What is the recommended work‑up and step‑wise management for a patient with chronic tinnitus after excluding reversible causes such as cerumen impaction, middle‑ear infection, otosclerosis, acoustic neuroma, or ototoxic medication?

Chronic Tinnitus Management After Excluding Reversible Causes

Initial Work-Up

After excluding cerumen impaction, middle ear infection, otosclerosis, acoustic neuroma, and ototoxic medications, obtain a comprehensive audiologic examination to quantify hearing loss and characterize the tinnitus. 1, 2

Essential History Elements

• Determine if tinnitus is unilateral or bilateral, as unilateral tinnitus carries higher risk of underlying pathology requiring imaging 1, 3
• Assess whether tinnitus is pulsatile or non-pulsatile, since pulsatile tinnitus suggests vascular etiology and mandates different imaging approach 1, 3
• Screen for severe anxiety or depression using validated instruments, as tinnitus patients with psychiatric comorbidity have documented increased suicide risk requiring immediate intervention 3, 2
• Quantify the degree to which tinnitus is bothersome, as this distinction fundamentally determines treatment intensity 2

Audiometric Testing

• Perform comprehensive audiometry on all patients with persistent tinnitus (≥6 months), unilateral tinnitus, or any associated hearing difficulties 2
• Document the presence and degree of sensorineural hearing loss, which is the most common underlying cause of chronic tinnitus 3, 4

Imaging Decisions

• Do NOT obtain imaging for bilateral, non-pulsatile tinnitus without focal neurologic abnormalities or asymmetric hearing loss 2
• DO obtain MRI with contrast for unilateral tinnitus to exclude vestibular schwannoma, even after initial negative otoscopic examination 1, 3
• DO obtain CT angiography of head/neck plus CT temporal bone for pulsatile tinnitus to identify vascular abnormalities (arteriovenous fistulas, sigmoid sinus diverticulum, arterial dissection) 1, 3

Step-Wise Management Algorithm

Step 1: Education and Counseling (All Patients)

Provide structured education about tinnitus mechanisms and reassurance that it is not life-threatening, as this alone provides relief for the majority of patients who adapt over time. 2, 4

• Explain that approximately 80% of tinnitus patients adapt without requiring intensive intervention 4
• Clarify that tinnitus is a symptom, not a disease, and that management focuses on reducing its impact on quality of life rather than eliminating the sound 5, 6

Step 2: Address Hearing Loss (If Present)

Recommend hearing aid evaluation for ANY degree of documented hearing loss, even if mild or unilateral, as amplification is one of only two evidence-based treatments that improve quality of life. 1, 2

• For unilateral hearing loss (single-sided deafness), consider CROS hearing aids that transmit sound from the affected ear to the better ear 1
• For unilateral hearing loss with preexisting loss in the better ear, consider BiCROS hearing aids that provide both crossover and amplification 1
• For patients who decline conventional hearing aids, evaluate osseointegrated bone conductive devices as surgical options 1

Step 3: Cognitive Behavioral Therapy (For Persistent, Bothersome Tinnitus)

Recommend cognitive behavioral therapy as the ONLY treatment proven in large randomized controlled trials to improve quality of life in patients with persistent, bothersome tinnitus. 1, 2, 4

• CBT has the strongest evidence base of any tinnitus intervention, superior to all pharmacologic and device-based therapies 2, 4
• CBT addresses the psychosocial and emotional manifestations rather than attempting to eliminate the phantom sound 1

Step 4: Sound Therapy (Optional Adjunct)

Consider sound therapy (hearing assistive technology, white noise generators) as an option for persistent, bothersome tinnitus, though evidence is less robust than for CBT. 1, 2

• Sound therapy provides symptomatic relief through auditory masking but does not improve underlying quality of life measures as consistently as CBT 2

Treatments to AVOID

Pharmacologic Interventions

Do NOT routinely prescribe antidepressants, anticonvulsants, anxiolytics, or intratympanic medications as primary treatment for tinnitus, as there is insufficient evidence of benefit and potential for harm. 1, 2

• The exception is treating comorbid psychiatric disease (depression, anxiety) when present, which requires intervention due to suicide risk 3, 2

Dietary Supplements

Do NOT recommend Ginkgo biloba, melatonin, zinc, or other dietary supplements, as they lack consistent evidence of efficacy. 1, 2

Long-Term Follow-Up

Establish regular follow-up visits because underlying etiologies become apparent in 10-15% of bilateral tinnitus cases only after extended observation. 2

• Coordinate care between otolaryngology, audiology, and mental health professionals for optimal management 2
• Monitor for delayed-presentation causes that may not be evident at initial evaluation 2
• Reassess patients whose symptoms do not improve to ensure alternative diagnoses (Menière's disease, otosclerosis, delayed acoustic neuroma) are not missed 7, 2

Critical Pitfalls to Avoid

• Never delay audiologic evaluation, as early identification of hearing loss allows earlier hearing aid intervention 1
• Never skip psychiatric screening, as missing severe anxiety or depression can result in preventable suicide 3, 2
• Never assume bilateral tinnitus is benign without proper history, as 10-15% have identifiable underlying causes requiring long-term follow-up 2
• Never prescribe medications or supplements without clear evidence, as this exposes patients to side effects without proven benefit 1, 2