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Tinnitus assessment: The key to successful tinnitus patient management

July 2015

BY THOMAS STARK, M.D. AND TERESA SCHRODER, AU.D., CCC-A, THOMAS STARK M.D., ENT, practice in Montgomery and The Woodlands, Texas

Tinnitus or “ringing in the ears” is a common patient complaint that is experienced by 10-15% of the adult population which translates to about 50 million Americans. From 10 – 12 million of those seek medical help for tinnitus. For most people who have tinnitus, the sound is constant or near constant. In severe cases, tinnitus can interfere with work and sleep. It can be associated with anxiety, depression, and reduced perception of the quality of life.

Tinnitus is not a disease, but a symptom that can result from multiple conditions affecting the auditory system, which includes the ear, the auditory nerve that connects the inner ear to the brain, and the parts of the brain that process sound. Intriguing new research points to changes that take place in the brain when hearing is damaged that cause random neurons to fire erratically and create “noise,” in much the same way a phantom limb causes pain. Hearing loss in the auditory periphery is likely a prerequisite, but not sufficient in itself, for tinnitus to occur. The lack of auditory input due to hearing loss leads to hyperactivity in the central auditory pathway, and this may just be the neural correlate of tinnitus (Reavis et al, 2012).

Tinnitus can be linked to a long-term history of excessive noise exposure and some drugs that are toxic to the inner ear hair cells. The list of underlying conditions includes ear and sinus infections, cerumen impaction, high blood pressure, arteriosclerosis, Lyme disease, Meniere’s disease, and rare conditions like acoustic neuroma.

Tinnitus sufferers can be a challenging group, but there are many successful treatment options when a proper evaluation is completed.

The American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) recently (2014) published an evidence-based clinical practice guideline for the evaluation and treatment of chronic tinnitus. The guideline was developed by a multidisciplinary team of otolaryngologists, audiologists, and other healthcare professionals as well as consumer advocates. The guideline begins with recommendations about patient examinations. First, clinicians should perform a targeted history and physical examination, to identify conditions that if quickly identified and managed might relieve tinnitus.

Second, clinicians should obtain a prompt and comprehensive audiological examination in patients with tinnitus that is unilateral, persistent (present for at least six months) or associated with hearing difficulties.

Clinicians are then encouraged to distinguish patients with bothersome tinnitus from patients with non-bothersome tinnitus. Once an underlying hearing loss is identified and addressed, it is essential to determine if the patient is in need of additional workup or management.

Hearing aid evaluation is suggested for patients with hearing loss, and persistent and bothersome tinnitus. Hearing instrument amplification provides a method through which sound is delivered therapeutically in two ways: They amplify environmental sounds and thus reduce the contrast between the tinnitus and the environment and they restore audibility in frequency regions associated with deprivation-related changes in the auditory pathway activity (Fagelson, 2014). The amplification of external sounds can provide sufficient activation of the auditory nervous system to reduce tinnitus perception and possibly in part, restore neural function due to neuroplastic changes occurring with increased sound stimulation. (Del Bo and Ambrosetti, 2007)

Sound therapy can be a secondary option for those who are not assisted by amplification alone. Sound therapy may include completing therapy aimed at those with sound intolerance such as hyperacusis and misophonia. Sound therapy is initiated following a complete tinnitus assessment.

Cognitive behavioral therapy is another tool that can provide support in realigning the patient response to the tinnitus.

Audiologist directed treatment methods: The primary form of tinnitus management offered by Audiologists is through the use of sound therapy in a structured and supervised program. Sound therapy promotes habituation (desensitization) to tinnitus and sound sensitivity problems. For many patients, the initiation of sound therapy quickly brings relief from symptoms. With continued use, sound therapy ultimately can reduce the perception of tinnitus and restore normal sound perception. There are many types of sound therapy available for management of tinnitus and sound sensitivity.

Tinnitus Retraining Therapy uses a combination of low-level broadband noise and counseling to achieve the habituation of tinnitus, such that patients are no longer aware of the tinnitus unless they specifically focus their attention on it. TRT is effective for all types of bothersome tinnitus and its effectiveness does not depend on the etiology of the tinnitus per Dr. Pawell Jastreboff, Ph.D, ScD, MA, professor of otolaryngology at Emory University School of Medicine, who pioneered this approach. James Henry, Ph.D., and colleagues at the Veterans Affairs National Center for Rehabilitative Audiology Research use an approach that requires a diversity of sounds which is termed Progressive Tinnitus Management. The approach advocates the use of various sounds to alleviate tinnitus symptoms.

Other Sound Therapy and Management Options:

Other options for sound therapy may be self-directed and can include devices such as music players, table-top sound generators, and other masking devices. Lifestyle changes may be recommended. These may include limiting noise exposure, use of hearing protection, incorporation of stress management and relaxation strategies, and a review of how current diet and medications may be affecting the tinnitus. Each patient is different, and the type of therapy that is most effective must be determined on an individual basis to achieve a high level of success.

Resources:

Callaway, S. (2014). The Oticon Approach to Tinnitus Management. Whitepaper published 2014, 1-10.

Del Bo, L, Ambrosetti, U. (2007) Hearing aids for the treatment of tinnitus. Progress In Brain Research, 166, 341-345.

Fagelson, M. (2014) Approaches to Tinnitus Management and Treatment. Seminars in Hearing, 35, (2), 92-104.

Hoare, D.J., et al. (2014). Sound therapy for tinnitus management: Practical options. Journal of the American Academy of Audiology, 25, (1), 62-75 Reavis, K.M., et al. (2012) Temporary suppression of tinnitus by modulated sounds. Journal of the Association of Research in Otolaryngology, 13, 561-571.

Weaver, J. (2014) First Evidence-Based Tinnitus Guideline shines Light on Treatment, Hearing Journal, 67(12):19,22-24.

Tunkel, David E., et al. (2014). Clinical Practice Guideline: Tinnitus. Otolaryngology – Head and Neck Surgery Vol. 151 (2) supplement S1-S40. Copyright ©2014 by American Academy of Otolaryngology – Head and Neck Surgery Foundation. Reprinted by permission of SAGE Publications, Inc.