What are the treatment options for patients with tinnitus and hearing loss?

Treatment Options for Tinnitus and Hearing Loss

For patients with tinnitus and hearing loss, the most effective treatment approach includes hearing aid evaluation, cognitive behavioral therapy, and sound therapy, with hearing aids being particularly beneficial even for mild hearing loss.

Initial Assessment

• Comprehensive audiologic examination should be performed for all patients with tinnitus, regardless of laterality, duration, or perceived hearing status, to identify underlying hearing loss which is frequently associated with tinnitus 1
• Imaging studies should not be obtained for tinnitus evaluation unless there is unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss 1
• Distinguish between bothersome and non-bothersome tinnitus, and determine if tinnitus is recent onset or persistent (≥6 months) to guide treatment decisions 1, 2

First-Line Treatment Options

Hearing Aids

• Hearing aid evaluation should be recommended for all patients with hearing loss and persistent, bothersome tinnitus, even if hearing loss is only mild or unilateral 1, 3, 2
• Hearing aids provide two benefits: they make the patient less aware of tinnitus and improve communication by reducing the sensation that sounds are masked by tinnitus 4
• Hearing aids can provide sufficient activation of the auditory nervous system to reduce tinnitus perception and may elicit neural plasticity that can have long-term beneficial effects 4
• For optimal results, hearing aids should be fitted to both ears, use an open ear aid with wide amplification band, and have disabled noise reduction controls 4

Cognitive Behavioral Therapy (CBT)

• CBT has the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus 1, 3, 5
• CBT should be recommended for all patients with persistent, bothersome tinnitus 2
• CBT helps patients develop coping strategies and modify negative thought patterns associated with tinnitus 3, 2

Sound Therapy

• Sound therapy may be recommended as a management option for persistent tinnitus, providing symptomatic relief 3, 6
• Sound therapy includes various options such as masking devices, environmental sound enrichment, and combination devices (hearing aid + sound generator) 3, 6

Education and Counseling

• Education and counseling should be provided to all patients with persistent, bothersome tinnitus about management strategies 1, 7, 2
• Counseling should include information about the causes of tinnitus, its natural course, and available treatment options 7, 5

Treatments Not Recommended

• Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications should not be routinely recommended for treating persistent, bothersome tinnitus due to insufficient evidence and potential side effects 1, 3, 2
• Dietary supplements, including Ginkgo biloba, melatonin, zinc, or other supplements, should not be recommended due to lack of consistent benefit 3, 2
• Transcranial Magnetic Stimulation (TMS) should not be recommended for routine tinnitus treatment 2

Treatment Algorithm

1. Perform comprehensive audiologic examination to identify hearing loss 1, 7
2. For patients with hearing loss and tinnitus:
   • Recommend hearing aid evaluation as first-line treatment 1, 3, 2
   • Consider combination devices (hearing aid + sound generator) for patients with significant tinnitus distress 3, 4
3. For all patients with persistent, bothersome tinnitus:
   • Recommend CBT 1, 2
   • Provide education and counseling about tinnitus management strategies 1, 7, 2
   • Consider sound therapy options 3, 6
4. For patients with sleep disturbance, anxiety, or depression related to tinnitus:
   • Address these specific issues with appropriate interventions 5, 6

Common Pitfalls to Avoid

• Overlooking mild hearing loss that could benefit from hearing aid intervention 3, 2
• Prescribing medications without clear evidence of benefit that may cause side effects or worsen tinnitus 3, 2
• Recommending dietary supplements that lack evidence of efficacy 3, 2
• Failing to distinguish between different types of tinnitus (pulsatile vs. non-pulsatile) which require different evaluation approaches 7, 8
• Neglecting to provide adequate education and counseling, which are essential components of tinnitus management 1, 7, 2