Eur Arch Otorhinolaryngol

DOI 10.1007/s00405-016-4401-y

REVIEW ARTICLE

A multidisciplinary systematic review of the treatment for chronic

idiopathic tinnitus
Hans-Peter Zenner1 • Wolfgang Delb2 • Birgit Kröner-Herwig3 • Burkhard Jäger4 •
Ingrid Peroz5 • Gerhard Hesse6 • Birgit Mazurek7 • Gerhard Goebel8 •
Christian Gerloff9 • Regina Trollmann10 • Eberhard Biesinger11 • Harald Seidler12 •
Berthold Langguth13

Received: 11 July 2016 / Accepted: 19 November 2016

Ó Springer-Verlag Berlin Heidelberg 2016

Abstract The majority of tinnitus patients are affected by
chronic idiopathic tinnitus, and almost 60 different treat-
ment modalities have been reported. The present study is a
multidisciplinary systematic analysis of the evidence for
the different forms of treatment for chronic tinnitus. The
results are used to form the basis of an S3 guideline. A
systematic search was carried out in PubMed and the
Cochrane Library. The basis for presenting the level of
evidence was the evidence classification of the Oxford
Centre of Evidence-based Medicine. Whenever available,
randomised controlled trials were given preference for
discussing therapeutic issues. All systematic reviews and
meta-analyses were assessed for their methodological
quality, and effect size was taken into account. As the need
for patient counselling is self-evident, specific tinnitus
counselling should be performed. Due to the high level of
evidence, validated tinnitus-specific, cognitive behavioural
therapy is strongly recommended. In addition, auditory
therapeutic measures can be recommended for the treat-
ment of concomitant hearing loss and comorbidities; those
should also be treated with drugs whenever appropriate. In
particular, depression should be treated, with pharmaco-
logical support if necessary. If needed, psychiatric treat-
ment should also be given on a case-by-case basis. With
simultaneous deafness or hearing loss bordering on deaf-
ness, a CI can also be indicated. For auditory therapeutic
measures, transcranial magnetic or direct current stimula-
tion and specific forms of acoustic stimulation (noise-
r/masker, retraining therapy, music, and coordinated reset)
for the treatment of chronic tinnitus the currently available
evidence is not yet sufficient for supporting their
recommendation.
Keywords Tinnitus
Cognitive behavioural therapy

Drug therapy
Cochlear implant
Retraining therapy

& Hans-Peter Zenner 7

Charité Hospital, Medical School Berlin, University
ut@hpzenner.de Otorhinolaryngology Clinic, Berlin, Germany
8
1 Department of Behavioural Medicine, Psychosomatics,
Department of Otolaryngology, Head and Neck Surgery,
Psychiatry and Psychotherapy, Schön Clinic in Roseneck,
University of Tübingen, Elfriede-Aulhorn-Str. 5,
Prien am Chiemsee, Germany
72076 Tübingen, Germany
9
2 Clinic and Outpatient Clinic for Neurology, University
Otorhinolaryngology Centre, Kaiserslautern, Germany
Hospital of Hamburg-Eppendorf, Hamburg, Germany
3
Department of Psychology, Georg-August University of 10
Social Paediatric Centre, Neuropaediatrics and Epileptology,
Göttingen, Göttingen, Germany
University Paediatric Clinic, Erlangen, Germany
4
Mental Health Centre, Clinic for Psychosomatics and 11
Otorhinolaryngology Centre, Traunstein, Germany
Psychotherapy, Medical University of Hannover, Hannover,
12
Germany MedClin Bosenberg Clinics, Saint Wendel, Germany
5 13
Department for Dental Prosthetics, Geriatric Dentistry and Department for Psychiatry and Psychotherapy, University of
Function, Charité Hospital, Medical School Berlin, Berlin, Regensburg, Regensburg, Germany
Germany
6
Tinnitus Clinic, Bad Arolsen Hospital, Arolsen, Germany

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Introduction
Tinnitus is a common complaint, with a prevalence
affecting an estimated 22% of the studied population [134].
