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ent.tinnitus.core.v1

Chronic bothersome tinnitus (AAO-HNSF 2014 CPG — CBT first-line; AGAINST routine pharmacotherapy)

general_internal_medicinechronicsubacuteadultgeriatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as a CHRONIC outpatient engine for ADULT primary bothersome tinnitus per AAO-HNSF 2014 (Tunkel OHNS PMID 25273878). Two jobs: (A) screen out secondary / red-flag causes (vestibular schwannoma, vascular pulsatile, sudden SNHL, intracranial / vascular pathology) — recognise and route OUT; (B) run the evidence-based ladder — education + audiometry + hearing-aid trial + CBT first-line for chronic bothersome + sound therapy adjunct — AGAINST routine pharmacotherapy for primary tinnitus.

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primary-tinnitus scope confirmed; secondary / red-flag causes routed OUT by engine_id

Patient inputs (13)

Coexisting hearing loss (age-related presbycusis, noise-induced HL) is present in the majority of chronic tinnitus and is a treatment lever — hearing-aid trial is an AAO-HNSF 2014 recommendation when bothersome tinnitus + documented hearing loss (Tunkel PMID 25273878)

Aminoglycosides, loop diuretics, platinum chemo, high-dose salicylates / NSAIDs, quinine, macrolides — reversible (some) or permanent ototoxicity; identify and minimise or stop where clinically possible (Tunkel PMID 25273878)

Depression, anxiety, and insomnia are common comorbidities and drive bothersome burden; CBT addresses both tinnitus distress and comorbid mood / sleep (Cima Lancet 2012 PMID 22633033; Beukes Int J Audiol 2018 PMID 30295113)

Duration ≥6 months defines CHRONIC tinnitus per AAO-HNSF 2014; <6 months is RECENT-ONSET, which prioritises spontaneous-resolution counselling over treatment ladders (Tunkel OHNS PMID 25273878)

Unilateral persistent tinnitus is a RED FLAG for vestibular schwannoma / retrocochlear pathology — mandates MRI IAC (Tunkel OHNS 2014 PMID 25273878 — strong recommendation against routine imaging EXCEPT for unilateral / pulsatile / asymmetric SNHL / focal neuro)

Tinnitus Handicap Inventory (THI) or Tinnitus Functional Index (TFI) quantifies BOTHERSOME burden — AAO-HNSF 2014 strong recommendation to distinguish bothersome from non-bothersome and prioritise interventions (Tunkel PMID 25273878)

Comprehensive audiometric examination (pure-tone + speech) is the AAO-HNSF 2014 RECOMMENDATION for tinnitus that is unilateral, persistent ≥6 mo, or associated with hearing difficulties; the audiometric profile drives the hearing-aid decision and the imaging gate (Tunkel PMID 25273878)

Pulsatile or objective tinnitus is a vascular RED FLAG — MRA/MRV head + ENT/neuro-otology (dural AVF, glomus, venous sinus stenosis, dehiscent jugular bulb); subjective non-pulsatile tinnitus follows the primary ladder (Tunkel PMID 25273878)

Focal neurological signs, severe new headache, papilloedema, or new asymmetric SNHL → urgent imaging and specialist referral; do NOT treat as primary tinnitus (Tunkel PMID 25273878)

TMD, cervical / neck pain, somatosensory modulation (volume changes with jaw or neck movement) anchor the SOMATOSENSORY TINNITUS subtype — treat the somatosensory driver (PT, splint, TMD pathway) rather than the tinnitus itself (Tunkel PMID 25273878)

MRI internal auditory canals when tinnitus is unilateral with asymmetric SNHL, pulsatile, or with focal neuro signs — to exclude vestibular schwannoma, retrocochlear pathology, vascular cause; AAO-HNSF 2014 recommends AGAINST routine imaging when tinnitus is non-localising / non-pulsatile / no focal signs / no asymmetric SNHL (Tunkel PMID 25273878)

Occupational or recreational noise exposure is a modifiable driver of tinnitus and a key prevention message; hearing-protection counselling is part of every visit

Episodic vertigo + fluctuating low-mid SNHL + tinnitus + aural fullness → Meniere disease pathway (ent.meniere-disease.core.v1) rather than primary tinnitus

