David Tunkel, M.D.

Credit: Johns Hopkins Medicine

Tinnitus or ringing in the ears — a phantom sound with no identifiable external source — affects millions of Americans, some of them chronically. Yet despite its prevalence, so far there have been no evidence-based clinical guidelines on how to evaluate and treat the condition.      

Now a panel led by Johns Hopkins otolaryngologist David Tunkel, M.D., has developed the first-ever multidisciplinary, evidence-based clinical guidelines to help specialists and primary care clinicians manage and treat tinnitus. The guidelines, developed on behalf of the American Academy of Otolaryngology—Head and Neck Surgery Foundation, are published in the October issue of the journal Otolaryngology—Head and Neck Surgery.

“We hope that these guidelines will improve clinical decision-making, clarify the choice of therapy and help expedite the diagnoses of any underlying pathologies in some of the more complex cases,” Tunkel says. “At the same time, the guidelines can help tinnitus sufferers avoid unnecessary testing and treatments that are not helpful.”  

Tinnitus is the perception of sound in one or both ears without an identifiable external source and is often described as a roaring, buzzing, clicking or pulsating sensation. Primary tinnitus has no identifiable cause and is often associated with hearing loss. Secondary tinnitus stems from an underlying disease and can accompany high blood pressure, inner-ear disorders and, rarely, head and neck tumors.

Some of the panel’s recommendations include:

• Clinicians must distinguish patients with nonbothersome tinnitus from those with bothersome tinnitus. Bothersome tinnitus can cause irritability, communication problems, difficulty concentrating and troubles with sleep.
• Clinicians should distinguish patients with tinnitus of recent onset from those with persistent tinnitus, which lasts six months or longer.
• Clinicians should not order routinely head and neck imaging tests for tinnitus. Patients may need such testing if they experience one-sided and/or pulsatile tinnitus, neurologic abnormalities or more pronounced hearing loss in one ear.
• Clinicians may order audiology testing for anyone with tinnitus, but patients with persistent or one-sided tinnitus and those with hearing difficulties should undergo such testing promptly.
• Clinicians should educate patients that while there is no cure for tinnitus, a wide range of interventions can help manage the effects of the condition and improve a patient’s quality of life.
• Clinicians should recommend a hearing aid evaluation for patients with hearing loss and persistent, bothersome tinnitus, as hearing aids can mitigate both conditions.
• Cognitive behavioral therapy (CBT) is recommended for patients with persistent bothersome tinnitus. Research shows that CBT can go a long way toward improving a patient’s mood and quality of life.
• Clinicians should not prescribe antidepressants and anti-anxiety medications as routine or first-line treatment for persistent tinnitus. Such medications should be used selectively, in patients with accompanying depression or anxiety.
• Clinicians should not recommend the use of dietary supplements, such as ginkgo biloba, melatonin and zinc, due to little to no evidence about their therapeutic benefits.

Experts estimate that some 50 million American adults have experienced tinnitus at some point in their lives, and one in five seeks medical attention for it. Tinnitus is particularly prevalent among the elderly and military personnel. It is the most common service-related disability among veterans.