Tinnitus is the perception of a sound in the ears or in the head with no corresponding external stimuli. There are more than 200 potential causes for tinnitus. They can originate from within or outside of the auditory system. Metabolic, pharmacological, dental, somatic and psychological disorders are all possible culprits for tinnitus. Therefore, it is important to note that every patient is different, and that a single treatment will never be able to satisfy the full spectrum of tinnitus patients. Furthermore, patients with other symptoms in addition to tinnitus need to be treated differently.
The use of external sound(s) can provide relief from tinnitus by inducing neurophysiologic functional changes in the different auditory pathways. The aim of sound therapy is to decrease prominence of the tinnitus and facilitate tinnitus habituation while transforming the individual’s reaction to tinnitus through counseling.
There are two types of tinnitus:
- Objective – meaning the tinnitus is audible to someone else besides the patient. This type of tinnitus generally originates from middle ear or vascular system.
- Subjective – meaning the tinnitus is audible just to the patient. It is often considered as the perceptual consequence of modified neural activity, generated by the central auditory pathway, after peripheral damage. High frequency hearing loss is the highest predictive risk factor for tinnitus.
Subjective tinnitus is a common problem affecting approximately 1 in 5 individuals, although the epidemiologic studies show variable rates. It is considered that 10-15% of the population has chronic and persistent tinnitus; and around 20% of those reporting tinnitus find the condition disruptive enough to seek specialized treatment.
There is strong evidence to suggest that acoustic therapy can help mitigate the effects of subjective tinnitus. Acoustic therapy can occur in many forms such as: fitting the patient with appropriate amplification, modifying advanced signal processing features for the purpose of tinnitus treatment, or following a formal tinnitus protocol such as Tinnitus Retraining Therapy (TRT). Signia offers solutions that can be adapted for any therapy protocol to fit the needs of the Hearing Care Professional (HCP) and the patient.
Use of sound therapy for tinnitus
Sound therapy for tinnitus has been defined as any use of sound intended to alter the tinnitus perception and reactions for clinical benefit. Besides hearing instrument use for tinnitus relief, numerous methods of sound therapy have been used since tinnitus masking was introduced in the 1970s Two general types of sound therapy approaches have been investigated for tinnitus management:
- Total masking – using an alternative stimulus
to cover up (mask) the perceived tinnitus.
- Partial masking – the addition of an alternative
stimulus to reduce the focus of the patient’s
subjective tinnitus on both a conscious
(psychological level) and unconscious level
(central auditory perception).
Both employ the use of broadband noise sound generators, hearing instruments, or combination devices.
The clinical application of sound therapies has generally focused on managing reactions to tinnitus and suppressing perception of tinnitus. Sound therapy is thought to provide relief from tinnitus and reduce the emotional consequences of tinnitus. Some individuals experience residual inhibition following total or partial masking (i.e., tinnitus suppression or temporary disappearance of the tinnitus sensation after exposure to an external sound). Additionally, sound therapy may promote habituation to the tinnitus by reducing the contrast between the tinnitus and environmental sound.
Habituation “is the reduction or elimination of Central Nervous System (CNS) activity in response to repetitive stimuli” (Encyclopedia of Neuroscience, 1987). It is a natural process of the CNS and crucial to brain function enabling humans to perform many tasks simultaneously. Habituation is the basis for Dr. Pawel Jastreboff’s Neurophysiologic model of tinnitus (Fig. 1), the predecessor of TRT.
In this model, the starting point is the generation of tinnitus by the cochlea or the 8th cranial nerve. The tinnitus is then detected on a subcortical level and, finally, perceived for interpretation by the auditory cortex. At this point, if the tinnitus results in an emotional reaction from the patient, an involvement from the limbic system can occur. The limbic system controls motivation, mood, and emotion. Therefore, a limbic system reaction to tinnitus can cause insomnia, anxiety, depression, and fear. Further complication arises if the emotional reaction is not quelled as the patient may develop physical symptoms related to the patient’s autonomic nervous system
Whether or not the patient has the ability to habituate to their tinnitus spontaneously is thought to correlate with the impact that tinnitus has on a patient’s daily life. It has been reported that of those reporting the symptom of tinnitus: 80% report no impact on their lives, 15% feel their tinnitus impacts them, and 5% are incapacitated by their tinnitus (Fig. 2).
