Approach
Treatment is challenging, as tinnitus is a symptom not a disease; intervention depends on treating the underlying cause.[9] Persistent tinnitus should be managed with symptomatic treatment.[50]
Counselling the patient on how to manage the problem is very important.[7] Treatment should decrease the negative effects on quality of life and lower the risk of complications such as depression, sleep deprivation, and loss of function. There is currently no drug on the market that is approved for tinnitus, and evidence-based pharmacological approaches are limited to the treatment of comorbidities such as depression, anxiety, or insomnia.[51]
Symptomatic treatment
All patients with troublesome tinnitus should receive education about the condition and counselling on management. During the sessions, patients are advised to avoid medicines such as non-steroidal anti-inflammatory drugs and other ototoxic drugs. Exposure to loud noises should be discouraged. Some patients are sensitive to caffeine, alcohol, simple sugars, aspartame, nutrasweet, monosodium glutamate, food colourings and dyes, and tobacco. A 6- to 8-week trial of avoidance can be considered.
Reduction in anxiety can be achieved by teaching patients relaxation techniques. Hypnosis or biofeedback techniques are also used to try to decrease anxiety.
Cognitive behavioural therapy (CBT) should be initiated when patients indicate to their physician that their tinnitus causes anxiety, prevents them from performing enjoyable activities, and disturbs their lives. CBT helps patients identify negative behaviours, beliefs, and reactions, and suggests thought mechanisms to substitute them for more positive and appropriate responses. One randomised controlled trial found that CBT reduces the severity and impairment of tinnitus and improves quality of life in patients regardless of severity.[52] CBT has greater benefit than the above-mentioned counselling techniques.[2]
If the patient has hearing loss (even if mild), hearing aids should be used. Success at treating tinnitus with hearing aids in these patients is about 50%.[2]
Background masking of sound during sleep or in silent environments is useful to decrease the perception of tinnitus. Although one systematic review found a lack of quality research was in part responsible for a lack of strong evidence for the efficacy of this treatment, the authors note that this absence of conclusive evidence should not be interpreted as evidence of lack of effectiveness.[53] Tinnitus maskers are devices similar to hearing aids that fit behind the ear. These devices generate and deliver white noise to the ear that mask (i.e., cover up) the tinnitus in patients with normal or near-normal hearing. The patient is instructed to wear the devices continuously through the day and even during sleep.
Tinnitus retraining therapy is counselling accompanied by devices similar to hearing aids that create a low-level white noise (i.e., tinnitus-masking devices).[7] Patients usually use this therapy for a period of 1-2 years. The rate of success varies between patients.[7]
Neuromonics (a device with music and an acoustic neural stimulus) and other sound therapies may benefit some patients.[14]
There are no cures for tinnitus; however, there are many things that can be tried to ameliorate the symptom. What works for one person may not necessarily be effective for the next person. There are many alternative therapies that have some ability to mitigate the tinnitus in some patients and these options should not be disregarded. Typically integrative therapies (hypnosis, acupuncture, supplements, and herbs) have a positive effect approximately 40% of the time, although good-quality evidence is often lacking.[54][55][56]
Associated depression or anxiety
Tinnitus, when severe, may often be associated with psychological symptoms such as depression or anxiety. Whether the condition causes these psychological events or whether tinnitus is more prevalent in people with psychological disease is under debate.[57][58] Pharmacological treatments may help patients with tinnitus that is associated with depression. Tricyclic antidepressants, selective serotonin reuptake inhibitors, and anxiolytics may help reduce symptoms of tinnitus in patients with depression.[58] However, there is poor evidence to suggest their use in patients who have tinnitus without associated depression or anxiety.[57]
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