What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) is the most effective evidence-based treatment for persistent, bothersome tinnitus and should be recommended as first-line therapy. 1

Classification of Tinnitus

Proper treatment depends on accurate classification:

• Subjective vs. Objective Tinnitus:

  • Subjective tinnitus (heard only by patient) - most common form 2
  • Objective tinnitus (audible to examiner) - rare, suggests underlying vascular abnormality 2

• Pulsatile vs. Non-pulsatile Tinnitus:

  • Pulsatile tinnitus - repetitive sound coinciding with heartbeat, requires imaging 2
  • Non-pulsatile tinnitus - continuous sound, most common variant 2

• Primary vs. Secondary Tinnitus:

  • Primary (idiopathic) - no identifiable underlying cause 2
  • Secondary - associated with identifiable underlying condition 2

Diagnostic Evaluation

Proper evaluation is essential before initiating treatment:

• Comprehensive otologic examination to identify potential vascular retrotympanic masses 2, 3
• Audiometric testing - essential for all patients with tinnitus, especially unilateral or persistent (≥6 months) 1
• Imaging studies - indicated for:
  • Pulsatile tinnitus (objective or subjective) 2, 3
  • Unilateral tinnitus 3, 1
  • Tinnitus with focal neurologic abnormalities 2
  • Tinnitus with asymmetric hearing loss 2

Evidence-Based Treatment Options

First-Line Treatments:

• Cognitive Behavioral Therapy (CBT) - strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus 1
• Hearing aids - recommended for patients with hearing loss and tinnitus, even if hearing loss is mild or unilateral 1
• Education and counseling - essential component for all patients with persistent tinnitus 1

Second-Line Treatments:

• Sound therapy - may provide relief but evidence is inconclusive 1, 4
• Tinnitus retraining therapy - combines sound therapy with counseling, but evidence remains limited 4

Treatments for Specific Causes:

• Pulsatile tinnitus due to vascular abnormalities:
  • Arterial dissection - anticoagulation or antiplatelet therapy 3
  • Sigmoid sinus diverticulum/dehiscence - surgical repair or endovascular embolization 3
  • Superior semicircular canal dehiscence - surgical repair for severe symptomatic cases 3

Treatments NOT Recommended

• Medical therapy including antidepressants, anticonvulsants, and anxiolytics is not recommended for primary tinnitus treatment 1
• Dietary supplements such as Ginkgo biloba, melatonin, or zinc are not recommended 3, 1
• Transcranial Magnetic Stimulation (TMS) is not recommended for routine tinnitus treatment 1

Special Considerations

• Pulsatile tinnitus almost always requires imaging evaluation, unlike bilateral non-pulsatile tinnitus 3
• Patients with severe anxiety or depression require prompt identification and intervention due to increased suicide risk in tinnitus patients with psychiatric comorbidities 2
• Noise exposure avoidance may help prevent development or progression of tinnitus 4

Treatment Algorithm

1. Determine tinnitus characteristics:

   • If pulsatile or unilateral → imaging studies to identify treatable causes 2, 3
   • If non-pulsatile and bilateral → proceed to audiologic evaluation 1

2. Address any underlying treatable conditions if identified 2

3. For persistent, bothersome tinnitus:

   • If hearing loss is present → hearing aid evaluation 1
   • For all patients → CBT and education/counseling 1
   • Consider sound therapy as adjunctive treatment 1, 4

4. Monitor response using validated tools like Tinnitus Handicap Inventory (THI) 5