Management

• Principles of management of tinnitus includes:
  
  
  • history and examination
  • audiogram
  • referral if appropriate
  • explanation - The British Tinnitus Association may help
  • If the history and examination do not reveal a condition which should be referred, and the audiogram is normal, then the condition should be managed in general practice
    
    
• several treatments are available to help people cope with tinnitus (1)
  • these include:
    • counselling
      • give positive encouragement such as “Spontaneous disappearance is possible”, “Improvement is usual”, “There are means of helping such as learning relaxation techniques”
      • avoid telling negative words such as ‘incurable’, ‘permanent’ or ‘you’ve got to live with it’ which will result in worsening of the perception on tinnitus
      • inform patients to take their attention away from tinnitus (2)
    • hearing aids
      • sometimes tinnitus is also associated with hearing loss and these patients may benefit from a hearing aid
      • hearing aids may emphasise beneficial sounds in the environment and decrease the attention the patient gives to hearing problems.
      • hearing aids also amplify background noise, and helps patients feel better
    • sound therapy
      • patients may feel comfortable when there is background noise or music
      • sound therapy is used in many ways to reduce the effects of tinnitus
        • by masking
        • by reducing its loudness
        • by distracting the patient
      • several types of sounds are used in sound therapy. These include:
        • broadband noise
        • music (soft, light, and background music)
        • sound produced specifically for relaxation (e.g., waves lapping against the shore, raindrops falling on leaves)
      • several different devices produce these sounds:
        • wearable devices similar to hearing aids
        • wearable devices with earphones
        • non-wearable devices (radios, tape players, compact disc players)
    • psychological therapy
      • cognitive behaviour modification
      • relaxation therapy (there is a strong association between tinnitus and stress)
    • medical management
      • sedatives or antidepressants help secondary agitation or depression but do not eliminate tinnitus.
      • surgery is limited to a few remediable otological causes (3)
      • intravenous lidocaine seems to be effective, but the short duration of the effect and the adverse reactions prevent its use (4)

NICE state (5):

Amplification devices

• offer amplification devices to people with tinnitus who have a hearing loss that affects their ability to communicate
• consider amplification devices for people with tinnitus who have a hearing loss but do not have difficulties communicating
• do not offer amplification devices to people with tinnitus but no hearing loss.

Psychological therapies for people with tinnitus-related distress

• consider a stepped approach to treat tinnitus-related distress in adults whose tinnitus is still causing an impact on their emotional and social wellbeing, and day-to-day activities, despite having received tinnitus support. If a person does not benefit from the first psychological intervention they try or declines an intervention, offer an intervention from the next step in the following order:
  • digital tinnitus-related cognitive behavioural therapy (CBT) provided by psychologists
  • group-based tinnitus-related psychological interventions including mindfulness-based cognitive therapy (delivered by appropriately trained and supervised practitioners), acceptance and commitment therapy or CBT (delivered by psychologists)
  • individual tinnitus-related CBT (delivered by psychologists).

Betahistine - do not offer betahistine to treat tinnitus.

Reference:

• (1) treatment options for tinnitus, Department of Otolaryngology at University of Iowa Hospitals and Clinics,USA.
• (2) British Tinnitus Association 2009. Tinnitus guidelines for primary care
• (3) Hanna A et al. BMJ, 2005;330(7485):237
• (4) Espinosa-Sánchez JM et al. Pharmacotherapy for tinnitus: much ado about nothing. Rev Neurol 2014 Aug 16;59(4):164-74.
• (5) NICE (March 2020). Tinnitus:assessment and management