A recent British surveillance study of 4.7 million inhabi-
tants reported an incidence of 5.4 new cases/10,000
inhabitants [116]. In ‘‘subjective tinnitus’’, neither an
external nor endogenous sound source is present; instead,
the tinnitus is caused by abnormal bioelectric, biome-
chanical, or biochemical activity in the inner ear and/or
central nervous system.
Tinnitus is a symptom of the auditory system. The
current state of knowledge regarding the aetiology and
pathogenesis of tinnitus suggests that its aetiology,
whether symptomatic or idiopathic, is often based on a
primary pathophysiological process in the ear. With
simultaneous hearing loss, the tinnitus frequency often
appears within the range of the greatest hearing loss
[129, 170]. However, the inner ear damage does not
need to be obvious in the tone threshold audiogram
[52, 169, 190, 198]. Later in the pathophysiological
process, highly sensitive central feedback mechanisms
are thought to be affected, which then contribute to the
perception of tinnitus [87]. In severely affected indi-
viduals with tinnitus, central nervous system processing
often leads to pathologically exaggerated stimulus
responses, such as exaggerated attention steering towards
the tinnitus, induction of anxiety, and insomnia. Central
psychophysiological and neurophysiological processing
mechanisms are currently thought to be culpable for the
pathologically exaggerated tinnitus stimulus responses.
Psychophysiologically, a specific learning process,
namely, cognitive sensitisation, has been suggested to be
involved at the cognitive (perception) level of the brain
[208]. Neurophysiologically, in the area of the central
auditory pathway, changes in neuronal firing rate, neu-
ronal synchronicity, and changes in tonotopic organisa-
tion can be found after cochlear damage [50, 161, 191].
These changes may reflect neuroplastic processes
[40, 54, 101, 124, 178, 183]. In addition, patients with
chronic tinnitus exhibit functional changes not only in
the auditory structures, but also in the limbic, parietal,
and frontal areas [2, 110].
Current understanding may be explained in terms of the
different models, e.g., the ‘‘neurophysiological model’’ by
Jastreboff [88], the ‘‘cognitive sensitization model’’ by
Zenner et al. [208], the ‘‘framework model’’ by De Ridder
et al. [41], or the ‘‘gating model’’ by Rauschecker et al.
[156]. Other authors made some effort in the last years to
summarize the knowledge on tinnitus therapy in review
papers (e.g., [20, 109]).
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Eur Arch Otorhinolaryngol
Chronic tinnitus is often associated with comorbidities
that can be pre-existing or triggered by tinnitus. Frequent
psychiatric and/or psychosomatic comorbidities are anxiety
disorders, depression, and insomnia [104, 175]. On the other
hand, depression and other mental disorders represent risk
factors for tinnitus perception and can subjectively reinforce
the tinnitus [59, 207]. The stronger the tinnitus distress, the
more likely the presence of a comorbidity [56, 108].
The vast majority of those affected with tinnitus have a
chronic subjective tinnitus. In 1998, Biesinger et al. [24]
reported that almost 60 different treatment modalities have
been used in the treatment of chronic idiopathic tinnitus.
The present study is a multidisciplinary systematic review
with the intention of analysing the evidence base for the
different forms of treatment. Results have influenced a
recent S3 guideline [210, 211].
Materials and methods
A systematic search was carried out in PubMed and the
Cochrane Library (http://www.ncbi.nlm.nih.gov/pubmed,
http://www.thecochrancelibrary.com). Defined search
strategies and selection criteria were used to evaluate the
different therapies for tinnitus (for details, see Appendix 2,
Chapters 1, and 2.3–2.8 of the guideline; Zenner et al.
[211]). Keywords (‘‘MeSH’’) were favoured over words in
the text body.
