Evidence-Based Guidelines for Tinnitus Management
Tinnitus, the perception of sound without an external source, affects more than 50 million people in the United States, with an estimated prevalence of 10% to 15% in adults. Despite its high prevalence and potential impact on quality of life, evidence-based, multidisciplinary clinical practice guidelines are essential to assist clinicians in its management.
This guideline provides clinicians with a logical framework to improve patient care and mitigate the personal and social effects of persistent, bothersome tinnitus. The focus of this guideline is on tinnitus that is both bothersome and persistent (lasting 6 months or longer), which often negatively affects the patient's quality of life.
The target audience for the guideline is any clinician, including nonphysicians, involved in managing patients with tinnitus. The purpose of this guideline is to provide evidence-based recommendations for clinicians managing patients with tinnitus.
Common Tinnitus Pitches
Development of Clinical Practice Guidelines
The most recent US clinical practice guideline (CPG) for tinnitus was published in 2014. The US Department of Veterans Affairs (VA)/US Department of Defense Tinnitus Clinical Practice Guideline Work Group recently completed a new guideline.
The work group consisted of experts across disciplines who were supported by the VA Office of Quality and Patient Safety and the Defense Health Agency Clinical Quality Improvement Program. The guideline was based on a systematic review of clinical and epidemiological evidence. Rigorous methods determined the strength of the recommendations.
Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical associations between various care options and health outcomes while rating the quality of the evidence and strength of the recommendations for 20 questions focused on evaluating and managing care for adults with bothersome tinnitus.
The CPG offers patients with tinnitus and clinicians an overview of evidence-based education and self-management, care options, and recommended outcome measures to monitor effectiveness and potentially improve patient health and well-being.
Findings of a lack of sufficient evidence resulted from evaluating the quality of the body of evidence and emphasize the gaps in knowledge that need further study. Addressing these gaps may enable a comprehensive evaluation of the potential benefits and limitations of various tinnitus care options, ultimately improving patient care and clinical practice.
Key Recommendations for Clinicians
The development group made a strong recommendation that clinicians distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus. The development group made a strong recommendation against obtaining imaging studies of the head and neck in patients with tinnitus, specifically to evaluate tinnitus that does not localize to 1 ear, is nonpulsatile, and is not associated with focal neurologic abnormalities or an asymmetric hearing loss.
The panel made the following recommendations:
- Clinicians should (a) 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; (b) obtain a prompt, comprehensive audiologic examination in patients with tinnitus that is unilateral, persistent (≥ 6 months), or associated with hearing difficulties; (c) 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; (d) educate patients with persistent, bothersome tinnitus about management strategies; (e) recommend a hearing aid evaluation for patients who have persistent, bothersome tinnitus associated with documented hearing loss; and (f) recommend cognitive behavioral therapy to patients with persistent, bothersome tinnitus.
The panel recommended against (a) antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for the routine treatment of patients with persistent, bothersome tinnitus; (b) Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating patients with persistent, bothersome tinnitus; and (c) transcranial magnetic stimulation for the routine treatment of patients with persistent, bothersome tinnitus.
The development group provided the following options:
- Clinicians may (a) obtain an initial comprehensive audiologic examination in patients who present with tinnitus (regardless of laterality, duration, or perceived hearing status); and (b) recommend sound therapy to patients with persistent, bothersome tinnitus.
Audiological Evaluation and Management
Audiologists are qualified to evaluate, diagnose, develop management strategies, and provide treatment and rehabilitation for patients with tinnitus. It is important to consider the entire person, not merely the audiogram and/or the characteristics of tinnitus.
This guideline discusses the evaluation of patients with tinnitus and management procedures including counseling, cognitive behavioral therapy, habituation and tinnitus retraining therapy, hearing aids and tinnitus instruments, self-help and support/education groups, and stress management. It also discusses external referrals, outcome measures, and CPT code considerations.
Overview of Tinnitus Treatment Options