Impact on quality of life/level of distress
The Tinnitus Handicap Inventory (THI) is a good tool to assess the impact of tinnitus on quality of life and patients’ progress. Patients with tinnitus appear to have poorer quality of life compared with people who do not have tinnitus, notably in those with disabling hearing loss. Reported consequences include anxiety, concentration difficulties, depression, and irritability.
Similarly, reducing tinnitus intensity has a direct impact on the improvement in patients’ quality of life. It is interesting to note that children’s quality of life is affected less by tinnitus. Although children experience tinnitus, they complain about it less frequently. It could be that children adjust better and quicker to the tinnitus or that they consider tinnitus to be a more normal event and distract themselves with other activities, thereby ignoring it more easily.
Ideally, the treatment of tinnitus consists of treating the underlying etiology. This includes stopping an ototoxic drug and treating arteriovenous malformations or strokes. In the case of dysfunction of the cervical spine or the temporomandibular joint, manipulations, exercises, occlusion adjustments, and trigger point treatment can improve tinnitus severity. If the tinnitus is caused by a tumor, stereotactic radiosurgery or microscopic decompression may be needed.
Most patients are affected by chronic idiopathic tinnitus. In these cases, a comprehensive evaluation should be conducted to identify comorbidities such as depression, anxiety, alcohol and substance abuse as well as insomnia. By treating these comorbidities, tinnitus severity might decrease.
Auditory therapeutic measures. For tinnitus associated with hearing loss or deafness, hearing aids are used; a cochlear implant may be indicated. Acoustic simulation during sleep has also been shown to reduce tinnitus intensity and improve patients’ quality of life.11
Pharmacotherapy. Psychiatric medications such as anxiolytics, antidepressants, mood stabilizers, and antipsychotics may also be used (Table). Benzodiazepines such as alprazolam, midazolam, and clonazepam are effective treatments and decrease the amplitude of tinnitus. This treatment carries multiple complications with addiction, cognitive difficulties, and gait disturbances in the elderly population.
Antidepressants such as nortriptyline, sertraline, and duloxetine have been shown to be beneficial in studies.12 It is recommended that bupropion be avoided in patients because its activating dopaminergic effect could worsen the tinnitus. Mirtazapine should be avoided as it could increase tinnitus perception.
Mood stabilizers and/or anticonvulsants have been investigated in the treatment of tinnitus. Carbamazepine, valproic acid, and gabapentin have shown some benefit.13 Mood stabilizers are mainly used when tinnitus is comorbid with bipolar disorder, seizure disorder, or migraine.
Antipsychotics should be used as a last resort unless patients have a comorbid psychotic disorder. Antipsychotics have been found helpful in moderate to severe obsessive-compulsive disorders worsening tinnitus and for short-term treatment of hyperacusis.
Dr Chemali is Director, Neuropsychiatry Clinics; Director, Behavioral Neurology-Neuropsychiatry Fellowship; Director, Global Implementation Program in Neuropsychiatry, Behavioral and Social Sciences; Associate Professor, Harvard Medical School, Massachusetts General Hospital, Boston, MA. Dr Nehme is Psychiatry Fellow, Consult-Liaison Psychiatry, Cambridge Health Alliance, Cambridge, MA. The authors report no conflicts of interest concerning the subject matter of this article.
1. Muhlnickel W, Elbert T, Taub E, et al. Reorganization of auditory cortex in tinnitus. Proc Natl Acad Sci USA. 1998;95:10340-10343.
2. Landgrebe M, Langguth B, Rosengarth K, et al. Structural brain changes in tinnitus: grey matter decrease in auditory and non-auditory brain areas. Neuroimage. 2009;46:213-218.
3. Hebert S, Canlon B, Hasson D. Emotional exhaustion as a predictor of tinnitus. Psychother Psychosom. 2012;81:324-326.
4. Shargorodsky J, Curhan GC, Farwell WR. Prevalence and characteristics of tinnitus among US adults. Am J Med. 2010;123:711-718.
5. Durai M, Searchfield G. Anxiety and depression, personality traits relevant to tinnitus: a scoping review. Int J Audiol. 2016;55:605-615.
6. Belli S, Belli H, Bahcebasi T, et al. Assessment of psychopathological aspects and psychiatric comorbidities in patients affected by tinnitus. Eur Arch Otorhinolaryngol. 2008;265:279-285.
7. Hiller W, Janca A, Burke KC. Association between tinnitus and somatoform disorders. J Psychosom Res. 1997;43:613-624.
8. Das SK, Wineland A, Kallogjeri D, et al. Cognitive speed as an objective measure of tinnitus. Laryngoscope. 2012;122:2533-2538.
9. Baigi A, Oden A, Almlid-Larsen V, et al. Tinnitus in the general population with a focus on noise and stress: a public health study. Ear Hear. 2011;32:787-789.
10. Koo M, Hwang JH. Risk of tinnitus in patients with sleep apnea: A nationwide, population-based case control study. Laryngoscope. 2017;127:2171-2175.
11. Drexler D, Lopez-Paullier M, Rodio S, et al. Impact of reduction of tinnitus intensity on patients’ quality of life. Int J Audiol. 2016;55:11-19.
12. Chang JP, Wu CC. Serotonin-norepinephrine reuptake inhibitor treatment for tinnitus and depression. J Clin Psychopharmacol. 2012;32:729.
13. Hoekstra CE, Rynja SP, van Zanten GA, et al. Anticonvulsants for tinnitus. Cochrane Database Syst Rev. 2011;(7):CD007960.
14. Hesser H, Weise C, Westin VZ, et al. A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioral therapy for tinnitus distress. Clin Psychol Rev. 2011;31:545-553.
15. Rogha M, Rezvani M, Khodami AR. The effects of acupuncture on the inner ear originated tinnitus. J Res Med Sci. 2011;16:1217-1223.
16. van Zwieten G, Smit JV, Jahanshahi A, Temel Y, Stokroos RJ. Tinnitus: is there a place for brain stimulation? Surg Neurol Int. 2016;7(Suppl 4):S125-S129.
17. De Ridder D, Vanneste S, Menovsky T, et al. Surgical brain modulation for tinnitus: the past, present and future. J Neurosurg Sci. 2012; 56:323-340.
18. Auffret M, Rolland B, Deheul S, et al, for the CAMTEA team. Severe tinnitus induced by off-label use baclofen. Ann Pharmacother. 2014;48:656-659.
19. Smith PF, Zheng Y, Darlington CL. Revisiting baclofen for the treatment of severe chronic tinnitus. Front Neurol. 2012;3:34.
20. Azevedo AA, Figueiredo RR. Tinnitu treatment with acamprosate: double-blind study. Braz J Otorhinolarygol. 2005;71:618-623.