Management of Tinnitus: Guidelines From the VA/DoD

Tinnitus, the perception of sound without an external source, can be constant or intermittent and is most often secondary to auditory system damage. Patients with tinnitus can describe ringing, buzzing, hissing, sizzling, roaring, chirping, or other sounds. One in five people with chronic tinnitus finds it bothersome enough to seek care. The US Department of Veterans Affairs and US Department of Defense (VA/DoD) published guidelines on the management of tinnitus in patients with bothersome tinnitus with or without hearing difficulty.

Educational counseling improves tinnitus severity compared with traditional support or no treatment; only one study did not use any educational counseling in the control group. Education should include information about available management strategies, natural history and prognosis, the association between hearing loss and tinnitus, the effects of lifestyle on tinnitus, importance of hearing protection, and realistic expectations regarding improving quality of life with tinnitus.

Internet- or app-based self-management lacks sufficient evidence, although one small trial suggested improvement compared with sound therapy. Although computer-based games have not been studied extensively, the existing trials show no benefit.

Hearing Aids

For patients with tinnitus and hearing loss, hearing aid use significantly improves speech understanding, communication, and sound awareness. A sound generator is not more helpful. There is insufficient evidence to recommend hearing aids with contralateral routing of signal/sound, which are commonly used for single-sided deafness, because existing evidence suggests no improvement.

Surgical

Cochlear implantation is recommended for patients who meet candidacy requirements because tinnitus-related outcomes are improved for more than 1 year. Bone conduction devices lack sufficient evidence, although one small study suggested benefits in tinnitus-related outcomes. Because of better tinnitus-related outcomes, cochlear implants are recommended over bone conduction devices and contralateral routing of signal/sound hearing aids, despite rare adverse events with the implants.

Sound-Based Interventions

The therapeutic use of sound reduces the self-perceived handicap of tinnitus, whether delivered by ear-level devices or external speakers. Sound enrichment combined with tinnitus education improves quality of life compared with education alone. Sound can be delivered with ear-level devices (eg, hearing aids, sound generators, wireless earphones) or through external sound-playing devices (eg, mobile phones, music devices, tabletop sound spas). Using altered music has mixed results in reducing the impact of tinnitus compared with regular music, but listening to altered music for up to 2 hours per day can be undesirable for patients.

Cognitive behavior therapy improves clinical outcomes in tinnitus, including distress, compared with passive controls. Combining sound therapy and cognitive behavior therapy improves outcomes compared with sound therapy alone. Acceptance and Commitment Therapy, mindfulness-based therapies, and Mindfulness-Based Stress Reduction lack sufficient evidence of benefit at follow-up.