What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) is the most strongly recommended treatment for persistent, bothersome tinnitus, as it has the strongest evidence base for improving quality of life. 1, 2

Initial Classification and Evaluation

• Tinnitus should be classified as pulsatile or non-pulsatile, and primary or secondary to guide appropriate treatment 1
• Unilateral pulsatile tinnitus almost always requires imaging evaluation, as it frequently indicates underlying vascular abnormalities that may be treatable 1, 3
• A comprehensive otologic examination is essential to identify potential vascular retrotympanic masses 1
• Audiologic evaluation is recommended for patients with unilateral tinnitus, tinnitus persisting ≥6 months, or tinnitus associated with hearing difficulties 2, 4

Evidence-Based Treatment Options

First-Line Treatments

• Cognitive Behavioral Therapy (CBT) is recommended for all patients with persistent, bothersome tinnitus based on strong evidence showing benefits over harm 2, 5
• Hearing aids should be provided for patients with hearing loss and tinnitus, even if the hearing loss is mild or unilateral 1, 2
• Education and counseling about tinnitus management strategies are essential components for all patients 1, 2

Second-Line and Adjunctive Approaches

• Sound therapy may be used as an adjunct treatment, though evidence is less conclusive than for CBT 4, 5
• Tinnitus retraining therapy combines sound therapy with directed counseling, but has limited evidence support 4
• Treatment of underlying conditions should be prioritized when tinnitus has an identifiable cause 1, 3

Treatments Not Recommended

• Medical therapy with antidepressants, anticonvulsants, or anxiolíticos is not recommended for routine tinnitus treatment 3, 2
• Dietary supplements such as Ginkgo biloba, melatonin, or zinc are not recommended 3, 2
• Transcranial Magnetic Stimulation (TMS) is not recommended for routine tinnitus treatment 2
• There is insufficient evidence to recommend acupuncture 2

Special Considerations

Pulsatile Tinnitus Management

• Pulsatile tinnitus requires specific imaging studies including CT of temporal bone and/or CT angiography of head and neck with contrast 3
• MRI and MR angiography with contrast are second-line imaging options, especially useful for evaluating cerebellopontine angle lesions and vascular malformations 3
• Common causes of pulsatile tinnitus may require specific treatments:
  • Arterial dissection: anticoagulation or antiplatelet therapy 3
  • Sigmoid sinus diverticulum or dehiscence: surgical repair or endovascular embolization 3
  • Superior semicircular canal dehiscence: surgical repair in severe symptomatic cases 3

Psychiatric Comorbidities

• Prompt identification and intervention for patients with severe anxiety or depression is crucial due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1
• While antidepressants are not recommended for tinnitus itself, they may be appropriate for treating comorbid depression 2, 4

Treatment Algorithm

1. Determine tinnitus characteristics (pulsatile vs. non-pulsatile, unilateral vs. bilateral) 1
2. Conduct appropriate diagnostic workup including audiologic evaluation and imaging when indicated 1, 2
3. Address any underlying treatable conditions 1, 3
4. For persistent, bothersome tinnitus:
   • Provide CBT as primary treatment 1, 2
   • Evaluate for hearing aids if hearing loss is present 1, 2
   • Provide education and counseling about tinnitus management 1, 2
   • Consider sound therapy as an adjunctive approach 4, 5

Common Pitfalls to Avoid

• Failing to identify potentially dangerous causes of tinnitus such as vascular abnormalities or vestibular schwannoma, especially in unilateral cases 3, 4
• Relying on unproven treatments like dietary supplements or medications not indicated for tinnitus 3, 2
• Neglecting to address hearing loss, which is frequently associated with tinnitus 2, 5
• Overlooking psychiatric comorbidities that may worsen tinnitus perception and impact quality of life 1, 4