How to manage tinnitus?

Tinnitus Management: Evidence-Based Approach

Cognitive behavioral therapy is the only treatment proven to improve quality of life in tinnitus patients and should be considered as the primary intervention for persistent bothersome tinnitus. 1, 2

Diagnostic Evaluation

Initial Assessment

1. Classify tinnitus characteristics:

   • Pulsatile vs. non-pulsatile
   • Unilateral vs. bilateral
   • Recent onset vs. persistent
   • Associated with hearing loss or neurological symptoms
   • Bothersome vs. non-bothersome 1

2. Perform otoscopic examination to identify:

   • Cerumen impaction
   • Middle ear fluid
   • Tympanic membrane perforation
   • Other visible abnormalities 1

Red Flags Requiring Immediate ENT Referral

• Pulsatile tinnitus
• Unilateral tinnitus
• Tinnitus with sudden hearing loss
• Tinnitus with focal neurological symptoms
• Visible abnormality on otoscopic examination 1

Appropriate Imaging

Clinical Presentation	Recommended Imaging
Pulsatile tinnitus	CT angiography or MR angiography
Unilateral tinnitus with asymmetric hearing loss	MRI with contrast of internal auditory canals
Focal neurological findings	MRI brain with contrast
Tinnitus localizing to one ear	Appropriate imaging based on clinical findings [1]

Treatment Algorithm

Step 1: Address Underlying Causes

• Remove impacted cerumen if present
• Treat any identified middle ear pathology
• Consider medication review for potential ototoxic agents 1

Step 2: Audiologic Evaluation and Intervention

• Comprehensive hearing assessment for patients with:
  • Unilateral tinnitus
  • Persistent tinnitus (>6 months)
  • Tinnitus with hearing difficulties 1, 2
• Hearing aids for patients with identified hearing loss (even mild or unilateral) 1, 3

Step 3: Evidence-Based Interventions

1. Cognitive Behavioral Therapy (CBT):

   • First-line treatment for bothersome tinnitus
   • Only intervention with strong evidence for improving quality of life 1, 2, 3
   • Consider internet-based CBT (ICBT) where available 4

2. Sound Therapy:

   • Wide-band sound therapy can be beneficial
   • Often combined with CBT for better outcomes 1, 3

3. Tinnitus Retraining Therapy:

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

Special Considerations

Comorbid Conditions

• Assess and treat associated conditions:
  • Anxiety and depression (may require antidepressants)
  • Sleep disturbance (consider melatonin)
  • Cognitive impairments (may benefit from cognitive training) 2

Prevention

• Advise patients to avoid noise exposure to prevent development or progression of tinnitus 2
• Counsel patients about the natural progression of tinnitus and realistic expectations 2

Common Pitfalls to Avoid

• Failing to remove cerumen before assessment
• Overlooking non-otologic causes
• Not performing comprehensive audiologic evaluation when indicated
• Using unproven medications or supplements
• Ordering unnecessary imaging for non-concerning tinnitus presentations
• Delayed referral for unilateral tinnitus
• Missing red flags that warrant urgent evaluation 1

Multidisciplinary Approach

For optimal management, involve appropriate specialists:

• Otolaryngologist (ENT): Primary specialist for tinnitus evaluation
• Audiologist: Hearing evaluation and hearing aid fitting
• Psychologist/Psychiatrist: For CBT and management of psychological comorbidities
• Neurologist: When associated neurological symptoms are present 1

Remember that tinnitus is a symptom, not a disease, and affects approximately 10-15% of adults, with higher prevalence in older populations 5, 6. While there is no cure for most forms of tinnitus, appropriate management can significantly improve quality of life and reduce the impact of this potentially debilitating symptom.