What are the treatment options for tinnitus (ringing in the ears)?

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 primary intervention for persistent tinnitus. 1, 2

Evaluation and Classification

Before initiating treatment, proper evaluation 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
  • Pulsatile tinnitus
  • Unilateral tinnitus with asymmetric hearing loss 1

Treatment Algorithm

First-Line Interventions

1. Hearing aids for patients with identified hearing loss (even mild or unilateral)

   • Improves auditory input and often reduces tinnitus perception 1

2. Sound therapy

   • Uses external noise to mask or distract from tinnitus
   • Options include tabletop sound generators, wearable sound generators, and combination devices (hearing aid + sound generator) 1, 3

3. Cognitive Behavioral Therapy (CBT)

   • Most evidence-supported intervention for improving quality of life
   • Helps patients develop coping strategies and change negative thought patterns about tinnitus 1, 2, 3

Second-Line Interventions

1. Tinnitus Retraining Therapy (TRT)

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

2. Supportive measures for associated conditions

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

Special Considerations

Management Based on Underlying Cause

• Hearing loss-related tinnitus: Hearing aids are particularly beneficial 1
• Medication-induced tinnitus: Consider discontinuation of ototoxic medications when possible 1
• Meniere's disease: Treat underlying condition with salt restriction, diuretics, or surgical interventions as appropriate 4
• Vascular causes: Surgical intervention may be necessary for arteriovenous malformations or fistulae 4

Referral Guidelines

• Immediate ENT referral for:

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

• Audiologist referral for:

  • Comprehensive audiologic examination for unilateral tinnitus
  • Persistent tinnitus
  • Tinnitus associated with hearing difficulties 1

Common Pitfalls to Avoid

• Using unproven medications or supplements without evidence of efficacy 1
• Telling patients "nothing can be done" - this is inappropriate and harmful 4
• Ordering unnecessary imaging for non-concerning tinnitus presentations 1
• Delaying referral for unilateral tinnitus or missing red flags that warrant urgent evaluation 1
• Failing to provide comprehensive audiologic evaluation for persistent tinnitus 1, 2

Ineffective Treatments to Avoid

• No FDA-approved medications specifically for tinnitus
• Limited evidence for supplements, herbal remedies, or alternative therapies
• Surgical interventions are only indicated for specific underlying pathologies, not for idiopathic tinnitus 5, 2

Remember that while tinnitus often cannot be cured completely, proper management can significantly reduce its impact on quality of life, with CBT showing the strongest evidence for effectiveness.