The basis for presenting the level of evidence was the
evidence classification of the Oxford Centre of Evidence-
based Medicine. Whenever available, randomised con-
trolled trials (RCTs) were given preference for discussing
therapeutic issues.
The quality of RCTs was assessed by considering four
questions: (a) does the study contain an adequate descrip-
tion of concealed randomisation (‘‘concealment of alloca-
tion’’)? (b) is the study blinded regarding the most
important target criteria (whenever possible)? (c) were all
patients reporting to the originally randomised group
evaluated in the follow-up [‘‘intention-to-treat (ITT) anal-
ysis’’]?; and (d) were no more than 10% of patients in the
primary analysis missing? When a study had to exclude
patients from the analysis due to non-compliance or the
drop-out rate differed significantly between the groups, the
study had to be evaluated as negative with respect to the
ITT principle. All systematic reviews and meta-analyses
were assessed for their methodological quality (method-
ological significance) with regard to any possible devalu-
ations of significant findings, clinical effect strengths, or
positive distortions. Whether the number of cases and/or
small differences prevented the establishment of an
Eur Arch Otorhinolaryngol
adequate evidence base (i.e., low methodological quality)
was considered. The effect size was also taken into
account; even if a difference was significant, the effect
could be so low that no clinical benefit was evident (in-
sufficient effect size). Side effects were also included in the
analysis, as well as statistical tests, evaluations, the accu-
racy of formulation, safety (report on adverse events
according to CONSORT Extension for Harms, ICH E2,
ICH E3), reproducibility (according to DIN ISO 5725), and
a discussion of data from the literature.
The meta-analysis was then used as a basis for a German S3
guideline and, as such, is consistent with this extended guide-
line and its shortened form [210, 211]. The extended guideline
also includes additional methodological information.
To clarify conflicts of interest, written declarations were
requested using the AWMF template. No conflicts of
interest were found on the part of the authors (for details,
see Zenner et al. [211]).
Results
Tinnitus counselling
For the treatment of chronic tinnitus, counselling is often
recommended [55, 64, 94, 103, 171]. The effectiveness of
tinnitus counselling has only been assessed in conjunction
with other procedures, such as retraining [87] and cognitive
behavioural therapy [209]. RCTs of the effectiveness of
counselling alone are not available; any implementation of
such a study would be problematic for both methodological
and ethical reasons. No study has systematically compared
the various forms of counselling.
Acoustic therapy measures
A meta-analysis from 2010 presented weak evidence that
auditory therapeutic measures, such as acoustic or audio
therapy (e.g., training of directional hearing) or focussing
and differentiation during exposure to disruptive noise with
and without hearing aids [67, 68], may be effective with
regard to treating tinnitus in cases of frequent simultane-
ously detectable hearing loss (also unilateral) or primarily
central or psychogenically induced hearing loss [74].
Another suggested approach was auditory discrimination
training (ADT), in which tinnitus patients practice exer-
cises in frequency discrimination [61–63]. One meta-
analysis of ten studies assessed the effectiveness of general
auditory perception training. Significant improvement in
tinnitus distress was described, but because of low
methodological quality, the evidence was weak [74]. The
statistical analysis revealed low methodological quality and
insufficient effect size.
Reports have also been published about the effects of
conventional and implantable hearing aids (reviewed in
Olze et al. [136]). However, regarding the effectiveness of
conventional hearing aids in tinnitus, studies have provided
only a moderate or weak evidence base [77, 122, 145, 195].
The statistical analysis revealed low methodological qual-
ity and insufficient effect size. The results were also con-
tradictory [122, 145, 173, 195]. Overall, convincing
prospective studies that confirm the effectiveness of hear-
ing aids in tinnitus are lacking. Evaluable studies on active
middle ear implants (implantable hearing aids) with tinni-
tus are also lacking. Accordingly, Hoare et al. [77] came to
the conclusion in their Cochrane analysis that no recom-
mendation can be made for the use of hearing aids alone in
the treatment of tinnitus.
