From the Guidelines
Tinnitus treatment should prioritize a comprehensive approach, focusing on managing symptoms and improving quality of life, as there is no universal cure, and cognitive behavioral therapy (CBT) is recommended for patients with persistent, bothersome tinnitus, as stated in the 2014 clinical practice guideline 1.
Key Considerations
- Tinnitus can be persistent, bothersome, and costly, affecting over 50 million people in the United States, with a prevalence of 10% to 15% in adults, and around 20% of adults who experience tinnitus will require clinical intervention 1.
- The effects of tinnitus on health-related quality of life (QOL) vary widely, with most patients less severely affected but some experiencing anxiety, depression, and extreme life changes, and patients who have tinnitus accompanied by severe anxiety or depression require prompt identification and intervention 1.
- Tinnitus can occur on one or both sides of the head and can be perceived as coming from within or outside the head, with the quality of tinnitus varying, including ringing, buzzing, clicking, pulsations, and other noises described by patients with tinnitus 1.
Treatment Approach
- Start by consulting a healthcare provider to identify any underlying causes like ear infections, medication side effects, or hearing loss, and perform a targeted history and physical examination at the initial evaluation of a patient with presumed primary tinnitus to identify conditions that if promptly identified and managed may relieve tinnitus, as recommended in the 2014 clinical practice guideline 1.
- Common treatments include sound therapy using white noise machines, fans, or smartphone apps to mask the ringing sensation, and hearing aids can help if tinnitus is related to hearing loss, as suggested in the 2014 clinical practice guideline 1.
- Cognitive behavioral therapy (CBT) is effective for reducing tinnitus-related distress by changing how you respond to the sound, and clinicians should recommend CBT to patients with persistent, bothersome tinnitus, as stated in the 2014 clinical practice guideline 1.
- Some medications may help, including low doses of antidepressants like amitriptyline (10-50 mg at bedtime) or nortriptyline (10-75 mg at bedtime), though these aren't FDA-approved specifically for tinnitus, and clinicians should not routinely recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for a primary indication of treating persistent, bothersome tinnitus, as recommended in the 2014 clinical practice guideline 1.
- Lifestyle modifications can also help, such as limiting caffeine, alcohol, and nicotine; managing stress through relaxation techniques; protecting your ears from loud noises; and maintaining good cardiovascular health through regular exercise, as suggested in the example answer.
Recent Guidelines
- The 2023 ACR Appropriateness Criteria® Tinnitus update recommends a targeted history and clinical examination as the initial evaluation and determination as to whether the tinnitus is bothersome or not, before any imaging, and suggests that some patients with severe anxiety, depression, or psychological disturbances may need prompt identification and intervention 1.
- The 2017 ACR Appropriateness Criteria® Tinnitus recommends a comprehensive otologic examination to determine if a vascular retrotympanic mass is present, audiometric examination, and review of medical history and medications (including over the counter) before imaging, and notes that patients with tinnitus and severe anxiety or depression require prompt identification and intervention because suicide is reported in tinnitus patients with co-existing psychiatric illness 1.
From the Research
Tinnitus Treatment Options
- Cognitive Behavioral Therapy (CBT) is a recommended treatment for tinnitus, as it has been shown to improve quality of life and reduce tinnitus-related distress 2, 3, 4, 5
- Notched Sound Therapy (NST) is also an effective treatment for tinnitus, particularly in reducing tinnitus loudness 2
- Sound therapy and tinnitus retraining therapy are other treatment options, but the evidence for their effectiveness is inconclusive 3, 6
- Melatonin, antidepressants, and cognitive training may help with sleep disturbance, mood disorders, and cognitive impairments associated with tinnitus, but their use is not recommended as a routine treatment 3, 6
Evaluation and Diagnosis
- A comprehensive audiologic evaluation should be performed for patients with unilateral tinnitus, tinnitus that has been present for six months or longer, or that is accompanied by hearing problems 3, 6
- A targeted history and physical examination should be conducted to identify treatable causes and associated symptoms that may improve with treatment 3, 6
- Neuroimaging is not part of the standard workup unless the tinnitus is asymmetric or unilateral, pulsatile, associated with focal neurologic abnormalities, or associated with asymmetric hearing loss 3, 6
Treatment Recommendations
- Clinicians should distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus and prioritize intervention accordingly 6
- CBT is recommended for patients with persistent, bothersome tinnitus 6, 4, 5
- A hearing aid evaluation is recommended for patients with persistent, bothersome tinnitus associated with documented hearing loss 6
- Sound therapy may be recommended for patients with persistent, bothersome tinnitus, but the evidence for its effectiveness is limited 6, 5