What is the recommended management for a patient with chronic subjective tinnitus?

Management of Chronic Subjective Tinnitus

For patients with chronic subjective tinnitus, cognitive behavioral therapy (CBT) is the single most effective treatment for improving quality of life and should be offered as first-line therapy, combined with hearing aids when any degree of hearing loss is present. 1

Initial Clinical Assessment

Perform a comprehensive otoscopic examination immediately to exclude cerumen impaction, middle ear effusion, or vascular retrotympanic masses before initiating any tinnitus-specific therapy. 1, 2 This simple step prevents unnecessary testing and may identify immediately treatable causes.

Determine whether the tinnitus is bothersome versus non-bothersome, as this classification fundamentally guides treatment intensity—non-bothersome tinnitus requires only reassurance and education, while bothersome tinnitus warrants active intervention. 1

Screen all patients for severe anxiety or depression using validated instruments, because these psychiatric comorbidities are associated with increased suicide risk in tinnitus patients and require immediate psychiatric intervention when identified. 1, 2

Required Diagnostic Testing

Order comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) within 4 weeks for any patient with persistent tinnitus (≥6 months), unilateral tinnitus, or tinnitus associated with hearing difficulties. 1 This testing is essential even when patients deny hearing problems, as mild hearing loss amenable to amplification is frequently missed. 1

Do NOT order imaging studies for bilateral, symmetric, non-pulsatile tinnitus without focal neurological deficits or asymmetric hearing loss—this represents low-value care with no diagnostic yield. 1, 2 The American Academy of Otolaryngology-Head and Neck Surgery explicitly advises against this practice. 1

Evidence-Based Treatment Algorithm

Step 1: Education and Counseling (All Patients)

Provide education about tinnitus mechanisms, natural history, and management strategies at the initial visit for all patients with persistent, bothersome tinnitus. 1 This foundational intervention sets realistic expectations and improves treatment adherence.

Step 2: Hearing Aid Evaluation (If Hearing Loss Present)

Recommend hearing aid evaluation for any degree of documented hearing loss, even if mild or unilateral, as hearing aids provide significant tinnitus relief with strong supporting evidence. 1, 2 The American Academy of Otolaryngology-Head and Neck Surgery gives this a strong recommendation based on consistent benefit across multiple studies. 1

Step 3: Cognitive Behavioral Therapy (Primary Treatment)

Offer CBT as the primary therapeutic intervention for persistent, bothersome tinnitus, as it has the strongest evidence base for improving quality of life and reducing tinnitus-related distress. 1, 3, 4 A 2024 randomized trial demonstrated that CBT significantly reduces tinnitus severity scores and psychological distress more effectively than sound-based therapies. 3 A 2019 randomized controlled trial of 100 patients showed CBT plus sound therapy achieved significantly higher total effective rates compared to sound therapy alone, with marked reductions in depression, anxiety, and Tinnitus Handicap Inventory scores. 4

Step 4: Sound Therapy (Adjunctive Option)

Consider sound therapy as an adjunctive management option for providing symptomatic relief, though it is less effective than CBT for improving quality of life. 1 The 2024 study found that notched sound therapy was more effective at reducing tinnitus loudness perception but less effective than CBT at reducing overall distress. 3

Treatments to Avoid

Do NOT prescribe antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for routine treatment of persistent tinnitus, as the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against these due to insufficient evidence of benefit and potential for adverse effects. 1

Do NOT recommend dietary supplements including Ginkgo biloba, melatonin, or zinc, as these lack consistent evidence of efficacy. 1

Special Considerations and Red Flags

Pulsatile tinnitus almost always requires imaging evaluation (CT angiography or high-resolution CT temporal bone), unlike bilateral non-pulsatile tinnitus, because identifiable structural or vascular causes are present in >70% of cases. 5, 2 Missing life-threatening entities such as dural arteriovenous fistula or arterial dissection can result in catastrophic hemorrhage or stroke. 5

Unilateral tinnitus requires MRI of internal auditory canals with contrast to exclude vestibular schwannoma or other retrocochlear pathology. 1, 2

Tinnitus associated with focal neurological deficits requires emergent imaging with CT angiography of head and neck, as this represents a red flag for serious intracranial pathology including stroke, hemorrhage, or vascular malformation. 5

Long-Term Management and Follow-Up

Arrange regular follow-up visits because underlying etiologies may become apparent only after extended observation—10-15% of bilateral tinnitus cases have identifiable causes discovered during long-term follow-up. 1

Reassess patients whose tinnitus does not improve to exclude alternative diagnoses such as Menière's disease, otosclerosis, or delayed acoustic neuroma. 1

Utilize a multidisciplinary team approach involving otolaryngology for medical oversight, audiology for hearing aid fitting and sound therapy devices, and mental health professionals for CBT delivery, as this coordinated care model optimizes outcomes. 1

Critical Pitfalls to Avoid

• Failing to perform otoscopy before ordering expensive imaging studies, which may miss simple treatable causes like cerumen impaction. 2
• Ordering brain imaging for bilateral, symmetric, non-pulsatile tinnitus without neurological deficits, which represents inappropriate resource utilization. 1, 2
• Overlooking mild hearing loss that could benefit from amplification, by failing to obtain audiometry when patients deny hearing difficulties. 1
• Neglecting psychiatric screening, which can miss heightened suicide risk in patients with severe anxiety or depression. 1, 2
• Dismissing pulsatile tinnitus as benign without imaging, potentially missing treatable and life-threatening vascular causes. 5, 2