Is Hyperbaric Oxygen Therapy (HBOT) a suitable treatment option for a patient with tinnitus?

HBOT Treatment of Tinnitus

HBOT is not recommended for the treatment of isolated chronic tinnitus, but may be considered as an adjunctive therapy within 2-4 weeks of onset only when tinnitus accompanies sudden sensorineural hearing loss (SSNHL).

Critical Distinction: Tinnitus Type Matters

The evidence for HBOT in tinnitus depends entirely on whether the tinnitus is:

• Associated with acute SSNHL: HBOT may offer benefit when combined with steroids within 2 weeks of onset 1
• Isolated chronic tinnitus: No evidence supports HBOT use 2

When HBOT May Be Considered (Tinnitus with SSNHL)

For tinnitus accompanying sudden sensorineural hearing loss, the American Academy of Otolaryngology-Head and Neck Surgery provides specific guidance:

• Initial therapy: HBOT combined with steroid therapy may be offered within 2 weeks of SSNHL onset 1
• Salvage therapy: HBOT combined with steroid therapy may be offered within 1 month of SSNHL onset for patients who failed initial treatment 1
• Optimal timing: Treatment is more effective when performed within 2 weeks of acute onset 1
• Best candidates: Patients with moderate to severe hearing losses (≥60 dB) show greater improvement than those with mild losses 1

Treatment Protocol for SSNHL-Associated Tinnitus

• Pressure: 100% oxygen at >1 atmosphere absolute (ATA) 1, 3
• Duration: 10-20 sessions of 30-90 minutes each 3
• Combination therapy: Must be combined with corticosteroid therapy (systemic or intratympanic) 1

When HBOT Should NOT Be Used

For chronic isolated tinnitus (>6 months duration), the evidence is clear:

• A Cochrane systematic review found no significant improvements in tinnitus for chronic presentation 2
• The review explicitly states: "There is no evidence of a beneficial effect of HBOT on chronic ISSHL or tinnitus and we do not recommend the use of HBOT for this purpose" 2
• Studies of chronic tinnitus patients showed highly variable results, with 6.9% experiencing deterioration 4

Evidence Against HBOT for Chronic Tinnitus

• In a study of 360 patients with chronic tinnitus, only 3.3% experienced complete remission, while 6.9% worsened 4
• The therapeutic effect was significantly influenced by patient expectation (60.3% improvement in those with positive expectations vs 19% in those with negative expectations), suggesting substantial placebo effect 4
• A study of 20 patients with chronic distressing tinnitus (>1 year duration) found that 2 patients experienced adverse effects, and outcomes were mixed at best 5
• Improvement rates decreased significantly when time from tinnitus onset exceeded 40 days 6

Risks and Practical Considerations

Common complications that must be discussed with patients:

• Middle ear or sinus barotrauma occurs in 6-17% of patients 1, 7
• Difficulty equalizing pressure in the middle ear (17% of patients) 1
• Eustachian tube dysfunction (45% in some series) 1
• Temporary myopia 1, 7
• Claustrophobia during chamber confinement 1, 7
• Rare oxygen toxicity and seizures 7

Cost considerations:

• HBOT costs $600-700 per session 7
• A full course of 10-20 sessions represents substantial expense ($6,000-14,000) 7
• Requires specialized facilities not widely available 7

Clinical Algorithm

Step 1: Determine if tinnitus is associated with acute SSNHL

• If YES and <2 weeks from onset → Consider HBOT + steroids 1
• If YES and 2-4 weeks from onset with moderate-severe hearing loss → Consider HBOT + steroids 1
• If YES but >1 month from onset → HBOT unlikely to benefit 1

Step 2: If isolated chronic tinnitus (no SSNHL)

• Do NOT offer HBOT 2
• Pursue evidence-based tinnitus management strategies instead

Step 3: If HBOT is considered appropriate

• Ensure patient has realistic expectations (not a cure, modest benefit at best) 2
• Screen for contraindications (inability to equalize pressure, severe claustrophobia) 1
• Combine with corticosteroid therapy 1
• Initiate as early as possible within the therapeutic window 1

Key Pitfalls to Avoid

• Do not offer HBOT for chronic isolated tinnitus - the evidence does not support this use and patients may experience worsening 2, 5
• Do not use HBOT as monotherapy - it must be combined with steroids when treating SSNHL-associated tinnitus 1
• Do not delay treatment - efficacy decreases significantly after 2 weeks and is minimal after 1 month 1, 6
• Do not oversell benefits - even in acute SSNHL, the clinical significance of improvements remains unclear and results should be interpreted cautiously 2