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

Treatment of Hearing Loss and Tinnitus

For patients with both hearing loss and tinnitus, hearing aids are the first-line treatment and should be recommended even for mild or unilateral hearing loss, combined with cognitive behavioral therapy (CBT) for persistent, bothersome tinnitus. 1, 2

Initial Evaluation Algorithm

Step 1: Obtain Comprehensive Audiologic Testing

• Perform pure tone audiometry, speech audiometry, and acoustic reflex testing within 4 weeks of presentation for any patient with tinnitus that is unilateral, persistent (≥6 months), or associated with hearing difficulties 1, 3
• Consider audiologic examination for all tinnitus patients regardless of laterality or duration, as hearing loss may be present even when not perceived by the patient 1, 3

Step 2: Classify Tinnitus Severity and Duration

• Distinguish bothersome from non-bothersome tinnitus, as this determines treatment intensity 1, 3
• Separate recent onset (<6 months) from persistent tinnitus (≥6 months), since interventions are primarily studied in persistent cases 1, 4

Step 3: Determine Need for Imaging

• Do NOT obtain imaging for bilateral, non-pulsatile tinnitus without neurological findings 1, 3
• DO obtain imaging only if: unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss are present 1, 3

Evidence-Based Treatment Protocol

For Patients WITH Hearing Loss and Tinnitus

Primary Intervention: Hearing Aid Evaluation

• Recommend hearing aid evaluation for all patients with documented hearing loss and persistent, bothersome tinnitus 1, 4
• Hearing aids benefit tinnitus even with mild or unilateral hearing loss by restoring auditory input and reducing tinnitus awareness 1, 2, 5
• Fit hearing aids to both ears when bilateral hearing loss exists, use open ear aids with wide amplification bands, and disable noise-reducing controls for optimal tinnitus benefit 5
• Hearing aids improve quality of life by both reducing tinnitus perception and improving communication 1, 5

Secondary Intervention: Cognitive Behavioral Therapy

• Recommend CBT for all patients with persistent, bothersome tinnitus, regardless of hearing loss severity or tinnitus duration 1, 2
• CBT typically consists of 8 weekly sessions of approximately 120 minutes each, including cognitive restructuring, applied relaxation, behavioral activation, and positive mental imagery 2
• CBT has the strongest evidence base (Grade B from RCTs) for improving quality of life in tinnitus patients 2, 4
• CBT works equally well across all patient subgroups, making it universally applicable 2

Foundational Support: Education and Counseling

• Provide education about tinnitus mechanisms, natural history, and management strategies to all patients with persistent, bothersome tinnitus 1, 3, 4
• Counseling reduces anxiety and helps patients understand that tinnitus rarely indicates serious pathology 1, 6

Optional Adjunct: Sound Therapy

• May recommend sound therapy (background noise, white noise, nature sounds) for symptomatic relief in persistent, bothersome tinnitus 1, 4
• Sound therapy has weaker evidence than CBT or hearing aids but provides an additional management option 1, 4

For Patients WITHOUT Hearing Loss but WITH Tinnitus

Primary Interventions:

• Recommend CBT as first-line treatment for persistent, bothersome tinnitus without hearing loss 1, 2
• Provide education and counseling about management strategies 1, 4
• May offer sound therapy as adjunctive symptomatic relief 1, 4

Treatments to AVOID

Medications: Do NOT Routinely Prescribe

• Do NOT recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary tinnitus treatment 1, 4
• These medications have insufficient evidence (Grade B from flawed RCTs), potential significant side effects, and some may worsen tinnitus 1, 2
• Exception: May consider these medications if treating comorbid psychiatric conditions (depression, anxiety), but not for tinnitus itself 1, 4

Dietary Supplements: Do NOT Recommend

• Do NOT recommend Ginkgo biloba, melatonin, zinc, or other dietary supplements for tinnitus treatment 1, 4
• These lack consistent evidence of benefit and represent unnecessary expense 1, 4

Other Unproven Therapies

• Do NOT recommend transcranial magnetic stimulation (TMS) for routine treatment 1
• Acupuncture has insufficient evidence to make a recommendation either way 1, 7

Common Pitfalls to Avoid

• Overlooking mild hearing loss: Even mild or unilateral hearing loss benefits from hearing aid evaluation, as this can significantly improve both hearing and tinnitus 1, 4
• Prescribing medications without evidence: Antidepressants and anticonvulsants lack efficacy for tinnitus and carry side effect risks including potentially worsening tinnitus 1, 2
• Ordering unnecessary imaging: Bilateral, non-pulsatile tinnitus without neurological findings does not require imaging 1, 3
• Delaying audiologic testing: Comprehensive audiometry should be obtained promptly (within 4 weeks) to identify treatable hearing loss 1, 3
• Relying on patient self-report of hearing: Patients cannot accurately assess their own hearing status; objective audiometry is essential 1, 3

Special Considerations

Pulsatile Tinnitus

• Pulsatile tinnitus almost always requires imaging evaluation (CTA or MRA) to identify vascular abnormalities 3, 4, 8
• This represents a distinct entity from non-pulsatile tinnitus and may indicate serious underlying pathology 4, 8

Psychiatric Comorbidities

• Promptly identify and intervene for patients with severe anxiety or depression, as suicide risk is increased in tinnitus patients with psychiatric illness 1, 4
• While psychiatric medications may be appropriate for treating comorbid conditions, they should not be prescribed primarily for tinnitus 1, 4

Chemotherapy-Induced Tinnitus

• No causative treatment exists for established platinum-based chemotherapy ototoxicity 4
• Hearing aids remain beneficial for chemotherapy-induced hearing loss and tinnitus 4
• CBT strategies can be offered with moderate supporting evidence 4