Easing the Burden of Tinnitus: A Narrative Review for Exploring Effective Pharmacological Strategies

Many individuals seek medical attention for tinnitus, desiring relief from the distress caused by the condition; however, the treatment process is far from straightforward. The most effective treatments for chronic subjective tinnitus, such as tinnitus retraining therapy (TRT) and cognitive behavioral therapy (CBT), require considerable time and efforts. As a result, many of them express a desire for alleviation through medication. While it is true that medication is not generally recommended in treatment guidelines for chronic subjective tinnitus, in specific situations such as when accompanied by symptoms of depression or anxiety-drugs like antidepressants or anxiolytics may have a meaningful impact on symptom reduction. Additionally, medication can prove effective in certain specialized forms of tinnitus, such as typewriter tinnitus, as opposed to chronic subjective tinnitus. Although intratympanic dexamethasone injections for tinnitus have been reported to lack efficacy compared to a placebo, if patients perceive subjective satisfaction due to a placebo effect, it holds significance. From the perspective of patients suffering from tinnitus, even if the therapeutic mechanism is set aside, experiencing some degree of relief through certain medications can enhance compliance with evidence-based treatments like TRT and CBT.

State of the art: non-invasive electrical stimulation for the treatment of chronic tinnitus

Subjective tinnitus is the perception of sound in the absence of external stimulation. Neuromodulation is a novel method with promising properties for application in tinnitus management. This study sought to review the types of non-invasive electrical stimulation in tinnitus to provide the foothold for further research. PubMed, EMBASE, and Cochrane databases were searched for studies on the modulation of tinnitus by non-invasive electrical stimulation. Among the four forms of non-invasive electrical modulation, transcranial direct current stimulation, transcranial random noise stimulation, and transauricular vagus nerve stimulation yielded promising results, whereas the effect of transcranial alternating current stimulation in the treatment of tinnitus has not been confirmed. Non-invasive electrical stimulation can effectively suppress tinnitus perception in some patients. However, the heterogeneity in parameter settings leads to scattered and poorly replicated findings. Further high-quality studies are needed to identify optimal parameters to develop more acceptable protocols for tinnitus modulation.

Prognostic Factors Influencing the Tinnitus Improvement After Idiopathic Sudden Sensorineural Hearing Loss Treatment

PURPOSE

Logistic regression analysis was used to explore the factors that influence tinnitus improvement after idiopathic sudden sensorineural hearing loss (ISSNHL) treatment.

MATERIALS AND METHODS

In this retrospective study, 137 ISSNHL patients with tinnitus were recruited at the Sun Yatsen Memorial Hospital of Sun Yat-sen University, China. They underwent audiological examinations, vestibular assessments, tinnitus examinations, a Tinnitus Handicap Inventory (THI) assessment and ISSNHL treatments. Logistic regression analysis was performed to investigate factors that affected tinnitus improvement.

RESULTS

Participants were divided into an effective group (73 patients) and noneffective group (64 patients) according to THI scores before and after treatment. The effective group had better averaged hearing threshold than the noneffective group (effective group vs. noneffective group: 74.47 vs. 87.66 dB HL; t = 3.03, p < 0.05). Additionally, before intervention there were significant difference in profound audiogram configuration (effective group vs. noneffective group: 17.81% vs. 46.88%, x2 = 23.63; p < 0.001), mid tinnitus pitch (effective group vs. noneffective group: 19.18% vs. 35.94%, x2 = 6.58; p = 0.037) and mean THI scores (effective group vs. noneffective group: 57.07 ± 22.27 vs. 36.78 ± 24.41, t = -5.09, p < 0.001) between the effective and noneffective tinnitus groups. Logistic regression analysis showed that audiogram configurations (profound audiogram: OR = 0.10, 95% CI 0.01-0.72, p = 0.022), tinnitus pitch (mid tinnitus pitch: OR = 0.16, 95% CI 0.05-0.57, p = 0.004) and THI scores (OR = 1.05, 95% CI 1.03-1.07, p < 0.001) were independent factors associated with tinnitus improvement.

CONCLUSION

Audiogram configuration, tinnitus pitch, and THI scores before intervention appear to be predictive of the effectiveness of acute tinnitus improvement following ISSNHL treatment.

