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Severe tinnitus that has been present for many years does not usually resolve completely in response to any form of treatment. Like many neurologic symptoms, tinnitus usually doesn't disappear completely after it has persisted for a year or more. A relatively small percentage of tinnitus cases have completely resolved after years of persistence. Some of these successes can be attributed to surgical intervention (such as stapedectomy, tumor removal, microvascular decompression, or cochlear implantation) or to a fortunate change in medication such as the author of the letter describes. However, compared with the total number of cases of chronic tinnitus, these are rare occurrences.

Even though I am happy for the patient mentioned in the letter, I caution clinicians and patients against searching for “complete resolution” (that is, a cure) for most cases of chronic tinnitus that are associated with sensorineural hearing loss. Many exhaustive—and usually fruitless—quests for a tinnitus “cure” have resulted in disappointment and frustration for clinicians and their patients. More realistic management strategies include: helping patients understand and gain control over their tinnitus, rather than it having control over them; helping patients learn how to pay less attention to their tinnitus until it is no longer a negative factor in their lives; using external sounds (including table top sound machines, pillow speakers, tapes, CDs, in-the-ear sound generators, and those amplified by hearing aids) to give patients relief from tinnitus; effective treatment of depression, anxiety and insomnia—common exacer-bators of tinnitus.

Medications are often an integral part of depression treatment programs. Because selecting the most appropriate and effective antidepressant medication for an individual can be a challenging and complex process, we recommend that patients consult with experts in this field—psychiatrists—to help them make this important decision. As we wrote in our 1999 article, 1 “Sullivan et al 2 reported some success treating depressed tinnitus patients with the antidepressant medication nortriptyline. However, one of the many other antidepressants available might be preferable for a particular patient.” Dobie et al 3 stated that “Insomnia is a prominent component of distress for tinnitus patients, with and without major depression, and adequate antidepressant therapy usually improves sleep.” Antidepressant medications can provide multiple benefits for some patients, even if the medication doesn't directly affect their tinnitus.

The author of the letter warned that “tinnitus can sometimes be a side-effect to tricyclic antidepressants” such as nortriptyline. For this reason (and the success with paroxetine in one patient), the author seem to be recommending serotonergic reuptake inhibitor (SRI) antidepressants over tricyclics. The author failed to notice that the Physicians' Desk Reference 4 lists tinnitus as a potential side effect for all of the SRI antidepressants including paroxetine. In fact, most psychotropic substances have the potential to trigger tinnitus for a small percentage of patients. However, like tinnitus caused by large doses of aspirin, most cases of tinnitus attributable to antidepressants or anxiolytics are reversible after patients stop taking these medications. Fear of an unlikely side effect such as tinnitus should not keep patients from trying a medication that has a good chance of improving their condition.

I agree that further studies of SRIs are warranted, but not necessarily as potential cures or even treatments for tinnitus per se. Instead, controlled studies should focus on the effectiveness of particular SRIs for the treatment of depression, anxiety, insomnia, obsessive-compulsive tendencies, and various phobias that are sometimes present in patients experiencing severe tinnitus. Numerous studies have shown that the matched loudness of a patient's tinnitus is not correlated with its severity. 5 Because tinnitus that has been present for a year or more is likely to persist indefinitely, we should help patients learn how to live with the symptom so it doesn't detract from their enjoyment of life. This can be a very time-consuming process. When necessary, we refer patients to mental health professionals for ongoing psychotherapy. A series of effective counseling sessions is required to identify and begin to change counterproductive thoughts and behaviors exhibited by some patients. In fact, psychotherapy should be given priority over medication in the treatment of depression, anxiety, and obsessive-compulsive disorders. For complex problems such as these, medication alone is not sufficient.

Robert L. Folmer, PhD Assistant Professor of Otolaryngology OHSH Tinnitus Clinic Oregon Health & Science University Mail Code NRC04 3181 SW Sam Jackson Park Road Portland, Oregon 97201 e-mail, folmerr@ohsu.edu

23/8/118689 doi:10.1067/mhn2001.