This article discusses the use of an integrative approach to treating tinnitus. The authors begin with a discussion of their approach to tinnitus patients, followed by a detailed look at the physiology of tinnitus and several theories of its mechanism. The many viable options for tinnitus relief are discussed, including sound therapies, Western medical approaches, and herbal and traditional medicines that can be used as integrative and complementary treatments. It concludes with a reminder that a variety of treatment options are available to tinnitus patients to help them take control of their symptoms.
Key points
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Tinnitus is defined as the perception of sound within the central nervous system (classical auditory pathway) without an external source.
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Data suggest that tinnitus can also be processed through nonclassical pathways in the amygdala and limbic structures, which are areas of the brain thought to be responsible for some affective disorders.
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There are several types of sound therapy for tinnitus that studies suggest can be successful, including maskers, hearing aids, Neuromonics, and Sound Cure. The common denominator in all of these treatment modalities is professional counseling by an experienced audiologist.
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Tinnitus studies with transcranial magnetic stimulation (TMS) have shown mixed results concerning the effect on tinnitus duration and responsiveness to TMS, but do show significant reduction of tinnitus loudness and perception with higher-frequency stimulation (10–25 Hz).
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Agents such as anesthetics, anticonvulsants, benzodiazepines, and antidepressant medications have all been used in the treatment of tinnitus, with some positive effects.
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Many herbal and traditional medicines are used as a means to treat tinnitus, including gingko biloba, zinc, melatonin, vitamin B 12 , garlic, and others; however, evidence-based medicine is severely lacking for almost all of these treatment modalities, and clinicians rely on patient testimonials.
Overview
Giving tinnitus patients the respect and time they deserve to properly diagnose and treat their symptoms requires an integrative approach. Too often physicians tell patients with classic, nonpulsatile subjective tinnitus, “there is nothing you can do for your problem, you are going to have to learn to live with it.” This answer is not the one most tinnitus patients are looking for. Patients want a physician to listen to their symptoms, give them an explanation for their symptoms, and provide potential treatment options, other than “to live with it.”
Tinnitus symptoms can be divided into pulsatile and nonpulsatile, with nonpulsatile symptoms present in the overwhelming majority of patients. This article briefly covers the less common pulsatile tinnitus, its etiology, workup, and treatment options; however, most of the article discusses the treatment of patients with nonpulsatile tinnitus, as these patients benefit most from the integrative treatment approach.
The authors are proud of their approach to the treatment of tinnitus patients because at the end of the patient evaluation they are extremely satisfied with the time, effort, and respect given to them. The authors use a team approach involving a nurse/nurse practitioner, physician, and audiologist. Once the history and physical examination have been performed, and all testing and studies have been reviewed, a long discussion is undertaken with the patient regarding diagnosis, the etiology of symptoms, and a sweeping overview of treatment options, including conventional allopathic, alternative, and holistic options. A standardized tinnitus informational packet with information about tinnitus and various treatment options is given to the patients. The most important part of this packet is a series of 3 questionnaires used to establish a baseline severity of symptoms, which include a tinnitus handicap index and quality-of-life questionnaires.
The last step of this team approach is an optional 1.5-hour consultation appointment with an audiologist who has specific training and a special interest in treating patients with tinnitus. The physician may recommend behavioral modifications (masking), medication, or supplements on a patient-by-patient basis; the audiologist is responsible for helping the patient decide if any other options are worth pursuing, including hearing aids, other forms of masking, sound therapy (ie, Neuromonics or Sound Cure), or even an evaluation with a psychologist if severe anxiety or depression are thought to be major contributing factors.
Since the authors started using this approach, it has resulted in an extremely high rate of patient satisfaction. There are so many treatment options for tinnitus because there is very little evidence-based research to validate their effectiveness or lack thereof. However, of the many treatments available the authors are able to confidently tell patients that one of the various options discussed will offer some degree of relief.
Overview
Giving tinnitus patients the respect and time they deserve to properly diagnose and treat their symptoms requires an integrative approach. Too often physicians tell patients with classic, nonpulsatile subjective tinnitus, “there is nothing you can do for your problem, you are going to have to learn to live with it.” This answer is not the one most tinnitus patients are looking for. Patients want a physician to listen to their symptoms, give them an explanation for their symptoms, and provide potential treatment options, other than “to live with it.”
