What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) combined with sound therapy is the first-line treatment for tinnitus management due to its strong evidence base. 1

First-Line Approaches

Education and Counseling

• Provide information about tinnitus mechanisms and management strategies 1
• Help patients understand the condition to reduce anxiety and improve coping
• Focus on acceptance of tinnitus while pursuing valued life activities

Cognitive Behavioral Therapy

• CBT is the most evidence-based treatment option for tinnitus 1, 2
• Acceptance and Commitment Therapy (ACT) appears particularly effective among CBT variations 1
• CBT is the only treatment shown to definitively improve quality of life in tinnitus patients 3

Sound Therapy

• Recommended as a complement to CBT-based counseling 1
• Can be implemented using three types of sound:
  1. Soothing sounds - to provide relief from tinnitus-associated stress
  2. Background sounds - to reduce contrast between tinnitus and environment
  3. Interesting sounds - to actively divert attention from tinnitus 4
• Sound therapy options include environmental sounds, music, and speech 4

Hearing Aids

• Strongly recommended for patients with hearing loss and persistent tinnitus 1
• Helps by amplifying external sounds, reducing the perception of tinnitus

Diagnostic Evaluation

When to Conduct Comprehensive Audiologic Examination

• If tinnitus persists beyond medication discontinuation
• If tinnitus is unilateral
• If tinnitus is associated with hearing difficulties 1

When to Consider Imaging

• Unilateral tinnitus: CT scan or MRI with internal auditory canal protocol
• Pulsatile tinnitus: Temporal bone CT scan or CT angiography
• Tinnitus with focal neurological abnormalities: CT scan or MRI
• Tinnitus with asymmetric hearing loss: CT scan or MRI 1

Red Flags Requiring Immediate Attention

• Worsening headache
• Focal neurological deficits
• Confusion or memory problems
• Increased sleepiness 1

Treatments to Avoid

The following treatments are NOT recommended due to lack of evidence or inconclusive results:

• Dietary supplements (Ginkgo biloba, melatonin, zinc)
• Medications (antidepressants, anticonvulsants, anxiolytics) except in acute phase
• Transcranial Magnetic Stimulation (TMS)
• Acupuncture 1

Management Algorithm

1. Initial Assessment:

   • Identify and discontinue any causative medications 1
   • Screen for red flags requiring immediate attention
   • Evaluate for hearing loss

2. First-Line Treatment:

   • Begin CBT-based counseling with focus on education and acceptance 1, 2
   • Implement sound therapy as a complementary approach 1, 5
   • Prescribe hearing aids if hearing loss is present 1

3. For Persistent Cases:

   • Intensify CBT with more sessions
   • Adjust sound therapy approach based on patient response
   • Consider tinnitus retraining therapy (though evidence is inconclusive) 3

4. For Severe Cases:

   • Consider multidisciplinary approach with psychology, audiology, and otolaryngology 1
   • Address comorbid conditions (sleep disturbance, mood disorders) 3

Important Considerations

• Tinnitus is often associated with sensorineural hearing loss 3
• About 20% of tinnitus sufferers will require clinical intervention 6
• Noise exposure avoidance may help prevent development or progression of tinnitus 3
• Inner ear ablation should only be considered in very specific contexts, primarily for controlling vertigo rather than tinnitus 1

While various treatment options exist, the combination of CBT and sound therapy has the strongest evidence base for managing tinnitus. The approach should target both the perception of tinnitus and the psychological response to it for optimal outcomes.