From the Guidelines
Tinnitus diagnosis and treatment should prioritize a targeted history and clinical examination, followed by a comprehensive audiological examination, and potentially cognitive behavioral therapy (CBT) and sound therapy to manage symptoms and improve quality of life. According to the most recent guidelines 1, the initial evaluation of patients with tinnitus should focus on determining whether the tinnitus is bothersome or not, and whether it is pulsatile or nonpulsatile, to guide further imaging and treatment.
Diagnosis
The diagnosis of tinnitus involves classifying it as primary or secondary, subjective or objective, and pulsatile or nonpulsatile 1. Primary tinnitus is idiopathic, whereas secondary tinnitus is associated with an underlying cause. Subjective tinnitus is perceived by the patient only and comprises 70% to 80% of cases, while objective tinnitus can be detected on examination by the clinician.
Treatment
For treatment, sound therapy using white noise machines, fans, or smartphone apps can help mask tinnitus sounds, especially at night. CBT can also help reduce the distress associated with tinnitus 1. Additionally, antidepressants like amitriptyline (10-50 mg at bedtime) or nortriptyline may be considered if tinnitus is causing significant distress or sleep problems. It is essential to avoid potential triggers such as loud noise exposure, excessive caffeine, alcohol, and aspirin or NSAIDs in high doses. Hearing aids can be beneficial if tinnitus is accompanied by hearing loss. Tinnitus retraining therapy, which combines sound therapy with educational counseling, may help the brain habituate to the tinnitus sounds over time.
Management Strategies
The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) guidelines recommend educating patients with persistent, bothersome tinnitus about management strategies, including the value of education and counseling 1. The underlying mechanism of tinnitus often involves damage to the inner ear's hair cells, leading to abnormal neural activity interpreted by the brain as sound. While tinnitus is rarely curable, these management strategies can significantly reduce its impact on quality of life.
Key considerations in managing tinnitus include:
- Identifying and addressing underlying causes or associated conditions
- Providing patient education and counseling on management strategies
- Utilizing sound therapy and CBT to reduce symptoms and distress
- Avoiding potential triggers and exacerbating factors
- Considering the use of hearing aids if accompanied by hearing loss
- Potentially using antidepressants for significant distress or sleep problems under the guidance of a healthcare professional.
From the Research
Diagnosis of Tinnitus
- Tinnitus is defined as the perception of noise in the absence of an acoustic stimulus outside of the body 2
- The underlying cause of tinnitus must be determined to best help patients, as it is a symptom and not a disease 2
- Common causes of tinnitus include sensorineural hearing loss, otologic, vascular, neoplastic, neurologic, pharmacologic, dental, and psychological factors 2, 3
- A standard workup for tinnitus begins with a targeted history and physical examination to identify treatable causes and associated symptoms 3
- Audiometry with tympanometry should be performed for almost all patients with tinnitus, and some patients may require neuroimaging or assessment of vestibular function with electronystagmography 2
Treatment of Tinnitus
- Cognitive behavior therapy is the only treatment that has been shown to improve quality of life in patients with tinnitus 3
- 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
- Transcranial direct current stimulation (tDCS) has shown promising therapeutic outcomes for tinnitus, with moderate to significant treatment effects on tinnitus symptoms 4
- Antidepressant drugs have been used to treat tinnitus, but there is insufficient evidence to say that they improve tinnitus 5
- Patient education and preventive measures, as well as the physician's reassurance and assistance with the psychologic aftereffects of tinnitus, can be valuable therapies for patients with tinnitus 6
Treatment Options
- Medical therapy: may be used to treat underlying conditions that contribute to tinnitus 6
- Surgical therapy: may be used to treat conditions such as conductive tinnitus or vestibular schwannoma 6
- Psychologic therapy: may be used to help patients cope with the psychologic aftereffects of tinnitus 6
- Masking therapies: may be used to help patients manage their tinnitus symptoms 6