From the Guidelines
Tinnitus is a symptom that can be managed with a combination of diagnostic testing, treatment, and supportive care, with the goal of improving quality of life by reducing awareness of the sound and its impact on daily functioning. The causes of tinnitus are varied and can include hearing loss, exposure to loud noise, ear infections, earwax blockage, medications, head or neck injuries, blood vessel disorders, and age-related changes 1.
Diagnostic Testing
Diagnostic testing for tinnitus typically begins with a comprehensive medical history and physical examination, followed by hearing tests including audiometry to assess hearing loss 1. Additional tests may include imaging studies like MRI or CT scans to rule out structural abnormalities, blood tests to check for underlying conditions, and movement tests to evaluate how tinnitus responds to certain head or eye movements. The American Academy of Otolaryngology and Head and Neck Surgery Foundation (AAO-HNS) guidelines recommend targeted history and clinical examination as the initial evaluation and determination as to whether the tinnitus is bothersome or not, before any imaging 1.
Treatment Options
Treatment options for tinnitus vary based on the underlying cause. If a specific cause is identified, addressing it may resolve tinnitus. For persistent tinnitus, sound therapy using white noise machines or hearing aids can help mask the sound 1. Cognitive behavioral therapy (CBT) is recommended for patients with persistent, bothersome tinnitus, as it can help patients manage their reaction to tinnitus 1. Medications like antidepressants, anti-anxiety drugs, or steroids may help in some cases, though no drug specifically treats tinnitus.
Supportive Care
Supportive care for tinnitus includes avoiding triggers like loud noises, reducing stress through relaxation techniques, limiting caffeine and alcohol consumption, and joining support groups to connect with others experiencing similar challenges. The AAO-HNS guidelines also suggest that some patients with severe anxiety, depression, or psychological disturbances may need prompt identification and intervention 1.
Key Recommendations
- Clinicians should perform a targeted history and physical examination at the initial evaluation of a patient with presumed primary tinnitus 1.
- Imaging studies of the head and neck should not be obtained in patients with tinnitus, unless they have 1 or more of the following: tinnitus that localizes to 1 ear, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss 1.
- CBT should be recommended to patients with persistent, bothersome tinnitus 1.
From the FDA Drug Label
ADVERSE REACTIONS Adverse reactions, occurring most often early in therapy, include ... hearing dysfunction or tinnitus... The FDA drug label does not answer the question.
From the Research
Causes of Tinnitus
- Tinnitus is a common hearing disorder with wide-ranging risk factors, including age, hearing loss, noise exposure, inflammatory diseases or tumors of the ear, ototoxic drugs, head or cervical vertebra trauma, and psychological disorders (e.g., anxiety and depression) 2
- Sensorineural hearing loss is the most common identified cause of tinnitus 3, 4
- Other causes of tinnitus include otologic, vascular, neoplastic, neurologic, pharmacologic, dental, and psychological factors 4
- Tinnitus can be subjective (audible only by the patient) or objective (audible to the examiner), with subjective tinnitus being more common 5
Diagnostic Testing
- Diagnosis of tinnitus mainly relies on subjective assessments and self-reports, such as case history, audiometric tests, detailed tinnitus inquiry, tinnitus matching, and neuropsychological assessment 2
- A standard workup for tinnitus includes a targeted history and physical examination to identify treatable causes and associated symptoms 3
- A comprehensive audiologic evaluation should be performed for patients who experience unilateral tinnitus, tinnitus that has been present for six months or longer, or that is accompanied by hearing problems 3
- Neuroimaging is not part of the standard workup unless the tinnitus is asymmetric or unilateral, pulsatile, associated with focal neurologic abnormalities, or associated with asymmetric hearing loss 3
Treatment Options
- Counseling, psychotherapy, pharmacological approaches, masking devices, individualized sound stimulation, and cognitive behavioral therapy (CBT) are the most widely used strategies for treating tinnitus 2
- CBT is the only treatment that has been shown to have a definite improvement effect on tinnitus in a large randomized controlled trial 2
- Sound therapy and tinnitus retraining therapy are treatment options, but evidence is inconclusive 3
- Melatonin, antidepressants, and cognitive training may help with sleep disturbance, mood disorders, and cognitive impairments, respectively 3
Supportive Care
- Supportive counseling should begin during the initial evaluation to help patients cope with tinnitus 4
- Counseling may also improve the chances of successful subsequent treatment 4
- Providing information about the natural progression of tinnitus and being familiar with the causes that warrant additional evaluation, imaging, and specialist involvement are essential to comprehensive care 3
- Avoidance of noise exposure may help prevent the development or progression of tinnitus 3