How to manage tinnitus in a patient with hypothyroidism (myxoedema)?

Managing Tinnitus in Hypothyroidism (Myxoedema)

Treat the underlying hypothyroidism with levothyroxine replacement therapy first, as this is the primary intervention that may resolve tinnitus associated with myxoedema. 1, 2

Initial Assessment and Thyroid Optimization

The cornerstone of management is achieving euthyroid status through appropriate levothyroxine replacement, as tinnitus in hypothyroidism is a symptom of the underlying metabolic disorder rather than a primary auditory condition. 1, 2

Key thyroid management considerations:

• Start levothyroxine replacement immediately, with dosing based on severity of hypothyroidism and patient age/cardiac status 1
• Monitor TSH and free T4 levels closely during titration, aiming for normalization of thyroid function 1
• In severe myxoedema with poor compliance or absorption issues, intramuscular levothyroxine (200-500 mcg weekly) can be considered as an alternative route 1
• Allow adequate time (typically 6-12 weeks) for thyroid hormone levels to stabilize before concluding that tinnitus is unresponsive to thyroid replacement 1

Comprehensive Tinnitus Evaluation After Thyroid Stabilization

If tinnitus persists despite achieving euthyroid status, proceed with standard tinnitus evaluation protocols. 3, 4

Determine tinnitus characteristics:

• Classify as pulsatile versus non-pulsatile, as this fundamentally changes diagnostic approach and urgency 3, 5
• Document laterality (unilateral versus bilateral), duration, quality, and associated symptoms 3, 6
• Assess whether tinnitus is bothersome versus non-bothersome, as this guides treatment intensity 3, 4

Mandatory audiologic testing:

• Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for any unilateral or persistent tinnitus (≥6 months) 3, 4
• This should be performed even if the patient denies hearing difficulties, as sensorineural hearing loss is the most common association with tinnitus 3, 7

Imaging Decision Algorithm

Do NOT obtain imaging if:

• Tinnitus is bilateral, symmetric, non-pulsatile, and without focal neurologic abnormalities 3, 4
• This represents inappropriate resource utilization with no benefit 3

DO obtain imaging if any of the following are present:

• Unilateral tinnitus (order MRI internal auditory canals with contrast to evaluate for vestibular schwannoma) 3, 4
• Pulsatile tinnitus (order high-resolution CT temporal bone or CTA head/neck depending on suspected etiology) 3, 5
• Asymmetric hearing loss on audiometry 3, 4
• Focal neurological abnormalities 3, 4

Evidence-Based Treatment for Persistent Tinnitus

Once hypothyroidism is adequately treated and secondary causes excluded, management focuses on symptom control and quality of life improvement. 3, 4

Recommended interventions:

• Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus 3, 4
• Hearing aid evaluation and fitting for any documented hearing loss, even if mild or unilateral 3, 4
• Education and counseling about tinnitus mechanisms, natural history, and management strategies 3, 4
• Sound therapy may be offered as a management option for symptomatic relief 3

Treatments NOT recommended:

• Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications lack evidence for routine use 3, 4
• Dietary supplements (Ginkgo biloba, melatonin, zinc) should not be recommended due to lack of consistent benefit 3, 4

Critical Pitfalls to Avoid

Do not dismiss tinnitus as purely psychological without proper thyroid optimization and evaluation. 3, 1

• Ensure adequate levothyroxine dosing and compliance before concluding tinnitus is unrelated to hypothyroidism 1
• Do not overlook mild hearing loss that could benefit from hearing aid intervention 3, 4
• Avoid prescribing medications without clear evidence of benefit that may cause side effects 3, 4
• Recognize that patients with severe anxiety or depression require prompt identification and intervention due to increased suicide risk 8, 3

Special Considerations in Myxoedema

In severe myxoedema, multiple organ systems are affected, and tinnitus may be one of several auditory or neurologic manifestations. 1, 2

• Laryngeal myxoedema can cause upper airway obstruction and requires urgent management with levothyroxine and hydrocortisone 2
• Cognitive impairment from severe hypothyroidism may affect patient reporting of tinnitus characteristics 1
• Complete recovery of tinnitus may lag behind normalization of thyroid function tests by several weeks to months 1