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 neurological 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 — Treatment for tinnitus includes correcting identified 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]. A comparative effectiveness study on treatment for tinnitus for the Agency for Healthcare Research and Quality found that research is limited by the lack of data regarding measures to assess patients, and poorly collected data regarding adverse effects of a variety of interventions [4].
Associated factors — Prior to initiating therapy for tinnitus, it is important to address other associated conditions that can exacerbate tinnitus.
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), though tinnitus severity was insignificantly improved [5]. Suicidality may be increased in patients with tinnitus, but a cause and effect relationship is uncertain [6]. 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 evidence inconclusive for the effectiveness of antidepressants in this condition [7]. There was a suggestion of tinnitus improvement in a patient subgroup that received higher doses of paroxetine (50 mg) in one study [8], 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 severity of tinnitus [9]. (See "Overview of the treatment of insomnia in adults".)
Vascular abnormalities — Patients with vascular tinnitus may benefit from a variety of procedures. As examples, a bruit from an arteriovenous malformation (AVM), dural arteriovenous fistula (AVF), or dehiscent jugular bulb may be treated by ligation or embolization, and glomus tumors can be treated by angiographic embolization and surgical resection.
Reassurance for patients with venous hums or benign arterial variants causing pulsatile tinnitus may be helpful and is usually adequate. 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.
Presbycusis and other hearing loss — Hearing aids in patients with presbycusis usually result in an improvement in tinnitus symptoms.
Patients with conductive hearing loss due to outer ear or middle ear disease may benefit from surgery to correct the conductive defect (table 1). These patients may also derive some benefit from 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. Electrical stimulation of the auditory pathway is associated with a loss or reduction of tinnitus in 34 to 93 percent of patients receiving cochlear implants, although some individuals develop tinnitus postoperatively [10-13]. Cochlear implants are only available for selected patients and a full evaluation for candidacy is required before an implant can be considered.
Drug toxicity — Tinnitus due to ototoxic effects on the hair cells of the cochlea may be reversible in patients after stopping ototoxic medications (table 2). 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.
Other associated factors
●Cochlear rescue medications are under investigation in patients with chemotherapy-induced tinnitus [14,15]. Investigational therapies aimed at protecting the inner ear from trauma (noise induced damage) will likely also reduce the incidence of tinnitus seen with such damage [16-18].
●Metabolic and hormone imbalances, if present, should be corrected and may result in resolution of the tinnitus.
●In patients with myoclonus of the palatal muscles or middle ear structures, treatment with botulinum toxin injections into the palate or sectioning of the tendons within the middle ear usually relieves the symptoms [19].
●A patulous Eustachian tube can be treated with a variety of agents, including application of mucosal irritants (such as tetracycline) to the nasopharynx, which result in swelling or scarring of the Eustachian tube orifice [20]. If these treatments fail, surgery may be successful with placement of silicone plugs [21] through the middle ear, or various endoscopic techniques to close the nasopharyngeal orifice [22-24].
Behavioral therapies — A number of behavioral treatments have been studied with some success:
●Tinnitus retraining therapy (TRT)
●Biofeedback and stress reduction programs
●Cognitive behavioral therapy (CBT)
Multidisciplinary programs at tinnitus centers are available to assist patients with disabling tinnitus. A randomized trial, performed in an audiological 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 [25]. 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.
Above all, patients should not be discouraged or advised that there are no treatment options.
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 [26]. 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.
Significant improvement has been reported in as many as 80 percent of patients with high-pitched tinnitus using TRT with combined counseling and noise generators [26-29]. The long-term impact may be less reliable [30]. TRT can take one to two years before the patient no longer needs the external device.
In a systematic review that included only one randomized trial of 123 participants with tinnitus, TRT was more effective than tinnitus masking in improving symptoms [31].
Biofeedback and stress reduction — Biofeedback is a relaxation technique that teaches people to control certain autonomic body functions. The goal of biofeedback is to help people manage tinnitus-related distress by changing the patient's reaction to it. Many people notice a reduction in tinnitus when they are able to modify their reaction to it [32]. Biofeedback was first described as a stand-alone therapy for complex tinnitus in the 1980s and continues to be used as part of a battery of therapy options at many tinnitus centers.
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 [33]. Patients must be motivated, as they are required to keep diaries and perform homework as part of CBT. In a meta-analysis of 10 randomized trials evaluating different forms of CBT delivery (by therapists and over the internet), CBT improved tinnitus symptoms compared with non-CBT controls [2]. Self-help books have also been shown to benefit patients with troubling or disabling tinnitus [34]. Internet-delivered CBT, which is as effective as face-to-face CBT [35], and self-help books are especially useful in patients who cannot afford or access a formal CBT program.
