Tinnitus
Guidelines
1. Classification and risk stratification
Disease classification::
- Classify patients as having either bothersome tinnitus or non-bothersome tinnitus.
- Classify patients with bothersome tinnitus as having symptoms of recent onset (< 6 months) or persistent symptoms (≥ 6 months) to prioritize intervention and facilitate discussions about natural history and follow-up care.
2. Diagnostic investigations
Initial evaluation:
Elicit a targeted history and perform a focused physical examination as part of the initial evaluation of patients with presumed primary tinnitus to identify conditions that, if promptly identified and managed, may relieve tinnitus.
Audiologic examination:
Obtain a prompt, comprehensive audiologic examination in patients with tinnitus that is unilateral, persistent (> 6 months), or associated with hearing difficulties.
Imaging studies:
Avoid obtaining imaging studies of the head and neck as part of the evaluation of patients with tinnitus, unless they have 1 or more of the following: tinnitus that localizes to 1 ear, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss.
3. Medical management
Pharmacologic treatment:
Avoid routinely initiating antidepressants, anticonvulsants, anxiolytics, or intratympanic medications as a treatment for persistent, bothersome tinnitus.
4. Nonpharmacologic interventions
Hearing aid evaluation:
Refer patients with hearing loss and persistent, bothersome tinnitus for a hearing aid evaluation.
Sound therapy:
Consider providing sound therapy in patients with persistent, bothersome tinnitus.
Cognitive behavioral therapy:
Refer patients with persistent, bothersome tinnitus for CBT.
Dietary supplements:
Avoid recommending Ginkgo biloba, melatonin, zinc, or other dietary supplements for symptom relief in patients with persistent, bothersome tinnitus.
Acupuncture:
Insufficient evidence to make a recommendation regarding the effect of acupuncture in patients with persistent bothersome tinnitus.
5. Therapeutic procedures
Transcranial magnetic stimulation:
Avoid transcranial magnetic stimulation for the routine treatment of patients with persistent, bothersome tinnitus.
Cochlear implants:
Obtain standard medical workup and monitoring in patients with sudden and/or rapid progression of single-sided deadness to determine if the hearing spontaneously improves or is recoverable with treatment. Offer cochlear implantation not earlier than 3-6 months after the sudden hearing loss to allow ample time for potential recovery of hearing.
6. Patient education
General counseling:
Educate patients with persistent, bothersome tinnitus about management strategies.