Hearing management

Updated 08 September 2016

An overview of Tinnitus patient management

Tinnitus is characterised by a persistent sound in one or both ears. It may be a ringing, buzzing, clicking or roaring sound and can range from severe to only mildly distracting.

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Tinnitus: patient management

By Robert W. Sweetow, Ph.D.

Summary

Tinnitus, a subjective, and usually incurable symptom, creates a significant management dilemma for audiologists. For the suffering person to whom the statement "There is nothing that can be done for you" has been made, the audiologist often represents the “final hope”. Yet most audiologists do not provide tinnitus management programs. Still, all audiologists need to have a basic understanding about tinnitus and its effect on people, as well as how to counsel patients and refer for specialized treatment.

Although tinnitus affects millions of individuals, it remains a poorly understood phenomenon. While a variety of clinical management procedures exist, none have proven universally effective and none have withstood the rigours of the test of time.

In this article, theories about how tinnitus is caused and how it can create devastating emotional effects will be discussed. In addition, viable treatments that can be delivered by audiologists, with particular emphasis on Tinnitus Retraining Therapy, Neuromonics acoustic desensitization protocol, and Cognitive-Behavioral Therapy are presented. The use of sound therapy, particularly with hearing aids, is detailed. The article is designed to provide readers with practical solutions and functional skills that can be immediately utilized in their clinical practice. 

Introduction

The incidence of tinnitus in industrialized nations is estimated to be 10-15% of the general population1. Approximately 1% of those individuals report that their tinnitus is severe enough to disrupt their daily lives, but as many as 10% of adults with tinnitus will seek professional consultation.

Yet despite these high numbers and the urgent need for management, the majority of audiologists do not offer comprehensive possible tinnitus management programs. There are a several explanations for this lack of involvement. One reason is the belief that providing management takes a considerable amount of time and is cost ineffective. Another is the perception that the emotional distress often associated with tinnitus patients makes this a difficult population to work with and may be beyond the professional scope of the audiologist.

But perhaps the most prevalent, yet distressing and unfounded rationale for not providing tinnitus management programs is the belief that since most cases of idiopathic tinnitus or tinnitus secondary to a sensorineural hearing loss are not curable, these patients cannot be helped. This perception unfortunately leads to the ill-advised statement made by health professionals from many disciplines that “There is nothing that can be done. You just have to learn to live with it”.

The purposes of this article are to identify levels of involvement that the audiologist can participate in, and to present an overview of management procedures available to the audiologist. Although not every audiologist will want to (or realistically, should) become immersed in comprehensive and detailed tinnitus patient management, all audiologists owe it to their patients and the profession to have a basic knowledge about the effects of tinnitus and how basic counseling techniques and simple acoustic therapies can minimize the negative impact tinnitus may have on patients.

Hopefully this manuscript will encourage audiologists to recognize that although the cure of tinnitus may not currently be possible, the relief of symptoms that the audiologist can offer to the patient is worthwhile and noble.

Causes still being researched

Subjective tinnitus is a symptom that is associated with practically every known otologic disorder. A growing body of evidence 2,3 suggests when there is a peripheral attenuation of acoustic stimulation (as would be caused by a hearing loss), there is also an increase in central auditory nervous system gain at a number of anatomical sites including the dorsal cochlear nucleus, inferior colliculus and auditory cortex. This finding has been verified via neuroimaging techniques 4. Further support for a central auditory model of tinnitus perception comes from the fact that tinnitus patients whose symptoms are presumably caused by peripheral inner ear damage from noise exposure, may still “hear” tinnitus following the surgical destruction of the auditory nerve. 

Even normal hearing individuals can experience tinnitus in very quiet situations. This occurs because the brain is preprogrammed to always expect auditory stimulation. For example, humans can close their eyes and shut out visual input, but they cannot close their ears (except by plugging them) to shut out sound. There is a constant, but random stream of electrical activity occurring in both the ears and the brain. Normally, however, the conscious brain suppresses this random activity and associates it with silence. But when the brain does not receive the auditory stimulation it expects (as in a silent environment, or when a person has hearing loss), it tends to “turn up” its internal volume control to look for some kind of sensation. This is similar to what a person with phantom limb syndrome experiences. It occurs because the nerves in the body (or the ear) are damaged, but the nerves associated with those sensations in the brain are not, and are thus expecting to be stimulated on a regular basis.