In addition, sound therapy, such as with frequency
unmodulated noise generators involving the use of recor-
ded noise or a special noiser or masker device, has been
considered [89, 133]. A Cochrane meta-analysis evaluated
six studies with a total of 553 participants and found no
measurable improvement in tinnitus after the application of
external noise alone or amplified noise (i.e., using hearing
aids). However, the sound therapy was supportive in those
studies. A clear evidence assessment could not be carried
out, because the therapeutic approaches were generally
multimodal [79].
Cervical spine (CS) therapy
When the tinnitus has been shown to be modulated by
head- or neck movements, some have considered manual
medical or physiotherapeutic treatment of the cervical
spine. Both osteopathy and muscular feedback have been
mentioned for the treatment of tension [25, 35, 151], but
sufficiently large controlled studies are lacking [201].
Dental functional therapy/orthodontic therapy
Whenever there are pathologies of the masticatory appa-
ratus and jaw, especially when they lead to
detectable modulation of the tinnitus, appropriate dental
functional therapy is recommended [27]. An analysis of the
literature reveals differing effects of various dental mea-
sures on tinnitus, with an evidence level of Ib whenever
tinnitus is associated with temporomandibular dysfunction.
As such, whenever temporomandibular dysfunctions are
present, they could be reversibly treated on a case-by-case
and experimental basis. Only when an influence of the
therapy on tinnitus can be confirmed over a period of up to
6 months based on such intra-individual, control definitive
dental procedures make sense on a case-by-case basis,
unless there are other grounds for the dental indication
[53].
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Self-help
Self-help organisations provide additional advice and
support. Their main purpose is to act as a place, where
individual members can exchange information. One meta-
analysis suggested that self-help interventions may be
effective in reducing tinnitus distress, but provided no
definitive assessment [130].
Drug therapy
A specific drug therapy with proven efficacy for the
treatment of chronic tinnitus could not be found. However,
treatable comorbidities (e.g., depression) can be specifi-
cally treated using drugs.
Many different drugs with differing mechanisms of
action have been studied for the treatment of tinnitus.
There are meta-analyses, RCTs with evaluable results, and
publications that cannot be evaluated. For some prepara-
tions, sporadic randomised clinical trials have provided
indications for potential efficacy. However, no positive
results have been replicated for any preparation in ran-
domised clinical trials with a sufficient level of evidence,
and there have been no positive results from meta-analyses.
Accordingly, neither the European Medicines Agency
(EMA) nor the Food and Drug Administration (FDA) have
approved any preparation for the treatment of tinnitus
[108].
Ginkgo biloba
Large studies carried out as long ago as 2001 assessed the
efficacy of ginkgo extract in tinnitus patients among a
cohort of 1121 participants in a double-blind, placebo-
controlled study. The ginkgo preparation led to the same
(low) improvement in tinnitus penetrance and intensity as
the placebo [49]. Other negative results from RCTs were
also reported by Drew and Davies in 2001 [49], Han et al.
in 2012 [54], and Rejali et al. in 2004 [160]. In addition, a
number of non-evaluable studies have appeared on the
subject [82, 157].
A recent review serving as an update of a Cochrane
Review evaluated a number of recent RCTs on the efficacy
of ginkgo biloba among a total of 6000 patients, and no
evidence of efficacy was found [164]. Instead, side effects,
such as dizziness, stomach upset, or allergic reactions, and
sometimes even an increased tendency to bleed, were
reported [28, 72, 73, 160].
Steroids
Controlled studies on the treatment of chronic tinnitus with
systemic steroids have not been published. In some studies,
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Eur Arch Otorhinolaryngol
corticosteroids were intratympanically applied but without
any significant effect [8, 36, 194]. In one randomised study,
70 adult tinnitus patients were treated intratympanically
with either methylprednisolone or saline. The severity of
the tinnitus distress did not change significantly in either
group [194]. In another study, treatment was also ran-
domised and carried out intratympanically (n = 36) with
either dexamethasone or saline, resulting in no significant
differences [8].