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningsudden_tinnitus_with_acute_hearing_loss
    Sudden onset tinnitus (≤72 h) with sudden severe sensorineural hearing loss — sudden SNHL is a time-critical otologic emergency with a steroid window of ~2 weeks (Tunkel PMID 25273878)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereunilateral_tinnitus_with_asymmetric_snhl_red_flag
    UNILATERAL persistent tinnitus with documented asymmetric sensorineural hearing loss — vestibular schwannoma until proven otherwise (AAO-HNSF 2014 Tunkel PMID 25273878 — strong recommendation against routine imaging EXCEPT this scenario)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepulsatile_or_objective_tinnitus_vascular_red_flag
    Pulsatile or objective tinnitus (heard by examiner with stethoscope) — vascular cause (dural AV fistula, glomus tumour, venous sinus stenosis, dehiscent jugular bulb, carotid stenosis) (Tunkel PMID 25273878)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_bothersome_with_suicidal_ideation
    Severe bothersome tinnitus (high THI / TFI) with comorbid severe depression and suicidal ideation — rare but documented
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateototoxic_medication_exposure_modifiable
    Ototoxic medication exposure during chronic-tinnitus course — aminoglycosides, loop diuretics, platinum chemotherapy, high-dose salicylates / NSAIDs, quinine, macrolides (Tunkel PMID 25273878)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildsomatosensory_tinnitus_subtype
    Tinnitus volume / character changes with jaw or neck movement — somatosensory tinnitus, often driven by TMD or cervical pathology (Tunkel PMID 25273878)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Chronic bothersome primary tinnitus — non-pharmacologic ladder (AAO-HNSF 2014 CPG); AGAINST routine pharmacotherapy
axis: chronic_tinnitus_nonpharm_ladder_against_routine_pharmacotherapystep 1 - Step 1 — Education + bothersome-vs-non-bothersome distinction (AAO-HNSF 2014 STRONG recommendation)
Selected step "Step 1 — Education + bothersome-vs-non-bothersome distinction (AAO-HNSF 2014 STRONG recommendation)" — All patients with chronic (≥6 mo) tinnitus on first presentation — STRONG recommendation foundation step (Tunkel OHNS PMID 25273878)
  • patient_education_natural_history_and_management_strategies
    first line
    patient_education
    triggers: chronic_tinnitus_initial_visit
    AAO-HNSF 2014 Tunkel (PMID 25273878) — STRONG recommendation to educate patients with persistent, bothersome tinnitus about management strategies; sets realistic expectations and reduces anxiety-driven amplification
  • distinguish_bothersome_from_non_bothersome_THI_TFI
    first line
    screening_decision_gate
    triggers: baseline_assessment
    AAO-HNSF 2014 Tunkel (PMID 25273878) — STRONG recommendation to distinguish bothersome from non-bothersome; only bothersome chronic tinnitus warrants intervention beyond reassurance

outpatient playbook — drug actions (1)

  1. 1. NONE — pharmacotherapy is AGAINST routine recommendation for primary tinnitus
    N/A • N/A • N/A
    trigger: Primary chronic bothersome tinnitus on all presentations
    AAO-HNSF 2014 Tunkel PMID 25273878 — STRONG recommendations AGAINST antidepressants, anticonvulsants, anxiolytics, intratympanic meds, Ginkgo, melatonin, zinc, supplements, and TMS for primary tinnitus

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Persistent subjective tinnitus ≥6 months (ringing, buzzing, hissing, roaring) — chronic-tinnitus entry per AAO-HNSF 2014 (Tunkel OHNS PMID 25273878); Tinnitus reported as bothersome — affecting concentration, sleep, mood, or quality of life; the AAO-HNSF 2014 management focus is the BOTHERSOME subset (Tunkel PMID 25273878); PULSATILE / objective tinnitus (heard by examiner) — mandates imaging (MRA/MRV) and ENT/neuro-otology referral; vascular causes (dural AVF, glomus tumour, venous sinus stenosis, dehiscent jugular bulb).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Chronic bothersome tinnitus (AAO-HNSF 2014 CPG — CBT first-line; AGAINST routine pharmacotherapy)** (ent.tinnitus.core.v1).
Phenotype framing: Terminal differential: primary (idiopathic) bothersome tinnitus (most common — typically bilateral + symmetric SNHL + non-pulsatile pivot) vs vestibular schwannoma (unilateral + asymmetric SNHL + MRI IAC pivot — route to neuro-otology) vs vascular pulsatile tinnitus (objective / pulsatile + MRA pivot — route ENT/neuro-otology) vs Meniere disease (episodic vertigo + fluctuating low/mid SNHL + aural fullness pivot — route to ent.meniere-disease.core.v1) vs ototoxicity (drug exposure + temporal pivot — discontinue offending agent) vs somatosensory tinnitus (jaw / neck modulation pivot — TMD / cervical PT pathway) vs sudden SNHL (sudden onset + audiometric documentation pivot — route to ent.sudden-sensorineural-hearing-loss.core.v1)
Scope: Frame as a CHRONIC outpatient engine for ADULT primary bothersome tinnitus per AAO-HNSF 2014 (Tunkel OHNS PMID 25273878). Two jobs: (A) screen out secondary / red-flag causes (vestibular schwannoma, vascular pulsatile, sudden SNHL, intracranial / vascular pathology) — recognise and route OUT; (B) run the evidence-based ladder — education + audiometry + hearing-aid trial + CBT first-line for chronic bothersome + sound therapy adjunct — AGAINST routine pharmacotherapy for primary tinnitus.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Chronic bothersome primary tinnitus — non-pharmacologic ladder (AAO-HNSF 2014 CPG); AGAINST routine pharmacotherapy** — step "Step 1 — Education + bothersome-vs-non-bothersome distinction (AAO-HNSF 2014 STRONG recommendation)".
1. patient_education_natural_history_and_management_strategies (patient_education, first line) — AAO-HNSF 2014 Tunkel (PMID 25273878) — STRONG recommendation to educate patients with persistent, bothersome tinnitus about management strategies; sets realistic expectations and reduces anxiety-driven amplification
2. distinguish_bothersome_from_non_bothersome_THI_TFI (screening_decision_gate, first line) — AAO-HNSF 2014 Tunkel (PMID 25273878) — STRONG recommendation to distinguish bothersome from non-bothersome; only bothersome chronic tinnitus warrants intervention beyond reassurance

