How should I manage chronic tinnitus after excluding reversible causes?

Management of Chronic Tinnitus After Excluding Reversible Causes

For chronic tinnitus after ruling out treatable causes, cognitive behavioral therapy (CBT) is the only treatment proven to improve quality of life, and should be combined with hearing aids for any degree of hearing loss (even mild or unilateral) plus education and counseling. 1

Initial Classification and Assessment

Before initiating treatment, determine whether the tinnitus is bothersome versus non-bothersome, as this fundamentally guides treatment intensity—most patients adapt to tinnitus over time without intervention, but approximately 20% require clinical management. 1, 2

Obtain comprehensive audiologic examination (pure-tone audiometry, speech audiometry, acoustic reflex testing) within 4 weeks if not already completed, as sensorineural hearing loss is the most common underlying association and directly influences treatment selection. 1, 3

Screen for psychiatric comorbidities using validated instruments, particularly anxiety and depression, because these conditions frequently coexist with tinnitus and require prompt intervention due to increased suicide risk in severe cases. 1, 3

Evidence-Based Treatment Algorithm

First-Line Interventions (All Patients with Bothersome Tinnitus)

1. Education and Counseling (Mandatory)

• Provide detailed explanation of tinnitus mechanisms, natural history, and realistic expectations at the initial visit to reduce anxiety and empower patients. 1
• Emphasize the benign nature of idiopathic tinnitus and teach coping strategies, as patient perception and approach significantly influence outcomes. 4

2. Hearing Aid Evaluation (If Any Hearing Loss Present)

• Recommend hearing aids even for mild or unilateral hearing loss, as this intervention has strong evidence for tinnitus relief and addresses the most common underlying cause. 1, 5
• Hearing aids provide dual benefit by amplifying environmental sounds that mask tinnitus and correcting auditory deprivation that may perpetuate central nervous system changes. 1, 5

3. Cognitive Behavioral Therapy

• CBT is the only treatment with definitive evidence from large randomized controlled trials showing improvement in quality of life for persistent, bothersome tinnitus. 1, 2, 6
• CBT targets the psychological response to tinnitus rather than the tinnitus tone itself, addressing secondary symptoms like anxiety, depression, and sleep disturbance. 6
• The strongest evidence supports combination therapy of CBT-based counseling with sound therapy rather than either intervention alone. 5

Second-Line Interventions (Adjunctive Options)

Sound Therapy

• May be recommended as a management option providing symptomatic relief, though evidence is less robust than for CBT. 1
• Wide-band sound therapy can be delivered through tabletop devices, smartphone applications, or in-ear noise generators. 5, 4

Tinnitus Retraining Therapy

• Aims to suppress conscious awareness of tinnitus through habituation, often using in-ear noise generators combined with counseling. 4
• Evidence for efficacy remains inconclusive compared to CBT. 7

Treatments to AVOID (Strong Recommendations Against)

Do NOT routinely prescribe:

• Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment due to insufficient evidence and potential side effects. 1
• Intratympanic medications lack evidence for persistent tinnitus management. 1
• Dietary supplements (Ginkgo biloba, melatonin, zinc) should not be recommended due to lack of consistent benefit. 1

Important exception: Antidepressants or anxiolytics may be appropriate when treating comorbid depression or anxiety as separate diagnoses, not for tinnitus itself. 7

Special Clinical Considerations

For Tinnitus with Severe Psychiatric Comorbidity:

• Require immediate mental health referral due to documented increased suicide risk in tinnitus patients with severe anxiety or depression. 1, 3

For Ménière's Disease-Associated Tinnitus:

• Manage by controlling the underlying vestibular disorder rather than treating tinnitus specifically, as tinnitus often improves with disease control. 1

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

• No causative treatment exists for established ototoxicity; hearing aids and CBT remain beneficial for symptom management. 1

Team-Based Approach

Optimal management requires coordination between:

• Otolaryngology for ongoing medical oversight and exclusion of delayed-presentation causes (10-15% identified only after long-term follow-up). 8, 1
• Audiology for hearing aid fitting, sound therapy devices, and hearing-assistive technology. 8, 1
• Mental health professionals for CBT delivery and management of psychiatric comorbidities. 1

Common Pitfalls to Avoid

• Prescribing medications without clear evidence that may cause side effects or worsen tinnitus (particularly benzodiazepines, which can be habit-forming). 1
• Recommending supplements lacking efficacy, which wastes patient resources and may delay effective treatment. 1
• Overlooking mild hearing loss that could benefit from amplification—even unilateral or mild loss warrants hearing aid evaluation. 1, 5
• Failing to screen for psychiatric comorbidities, missing opportunities for intervention that significantly impacts quality of life. 1
• Dismissing patient distress because "nothing can be done"—while no cure exists, evidence-based interventions meaningfully improve quality of life. 1, 2

Long-Term Management

Ongoing follow-up is essential because some patients will have underlying causes identified only after extended observation, and those with partial or no improvement require continued audiological and psychological support. 8

Familiarity with implantable hearing solutions (cochlear implants, bone-anchored hearing aids) may be necessary for patients with severe hearing loss and persistent bothersome tinnitus. 8