Glutamate antagonists
Four glutamate antagonists have been used in clinical
studies of tinnitus patients: acamprosite/acamprosate,
memantine, neramexane, and caroverine. All antagonists
were applied as off-label medications or had not yet been
approved [17, 18, 176]. The neramexane study [185] is an
example of an excellently planned study. This was a phase
II, multicentre, randomised, placebo-controlled, double-
blind, parallel-grouped, four armed study carried out using
three concentrations in 316 patients. However, no adequate
statistical evidence could be obtained in favour of ner-
amexane as compared to placebo. This was partly due to
the high drop-out rate from vertigo that reduced the number
of cases in the treatment group. On the other hand, the
studies with caroverine [46, 48, 172] were all too small and
revealed no improvement.
Even if studies investigating accamprosate found sig-
nificant improvement with this drug [18, 176], these results
cannot be considered as adequate evidence of efficacy due
to low methodological quality and insufficient sample
sizes.
Other drugs
No sufficient evidence of an effect on tinnitus could be
produced for a wide variety of other drugs, including
antidepressants [21], melatonin [85], pramipexole [188],
alprazolam [86], sulpiride and melatonin [114], sertraline
[212], botox A [184], and nortriptyline [186]. Though
positive results were sometimes shown in the RCT,
methodological analysis revealed low methodological
quality and insufficient effect size.
In addition, a number of studies have reported negative
results from RCTs. Assessed drugs include piribedil [19],
vardenafil [118], trazodone [47], atorvastatin [112],
gabapentine [149, 200], paroxetine [162, 163], lamotrigine
[179], anticonvulsants (Cochrane analysis; Hoekstra et al.
[80]), cyclandelate [70], melatonin [165], baclofen [199],
zinc [142], nicotinamide [84], and tocainide [83].
Furthermore, a wide range of studies do not provide
appropriate information due to insufficient methodological
quality: sulpiride and melatonin due to non-double-blind,
Eur Arch Otorhinolaryngol
inadequate study design [113, 114], misoprostol due to
inadequate statistics [3, 203] and inadequate study design
[30], EGb 761 due to inadequate methodology and high
drop-out rate [123], amitriptyline due to inadequate study
design [22], alprazolam due to inadequate study design [91],
carbamazepine due to inadequate report quality and too little
information on study design [83], melatonin due to inade-
quate report quality with no information on drop-outs, means
without unity, and no details regarding study design
[126, 127] and inadequate methodology and statistics [165],
sulpiride and melatonin due to inadequate methodology and
statistics [114], zinc due to inadequate methodology and
statistics [9] and inadequate statistics [9], Paaske et al. [142],
inadequate methodology and statistics, Yetiser et al. [202],
inadequate statistics, non-controlled, non-randomised, no
effects, Ochi et al. [131], inadequate statistics, cross-sec-
tional comparison with healthy individuals, not randomised,
Paaske et al. [141], inadequate study design, no distress/
annoyance endpoint, no effect, pramipexole, and D2/D3
dopamine due to inadequate study design, inadequate
statistics, and follow-up of only 4 weeks [188].
Dietary supplements, antioxidants, and drug
combinations
No efficacy studies on dietary supplements, antioxidants,
and drug combinations of appropriate methodological
quality have been published. Relevant studies are either
non-controlled, non-randomised, or inadequately designed
[33, 65, 95, 119, 132, 146, 159, 168], have no tinnitus-
related criteria as primary or secondary endpoints [90], are
not intervention studies [125], suffer from inadequate
reporting (i.e., information on significance is missing, no
information on study design) [126, 127], or have no end-
point for describing tinnitus distress [189].
