A triage guide for tinnitus
Ringing in the ears may be symptomatic of a serious condition—or it may be benign. This guide can help you tell the difference.
Some patients experience extreme anxiety or depression in response to tinnitus and should be referred to a mental health professional on the day they present with symptoms. Suicidal ideation warrants special attention, of course—possibly including the need to escort the patient to the emergency department or to a behavioral specialist.21-23
Nonurgent medical referral. Ideally, all patients who present with tinnitus should see an audiologist and an otolaryngologist, but those who have no serious symptoms should be referred on a nonurgent basis. Such patients need to have a comprehensive hearing evaluation—ideally, before they see the otolaryngologist so the test results are available at the time of the exam. The audiologist should also assess the severity of the tinnitus, using a validated questionnaire such as the Tinnitus Handicap Inventory, for the initial assessment and to monitor changes in the severity of the tinnitus as an outcome measure of therapy.24
Enlist an interdisciplinary team
For patients with somatic tinnitus, the treatment—and the specialist who provides it—depends on the underlying cause. A patient who has unilateral tinnitus may be referred by an audiologist or otolaryngologist to a neurologist, for example, if he or she is found to have Meniere’s disease; a patient with pulsatile tinnitus may be sent back to his or her primary care physician after diagnostic testing has ruled out serious causes.
For patients with neurophysiologic tinnitus (and any patient with untreatable somatic tinnitus), a well-organized interdisciplinary team that includes the family physician, an audiologist, and a psychologist is the best approach. The variety of available management options (TABLE 2) incorporate medical approaches, complementary and alternative treatments, psychological interventions, and sound-based methods. Lifestyle modifications, such as improved sleep hygiene, regular exercise, and dietary modifications, may help, as well.25-27 First-line strategies include:
Adjusting medications. Eliminating tinnitus-inducing medications, if medically safe, is a common starting point. No prescription drug has been developed specifically for tinnitus. But some antidepressants or anxiolytics (eg, amitriptyline or lorazepam) are commonly used to address coexisting sleep and mental health disorders—primarily depression and anxiety—that may be associated with, or exacerbated by, tinnitus.28-30
Addressing hearing problems. Patients should undergo a hearing evaluation and receive help in managing a hearing problem, if necessary. Hearing aids improve hearing and reduce the perception of tinnitus.31
Using therapeutic sound. Some audiologists are trained to implement various forms of sound-based therapy. Tinnitus retraining therapy involves the use of background sound to facilitate habituation to tinnitus; tinnitus masking involves the use of soothing sound to provide a sense of relief. Progressive tinnitus management is a more recent method that educates patients in the use of all types of therapeutic sound.32 These sound-based methods often include the use of hearing aids, sound generators, and other devices.
Circling in a mental health professional. It is essential to involve psychologists or other mental health specialists in the care of patients with clinically significant tinnitus to ensure that psychological and other barriers to successful management of the condition are identified and addressed. Cognitive-behavioral therapy (CBT) has been shown to be helpful for patients with tinnitus.33 In fact, we have been successful in teaching patients to manage their reactions to tinnitus—resulting in a better quality of life—using a combination of educational counseling, therapeutic sound, and CBT. JFP
Acknowledgments
Funding for this work was provided by Veterans Health Administration, and Veterans Affairs Rehabilitation Research and Development (RR&D) Service (C4488R). Thanks to Robert Folmer, PhD, William Martin, PhD, Dennis Trune, PhD, and Baker Shi, MD, PhD, for advice that contributed to this manuscript. Special thanks to Martin Schechter, PhD, for his significant contributions to our research. The authors also wish to thank Stephen Fausti, PhD, and Sara Ruth Oliver, AuD, for their consistent support of our research.
CORRESPONDENCE James A. Henry, PhD, VA Medical Center (NCRAR), Post Office Box 1034, Portland, OR 97207; james.henry@va.gov
