Tinnitus management: what the evidence shows about sound therapy, hearing aids, and CBT

Tinnitus is the experience of hearing sounds that do not come from an external source. These sounds can include ringing, buzzing, humming, hissing, or clicking. It's a common condition, affecting about 10% to 21% of adults [1, 2, 3]. For most people, tinnitus is a mild annoyance. However, for an estimated 1% to 3% of adults, it can cause severe problems and negatively affect their quality of life [1, 2].

Currently, there is no cure for tinnitus. Instead, the focus of care is on managing the symptoms and helping people live better with the condition. This article looks at what the evidence shows about common management strategies like sound therapy, hearing aids, and cognitive behavioural therapy (CBT).

When to seek prompt medical care

While tinnitus is often not a sign of a serious problem, certain types or accompanying symptoms should prompt a medical assessment. You should seek prompt medical care if you experience:

• Pulsatile tinnitus: Tinnitus that beats in time with your pulse.
• One-sided tinnitus: Tinnitus that occurs in only one ear.
• Tinnitus with sudden hearing loss: If your tinnitus appears along with a sudden change in your hearing.

A healthcare professional can assess your situation to identify any underlying conditions that might be causing your tinnitus and could be treated [3].

Understanding tinnitus management

For persistent and bothersome tinnitus, healthcare guidelines recommend a few key steps. These include a comprehensive hearing evaluation, education about tinnitus, and specific therapies [3]. The goal of these approaches is to reduce the impact of tinnitus on your daily life, rather than to eliminate the sound itself.

Cognitive Behavioural Therapy (CBT) for tinnitus

Cognitive behavioural therapy, or CBT, is a type of talk therapy. It uses psychological techniques based on how we think and behave [1]. For tinnitus, CBT aims to help you change your reactions to the sound, making it less bothersome. If you want to learn more about how talk therapy works in general, you can read our guide: Does Therapy Work?.

What the evidence shows about CBT

A detailed review of studies on CBT for tinnitus found that it may help people manage the condition [1].

• Impact on quality of life: CBT may reduce how much tinnitus affects your quality of life [1]. One way to measure this is with a score called the Tinnitus Handicap Inventory (THI). Studies found that people receiving CBT had THI scores about 10.91 points lower than those who didn't receive an intervention [1]. A 7-point change on this scale is considered a meaningful difference [1].
• Comparison to other care: When compared to standard audiological care, CBT probably reduces the impact of tinnitus on quality of life [1]. The average difference was 5.65 points lower on the THI for those receiving CBT [1].
• Loudness of tinnitus: It's important to note that CBT does not change the actual loudness of the tinnitus sound [1]. Instead, it helps change your perception and reaction to the sound.
• Other effects: CBT may lead to a slight reduction in symptoms of depression [1]. However, there is less certainty about whether CBT reduces anxiety, improves general health-related quality of life, or changes how negatively people interpret their tinnitus [1].
• Safety: Studies generally reported few or no serious adverse effects from CBT for tinnitus [1].

Most of the studies included in this review were from Europe, involved participants with tinnitus for at least three months, and the CBT sessions lasted between 3 and 22 weeks, often conducted in hospitals or online [1].

Sound therapy and hearing aids

Sound therapy involves using external sounds to help manage tinnitus. This can include devices like hearing aids, sound generators, or combination devices that offer both [2]. These devices are often a first step in managing tinnitus, especially for people with hearing loss [2, 3].

What the evidence shows about sound therapy and hearing aids

A review of studies on sound therapy found that the evidence for its effectiveness is limited [2].

• Limited data: There was not enough data to compare hearing aids, sound generators, or combination devices against a waiting list, a placebo, or just education without a device [2].
• No clear winner between devices: When comparing different types of devices against each other, there was no clear evidence that one type was better than another [2].
  • One study compared sound generators to hearing aids and found no difference in their effects on tinnitus severity after 3, 6, or 12 months [2].
  • Three studies compared combination hearing aids (which offer both amplification and sound generation) to hearing aids alone and found no difference between them in tinnitus symptom severity [2].
• Overall effect: While there wasn't a clear winner among device types, the use of both types of devices (hearing aids and sound generators) was associated with a clinically meaningful reduction in tinnitus symptom severity [2]. This suggests that using some form of sound device may be helpful.
• Evidence certainty: The evidence for these findings was of low quality, meaning more research is needed to be certain about the effects [2].
• Other outcomes: None of the studies included in this review measured effects on depression, anxiety, or general health-related quality of life [2]. Adverse effects from wearing the devices, such as pain or skin irritation, were also not assessed [2].

Guideline recommendations for tinnitus management

The American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) published a clinical practice guideline for tinnitus management [3]. It makes several recommendations based on the available evidence for adults with bothersome and persistent tinnitus (lasting six months or longer):

• Hearing evaluation: A comprehensive hearing evaluation is recommended for patients with tinnitus that is one-sided, persistent, or linked to hearing difficulties [3].
• Education and counselling: Patients with persistent, bothersome tinnitus should receive education about management strategies [3].
• Hearing aids: For those with persistent, bothersome tinnitus and documented hearing loss, a hearing aid evaluation is recommended [3].
• Cognitive Behavioural Therapy (CBT): CBT is recommended for patients with persistent, bothersome tinnitus [3].
• Sound therapy: Clinicians may recommend sound therapy for patients with persistent, bothersome tinnitus [3].

The guideline also recommends against routinely using certain medications (antidepressants, anticonvulsants, anxiolytics, intratympanic medications) or supplements (Ginkgo biloba, melatonin, zinc) for tinnitus [3].

Limitations of the evidence

It's important to remember that research on tinnitus management is ongoing.

• CBT: While CBT shows promise for reducing the impact of tinnitus on quality of life, the certainty of the evidence is often low or very low, especially for outcomes like anxiety or general quality of life [1]. More high-quality studies are needed.
• Sound therapy: The evidence for sound therapy devices is limited, and the quality of evidence is generally low [2]. This means we need more robust studies to understand which devices work best and for whom. Many studies did not provide enough detail to assess the risk of bias, and blinding participants or clinicians was often not used, which can affect results [2].

What this means for you

Living with persistent tinnitus can be challenging, but there are strategies that can help you manage its impact on your life.

• Get assessed: If your tinnitus is new, one-sided, pulsatile, or accompanied by sudden hearing loss, speak to a healthcare professional for an assessment.
• Consider CBT: If tinnitus significantly affects your quality of life, CBT is a recommended option that may help you reduce its impact, even if the sound itself doesn't change [1, 3].
• Explore sound therapy and hearing aids: If you have hearing loss along with tinnitus, a hearing aid evaluation is recommended [3]. Even without hearing loss, sound therapy may be an option to discuss with a healthcare professional [3]. While the evidence is limited, using these devices may help reduce how bothersome your tinnitus is [2].
• Focus on management: Remember that the goal is often to manage the symptoms and improve your quality of life, as there is currently no cure for tinnitus.
• Talk to a professional: A licensed audiologist or other healthcare professional can assess your specific situation and help you understand which management strategies might be most suitable for you.