Cognitive behavioural therapy (CBT)
Efficacy regarding tinnitus distress and quality of life has
been shown in a number of controlled studies for structured
tinnitus-specific variants of CBT [7, 38, 92, 106, 197, 204,
209]. The interventions were aimed at reducing attention
towards ear noise, a reevaluation of tinnitus and its con-
sequences (‘‘decatastrophising’’, reduction of anxiety), and
improved coping (e.g., confidence in one’s own ability to
influence the condition, reduction of avoiding behaviour).
Typically, the therapeutic procedure is structured and may
be laid out in manuals, both describing a validated and
clearly structured therapeutic framework. The manuals are
often designed for group therapies (for the German lan-
guage version, see Kröner-Herwig [105] and Delb et al.
[45]), but there are also validated structures for individual
therapy available [209].
According to the evidence levels defined by the Centre
for Evidence-Based Medicine in Oxford, this form of CBT
meets the evidence level of la (systematic reviews based on
RCTs regarding tinnitus distress and quality of life). One
typical RCT [6] showed a mean effect size of 0.86, indi-
cating high efficacy. The aforementioned Cochrane meta-
analysis [117] in which five RCTs were assessed deter-
mined a significant difference from controls (SMD 0.64;
95% confidence interval 0.29–1.00; I2 = 0%). Significant
reductions in depression scores were also observed in
individual RCTs (effect sizes from 29 to 0.37, SMD 0.37;
95% confidence interval 0.15–0.59; I2 = 0% [117]. How-
ever, the actual perception of the loudness of tinnitus does
not change with CBT.
Whether CBT-based self-management training based on
written or internet-based learning materials (reduced or no
direct personal contact with the therapist, with contact via
telephone or email) can be qualified as effective and has
not yet been confirmed [130]. As such, the meta-analysis
was able to show that a self-initiated and propagated cop-
ing process provides significant advantages in terms of
tinnitus distress over passive control groups, and that it
does not significantly differ from face-to-face therapy.
However, the difference from the passive control group
was only moderate (effect sizes 0:33–0:48). There is also
evidence of a degree of positive distortion in the results
(e.g., publication bias). However, the acceptance of such
therapies among patients is already well established
[6, 69, 92, 130].
Cochlear implants (CIs)
Controlled studies on CIs for tinnitus alone without hearing
loss do not exist. Profound hearing loss or deafness can
represent an indication for CI therapy to improve hearing.
Whenever these patients also have tinnitus, retrospective
analysis reveals a significant improvement of the condition
[4, 29, 99, 131, 136, 167, 182]. This was true for unilateral
CI implantation for homolateral [154], contralateral [154],
or bilateral [138, 139, 143, 205] tinnitus. With a second
implant, quality of life can be improved further [138, 139].
Provision of a CI produced retrospectively comparable
results in unilaterally deaf patients who had very distress-
ing tinnitus [16, 31, 196], and meta-analysis [26]. The
effect on ear noise did not depend on the ‘‘quality’’ of the
tinnitus. Narrowband noises, tonal tinnitus, and polyphonic
tinnitus responded equally [154].
Even prospective observations of the course of tinnitus
after CI implantation came to the same conclusion, though
the number of study participants overall was still rather low
[29, 102, 143]. In a prospective study of 174 CI users,
71.8% had tinnitus before implantation. In 20%, the tin-
nitus disappeared completely by 6 months after the
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operation, whereas an improvement was observed in 51.2%
over the same period [102]. Improvements were also
observed when additional stress-processing and coping
strategies were queried [138–140]. Exacerbation of tinnitus
could also occur, but it remained an exception. A single
non-controlled pilot study [71] involving 21 CI implanta-
tions with the indication of unilateral tinnitus reported
improvements for the patients.
In some cases of chronic tinnitus in which the CI only
occasionally influenced, or even failed to influence the
tinnitus, stimulation was carried out using biphasic elec-
trical stimuli with a fixed stimulation rate of 100–200 or
5000 stimuli/s at a pleasant volume. Some of the patients
reacted positively to at least one of the tested modes of
stimulation, i.e., the tinnitus was partially suppressed [34].
