What are the treatment options for tinnitus?

Treatment Options for Tinnitus

The first-line management for tinnitus should include education and counseling, followed by sound therapy and cognitive behavioral therapy (CBT), as these are the most evidence-based approaches to improve quality of life in tinnitus patients. 1

Initial Assessment and Classification

• Patient evaluation should include:

  • Determining if tinnitus is pulsatile or non-pulsatile
  • Assessing duration (recent onset <6 months or persistent ≥6 months)
  • Evaluating whether the tinnitus is bothersome or non-bothersome
  • Checking for associated hearing loss
  • Documenting impact on quality of life and sleep 1

• Otoscopic examination to visualize ear canals and tympanic membranes for:

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

• Comprehensive audiologic examination is recommended for:

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

Evidence-Based Treatment Options

First-Line Treatments

1. Education and Counseling

   • Provide reassurance that tinnitus is not life-threatening
   • Explain potential causes and management options
   • Begin supportive counseling during initial evaluation 1, 2

2. Cognitive Behavioral Therapy (CBT)

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

3. Sound Therapy

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

4. Hearing Aids

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

Adjunctive Treatments

• Melatonin - May help with sleep disturbance associated with tinnitus 2
• Antidepressants - Can address mood disorders that may accompany tinnitus 2
• Cognitive training - May help with cognitive impairments 2

Special Considerations for Specific Tinnitus Types

Pulsatile Tinnitus

• Requires CT angiography or MR angiography
• Often indicates underlying vascular abnormality that may be serious or life-threatening 1

Unilateral Tinnitus with Asymmetric Hearing Loss

• Requires MRI with contrast of internal auditory canals
• Important to rule out vestibular schwannoma 1, 2

Common Pitfalls to Avoid

1. Failing to remove cerumen before assessment - Can cause temporary tinnitus or mask other causes 1
2. Overlooking non-otologic causes - Vascular, neurologic, or metabolic disorders can cause tinnitus 1, 3
3. Not performing comprehensive audiologic evaluation for unilateral or persistent tinnitus 1
4. Using unproven medications or supplements - Many lack evidence for efficacy 1
5. Ordering unnecessary imaging for non-concerning tinnitus presentations 1, 2

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

Remember that tinnitus is a symptom, not a disease, and management should focus on identifying any underlying treatable causes while implementing strategies to improve quality of life for patients with persistent tinnitus.