Treatment of Tinnitus

Tinnitus management is very dependent on the clinician’s approach and might include a variety of strategies. These include observation, teaching, and counseling; cognitive-behavioral treatment (CBT); amplification devices; tinnitus retraining therapy (TRT); and other sound-based interventions. A mixture of these approaches, known as progressive tinnitus management, is commonly used. While some of these therapies have been demonstrated to lessen tinnitus awareness and related suffering, they are time-consuming and costly.

For patients with severe to profound hearing loss, restoring afferent input with electrical stimulation, such as cochlear implantation, has been shown to effectively decrease tinnitus. Recent research has also shown that cochlear implants help reduce the impression of tinnitus in those with unilateral deafness. However, in the United States, cochlear implantation is FDA-approved for bilateral severe to profound sensorineural hearing loss (SNHL). Most tinnitus sufferers do not match these criteria; hence, they are not candidates for this procedure. Furthermore, unilateral deafness is still not an FDA-approved indication; thus, it is rarely reimbursed by insurance.

Alternative neuromodulation approaches, such as repetitive transcranial magnetic stimulation (rTMS), vagal nerve stimulation, bimodal stimulation with somatosensory and trigeminal nerve inputs, deep brain stimulation, and cortical stimulation, appear to have potential benefits. Although these procedures are currently experimental, they show promise for future therapeutic alternatives.

Several drugs have been used to treat tinnitus; however, none have received FDA approval for this specific indication. Oral or intratympanic steroids are frequently used to treat sudden-onset tinnitus, which is often caused by acoustic trauma or idiopathic sensorineural hearing loss. Intravenous lidocaine has previously been suggested as a therapy option, but it is widely seen as impractical due to its short half-life, with tinnitus alleviation lasting only 30 minutes to a few hours.

Off-label usage of antidepressants—such as selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants—and anxiolytics is common, however it is unclear whether these medications directly alleviate tinnitus symptoms or primarily target accompanying psychological concerns. Furthermore, there is minimal data to support their efficacy in people without concomitant depression. Similarly, medicines such as carbamazepine and gabapentin have been investigated, although their efficacy appears to be uncertain.

Tinnitus Counseling

Tinnitus counseling is a therapy procedure in which people with tinnitus receive assistance and guidance from experienced professionals to help them handle the psychological and emotional issues that come with their disease. The primary goal of counseling is to reduce the impact of tinnitus on an individual’s quality of life by providing comprehensive information about the condition, discussing effective coping strategies, exploring stress management techniques, and providing relaxation exercises, emotional support, and tools to improve self-efficacy. Recent advancements, such as therapy given via smartphone apps, hold promise for improving accessibility and patient participation.

Cognitive Behavioral Therapy (CBT) for Tinnitus

Cognitive-behavioral therapy (CBT) originated in psychotherapy and tries to detect and modify maladaptive cognitions (thoughts) while also promoting beneficial behaviors. The technique includes psychoeducation, counseling, relaxation training, behavioral activation, and mindfulness-based activities. CBT is widely regarded as the gold standard for treating a variety of mental health issues, including anxiety disorders, depression, and insomnia. It can also be used to manage lifestyle disorders like diabetes, obesity, and alcoholism. Since the 1980s, cognitive behavioral therapy has been used to treat tinnitus. Decades of study and clinical experience have shown that cognitive behavioral therapy (CBT) can help reduce tinnitus-related irritation, distress, depression, anxiety, and sleep disturbance. The American Academy of Otolaryngology-Head & Neck Surgery Foundation’s clinical recommendations advocate CBT as the primary treatment option for patients with persistent and bothersome tinnitus.

CBT for tinnitus typically consists of 8 to 24 weekly sessions that last 60 to 120 minutes. It can be provided face-to-face, in individual or group settings (often with 6 to 8 participants), and the severity of the tinnitus can vary. Tinnitus psychoeducation, dysfunctional belief restructuring, exposure approaches, mindfulness-based solutions, stress alleviation, and attention redirection via movement therapy and relaxation exercises are all part of the treatment process. Remote delivery of CBT via the internet has demonstrated comparable efficacy to traditional face-to-face therapy, thereby improving accessibility while retaining effectiveness.

CBT in tinnitus management aims to help patients better regulate their emotional responses, reduce tinnitus-related suffering, and create coping mechanisms that improve their quality of life.

Auditory Treatments

Auditory treatments include a wide range of interventions, such as hearing aids, sound generators that mask or distract from tinnitus, and other auditory stimulation procedures. In cases of profound hearing loss, cochlear implants have shown outstanding efficacy in lowering tinnitus perception and related discomfort. As a result, unilateral unpleasant tinnitus in people with single-sided deafness may indicate the need for cochlear implantation, even if the person can converse effectively in most situations with their normal contralateral hearing.

