What are the treatment options for a patient with tinnitus?

Tinnitus Treatment

Initial Classification and Risk Stratification

The treatment of tinnitus depends entirely on whether it is pulsatile or non-pulsatile, and whether it is unilateral or bilateral—this classification determines both the urgency of evaluation and the therapeutic approach. 1

Pulsatile Tinnitus (Synchronous with Heartbeat)

• Pulsatile tinnitus requires immediate imaging evaluation in nearly all cases, as over 70% have an identifiable structural or vascular cause, including life-threatening conditions like dural arteriovenous fistulas or arterial dissection 2
• Order CT angiography (CTA) of head and neck with contrast as first-line imaging when suspecting arterial causes (atherosclerotic disease, dissection, arteriovenous malformations) or dural arteriovenous fistulas 2
• Order high-resolution CT temporal bone (non-contrast) when suspecting venous causes (sigmoid sinus abnormalities, jugular bulb variants), paragangliomas, or superior semicircular canal dehiscence 2
• If initial imaging is negative but clinical suspicion remains high, proceed to MRI with contrast and MR angiography 2

Unilateral Non-Pulsatile Tinnitus

• Unilateral tinnitus mandates imaging with MRI of internal auditory canals with contrast to exclude vestibular schwannoma or other retrocochlear pathology 3
• Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) within 4 weeks 3
• Approximately 10-15% of unilateral tinnitus cases have an identifiable underlying cause requiring specific treatment 3

Bilateral Non-Pulsatile Tinnitus

• Do NOT order imaging for bilateral, symmetric, non-pulsatile tinnitus without focal neurologic abnormalities or asymmetric hearing loss—this represents inappropriate resource utilization 1
• Proceed directly to audiologic evaluation and symptom-based treatment 1

Evidence-Based Treatment Algorithm

Step 1: Audiologic Evaluation and Hearing Aid Trial

• Obtain comprehensive audiologic examination for all patients with persistent tinnitus (≥6 months) or any unilateral tinnitus, regardless of whether the patient reports hearing difficulties 1
• Recommend hearing aid evaluation immediately for any patient with documented hearing loss, even if mild or unilateral—hearing aids have strong evidence for benefit and provide significant relief 1
• Hearing aids are beneficial even when hearing loss seems minimal or subclinical 3

Step 2: Education and Counseling

• Provide education and counseling about tinnitus mechanisms, natural history, and management strategies for all patients with persistent, bothersome tinnitus 1
• Explain that tinnitus is a symptom, not a disease, and that most cases are benign and associated with sensorineural hearing loss 4
• Counseling should begin during the initial evaluation to help patients cope and improve chances of successful subsequent treatment 5

Step 3: Cognitive Behavioral Therapy (CBT)

• Cognitive Behavioral Therapy is the ONLY treatment with strong evidence for improving quality of life in patients with persistent, bothersome tinnitus 1
• CBT should be recommended for patients with bothersome tinnitus that persists despite hearing aids and education 1
• The evidence base is strongest for a combination of sound therapy and CBT-based counseling 6

Step 4: Sound Therapy (Optional Adjunct)

• Sound therapy may be recommended as a management option for persistent tinnitus, providing symptomatic relief 1
• Wide-band sound therapy can be used in combination with CBT-based counseling 6

Treatments to AVOID

Medications NOT Recommended

• Do NOT prescribe antidepressants, anticonvulsants, anxiolytics (including benzodiazepines), or intratympanic medications for primary treatment of persistent tinnitus—insufficient evidence and potential for side effects 1
• The exception is treating co-existing psychiatric conditions (depression, anxiety) as separate diagnoses, not as tinnitus treatment 1

Supplements NOT Recommended

• Do NOT recommend dietary supplements including Ginkgo biloba, melatonin, zinc, or other supplements—lack of consistent benefit and evidence of efficacy 1

Special Populations and Considerations

Psychiatric Comorbidities

• Screen all patients with bothersome tinnitus for severe anxiety or depression—suicide is reported in tinnitus patients with co-existing psychiatric illness, requiring prompt identification and intervention 7
• Treat psychiatric conditions as separate diagnoses with appropriate psychiatric care, not as tinnitus-specific therapy 1

Menière's Disease

• When tinnitus occurs as part of Menière's disease, manage by controlling the underlying vestibular disorder rather than treating tinnitus specifically 1

Chemotherapy-Induced Tinnitus

• No causative treatment exists for established platinum-based chemotherapy ototoxicity 1
• Hearing aids and CBT remain beneficial for managing symptoms 1
• Sodium thiosulfate may prevent ototoxicity in children receiving cisplatin, but use in adults is uncertain 1

Sudden Hearing Loss with Tinnitus

• If sudden sensorineural hearing loss accompanies tinnitus, initiate urgent corticosteroid therapy 3

Common Pitfalls to Avoid

• Never dismiss pulsatile tinnitus as benign without imaging—treatable and life-threatening causes are common 2
• Never order imaging for bilateral, symmetric, non-pulsatile tinnitus without localizing features—this is low-yield, expensive testing with no benefit 1
• Never overlook mild hearing loss—even minimal hearing loss may benefit from hearing aid intervention 3
• Never prescribe medications or supplements without clear evidence of benefit—risk of side effects without proven efficacy 1
• Never delay audiologic testing—obtain comprehensive audiometry within 4 weeks for unilateral or persistent tinnitus 3