How do I treat tinnitus (ringing in the ear) and clicking sensations in the ear?

Treatment of Tinnitus and Clicking Sensations in the Ear

For tinnitus and clicking sensations in the ear, cognitive behavioral therapy (CBT) combined with sound therapy is the most effective treatment approach for improving quality of life and reducing symptom severity. 1, 2

Initial Evaluation

• Rule out cerumen impaction as a cause of tinnitus or clicking sensations, as this is a common and easily treatable cause 1
• Comprehensive audiologic examination is essential, especially for unilateral or persistent tinnitus, or tinnitus associated with hearing difficulties 2
• Imaging (MRI/CT) is not routinely indicated unless there are concerning features such as:
  • Unilateral or asymmetric tinnitus
  • Pulsatile tinnitus
  • Associated neurological symptoms
  • Sudden onset hearing loss 1

Treatment Algorithm for Tinnitus

First-Line Treatments

• Cognitive Behavioral Therapy (CBT)

  • Strongest evidence base for improving quality of life in tinnitus patients 2, 3
  • Helps patients develop coping strategies and change negative thought patterns about tinnitus 4

• Sound Therapy

  • Wide-band sound therapy can help mask tinnitus and reduce its perception 4
  • Options include:
    • White noise machines
    • Environmental sound generators
    • Smartphone apps with nature sounds or white noise 1, 2

• Hearing Aids

  • Recommended for patients with hearing loss and tinnitus, even if the hearing loss is mild or unilateral 2
  • Amplification can mask tinnitus and reduce auditory deprivation that may contribute to tinnitus 1, 4

Education and Counseling

• Provide reassurance about the benign nature of most tinnitus 1
• Explain that tinnitus is a symptom, not a disease, and often associated with hearing loss 3
• Discuss the natural course of tinnitus, which often improves over time 2
• Teach sound avoidance strategies to prevent worsening of symptoms 3

For Clicking Sensations Specifically

• If clicking is related to temporomandibular joint (TMJ) dysfunction:
  • Jaw relaxation exercises
  • Avoid excessive jaw movements
  • Consider dental consultation 1
• If clicking is related to eustachian tube dysfunction:
  • Nasal decongestants if associated with upper respiratory infection
  • Nasal steroids if allergic component is suspected 1

Treatments to Avoid

• Medications not recommended for primary treatment of persistent tinnitus:

  • Antidepressants (except for comorbid depression)
  • Anticonvulsants
  • Anxiolytics
  • Intratympanic medications 2

• Dietary supplements lack sufficient evidence:

  • Ginkgo biloba
  • Melatonin
  • Zinc 2, 3

• Transcranial Magnetic Stimulation (TMS) is not recommended for routine tinnitus treatment 2

Special Considerations

• For severe anxiety or depression related to tinnitus:

  • Prompt psychiatric evaluation is essential as suicide risk may be elevated 1, 2
  • Appropriate psychiatric medications may be indicated for the mood disorder, not the tinnitus itself 3

• For sleep disturbances:

  • Melatonin may help with sleep issues but not the tinnitus directly 3, 5
  • Sound therapy at bedtime can mask tinnitus and improve sleep quality 4, 5

Prevention of Further Damage

• Avoid excessive noise exposure
• Use hearing protection in loud environments
• Avoid ototoxic medications when possible 2, 3

Follow-up Care

• Regular audiologic evaluations to monitor hearing status
• Adjustment of treatment strategies based on response and tinnitus severity
• Continued counseling and support for persistent symptoms 2, 3

Common Pitfalls to Avoid

• Focusing solely on finding a "cure" rather than managing symptoms and improving quality of life 6
• Neglecting the psychological impact of tinnitus 1
• Excessive medical testing without clear indications 1
• Promising complete resolution, as many forms of tinnitus can be managed but not eliminated 6, 5