What are the treatment options for tinnitus (ringing in the ears)?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) is the strongest evidence-based treatment for persistent, bothersome tinnitus and should be recommended as first-line therapy for all patients with persistent, bothersome tinnitus. 1

Initial Evaluation

Before initiating treatment, a proper diagnostic workup is essential:

1. Comprehensive audiologic evaluation including:

   • Pure tone audiometry
   • Speech audiometry
   • Tympanometry 1

2. Imaging studies based on specific presentations:

   • MRI of internal auditory canal for unilateral tinnitus with asymmetric hearing loss
   • CT or MR angiography for pulsatile tinnitus
   • MRI brain with contrast for focal neurological findings 1

3. Physical examination including:

   • Otoscopic examination to check for cerumen impaction, middle ear fluid, or tympanic membrane perforation
   • Tuning fork tests (Weber and Rinne) to differentiate between conductive and sensorineural hearing loss 1

Treatment Algorithm

First-Line Treatments

1. Education and Counseling

   • Explain the natural history of tinnitus
   • Provide coping strategies
   • Discuss management options 1

2. Cognitive Behavioral Therapy (CBT)

   • Most effective evidence-based treatment
   • Improves quality of life and coping strategies
   • Should be recommended for all patients with persistent, bothersome tinnitus 1

3. Sound Therapy

   • White noise machines
   • Smartphone apps
   • Environmental sound enrichment 1

4. Hearing Aids (for patients with hearing loss)

   • Improves tinnitus by amplifying external sounds
   • Reduces auditory deprivation 1

Second-Line Treatments

1. Tinnitus Retraining Therapy (TRT)

   • Combines counseling with sound therapy
   • Evidence is less conclusive than for CBT 2

2. Supportive Therapies for Associated Symptoms

   • Melatonin for sleep disturbance
   • Antidepressants for mood disorders
   • Cognitive training for cognitive impairments 2

Special Considerations

Pulsatile Tinnitus

• Requires vascular imaging (CT angiography or MR angiography)
• May indicate underlying vascular abnormalities 1

Unilateral Tinnitus

• Requires MRI with contrast of internal auditory canals
• Important to rule out vestibular schwannoma 1

Acute Tinnitus

• Treated similarly to sudden hearing loss
• Requires prompt evaluation 3

Common Pitfalls to Avoid

1. Failing to remove cerumen before assessment 1
2. Overlooking non-otologic causes 1
3. Not performing comprehensive audiologic evaluation for unilateral or persistent tinnitus 1
4. Using unproven medications or supplements without sufficient evidence 1
5. Ordering unnecessary imaging for non-concerning tinnitus presentations 1
6. Prolonged use of vestibular suppressants which can delay central compensation 1

Follow-up Recommendations

• Document resolution, improvement, or worsening of symptoms
• Schedule follow-up within 4-6 weeks to assess response to initial management
• Consider referral to specialized tinnitus/hyperacusis clinic for persistent or worsening symptoms 1

Prevention

• Noise exposure avoidance may help prevent development or progression of tinnitus 2
• Hearing protection in loud environments is recommended

Remember that tinnitus is a symptom, not a disease, and management should focus on identifying and addressing the underlying cause when possible, while providing effective strategies to improve quality of life when the cause cannot be treated directly.