What are the treatment options for tinnitus?

Tinnitus Treatment Options

Cognitive behavioral therapy (CBT) is the only treatment shown to improve quality of life in tinnitus patients and should be considered as the primary intervention in a comprehensive management plan. 1, 2

Diagnosis and Evaluation

Before initiating treatment, proper evaluation is essential:

• 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

• 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

Treatment Algorithm

First-line Treatments:

1. Cognitive Behavioral Therapy (CBT)

   • Most evidence-based intervention for improving quality of life 1, 2
   • Helps patients develop coping strategies and reduce tinnitus-related distress

2. Hearing Aids

   • Indicated when tinnitus is associated with hearing loss (even mild or unilateral) 1, 3
   • Improves auditory input and can reduce tinnitus perception

3. Sound Therapy

   • Can be used in three different ways:
     • Soothing sound: Provides relief from tinnitus-associated stress
     • Background sound: Reduces contrast between tinnitus and acoustic environment
     • Interesting sound: Actively diverts attention from tinnitus 4
   • Can utilize environmental sounds, music, or speech 4

Additional Treatment Options:

1. Tinnitus Retraining Therapy (TRT)

   • Combines sound therapy with directive counseling
   • Evidence is less conclusive than for CBT 2, 4

2. Supportive Interventions

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

Special Considerations

• Avoid unproven treatments:

  • No FDA-approved medications specifically for tinnitus
  • Be cautious about supplements or alternative therapies with limited evidence 1

• Address underlying causes when possible:

  • Remove impacted cerumen if present
  • Consider medication review for potential ototoxic agents (antibiotics, salicylates, NSAIDs, loop diuretics, chemotherapeutic agents) 1

• Preventive measures:

  • Noise protection to prevent worsening
  • Avoidance of further noise exposure 2

Multidisciplinary Approach

Tinnitus management often requires collaboration between:

• Otolaryngologists (ENT specialists)
• Audiologists
• Psychologists/psychiatrists
• Neurologists (when neurological symptoms are present) 1

Common Pitfalls to Avoid

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

While many treatment options exist for tinnitus, the strongest evidence supports a combination of CBT and sound therapy, with hearing aids when hearing loss is present. The management approach should be guided by tinnitus characteristics and impact on quality of life.