Effectiveness of Intratympanic Dexamethasone Injection for Tinnitus Treatment: A Systematic Review and Meta-Analysis

Objectives

Intratympanic dexamethasone injection (ITDI) has been introduced as a treatment option for subjective tinnitus. However, the effects of ITDI on patients with tinnitus remain unclear. In the present systematic review and metaanalysis, we evaluated the effectiveness of ITDI for tinnitus treatment.

Methods

We searched Medline, the Cochrane Central Register of Controlled Trials, and Embase. Four double-blind randomized controlled trials that tested the efficacy of ITDI compared with a placebo were deemed eligible for a quantitative meta-analysis, while four prospective studies and seven retrospective studies reporting the effectiveness of ITDI on tinnitus treatment were included in a qualitative synthesis.

Results

In the four studies included in the quantitative meta-analysis, ITDI did not show evidence of tinnitus improvement compared with placebo (odds ratio [OR], 1.38; 95% confidence interval, 0.53-3.61). In the 11 studies included in the qualitative synthesis, seven retrospective studies without controls reported rates of tinnitus improvement after ITDI ranging from 35.9% to 91.3%. In the four prospective studies with controls, ITDI seemed to be effective when combined with other drugs for tinnitus treatment.

Conclusion

ITDI alone did not show a significant effect for treating tinnitus compared with placebo. However, the potential of combination treatment of ITDI with other drugs for tinnitus therapy should be further studied in more systematic research.

Evidence of Cochlear Synaptopathy and the Effect of Systemic Steroid in Acute Idiopathic Tinnitus With Normal Hearing

OBJECTIVE

To evaluate the electrophysiologic evidence of cochlear synaptopathy and the effects of systemic steroids in acute idiopathic tinnitus with normal hearing.

STUDY DESIGN

Retrospective review of medical data.

SETTING

Tertiary referral center.

PATIENTS

Fifty-nine patients who experienced acute-onset idiopathic tinnitus (within 12 weeks) with normal hearing and the same number of age- and pure-tone threshold-matched control groups.

INTERVENTION

Electrophysiologic studies of the auditory pathway, oral steroids, and ginkgo biloba.

MAIN OUTCOME MEASURES

Pure-tone thresholds, wave I and wave V amplitudes of the auditory brainstem response (ABR), tinnitus handicap inventory (THI), and visual analog scale (VAS).

RESULTS

Significantly reduced ABR wave I amplitude and wave I/wave V ratio were found in the tinnitus group compared with the no tinnitus group. Age and pure-tone threshold were significantly correlated with reduced wave I amplitude and small wave I/wave V ratio. The THI and VAS scores were decreased at 3 and 12 weeks after steroid administration; however, overall changes in THI and VAS scores were not significantly different between the steroid and ginkgo biloba groups.

CONCLUSION

Potential cochlear synaptopathy was suspected in the early stage of acute idiopathic tinnitus, even in patients with normal hearing. Age and hearing threshold were potentially associated with the development of cochlear synaptopathy. Low-dose oral steroids and ginkgo biloba induced early subjective relief of tinnitus, which maintained up to 12 weeks, however, those changes did not differ between groups.

Review of Pharmacotherapy for Tinnitus

Various medications are currently used in the treatment of tinnitus, including anesthetics, antiarrhythmics, anticonvulsants, antidepressants, antihistamines, antipsychotics, anxiolytics, calcium channel blockers, cholinergic antagonists, NMDA antagonists, muscle relaxants, vasodilators, and vitamins. To date, however, no medications have been specifically approved to treat tinnitus by the US Food and Drug Administration (FDA). In addition, medicines used to treat other diseases, as well as foods and other ingested materials, can result in unwanted tinnitus. These include alcohol, antineoplastic chemotherapeutic agents and heavy metals, antimetabolites, antitumor agents, antibiotics, caffeine, cocaine, marijuana, nonnarcotic analgesics and antipyretics, ototoxic antibiotics and diuretics, oral contraceptives, quinine and chloroquine, and salicylates. This review, therefore, describes the medications currently used to treat tinnitus, including their mechanisms of action, therapeutic effects, dosages, and side-effects. In addition, this review describes the medications, foods, and other ingested agents that can induce unwanted tinnitus, as well as their mechanisms of action.

The Efficacy of Intratympanic Steroid Injection in Tinnitus Cases Unresponsive to Medical Treatment

OBJECTIVES

To examine the efficacy of an intratympanic steroid injection in tinnitus cases unresponsive to medical treatment.

