A compelling, evidence-based blueprint for high quality tinnitus care was offered at Tinnitus Talk Day 2025, says Brazilian-born Sydney audiologist Dr CELENE MCNEILL PhD. She reports on lessons learnt from the event that focused on multidisciplinary management models.
By Dr Celene McNeill PhD, audiologist Healthy Hearing & Balance Care, Sydney
Tinnitus Talk Day 2025, chaired by ENT specialist Dr Clarice Saba in Salvador, Brazil, presented a robust and coordinated model of tinnitus care. The event challenged the prevailing belief that tinnitus is largely untreatable and emphasised its nature as a symptom with diverse potential causes.
The Brazilian approach integrates medical and allied health specialists from the outset, offering a comprehensive protocol that may be relevant for Australian practitioners.
Multidisciplinary investigation
In Brazil, the ENT specialist serves as the case manager for tinnitus patients. A detailed hour-long case history is considered essential, providing the foundation for exploring possible auditory, metabolic, vascular, somatosensory, psychological and iatrogenic contributors.
This depth of inquiry reflects the understanding that tinnitus is rarely caused by a single system and is instead frequently multifactorial.
After the initial consultation, patients undergo an extensive audiological assessment. Standard auditory testing includes air and bone conduction audiometry, speech perception testing, loudness discomfort levels, tympanometry, acoustic reflexes, otoacoustic emissions and auditory evoked potentials.
Vestibular function tests which often include VEMPs (vestibular evoked myogenic potentials), nystagmography, calorics and vHIT (video head impulse test), help identify peripheral and/or central involvement of the audio-vestibular pathway.
Tinnitus-specific measures such as pitch and loudness matching, minimum masking levels and residual inhibition provide further insight into tinnitus characteristics and their relationship with auditory function.
Full tinnitus resolution
A defining feature of the Brazilian diagnostic model is its thorough investigation of metabolic factors. Clinicians routinely assess fasting glucose and insulin, HbA1c, lipid profiles, thyroid function, sex hormones when indicated, and micronutrient levels including vitamin B12, vitamin D, iron studies and magnesium.
Abnormalities in these areas are recognised as potential contributors to cochlear and neural instability. Several cases presented demonstrated full tinnitus resolution once metabolic dysfunctions, particularly insulin resistance and dyslipidaemia, were appropriately managed.
Vascular causes are also explored in depth in cases of pulsatile tinnitus.
Vascular tinnitus typically presents as a pulsatile, heartbeat-synchronous sound and may indicate disturbed blood flow near the auditory system.
Diagnostic considerations include arterial disorders such as carotid atherosclerosis, dissection or aberrant carotid anatomy; venous contributors such as idiopathic intracranial hypertension, venous sinus stenosis, high-riding jugular bulbs or sigmoid sinus anomalies.
Systemic influences including anaemia, hyperthyroidism and uncontrolled hypertension are also investigated as well as imaging pathways commonly involving brain MRI (magnetic resonance investigation), MRA (magnetic resonance angiography), CTA (computed tomography angiography) and temporal bone CT and MRI scans, depending on the suspected mechanism.
Somatosensory factors receive the same level of attention as auditory and metabolic contributors. This reflects the growing body of evidence that cranial-cervical structures can significantly influence tinnitus perception.
Dental TMJ evaluation
Dentists undertake a comprehensive evaluation of temporomandibular joint (TMJ) dysfunction, assessing joint mechanics, loading patterns, and disc behaviour. This occurs alongside screening for bruxism (teeth grinding), both sleep-related and awake, given its strong association with muscular hyperactivity and referred ear symptoms.
Occlusion relationships and the presence of joint inflammation are also reviewed, as these can contribute to altered sensory input along the trigeminal pathway.
Physiotherapists complement this by performing a detailed cervical assessment, examining posture, segmental mobility, cervical-cranial alignment, and myofascial integrity. Palpation of trigger points in the sternocleidomastoid, upper trapezius, masseter, and sub-occipital muscles is routine, as these structures frequently refer symptoms into the ear.
Clinicians also evaluate for neural irritation, including involvement of the greater occipital, auriculotemporal, and trigeminal branches, which can interplay with auditory circuits at the level of the dorsal cochlear nucleus.
A key part of this assessment involves exploring whether the tinnitus can be modulated through somatic manoeuvres such as jaw protrusion, clenching, lateral deviation, neck rotation, or resistance-based movements which are interpreted as a meaningful clinical sign that implicates musculoskeletal or neural pathways in the tinnitus experience.
When modulation is present, it helps clinicians triage patients more effectively toward targeted interventions, such as TMJ stabilisation, bite-splint therapy, cervical physiotherapy, myofascial release, dry needling, posture correction, or trigeminal-focused neural-modulation strategies.
