Treatment of tinnitus

INTRODUCTION — Tinnitus is a perception of sound in proximity to the head in the absence of an external source. The sound may be a buzzing, ringing, or hissing, although it can also sound like other noises.

Tinnitus is most commonly associated with hearing loss, though it may be a presenting symptom of vascular or neurologic abnormalities. Once a serious underlying medical condition has been ruled out, treatment should be directed at the symptom itself, which severely interferes with the quality of life in approximately 10 percent of patients with tinnitus [1].

This topic will review the treatment of tinnitus. The epidemiology, pathogenesis, and diagnosis of tinnitus are discussed separately. (See "Etiology and diagnosis of tinnitus".)

Treatment for tinnitus includes correcting identified causes and comorbidities as well as directly addressing the effects of tinnitus on quality of life. For many patients, tinnitus is a chronic condition; goals of treatment are to lessen its impact and any associated disability, rather than to achieve absolute cure. Several treatment modalities have been studied, including behavioral treatments and medications, but the benefit for most of these interventions has not been conclusively demonstrated in randomized trials [2-4]. High-quality treatment trials are lacking [4].

ADDRESSING PATIENT CONCERNS — Patients may be concerned that tinnitus is a symptom of something worrisome. If, after an appropriate evaluation, the cause is determined not to be worrisome, patients benefit from reassurance and education.

TREATABLE CAUSES — Certain causes of tinnitus can be addressed directly.

Vascular abnormalities — Patients with vascular tinnitus may benefit from a variety of procedures. As examples, a bruit from an arteriovenous malformation, dural arteriovenous fistula, or dehiscent jugular bulb may be treated by ligation or embolization, and glomus tumors can be treated by angiographic embolization and surgical resection [5-7].

By contrast, reassurance is usually adequate for patients with venous hums or benign arterial variants causing pulsatile tinnitus. Rarely, surgical or angiographic ligation of the offending vessel is indicated for patients whose pulsatile tinnitus is so loud that it cannot be adequately treated with masking or other noninvasive treatment strategies and who experience significant impairment in their quality of life [8,9].

Drug toxicity — Tinnitus due to ototoxic effects on the hair cells of the cochlea may be reversible in patients after stopping ototoxic medications (table 1). Often tinnitus is the first sign that ototoxicity is occurring and can herald more severe injury to the inner ear. Discontinuing these medications can prevent progression to hearing loss and/or balance systems dysfunction in some patients even if tinnitus does not resolve. Cochlear rescue medications are under investigation in patients with chemotherapy-induced tinnitus [10-13].

Hearing loss — For patients with bothersome tinnitus related to hearing loss lasting more than six months, the use of an appropriately fitted hearing aid may act to mask the tinnitus. As with other masking strategies, the tinnitus tends to return some time after the hearing aid is removed. In a trial comparing hearing aid use with a sound generator for tinnitus associated with hearing loss, both interventions had comparable benefits [14,15]. Patients with conductive hearing loss due to outer ear or middle ear disease may benefit from surgery to correct the conductive defect which may then improve the severity of the tinnitus (table 2) [16,17]. These patients may also derive some benefit of a reduction in tinnitus severity by improving hearing levels with hearing aids if surgery is not an option.

Cochlear implantation is a well-accepted therapy in adults and children with severe hearing impairment who are not benefiting from hearing aids. This electrical stimulation of the auditory pathway is also associated with a loss or reduction of tinnitus in 34 to 93 percent of patients receiving cochlear implants, although some individuals develop tinnitus postoperatively [18-21]. In a case series of 21 patients with incapacitating tinnitus and unilateral deafness, cochlear implantation in the deaf ear resulted in reduction of tinnitus loudness and distress [22]. However, a full evaluation for candidacy is required before a cochlear implant can be considered.

Patulous Eustachian tube — Treatment of patulous Eustachian tube can help to improve or resolve tinnitus [23]. A patulous Eustachian tube can be treated with a variety of agents, including application of mucosal irritants to the nasopharynx, which result in swelling or scarring of the Eustachian tube orifice, or various surgical techniques to close the nasopharyngeal orifice. This is discussed in more detail elsewhere. (See "Eustachian tube dysfunction", section on 'Patulous dysfunction'.)

Other causes — Investigational therapies aimed at protecting the inner ear from noise trauma (noise induced damage) are being studied. To date there are only low levels of evidence for pharmacologic treatments for noise-induced tinnitus [24].

COEXISTING CONDITIONS — Certain conditions tend to coexist with tinnitus and should be treated concurrently.

