What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) is the most effective treatment for tinnitus management and should be recommended as first-line therapy for persistent, bothersome tinnitus. 1

Diagnostic Approach

Before initiating treatment, a proper evaluation is essential to identify potentially treatable causes:

• Perform targeted history and physical examination focusing on:

  • Otologic factors (hearing loss, cerumen impaction)
  • Vascular abnormalities (pulsatile tinnitus)
  • Neurologic factors
  • Medication review (ototoxic drugs)
  • Dental and psychological factors 1

• Comprehensive audiologic examination is necessary for:

  • Unilateral tinnitus
  • Persistent tinnitus (≥6 months)
  • Tinnitus with hearing difficulties 1, 2

• Imaging is NOT recommended for tinnitus that is:

  • Bilateral
  • Non-pulsatile
  • Without focal neurological abnormalities
  • Without asymmetric hearing loss 1

Evidence-Based Treatment Options

First-Line Treatments

1. Cognitive Behavioral Therapy (CBT)

   • Has the strongest evidence base among all interventions 1, 2
   • Acceptance and Commitment Therapy (ACT) appears particularly effective among CBT variations 1
   • Focuses on accepting tinnitus while pursuing valued life activities
   • Only treatment shown to improve quality of life in tinnitus patients 2

2. Sound Therapy

   • May provide relief from tinnitus-associated stress or passive distraction 1, 3
   • Can be used with three objectives:
     • Producing relief from tinnitus-associated stress (soothing sound)
     • Passively diverting attention (background sound)
     • Actively diverting attention (interesting sound) 3
   • Evidence is less robust than for CBT 1

3. Hearing Aids

   • Recommended for patients with hearing loss and persistent tinnitus 1
   • Improve auditory input and reduce contrast between tinnitus and background sound 1

Treatments to Avoid

The following treatments are NOT recommended for routine management of persistent tinnitus:

• Antidepressants
• Anticonvulsants
• Anxiolytics (except in acute phase)
• Intratympanic medications (except in acute phase)
• Ginkgo biloba, melatonin, zinc, or other dietary supplements 1, 4
• Transcranial magnetic stimulation 4

Management Algorithm

1. For Acute Tinnitus (< 6 months):

   • Address underlying cause if identified (cerumen removal, treating middle ear disorders)
   • Education and counseling about tinnitus mechanisms
   • Consider short-term anxiolytics if severe distress present 1

2. For Chronic Tinnitus (≥ 6 months):

   • Initiate CBT as first-line treatment 1, 2
   • Add sound therapy as adjunctive treatment 1, 3
   • Evaluate for hearing aids if hearing loss is present 1
   • Provide education and counseling about management strategies 1

Clinical Pitfalls to Avoid

• Failing to distinguish between bothersome and non-bothersome tinnitus 4
• Neglecting to address hearing loss that often accompanies tinnitus 1
• Overlooking psychological aspects of tinnitus management 1
• Ordering unnecessary imaging studies for typical bilateral, non-pulsatile tinnitus 1, 4
• Using unproven dietary supplements or medications that lack evidence 1, 4

Despite the variety of treatment options available, it's important to note that success rates remain suboptimal, leading to frustration for both patients and clinicians 5. The heterogeneous nature of tinnitus means that no single mechanism explains all cases, and therefore no standardized management pathway exists 6, 5. This underscores the importance of using evidence-based approaches like CBT while continuing to tailor treatments to individual presentations.