Hearing aids are recommended when hearing loss coexists and requires action.

Music therapy and hearing training programs have been offered as solutions for managing tinnitus, with or without concurrent hearing loss.

Overall, many patients appear to benefit from acoustic distraction—such as listening to music, white noise, or natural sounds—in some conditions, especially while attempting to go to sleep or enhance focus.

Tinnitus Retraining Therapy (TRT)

TRT is a method of adjusting to tinnitus by minimizing its auditory, emotional, and autonomic impact. This technique combines counseling and sound treatment using broadband noise. TRT can serve as a long-term intervention.

Tailor-Made Notched Music Therapy & Music Therapy

Tailor-made notched music treatment (TMNMT) uses music that has been carefully tailored to eliminate the tinnitus frequency. This method may be especially useful for people who enjoy music-based interventions. According to recent studies, TMNMT is not significantly more effective than other interventions such as traditional music therapy, frequency removal at random, counseling, or tinnitus retraining therapy (TRT).

Neuro-Modulation and Brain Stimulation

Transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) are two neuromodulation treatments that frequently target the left auditory and prefrontal cortex. The new concept of bimodal stimulation in tinnitus care has received attention, embracing multimodal techniques that combine visual, aural, and tactile components. One of the most basic approaches for creating bimodal stimulation is to combine neuromodulation with sound therapy. Furthermore, the combination of several stimulation modalities has shown potential in lowering tinnitus severity.

Neurofeedback

Neurofeedback shows potential in treating tinnitus distress and its related symptoms.

Bimodal Stimulation

Bimodal stimulation tactics, which combine auditory inputs with multiple types of brain stimulation, are producing encouraging results. Initial investigations with large sample sizes have shown that combining auditory stimulation with electrical stimulation of the tongue can help. Furthermore, integrating auditory input with electrical stimulation of the face or neck, as well as vagus nerve stimulation, has shown promising results.

Hearing Aids

All relevant guidelines encourage the use of hearing aids (HAs) for those with hearing loss and tinnitus. Hearing aids compensate for auditory deprivation by enhancing ambient environmental sounds, which reduces attentional focus on tinnitus and reverses central neuronal alterations associated with tinnitus in the auditory cortex. Furthermore, they serve to relieve the stress and tension created by straining to hear, lowering overall stress levels.

Cochlear Implants

Clinical recommendations recommend cochlear implants (CIs) when hearing aids are insufficient to treat hearing loss, even in situations of unilateral hearing loss. CIs have shown promise in lowering tinnitus-related suffering while also increasing overall quality of life. A recent study has highlighted the benefits of CI for individuals with single-sided deafness, focusing on improvements in speech perception, tinnitus control, sound localization, and quality of life. Furthermore, there is continuing research into CI programming strategies for tinnitus suppression, which have demonstrated potential benefits in reducing tinnitus severity. Various aspects, including electrode placement and stimulation intensities, may influence tinnitus therapy outcomes. Furthermore, some research used smartphone apps, such as ReSound Tinnitus Relief, in conjunction with CIs. The results have been mixed but positive, with some users reporting improvements in tinnitus problems.

Complementary and Alternative Therapies

Acupuncture is one of the most extensively investigated supplementary treatments, although the outcomes are inconsistent and unclear. Many more techniques have been proposed and tested, but the evidence for their efficacy remains limited.

Dietary supplements

A recent German recommendation cautions against taking dietary supplements such as vitamins, traditional herbal medicine, minerals, homeopathy, and lipoflavonoids for tinnitus treatment due to insufficient evidence of efficacy. Similarly, an online survey-based study found that while caffeine, alcohol, and salt had a minor impact on tinnitus severity for certain participants, the effects were generally mild. The researchers stressed that dietary changes are not a major treatment for persistent tinnitus in the general population, though some people may see significant benefits. While dietary supplements are important for overall health, tinnitus is influenced by factors other than nutrition. Furthermore, middle-aged people (ages 51-60) with tinnitus had lower vitamin B2 intake, as well as lower water, protein, and vitamin B3 intake, which was associated with tinnitus-related unpleasantness.

Physiotherapy and head and neck manipulation

Tinnitus, which is commonly caused by orofacial variables such as temporomandibular disorders (TMD) or neck pain, can be treated with physiotherapy and head and neck manipulation. TMD pain relief supports the improvement of somatic tinnitus following orofacial therapy, highlighting the relationship between these parameters. Orofacial treatment, or the combination of cervico-mandibular manual therapies, exercise, and education, produces superior results for TMD-associated tinnitus.