While the vast majority of tinnitus sufferers display at least some degree of sensorineural hearing loss, there are a host of non-auditory pathologies that may be related to the perception of tinnitus. Moller 5 has speculated that ephaptic transmission, or phase locked spontaneous activity between damaged neurons, especially in the brain stem, could account for some of the non-auditory causes of tinnitus such as temperomandibular joint disorders and cervical injuries. The rich network of collateral neurons can explain this relationship.

There are many anecdotal reports regarding tinnitus secondary to systemic diseases, relations to elevated cholesterol, elevated triglycerides, allergies, thyroid problems, diabetes, hyperlipidemia, hypertension, hypotension, syphillis, cardiovascular, endocrine, and metabolic diseases. In addition, physical injuries, obesity, allergies, (including food allergies), stress, dietary deficiencies, and intake of stimulants such as nicotine and caffeine have been cited as exacerbating factors 6.

Obviously, if the underlying source of tinnitus is identified and treatable, medical or surgical treatment to eliminate the cause would be the preferred course of action. This is why it is essential that all tinnitus patients receive a thorough medical evaluation by a qualified otolaryngologist prior to audiologic tinnitus management intervention. However, given the fact that the vast majority of subjective tinnitus sufferers do not have “curable” tinnitus, the next best course of action is to provide the patient with a program designed to minimize the negative emotional reaction and maladaptive behaviors that often result from both the perception and the interpretation of the signal.

The Audiologic Evaluation

Prior to selecting a course of action, it is first necessary to determine whether the tinnitus is related to a hearing loss or an etiology amenable to medical or surgical treatment. The audiologic evaluationshould include, at a minimum, threshold assessment (air and bone conduction, including inter-octaves 3KHz and 6KHz, and possibly the ultra high frequencies). It may be preferable to use a warbled, rather than a pure, tone to minimize confusion with the tinnitus. In addition, word recognition testing, immitance testing, tinnitus matching, and measurement of masking ability and residual inhibition can be useful. 

Questions have been raised regarding the reliability of tinnitus pitch and loudness masking 7. Even so, it is believed by some to be essential, particularly when acoustic therapies are prescribed. Even if sound stimulation is not being considered as a therapy, variability or changes in tinnitus matches may be useful as a means of monitoring other forms of therapeutic progress.

The ability to mask an individual's tinnitus and the presence of residual inhibition (temporary absence or diminution of tinnitus perception following the termination of the masking stimulus) should be assessed in an effort to determine the likelihood of success with tinnitus masking and acoustic desensitization protocols (see below). The audiologist should be aware, however, that the intensity level required to mask tinnitus may change over time 8.   

Other audiologic procedures such as otoacoustic emission testing, auditory brainstem evoked response testing, electrocochleography, and additional site of lesion procedures should be administered, as required. 

Tinnitus Severity Scaling

There is no objective way to measure subjective tinnitus. Attempts have been made to utilize electrophysiologic methods such as auditory brainstem evoked response testing but the fact that most tinnitus patients also present a sensorineural hearing loss confounds the interpretation. 

Because tinnitus, like pain, is subjective, two individuals may demonstrate identical loudness and pitch matches yet be affected in significantly different manners. The severity of the tinnitus then, is largely a function of the individual's reaction to the tinnitus (even though the reaction may not be totally independent of the actual pitch and loudness). Thus, it is imperative to assess the degree and manner in which the tinnitus affects a given individual. This can be done using subjective tinnitus severity scaling techniques.  Several good scales are available 9-11. Used properly, these scales can be used as a baseline measure to assess therapeutic progress. 

Need for Intervention

Determination of which management approach is most appropriate for a given patient is a combination of what the professional feels comfortable and competent with, and the extent of the tinnitus reaction reported by the patient. Dobie 12 proposed a hierarchy of patients with tinnitus in which the majority have non-bothersome tinnitus, a lesser number require only education and reassurance, still fewer present more severe reactions and problems, and a small fraction of people with tinnitus being debilitated by the symptom. 

