title: Clinical practice guideline: tinnitus.
abstract: 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.
  
  
  OBJECTIVE
  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.
  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.
authors.affiliation: Otolaryngology-Head and Neck Surgery, Johns Hopkins Outpatient Center, Baltimore, Maryland, USA dtunkel@jhmi.edu.
authors.forename: David E
authors.initials: DE
authors.lastname: Tunkel
authors.affiliation: Division of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA.
authors.forename: Carol A
authors.initials: CA
authors.lastname: Bauer
authors.affiliation: Partnership for Health Analytic Research, LLC, Los Angeles, California, USA.
authors.forename: Gordon H
authors.initials: GH
authors.lastname: Sun
authors.affiliation: Department of Otolaryngology, State University of New York at Downstate Medical Center, Brooklyn, New York, USA.
authors.forename: Richard M
authors.initials: RM
authors.lastname: Rosenfeld
authors.affiliation: New York Otology, New York, New York, USA.
authors.forename: Sujana S
authors.initials: SS
authors.lastname: Chandrasekhar
authors.affiliation: Department of Research and Quality Improvement, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA.
authors.forename: Eugene R
authors.initials: ER
authors.lastname: Cunningham
authors.affiliation: Divisions of Rhinology & Sinus Surgery and Facial Plastic & Reconstructive Surgery, University of Kentucky, Lexington, Kentucky, USA.
authors.forename: Sanford M
authors.initials: SM
authors.lastname: Archer
authors.affiliation: Department of Otolaryngology, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Brian W
authors.initials: BW
authors.lastname: Blakley
authors.affiliation: Department of Otolaryngology, Tulane University, New Orleans, Louisiana, USA.
authors.forename: John M
authors.initials: JM
authors.lastname: Carter
authors.affiliation: Division of Geriatric Medicine and Aging, Columbia University, New York, New York, USA.
authors.forename: Evelyn C
authors.initials: EC
authors.lastname: Granieri
authors.affiliation: National Center for Rehabilitative Auditory Research, Portland VA Medical Center, Portland, Oregon, USA.
authors.forename: James A
authors.initials: JA
authors.lastname: Henry
authors.affiliation: ENT Specialists of Northern Virginia, Falls Church, Virginia, USA.
authors.forename: Deena
authors.initials: D
authors.lastname: Hollingsworth
authors.affiliation: Ochsner Health System, Kenner, Louisiana, USA.
authors.forename: Fawad A
authors.initials: FA
authors.lastname: Khan
authors.affiliation: Mitchell & Cavallo, P.C., Houston, Texas, USA.
authors.forename: Scott
authors.initials: S
authors.lastname: Mitchell
authors.affiliation: Department of Otology and Neurotology, The George Washington University, Washington, DC, USA.
authors.forename: Ashkan
authors.initials: A
authors.lastname: Monfared
authors.affiliation: Department of Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA.
authors.forename: Craig W
authors.initials: CW
authors.lastname: Newman
authors.affiliation: Morehouse School of Medicine, East Point, Georgia, USA.
authors.forename: Folashade S
authors.initials: FS
authors.lastname: Omole
authors.affiliation: Department of Head and Neck Imaging, Weill Cornell Medical Center, New York-Presbyterian Hospital, New York, New York, USA.
authors.forename: C Douglas
authors.initials: CD
authors.lastname: Phillips
authors.affiliation: Department of Psychiatry, University of California, San Diego, La Jolla, California, USA.
authors.forename: Shannon K
authors.initials: SK
authors.lastname: Robinson
authors.affiliation: Department of Medicine, UCLA Center for East-West Medicine, Los Angeles, California, USA.
authors.forename: Malcolm B
authors.initials: MB
authors.lastname: Taw
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, The University of Iowa, Iowa City, Iowa, USA.
authors.forename: Richard S
authors.initials: RS
authors.lastname: Tyler
authors.affiliation: Department of Surgery, University of Alabama School of Medicine, Birmingham, Alabama, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Waguespack
authors.affiliation: Consumers United for Evidence-Based Healthcare, Fredericton, New Brunswick, Canada.
authors.forename: Elizabeth J
authors.initials: EJ
authors.lastname: Whamond
mesh_terms: D000293:Adolescent; D000328:Adult; D006801:Humans; D017410:Practice Guidelines as Topic; D014012:Tinnitus / Q000175:diagnosis* / Q000628:therapy*; D055815:Young Adult
keywords: amplification; hearing aids; hearing loss; quality of life; sound therapy; tinnitus