Clinical Practice Guideline: Tinnitus Update

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. 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. PURPOSE: The purpose of this guideline is to provide and update 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 discusses the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It then focuses on the treatment of patients with persistent tinnitus, with recommendations to guide the measurement of the effect of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for people with tinnitus and associated comorbidities. METHODS: This guideline was developed using the 55-page protocol published as the American Academy of Otolaryngology-Head and Neck Surgery Foundation's Clinical Practice Guideline Development Manual (3rd edition), which summarizes the methodology for assessments of current data, topic prioritization, development of key action statements (KASs), application of value judgments, and related procedures. The guideline group was represented by adult otolaryngologists, audiologists, otologists/neurotologists, a geriatrician, a behavioral neuroscientist, a neurologist, a radiologist, a psychiatrist, an internist, a nurse practitioner, an otolaryngology resident physician, and a consumer advocate who represented participating, national professional organizations. ACTION STATEMENTS: The Guideline Update Group made strong recommendations for the following Key Action Statements (KAS): Clinicians should distinguish patients with bothersome tinnitus from patients with non-bothersome 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).