Key Points
- Tinnitus is the perception of sound without an external source.
- More than 50 million people in the United States have reported experiencing tinnitus, resulting in an estimated prevalence of 10%-15%
in adults. - About 20% of adults who experience tinnitus will seek clinical intervention.
- The estimated prevalence in the United States of experiencing tinnitus at any time is 25.3% and experiencing frequent (almost always or at least once a day) tinnitus is 7.9%.
- Not a disease in and of itself, tinnitus is actually a symptom that can be associated with multiple causes and aggravating co-factors such as Meniere’s disease, sudden sensorineural hearing loss (SNHL), otosclerosis, vascular tumor and vestibular schwannoma (VS).
- Patients with these identifiable and other causative diagnoses of secondary tinnitus are excluded from the management recommendations of this guideline.
Table 1. Abbreviations and Definitions of Common Terms
Term | Definition |
|---|---|
| Tinnitus | The perception of sound when there is no external source of the sound. |
| Primary tinnitus | Tinnitus that is idiopathica and may or may not be associated with SNHL. |
| Secondary tinnitus | Tinnitus that is associated with a specific underlying cause (other than SNHL) or an identifiable organic condition. |
| Recent onset tinnitus | <6 months in duration (as reported by the patient). |
| Persistent tinnitus | ≥6 months in duration. |
| Bothersome tinnitus | Distressed patient, impacted quality of life (QOL)b and/or functional health status. Patient is seeking active therapy and management strategies to alleviate tinnitus. |
| Non-bothersome tinnitus | Tinnitus that does not have a significant impact on a patient’s QOL but may result in curiosity or concern about the cause or natural history and how it might progress or change. |
a The word idiopathic is used here to indicate that a cause other than SNHL is not identifiable. b Quality of life (QOL) is the degree to which persons perceive themselves able to function physically, emotionally, mentally, and/or socially. | |
Table 2. Summary of Guideline Key Action Statements (KAS)
| Statement | Action | Strength of Rec |
|---|---|---|
| 1. History and Physical Examination | Clinicians should perform a targeted history and physical examination at the initial evaluation of a patient to identify conditions that if promptly identified and managed may relieve tinnitus. | R-C |
| 2a. Prompt Audiologic Examination | Clinicians should obtain a prompt, comprehensive audiologic examination in patients with tinnitus that is unilateral, persistent (≥6 months), or associated with hearing difficulties. | R-C |
| 2b. Routine Audiologic Examination | Clinicians may obtain an initial comprehensive audiologic examination in patients who present with tinnitus (regardless of laterality, duration, or perceived hearing status). | O-C |
| 3. Imaging Studies | Clinicians should NOT obtain imaging studies of the head and neck in patients with tinnitus, specifically to evaluate the tinnitus, unless they have one or more of the following: tinnitus that localizes to one ear, pulsatile tinnitus, focal neurologic abnormalities, or asymmetric hearing loss. | S-C Against |
| 4. Bothersome Tinnitus | Clinicians must distinguish patients with bothersome tinnitus from patients with non-bothersome tinnitus. | S-B |
| 5. Persistent Tinnitus | Clinicians should distinguish patients with bothersome tinnitus of recent onset from those with persistent symptoms (≥6 months) to prioritize intervention and facilitate discussions about natural history and follow-up care. | R-B |
| 6. Management Strategies | Clinicians should educate patients with persistent, bothersome tinnitus about management strategies. | R-B |
| 7. Hearing Aid Evaluation | Clinicians should recommend a hearing aid evaluation for patients with hearing loss and persistent, bothersome tinnitus. | R-C |
| 8. Sound Therapy | Clinicians may recommend sound therapy to patients with persistent, bothersome tinnitus. | O-B |
| 9. Cognitive Behavior Therapy | Clinicians should recommend cognitive behavior therapy to patients with persistent, bothersome tinnitus. | R-A |
| 10. Medical Therapy | Clinicians should NOT routinelya recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for a primary indication of treating persistent, bothersome tinnitus. | R-B Against |
| 11. Dietary Supplements | Clinicians should NOT recommend ginkgo biloba, melatonin, zinc, or other dietary supplements for treating patients with persistent, bothersome tinnitus. | R-C Against |
| 12. Acupuncture | No recommendation can be made regarding the effect of acupuncture in patients with persistent, bothersome tinnitus. | N-C |
| 13. Transcranial Magnetic Stimulation | Clinicians should NOT recommend TMS for the routinea treatment of patients with persistent, bothersome tinnitus. | R-B Against |
| a The word “routinely” is used to avoid setting a legal precedent and to acknowledge there may be individual circumstances for which clinicians and patients may wish to deviate from the prescribed action in the statement. | ||
Diagnosis
- Tinnitus can occur on one or both sides of the head and can be perceived as coming from within or outside the head.
