What is the recommended management approach for a patient presenting with tinnitus?

Tinnitus Management Approach

For patients presenting with tinnitus, begin with a targeted history and physical examination to identify treatable causes, obtain audiologic testing for unilateral or persistent cases, and for bothersome tinnitus lasting ≥6 months, recommend cognitive behavioral therapy (CBT) as first-line treatment, with hearing aids if hearing loss is present. 1, 2

Initial Evaluation

History and Physical Examination

• Obtain detailed tinnitus characteristics: onset, duration, laterality (unilateral vs bilateral), quality, pitch, loudness, and pattern to identify potentially treatable underlying conditions 3, 4
• Assess for associated symptoms including hearing loss, vertigo, otalgia, otorrhea, or focal neurological symptoms 4
• Perform otoscopic examination to identify cerumen impaction, tympanic membrane abnormalities, or middle ear pathology 4
• Conduct cranial nerve examination, focusing on CN VIII (hearing) 4
• If pulsatile tinnitus is reported, auscultate the neck, periauricular region, and temporal area for bruits 4

Audiologic Testing

• Obtain prompt comprehensive audiologic examination (within 4 weeks) for patients with unilateral tinnitus, persistent tinnitus (≥6 months), or associated hearing difficulties 3
• Testing should include pure tone audiometry, speech audiometry, and acoustic reflex testing 4, 5
• Consider routine audiologic examination for all tinnitus patients regardless of laterality, duration, or perceived hearing status, as hearing loss may be unsuspected 3
• If sound tolerance problems (hyperacusis) are present, measure loudness discomfort levels at audiometric frequencies 4, 6

Imaging Studies

• Do NOT obtain imaging studies unless one or more of the following are present: unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss 3, 1, 2
• This strong recommendation against routine imaging avoids unnecessary testing with low diagnostic yield, reduces costs, and prevents detection of incidental findings 3
• For pulsatile tinnitus specifically, obtain CTA or MRA to identify potentially treatable vascular causes 1

Classification for Treatment Planning

Distinguish Bothersome vs Non-Bothersome Tinnitus

• This classification is critical as it guides treatment intensity and determines which patients require active intervention 3, 1, 4
• Assess impact on quality of life, sleep, concentration, and emotional well-being 2

Differentiate Recent Onset vs Persistent Tinnitus

• Persistent tinnitus is defined as lasting ≥6 months 3, 2
• This distinction prioritizes intervention and facilitates discussions about natural history and follow-up care 2

Evidence-Based Treatment for Persistent, Bothersome Tinnitus

First-Line Treatments

Cognitive Behavioral Therapy (CBT)

• CBT has the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus 1, 2, 7
• This should be recommended as primary treatment for patients with significant tinnitus-related distress 2

Hearing Aids

• Recommend hearing aid evaluation for all patients with any degree of hearing loss and persistent, bothersome tinnitus, even if hearing loss is mild or unilateral 1, 5, 2, 7
• Hearing aids provide significant relief for patients with associated hearing loss 1
• Initiate discussions early when hearing loss is first discovered 5

Education and Counseling

• Provide education about tinnitus management strategies for all patients with persistent, bothersome tinnitus 1, 2
• Reassure patients that tinnitus is not life-threatening 8

Sound Therapy

• May be offered as a management option for symptomatic relief in persistent tinnitus 1, 5, 2
• Evidence is inconclusive but can be considered as an option 9

Treatments NOT Recommended

Medications

• Do NOT routinely recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary tinnitus treatment due to insufficient evidence and potential side effects 1, 2
• These medications may be appropriate only for treating comorbid psychiatric conditions, not tinnitus itself 1

Dietary Supplements

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

Other Interventions

• Do NOT routinely recommend transcranial magnetic stimulation 2

Special Considerations

Psychiatric Comorbidities

• Screen for anxiety and depression, as tinnitus patients with psychiatric comorbidities have increased suicide risk requiring prompt identification and intervention 1
• Refer to mental health professionals when severe anxiety or depression is identified 1

Pulsatile Tinnitus

• Pulsatile tinnitus almost always requires imaging evaluation to identify potentially treatable vascular causes 1

Multidisciplinary Approach

• Optimal management requires a team approach involving otolaryngology, audiology, and mental health professionals 1
• Long-term follow-up is necessary, as 10-15% of bilateral tinnitus cases have identifiable underlying causes that may only be identified after extended observation 1

Common Pitfalls to Avoid

• Do NOT overlook mild hearing loss that could benefit from hearing aid intervention 1, 4
• Do NOT prescribe medications without clear evidence of benefit that may cause side effects or worsen tinnitus 1
• Do NOT obtain unnecessary imaging studies for non-pulsatile, bilateral tinnitus without neurological symptoms 4
• Do NOT recommend unproven treatments such as dietary supplements 4
• Do NOT wait 6 months to obtain audiologic testing if clinically indicated earlier 3