The 80% with no impact are thought to be the patients that habituate with no intervention. The 15% with impact correlate to those tinnitus sufferers that have developed an emotional response to their tinnitus and the 5% correlate to individuals experiencing a physical response from the Autonomic Nervous System. Many researchers have theorized that if a tinnitus patient is treated early, with effective counseling and sound therapy, you may be able to mitigate the effects of the tinnitus before a patient reaches the ‘incapacitation’ stage.
Established sound therapy protocols
• Amplification alone – Searchfield, G.D.
• Tinnitus Activities Treatment – TAT Tyler, R.S.
• Tinnitus Retraining Therapy – TRT Jastreboff, P.J.
• Progressive Tinnitus Management – PTM Henry, J.A.
• Cognitive Habituation Tinnitus Treatment – CHaTT
Tinnitus counseling guide
Traditional tinnitus treatment typically addresses the obvious symptom of tinnitus and often includes the use of audiological devices that can deliver sound therapies. While treatment of the tinnitus may reduce or alleviate the stressors associated with it, for example, depression, anxiety, and insomnia, many patients need additional help coping with these ancillary symptoms. Habituation to tinnitus can take between 12-18 months even with appropriate sound therapy; therefore, many patients return to their HCP feeling discouraged, frustrated, and desperate for more immediate relief. Unfortunately, what is often heard is, “There is nothing else that can be done” and “Learn to live with it.” Such messages can quickly diminish hope, leaving the patient feeling misunderstood and afraid that things cannot improve.
The clinician should emphasize to their patient that although there is no “cure” for tinnitus, there are effective, logical techniques that they can do to make tinnitus less noticeable and thereby improve their quality of life. There are a wide variety of tinnitus management counseling options available. These options range from providing basic education and information about tinnitus, to focused activities such as Cognitive Behavior Therapy (CBT), relaxation techniques, and meditation.
Counseling is an essential part of tinnitus treatment. The patient must understand what tinnitus is in order to overcome or avoid the negative associations that inhibit habituation. For some patients, a simple explanation of the causes of tinnitus and the relationship between hearing loss and tinnitus is enough to facilitate a positive outcome. For others, more in-depth systematic counseling may be necessary. This counseling may be provided by the HCP utilizing the various programs’ tools or it may be provided by a mental health professional upon referral.
In TRT, the link between the limbic system and the tinnitus is decreased by using a process called “directive counseling” or “demystification”. This involves a series of intense educational sessions where anatomy, physiology and real examples are discussed in story format to make the tinnitus phenomenon understandable and demystified. For more information go to the TRT website: http://www.tinnitus-pjj.com/.
In TAT, counseling focuses on the whole person, and considers individual differences and needs. TAT provides structured counseling focused in four areas: thoughts and emotions, hearing and communication, sleep, and concentration in a picture-based approach that facilitates engagement of the patient.
TAT also engages the patient by including homework and activities to demonstrate understanding and facilitate progress. TAT counseling material is free for download and can be easily found at the University of Iowa website: http://www.medicine.uiowa.edu/oto/research/tinnitus/.
Cognitive Habituation Tinnitus Therapy (CHaTT©) was developed by Dr. Natan Bauman. CHaTT is a modified TRT program which also includes components of CBT, pictorial representation, and music as a form of distraction and relaxation. http://www.tinnituspractitioners.com.
With Progressive Tinnitus Management (PTM), developed for the Veteran’s Administration by James Henry, a hierarchal approach is used to determine whether a patient is a candidate for group counseling and sound therapy or a higher level of individual services including individual counseling by an audiologist and/or a mental health professional. All PTM-related information may be found at the government website: http://www.ncrar.research.va.gov/
Many psychologists specialize in CBT which is commonly used in treating a patient’s psychological response to tinnitus. The HCP may consider a multidisciplinary approach to tinnitus treatment in which the HCP fits and adjusts the hearing instruments for effective sound therapy and provides the initial tinnitus counseling. This should include the anatomy of the ear, auditory system involved, and how tinnitus relates to hearing loss. Once sound therapy has begun, a psychologist may provide additional counseling and CBT to further support the emotional well-being of the patient.
There are many forms of sound therapy for the treatment of tinnitus. Providing ear-level devices such as hearing aids, maskers, and combination devices are an accepted and researched part of sound therapy