Depression — Patients with depression require appropriate treatment. In a randomized trial, treatment with nortriptyline 100 mg, compared with placebo, resulted in overall benefit for patients with disabling tinnitus (67 versus 40 percent), although tinnitus severity was not significantly improved [25]. A meta-analysis of six randomized trials of antidepressants for treatment of tinnitus (four evaluating tricyclic antidepressants, one using paroxetine initiated at 10 mg daily, one studying trazodone) found no conclusive evidence for the effectiveness of antidepressants in this condition [26]. There was a suggestion of tinnitus improvement in a patient subgroup that received higher doses of paroxetine (50 mg) in one study [27], but this requires further evaluation.

Insomnia — Patients with tinnitus who have insomnia should be treated for their sleep disorder with the goal of reducing the extent to which the tinnitus affects their quality of life [28]. (See "Overview of the treatment of insomnia in adults".)

BEHAVIORAL THERAPIES — For patients in whom a treatable cause cannot be found, or for those who continue to have bothersome symptoms after available treatments, behavioral interventions may be useful. There has been reported success with:

●Tinnitus retraining therapy (TRT)

●Cognitive behavioral therapy (CBT)

●Biofeedback and stress reduction programs

Multidisciplinary programs at tinnitus centers are available to assist patients with disabling tinnitus. A randomized trial, performed in an audiologic referral center, compared a multidisciplinary stepped therapy approach (incorporating TRT and CBT and involving clinical psychologists, movement therapists, physical therapists, speech therapists, social workers, and audiologists) to usual care for 492 adult patients with tinnitus [29]. At 12 months, patients assigned to the stepped therapy had significant improvement in scores reflecting health-related quality of life, tinnitus impairment, and tinnitus severity.

Tinnitus retraining therapy — TRT is based upon bypassing or overriding abnormal auditory cortex neural connections. These therapies are performed at specialized tinnitus centers and in some audiologic practices; techniques vary among practitioners and each center has its own specific rates of success.

TRT is based on the principle that all levels of the auditory pathways and several nonauditory systems play essential roles in tinnitus; TRT enhances the role of nonauditory systems in determining the level of tinnitus annoyance [30]. TRT involves inducing and facilitating habituation to the tinnitus signal. The goal is to reach a stage in which patients are unaware of their tinnitus unless they specifically and consciously focus on it. Furthermore, even when perceived, tinnitus does not evoke annoyance. Habituation is achieved by directive counseling combined with low-level, broad-band noise generated by wearable generators, and environmental sounds, according to a specific protocol.

High-quality data are limited [31]. Significant improvement has been reported in case series and wait-list controlled studies, with as many as 80 percent of patients with high-pitched tinnitus experiencing improvement when using TRT with combined counseling and noise generators [30,32-34]. The long-term impact may be less reliable [35]. TRT can take one to two years before the patient no longer needs the external device.

In a trial among 123 participants with tinnitus, TRT treatments every three months for 18 months were more effective at 12 months than tinnitus masking in improving symptoms as measured by self-administered tinnitus questionnaires [36].

Cognitive behavioral therapy — CBT is an intervention directed at teaching patients to alter their psychological response to their tinnitus by identifying and reinforcing coping strategies, distraction skills, and relaxation techniques [37]. Patients must be motivated, as they are required to keep diaries and perform homework as part of CBT.

In a meta-analysis of 10 trials comparing different forms of CBT delivery (including group therapy and internet therapy) to controls, CBT improved tinnitus symptoms in nine trials [2]. Internet-delivered CBT and self-help books may be useful in patients who cannot access a formal CBT program [38].

Biofeedback and stress reduction — Biofeedback is a relaxation technique that teaches people to control certain autonomic body functions. It was first described as a stand-alone therapy for tinnitus in the 1980s and continues to be used as part of a battery of therapy options at many tinnitus centers. The goal is to help people manage tinnitus-related distress by changing the patient's reaction to it. High quality data are limited, although many people notice a reduction in tinnitus when they are able to modify their reaction to it [39,40].

LIMITED ROLE FOR MEDICATIONS — Medications are not a mainstay of tinnitus treatment. Systematic reviews of antidepressant therapies and anticonvulsants for tinnitus have not found evidence of efficacy [26,41]. The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) guidelines state that clinicians should not routinely recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for treatment of treating persistent, bothersome tinnitus [42]. Further, they also state that clinicians should not recommend ginkgo biloba, melatonin, zinc, or other dietary supplements for this purpose [42]. Lidocaine should not be used in the treatment of tinnitus [3].

Some medication therapies may have value:

●Benzodiazepines (eg, alprazolam) have been found in small trials to be effective in the treatment of tinnitus [43,44] and are thought to act on the anxiety often associated with tinnitus.

●Intratympanic medications, such as dexamethasone, have been used with some success in patients with tinnitus, particularly in those with cochlear disease (eg, sudden hearing loss, autoimmune inner ear disease, Meniere disease) [45,46]. In a small randomized trial of patients with idiopathic tinnitus of less than three months' duration, those who were assigned to combination intratympanic dexamethasone and oral alprazolam reported greater improvement in tinnitus symptoms, compared with oral alprazolam alone [47].