Henry et al 13 proposed an approach called “Progressive Audiologic Tinnitus Management” comprised of five levels of tinnitus intervention. Level 1 is the initial point of contact with any health care provider to whom a patient complains about tinnitus. This triage with all patients reporting tinnitus to a health professional results in referral to audiologists, otolaryngologists (ENT doctors), emergency rooms, or mental health professionals. Levels 2-5 are administered by audiologists, with referral to other clinics as appropriate. Level 2 is for clinical evaluation by an audiologist (as discussed above). Level 3 is for group education of tinnitus patients. Level 4 is for more detailed individual tinnitus counseling and education, and Level 5 is for individual management of a patient including the treatments outlined below. The determination of where a given patient belongs in this scheme is a function of how the individual reacts to the tinnitus.

There are three component of tinnitus that are bothersome to various degrees for patients who require management. They are acoustical, attentional, and emotional. All patients reporting tinnitus have the acoustical component. For many, their attention is directed to the tinnitus to a degree that it negatively affects their daily life, for example, by disrupting their ability to concentrate or work efficiently. The third, and most troubling component is when the emotional well-being of a patient is impacted, leading to anxiety, feelings of hopelessness, depression, and even thoughts of suicide. All three of these components must be addressed, when they exist.

Management Approaches

A wide variety of management approaches have been described in the literature. None have been totally successful, yet anecdotal reports have filtered their way into the popular press and have been embraced by a very vulnerable patient population. It is therefore the responsibility of hearing health care professionals to carefully analyze new reports of tinnitus management procedures to determine the potential effectiveness, possible side effects, and cost efficiency of the treatments.

The primary management strategies employed by audiologists are tinnitus retraining therapy (TRT), acoustic desensitization, and cognitive-behavioral therapy (CBT). All three of these approaches share in common the extensive use of counseling to help control the emotional, and to some degree the attentional, component of tinnitus. TRT and acoustic desensitization further employ the use of sound to facilitate habituation (acclimatization).

There is no clear evidence that supports the effectiveness of one of these approaches over the others. Regardless of the treatment chosen, it is vital to be honest with the patient and to set realistic expectations at the outset of the professional relationship. The patient must understand that the logical outcome of the audiologic intervention is not going to be a disappearance of the tinnitus perception. Rather, the objective should be to minimize any disruption in the quality of life caused by the tinnitus. While each of these approaches are deserving of a detailed explanation that also is far beyond the scope of this article, a brief description of each follows:

Tinnitus Retraining Therapy

TRT, as popularized by the extensive work of Jastreboff and Hazell 14, 15 uses a combination of directive counseling and auditory (low level sound) therapy to initiate and facilitate habituation to the tinnitus perception. It is based on a neurophysiological model that offers an explanation for the distress experienced by tinnitus patients. According to this model, there is an initial trigger or specific event that creates the tinnitus signal. The actual site of generation for the tinnitus is irrelevant. Following the detection of the signal in the brain at sub-cortical levels, perception and evaluation is made at the level of the auditory cortex.

Frequently, an association is made by the limbic system (the emotional control center of the brain) that subsequently triggers release of neurotransmitters activating the autonomic nervous system. This process creates a gradual accumulation of plastic changes within nervous system that helps to maintain both the perception of the phantom sound as well as the negative emotional reaction via a feedback loop. When the limbic system associates tinnitus with fear or threat, attention is directed toward "salient" or information-bearing stimuli. The counseling aspect of TRT is designed to educate the patient so that the limbic system can “understand” that tinnitus itself is not a threat. This “retraining” can occur because the brain can sort out meaningful stimuli from those which are not relevant. But this will only occur if the tinnitus perception no longer carries a negative emotional association. So the goal is for the brain to adopt a pattern that will de-emphasize the importance of the tinnitus.