- The severity of tinnitus can fluctuate.
- The character of tinnitus can also vary, with ringing, buzzing, clicking, pulsations, and other noises described by tinnitus patients.
- Tinnitus most often occurs in the setting of concomitant SNHL, particularly among patients with bothersome tinnitus and no obvious ear pathology.
- Psychiatric conditions are common in patients with bothersome tinnitus. The association of major depression and tinnitus has been studied, with depression reported in 48%-60% of tinnitus sufferers.
Table 3. Key Details of Medical History in the Tinnitus Patient
| Key issue | Significance | Implication |
|---|---|---|
| Unilateral tinnitus | Concern for focal auditory lesion, some serious, such as VS or vascular tumor. | Referral for comprehensive audiologic assessment, an otologic evaluation, and additional testing such as imaging where indicated. |
| Pulsatile tinnitus | Concern for vascular lesion, systemic cardiovascular illness. | Consider cardiovascular and general physical examination (hypertension, heart murmurs, carotid bruits, venous hums); examination of the head and neck for signs of vascular tumors or other lesions; comprehensive audiology; imaging and other testing where indicated. |
| Hearing loss | Tinnitus is frequently associated with hearing loss, particularly SNHL. Differentiate between conductive and SNHL, unilateral and bilateral. Establish severity of hearing loss. | Referral for comprehensive audiology and otologic evaluation for the wide range of pathologies that could cause hearing loss associated with tinnitus. Consider hearing aid evaluation when indicated. |
| Sudden onset of hearing loss with tinnitus | Sudden hearing loss requires prompt treatment to stabilize or improve hearing. | See Stachler RJ, Chandrasekhar SS, Archer SM, et al. Clinical practice guideline: sudden hearing loss. Otolaryngol Head Neck Surg. 2012;146(3 suppl):S1-S35. |
| New onset tinnitus | Tinnitus perception may diminish or disappear, and/or tinnitus reactions may be reduced. | Evaluation and treatment is based on severity and presence and absence of other symptoms. |
| Noise exposure | Tinnitus may be associated with prolonged or repeated noise exposure from occupational or recreational activities. | Counseling and education related to potential damaging effect of noise, acoustic trauma, and pertinent environmental exposures. Referral for comprehensive audiologic assessment. |
| Medications and potential ototoxic exposures | Some medications such as salicylates are associated with tinnitus. Ototoxins can cause hearing loss and tinnitus. Interactions between medications have unknown effects and can exacerbate tinnitus symptoms. | Counseling regarding medication use, etiology of tinnitus is facilitated. Patients can be provided a list of known ototoxic medications as part of counseling. Comprehensive audiologic assessment. |
| Unilateral or asymmetric hearing loss | Possible presentation of serious lesion such as VS. | Audiologic and otologic assessment. Imaging where indicated. |
| Vertigo or other balance malfunction | Possible cochlear, retrocochlear, or other central nervous system disorder (Meniere’s disease, superior canal dehiscence, VS, other). | Audiologic, otologic, vestibular assessment. Imaging and referral where indicated. |
| Symptoms of depression and/or anxiety | Tinnitus is often accompanied by symptoms of depression and anxiety. The presence and severity of such symptoms will dictate the pace of evaluation and treatment as well as the need for referral to treat these issues. | Referral to mental health professionals for assessment and treatment of depression and/or anxiety. Urgent referral for suicidal patients. |
| Apparent cognitive impairments | Elderly patients at risk for tinnitus are also at risk for cognitive decline from dementia. | The presence of dementia will affect the results of tinnitus and audiologic assessments. |
Evidence Quality and Recommendation Grades a
| Evidence Quality for: | Recommendation | |||
|---|---|---|---|---|
| Treatment and Harm | Diagnosis | Strength | ||
| A | High-quality RCTs | Systematic review of consistent cross-sectional studies | S | Strong recommendation |
| B | Consistent RCTs | Consistent individual cross-sectional studies | R | Recommendation |
| C | Observational studies | Nonconsecutive studies, case-control studies, or other studies of poor quality | O | Option |
| D | Case reports, consensus opinions | |||
| X | Exceptional situations with clear benefit | |||
| a See full text guidelines for details. | ||||