What are the treatment options for tinnitus?

Treatment Options for Tinnitus

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 for bothersome tinnitus. 1

Evaluation and Classification

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

1. Characterize tinnitus by:

   • Duration (recent vs. persistent)
   • Quality (pulsatile vs. non-pulsatile)
   • Laterality (unilateral vs. bilateral)
   • Associated symptoms (hearing loss, neurological symptoms)
   • Impact on quality of life and sleep 1

2. Perform comprehensive audiometry within 14 days of symptom onset, including:

   • Pure tone audiometry
   • Speech audiometry
   • Tympanometry
   • Acoustic reflex testing 1

Treatment Algorithm

First-Line Treatments

1. Cognitive Behavioral Therapy (CBT)

   • Most effective evidence-based intervention
   • Helps patients develop coping strategies
   • Reduces tinnitus-related distress 1, 2

2. Sound Therapy

   • Includes hearing aids for patients with hearing loss
   • Wide-band sound generators
   • Environmental sound enrichment
   • May provide relief by masking or partially masking tinnitus 1, 3

3. Hearing Aids

   • Particularly beneficial for patients with associated hearing loss
   • Can be effective even with mild or unilateral hearing loss 1, 3

Additional Interventions

1. Tinnitus Retraining Therapy (TRT)

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

2. Supportive Counseling

   • Should begin during initial evaluation
   • Educate patients about tinnitus mechanisms
   • Reassure that tinnitus is not life-threatening 4, 2

3. Adjunctive Treatments

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

Special Considerations

Red Flags Requiring Immediate Investigation

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

Referral Guidelines

1. Immediate ENT Referral for:

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

2. Audiologist Referral for:

   • Comprehensive audiologic examination
   • Particularly for unilateral or persistent tinnitus
   • Tinnitus associated with hearing difficulties 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
• Missing red flags that warrant urgent evaluation 1

Treatment Effectiveness

It's important to note that while many treatments are available, the evidence base is strongest for a combination of sound therapy and CBT-based counseling 3. No effective drug treatments have been definitively proven for primary tinnitus management 3, though medications may help with associated conditions like depression or sleep disturbances 2.

Patients should be counseled that tinnitus is often a chronic condition, but proper management can significantly reduce its impact on quality of life. The degree to which tinnitus bothers the patient should guide the intensity of treatment 5.