Clinical Evidence Handbook: Tinnitus - February 1, 2004

February 1, 2004 Table of Contents

CLINICAL EVIDENCE CONCISE: A PUBLICATION OF BMJ PUBLISHING GROUP

Tinnitus

ANGUS WADDELL, University of Bristol, Bristol, United Kingdom

RICHARD CANTER, University of Bath, Bath, United Kingdom

Am Fam Physician. 2004 Feb 1;69(3):591-592.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The practice recommendations in this activity are available at http://www.clinicalevidence.com/lpBinCE/lpext.dll?f=templates&fn=main-h.htm&2.0.

What are the effects of treatments for chronic tinnitus?

LIKELY TO BE BENEFICIAL

Tricyclic Antidepressants

One small randomized controlled trial (RCT) in people with depression and chronic tinnitus found that tricyclic antidepressants (nortriptyline) versus placebo significantly improved tinnitus-related disability, audiometric tinnitus loudness matching, and symptoms of depression, but found no significant difference in tinnitus severity at six weeks. One small RCT in people with tinnitus but without depression found that a greater proportion of people rated themselves as improved with tricyclic antidepressants (amitriptyline) versus placebo at six weeks.

UNKNOWN EFFECTIVENESS

Psychotherapy

One systematic review found insufficient evidence about effects of cognitive behavior treatment, relaxation therapy, counseling, education, hypnosis, biofeedback, or stress management compared with other or no treatment in people with chronic tinnitus.

Acupuncture; Antiepileptics; Baclofen; Benzodiazepines; Cinnarizine; Electromagnetic Stimulation; Hyperbaric Oxygen; Hypnosis; Low-Power Laser; Nicotinamide; Tinnitus Masking Devices; Zinc. We found insufficient evidence about the effects of these interventions.

LIKELY TO BE INEFFECTIVE OR HARMFUL

Ginkgo Biloba

One systematic review and one subsequent RCT found no significant difference with ginkgo biloba versus placebo in tinnitus symptoms.

Tocainide

One RCT found no significant difference with tocainide versus placebo in improving symptoms, but found evidence that tocainide caused significantly more adverse effects after 30 days of treatment.

Definition

Tinnitus is defined as the perception of sound, which does not arise from the external environment, from within the body (e.g., vascular sounds), or from auditory hallucinations related to mental illness. This review concerns the management of chronic tinnitus, where tinnitus is the only, or the predominant, symptom in an affected person.

Incidence/Prevalence

Up to 18 percent of the general population in industrialized countries is mildly affected by chronic tinnitus, and 0.5 percent report tinnitus having a severe effect on their ability to lead a normal life.1

Etiology/Risk Factors

Tinnitus may occur as an isolated idiopathic symptom or in association with any type of hearing loss. Tinnitus may be a particular feature of presbycusis, noise-induced hearing loss, Ménière's disease, or the presence of an acoustic neuroma. In people with toxicity from aspirin or quinine, tinnitus can occur while hearing thresholds remain normal. Tinnitus also is associated with depression, although it may be unclear whether the tinnitus is a manifestation of the depressive illness or a factor contributing to its development.2

Prognosis

Tinnitus may have an insidious onset, with a long delay before clinical presentation. It may persist for many years or decades, particularly when associated with a sensori-neural hearing loss. In Ménière's disease, the presence and intensity of tinnitus can fluctuate. Tinnitus may cause disruption of sleep patterns, an inability to concentrate, and depression.3

SEARCH DATE: October 2002

Adapted with permission from Waddell A, Canter R. Tinnitus. Clin Evid Concise 2003;10:118-9.

EDITOR'S NOTE: Cinnarizine is not available in the United States. Nicotinamide is called niacinamide in the United States.

REFERENCES

1. Coles RR. Epidemiology of tinnitus (1). J Laryngol Otol. 1984;9suppl:7–15.

2. Sullivan MD, Katon W, Dobie R, et al. Disabling tinnitus: association with affective disorder. Gen Hosp Psychiatry. 1988;10:285–91.

3. Zoger S, Svedlund J, Holgers KM. Psychiatric disorders in tinnitus patients without severe hearing impairment: 24 month follow-up of patients at an audiological clinic. Audiology. 2001;40:133–40.

This is one in a series of chapters excerpted from Clinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom. Clinical Evidence Concise is published in print twice a year and is updated monthly online. Each topic is revised every eight months, and users should view the most up-to-date version at http://www.clinicalevidence.com. If you are interested in contributing to Clinical Evidence, please contact Claire Folkes (cfolkes@bmj-group.com). This series is part of the AFP's CME. See “Clinical Quiz” on page 477.

Copyright © 2004 by the American Academy of Family Physicians.
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