Tinnitus symptoms can be divided into pulsatile and nonpulsatile, with nonpulsatile symptoms present in the overwhelming majority of patients. This article briefly covers the less common pulsatile tinnitus, its etiology, workup, and treatment options; however, most of the article discusses the treatment of patients with nonpulsatile tinnitus, as these patients benefit most from the integrative treatment approach.
The authors are proud of their approach to the treatment of tinnitus patients because at the end of the patient evaluation they are extremely satisfied with the time, effort, and respect given to them. The authors use a team approach involving a nurse/nurse practitioner, physician, and audiologist. Once the history and physical examination have been performed, and all testing and studies have been reviewed, a long discussion is undertaken with the patient regarding diagnosis, the etiology of symptoms, and a sweeping overview of treatment options, including conventional allopathic, alternative, and holistic options. A standardized tinnitus informational packet with information about tinnitus and various treatment options is given to the patients. The most important part of this packet is a series of 3 questionnaires used to establish a baseline severity of symptoms, which include a tinnitus handicap index and quality-of-life questionnaires.
The last step of this team approach is an optional 1.5-hour consultation appointment with an audiologist who has specific training and a special interest in treating patients with tinnitus. The physician may recommend behavioral modifications (masking), medication, or supplements on a patient-by-patient basis; the audiologist is responsible for helping the patient decide if any other options are worth pursuing, including hearing aids, other forms of masking, sound therapy (ie, Neuromonics or Sound Cure), or even an evaluation with a psychologist if severe anxiety or depression are thought to be major contributing factors.
Since the authors started using this approach, it has resulted in an extremely high rate of patient satisfaction. There are so many treatment options for tinnitus because there is very little evidence-based research to validate their effectiveness or lack thereof. However, of the many treatments available the authors are able to confidently tell patients that one of the various options discussed will offer some degree of relief.
Defining tinnitus
Tinnitus is defined as the perception of sound without an external source. Historically it has been broken down into 2 categories: objective or subjective. Subjective tinnitus represents the vast majority of cases; the sound perception reported by patients can be continuous, intermittent, or pulsatile. It is often described as a hissing, ringing, whooshing, or static-like noise. The tinnitus, whether constant or pulsatile, cannot be heard by the examiner. Objective tinnitus that is reported by a patient can be detected by an examiner using an ear-canal microphone or stethoscope. It is always pulsatile and is extremely uncommon. For the purposes of this discussion of current theories and evolving evaluation and treatment, subjective, nonpulsatile tinnitus is the main focus.
Tinnitus affects nearly 30 million Americans. These estimates may be slightly low, considering that most tinnitus is benign and often underreported; those affected do not always seek medical attention. Of those affected, approximately 3% to 5% are estimated to suffer from severe disturbing tinnitus causing disability and disruption in daily functioning. What makes one patient consider their symptoms debilitating, and another with the same complaints not debilitating? Methods to quantify the intensity and character of tinnitus have typically led to poor results in trying to correlate sound intensity with the disability caused by tinnitus. Patients with severe disabling tinnitus often give the intensity of their tinnitus a rating similar to that of someone with benign tinnitus. Masking and matching studies found that 75% of unilateral tinnitus patients matched their tinnitus in the unaffected ear to sounds that are at a 10-dB sensation level or less, and a large study evaluating masking levels found the average level required to mask tinnitus to be only 23.8 dB. The volume of the tinnitus that patients experience may be low, but the disturbance it causes can be high in some patients. This type of data suggests that different pathways exist for the neural signaling and processing involved in tinnitus, as opposed to normal external sound processing by the auditory pathways.
Physiology and anatomy
The classical auditory pathway responsible for how we hear involves input to the primary auditory cortex by way of neural impulses generated by mechanical displacement of kinocilium on the cochlear hair cells. Tinnitus, along with the emotional reactions patients have to their symptoms, is processed through nonclassical pathways of the amygdala and limbic structures, which are areas of the brain thought to be responsible for some affective disorders such as depression and anxiety. Similar to our other senses, such as olfaction and vision, evidence favors the idea that these accessory or nonclassical pathways may play some role in the creation of abnormalities. A recent study using single-photon emission computed tomography (SPECT) and magnetic resonance fusion imaging demonstrated altered uptake in the medial temporal, inferotemporal, and temporoparietal areas in 55 patients with chronic tinnitus, suggesting that these associative auditory cortices are more involved with tinnitus generation than the primary auditory cortex.
