What are the treatment options for tinnitus?

Treatment Options for Tinnitus

The most effective treatment options for tinnitus include education and counseling, sound therapy, hearing aids for those with hearing loss, and cognitive behavioral therapy (CBT), with CBT being the only treatment shown to improve quality of life in patients with tinnitus. 1

Initial Evaluation and Diagnosis

Before initiating treatment, proper evaluation is essential:

• Perform targeted history and physical examination focusing on:

  • Tinnitus characteristics (pulsatile vs. non-pulsatile)
  • Associated symptoms
  • Aggravating/alleviating factors
  • Medication history
  • Noise exposure history
  • Impact on quality of life and sleep 1

• Comprehensive audiologic examination is necessary for:

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

• Otoscopic examination to identify:

  • Cerumen impaction
  • Middle ear fluid
  • Tympanic membrane perforation 1

Treatment Options

First-Line Treatments

1. Education and Counseling

   • Explain the natural history of tinnitus
   • Provide coping strategies
   • Reassure that tinnitus is not life-threatening when appropriate 1

2. Sound Therapy

   • White noise machines
   • Smartphone apps
   • Tinnitus masking devices 1

3. Hearing Aids

   • Recommended for patients with hearing loss and persistent tinnitus
   • Improve tinnitus by amplifying external sounds and reducing auditory deprivation 1

4. Cognitive Behavioral Therapy (CBT)

   • The only treatment shown to improve quality of life in tinnitus patients
   • Should be considered for all patients with bothersome tinnitus 1, 2

Additional Treatment Approaches

1. Tinnitus Retraining Therapy

   • Combines sound therapy and counseling
   • Has supportive but not conclusive evidence 1, 2

2. Supportive Treatments

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

Special Considerations

Pulsatile Tinnitus

• Requires urgent evaluation as it may indicate serious vascular pathology:
  • Arteriovenous shunts or malformations
  • Carotid artery stenosis or dissection
  • Intracranial hypertension
  • Vascular tumors 1
• Imaging (CT angiography or MR angiography) is indicated 1

When to Consider Imaging

Imaging is NOT routinely recommended but is indicated for:

• Pulsatile tinnitus
• Unilateral tinnitus with asymmetric hearing loss
• Focal neurological findings
• Tinnitus localizing to one ear with concerning features 1

Follow-up and Referral

• Schedule follow-up within 4-6 weeks to assess response to initial management
• Consider referral to specialized care if:
  • Symptoms persist or worsen
  • Imaging reveals a vascular abnormality requiring intervention 1

Common Pitfalls to Avoid

• Failing to remove cerumen before assessment
• Overlooking non-otologic causes
• Not performing comprehensive audiologic evaluation for unilateral or persistent tinnitus
• Using unproven medications or supplements
• Ordering unnecessary imaging for non-concerning tinnitus presentations 1

Treatment Algorithm

1. Identify and treat underlying causes if present (cerumen impaction, medication side effects)
2. Assess impact on quality of life to determine treatment intensity needed
3. For all patients: Provide education and counseling
4. For patients with hearing loss: Recommend hearing aids
5. For bothersome tinnitus: Implement sound therapy and refer for CBT
6. For patients with sleep or mood disturbances: Consider adjunctive treatments
7. For pulsatile tinnitus or concerning features: Obtain appropriate imaging and specialist referral

Remember that tinnitus is a symptom affecting over 37 million Americans, with adults age 40-70 most commonly affected 3. The degree to which tinnitus bothers the patient should help determine the extent of treatment necessary.