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

Treatment for Tinnitus

Cognitive Behavioral Therapy (CBT) is the only treatment with strong evidence for improving quality of life in patients with persistent, bothersome tinnitus, and should be offered as first-line therapy alongside education, counseling, and hearing aids for those with any degree of hearing loss. 1

Initial Classification and Evaluation

Before initiating treatment, you must classify the tinnitus to identify potentially treatable underlying causes:

• Determine if tinnitus is pulsatile or non-pulsatile – this fundamentally changes both the diagnostic workup and treatment approach, as pulsatile tinnitus has an identifiable structural or vascular cause in over 70% of cases and almost always requires imaging evaluation 1, 2

• Assess whether tinnitus is unilateral or bilateral – unilateral tinnitus has higher likelihood of identifiable structural cause and requires comprehensive audiologic examination 1

• Distinguish bothersome from non-bothersome tinnitus – this classification guides treatment intensity, as most patients habituate to tinnitus and only 20% seek clinical intervention 1, 3

• Perform otoscopic examination immediately to exclude simple treatable causes like cerumen impaction, retrotympanic masses, or middle ear infection before pursuing expensive studies 4

• Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for any patient with unilateral tinnitus, persistent tinnitus (≥6 months), or associated hearing difficulties 1

Evidence-Based Treatment Options

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 is the only treatment shown to have definite improvement in large randomized controlled trials 1, 3, 5

• Hearing aids should be recommended for ALL patients with hearing loss and tinnitus, even if the hearing loss is mild or unilateral – this intervention provides significant relief and has strong evidence for benefit 1

• Education and counseling are essential components for all patients with persistent tinnitus, covering tinnitus mechanisms, natural history, and management strategies 1

Second-Line Treatment Options

• Sound therapy may be offered as a management option for persistent tinnitus to provide symptomatic relief, though evidence is less conclusive than for CBT 1, 5

• Tinnitus retraining therapy is a treatment option, but evidence remains inconclusive 5

Treatments NOT Recommended

The following interventions should NOT be routinely recommended due to insufficient evidence and potential side effects:

• Antidepressants, anticonvulsants, or anxiolytics should not be used for primary treatment of persistent tinnitus 1

• Intratympanic medications are not recommended for routine tinnitus management 1

• Dietary supplements including Ginkgo biloba, melatonin, or zinc should not be recommended due to lack of consistent benefit 1

Special Populations and Considerations

Pulsatile Tinnitus

• Pulsatile tinnitus requires imaging evaluation in nearly all cases – do not dismiss as benign, as treatable and life-threatening causes (dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease) are common 2

• Order CT angiography (CTA) of head and neck with contrast when suspecting vascular causes like dural AVF, arterial dissection, or atherosclerotic disease 2

• Order high-resolution CT temporal bone (non-contrast) when suspecting paragangliomas, glomus tumors, jugular bulb abnormalities, or superior semicircular canal dehiscence 2

Tinnitus with Psychiatric Comorbidities

• Patients with severe anxiety or depression require prompt psychiatric intervention due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1, 4

• A team approach involving otolaryngology, audiology, and mental health professionals is recommended for optimal management, particularly for patients with comorbid depression or anxiety 1

Chemotherapy-Induced Tinnitus

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

• Hearing aids and CBT remain beneficial for managing symptoms of chemotherapy-induced tinnitus 1

• Sodium thiosulfate may prevent ototoxicity in children receiving cisplatin, but its use in adults is uncertain due to concerns about tumor protection 1

Ménière's Disease

• Manage tinnitus occurring as part of Ménière's disease by controlling the underlying vestibular disorder rather than treating tinnitus specifically 1

Treatment Algorithm

Step 1: Classify the tinnitus

• Pulsatile vs. non-pulsatile 1
• Unilateral vs. bilateral 1
• Bothersome vs. non-bothersome 1

Step 2: Perform otoscopic examination

• Rule out cerumen, infection, retrotympanic masses 4

Step 3: Obtain audiologic testing

• For unilateral, persistent (≥6 months), or hearing-related tinnitus 1

Step 4: Determine imaging needs

• Image if: pulsatile, unilateral, focal neurologic deficits, or asymmetric hearing loss 1
• Do NOT image if: bilateral, symmetric, non-pulsatile, no localizing features 1

Step 5: Initiate evidence-based treatment

• Offer CBT for persistent, bothersome tinnitus 1
• Recommend hearing aids for ANY degree of hearing loss 1
• Provide education and counseling to all patients 1
• Consider sound therapy as adjunctive treatment 1

Step 6: Address psychiatric comorbidities

• Screen for anxiety and depression 1
• Refer immediately if severe psychiatric symptoms present 1, 4

Critical Pitfalls to Avoid

• Do not dismiss pulsatile tinnitus as benign without imaging – over 70% have identifiable causes, some life-threatening 2

• Do not overlook mild hearing loss – even mild or unilateral hearing loss benefits from hearing aid intervention 1

• Do not order imaging for bilateral, symmetric, non-pulsatile tinnitus without localizing features – this represents inappropriate resource utilization 1, 4

• Do not prescribe medications without clear evidence of benefit that may cause side effects or worsen tinnitus 1

• Do not fail to perform otoscopy before ordering expensive studies – simple treatable causes like cerumen must be excluded first 4

• Do not miss dural arteriovenous fistulas – this life-threatening cause can present with isolated pulsatile tinnitus before catastrophic hemorrhage 2

• Do not overlook intracranial hypertension, particularly in young, overweight women with headaches and pulsatile tinnitus, as this can lead to vision loss if missed 2