An electrode completely (‘‘full length’’) inserted had a
superior effect to partial insertion [155]. Systematic studies
are lacking, and this procedure is currently considered to be
experimental.
As long as CI-relevant (and even unilateral) hearing loss
is present, the simultaneous presence of tinnitus can rein-
force the indication for a CI, even if it does not represent an
indication in its own right [102, 136, 143, 167, 182].
Deafness or hearing loss bordering on deafness needs to be
present as the main indication.
Electromagnetic procedures
Various electromagnetic stimulation procedures have been
studied for the treatment of tinnitus. Repetitive transcranial
magnetic stimulation (TMS) over the temporal or tem-
poroparietal brain regions was studied in 15 RCTs
[5, 37, 81, 96, 97, 100, 111, 115, 121, 150–153, 166, 180].
The majority of studies (n = 10) reported a significant
efficacy of rTMS. Systemic reviews, including a Cochrane
analysis, concluded that short-term treatment effects are
detectable, but more studies are needed before final con-
clusions about longer lasting effects and side effects can be
drawn [120, 147].
Cohort studies or randomised trials without placebo
controls involving a total of 1140 patients revealed an
effect of transcranial magnetic stimulation and reported
that the treatment effects in some cases were detectable up
to 4 years after treatment [32], but large-scale, prospective,
controlled studies are still missing.
For transcranial direct current stimulation (tDCS), one
meta-analysis suggested a significant reduction in tinnitus
intensity after transcranial direct current stimulation,
though the validity of this study was somewhat compro-
mised by the fact that only a small number of studies were
evaluated [42, 177, 181].
In a recent published randomised study on tDCS, De
Ridder et al. reported on vagus new stimulation [43]. In
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addition, studies on direct electrical stimulation of the brain
by implanting electrodes on the dura or intracranially have
been published.
A very recent review by Hoare et al. provides a good
overview on different types of electrical stimulation pro-
cedures and their effect on tinnitus [78]. However, the
evidence base of all these procedures can only be consid-
ered moderate.
Other electrical stimulation methods (e.g., transcuta-
neous electrical stimulation in the area of the ear and the
CS, vagus nerve stimulation, and transcutaneous vagus
nerve stimulation) were also examined in individual pilot
studies, but these allowed no concluding assessments to be
made [193]. Therefore, these methods are considered to be
experimental. The evidence base is weak.
Retraining therapy (RT)
The essence of RT is to provide a therapy that combines
counselling with the already described sound therapy in
which e.g., white noise is applied [60, 89]. No publications
have provided any evidence of efficacy of RT [148] or for
either single procedure (for counselling see Reports,
Chapter 1; for application of noise see Reports, Chapter 2).
In addition, combinations of sound therapy with CBT have
been proposed [1, 24, 44, 45, 55, 66, 75, 128, 133, 148,
174, 187]. The quoted studies did not show any additional
benefit of sound therapy for patients in addition to that
provided by CBT alone. The therapeutic benefits of RT
combined with CBT seem to be attributable mainly to the
evidence-based CBT [45], to which therapy can be
restricted accordingly.
Passive music therapy
For so-called tinnitus-centred music therapy, in which the
music is modified in relation to the tinnitus frequency, a
single surveillance study involved 158 patients with acute
tinnitus and 18 patients with chronic tinnitus [39]. Another
working group reported on two patient-specific filtered
music applications, also referred to as ‘‘notched music’’, in
39 resp. 24 tinnitus patients. One of these studies included
a control group and was carried out in a pseudorandomised,
double-blind manner [135, 192]. A large-scale phase III
study was initiated based on the study results [144]. The
results available until now do not constitute an adequate
evidence base for a treatment recommendation.
Active music therapy
Active music therapy is conducted under the guidance of a
music therapist. Argstatter et al. [10–14] and Grapp et al.
