What are the treatment options for tinnitus?

Treatment Options for Tinnitus

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

Evaluation and Classification

Before initiating treatment, proper evaluation and classification of tinnitus is essential:

• Classify tinnitus as:

  • 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 investigation:

  • Sudden onset bilateral hearing loss
  • Focal neurological findings
  • Severe headaches
  • Concurrent severe bilateral vestibular loss
  • Pulsatile tinnitus
  • Visible abnormality on otoscopic examination 1

Treatment Options

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 change negative thought patterns about tinnitus

2. Hearing Aids

   • Beneficial for patients with hearing loss and tinnitus 1
   • Improves auditory input and may reduce tinnitus perception

3. Sound Therapy

   • Includes various approaches:
     • Sound masking devices
     • Tinnitus retraining therapy
     • Neuromonics
   • Provides background noise to reduce tinnitus perception 1, 3

Additional Treatment Approaches

1. Counseling and Education

   • Should begin during initial evaluation 4
   • Explain the natural progression of tinnitus
   • Provide reassurance about benign nature in most cases

2. Management of Associated Conditions

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

3. Specialized Interventions

   • Transcranial magnetic stimulation for severe cases unresponsive to other treatments 3
   • Auditory masking devices 5

4. Treatment of Underlying Causes

   • Address myofascial disorders of head and neck, which are a major cause of tinnitus 6
   • Manage Meniere's disease if present
   • Remove cerumen impaction if contributing to symptoms 5

Referral Guidelines

• Immediate ENT referral for:

  • Pulsatile tinnitus
  • Unilateral tinnitus
  • Tinnitus with sudden hearing loss
  • Tinnitus with focal neurological symptoms 1

• Audiologist referral for:

  • Comprehensive audiologic examination
  • Unilateral tinnitus
  • Persistent tinnitus (>6 months)
  • Tinnitus associated with hearing difficulties 1, 2

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
• Missing red flags that warrant urgent evaluation 1

Treatment Algorithm

1. Identify and treat underlying causes if possible
2. For bothersome tinnitus without treatable cause:
   • Start with CBT
   • Add sound therapy and/or hearing aids if appropriate
   • Consider management of associated conditions (sleep, mood)
3. For severe, treatment-resistant tinnitus:
   • Consider transcranial magnetic stimulation
   • Ensure specialist involvement

Remember that while many treatments may provide symptomatic relief, there is currently no definitive cure for most cases of tinnitus 3.