What treatments are available for ringing in the ears (tinnitus) and dizziness?

Treatment Options for Tinnitus and Dizziness

For patients with tinnitus and dizziness, a stepwise treatment approach is recommended, starting with proper diagnosis to identify underlying causes such as Ménière's disease, followed by appropriate medical interventions including cognitive behavioral therapy for tinnitus and vestibular rehabilitation for dizziness.

Diagnosis

• Tinnitus (ringing in the ears) and dizziness occurring together often suggest an inner ear disorder, with Ménière's disease being a common cause characterized by episodes of vertigo, fluctuating hearing loss, ear fullness, and tinnitus 1
• Proper diagnosis requires distinguishing between subjective tinnitus (heard only by the patient) and objective tinnitus (can be heard by the examiner), as well as determining if the tinnitus is pulsatile or non-pulsatile 2, 3
• Comprehensive audiologic evaluation is essential for patients with unilateral tinnitus, tinnitus present for ≥6 months, or tinnitus accompanied by hearing difficulties 4
• Neuroimaging is indicated for unilateral, pulsatile tinnitus, or tinnitus associated with asymmetric hearing loss or focal neurologic abnormalities 5, 2

Treatment for Tinnitus

First-Line Treatments

• Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus and should be recommended as first-line therapy 2, 5, 4
• Hearing aids are strongly recommended for patients with hearing loss and tinnitus, even if the hearing loss is mild or unilateral 2, 4
• Sound therapy may provide symptomatic relief for persistent tinnitus by masking the tinnitus sound 2, 4
• Education and counseling are essential components of tinnitus management for all patients 2

Treatments Not Recommended

• Antidepressants, anticonvulsants, and anxiolytics are not recommended for routine treatment of persistent tinnitus due to insufficient evidence and potential side effects 2, 4
• Dietary supplements including Ginkgo biloba, melatonin, zinc, or other supplements should not be recommended due to lack of consistent benefit 2, 4

Treatment for Dizziness

• For dizziness related to Ménière's disease, treatment options include:
  • Lifestyle modifications such as low-salt diet and avoiding caffeine, alcohol, and tobacco 1
  • Medications such as meclizine for symptomatic relief of vertigo 6
  • Vestibular rehabilitation exercises to improve balance and reduce dizziness 1
  • For severe cases unresponsive to medical therapy, more invasive procedures may be considered 1

Special Considerations

• Pulsatile tinnitus almost always requires imaging evaluation to rule out vascular abnormalities 2, 7
• Patients with severe anxiety or depression related to tinnitus require prompt identification and intervention due to increased suicide risk 2
• Avoid overlooking mild hearing loss that could benefit from hearing aid intervention 2

Treatment Algorithm

1. Determine if tinnitus is bothersome and persistent (≥6 months) 4
2. Identify if tinnitus is unilateral, pulsatile, or associated with hearing loss or neurological symptoms 2, 3
3. For patients with associated hearing loss: Recommend hearing aid evaluation 2, 4
4. For patients with persistent bothersome tinnitus: Recommend CBT 2, 5, 4
5. For patients with dizziness suggestive of Ménière's disease: Consider lifestyle modifications and symptomatic medications 1, 6
6. For patients with severe symptoms affecting quality of life: Consider referral to specialist 1

By following this evidence-based approach, most patients with tinnitus and dizziness can experience significant improvement in their symptoms and quality of life.