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 evidence-based intervention that improves quality of life. 1

Diagnostic Approach Before Treatment

Before initiating treatment, a proper diagnostic evaluation should include:

1. Audiologic Evaluation

   • Comprehensive audiologic testing including pure tone audiometry, speech audiometry, tympanometry, acoustic reflex testing, and otoacoustic emissions 1
   • Essential for distinguishing between different types of tinnitus and guiding treatment

2. Imaging (only when indicated)

   • Not routinely recommended unless there are specific red flags 1, 2
   • Indications for imaging:
     • Unilateral tinnitus
     • Pulsatile tinnitus (CT/MR angiography)
     • Focal neurological abnormalities (MRI brain with contrast)
     • Asymmetric hearing loss (MRI with contrast of internal auditory canals)

Evidence-Based Treatment Options

First-Line Treatments

1. Cognitive Behavioral Therapy (CBT)

   • Most effective evidence-based treatment for persistent tinnitus 1
   • Improves quality of life and helps patients develop coping strategies
   • Should be initiated early in management

2. Sound Therapy

   • Recommended for persistent, bothersome tinnitus 1
   • Options include:
     • White noise machines
     • Environmental sound generators
     • Smartphone apps
     • Tabletop sound machines

3. Hearing Aids

   • Recommended for patients with hearing loss-associated tinnitus 1
   • Beneficial even with mild or unilateral hearing loss
   • Mechanism: amplifies external sounds, reduces auditory deprivation, decreases listening effort

Supportive Treatments

1. Counseling

   • Should begin during initial evaluation 3
   • Helps patients understand tinnitus and develop coping strategies
   • Improves chances of successful subsequent treatment

2. Mental Health Support

   • Depression and anxiety screening recommended 1
   • Suicide risk assessment for patients with severe psychological distress

Treatments to Avoid

Clinicians should not routinely recommend:

• Antidepressants
• Anticonvulsants
• Anxiolytics
• Intratympanic medications
• Dietary supplements

These lack evidence of benefit and may cause side effects 1

Treatment Algorithm

1. Initial Assessment:

   • Complete audiologic evaluation
   • Determine if imaging is needed based on specific indicators
   • Screen for depression/anxiety

2. First-Line Management:

   • Start CBT for persistent, bothersome tinnitus
   • Implement sound therapy
   • Prescribe hearing aids if hearing loss is present

3. Follow-up:

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

Common Pitfalls to Avoid

• Ordering unnecessary imaging for bilateral, non-pulsatile tinnitus without other concerning features 1
• Delaying audiologic evaluation in patients with unilateral tinnitus 1
• Using medications without strong evidence of benefit 1
• Failing to address psychological aspects of tinnitus 1, 4
• Overlooking the need for hearing aids in patients with even mild hearing loss 1

Special Considerations

• Tinnitus can be a lifelong disorder causing significant distress, including anxiety, depression, insomnia, and concentration difficulties 4
• Approximately 20% of sufferers will require clinical intervention 4
• While many treatments are available, CBT has the strongest evidence base for improving quality of life 1, 2