A common theory in the generation of tinnitus involves the mechanism of neural plasticity. Neuroplasticity is a term referring to the ability of the brain and nervous system to change structure and functionally as a result of input from the environment. For example, parallels can be drawn between the causes of tinnitus and phantom limb syndrome. The phenomenon of phantom limb syndrome is defined by continued sensation of the presence of an absent limb after an amputation. The disturbance caused from amputation has been shown to be worsened in unexpected as opposed to planned amputations. Acute transient tinnitus is almost universal in those affected by acoustic trauma with explosives, gunfire, or excessively loud noise, just as phantom limb sensation is after traumatic amputation. About 30% of those inflicted with acute tinnitus after acoustic trauma will develop chronicity, as suggested in several military studies. It is unknown whether acoustic trauma–induced tinnitus and noise-induced hearing loss (NIHL) associated with tinnitus share the same pathogenesis, but studies have found that 50% to 70% of those with noise-induced hearing loss experience chronic tinnitus. The mechanism of hair-cell and neural injury is likely related to the idea that intense sound exposure causes a reduction of blood flow, which triggers inflammatory mediators and resultant cell death within the cochlea. The overall hypothesis is that hearing loss decreases the afferent stream of neural input from the cochlea to the auditory cortex. Injury to the auditory pathway alters activity in the brainstem and subcortical regions, which may lead to reorganization of the auditory cortex and result in subjective tinnitus.
An alternative theory concerning tinnitus pathology is linked to the somatic tinnitus hypothesis, which suggests that the reduction of afferent inputs from the cochlea may allow for inappropriate upregulation of inputs from somatosensory fibers to the auditory brainstem. Nonclassical auditory pathways help explain why some patients experience relief from their tinnitus with electrical stimulation of the trigeminal and median nerves.
The exact mechanism of tinnitus is not known, although it is agreed that a change in normal neural code leads to the pathogenesis of tinnitus. Dividing subjective tinnitus into subtypes based on common causes (traumatic, noise-induced, postinflammatory, presbycusis, anxiety, and so forth) can be useful in diagnosing and treating tinnitus, because treatments that are effective in one group of tinnitus patients may be ineffective in another group because of differing causes of their symptoms. Treating all tinnitus patients in the same way will lead to poor results. Each case must be addressed on an individual basis, which is why intensive counseling with both an experienced physician and audiologist is crucial to patient satisfaction and success.
Pulsatile Tinnitus
In establishing a treatment algorithm for tinnitus it is recommended that the definition of tinnitus be broadened to include both subjective and objective tinnitus, to encompass those patients referred with pulsatile complaints. Pulsatile tinnitus has a broad differential diagnosis ( Box 1 ). It can be a result of normal anatomic variations, such as a right dominant or dehiscent sigmoid sinus or a dehiscent carotid artery in the middle ear. Other pathologic causes include glomus (tympanicum or jugulare) tumors, superior canal dehiscence, patulous eustachian tube, otitis media, or intracranial vascular aneurysms or vascular malformations. Atherosclerotic carotid artery disease, hypertension, and tortuous vessels (anterior inferior cerebellar artery loop) can be seen in patients complaining of pulsatile tinnitus. Some recent literature presented cases of benign intracranial hypertension or pseudotumor cerebri as a causative agent behind pulsatile tinnitus. Because this form of tinnitus may involve both otologic and nonotologic sources, it is imperative to make the distinction and refer these patients onward for further medical workup before considering the treatment options outlined here.
