What are the management options for tinnitus?

Tinnitus Management Options

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

Initial Assessment and Classification

Proper management begins with appropriate classification of tinnitus:

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

Evidence-Based Management Options

First-Line Approaches

1. Cognitive Behavioral Therapy (CBT)

   • Strongest evidence base for improving quality of life
   • Should be part of comprehensive management plan 1, 2

2. Hearing Aids

   • Recommended for patients with associated hearing loss (even mild or unilateral)
   • Can provide significant symptom relief 1, 3

3. Sound Therapy

   • Wide-band sound generators
   • Environmental sound enrichment
   • Tailored to individual patient preferences 1, 3

Second-Line Approaches

1. Tinnitus Retraining Therapy (TRT)

   • Combines sound therapy with directive counseling
   • Evidence is less conclusive than for CBT 2, 3

2. Supportive Management for Associated Conditions

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

Multidisciplinary Approach

Tinnitus management often requires coordination between:

• Otolaryngologists (ENT): Primary specialists for evaluation
• Audiologists: For hearing evaluation and hearing aid fitting
• Psychologists/Psychiatrists: For CBT and management of associated psychological conditions
• Neurologists: For cases with associated neurological symptoms 1

Diagnostic Imaging Recommendations

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

Note: Neuroimaging is not part of standard workup for bilateral, non-pulsatile tinnitus without other concerning features 1, 2

Common Pitfalls to Avoid

• Failing to remove cerumen before assessment
• Overlooking non-otologic causes
• Not performing comprehensive audiologic evaluation for persistent (>6 months) or unilateral tinnitus
• 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, 2

Prevention Strategies

• Noise exposure avoidance
• Proper use of hearing protection in loud environments
• Monitoring and adjusting potentially ototoxic medications 2

Remember that tinnitus is a symptom, not a disease, and affects 10-15% of the population, with 1-2% experiencing severe impairment of quality of life 4. Patient education about the natural progression of tinnitus and reassurance that it is not life-threatening are essential components of management 5.