MATERIALS AND METHODS

The study was carried out at the Ear, Nose, and Throat Department with 107 patients (46 male, 61 female) between the ages of 20 and 77 with a mean of 42.8 years who had idiopathic tinnitus. Patients were randomized by simple randomization to receive intratympanic dexamethasone or isotonic solution. The patients received six intratympanic injections, two per week for three weeks. Tinnitus handicap index (THI) was performed before treatment and at first week, first month, and six months after the completion of the study protocol. The audiometric tests were performed six months after the treatment.

RESULT

In the study group, pretreatment THI and post-treatment first month THI scores and pretreatment THI and post-treatment sixth month THI scores were significantly different whereas the same scores were not significantly different in the control group. The comparison of THI scores between the groups revealed significantly lower scores in the first and sixth months for the study group.

CONCLUSION

The effect of the intratympanic injection of dexamethasone on the efficacy of treatment of tinnitus severity was statistically significant.

Methodological Aspects of Randomized Controlled Trials for Tinnitus: A Systematic Review and How a Decision Support System Could Overcome Barriers

Although a wide range of tinnitus management interventions is currently under research and a variety of therapeutic interventions have already been applied in clinical practice, no optimal and universal tinnitus treatment has been reached yet. This fact is to some extent a consequence of the high heterogeneity of the methodologies used in tinnitus related clinical studies. In this manuscript, we have identified, summarized, and critically appraised tinnitus-related randomized clinical trials since 2010, aiming at systematically mapping the research conducted in this area. The results of our analysis of the 73 included randomized clinical trials provide important insight on the identification of limitations of previous works, methodological pitfalls or gaps in current knowledge, a prerequisite for the adequate interpretation of current literature and execution of future studies.

Predictive Factors for the Success of Intratympanic Dexamethasone Treatment of Acute Subjective Tinnitus

OBJECTIVES

The purpose of this study was to determine the factors predicting the success or failure of intratympanic dexamethasone (ITD) injection in the treatment of acute subjective tinnitus (AST).

MATERIALS AND METHODS

We enrolled patients who were treated with ITD within 3 months of the onset of tinnitus, between 2013 and 2017. We compared the clinical characteristics and audiological data of the patients in the cured group (n=38, 45.6±13.3 years old) and the nonresponder group (n=40, 48.9±18.6 years old).

RESULTS

The cured group was predominantly female (p=0.002). The mean duration of tinnitus before ITD was shorter in the cured group than the nonresponder group (p=0.002). The pure-tone averages in both sides were lower in the cured group than in the nonresponder group (p=0.018). The time of tinnitus awareness was shorter in the cured group than in the nonresponder group (p=0.014). Multivariable analysis showed that the duration of tinnitus (odds ratio [OR]=1.045), a history of exposure to noise just before tinnitus development (OR=7.766), and distortion product otoacoustic emissions results (OR=4.580) predicted the outcome of ITD treatment in AST.

CONCLUSION

A short duration of tinnitus, no history of immediate noise exposure, and normal distortion product otoacoustic emissions could be favorable prognostic factors for AST treated with ITD injection.

Inner Ear Therapeutics: An Overview of Middle Ear Delivery

There are a variety of methods to access the inner ear and many of these methods depend on utilizing the middle ear as a portal. In this approach the middle ear can be used as a passive receptacle, as part of an active drug delivery system, or simply as the most convenient way to access the inner ear directly in human subjects. The purpose of this volume is to examine some of the more cutting-edge approaches to treating the middle ear. Before considering these therapies, this manuscript provides an overview of some therapies that have been delivered through the middle ear both in the past and at the current time. This manuscript also serves as a review of many of the methods for accessing the inner ear that directly utilize or pass though the middle ear. This manuscript provides the reader a basis for understanding middle ear delivery, the basis of delivery of medicines via cochlear implants, and examines the novel approach of using hypothermia as a method of altering the responses of the inner ear to damage.

Round Window Niche Drilling with Intratympanic Steroid Is a Salvage Therapy of Sudden Hearing Loss

OBJECTIVE

To explore the effectiveness and safety of round window niche drilling combined with intratympanic methylprednisolone injection for the salvage treatment of sudden sensorineural hearing loss (SSNHL) and its associated tinnitus after failed primary treatment.

