Clinical question

  Key action statement

Strength of recommendation

Recommendation

Level of evidence

Study type^Refernce

Definition of Tinnitus

A condition described as ringing, buzzing,  clicking or pulsating noise perceived only by the patient(subjective) or the examiner and the patient objective.   it may be without an aberrant cause (Primary) or due to a specific cause (Secondary).

Strong Recommendation

Moderate

RCT⁸

History and physical exam

Clinicians should 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.

Strong Recommendation

Moderate

RCT^9-11

Bothersome tinnitus

Clinicians must distinguish patients with bothersome tinnitus from patients with no bothersome tinnitus.

Strong Recommendation

Moderate

RCT^12,13

Persistent tinnitus

Clinicians should distinguish patients with bothersome tinnitus of recent onset from those with persistent symptoms (≥ 6 months) to prioritise intervention and facilitate discussions about natural history and follow-up care.

Strong Recommendation

Moderate

RCT¹⁴

Prompt Audiologic

Examination

Clinicians should obtain a prompt, comprehensive audiologic examination in patients with tinnitus that is unilateral, persistent (≥ 6 months), or associated with hearing difficulties.

Strong Recommendation

Moderate

RCT¹⁵

Routine Audiologic

Examination

Clinicians may obtain an initial comprehensive audiologic examination in patients who present with tinnitus  (regardless of laterality, duration, or perceived hearing status).

Conditional recommendation

High

Well-organized RCT¹⁶

Imaging studies

Clinicians should obtain imaging studies of the head and neck in patients with tinnitus especially if they have 1 or more of the following:  tinnitus  that  localizes to 1 ear, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss.( MRI temporal bone with contrast with special emphasis on IAC and CPA to  exclude  retrocochlear  lesion, CT temporal bone to exclude dehiscent jugular vein, dehiscent carotid canal, glomus, or other causes and MRI with contrast and MRA to exclude vascular loop).

Strong Recommendation

High

Systematic review¹⁷

Education and

Counselling

Clinicians should educate patients with persistent, bothersome tinnitus about management strategies.

Strong Recommendation

High

Systematic review¹⁸

Hearing aid evaluation

Clinicians should recommend a hearing aid evaluation for patients with hearing loss and persistent, bothersome tinnitus.

Strong Recommendation

High

Systematic review¹⁹

Sound therapy

Clinicians may recommend sound therapy to patients with persistent, bothersome tinnitus.

Strong Recommendation

Low

Observational studies^20,21

Cognitive behavioural therapy (CBT)

Clinicians should recommend cognitive behavioural therapy to patients with persistent, bothersome tinnitus.

 Strong Recommendation

High

Systematic review²²

Medical therapy

Clinicians can recommend antidepressants, anticonvulsants, or anxiolytics for a primary indication of treating persistent, bothersome tinnitus (Neramexane, Vestipitant alone or in combination with paroxetine, acamprosate, and dietary zinc supplements).

Conditional recommendation

Low

Observational study²³

Dietary supplements

Clinicians can recommend Ginkgo  biloba,  melatonin,  zinc, or other dietary supplements for treating patients with persistent, bothersome tinnitus.

Conditional recommendation

High

Well-organized RCT²⁴

Acupuncture

No recommendation can be made regarding the effect of acupuncture in patients with persistent bothersome tinnitus.

Strong Recommendation

   High

Systematic review²⁵

Intratympanic

injection

A-Intratympanic steroids

B- Intratympanic lidocaine

C- combined Intratympanic steroids and lidocaine

Clinicians should have enough experience with Intratympanic injection. Intratympanic injection should be done once weekly for 3-5 times.

Intratympanic steroids should be used in acute tinnitus, cases with sudden SNHL and cases with SNHL not more than 30 dB.

Intratympanic lidocaine should be tried only for chronic tinnitus.

The combination reduces the irritative effect of lidocaine.

Conditional recommendation

Moderate

RCT^26-28

Surgical  treatment of tinnitus

Surgical treatment is offered for specific causes of tinnitus (e.g. glomus, vestibular schwannoma).

Strong Recommendation

Moderate

RCT²⁹