Benign intracranial hypertension/pseudotumor cerebri
Chiari malformation
Dehiscent carotid artery in the middle ear
Dominant sigmoid sinus (usually right-sided)
Dehiscent sigmoid sinus into mastoid air cells
Glomus tumor (tympanicum, jugulare)
Intracranial vascular malformation (aneurysm, arteriovenous malformation)
Menière disease
Otitis media
Patulous eustachian tube
Persistent stapedial artery
Petrous apex lesion
Sigmoid sinus diverticulum
Superior canal dehiscence syndrome
Vascular compression syndrome of the cochleovestibular nerve
After a detailed history and physical examination that includes auscultating with a standard and an otologic stethoscope to evaluate for objective pulsatile tinnitus, basic pulsatile tinnitus diagnostic workup includes a noncontrast computed tomography (CT) scan of the temporal bone, magnetic resonance imaging (MRI), magnetic resonance angiography, magnetic resonance venography, and a fundoscopic evaluation by an ophthalmologist to assess for papilledema, which can be a sign of pseudotumor cerebri. Rarely, imaging can miss subtle vascular findings. An angiogram is considered the gold standard for vascular malformation; however, with modern imaging techniques a CT angiogram can provide a less invasive alternative to an angiogram, and provide excellent resolution of the intracranial vascular system. Even after an exhaustive search and thorough diagnostic workup, many patients will be diagnosed with idiopathic pulsatile tinnitus for which the main treatment is reassurance.
Nonpulsatile Tinnitus
Subjective tinnitus is a challenging chronic condition that is predominantly managed symptomatically because little evidence-based research exists concerning the pathogenesis behind the condition. The initial workup for patients with subjective tinnitus should include a comprehensive audiometric evaluation including audiogram with tinnitus matching, tympanograms, testing for hyperacusis, and tests of central auditory processing when indicated. Acoustic reflex testing is a simple addition to most audiologic evaluations and is especially useful if there is suspicion of tensor tympani or stapedius myoclonus. However, in the authors’ office reflexes are rarely performed on tinnitus patients, owing to the high prevalence of hyperacusis and the risk or exacerbating a patient’s symptoms and eroding patient trust. A contrast-enhanced MRI of the brain is the most useful radiologic test and can reveal acoustic neuromas, multiple sclerosis, ischemic microvascular disease, temporomandibular joint disorder, and Chiari malformations as well. Performing other audiometric tests such as otoacoustic emissions, electrocochleography, auditory brainstem response, and vestibular evoked myogenic potential is determined based on the clinical picture. Finally, blood work including antinuclear antibodies, vitamin B 12 , erythrocyte sedimentation rate, fluorescent treponemal antigen, 20-channel serum multiple analysis, complete blood count, hemoglobin A 1c , fasting glucose, thyroid-stimulating hormone, and antimicrosomal antibodies can assist in a workup looking for metabolic, syphilis-related, or autoimmune causes of tinnitus.
All patients seen in the authors’ office fill out a Tinnitus Handicap Inventory (THI) questionnaire. The THI is a validated measure that is helpful in the quantification of tinnitus and how it affects daily living. The questionnaire can be used at a patient’s initial evaluation and after treatment to measure progress. A questionnaire such as the THI allows for a standardized, validated evaluation for physicians and audiologists to better understand how incapacitating the disease process may be and to help in treatment planning.
Medical treatment approaches and outcomes
Sound Therapy: Masking, Tinnitus Retraining Therapy, Hearing Aid, and Modulated Sound Therapy
There are several types of sound therapy for tinnitus. The common denominator in all of these modalities is counseling by an experienced audiologist to personalize the treatment plan. Tinnitus retraining therapy (TRT) and hearing aids have been around for decades, while commercially available devices that provide acoustic desensitization through sound modulation such as Neuromonics and Sound Cure are more recent additions the menu of treatment options. However, without counseling by an experienced audiologist, patients will not achieve optimal results.
Sound therapy to help patients cope with tinnitus is one of the easiest recommendations. There are few to no side effects, and the presence of sound can provide adequate coverage to prevent awareness of the tinnitus. Whereas some patients may become fixated on the tinnitus so that even very loud masking sounds cannot cover it, many patients will learn to habituate to the tinnitus with time. Sound therapy can help them cope with the tinnitus and reduce the time to habituation. Sound therapy is most effective when combined with counseling to help patients better understand the tinnitus and their reaction to it.