METHOD

SSNHL patients who showed a less than 10-dB improvement of pure-tone average after receiving standard systemic treatment and intratympanic steroid injection were enrolled. All included patients were randomly divided into two groups (control and study). Patients in the study group received round window niche drilling combined with daily intratympanic methylprednisolone for 7 times; the control group received only daily intratympanic methylprednisolone for 7 times. One month after treatment, the improvements of PTA, speech discrimination score (SDS), tinnitus and the incidence of adverse events were analyzed.

RESULTS

20 patients (10 for each group) were included in this study. The baseline between two groups showed no statistical significance. Patients in the study group experienced an average hearing improvement of 20.38 dB, SDS 19.3 compared with 2.1 dB and SDS 2.0 in the control group. None (0%) in the control group and 4 patients (40%) showed marked recovery, 5 patients (50%) showed slight improvement of hearing in the study group after 1 month. All patients in the study group showed significant recovery of tinnitus. Both tinnitus handicap inventory and a symptom visual analogue scale between two groups revealed statistical differences (p < 0.001, p = 0.002, respectively). None in the control and study groups experienced vertigo, infection and facial paralysis.

CONCLUSION

Round window niche drilling increases the contact area and time of methylprednisolone. It is an effective and safe salvage therapy of idiopathic SSNHL and its induced tinnitus.

Steroid intracochlear distribution differs by administration method: Systemic versus intratympanic injection

OBJECTIVE

Steroids have been widely used to treat inner-ear diseases such as sudden sensorineural hearing loss, tinnitus, and Meniere's disease. They can be given via either systemic or intratympanic (IT) injection. The purpose of the present study was to explore differences in intracochlear steroid distribution by the administration method employed (systemic vs. IT injection).

STUDY DESIGN

Animal study.

METHODS

Twenty-three Sprague-Dawley rats were given fluorescein isothiocyanate-labeled dexamethasone (FITC-DEX) three times (on successive days) via intraperitoneal (IP) or IT injection. Cochlear uptake of FITC-DEX was evaluated via immunohistochemistry and flow cytometry at 6 hours, and 3 and 7 days after the final injection.

RESULTS

FITC-DEX uptake was evident in spiral ganglion cells (SGs), the organ of Corti (OC), and the lateral walls (LWs), the basal turns of which were stained relatively prominently in both groups. Animals receiving IP injections exhibited higher FITC-DEX uptakes by the SGs and OC, whereas IT injection triggered higher-level FITC-DEX accumulation by the OC and LWs. Flow cytometry revealed that intracochlear FITC-DEX uptake by IT-injected animals was higher and more prolonged than in animals subjected to IP injections.

CONCLUSION

We thus describe differences in cochlear steroid distributions after systemic and IT injections. This finding could help our understanding of the pharmacokinetics of steroids in the cochlea.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:189-194, 2018.

Clinical effect of intratympanic dexamethasone injection in acute unilateral tinnitus: A prospective, placebo-controlled, multicenter study

OBJECTIVE

The purpose of this study was to investigate the effectiveness of intratympanic dexamethasone injection (ITDI) in acute tinnitus of presumed cochlear origin.

STUDY DESIGN

A prospective, randomized, placebo-controlled, double-blinded, multicenter study.

METHODS

Between August 2013 and December 2015, 54 patients with unilateral tinnitus were enrolled at four different centers. Patients were assigned either to an ITDI (n = 27) or an intratympanic normal saline injection (ITNI; n = 27) group through block randomization. Intratympanic injections were administered four times over 2 weeks. At 4 weeks after initial injection, we analyzed the improvement rates of tinnitus using the tinnitus handicap Inventory (THI) and visual analogue scale (VAS) for loudness, awareness, and annoyance. We defined improvement as the reduction of more than 7 points or of more than 20% in the final THI score compared to the initial THI score.

RESULTS

The initial mean hearing thresholds and VAS and THI scores of the two groups did not differ significantly. At 4 weeks after initial injection, the mean VAS and THI scores of both groups had significantly reduced. However, the improvement rate did not differ significantly between the groups (ITDI, 51.9%; ITNI, 59.3%).

CONCLUSION

The results indicate that ITDI might not be more effective than ITNI for the treatment of acute unilateral tinnitus. Therefore, ITDI should not be considered as the main treatment for patients presenting with acute tinnitus as the primary symptom.

