What is the first line of management for tinnitus in patients with Multiple System Atrophy (MSA)?

Management of Tinnitus in Multiple System Atrophy

The first-line management for tinnitus in patients with Multiple System Atrophy (MSA) should include education and counseling about tinnitus, followed by sound therapy and cognitive behavioral therapy (CBT). 1, 2

Initial Evaluation for MSA Patients with Tinnitus

• Perform a targeted history and physical examination:

  • Determine if tinnitus is pulsatile or non-pulsatile
  • Assess duration (recent onset vs. persistent ≥6 months)
  • Evaluate whether the tinnitus is bothersome or non-bothersome
  • Check for associated hearing loss
  • Document impact on quality of life and sleep

• Comprehensive audiologic examination is essential, even if the patient does not perceive hearing difficulties 2

• Distinguish between:

  • Recent onset tinnitus (<6 months)
  • Persistent tinnitus (≥6 months) 1

Management Algorithm for Tinnitus in MSA

Step 1: Education and Counseling (First-line)

• Provide explanation about the relationship between MSA and tinnitus
• Reassure that tinnitus is not life-threatening
• Discuss coping strategies
• Address sleep disturbances that may be exacerbated by both tinnitus and MSA 2

Step 2: Sound Therapy (First-line)

• Recommend sound therapy options:
  • White noise machines
  • Smartphone applications
  • Tinnitus masking devices 2
• Sound therapy may help reduce the perception of tinnitus by providing background noise that makes the tinnitus less noticeable 3

Step 3: Hearing Aid Evaluation (If hearing loss is present)

• Recommend hearing aid evaluation for MSA patients with hearing loss and persistent tinnitus
• Hearing aids can improve tinnitus by amplifying external sounds and reducing auditory deprivation 1, 2

Step 4: Cognitive Behavioral Therapy (CBT)

• CBT is the only treatment shown to improve quality of life in patients with tinnitus 2, 4
• Should be considered for all MSA patients with persistent, bothersome tinnitus
• Particularly important as MSA patients often experience anxiety and depression that can worsen tinnitus perception

Special Considerations for MSA Patients

• MSA patients often have multiple neurological symptoms that can complicate tinnitus management:

  • Dysarthria (present in 98.4% of early MSA patients)
  • REM sleep behavior disorder (90.2%)
  • Constipation (82.0%)
  • Dysphagia (68.9%) 5

• Consider potential interactions between tinnitus management and other MSA symptoms:

  • Ensure sound therapy devices are accessible for patients with motor limitations
  • Adapt CBT approaches to accommodate cognitive changes in MSA
  • Monitor for worsening of autonomic symptoms with any medications used

Monitoring and Follow-up

• Schedule follow-up within 4-6 weeks to assess response to initial management 2
• Consider referral to specialized care if symptoms persist or worsen
• Regular reassessment is important as MSA is a progressive condition

Common Pitfalls to Avoid

• Failing to remove cerumen before assessment

• Overlooking non-otologic causes of tinnitus

• Not performing comprehensive audiologic evaluation

• Using unproven medications or supplements

• Ordering unnecessary imaging for non-concerning tinnitus presentations 2

• Pulsatile tinnitus requires different management and may indicate serious vascular pathology requiring imaging (CT angiography or MR angiography) 2

The evidence supports a structured approach to tinnitus management in MSA patients, focusing on education, sound therapy, and CBT as the cornerstones of treatment. While MSA presents unique challenges due to its progressive nature and multiple neurological manifestations, these interventions can significantly improve quality of life for patients experiencing tinnitus.