Coupled with the directive counseling is the use of low-intensity sound therapy, or “sound enrichment”. It has been suggested that in order to minimize increased central gain in the auditory system, silence should be avoided. A variety of methods of providing acoustic stimulation can be used to accomplish this. If there is a hearing loss, hearing aids can be very helpful, as will be discussed below. If the patient’s hearing acuity is such that amplification is not appropriate, a broad band or white noise generator coupled to the ear via an open fitting may facilitate habituation. It is emphasized that this noise is not utilized as a masker to completely cover up the tinnitus perception. In fact, the notion is underscored that initially, the tinnitus should be clearly audible along with the low intensity noise signal. A more detailed explanation of the use of acoustic stimulation is presented below.

 Cognitive-behavioral Therapy  

Regardless of the cause of tinnitus, the determination of whether the patient will require tinnitus patient management is ultimately a function of how the patient reacts to the tinnitus. If a person is not "bothered" by the tinnitus, it ceases to be a problem. This is not to suggest that attempts should not be made to identify and, if possible, rectify the underlying disease process.

But given the reality that most cases of subjective tinnitus are idiopathic in nature, psychological intervention aimed at successfully reducing the stress, distress, and distraction associated with the tinnitus can be very productive and often will produce the most attainable goals. Many of the techniques reported to have produced success with the management of tinnitus patients have been borrowed from chronic pain management.

Drawing on the finding that the correlation between tinnitus loudness match and tinnitus annoyance is not particularly high (r = < .5 ) 16, Sweetow 17 proposed that it is the patient's reaction to the tinnitus, rather than simply the presence of tinnitus that produces the problem. In fact, one’s reaction to the tinnitus also is not necessarily related to the loudness of the tinnitus.

For example, a very soft signal that carries a potential warning to danger (such as the squeak of a floorboard in an adjacent room when no one is supposed to be in that room), will gain attention and place the autonomic nervous system on alert even more so than louder sounds such as external traffic, which do not signal a potential negative outcome. Because of the many similarities of subjective tinnitus to pain (both are subjective, both are invisible, and both are effected by extraneous events), Sweetow advocated cognitive-behavioral therapy as an approach to managing the tinnitus patient.

There are extensive reviews of the principles and practices of cognitive-behavioral therapy as they apply to the tinnitus patient 18, 19. The goal of CBT is to modify maladaptive thoughts and behaviors by applying systematic, measureable implementation of strategies designed to alter unproductive actions. A reaction is a behavior, and all behaviors are subject to modification. The basic steps are:

1) define the problem,

2) identify the behaviors and thoughts affected by the tinnitus,

3) list the maladaptive strategies and cognitive distortions currently employed,

4) distinguish between the tinnitus experience and the maladaptive tinnitus behavior,

5) identify alternate thoughts, behaviors, and strategies,

6) devise and rehearse strategies that can be measured,

7) assess success or failure of coping strategies. 

Stress and maladaptive coping strategies are manifested in a variety of manners, both physical and psychological. Tinnitus patients are well served by education concerning the undeniable correlation between exacerbation of tinnitus perception and stress. 

Stress management courses are offered for groups or individuals through community health organizations as well as through professionals. Individuals can learn how certain physical functions can be altered via mental control. 

Relaxation, guided imagery, and self-hypnosis are examples of self help methods used to help combat the stress, anxiety, and sleep disturbances associated with tinnitus by many patients. CBT is most effective when combined with attention control, imagery training and relaxation.

Acoustic desensitization (Neuromonics treatment)

A recent approach combining detailed counseling with stimulation via music was proposed several years ago by Davis et al 20. The unique aspect of this approach is that it uses recorded music specifically chosen for its amplitude and tempo characteristics and then filtered in accordance with the patient’s hearing thresholds.

The auditory portion of this acoustic desensitization protocol is delivered via a wearable system consisting of a sound processor produced by Neuromonics and high fidelity headphones. The sound processor provides a background of music mixed with white noise and filtered out to a higher frequency (12,500 Hz), than can be reached via hearing aids.

The recorded music is presented to the tinnitus patient at a relatively soft intensity level (designed to just interfere with the tinnitus perception), and to be listened to passively (as opposed to actively) for 2-4 hours per day to induce relaxation and desensitization.

