What are the treatment options for a patient experiencing tinnitus (ringing in the ears)?

Treatment for Tinnitus (Ringing in the Ears)

Immediate Classification Required

The first critical step is determining whether your tinnitus is pulsatile (synchronous with heartbeat) or non-pulsatile, as this fundamentally changes both the diagnostic urgency and treatment approach. 1, 2

For Pulsatile Tinnitus:

• Urgent imaging is mandatory because over 70% of cases have an identifiable structural or vascular cause, including life-threatening conditions like dural arteriovenous fistulas or arterial dissection that can cause catastrophic hemorrhage if missed 2, 3
• Order CT angiography (CTA) of head and neck with contrast as first-line imaging when suspecting vascular causes 2, 3
• Order high-resolution CT temporal bone (non-contrast) when suspecting paragangliomas, glomus tumors, or jugular bulb abnormalities 2, 3

For Non-Pulsatile Tinnitus:

• Imaging is NOT indicated for bilateral, symmetric, non-pulsatile tinnitus without focal neurological findings 1, 2
• Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) if tinnitus is unilateral, persistent ≥6 months, or associated with hearing difficulties 1, 2
• Order MRI of internal auditory canals with contrast only if tinnitus is unilateral or associated with asymmetric hearing loss to exclude vestibular schwannoma 1, 2

Evidence-Based Treatment Algorithm

First-Line Treatments (Strong Evidence):

Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus and should be recommended for all such patients. 1, 2, 4

Hearing aids are strongly recommended for any degree of hearing loss—even mild or unilateral—as they provide significant relief and have robust evidence for benefit. 1, 2

• Education and counseling about tinnitus mechanisms, natural history, and management strategies are essential for all patients with persistent, bothersome tinnitus 1, 2
• Sound therapy may provide symptomatic relief for persistent tinnitus 1

Treatments to AVOID (Strong Recommendations Against):

Do NOT prescribe antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary tinnitus treatment due to insufficient evidence and potential harm. 1, 2

Do NOT recommend dietary supplements including Ginkgo biloba, melatonin, or zinc due to lack of consistent benefit. 1, 2

Critical Red Flags Requiring Urgent Evaluation

• Pulsatile tinnitus of any kind requires vascular imaging (CTA or MRA) to exclude treatable vascular abnormalities 1, 2, 3
• Unilateral or asymmetric tinnitus requires MRI with contrast to exclude vestibular schwannoma 1, 2
• Severe anxiety or depression requires prompt psychiatric intervention due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1, 2
• Focal neurological abnormalities shift the approach away from tinnitus-specific protocols to evaluation for stroke, hemorrhage, or mass lesions 3

Special Clinical Scenarios

Medication-Induced Tinnitus (e.g., Cisplatin):

• No causative treatment exists for established ototoxicity 1
• Hearing aids and CBT remain beneficial for symptom management 1
• Sodium thiosulfate may prevent ototoxicity in children receiving cisplatin, but use in adults is uncertain 1

Ménière's Disease:

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

Common Pitfalls to Avoid

• Dismissing pulsatile tinnitus as benign without imaging is dangerous, as identifiable causes exist in >70% of cases 2, 3
• Overlooking mild hearing loss that could benefit from hearing aid intervention—even unilateral or mild hearing loss warrants amplification 1, 2
• Prescribing medications without evidence (antidepressants, supplements) that may cause side effects or worsen tinnitus 1, 2
• Missing dural arteriovenous fistulas, which can present with isolated pulsatile tinnitus before catastrophic hemorrhage 3
• Inadequate otoscopic examination can delay diagnosis of vascular retrotympanic masses like paragangliomas 3

Treatment Expectations

No cure exists for tinnitus—treatment focuses on symptom management and quality of life improvement 2. The goal is habituation and reduced distress rather than elimination of the sound perception 1, 4.