LEVEL OF EVIDENCE

1b. Laryngoscope, 128:184-188, 2018.

Evidence and evidence gaps in tinnitus therapy

A nearly endless number of procedures has been tried and in particular sold for the treatment of tinnitus, unfortunately they have not been evaluated appropriately in an evidence-based way. A causal therapy, omitting the tinnitus still does not exist, actually it cannot exist because of the various mechanisms of its origin. However or perhaps because of that, medical interventions appear and reappear like fashion trends that can never be proven by stable and reliable treatment success. This contribution will discuss and acknowledge all current therapeutic procedures and the existing or non-existing evidence will be assessed. Beside external evidence, the term of evidence also encompasses the internal evidence, i.e. the experience of the treating physician and the patient's needs shall be included. While there is no evidence for nearly all direct procedures that intend modulating or stimulating either the cochlea or specific cervical regions such as the auditory cortex, there are therapeutic procedures that are acknowledged in clinical practice and have achieved at least a certain degree of evidence and generate measurable effect sizes. Those are in particular habituation therapy and psychotherapeutic measures, especially if they are combined with concrete measures for improved audio perception (hearing aids, CI, hearing therapies).

Effects of two different local anaesthetic methods vs no anaesthesia on pain scores for intratympanic injections

OBJECTIVE

This study compared the pain associated with the intratympanic injection combined with various local anaesthetics vs without anaesthesia.

METHODS

The study included 40 patients (aged 18-78 years) who received intratympanic steroid injections for sudden idiopathic hearing loss or tinnitus. Each patient underwent all three injection methods at one-week intervals. Patients received one of two local anaesthetics (lidocaine injection or lidocaine spray) or no anaesthesia before intratympanic injection, and used a visual analogue scale to indicate the pain level after 5 and 45 minutes.

RESULTS

Five minutes after injection, patients who did not receive anaesthesia and those who received lidocaine spray reported lower pain scores than those who received a lidocaine injection (p < 0.05). There was no difference in pain scores for all three methods at 45 minutes after intratympanic injection.

CONCLUSION

Neither of the local anaesthetics was found to be superior to having no anaesthesia.

Prognostic factors for the outcomes of intratympanic dexamethasone in the treatment of acute subjective tinnitus

OBJECTIVE

To determine the prognostic factors for the outcomes of treating acute subjective tinnitus with intratympanic dexamethasone (ITD).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

We enrolled 139 subjects who were treated with ITD for acute subjective tinnitus with symptoms lasting for 3 months or less. Overall, 114 of 139 subjects completed questionnaires 3 months after treatment or fully recovered within 3 months. Audiograms were performed 3 months after treatment in 43 patients.

INTERVENTION

ITD for acute subjective tinnitus.

MAIN OUTCOME MEASURE

Quantitative assessment of the severity of tinnitus by questionnaires and changes in hearing thresholds at all frequencies by pure-tone audiometry.

RESULTS

Tinnitus was cured in 43 of 114 patients (37.7%) within 3 months. The mean tinnitus loudness score, the mean tinnitus awareness score, and the mean tinnitus handicap inventory score were significantly reduced at 3 months after ITD. Audiometric responses were detected in 12 of 43 patients (27.9%) who underwent follow-up audiograms. The cure rate was significantly greater in patients with symptoms lasting for 2 weeks or less than in patients with symptoms lasting for more than 1 month (64.7% vs. 15.7%; p < 0.05). The mean global improvement index for tinnitus was significantly greater in patients with unilateral tinnitus than in patients with bilateral tinnitus (6.2 ± 1.9 vs. 5.0 ± 2.0; p < 0.05). Among patients with unilateral tinnitus, the audiometric response rate was significantly greater in patients with asymmetric hearing threshold than in patients with symmetric hearing threshold (48.8% vs. 4.8%; p < 0.01). The cure rate was significantly associated with the duration of symptoms. Unilateral tinnitus and audiologic asymmetry were positively associated with the audiometric response rate.

CONCLUSIONS

The duration of symptoms affected the cure rate of ITD for acute subjective tinnitus. Unilateral tinnitus was associated with better improvements in symptoms than bilateral tinnitus. Furthermore, unilateral tinnitus and audiologic asymmetry were positively associated with the audiometric response.

