing tinnitus perception
• Addresses the underlying sensorineural hearing loss present in most tinnitus patients

3. Education and Counseling 1

• Essential for all patients with persistent tinnitus
• Explain tinnitus mechanisms, natural history, and management strategies
• Begin during initial evaluation to improve coping and treatment success

Adjunctive Options

Sound therapy may provide symptomatic relief for some patients, though evidence is less robust than for CBT and hearing aids. 1

Treatments NOT Recommended

Do NOT routinely prescribe: 1

• Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment (insufficient evidence, potential side effects)
• Intratympanic medications (lack of efficacy data)
• Dietary supplements (Ginkgo biloba, melatonin, zinc) due to lack of consistent benefit

Exception: Treat comorbid depression or anxiety as separate conditions if present, but not as primary tinnitus therapy. 1

Special Clinical Scenarios

Pulsatile Tinnitus in Young Overweight Women

High suspicion for idiopathic intracranial hypertension (IIH), the second most common cause of pulsatile tinnitus, especially with headaches or vision changes. 3

• Urgent ophthalmologic evaluation for papilledema
• CTA or MRV to assess venous sinus abnormalities
• IIH-related pulsatile tinnitus responds dramatically to treatment in nearly 100% of cases 3

Tinnitus with Severe Psychiatric Symptoms

Immediate psychiatric intervention required for patients with severe anxiety or depression related to tinnitus due to increased suicide risk. 1, 2

Chemotherapy-Induced Tinnitus

No causative treatment exists for established platinum-based chemotherapy ototoxicity. 1

• Hearing aids remain beneficial
• CBT strategies can be offered
• Sodium thiosulfate may prevent ototoxicity in children receiving cisplatin (uncertain benefit in adults)

Ménière's Disease-Associated Tinnitus

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

Critical Pitfalls to Avoid

1. Missing life-threatening causes of pulsatile tinnitus 3

• Dural arteriovenous fistulas can present with isolated pulsatile tinnitus before catastrophic hemorrhage or stroke
• Arterial dissection requires urgent identification
• Never dismiss pulsatile tinnitus as benign without imaging

2. Ordering imaging for bilateral, symmetric, non-pulsatile tinnitus 4, 1

• Represents inappropriate resource utilization with no benefit
• Exposes patients to unnecessary radiation, contrast risks, and anxiety from incidental findings

3. Overlooking mild hearing loss 1

• Obtain audiometry even when patients don't report hearing difficulties
• Mild hearing loss amenable to hearing aid intervention is frequently missed

4. Inadequate otoscopic examination 2

• Failing to visualize vascular retrotympanic masses (paragangliomas) leads to delayed diagnosis and inappropriate imaging selection
• Simple treatable causes like cerumen impaction or otitis externa may be missed

5. Prescribing unproven medications 1

• Avoid medications without clear evidence that may cause side effects or worsen tinnitus
• Dietary supplements lack efficacy and should not be recommended