Sound enrichment can be as simple and natural as sitting next to the ocean and listening to the waves crash on the shoreline, or as complex as a surround-sound speaker array with a multitude of acoustic stimuli presented. Careful questioning of the patient often leads to 1 or 2 sounds that either completely or partially mask the tinnitus. Inexpensive sound machines are available that create an array of musical or nature sounds; these can serve as maskers and deliver soothing sound to promote relaxation. Although these sounds provide only short-term relief, they can be a basis for counseling and can be very successful in cases of normal hearing to moderately severe hearing loss. In cases of binaural severe or profound hearing loss, sound enrichment can be very difficult. Cochlear implantation may be an option to improve hearing, with the potential benefit of tinnitus reduction in patients who meet cochlear implantation criteria.
In today’s world, technology is at many patients’ finger tips. The availability of tinnitus sound applications on many smartphones allows patients to try a variety of different sounds at a very low price. Patients can also plug their phone or MP3 player into a speaker that is embedded in a pillow to allow sound to reach the better hearing ear, especially if they are a stomach or side sleeper.
Maskers and Tinnitus Retraining Therapy
Maskers, which have been in use since the early 1970s, can be worn at the ear level with appearance similar to that of hearing aids, or be table side. Maskers can provide white noise (broad-band), pink noise (less high-frequency emphasis), or even notched noise (sound centered on a specific frequency). Many patients find that they experience a temporary reduction in their tinnitus after they stop listening to the masker. This phenomenon is termed residual inhibition. Ear-level maskers are used with TRT, developed by Pawel Jasterbowf in the 1990s. His theory of a neurophysiologic model of tinnitus is used in counseling along with a low level of broad-band noise to help patients habituate to the tinnitus. A concise outline of this theory can be found at http://www.tinnitus-pjj.com . Therapy can take 12 to 18 months to complete, and has been found to be successful. Bauer and Brozoski report that TRT shows moderate improvement for adults with moderate to severe tinnitus without significant hearing loss, depression, or hyperacusis. One drawback to TRT is the amount of time patients spend in active therapy, and many drop out before completion of their therapy.
Hearing Aids
Brief mention should be made regarding the benefit of hearing aids for tinnitus. With the advent of advanced digital signal processing, modern hearing aids are able to fit a precipitously sloping high-frequency hearing loss with an open ear canal style of fit. In the past this configuration of hearing loss made amplification difficult to fit without causing acoustic feedback from the hearing aid. As many patients with tinnitus have an accompanying hearing loss in the high frequencies, appropriately fit hearing aids should be tried in such cases. Parazzini and colleagues reported that open-fit hearing aids were equally as effective as sound generators in TRT therapy for the treatment of tinnitus.
Other areas of advancement in hearing-aid technology arise from combination devices. Masking noise can be modulated by frequency shaping, intensity, speed of modulation, and degree of modulation in combination with sound amplification. This type of masking sound can lead to habituation of tinnitus more quickly and comfortably. Another approach is with integrated musical tone therapy described as fractal tone, again delivered through the hearing aid. Sweetow and Sabes reported success in clinically reducing the annoyance of tinnitus through the combination of amplification with fractal tones.
Modulated Sound Therapy
Neuromonics uses a strict protocol whereby the patient spends 2 to 4 hours per day listening to spectrally modified music based on the patient’s hearing loss and tinnitus profile. The course of therapy is completed in a minimum of 6 months. During the first phase of therapy, the music is accompanied by a masking sound; this provides many patients with excellent relief from their tinnitus. Once they have achieved a degree of relief and have habituated to the music, the second phase removes the masking sound. The patient is now intermittently exposed to the tinnitus during the pauses in the music. Intermittent exposure helps desensitize the brain from engaging the limbic system to alert the individual to the tinnitus. Not all patients with tinnitus are good candidates for Neuromonics, and continuing tinnitus education and counseling are keys to a better outcome.
Newman and Sandrige did a cost analysis of Neuromonics versus a traditional ear-level masker in patients with normal hearing sensitivity, and found at the 6-month mark that the overall cost-effectiveness per unit of decrease on the Tinnitus Reaction Questionnaire was less with the ear-level masker. The strict protocol and clinical support provided by Neuromonics can assure patients of outcomes similar to those reported in the literature because of the standardization; however, experienced audiologists with a long-established practice with tinnitus patients may find equivalent results to Neuromonics using a more flexible program with an ear-level masker at a fraction of the cost. Each clinic should compile its own clinical data and critically evaluate its outcomes to best serve its patient population.
