How to manage tinnitus in a patient with unilateral hearing loss?

Managing Tinnitus in a Patient with Unilateral Hearing Loss

For a patient with unilateral hearing loss and tinnitus, you should recommend a hearing aid evaluation as the first-line intervention, even if the hearing loss is mild, because hearing aids provide significant relief for tinnitus and improve quality of life through both amplification and sound enrichment. 1

Initial Assessment and Audiologic Testing

• Obtain a comprehensive audiologic examination immediately, including pure tone audiometry, speech audiometry, and acoustic reflex testing, regardless of whether the patient reports hearing difficulties 1, 2
• Document tinnitus characteristics: laterality (confirm it's ipsilateral to hearing loss), duration, quality, pitch, and degree of bother using validated tools like the Tinnitus Handicap Inventory 1, 2
• Perform otoscopic examination to rule out cerumen impaction, middle ear pathology, or vascular retrotympanic masses 2
• Assess for associated symptoms including vertigo, otalgia, otorrhea, or neurological deficits that might indicate underlying pathology requiring imaging 1, 2

Imaging Considerations

Do NOT routinely order imaging for unilateral tinnitus with unilateral hearing loss unless specific red flags are present. 1

Order MRI of internal auditory canals with contrast if: 2, 3

• The hearing loss is asymmetric (worse than expected for age/noise exposure on one side)
• Tinnitus is pulsatile
• Focal neurological abnormalities are present
• The patient specifically requests evaluation for vestibular schwannoma

For bilateral, symmetric hearing loss with non-pulsatile tinnitus, imaging is not indicated and represents inappropriate resource utilization. 1, 3

Treatment Algorithm Based on Hearing Loss Severity

For Mild to Moderate Unilateral Hearing Loss:

Primary intervention: Hearing aid evaluation and fitting 1

• The American Academy of Otolaryngology explicitly states that hearing aids benefit tinnitus even with mild or unilateral hearing loss 1
• Hearing aids work through dual mechanisms: improving auditory input and providing sound enrichment that masks tinnitus 1, 4
• 86% of patients with unilateral hearing loss report significant hearing handicap, making amplification beneficial beyond tinnitus relief 1, 4

Amplification options for unilateral loss: 1, 4

• Monaural hearing aid if residual hearing in affected ear can benefit from amplification
• CROS (Contralateral Routing of Signal) device if affected ear has profound loss—microphone on bad ear transmits to good ear
• BiCROS if the better ear also has hearing loss requiring amplification
• Bone-anchored hearing aids for patients who cannot use conventional aids

For Severe to Profound Unrecovered Unilateral Loss:

Consider cochlear implantation, particularly if tinnitus is severe and bothersome 1, 4

• 96% of patients report tinnitus improvement post-cochlear implantation 4
• This option is especially appropriate when tinnitus significantly impacts quality of life despite other interventions 1

Adjunctive Management Strategies

Education and Counseling (Required for All Patients):

Provide structured education about: 1

• Tinnitus mechanisms and natural history
• The strong association between hearing loss and tinnitus
• Realistic expectations for treatment outcomes
• Safety concerns related to impaired sound localization with unilateral hearing loss 1, 4

Sound Therapy:

May recommend sound therapy as an adjunct to hearing aids 1

• Background sound generators, white noise machines, or smartphone apps
• Most effective when combined with counseling 5

Cognitive Behavioral Therapy:

Should recommend CBT for persistent, bothersome tinnitus (≥6 months duration) 1

• CBT is the only treatment proven to improve quality of life in tinnitus patients 6
• Addresses the emotional and cognitive reactions to tinnitus rather than the sound itself 1
• Strongest evidence exists for combination of sound therapy and CBT-based counseling 5

What NOT to Do

Do not routinely prescribe: 1

• Antidepressants, anticonvulsants, or anxiolytics as primary tinnitus treatment
• Intratympanic medications (steroids, gentamicin) for chronic tinnitus
• Ginkgo biloba, melatonin, zinc, or other dietary supplements
• Transcranial magnetic stimulation

These interventions lack evidence for efficacy and carry potential side effects without proven benefit. 1

Follow-Up and Monitoring

• Reassess tinnitus severity and hearing status at 3-6 month intervals after hearing aid fitting 4
• Adjust amplification settings based on patient feedback and audiometric changes 4
• Refer to otolaryngology if tinnitus worsens, becomes pulsatile, or new neurological symptoms develop 2, 3
• Consider mental health referral if depression or anxiety significantly impacts quality of life 6, 5

Critical Pitfalls to Avoid

• Delaying hearing aid fitting while pursuing other interventions—hearing aids are first-line treatment with strongest evidence 1, 4
• Assuming mild unilateral hearing loss doesn't warrant amplification—the guidelines explicitly state even mild or unilateral loss benefits from hearing aids for tinnitus 1
• Ordering imaging for non-pulsatile unilateral tinnitus with symmetric hearing loss—this is inappropriate unless asymmetric hearing loss or other red flags exist 1, 2, 3
• Prescribing medications as primary treatment—no pharmacologic therapy has proven efficacy for primary tinnitus management 1, 6