Tinnitus Recommendations: What to Do When There Is Ringing in the Ears

Gregory W. Rutecki, MD

Rutecki GW. Tinnitus recommendations: what to do when there is ringing in the ears. Consultant. 2016;56(11):1036.


An estimated 50 million US adults experience tinnitus, which is defined as the perception of sound without an acoustic stimulus.1 Despite the impressive number of individuals affected by the condition, only 20% of them seek medical attention.1 Many who seek that attention come to see their primary care provider.

How should patients with tinnitus be evaluated? Are there high-risk conditions that require prompt intervention and consultation? This month’s Top Paper provides a clinical guidelines synopsis, applying sparsely available evidence-based information about a common and enigmatic chief complaint.1

The authors of this Top Paper from the Journal of the American Medical Association focus on the most recent clinical practice guideline on tinnitus developed by the American Academy of Otolaryngology–Head and Neck Surgery.2

The Presentations Of Tinnitus

Most patients with tinnitus have no underlying identifiable cause for it. So, imaging should not be routinely ordered.1 But some individuals have a serious underlying etiology causing the tinnitus. How can these patients be identified? The history and physical examination are important. Unilateral tinnitus, pulsatile tinnitus, tinnitus with a focal neurologic defect, or tinnitus with an asymmetric hearing loss may be a warning sign of serious problems.

Although there are no clear-cut recommendations to guide imaging choice (evidence is not available), unilateral, nonpulsatile tinnitus with hearing loss is usually the consequence of a retrocochlear pathology. In this specific instance, contrast-enhanced magnetic resonance imaging is the best option. Pulsatile tinnitus should make one suspect a vascular etiology; thus, a thin-cut computed tomography (CT) scan of the temporal bones—with CT angiography and venography—provides the most information.

Our otorhinolaryngology consultants should be utilized when a patient’s tinnitus is unilateral, persistent, or associated with hearing difficulties. Primary care providers may be the most important source of care for the majority of patients without serious signs and symptoms. In this demographic, cognitive behavioral therapy may be beneficial. In patients with tinnitus and hearing difficulties, hearing aid trials may be an important recommendation. It is not good practice to routinely prescribe antidepressants, anticonvulsants, or anxiolytics to patients complaining of tinnitus. Likewise, over-the-counter supplements are not recommended.

Putting Recommendations Into Practice

Although this Top Paper is brief, and some of the recommendations have little supporting evidence, I found important and practical information nonetheless. I had a habit of “lumping” all patients with tinnitus into a single demographic group who had complaints that could not be fixed. Based on the recommendations in this Top Paper, I will expand my history in the future, specifically asking about pulsatile tinnitus and hearing loss. In patients who demonstrate symptoms suggestive of serious disease (6 months of unilateral tinnitus with hearing loss), I will pursue imaging and consultation. In more straightforward presentations, I will order audiologic testing and propose a trial of hearing aids. I will not cavalierly prescribe anxiolytics.

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the Consultant editorial board.


  1. Walker DD, Cifu AS, Gluth MB. Tinnitus. JAMA. 2016;315(20):2221-2222.
  2. Tunkel DE, Bauer CA, Sun GH, et al. Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. 2014;151(2 suppl):S1-S40.