Key Points for Practice
• Head and neck imaging should not be performed to specifically assess tinnitus in the absence of localization to one ear, pulsatile tinnitus, focal neurologic findings, or asymmetric hearing loss.
• Bothersome tinnitus should be distinguished from tinnitus that is not bothersome.
• An audiologic examination should be performed in patients whose tinnitus is unilateral, has lasted at least six months, or is accompanied by problems with hearing.
From the AFP Editors
Tinnitus, the perception of sound without an external source, can be caused by a variety of conditions. Prevalence in the United States is approximately 10% to 15%. It can be categorized as primary (idiopathic and accompanied by or not by sensorineural hearing loss) and secondary (caused by a specific condition or problem other than sensorineural hearing loss). This guideline from the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO–HNSF) provides guidance on the management of bothersome tinnitus lasting at least six months.
Head and neck imaging (e.g., computed tomography) should not be performed to specifically assess tinnitus, unless localization to one ear, pulsatile tinnitus, a focal neurologic abnormality, or asymmetric loss of hearing is present. Bothersome tinnitus, defined as being distressful or affecting quality of life or health, should be distinguished from tinnitus that is not bothersome, so that appropriate treatment can be initiated. This can occur by asking the patient if the tinnitus is bothersome, or bothersome enough to seek treatment; if the tinnitus affects being able to communicate, concentrate, sleep, or enjoy life; or how much time or effort has been spent pursuing treatment. Additionally, there are questionnaires and surveys to help distinguish bothersome from nonbothersome tinnitus (e.g., Tinnitus Functional Index).
The initial history and physical examination should assist in detecting conditions that, if immediately treated, may relieve symptoms. The history should include information on when symptoms started and how long they have lasted, as well as how they are affecting the patient's quality of life. Physical examination should focus on detecting secondary tinnitus and identifying any serious conditions related to the tinnitus. An audiologic examination should be performed, preferably within four weeks of when the patient first presents for evaluation, in those whose tinnitus is unilateral, has lasted at least six months, or is accompanied by problems with hearing. Audiologic examination is optional in all patients with tinnitus.
To prioritize treatment and assist with discussions about history and follow up, bothersome tinnitus that started recently should be distinguished from tinnitus lasting six months and longer, which is less likely to resolve spontaneously. Those with bothersome symptoms lasting at least six months should be counseled about treatment options, and cognitive behavior therapy should be recommended. If the patient is having difficulty hearing, a recommendation should be made for a hearing aid assessment. Antidepressants, anticonvulsants, anxiolytics, and intratympanic medications should not be routinely recommended. Because they lack data proving effectiveness, Ginkgo biloba, melatonin, zinc, and other dietary supplements, as well as transcranial magnetic stimulation, also should not be recommended. Sound therapy, which can provide a sense of relief and be a distraction, may be recommended for treatment of bothersome tinnitus lasting at least six months.
Guideline source: American Academy of Otolaryngology–Head and Neck Surgery Foundation
Evidence rating system used? Yes
Literature search described? Yes
Guideline developed by participants without relevant financial ties to industry? No
Published source: Otolaryngol Head Neck Surg. October 2014;151(2 suppl):S1–S40
Available at: http://oto.sagepub.com/content/151/2_suppl/S1.long