Executive Summary of the Clinical Practice Guideline on Tinnitus Update

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% to 15% in adults. 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 allied health professionals, involved in managing patients with tinnitus. The target patient population is limited to adults (18 years and older) with tinnitus that is persistent and bothersome.

The purpose of this guideline is to provide and update evidence-based recommendations for clinicians managing patients with tinnitus. The target audience for this guideline is any clinician involved in managing patients with tinnitus. People with tinnitus may be evaluated by a variety of health care providers, including primary care clinicians, specialty clinicians, and allied health professionals including audiologists and clinical psychologists. The target patient population is limited to adults (18 years and older) with tinnitus that is persistent and bothersome. Most people with tinnitus have associated hearing loss, such as sensorineural hearing loss (SNHL) secondary to aging (presbycusis), noise exposure (noise-induced hearing loss), or acoustic trauma. Tinnitus can also be a symptom of numerous auditory and non-auditory system disorders, ranging from middle ear diseases, such as otosclerosis and eustachian tube dysfunction, to inner ear and auditory nerve pathologies such as Ménière's disease and vestibular schwannoma. Nonauditory system disorders that can cause tinnitus include vascular anomalies, myoclonus, and intracranial hypertension. The Guideline Update Group (GUG) placed emphasis on the need for thorough clinical evaluation to identify these potentially treatable and sometimes serious disorders. However, patients with identifiable causative diagnoses other than sensorineural hearing loss are excluded from this guideline as they are excluded from nearly all randomized controlled trials of tinnitus management, making it impossible to generalize trial results to these patients. Nevertheless, clinicians should decide whether to apply the recommendations of this guideline to patients with these conditions on an individualized basis. The guideline also underscores the need to distinguish between subjective, objective, and pulsatile tinnitus to further direct patient evaluation and management. Comprehensive management of objective tinnitus and pulsatile tinnitus is not within the scope of this guideline. Pulsatile tinnitus is the perception of a rhythmic sound in the absence of an external source that may be pulse-synchronous, which is often but not always related to vascular causes, or pulse-asynchronous, which is typically associated with mechanical causes such as palatal or middle ear myoclonus.¹ Further, the guideline does not apply to transient ear noise, which is the sudden perception of a tonal or ringing sound in 1 ear, lasting fewer than 5 minutes, that may be accompanied by a sense of hearing loss or aural fullness, as it does not typically require clinical management.² The guideline also excludes patients with tinnitus related to complex auditory hallucinations or hallucinations related to psychotic or seizure disorders. This is an update to an evidence-based clinical guideline developed for the evaluation and management of tinnitus. This updated guideline provides clinicians with a logical framework to improve patient care and mitigate the personal and social effects of persistent, bothersome tinnitus. The first part of the guideline is focused on the clinical evaluation of patients with tinnitus, including the history, physical exam, and selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology and reduce the risk of self-harm. The remainder of the guideline is focused on the evaluation and treatment of patients with persistent, bothersome tinnitus, with recommendations to evaluate and measure its effects as well as to determine the most appropriate interventions to improve symptoms and quality of life.

The Guideline Update Group made strong recommendations for the following Key Action Statements (KAS): Clinicians should distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus (KAS 2). Clinicians should inquire about risks for self-harm in a patient with bothersome tinnitus (KAS 3). Clinicians should not obtain neuroradiologic imaging in patients with tinnitus specifically to evaluate the tinnitus unless specific concerning features are present (KAS 6). The Guideline Update Group made recommendations for the following KASs: Clinicians should perform a targeted history and physical examination at the initial evaluation of a patient with tinnitus (KAS 1). Clinicians should obtain a comprehensive audiological evaluation in patients with tinnitus (KAS 5). Clinicians should educate patients with tinnitus about the natural history and effects of, and management strategies for tinnitus (KAS 7). Clinicians should recommend a hearing aid evaluation for patients with hearing difficulties and persistent, bothersome tinnitus (KAS 8). Clinicians should refer patients with persistent, bothersome tinnitus for cochlear implant evaluation when they meet audiologic criteria for referral (KAS 9). Clinicians should recommend Cognitive Behavioral Therapy (CBT) to patients with persistent, bothersome tinnitus (KAS 11). Clinicians or their designee should assess and document outcomes of interventions in patients with persistent, bothersome tinnitus (KAS 15). The Guideline Update Group made recommendations against for the following KASs: Clinicians should not routinely recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for a primary indication of treating persistent, bothersome tinnitus (KAS 12). Clinicians should not recommend dietary supplements for the primary indication of persistent, bothersome tinnitus (KAS 13). Clinicians should not recommend repetitive transcranial magnetic stimulation (rTMS) for the treatment of patients with persistent, bothersome tinnitus (KAS 14A). The Guideline Update Group offered options for the following KASs: Clinicians may inquire about somatosensory features in patients with persistent, bothersome tinnitus (KAS 4). Clinicians may recommend sound enrichment to patients with persistent, bothersome tinnitus (KAS 10). Clinicians may offer bimodal neuromodulation to patients with persistent, bothersome tinnitus (KAS 14B).