The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published an updated clinical practice guideline for adults with tinnitus that is persistent (six months or more) and bothersome. Pulsatile and objective tinnitus are outside its scope.
Strong recommendations: distinguish bothersome from non-bothersome tinnitus; ask about risk of self-harm in patients with bothersome tinnitus; and do not order neuroimaging to evaluate tinnitus unless there are specific concerning features.
Recommendations: take a targeted history and examination; arrange comprehensive audiological evaluation; educate patients on natural history and management; recommend hearing aid evaluation where hearing is impaired; refer for cochlear implant assessment when criteria are met; recommend cognitive behavioural therapy; and document outcomes. The guideline recommends against routine antidepressants, anticonvulsants, anxiolytics or intratympanic drugs for tinnitus itself, against dietary supplements, and against rTMS. Sound enrichment and bimodal neuromodulation are options.
The self-harm question is the item most likely to be missing from a routine clinic. The no-imaging default matters wherever MRI is ordered reflexively.
- Ask every patient with bothersome tinnitus about thoughts of self-harm.
- Do not order MRI or CT for tinnitus alone unless specific concerning features are present.
- Arrange a full audiological evaluation for every patient.
- Recommend CBT, and hearing aids where hearing is impaired.
- Do not prescribe antidepressants, anticonvulsants or supplements to treat tinnitus itself.
Why it matters
Tinnitus clinics often default to imaging and supplements while missing the distress and self-harm risk that the guideline puts first.
Don't overread it
The advice against drugs applies to treating tinnitus itself, not to treating co-existing depression or anxiety.
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