Medications — Some medications may have modest efficacy in the treatment of tinnitus [36-38]:
●Two small placebo-controlled trials of misoprostol, a prostaglandin E1 analogue, have suggested limited benefit [39,40], but further studies are needed.
●Historically, lidocaine, either intratympanic or intravenous, has been found in observational studies to be modestly efficacious in reducing symptoms of tinnitus [41-43]. However, given the adverse effects of intravenous lidocaine that clearly outweigh any small benefits, lidocaine should not be used in the treatment of tinnitus [3].
●Benzodiazepines (eg, alprazolam) have been found in small trials to be effective in the treatment of tinnitus [44,45] and are thought to act on the anxiety often associated with tinnitus.
●Two small studies have shown efficacy of low doses of carbamazepine in treating rapid tapping pulsatile tinnitus in selected patients [37,38].
●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) [46,47]. 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 [48].
A number of other medications have been studied in patients with tinnitus but have not been found to be effective [49]:
●Anticonvulsants do not appear to be effective in improving symptoms of tinnitus that is not tapping or staccato in nature. A systematic review and meta-analysis including seven randomized trials of patients with chronic tinnitus found no clinically meaningful effect on symptoms comparing anticonvulsants (gabapentin, carbamazepine, lamotrigine, and flunarizine) with placebo [50].
●Ginkgo biloba and other bioflavonoids have been advertised to reduce tinnitus, but there is no evidence that ginkgo is effective for the treatment of tinnitus. (See "Clinical use of ginkgo biloba", section on 'Tinnitus'.)
●Melatonin has also not been found effective in controlled studies of tinnitus therapy [51].
●Niacin acts as a vasodilator and can potentially improve cochlear blood flow. However, niacin has not demonstrated clinical value in patients with long-standing tinnitus. No controlled studies have shown a significant benefit of niacin or other vitamins for tinnitus therapy.
●Zinc-, copper-, and manganese-based superoxide dismutases scavenge free radicals in the inner ear [52]. Animal models suggest that deficiencies in these enzymes leads to increased death of cochlear hair cells [53,54]. Studies correlating zinc levels with tinnitus in humans, as well as randomized, controlled trials of zinc therapy for tinnitus, have had inconsistent results [55-58]. This evidence does not support the use of zinc supplementation for the treatment of tinnitus.
Other therapies — A number of other types of treatments have been studied in patients with tinnitus, most of which have not been found to be more effective than placebo. Nevertheless, many tinnitus support groups have members who are helped by the treatments described below and individual patients who respond may be experiencing a true, non-placebo benefit.
Masking — Masking devices resemble hearing aids and are designed to produce low-level sounds that reduce the perception of tinnitus [59]. 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 six randomized trials found significant risk of bias and differences in outcome measures and evaluation techniques that precluded a definitive assessment of efficacy [60].
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) [61]. Further studies are needed to evaluate the long-term benefits of phase-shift treatment prior to clinical use.
Potential adverse effects of masking therapy include worsening of tinnitus, associated discomfort, or worsening hyperacusis.
For patients with tinnitus related to hearing loss, 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 randomized trial comparing hearing aid use with a sound generator for tinnitus associated with hearing loss, both interventions had comparable benefits [62,63].
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.
Electrical stimulation — 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 [64]. Electrical stimulation may be provided either through a single electrode or via multiply 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 [65,66].
Case reports of increasingly invasive procedures have been published including electrodes placement directly into a site in Heschl's gyrus that was mapped to respond to the tone of the perceived tinnitus [67]. This procedure was successful in one of two patients described.
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 [68].
Acupuncture — Acupuncture, alone or in conjunction with electrical stimulation, has not been found to be more effective than placebo [69,70].
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, 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 [71]. 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) [72]. Improvements were sustained during the 26-week follow-up period.
rTMS appears to be safe in short-term treatment, but 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 5th to 6th 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 10th to 12th 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
●The goal of treatment, for most patients, is to lessen awareness of tinnitus and its impact on quality of life.
●Treatment for tinnitus should be aimed at the underlying abnormality, when identified. We recommend treatment of underlying depression and insomnia, as these conditions may exacerbate symptoms of tinnitus (Grade 1B). Cochlear implants for patients with severe sensorineural hearing loss may improve tinnitus in 75 percent of patients. (See 'Associated factors' above.)
●We recommend tinnitus retraining therapy (TRT), in the context of directive counseling, for patients who are significantly impacted by their tinnitus symptoms (Grade 1C). We suggest a trial of biofeedback or cognitive behavioral therapy (CBT), which may also be helpful as an adjunct to TRT (Grade 2C). (See 'Behavioral therapies' above.)
●Medications for tinnitus have limited effectiveness. (See 'Medications' above.)
●Other medical treatments, including acupuncture and electrical stimulation (except for patients with profound hearing loss), are not demonstrably more effective than placebo. (See 'Other therapies' above.)