Intratympanic corticosteroids injections: a systematic review of literature

The objective of the study was to determine the evidence of intratympanic steroids injections (ITSI) for efficacy in the management of the following inner ear diseases: Ménière's disease, tinnitus, noise-induced hearing loss (NIHL) and idiopathic sudden sensorineural hearing loss (ISSNHL). The data sources were literature review from 1946 to December 2014, PubMed and Medline. A systematic review of the existing literature was performed. Databases were searched for all human prospective randomized clinical trials using ITSI in at least one treatment group. The authors identified 29 prospective randomized clinical trials investigating the benefits of an intratympanic delivery of steroids. Six articles on Ménière's disease were identified, of which one favored ITSI over placebo in vertigo control. Of the five randomized clinical trials on tinnitus therapy, one study found better tinnitus control with ITSI. The only available trial on NIHL showed significant hearing recovery with combination therapy (ITSI and oral steroids therapy). Seventeen studies were identified on ISSNHL, of which 10 investigated ITSI as a first-line therapy and 7 as a salvage therapy. Studies analysis found benefits in hearing recovery in both settings. Due to heterogeneity in treatment protocols and follow-up, a meta-analysis was not performed. Given the low adverse effects rates of ITSI therapy and good patient tolerability, local delivery should be considered as an interesting adjunct to the therapy of the ISSNHL and NIHL. Only one article over six where ITSI therapy offers potential benefits to patients with Ménière's disease in the control of tinnitus and vertigo was found. ITSI does not seem to be effective in the treatment of tinnitus.

Cervical epidural steroid injection for refractory somatic tinnitus

Somatic tinnitus is a common disorder, yet few treatments described in the literature have demonstrated strong efficacy. We report a case of a 61-year-old male with refractory somatic tinnitus, temporally related to a prior bacterial otitis media, wherein auditory symptoms were successfully treated with cervical epidural injections of long-acting corticosteroid. We discuss the proposed mechanism of somatic tinnitus and the means by which neuraxial steroids may inhibit somatic tinnitus symptoms.

Clinical Practice Guideline

Objective

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. Despite the high prevalence of tinnitus and its potential significant effect on quality of life, there are no evidence-based, multidisciplinary clinical practice guidelines to assist clinicians with management. 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 nonphysicians, involved in managing patients with tinnitus. The target patient population is limited to adults (18 years and older) with primary tinnitus that is persistent and bothersome.

Purpose

The purpose of this guideline is to provide evidence-based recommendations for clinicians managing patients with tinnitus. This guideline provides clinicians with a logical framework to improve patient care and mitigate the personal and social effects of persistent, bothersome tinnitus. It will discuss the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the effect of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers.

Action Statements

The development group made a strong recommendation that clinicians distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus. The development group made a strong recommendation against obtaining imaging studies of the head and neck in patients with tinnitus, specifically to evaluate tinnitus that does not localize to 1 ear, is nonpulsatile, and is not associated with focal neurologic abnormalities or an asymmetric hearing loss. The panel made the following recommendations: Clinicians should (a) 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; (b) obtain a prompt, comprehensive audiologic examination in patients with tinnitus that is unilateral, persistent (≥ 6 months), or associated with hearing difficulties; (c) distinguish patients with bothersome tinnitus of recent onset from those with persistent symptoms (≥ 6 months) to prioritize intervention and facilitate discussions about natural history and follow-up care; (d) educate patients with persistent, bothersome tinnitus about management strategies; (e) recommend a hearing aid evaluation for patients who have persistent, bothersome tinnitus associated with documented hearing loss; and (f) recommend cognitive behavioral therapy to patients with persistent, bothersome tinnitus. The panel recommended against (a) antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for the routine treatment of patients with persistent, bothersome tinnitus; (b) Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating patients with persistent, bothersome tinnitus; and (c) transcranial magnetic stimulation for the routine treatment of patients with persistent, bothersome tinnitus. The development group provided the following options: Clinicians may (a) obtain an initial comprehensive audiologic examination in patients who present with tinnitus (regardless of laterality, duration, or perceived hearing status); and (b) recommend sound therapy to patients with persistent, bothersome tinnitus. The development group provided no recommendation regarding the effect of acupuncture in patients with persistent, bothersome tinnitus.