What is the best treatment approach for chronic subjective tinnitus in adults without a reversible cause?

Best Treatment for Chronic Subjective Tinnitus

Cognitive Behavioral Therapy (CBT) is the single most effective treatment for chronic subjective tinnitus, as it is the only intervention proven in large randomized controlled trials to improve quality of life—the outcome that matters most for patients. 1, 2

First-Line Treatment Algorithm

Step 1: Audiologic Evaluation and Hearing Aid Fitting

• Obtain 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 hearing difficulties 2
• Recommend hearing aid evaluation for all patients with documented hearing loss and persistent bothersome tinnitus, even if the hearing loss is only mild or unilateral 1, 2
• Hearing aids provide significant relief for tinnitus patients with associated hearing loss and represent first-line audiologic intervention with strong evidence of benefit 1, 2

Step 2: Cognitive Behavioral Therapy

• CBT should be recommended to all patients with persistent, bothersome tinnitus as the strongest evidence-based treatment for improving quality of life 1, 2
• CBT is the only treatment shown to have definite improvement effect on tinnitus in large randomized controlled trials 3
• Recent high-quality evidence demonstrates CBT significantly reduces tinnitus-related distress, decreases scores on psychological measures (depression, anxiety, hostility), and improves Tinnitus Handicap Inventory scores 4, 5
• CBT works by addressing cognitive principles and reducing mood disorders rather than eliminating the phantom sound itself 4, 5

Step 3: Education and Counseling

• Provide education and counseling about tinnitus management strategies to all patients with persistent, bothersome tinnitus at the initial visit 1, 2
• Education should cover tinnitus mechanisms, natural history, and available management strategies to set realistic expectations 2
• Most patients (approximately 80%) adapt to tinnitus over time without requiring intensive intervention 2, 3

Step 4: Sound Therapy (Optional Adjunct)

• Sound therapy may be recommended as a management option for persistent tinnitus, providing symptomatic relief 1, 2
• Recent evidence shows notched sound therapy is more effective at reducing tinnitus loudness compared to CBT, though CBT remains superior for reducing tinnitus-related distress 4
• Sound therapy can be used as an adjunct to CBT rather than a replacement 4

Treatments to Avoid

Medications (Strong Recommendation Against)

• Do not routinely recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary treatment of persistent, bothersome tinnitus 1, 2
• Evidence from systematic reviews and RCTs shows insufficient benefit to justify routine use, especially given known harms, costs, and potential for some medications (particularly antidepressants) to worsen tinnitus 1
• The only exception: treat comorbid depression or anxiety as separate conditions when they are severe and independently warrant psychiatric intervention 2

Dietary Supplements (Strong Recommendation Against)

• Do not recommend Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating persistent tinnitus due to lack of consistent benefit 1, 2
• These supplements lack evidence of efficacy and represent unnecessary expense 1

Critical Screening and Safety Considerations

Psychiatric Risk Assessment

• Screen all tinnitus patients for severe anxiety or depression because these conditions are associated with increased suicide risk 2
• Patients with severe psychiatric symptoms require immediate psychiatric intervention, not just tinnitus-focused treatment 2

Rule Out Treatable Underlying Causes

• Perform targeted history and physical examination to identify potentially treatable conditions (cerumen impaction, middle ear effusion, Menière's disease, otosclerosis) 2
• Obtain imaging (MRI internal auditory canals with contrast) only if tinnitus is unilateral, pulsatile, associated with focal neurological abnormalities, or accompanied by asymmetric hearing loss 2
• Do not order imaging for bilateral, symmetric, non-pulsatile tinnitus without localizing features—this represents low-value care with no benefit 2

Common Pitfalls to Avoid

• Prescribing medications without clear evidence that may cause side effects or worsen tinnitus 2
• Recommending dietary supplements that lack efficacy evidence 2
• Overlooking mild hearing loss that could benefit from hearing aid intervention—even mild or unilateral hearing loss warrants hearing aid evaluation 1, 2
• Dismissing pulsatile tinnitus without imaging—this presentation requires vascular evaluation as treatable and life-threatening causes are common 2
• Neglecting psychiatric screening, which can miss heightened suicide risk 2
• Delaying audiometry—testing should be obtained promptly (within 4 weeks) for persistent or unilateral tinnitus 2

Long-Term Management

• Multidisciplinary team approach involving otolaryngology, audiology, and mental health professionals optimizes outcomes 2
• Regular follow-up is necessary because underlying causes may become apparent only after extended observation (10-15% of bilateral tinnitus cases have identifiable causes identified during long-term follow-up) 2
• Patients with partial or no improvement require continued audiologic and psychological support 2