Setting playbook (outpatient) — Diagnose primary vs secondary tinnitus, screen out red-flag mimics (vestibular schwannoma, vascular pulsatile, sudden SNHL), and run the AAO-HNSF 2014 evidence-based non-pharmacologic ladder (education + audiometry + hearing-aid trial + CBT + sound therapy) — AGAINST routine pharmacotherapy
3. NONE — pharmacotherapy is AGAINST routine recommendation for primary tinnitus N/A N/A N/A — Primary chronic bothersome tinnitus on all presentations (AAO-HNSF 2014 Tunkel PMID 25273878 — STRONG recommendations AGAINST antidepressants, anticonvulsants, anxiolytics, intratympanic meds, Ginkgo, melatonin, zinc, supplements, and TMS for primary tinnitus)

Non-pharmacologic actions:
- Step 1: educate + distinguish bothersome from non-bothersome (STRONG)
- Step 2: audiometric examination + hearing-aid trial if bothersome + hearing loss (RECOMMENDATION)
- Step 3: CBT in-person or audiologist-guided internet-CBT (RECOMMENDATION); sound therapy OPTION
- Step 4: bimodal stimulation (Lenire) emerging adjunct in refractory disease
- Step 5: treat comorbid depression / anxiety / insomnia on their own pathway (not for tinnitus per se)
- Hearing-protection counselling for ongoing noise exposure
- Re-screen ototoxin exposure at each visit

AVOID / contraindication checks:
- Do NOT prescribe antidepressants anticonvulsants anxiolytics melatonin Ginkgo zinc or supplements for primary tinnitus (AAO HNSF 2014 STRONG recommendations against — Tunkel OHNS PMID 25273878)
- Do NOT prescribe intratympanic medications for primary tinnitus (AAO HNSF 2014 STRONG recommendation against)
- Do NOT use transcranial magnetic stimulation as routine treatment for primary tinnitus (AAO HNSF 2014 STRONG recommendation against)
- Do NOT anchor on primary tinnitus when unilateral with asymmetric SNHL (MRI IAC mandatory — vestibular schwannoma)
- Do NOT anchor on primary tinnitus when pulsatile or objective (MRA/MRV head + ENT referral — vascular cause)
- Do NOT anchor on primary tinnitus when focal neuro or severe headache or papilloedema (urgent imaging)
- Sudden tinnitus with acute hearing loss is NOT primary tinnitus (route to ent.sudden sensorineural hearing loss.core.v1 within steroid window)
- Ototoxic medication review at every visit (aminoglycosides, loops, platinum, high dose ASA/NSAIDs, quinine, macrolides)
- Imaging NOT routine only for unilateral pulsatile asymmetric SNHL or focal neuro (AAO HNSF 2014 STRONG recommendation against routine imaging)

Monitoring

Regimen monitoring:
- THI or TFI at each visit drives step up or step down (Tunkel AAO-HNSF 2014 PMID 25273878)
- hearing aid acoustic adherence and benefit if amplification started
- CBT engagement module completion and clinical response at 3 6 12 months (Cima Lancet 2012 PMID 22633033 — peak benefit at 8-12 months)
- comorbid mood anxiety sleep screening at each visit
- ototoxic medication exposure review at each visit
- hearing protection adherence for ongoing noise exposure

Setting (outpatient) monitoring:
- THI / TFI trend at each visit
- Hearing-aid acoustic benefit + adherence; CBT module completion + benefit
- Comorbid mood / anxiety / sleep at each visit
- Return precautions: new asymmetric hearing loss, new pulsatility, new focal neuro, severe depression / suicidal ideation

