Treatment of Radiation and Chemotherapy-Induced Tinnitus
Refer all patients with tinnitus following platinum-based chemotherapy (especially cisplatin) or head/brain radiotherapy ≥30 Gy to an audiologist for comprehensive evaluation and management. 1
Who Is at Risk
Patients treated with the following are at increased risk for tinnitus:
- Cisplatin (any dose, with or without high-dose carboplatin >1500 mg/m²) 1
- Head or brain radiotherapy ≥30 Gy (particularly when temporal bone or brainstem are in the radiation field) 1
- Combined platinum and radiation therapy (highest risk) 1
Approximately 50% of childhood, adolescent, and young adult (CAYA) cancer survivors develop ototoxicity after these treatments, though tinnitus can occur in adults as well. 1
Evidence-Based Treatment Approach
First-Line Interventions
Cognitive Behavioral Therapy (CBT) is the cornerstone treatment with the strongest evidence for reducing tinnitus-related distress and improving quality of life. 2, 3 This should be the primary recommendation for persistent, bothersome tinnitus.
Audiological interventions include:
- Hearing aids if any degree of hearing loss is present (even mild or unilateral), as they address both hearing deficits and tinnitus simultaneously 2, 4
- Sound therapy to provide symptomatic relief through stress reduction and attention diversion 2
- Counseling and education about tinnitus mechanisms and management strategies 1, 2, 3
Specific Management Options
The International Late Effects of Childhood Cancer Guideline Harmonization Group recommends the following interventions can be offered: 1
- Psychological interventions: Cognitive behavioral therapy, counseling, education about management strategies 1
- Audiological interventions: Hearing aids, sound therapy, or both 1
- Tinnitus retraining therapy (TRT): Combines educational counseling with sound therapy 5
The goal is habituation and reduced distress, not elimination of tinnitus—approximately 80% of patients adapt over time without medical intervention. 2
Treatments to AVOID
Do not prescribe the following, as they lack evidence and may cause harm:
- Medications: Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary tinnitus treatment 2, 3, 4
- Dietary supplements: Ginkgo biloba, melatonin, zinc, or other supplements (no consistent benefit in RCTs) 2, 3
- Transcranial magnetic stimulation (TMS): Not recommended for routine treatment 3
Critical Pitfalls to Avoid
Do not overlook psychiatric comorbidities: Patients with severe anxiety or depression require prompt intervention due to increased suicide risk in tinnitus patients with psychiatric conditions. 2, 3 This is a quality-of-life and mortality issue that must be addressed.
Do not ignore hearing loss: Even mild or unilateral hearing loss warrants hearing aid evaluation, as this can improve both hearing and tinnitus. 2, 4 Many patients have hearing deficits that contribute to tinnitus distress.
Do not delay referral: Audiological assessment should occur promptly for symptomatic patients, as early intervention improves outcomes. 1, 3
Surveillance Recommendations
For cancer survivors at risk, healthcare providers should:
- Educate patients about the potential for tinnitus development 1
- Refer to audiologist when tinnitus symptoms develop (strong recommendation) 1
- Monitor for progression of symptoms, though the natural history of chemotherapy/radiation-induced tinnitus is not well-established 1
Special Considerations
Low-dose cisplatin regimens (40 mg/m² weekly) appear to cause less severe tinnitus than high-dose regimens (100 mg/m²), with >50% of patients reporting no tinnitus after treatment. 6 However, any cisplatin exposure carries risk.
Radiation dose matters: Mean cochlear doses <32 Gy are associated with <20% incidence of grade 2+ tinnitus, suggesting dose constraints may reduce risk. 7 Modern techniques like intensity-modulated radiotherapy (IMRT) reduce ototoxicity compared to older methods. 1
Behavioral interventions to preserve remaining hearing are critical—patients should avoid loud noise exposure to prevent further damage. 1, 3