The background white noise, which is employed to mask the tinnitus during the quiet intervals of the music is utilized during the first couple of months of treatment and then phased out. The Neuromonics treatment is designed to promote the habituation of tinnitus and hyperacusis recalibration process over a period of approximately six months.

Comparison of the three treatments

All three of these treatments have been reported to be successful in over 80% of patients receiving them. While they all focus on counseling, TRT and the acoustics desensitization protocol also emphasize the importance of acoustic therapy. CBT is designed to take approximately 2-3 months of intensive therapy, TRT requires as much as 18 – 24 months of less active participation, and the Neuromonics acoustic desensitization protocol is intended to require 6 months

Critics claim that a shortcoming of the TRT approach is that it does not consider depression and anxiety disorders, despite the fact that as many as 40% of tinnitus patients may suffer from depression and anxiety. Psychologists also have claimed that the interaction and collaboration aspects of CBT are more important than directive counseling, and that TRT does not teach coping strategies.

TRT and Neuromonics advocates argue that sound therapy (which is not a part of CBT) is essential to minimize increased central auditory gain and promote relaxation. Acoustic stimulation (sound enhancement) may facilitate habituation by increasing neuronal activity, decreasing contrast (between silence and tinnitus) in order to make tinnitus more difficult to detect, and minimizing increased central auditory gain. Because of the importance of sound therapy, the next section is devoted to a discussion of several methods of delivering appropriate acoustic stimuli.

Sound Therapies

Current sound treatments employ the use of wearable noise generators (preferably coupled to the ears so that the ear canals are not completely blocked), music, hearing aids, home sound enrichment approaches such as use of radio, TV, or electrical fans, and commercially available recordings that transmit relaxing sounds, such as ocean waves. The goal is to provide sounds that 1) stimulate and soothe the limbic system , 2) stimulate the neural pathways up through the auditory cortex, and 3) when appropriate, compensate for hearing deficits.

The aim is to have the tinnitus interact with a neutral sound, which is easily ignored. One should not actively listen to the chosen sound. To do so could activate the limbic system in an unwanted manner. The volume of the sounds should not be so high that it completely masks the tinnitus. Rather, the signal level should mix with the tinnitus in a manner such that both signals may be audible, but neither is particularly distressing. This can be defined as “the tinnitus interference or mixing level”; the tinnitus is not completely gone, but the annoying aspect of it is removed or minimized.

This approach differs significantly from the concept of masking, first described in 1928 by Jones and Knudsen 21 and popularized fifty years later by Vernon 22. Masking can be defined as the use of an externally produced sound delivered via a noise generator typically with a narrow band of noise centered around the pitch of the tinnitus and adjusted loud enough to either cover up, or in some way inhibit or alter production of tinnitus. Many patients report that external sounds are effective in masking out the tinnitus perception. This, in addition to the fact that attention is more occupied during the daytime, explains why so many patients indicate tinnitus is most noticeable when they are in quiet environments or at night. Unfortunately, a significant number of tinnitus sufferers find that after a short period, the masking noise is nothing more than a substitute of one annoying sound for another. 

Hearing aids can be enormously effective in assisting tinnitus patients 23. Patients with tinnitus and any degree of hearing loss may benefit from amplification. The rationale for selecting and programming the devices to a given person must be based on the individual’s needs and may differ somewhat from that used for patients with hearing loss only. 

The exact mechanism accounting for the beneficial effects of amplification is uncertain but is probably related to at least five factors.

One, it is likely that tinnitus is exacerbated by silence perhaps because the brain turns up its sensitivity to spontaneous electrical activity by seeking out the neural stimulation it is being deprived of because of the hearing loss. Amplification increases neural activity and thus may assist in “turning down” the brain’s sensitivity control.

Two, it is possible that tinnitus is related to a lack of neural inhibition. In other words, the brain is capable of suppressing the perception of tinnitus, but in an impaired auditory system this inhibitory ability is compromised. Perhaps the greater activity created by amplification allows the inhibitory function to correct itself to a degree.