Follow-up plan: Longitudinal chronic-disease arc: 3-6 monthly stable; sooner for sleep / mood / suicidal-ideation flares. Maintain hearing protection (concert/work). Reassess audiometry annually if hearing loss; sooner if change. Re-screen for ototoxic medication updates at every visit (DM aminoglycosides, oncology platinum, vancomycin courses). Re-counsel that AAO-HNSF 2014 is AGAINST routine pharmacotherapy — many patients will be offered gabapentin / sertraline by other clinicians and ask for it; reinforce evidence
- Close-out criterion: structured longitudinal + hearing-protection + ototoxin re-screen + pharmacotherapy-counter-counselling completed

Monitoring phase: Track at each 3-6-month visit: THI / TFI trend, hearing-aid acoustic adherence + benefit, CBT engagement and module completion, sleep / mood comorbidity, ototoxin exposure changes, hearing-protection adherence. Long-term improvement is gradual — counsel realistic expectations (Cima Lancet 2012 PMID 22633033 — Cohen d ~0.45 for tinnitus impairment at 12 months).

Disposition

Current setting: outpatient — Diagnose primary vs secondary tinnitus, screen out red-flag mimics (vestibular schwannoma, vascular pulsatile, sudden SNHL), and run the AAO-HNSF 2014 evidence-based non-pharmacologic ladder (education + audiometry + hearing-aid trial + CBT + sound therapy) — AGAINST routine pharmacotherapy

Disposition criteria:
- Stable bothersome chronic tinnitus on ladder → continued outpatient longitudinal management
- Red-flag mimic → specialist referral / imaging route OUT

Escalation triggers (move to higher acuity):
- New unilateral or asymmetric SNHL → MRI IAC + neuro-otology referral
- New pulsatile / objective tinnitus → MRA/MRV head + ENT referral
- Sudden severe hearing loss → ent.sudden-sensorineural-hearing-loss.core.v1 within steroid window
- Focal neuro / severe headache / papilloedema → urgent neurology / neurosurg
- Severe psychiatric distress, suicidal ideation → urgent mental-health referral

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Sudden onset tinnitus (≤72 h) with sudden severe sensorineural hearing loss — sudden SNHL is a time-critical otologic emergency with a steroid window of ~2 weeks (Tunkel PMID 25273878)
- [SEVERE] UNILATERAL persistent tinnitus with documented asymmetric sensorineural hearing loss — vestibular schwannoma until proven otherwise (AAO-HNSF 2014 Tunkel PMID 25273878 — strong recommendation against routine imaging EXCEPT this scenario)
- [SEVERE] Pulsatile or objective tinnitus (heard by examiner with stethoscope) — vascular cause (dural AV fistula, glomus tumour, venous sinus stenosis, dehiscent jugular bulb, carotid stenosis) (Tunkel PMID 25273878)

Citations

- AAO-HNSF Clinical Practice Guideline: Tinnitus — Tunkel et al, Otolaryngol Head Neck Surg 2014 (PMID 25273878 full; PMID 25274374 Executive Summary). Current US authority; no 2021-2026 society replacement at the time of authoring. CBT evidence: Cima et al, Lancet 2012 (PMID 22633033). Internet-CBT: Beukes et al, Int J Audiol 2018 (PMID 30295113). Bimodal stimulation emerging: Conlon et al, Sci Transl Med 2020 (PMID 33028707). All PMIDs live-PubMed-verified 2026-05-26. [PMID:25273878](https://pubmed.ncbi.nlm.nih.gov/25273878/)
- Cited evidence (PMID 25274374) [PMID:25274374](https://pubmed.ncbi.nlm.nih.gov/25274374/)
- Cited evidence (PMID 22633033) [PMID:22633033](https://pubmed.ncbi.nlm.nih.gov/22633033/)
- Cited evidence (PMID 30295113) [PMID:30295113](https://pubmed.ncbi.nlm.nih.gov/30295113/)
- Cited evidence (PMID 33028707) [PMID:33028707](https://pubmed.ncbi.nlm.nih.gov/33028707/)

Last reconciled with current guidelines: 2026-05-26.
References
  • AAO-HNSF Clinical Practice Guideline: Tinnitus — Tunkel et al, Otolaryngol Head Neck Surg 2014 (PMID 25273878 full; PMID 25274374 Executive Summary). Current US authority; no 2021-2026 society replacement at the time of authoring. CBT evidence: Cima et al, Lancet 2012 (PMID 22633033). Internet-CBT: Beukes et al, Int J Audiol 2018 (PMID 30295113). Bimodal stimulation emerging: Conlon et al, Sci Transl Med 2020 (PMID 33028707). All PMIDs live-PubMed-verified 2026-05-26. — PMID:25273878
  • Cited evidence (PMID 25274374) — PMID:25274374
  • Cited evidence (PMID 22633033) — PMID:22633033
  • Cited evidence (PMID 30295113) — PMID:30295113
  • Cited evidence (PMID 33028707) — PMID:33028707