ALEXANDRIA, VA—The American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) Foundation has published an extensive, evidence-based clinical practice guideline to improve the diagnosis and management of tinnitus.
The guideline, the first of its kind, appears as a supplement to the October 2014 issue of the journal Otolaryngology–Head and Neck Surgery. Its stated purpose is “to provide evidence-based recommendations for clinicians managing patients with tinnitus. The target audience is any clinician, including non-physicians, involved in managing these patients.”
The guideline includes 13 “key action statements” for clinicians to follow in the evaluation and treatment of tinnitus, which it defines as “the perception of sound—often ringing—without an external sound source.”
Some of the action statements recommend against the use of some popularly promoted “treatments” for tinnitus that the panel found were not supported by sound scientific evidence. The guideline advises against:
• the use of ginkgo biloba, melatonin, zinc, and other dietary supplements;
• the routine prescription of antidepressants, anticonvulsants, anxiolytics, or intratympanic medications; and
• transcranial magnetic stimulation for the routine treatment of patients with persistent, bothersome tinnitus.
Tinnitus: A Major Health Issue
Sujana S. Chandrasekhar, MD, one of the 23 co-authors of the guideline, explained the pressing need for the publication: “Tinnitus affects 10%-15% of adults in the United States [and] is the most common service-related disability among our military veterans. Yet, despite its prevalence and effect on quality of life, prior to this there weren’t any evidence-based guidelines about managing tinnitus.”
The guideline was developed by a panel whose members included representatives from otolaryngology, geriatrics, primary-care medicine, nursing, psychiatry, behavioral neuroscience, neurology, radiology, audiology, and psychoacoustics, as well as tinnitus patients. The recommendations were made by experienced clinicians and methodologists, drawing on the best available scientific evidence.
Tinnitus Patients: Identifying When Intervention is Needed
Among the guideline’s key recommendations is Action Statement #4, which states, “Clinicians must distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus.” According to Chandrasekhar, “About 20% of adults who experience tinnitus require clinical intervention. The rest are experiencing non-bothersome tinnitus.”
The first few Action Statements advise clinicians on what to do upon first seeing a patient with tinnitus. Statement 1 calls for conducting “a targeted history and physical examination to identify conditions that if promptly identified and managed may relieve tinnitus.”
Statement 2 advises that clinicians “should” obtain “a prompt, comprehensive audiologic examination” in patients with “tinnitus that is unilateral, persistent (≥6 months), or associated with hearing difficulties.” In other cases of tinnitus, it says, “Clinicians may obtain an initial comprehensive audiologic examination.”
The AAO-HNS guideline strongly advises clinicians not to obtain imaging studies of the head and neck specifically to evaluate a patient’s tinnitus, unless the patient has one or more of the following: tinnitus that localizes to one ear, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss.
The guideline advises clinicians to “educate patients with persistent, bothersome tinnitus about management strategies” and to recommend cognitive-behavioral therapy to patients with persistent, bothersome tinnitus.
The publication takes a neutral position on the use of acupuncture for treating tinnitus. Citing a lack of evidence as to benefit or harm, Action Statement 12 says, “No recommendation can be made regarding the effect of acupuncture in patients with persistent bothersome tinnitus.”
No Substitute for Clinical Judgement
In concluding, the authors of the clinical practice guideline note that it is “provided for information and educational purposes only.” They caution that it “is not intended as a sole source of guidance in managing patients with tinnitus. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies.
They add, “The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition and may not provide the only appropriate approach to diagnosing and managing this program of care.”
The AAO-HNS Foundation is a non-profit, educational organization that works to advance the art, science, and ethical practice of otolaryngology-head and neck surgery through education, research, and lifelong learning. It is affiliated with but separate from the American Academy of Otolaryngology—Head and Neck Surgery.