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 first-line treatment for bothersome tinnitus. 1, 2

Evaluation and Classification

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

1. Characterize the tinnitus:

   • Duration (recent onset 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. Audiologic evaluation:

   • Comprehensive audiometry should be performed within 14 days of symptom onset
   • Includes pure tone audiometry, speech audiometry, tympanometry, and acoustic reflex testing 1

Red Flags Requiring Urgent Evaluation

Immediate investigation is warranted for:

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

Treatment Algorithm

First-Line Treatments

1. Cognitive Behavioral Therapy (CBT)

   • The only treatment with strong evidence for improving quality of life 1, 2
   • Addresses psychological aspects of tinnitus perception and reaction

2. Hearing Aids

   • Indicated when tinnitus is associated with hearing loss (even mild or unilateral)
   • Can mask tinnitus and reduce awareness 1, 3

3. Sound Therapy

   • Wide-band sound generators
   • Environmental sound enrichment
   • Can provide relief by reducing contrast between tinnitus and background sound 1, 3

Second-Line Treatments

1. Tinnitus Retraining Therapy (TRT)

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

2. Targeted Interventions for Associated Conditions

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

Specialist Referrals

• Otolaryngologist (ENT): Primary specialist for tinnitus evaluation, particularly for:

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

• Audiologist: For comprehensive hearing evaluation, especially for:

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

Specific Treatments Based on Etiology

1. For hearing loss-related tinnitus:

   • Hearing aids
   • Sound therapy 1, 3

2. For medication-induced tinnitus:

   • Discontinuation of ototoxic medications when possible
   • Examples: certain antibiotics, salicylates, NSAIDs, loop diuretics, chemotherapeutic agents 1

3. For Meniere's disease-related tinnitus:

   • Disease-specific management
   • Salt restriction, diuretics, intratympanic treatments 1

Common Pitfalls to Avoid

• Using unproven medications or supplements
• Ordering unnecessary imaging for non-concerning tinnitus presentations
• Delayed referral for unilateral tinnitus
• Incomplete evaluation
• Missing red flags that warrant urgent evaluation
• Failing to remove cerumen before assessment 1

Ineffective Treatments

It's important to note that there are currently no effective drug treatments specifically for tinnitus, despite ongoing research 3. Many patients may seek unproven remedies, but these should not be recommended due to lack of evidence.

Tinnitus affects approximately 37 million Americans, with adults aged 40-70 most commonly affected 4. Since tinnitus is a symptom rather than a disease, treatment should focus on addressing underlying causes when possible and managing the impact on quality of life when the cause cannot be eliminated.