What are the treatment options for tinnitus?

Treatment Options for Tinnitus

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

Evaluation and Classification

Before initiating treatment, proper evaluation is essential to guide management:

1. 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

2. Red flags requiring immediate investigation:

   • Sudden onset bilateral hearing loss
   • Focal neurological findings
   • Severe headaches
   • Concurrent severe bilateral vestibular loss 1

Treatment Algorithm

First-Line Treatments

1. Cognitive Behavioral Therapy (CBT)

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

2. Hearing Aids

   • Recommended for patients with hearing loss (even mild or unilateral)
   • Can mask tinnitus and reduce perception by improving auditory input 1, 3

3. Sound Therapy

   • Uses external noise to mask or distract from tinnitus
   • Options include:
     • White noise machines
     • Tabletop sound generators
     • Wearable sound generators
     • Smartphone apps with nature sounds or white noise 1, 3

Second-Line Treatments

1. Tinnitus Retraining Therapy (TRT)

   • Combines sound therapy with directed counseling
   • Aims to habituate patients to their tinnitus perception
   • Evidence is less conclusive than for CBT 2, 3

2. Supportive Interventions

   • Melatonin for sleep disturbances
   • Antidepressants for comorbid mood disorders
   • Cognitive training for attention and concentration difficulties 2

Special Considerations

Referral Guidelines

Immediate ENT referral is necessary for:

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

Audiologist referral is recommended for:

• Unilateral tinnitus
• Persistent tinnitus
• Tinnitus associated with hearing difficulties 1

Common Pitfalls to Avoid

1. Using unproven medications or supplements without evidence of efficacy
2. Failing to perform comprehensive audiologic evaluation
3. Delayed referral for unilateral tinnitus
4. Missing red flags that warrant urgent evaluation
5. Ordering unnecessary imaging for non-concerning tinnitus presentations 1

Treatment Efficacy

It's important to note that while many treatments are available, the evidence base varies significantly:

• Strong evidence: CBT for quality of life improvement
• Moderate evidence: Sound therapy combined with counseling
• Limited evidence: Medications, dietary supplements, and alternative therapies 2, 3

The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that treatment should be tailored based on tinnitus classification, associated symptoms, and impact on quality of life 1. However, patients should be counseled that complete elimination of tinnitus is often not possible, and management focuses on reducing its impact on daily functioning and quality of life.