[57] have published studies on active music therapy. This is
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a standardised and manualised therapy consisting of nine
50-min sessions attended on five consecutive days. A
recently published [15] controlled, pseudo-randomised
study provided the first concrete evidence. Compared to
controls (counselling), in which scores on the tinnitus
questionnaire inventory according to Goebel-Hiller (TQ
score) improved 33%, music therapy achieved a 66%
improvement (odds ratio 4.34; 95% confidence interval
2.33–8.09). Methodologically, we can consider this a
moderately validated therapy programme, the efficacy of
which should at least be reproduced in another study at
another centre or within a multi-centre study.
Acoustic neuromodulation
Acoustic ‘‘coordinated reset’’ neuromodulation is designed
to eliminate pathologically synchronised, central neuronal
activity [191] that is presumed to be involved in tinnitus.
This procedure has not yet been investigated in sufficiently
large groups. A clinical dose-finding study of 63 patients
(unilaterally blinded, randomised, and placebo-controlled)
yielded significant improvements when the tinnitus ques-
tionnaire was used as the test instrument [191]. Results are
not yet available from large phase III trials [76].
Hyperbaric oxygen
A benefit of treating chronic tinnitus with hyperbaric
oxygen has not been proven [23].
Acupuncture
Studies showing an efficacy of acupuncture have not been
produced [98].
Discussion
Overall, a validated structured tinnitus-specific CBT (in an
individual or group design) is a proven therapeutic option
in addition to basic therapy with counselling. Regarding
tinnitus distress, quality of life, and depression scores, this
approach has been shown to be highly effective and can be
recommended. To prepare for structured CBT, the patient
should be guided through counselling [88] and not be left
alone with his or her tinnitus. Although compelling evi-
dence regarding the efficacy of counselling is lacking, the
value of counselling as a constituent of the normal services
a doctor may provide is thought to be self-evident. The
patient should be informed that gradual habituation to the
tinnitus is often achieved in response to CBT. Furthermore,
the patient should be attuned to the need for commitment
towards actively and extensively participating in the CBT
program. A symptomatic drug therapy for tinnitus is not
available.
For clinical practice, the following reasonable and evi-
dence-based approach for the treatment of chronic tinnitus
can be recommended: As the need for patient counselling is
self-evident, specific tinnitus counselling should be per-
formed. For the treatment of concomitant hearing loss,
auditory therapeutic measures can be recommended. Due
to the high level of evidence, tinnitus-specific, structured
CBT, e.g. using a validated therapy manual is strongly
recommended. Comorbidities should also be treated, with
drugs whenever appropriate. In particular, depression
should be treated, with pharmacological support if neces-
sary. If needed, psychiatric treatment should also be given
on a case-by-case basis. With simultaneous deafness or
hearing loss bordering on deafness, a CI can also be
indicated.
For auditory therapeutic measures, the efficacy of tran-
scranial magnetic or direct current stimulation and specific
forms of acoustic stimulation (noiser/masker, retraining
therapy, music, and coordinated reset) the available evi-
dence from the literature is still insufficient for supporting
their recommendation.
Compliance with ethical standards
Conflict of interest Hans-Peter Zenner declares that there is no con-
flict of interest. Wolfgang Delb declares that there is no conflict of
interest. Birgit Kröner-Herwig declares that there is no conflict of
interest. Burkhard Jäger declares that there is no conflict of interest.
Ingrid Peroz declares that there is no conflict of interest. Gerhard Hesse
declares that there is no conflict of interest. Birgit Mazurek declares that
there is no conflict of interest. Gerhard Goebel declares that there is no
conflict of interest. Christian Gerloff declares that there is no conflict of
interest. Regina Trollmann declares that there is no conflict of interest.
Eberhard Biesinger declares that there is no conflict of interest. Harald
Seidler declares that there is no conflict of interest. Berthold Langguth
declares that there is no conflict of interest.
Ethical approval This article does not contain any studies with
human participants or animals performed by any of the authors.
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