Department of Defense and Department of Veterans Affairs New Clinical Practice Guidelines to Improve Care for Patients with Tinnitus

Story by Ken Cornwell

Defense Health Agency

The new clinical practice guidelines on the diagnosis and management of tinnitus from the Department of Veterans Affairs and Department of Defense will offer better care for patients, said LaGuinn Sherlock, a research audiologist for the Defense Centers for Public Health-Aberdeen.

The “VA/DOD Clinical Practice Guideline for Tinnitus” released in July, 2024, was based on published clinical evidence and current information intended to provide general guidance and improve patient outcomes.

“These new guidelines are important, because tinnitus doesn’t have a cure, and it can affect quality of life significantly,” said Sherlock.

Tinnitus is the perception of sound when no actual external noise is present. Tinnitus can be perceived as a ringing, buzzing, hissing, sizzling, roaring, chirping, or other sound in one ear, both ears, or in the head.

“It’s a sound in your ears or head when there’s no sound in the environment,” said Sherlock. “In the DOD and VA, we use the definition of tinnitus as a sound that occurs for at least five minutes, two times a week.”

Tinnitus is a common condition, according to the National Institute of Deafness and Other Communication Disorders, estimated to affect about 10 to 25% of adults. For many, tinnitus may improve or even go away over time—but in some cases, it can get worse. Tinnitus lasting for six months or longer is considered chronic.

Sherlock said tinnitus becomes a problem when it affects daily life.

“For about 20% of people who have tinnitus in the general population, it’s bothersome for them,” she said. “’Bothersome’ means they have trouble sleeping and concentrating. They may feel depressed or anxious.”

Additionally, tinnitus affects service members in greater numbers.

“Tinnitus is more likely to occur if you have noise exposure,” said Sherlock. “In the military, there are many patients exposed to loud sounds frequently—sometimes almost daily. Rates are also very high in the VA as well.”

In fact, the Veterans Benefits Administration said tinnitus was the most prevalent service-connected disability in the VBA for fiscal year 2023, affecting 2,944,093 veterans.

Other exposures may also put service members at risk, added Sherlock. “The military population has a higher probability of chemical exposure and head injuries leading to tinnitus.”

Highlights of the Tinnitus CPG

Most providers focus on audiology as the way to manage tinnitus, said Sherlock.

“In the CPG, there are audiology guidelines including the use of hearing aids for individuals with hearing loss and cochlear implants for people who meet candidacy criteria,” she said. “Sound therapy, which means adding sound to the environment so you’re not noticing tinnitus as much, is also recommended.”

The CPG also includes evidence to support several other ways to manage tinnitus. These include guidelines for psychologists.

“Cognitive behavioral therapy techniques can help, and we have recommendations in this guideline that pertain to psychologists,” Sherlock explained. “This is important because there aren’t a lot of psychologists aware that tinnitus can be managed using those techniques.”

Dentists and physical therapists may also play a role.

“Oral/facial massage therapy can help patients experiencing somatosensory tinnitus, a tinnitus that changes volume, pitch, or location—or the presence or absence of tinnitus when you move your jaw, neck, or head.”

The Role of Medication

Sherlock said, some providers may prescribe medication to treat tinnitus, which is not recommended.

“There are still a fair number of providers who prescribe pharmaceuticals for tinnitus management,” said Sherlock. “For example, the patient may be given Xanax by a primary care provider. But the work group determined the patient should not be getting medications for the primary treatment of their tinnitus. There is not sufficient evidence to show these medications improve overall quality of life, and they can be habit-forming.”

Guidelines for Primary Care Providers

Sherlock noted there are algorithms within the CPG to help providers determine how to manage the patient best. “When the patient arrives to primary care, what questions should the provider ask? What referrals are most appropriate depending on the patient’s symptoms?”

According to Sherlock, this guideline is especially important because, “it supports a multidisciplinary approach to managing tinnitus.

“It’s not just the audiologist. It’s not just the psychiatrist or psychologist. It’s a group of providers working together to best help the patient,” she said.

“While not every patient needs the multidisciplinary approach,” added Sherlock, “this just lets providers know the approach is available to them.”

Ultimately, the benefit of the tinnitus CPG is better outcomes for patients.

“There are few providers in general who understand how to answer questions about tinnitus and direct the patient to the right care path,” noted Sherlock.

“We needed to look at the latest evidence and give some guidance,” she continued. “Not just to audiologists and otolaryngologists but also to nurse practitioners, pharmacists, dentists, and primary care.”

In collaboration with the VHA, the Defense Health Agency CPG team updates, develops, and monitors clinical practice guidelines utilizing evidence-based practice. This partnership along with understanding and incorporating the needs of patients from both the military and veteran health care systems, leads to improved patient outcomes. The Tinnitus CPG is the 25th guideline produced from this collaboration. To learn more, visit the CPG web page.