Three, the auditory system has two primary tasks, one is to analyze and interpret incoming sound, and the other is to suppress unwanted signals. Since tinnitus is not a sound that is subject to analysis, the brain may be incapable of making the necessary determination to decide whether the signal needs to be analyzed or suppressed. By providing amplification of “true” auditory signals, the brain may have a greater opportunity to remind itself what is true sound and what is pseudo-sound.

Four, hearing aids amplify enough background noise (wanted or otherwise) to partially “mask” the tinnitus or at least reduce its contrast to silence.

Five, if hearing aids assist in reducing the fatigue and stress that accompany having to strain to hear, the ability to cope with tinnitus is improved.

Sweetow and Henderson Sabes 24 reported on the use of a variety of acoustical stimuli that can be delivered through wearable hearing aids. A recent advance that shows considerable potential for assisting tinnitus patients is the presentation of fractal tones that can be programmed for variations in tempo and pitch. The authors found these relaxing tones (which sound like wind chimes) to be preferred over hearing aid amplification alone or over a broadband noise for the majority of tinnitus subjects in their study. They also have a possible advantage over other musical stimuli in that they are not predictable and thus may discourage active listening which could alter the rate of habituation.

The criterion for selecting specific models and features of hearing aids for tinnitus patient may be slightly different than for individuals with hearing loss alone. The most important considerations for fitting hearing aids on tinnitus patients are: 

  • Programmability and flexibility is vital because of the capability of changing the acoustics based on the preferences of the user;
  • Adjustable multi-band compression is helpful because lower compression kneepoints will increase amplification of sounds (providing partial masking with environmental sounds and increasing neural activity) while still protecting sensitive ears from loud sounds;
  • Multiple programs may allow for the user to adjust the hearing aids so that they can select different amplification for quiet (where they might want greater amplification of soft environmental noise) versus noisy environments (where they might want to suppress annoying background signals that interfere with communication);
  • Binaural fittings are usually appropriate (even if the tinnitus is perceived predominantly on one side) because it ensures neural stimulation on both sides of the brain and increases the chances for the effects described earlier.

One must be aware that a small percentage of patients report “reactive” tinnitus; that is, tinnitus that seems to be louder with external sounds. In addition, patients with sensorineural hearing loss are typically characterized as having loudness recruitment, so some tinnitus patients will complain that amplification exacerbates their tinnitus. In these cases, it is important that loudness growth be carefully measured prior to fitting hearing aids. Applying knowledge of earmold acoustics and dynamic range syllabic compression further assists the professional in helping these patients. 

Some Counseling Strategies

It is critical to allow the tinnitus sufferer to express his or her feelings. However, perseverating on negativity should not be allowed. It is important to educate the patient that most sensations occurring in the body can be suppressed by the brain, as long as the brain considers them to be irrelevant. For example, when people sit in a chair, they don’t constantly think about their body (in this case, the buttocks) touching the chair. This is because when the tactile response is delivered to the central nervous system, multiple parts of the brain interact with each other.

The sensation perceived will depend on which part of your brain receives the electrical signal. In the case of sound, this would be the auditory cortex. But then, other parts of the brain come into play, specifically the limbic system which both identifies the signal and makes a determination as to whether the signal is relevant enough to be attended to or irrelevant and therefore one that should be suppressed.

When sitting in a chair, the limbic system can identify the sensation and determine that that particular sensation does not require attention and therefore the brain releases chemical and electrical instructions to suppress it. A similar situation exists with sound. When people live near an airport, initially they may find that the frequent noise from the airplanes is quite distracting and annoying. Yet, after a short period of time, they actually begin to not perceive the sounds.

Of course, if a person actively listens, he or she will be able to hear the airplanes. In other words, the sound is there, it is reaching the auditory cortex, but the cortex and limbic system have analyzed it and decided that it is not important to attend to and thus should be suppressed. This is an important natural function that the brain performs thousands of times each day. If it didn’t do this, we would be overwhelmed with irrelevant sensations. Unfortunately, automatic functions cannot be easily and consciously controlled. In other words, one cannot eliminate a sensation by simply actively trying to not experience it.