Another newer sound therapy to recently gain approval from the Food and Drug Administration is Sound Cure. This modulated sound therapy is delivered via headphones with independent volume controls for each ear. It is not programmed specifically for each patient, and unlike Neuromonics it has no formal clinical protocol. The basis for the therapy is S-tones, a phenomenon that was first reported in the electrical domain with cochlear-implant patients and inhibition of tinnitus, but was also found to be effective in the auditory domain. This novel approach may be helpful for patients who are not as greatly disturbed by their tinnitus, because it can be used as much or as little as the patient would like. Clinical outcome data with which to compare the efficacy of Sound Cure with that of other similar sound-modulating products are not yet available.
Transcranial Magnetic Stimulation
Transcranial magnetic stimulation (TMS) is a newer method for both evaluation and treatment of tinnitus. TMS uses an electrical current to induce a magnetic field in the brain, thereby temporarily disrupting normal cortical neuronal activity. Depending on the frequency and length of TMS, the amount of cortical excitability can be increased or decreased, thus allowing for tailored treatment regimens that can lead to altered cortical plasticity. When combined with functional imaging such as functional MRI and positron emission tomography (PET), TMS can be directed toward specific brain structures, which may be beneficial both in the initial treatment of tinnitus and in future research. Tinnitus studies with TMS have shown mixed results concerning the effect of tinnitus duration on responsiveness to TMS, but do show significant reduction of tinnitus loudness and perception with higher-frequency stimulation (10–25 Hz). When combined with PET imaging, the areas shown to be correlated with tinnitus were located in the sensory association or nonclassical pathway associated with the limbic system, such as the temporal cortex, the right gyrus angularis, and the posterior cingulum.
Electrical Stimulation/Cochlear Implantation
Treatment of tinnitus using electrical stimulation has been an evolving therapy for centuries. Most recently, cochlear implantation has shown statistical significance in studies measuring its effect on the improvement of tinnitus. One study found that about two-thirds of patients with tinnitus noticed suppression of their symptoms on initial stimulation, and 93% found relief after a 2-month period of stimulation. The benefit of cochlear implantation is said to come from the decrease in spontaneous activity and increase in correlated firing in auditory nerve fibers achieved with direct stimulation. One theory in the pathogenesis of tinnitus involves deprivation of cochlear inputs, leading to plastic changes within auditory pathways. Stimulation from one cochlear implant has been shown to decrease the perception of tinnitus in the ipsilateral as well as the contralateral side, because the input from the auditory nerve to brainstem nuclei is bilateral.
Pharmacologic Treatment of Tinnitus
When applying an integrative approach to tinnitus, using traditional techniques of Western medicine can be a helpful adjunct for patients. Moderate success can be achieved in some patients by improving their sleeping habits, stress levels, anxiety, or depression. Correcting medical disorders such as hyperthyroidism or hypercholesterolemia can also provide patient relief. Many of the medications used to help tinnitus sufferers can have side effects, and interactions with other medications should be considered. Management in conjunction with a patient’s primary care physicians or mental health professionals is strongly recommended.
Initial efforts with pharmacologic intervention for tinnitus were directed toward neural inhibition, assuming symptoms were related to an imbalance in the spontaneous neural activity in the auditory system. Receptor-targeted therapy toward the glutamate system (excitatory neurotransmitter), the γ-aminobutyric acid (GABA) system (inhibitory neurotransmitter), and the dopamine and serotonin neuromodulators have been the main targets of pharmacologic treatment in hopes to treat the neural dysfunction that results in tinnitus.
Agents such as anesthetics (lidocaine, tocainide, mexilitine), anticonvulsants (carbamazepine, dilantin), benzodiazepines, and antidepressant medications (selective serotonin reuptake inhibitors [SSRIs]) have all been used in the treatment of tinnitus, with some positive effects. Studies on the effects of these inhibitory and modulatory agents on tinnitus have been unsuccessful as a whole in the treatment of a heterogeneous group of tinnitus patients. Clinical evidence from other treatment modalities suggests that tinnitus is a heterogeneous disorder, therefore testing such a group with a drug having a single mechanism of action is unlikely to yield high significance in studies.
