Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

known aetiology

1st line – treatment of underlying cause

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ACUTE
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known aetiology
1st line – 

treatment of underlying cause

Appropriate treatment for the underlying aetiology should be given as this may resolve tinnitus without further need for any treatment.

troublesome tinnitus

1st line – education and counselling

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ACUTE
|
troublesome tinnitus
1st line – 

education and counselling

Education about relaxation techniques to decrease anxiety associated with tinnitus can be provided. Hypnosis or biofeedback techniques are also sometimes used to reduce anxiety.

In counselling sessions the physician should show an understanding attitude towards the patient and provide them with information about the pathophysiology and prognosis of tinnitus.

The patient should understand that the goal of therapy is to reduce the negative impact of tinnitus on life, and not cure.

Coping strategies should be discussed to try to decrease the anxiety and stress caused by tinnitus.

Problems that can be managed separately and are unrelated to tinnitus, such as hearing loss, should be recognised and treated.

Complications of tinnitus such as insomnia and depression should be individually addressed.

Clinicians should realise the patient's need for psychological evaluation or even refer the patient to mental health professionals when necessary.[59]

Consider – cognitive behavioural therapy

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ACUTE
|
troublesome tinnitus
|
affecting quality of life
Consider – 

cognitive behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

The rationale behind prescribing a trial of cognitive behavioural therapy (CBT) is to discover and modify the irrational thoughts and maladaptive behaviour of an individual in order to alter unproductive actions.

The cognitive component, also termed cognitive restructuring, is defined as helping people to think differently and alter their thoughts to obtain a more positive attitude towards their condition.[7]

The behavioural component determines characteristics of a patient that exacerbate and contribute to the condition and corrects them with the help of attention control, imagery training, and relaxation methods.[60]

In controlled trials, this treatment improved the quality-of-life and depression scores in patients with tinnitus.[61] However, long-term follow-up demonstrating maintenance of this outcome within these trials is lacking. Additionally, compared with other treatment interventions, CBT has not been demonstrated to significantly decrease the subjective loudness of tinnitus associated with the condition.[59] However, 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] [ Cochrane Clinical Answers logo ]

ONGOING

hearing loss on audiogram

1st line – hearing aids ± masking device

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ONGOING
|
hearing loss on audiogram
1st line – 

hearing aids ± masking device

Hearing aids are successful in giving partial or total relief from tinnitus by amplifying external sound stimuli, thereby decreasing the awareness of the presence of tinnitus.

Hearing aids can also be used in combination with intensification and enrichment of background sound to increase the rate of success. This benefit has been postulated to be due to improvement in hearing and subsequent decrease in stress.[60]

Patients are advised to wear their hearing aids even during sleep.

Consider – antidepressants or anxiolytics

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ONGOING
|
hearing loss on audiogram
|
associated depression and anxiety
Consider – 

antidepressants or anxiolytics

Additional treatment recommended for SOME patients in selected patient group

Pharmacological treatments may help patients with tinnitus that is associated with depression or anxiety. There is poor evidence to suggest their use in patients who have tinnitus without associated depression or anxiety.[57]

Tricyclic antidepressants (TCAs) probably treat the underlying psychological problems rather than affect the tinnitus directly.[57][58]

The effectiveness of TCAs in the treatment of tinnitus is inconclusive.[57]

A randomised double-blind control trial demonstrated a decrease in the level of tinnitus intensity with the administration of alprazolam in 76% of patients.[62] The adverse effects of the drug are mostly due to the addictive nature of alprazolam, and some studies show recurrence of tinnitus after discontinuation of the drug.[63] Alprazolam dosing should start low and be gradually increased. If ineffective, tapering of the drug is recommended before discontinuing.[63]

The selective serotonin reuptake inhibitor paroxetine has demonstrated improvement in severity and aggravations from tinnitus.[57][58]

Primary options

nortriptyline: 25-50 mg orally once daily at bedtime

OR

alprazolam: 0.5 mg orally once daily at bedtime for 2 weeks, increase dose to 0.5 mg twice daily for 2 weeks, if inadequate response increase to 0.5 mg three times daily

OR

paroxetine: 10 mg orally daily, increase dose according to response, maximum 50 mg daily

normal hearing

1st line – tinnitus-masking devices

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ONGOING
|
normal hearing
1st line – 

tinnitus-masking devices

Also known as tinnitus habituation therapy.

Used in patients when hearing aids are not an option for treatment.

Delivers a continuous low-level noise or tone to the ear that results in masking of the tinnitus. In many cases, these devices cause significant reduction in perception of the tinnitus. Although a 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]

Problems include interference with hearing, although some patients report an improvement in hearing after prolonged use of the maskers because of a decrease in the perception of tinnitus.[2]

Patients may also complain that these devices only substitute one unpleasant sound with a different one.[7]

Plus – tinnitus retraining therapy (TRT): hearing loss and counselling

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ONGOING
|
normal hearing
|
affecting quality of life
Plus – 

tinnitus retraining therapy (TRT): hearing loss and counselling

Treatment recommended for ALL patients in selected patient group

Consists of counselling together with a tinnitus-masking device to deliver a low-level, constant white noise.

The masking device results in habituation of the patient's auditory system to the tinnitus, thereby decreasing the patient's awareness of their condition.[2] Neuromonics (a device with music and an acoustic neural stimulus) and other sound therapies could be considered.[14]

Typically requires at least 1-2 years to be effective.[2]

Educational counselling based on TRT has demonstrated statistical significance in improvement of the tinnitus severity index when compared with traditional support (no education) and no treatment at all over a 12-month period.[47]

Consider – antidepressants or anxiolytics

Back
ONGOING
|
normal hearing
|
associated depression and anxiety
Consider – 

antidepressants or anxiolytics

Additional treatment recommended for SOME patients in selected patient group

Pharmacological treatments may help patients with tinnitus that is associated with depression or anxiety. There is poor evidence to suggest their use in patients who have tinnitus without associated depression or anxiety.[57]

Tricyclic antidepressants (TCAs) probably treat the underlying psychological problems rather than affect the tinnitus directly.[57][58]

The effectiveness of TCAs in the treatment of tinnitus is inconclusive.[57]

A randomised double-blind control trial demonstrated a decrease in the level of tinnitus intensity with the administration of alprazolam in 76% of patients.[62] The adverse effects of the drug are mostly due to the addictive nature of alprazolam, and some studies show recurrence of tinnitus after discontinuation of the drug.[63] Alprazolam dosing should start low and be gradually increased. If ineffective, tapering of the drug is recommended before discontinuing.[63]

The selective serotonin reuptake inhibitor paroxetine has demonstrated improvement in severity and aggravations from tinnitus.[57][58]

Primary options

nortriptyline: 25-50 mg orally once daily at bedtime

OR

alprazolam: 0.5 mg orally once daily at bedtime for 2 weeks, increase dose to 0.5 mg twice daily for 2 weeks, if inadequate response increase to 0.5 mg three times daily

OR

paroxetine: 10 mg orally daily, increase dose according to response, maximum 50 mg daily

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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