Tinnitus and its management in patients with vestibular schwannoma.

Tinnitus is the second most common presenting symptom of vestibular schwannoma (VS) after hearing loss. There is conflicting evidence regarding the impact of tinnitus and its contribution to the overall quality of life in VS, and there are many theories regarding the pathogenesis of tinnitus in VS, including cochlear, neural, and central mechanisms. Assessment should include speech audiometry in addition to pure-tone audiometry, as VS patients often have worse speech discrimination than would be expected from their pure-tone thresholds. There is no objective measure of tinnitus. Questionnaires may be used to assess the impact of tinnitus and its common comorbidities. Management of VS-associated tinnitus starts with explanation and counseling. Addressing hearing loss is often helpful: if the affected ear still has useful hearing, conventional hearing aids may be used. If there is no useful hearing on the affected side, contralateral routing of signal (CROS) hearing aids, bone conduction hearing implants (BCHI), or cochlear implantation may be beneficial. For patients with bilateral profound hearing loss following VS surgery, auditory brainstem implantation may help. Psychologic therapies, including cognitive behavioral therapy and mindfulness-based cognitive therapy, are commonly recommended for use in general tinnitus clinics, although there is no evidence base supporting these modalities for VS patients.