Many modern antineoplastic drugs are ototoxic including bleomycin, cis-platinum, methotrexate, and bumetanide. These cause hearing loss and tinnitus that may not be reversible.

• Ethacrynic acid, acetazolamide, are diuretics listed as ototoxic
• Aspirin in higher doses causes tinnitus. Fortunately, this is reversible. Tinnitus has been reported with other NSAID medications.

Caution must be exercised in evaluating tinnitus from a new drug because of the very high incidence of tinnitus in the population. In a double-blind study, tinnitus may be reported as occurring in the placebo group. When anti-neoplastic drugs are used, regular hearing tests are done to watch for the onset of hearing loss or tinnitus so that the drug can be stopped if possible.

The symptoms of tinnitus include ringing, buzzing, roaring, hissing, or whistling in the ears. The noise may be intermittent or continuous. Most of the time, only the person who has tinnitus can hear it.

A physical exam should focus on the ear and the nervous system. The ear canal should be inspected for discharge, foreign body, and cerumen. The tympanic membrane should be inspected for signs of infection and tumor (red or bluish mass). A bedside hearing test should be done. Cranial nerves, particularly vestibular function, are tested along with peripheral strength, sensation, and reflexes. A stethoscope should be used to listen for vascular noise over the course of the carotid arteries and jugular veins and over and adjacent to the ear.

X-rays and MRI are not usually done for tinnitus unless there is an unexplained difference in hearing and balance in the ears.

An audiogram is a hearing test measuring hearing levels to determine hearing loss. The patient is asked to match which of the tones matches their tinnitus. The audiologist introduces that sound as to volume, and the patient estimates how loud they hear their tinnitus. Hearing via the bone of the ear is tested and compared with the hearing via the earphone called an air-bone test. If the patient hears better with the bone test, this suggests a condition called otosclerosis which is treatable. Patients with otosclerosis, in whom the stapes fail to move well, can have surgery that corrects the otosclerosis and restores air conduction. In some patients, the tinnitus is relieved. In others, tinnitus remains or becomes worse.

The audiologist measures how long tinnitus is relieved by masking tone. The longer the tinnitus is inhibited, the better the prognosis.[8][9][10]

The American Academy of Otolaryngology has issued clinical practice guidelines for tinnitus. These include:

• Stress Reduction: This includes using biofeedback, measured breathing, etc. Although stress itself is not a cause of tinnitus, as in any condition, stress and anxiety can make the condition worse.   
• Cognitive Therapy: The more the patient understands what tinnitus is and is not the less negative effect. Once the patient fully cognizes - understands that tinnitus is similar to itching, the symptoms are reduced. 
• Masking: When the body hears the same sound from the cell phone or sound device, this reduces the symptoms.  There are various forms of masking. Essentially these masking sounds take the attention away from the internal tinnitus sound and replace it with relaxing sounds.

1. Introduction of the same sound
2. Introduction of an altered sound
3. Music with the tinnitus sound removed
4. White noise or pleasant sounds

• Sleep improvement: Tinnitus can affect normal sleep and therapy should be directed to better sleep hygiene.

The official guidelines stress that no medication cures tinnitus. However various combinations of magnesium, alpha-lipoic acid, N-acetyl cysteine, and others have been tested for protection of hearing from noise. When these are effective, it is difficult to differentiate from the placebo effect or from the impact of having a program where the patient feels they are in charge bringing the brain into the healing process.

Recently beneficial results have been reported using deep brain stimulation. In theory, this alters unwanted neural circuits.

Primary to management is that tinnitus patients must never be told to live with it. Emphasis should be on reducing stress and given a program to follow. Tinnitus Retraining Therapy and Neuronomics are common programs used in therapy by individuals trained in their application. In Tinnitus Retraining the patient adapts to hearing the tinnitus; in Neuronomics the patient learns to ignore the tinnitus. 

A hearing aid is always of benefit when tinnitus is associated with hearing loss. Some aids come with built-in soothing or masking sounds. Success is variable.

Medication such as alprazolam can reduce symptoms, but can have adverse effects including habituation.

Anti-depressants may be indicated for patients who do not respond to protocol therapy.[11][12]

• Cytomegalovirus

• Hypercholesterolemia

• Lyme disease

• Measles

• Meningitis

• Neoplasm

• Neurosyphilis

• Rubella

• Sickle cell anaemia

• Small vessel disease

• Stroke

• Tumour

The diagnosis and management of tinnitus is made with an interprofessional team that consists of a primary care provider, nurse practitioner, ENT surgeon, audiologist and an internist. The treatment of tinnitus should follow guidelines established by the American Academy of Otolaryngology.  At the same time, the patient should be educated on the benefits of sleep hygiene. At present, there is no medication that can cure tinnitus. Various supplements have been tested but their efficacy remains in dispute. In the last decade, deep brain stimulation has been recommended but the treatment is not only invasive and costly it also has the potential to cause complications which may be worse than the tinnitus.

Patients should be encouraged to lower stress and some may benefit from a hearing aid, that may mask other sounds. Tricyclic antidepressants are sometimes used but these drugs also have many adverse effects, which may not be well tolerated. Overall, patients with tinnitus have a poor quality of life. [13][14](Level V)