This structured and deliberate approach not only improves diagnostic clarity but also expands the therapeutic avenues available, reinforcing the message that many tinnitus presentations are both interpretable and treatable when somatosensory mechanisms are properly investigated.
Medication evaluation
Iatrogenic contributors are also carefully evaluated. Medications such as aminoglycosides, platinum-based chemotherapeutics, loop diuretics, high-dose salicylates, certain antidepressants, anti-epileptics and anti-malarials are well recognised for their ototoxic potential.
Withdrawal from benzodiazepines or antidepressants may also provoke tinnitus due to acute neurochemical shifts. Non-pharmaceutical factors, including acoustic trauma from MRI scanners or surgical drilling, traumatic ear wax removal, ototoxic ear drops in the presence of tympanic membrane perforation and dental procedures involving prolonged mouth opening or high-frequency drilling, are also considered.
Psychological contributors are assessed in parallel rather than as an afterthought. Psychiatric and psychological evaluation focuses on anxiety, depression, panic symptoms, insomnia, hyper-vigilance and catastrophic thinking patterns. These factors may not cause tinnitus but strongly influence the degree of distress and the ability to habituate.
Audiological rehabilitation forms the therapeutic backbone in most cases. Interventions may involve hearing aids, sound generators, notch therapy, auditory training, tinnitus retraining therapy (TRT) and, when required, hearing implants.
These are supported by structured audiological counselling, regular follow-up and monitored by questionnaires such as Tinnitus Reaction Questionnaire (TRQ) and Tinnitus Handicap Inventory (THI).
Although complete resolution is less common in tinnitus caused purely by sensorineural hearing loss, a significant reduction in tinnitus perception, improvements in function and quality of life are routinely achieved when audiological treatment is integrated with broader care.
When metabolic abnormalities are identified, treatment may involve dietary modification, medical management of glucose or lipid disorders, correction of micronutrient deficiencies and hormonal treatment when appropriate.
Seminar outcomes showed that addressing metabolic dysfunction can lead not only to symptom reduction but, in many cases, total elimination of tinnitus perception.
Vascular causes are addressed according to their underlying mechanism. Treatment may include medical management of hypertension, thyroid disease or anaemia; weight management and cerebrospinal fluid regulation for idiopathic intracranial hypertension; endovascular interventions such as venous sinus stenting; or surgical management of vascular tumours or fistulas. Many patients experience substantial improvement once blood-flow turbulence is corrected.
Somatosensory and iatrogenic
Somatosensory tinnitus is managed through dental and physiotherapy interventions, often with excellent outcomes. TMJ rehabilitation, splint therapy, cervical physiotherapy, manual therapy, dry needling, myofascial release, postural correction and treatment for bruxism or malocclusion are commonly employed.
Numerous cases presented demonstrated complete resolution once musculoskeletal contributors were treated.
Iatrogenic tinnitus is managed through careful medication review, supervised tapering of medication when appropriate, counselling on ototoxic risks, protection against high-level clinical noise and rehabilitation for TMJ or cervical strain after dental or surgical procedures.
Preventative education plays a critical role in reducing recurrence. Psychological support is incorporated early. Cognitive behavioural therapy, acceptance and commitment therapy, mindfulness-based approaches and sleep-focused interventions help patients reduce tinnitus-related distress, enhance emotional regulation and improve habituation.
When psychiatric intervention is required, appropriate medication management further supports recovery.
An innovative feature of the seminar was a mind–body workshop for tinnitus patients and professionals with participants using dance and music as tools for teaching auditory anatomy, sensory integration and autonomic regulation.
This approach promoted relaxation, acceptance and social connection, and participants reported immediate benefit. While not a substitute for clinical treatment, such interventions may offer meaningful adjunctive support.
Implications for practice
The Brazilian model demonstrates that thorough assessment and interdisciplinary collaboration significantly improve diagnostic accuracy and treatment outcomes. It also highlights variability in international systems. Brazilian ENTs generally have more clinical availability and fewer surgical obligations than Australian ENTs, who manage higher surgical loads and serve a population with a substantially lower ENT-per-capita ratio.
Brazilians may consult ENTs directly but Australians must obtain a GP referral for Medicare coverage. This barrier can delay care, particularly when GPs lack specialised training in tinnitus assessment.
In Australia, audiologists are well placed to be the first port of call due to in-depth hearing health expertise. But many cases involve systemic, vascular or musculoskeletal factors that need medical oversight.
Developing clearer referral pathways, stronger inter-professional relationships and broader diagnostic frameworks may enhance outcomes for Australian patients. The Brazilian model demonstrates meaningful improvement, and in many cases, complete resolution, are achievable when tinnitus is approached as a multisystem symptom and addressed within a coordinated, patient-centred, multidisciplinary framework.
