Talk to patients about hearing protection devices. The US Environmental Protection Agency monitors all hearing protection devices and assigns them a Noise Reduction Rating (NRR). The adequacy of single vs double hearing protection depends on the dB exposure level, duration of exposure, and NRR for the protective device(s). In general, recommend single hearing protection (ear plugs, which are inserted in the ear canal, or ear muffs, which fit around the ears) to patients exposed to >80 dB and dual hearing protection (ear plugs and muffs) to those exposed to >95 dB. More guidance on single or dual hearing protection can be obtained from a local occupational health physician or from https://www.osha.gov/dts/osta/otm/noise/hcp/attenuation_estimation.html.
There are drawbacks to using certain forms of ear protection. Regular use can increase the likelihood of cerumen impaction or otitis externa, both of which can actually cause tinnitus. Proper training on how to use hearing protection devices and routine otologic examinations are advisable for patients who frequently use ear protection.
Techniques that can help patients to better cope
The most common therapies used to treat tinnitus are cognitive-behavioral therapy (CBT) and tinnitus retraining therapy (TRT). Both are techniques of habituation designed to change the way patients think about, and emotionally respond to, tinnitus.15,16
CBT is administered by a skilled therapist and employs relaxation exercises, coping strategies, and deconditioning techniques.16 The goal of CBT is to reduce arousal levels and reverse negative thoughts about tinnitus.16 A recent Cochrane review found that although CBT does not subjectively reduce the loudness of tinnitus, it does significantly improve quality of life and depression caused by tinnitus.17 CBT’s benefits also extend to other common comorbidities such as SNHL, insomnia, depression, and anxiety.16 Up to 75% of patients experience improvement in their score on the standardized Tinnitus Handicap Questionnaire one year after completing therapy.16
TRT combines counseling, education, and acoustic therapy—using soft music or a sound machine—to minimize the bothersome nature of the condition.15 TRT is delivered by a team of physicians, audiologists, and psychologists and requires commitment from patients because most therapies are performed at a specialized tinnitus center over the course of up to 2 years.15 Retrospective trials of TRT have generally been positive, finding that this approach minimizes the annoyance patients experience.15
Even in the absence of a formal TRT protocol, patients can take advantage of acoustic therapy. Patients should be advised to add pleasant noise to quiet environments with soft music or sound machines. “Masking” devices are also an option. These commercially available sound generators fit in the ear and may lessen patients’ perception of tinnitus.2,18
Evidence supporting medications is weak
Though many medications have been investigated for treating tinnitus, most have been studied in small clinical trials and none is FDA-approved for tinnitus.
Acamprosate, which is FDA-approved for maintaining alcohol abstinence in alcohol-dependent patients, is a relatively new tinnitus treatment option. In small randomized, double-blinded, placebo controlled trials, approximately 90% of patients treated with acamprosate experienced improvement in tinnitus severity and quality of life.19 Larger studies will be necessary to determine if frequent adverse effects (including depression, anxiety, diarrhea, and drowsiness) will hamper its usefulness.
Benzodiazepines (mainly alprazolam) tend to reduce tinnitus-associated anxiety and also may decrease tinnitus intensity via central suppression of the auditory pathway. However, because evidence is limited to small trials with methodological flaws, and because benzodiazepines have the potential for dependence, the risks and benefits of these agents must be weighed carefully.7,16
Lidocaine has a long history of use for tinnitus, by both intravenous and intratympanic routes. Its benefits are unclear. In some trials, lidocaine was moderately effective in the short term, whereas in others, it appeared to make tinnitus worse.7,20
Oral misoprostol also may be an option, according to a series of placebo-controlled trials.20 But the benefit of this medication may be limited to the perception of loudness, and not other tinnitus measures, such as improved sleep and concentration.20
Antidepressants can have a profound positive effect on tinnitus in patients with severe depression but do not have the same effect on patients who do not suffer from depression.20 Anticonvulsants such as gabapentin have not been found to be effective for tinnitus.21
Researchers are investigating centrally acting agents, such as the N-methyl-D-aspartate antagonist neramexane, for the treatment of tinnitus. With safety and tolerability now established, neramexane is in European phase III trials.22
The jury is out on alternative therapies
With data lacking for prescription medications, patients may look into complementary and alternative therapies. However, consistent evidence is lacking for these therapies, as well. Ginkgo biloba has been found to reduce tinnitus severity and loudness in limited studies,23 although some preparations may be superior to others.14 In a double-blind, randomized controlled trial, melatonin decreased tinnitus intensity significantly, particularly for men and for patients with severe symptoms or a history of noise exposure.24 Zinc supplements may improve tinnitus in patients with zinc deficiency.20,25 Acupuncture and electromagnetic stimulation have not proven efficacious in the treatment of tinnitus.21