What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive behavioral therapy (CBT) is strongly recommended as the first-line treatment for persistent, bothersome tinnitus as it is the most effective evidence-based intervention that improves quality of life. 1

Initial Evaluation and Workup

• A comprehensive audiologic examination should be performed within 4 weeks of presentation for all patients with tinnitus, regardless of laterality, duration, or perceived hearing status 1
• Assessment should include:
  • Tinnitus characteristics (laterality, duration, quality, timing, severity)
  • Associated symptoms (hearing loss, vertigo, aural fullness)
  • Audiologic testing (pure tone audiometry, speech audiometry, tympanometry, acoustic reflexes) 1

Imaging Considerations

• Imaging is NOT recommended for routine tinnitus evaluation unless one or more of the following are present:

  • Unilateral tinnitus
  • Pulsatile tinnitus
  • Focal neurological abnormalities
  • Asymmetric hearing loss 1

• When indicated, appropriate imaging includes:

  • Pulsatile tinnitus: CT angiography or MR angiography
  • Unilateral tinnitus with asymmetric hearing loss: MRI with contrast of internal auditory canals
  • Focal neurological findings: MRI brain with contrast 1

Treatment Algorithm

First-Line Treatments

1. Cognitive Behavioral Therapy (CBT)

   • Most effective evidence-based treatment for persistent tinnitus 1, 2
   • Improves quality of life and helps patients develop coping strategies

2. Sound Therapy

   • Options include white noise machines, environmental sound generators, smartphone apps, and tabletop sound machines 1
   • Helps mask the tinnitus and reduce its perception

3. Hearing Aids

   • Recommended for patients with hearing loss-associated tinnitus, even if hearing loss is mild or unilateral 1
   • Benefits include:
     • Amplification of external sounds
     • Reduction of auditory deprivation
     • Decreased listening effort

Psychological Support

• Screen for depression, anxiety, and suicide risk in patients with severe psychological distress 1
• Prompt identification and intervention are essential due to increased suicide risk in tinnitus patients 1
• Supportive counseling should begin during initial evaluation to help patients cope 3

Treatments to Avoid

• Clinicians should NOT routinely recommend:
  • Antidepressants
  • Anticonvulsants
  • Anxiolytics
  • Intratympanic medications
  • Dietary supplements 1

These medications lack evidence of benefit and may cause potential side effects.

Follow-up and Referral

• Schedule follow-up within 4-6 weeks to assess response to initial management 1
• If symptoms persist or worsen, consider referral to a specialized tinnitus/hyperacusis clinic 1

Common Pitfalls to Avoid

1. Ordering unnecessary imaging for bilateral, non-pulsatile tinnitus without asymmetric hearing loss 1
2. Delaying audiologic evaluation, especially in patients with unilateral tinnitus 1
3. Ordering imaging before completing audiometric testing 1
4. Telling patients "nothing can be done" - this is inappropriate as multiple management strategies exist 1, 4
5. Using medications with potential side effects without strong evidence of benefit 1

Special Considerations

• Tinnitus retraining therapy is an option, but evidence remains inconclusive 2
• Melatonin may help with sleep disturbance associated with tinnitus 2
• For acute tinnitus, treatment approaches similar to sudden hearing loss may be considered 5
• Underlying causes such as Meniere's disease, vestibular schwannoma, or vascular abnormalities must be identified and treated when present 4