The brain is also capable of accomplishing suppression for tinnitus, but it is more difficult. Because it is the auditory cortex that is receiving this signal, the assumption is made that this must be a sound. However, unlike airplane noise, the tinnitus is not a real sound; it is merely an electrical signal. Thus the auditory cortex cannot properly analyze it.

If it cannot properly analyze it, the limbic system has great difficulty deciding whether this “fake” auditory perception is relevant or not. In fact, tinnitus often becomes associated with a very negative meaning. After all, no one really likes “hearing” tinnitus, and it can trigger fears of progression, of underlying serious illnesses, of difficulty sleeping and concentrating, etc. Thus, the limbic system may logically, but erroneously, decide that the tinnitus may be relevant and therefore it

1) directs the auditory cortex to keep analyzing it, and
2) directs the autonomic nervous that there is something wrong and it should be on alert. This subsequently creates a release of chemical and electrical messages that may induce stress and anxiety. Thus, a vicious cycle occurs. The tinnitus makes one feel stressed, and the stress encourages the brain to focus more on the tinnitus.

Patients should understand that habituation from tinnitus can occur as quickly as a few months, or may take as long as two years. Hopefully, the sound generators, music, or hearing aids will produce some immediate decrease in the “perception” of the tinnitus.

The patient must recognize, however, that there will be days, particularly when therapy has first begun, that the tinnitus will seem to jump right out at the patient. If one is upset, tired, doesn’t feel well, or has been exposed to loud noise, the tinnitus may seem louder. There also may be days when the tinnitus is barely noticeable. Patients should not become overly optimistic on those days any more than they should become dejected on the difficult days. Patients must try to control irrational and negative thoughts.

The objective is to take control over the tinnitus rather than letting the tinnitus take control. This is a battle that can be won. It should not be approached from the perspective of eliminating or lowering the volume of the tinnitus; rather it is about improving the quality of life.

Counseling should conclude with an action plan that includes discussions about the patient’s sleep pattern, need for a change in diet or physical exercise (when appropriate), requirements for lifestyle alterations, plans to control the negative emotional reaction, and a plan for sound enrichment.

It is important to include statements about the following into counseling sessions:

Tinnitus is not unique to that one patient.

Tinnitus is not a sign of insanity or grave illness.

Tinnitus may be a “normal” consequence of hearing loss

Tinnitus probably is not a sign of impending deafness.

There is no evidence to suggest the tinnitus will get worse.

Tinnitus does not have to result in a lack of control.

Patients who can sleep can best manage their tinnitus.

Tinnitus is real, and not imagined.

Tinnitus may be permanent.

Reaction to the tinnitus is the source of the problem.

Reaction to the symptom is manageable and subject to modification.

If significance and threat is removed, habituation or "gating" of attention can be achieved.

Stay off the internet!

Conclusions

Mega-analytic reviews indicate that there is an approximate 60-70% success rate with counseling alone, and adding sound therapy brings success rate above the 80% level. Any of the approaches, discussed above can help tinnitus patients, though the choice of which will be best is based on the characteristics and needs of the patient and the comfort level and skills of the audiologist.

Despite the lack of a tinnitus "cure", it is unethical and immoral for audiologists to inform a tinnitus sufferer that "there is nothing that can be done for you, just learn to live with it". In this article, a variety of approaches have been discussed. Flexibility in thinking is needed and the patient must be made "a partner" in finding the best way to deal with this unwanted auditory disturbance.

(Robert W. Sweetow, Ph.D.,University of California, San Francisco, August 2010)

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Hearing Expert

Francis Slabber is a Speech & Language Therapist and Audiologist who has owned and run The Hearing Clinic in Wynberg, Cape Town for the last 17 years. Francis and her team have extensive experience in fitting and supplying hearing aids as well as assistive living devices. Francis has served as the Western Cape Chairperson for the South African Association of Audiologists for three years and has given many talks on the topic of hearing loss and amplification. The Hearing Clinic has a special interest in adult and geriatric hearing impairment, hearing aid fittings and hearing rehabilitation.

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