MASKING — Masking is a general term for using one sound to block the perception of another sound. Masking is used for patients with hearing loss and tinnitus. (See 'Hearing loss' above.)

Sound therapy uses maskers that are tuned by the audiologist to what is most effective for a specific patient. Masking devices resemble hearing aids and are designed to produce low-level sounds that reduce the perception of tinnitus [48]. Some patients report decrease in tinnitus with use of such devices, although there is no conclusive evidence from randomized trials to clarify the evidence of effectiveness. One systematic review of eight trials found no evidence to support the superiority of sound therapy for tinnitus over placebo or education [49].

Masking can also produce the phenomenon of residual inhibition, where the reduction or elimination of tinnitus perception continues for a short time after the masker is removed. One therapy under evaluation, phase-shift treatment, aims to enhance residual inhibition that results from masking. Similar to the concept used in sound cancellation headphones, phase-shift therapy uses a sound wave that is phase-shifted 180 degrees from the patient's endogenous sound wave. Residual inhibition lasting one hour to seven days was reported in 42 percent of patients during active phase-shift treatment for two weeks, and in no patients during nontreatment control weeks, in a crossover study (n = 61) [50].

Potential adverse effects of masking therapy include worsening of tinnitus, associated discomfort, or worsening hyperacusis [51].

Masking may also be accomplished using or enhancing ambient background noise. Use of background music, sound machines, radios on low volume, fans, and pillow speakers have been helpful to patients with tinnitus that is especially bothersome in quiet environments.

INEFFECTIVE TREATEMENTS

Electrical stimulation in patients without hearing loss — Electrical stimulation of the cochlea by directly placing electrodes on the bony cochlea or in the round window niche have resulted in tinnitus improvement in patients with hearing loss. Transcutaneous electrical stimulation is the only available electrical option that is not associated with a risk of causing hearing loss [52]. Electrical stimulation may be provided either through a single electrode or via multiple placed acupuncture needles over the mastoids or around the auricle.

In patients without hearing loss, however, electrical stimulation external to the middle or inner ear has not been demonstrated to be more effective for tinnitus suppression than placebo treatment; responses were approximately 38 to 43 percent for both groups [53,54].

Acupuncture — Acupuncture, alone or in conjunction with electrical stimulation, has not been found to be more effective than placebo [55-57].

Repetitive transcranial magnetic stimulation — Repetitive transcranial magnetic stimulation (rTMS) has been investigated in patients with different medical conditions (eg, movement disorders, seizures, and depression) and has shown modest effectiveness. However, the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) guidelines state that clinicians should not recommend rTMS for the routine treatment of patients with persistent, bothersome tinnitus [42]. In a systematic review that included five small randomized trials of patients with tinnitus (n = 233), there were limited data showing improvement in severity or disability of tinnitus with rTMS therapy [58]. A subsequent randomized trial in 64 participants with chronic tinnitus found that, compared with placebo, participants who received treatment with 10 consecutive days of rTMS were more likely to have improvement in tinnitus functional index (56 versus 22 percent) [59]. Improvements were sustained during the 26-week follow-up period. Although rTMS appears to be safe in short-term treatment, safety with long-term treatment is not known. Larger trials are needed to determine the conditions and parameters under which rTMS may be effective.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hearing loss and hearing disorders in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Tinnitus (ringing in the ears) (The Basics)")

●Beyond the Basics topics (see "Patient education: Tinnitus (ringing in the ears) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Treatable causes – Treatment for tinnitus is be aimed at the underlying abnormality, when identified. (See 'Treatable causes' above.)

•Sensorineural hearing loss – Cochlear implants for patients with severe sensorineural hearing loss may improve tinnitus. (See 'Hearing loss' above.)

•Vascular abnormalities – Patients with vascular tinnitus may benefit from a variety of procedures. (See 'Vascular abnormalities' above.)

•Drug toxicity – Discontinuing of offending medications can reverse tinnitus and may prevent progression to hearing loss and/or balance systems dysfunction. (See 'Drug toxicity' above.) (table 1)

•Patulous Eustachian tube – Treatment of this condition can reduce or resolve tinnitus. (See 'Patulous Eustachian tube' above.)

●Exacerbating conditions – We encourage treatment of underlying depression and insomnia, as these conditions may exacerbate symptoms of tinnitus. (See 'Coexisting conditions' above.)

●Behavioral therapies – For patients with no obvious treatable cause who are significantly impacted by their tinnitus symptoms, we suggest either tinnitus retraining therapy (TRT), or cognitive behavioral therapy (CBT) (Grade 2C). A trial of biofeedback may also be helpful as an adjunct to TRT or CBT. (See 'Behavioral therapies' above.)

●Limited role for medications – Medications for tinnitus have limited effectiveness. (See 'Limited role for medications' above.)