Klonopin, a benzodiazepine with known antiseizure activity, has been reported in various case reports to give relief of symptoms to some tinnitus patients. Benzodiazepines alter the GABA A inhibitory receptor and increase the effectiveness of GABA’s ability to open chloride channels and inhibit neural activity. In animal studies the benzodiazepines have reduced the signs of neural hyperactivity and restored temporal integration via the GABA receptor (inhibitory neural transmitter). Shulman and colleagues proposed that a benzodiazepine deficiency syndrome is thought to be involved in some patients with subjective idiopathic tinnitus. Subsequent SPECT studies involving a benzodiazepine ligand identified diminished benzodiazepine-binding sites in the medial temporal cortex of those with severe tinnitus, and are the basis of multiple pharmacologic interventions. Klonopin arguably assists the emotional components of tinnitus reported by many clinicians by treating anxiety that can exacerbate tinnitus and improve sleep hygiene. Klonopin, or any medication for that matter, gives patients some control over their symptoms, which can help them psychologically and may benefit by creating a placebo effect. No randomized controlled trials exist that demonstrate a significant benefit of benzodiazepines for tinnitus severity and loudness.
Gabapentin, a drug with a highly debated mechanism of action initially created to mimic the neurotransmitter GABA, has been used with altering efficacy. Its initial uses were for neuropathic pain and antiseizure treatment, and it was proposed to affect tinnitus by increasing neural inhibition. The drug was first introduced for tinnitus users in the early 1990s. Shulman and colleagues report long-term tinnitus relief with gabapentin supplemented with Klonopin, as shown by improvement in Tinnitus Intensity Index, Tinnitus Annoyance Index, and Tinnitus Stress Test scores. No statistical significance, however, was seen in the THI. In randomized controlled trials, gabapentin alone has failed to demonstrate statistical significance in tinnitus by measures in loudness score and Tinnitus Severity Index values.
The anesthetic medications are limited in utility by their side-effect profiles because most drugs used in tinnitus treatment require lifelong administration. Lidocaine infusion was originally introduced in 1980; however, the short duration of relief made it impractical as a treatment option. A study published in 2005 reproduced the statistical significance of lidocaine infusion affecting tinnitus loudness and distress. This study also demonstrated the short-lasting effect of lidocaine by the lack of statistical significance shortly after (20 minutes) drug administration, thus highlighting its shortfall as a realistic treatment modality.
Recent pharmacologic intervention using antidepressants for tinnitus has become extensively prescribed. Not only is there a well-documented association between mood disorders and tinnitus, but there is also a wealth of knowledge in the neuroscience literature indicating that serotonin and other neurotransmitters affect sensory and cognitive centers. It is hypothesized that serotonin may play a role in the behavioral conditioning and neuroplasticity within the auditory cortex.
Antidepressant medications were originally tried for tinnitus relief based on the hypothesis that depression can coincide with chronic tinnitus. Initial studies and case reports showed some efficacy in treatment with SSRIs and other serotonin and dopamine modulators. A Cochrane review of 5 trials found insufficient evidence to show that antidepressant medications improve tinnitus directly. Instead, improvement of tinnitus symptoms by SSRIs as measured by the THI may indeed be secondary to an improvement of coinciding depressive symptoms.
For many otologic disorders intratympanic injection of topical medications has been successful, particularly for sudden sensorineural hearing loss and episodic vertigo, such as Menière disease. There has been a recent attempt to apply this wealth of clinical data to tinnitus patients, and the results have been disappointing. Initial studies suggested a benefit of intratympanic steroid injection in treating subjective nonpulsatile tinnitus; however, several follow-up randomized controlled studies have not revealed any statistical significance to suggest benefit of intratympanic steroids over placebo. The one exception to these data is a recent prospective, double-blind study treating acute subjective tinnitus. Shim and colleagues reported that for acute subjective idiopathic tinnitus, the combination of alprazolam and intratympanic dexamethasone injections resulted in a significantly higher tinnitus improvement rate (75%) than treatment with alprazolam alone (50%). Few studies have been performed using intratympanic steroids; however, the low-risk profile and relative ease of administration make it a viable treatment option in the acute setting, and one more option to offer patients who can often be severely affected by tinnitus, particularly in the acute-phase.
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