20Q: Tinnitus - Developing a Practical Management Protocol

From the Desk of Gus Mueller

For those of you who work in a busy clinic, it’s very possible that you see a patient with tinnitus most every day. In fact, it might be so common that you do not think much about it, except to note it in his or her medical records. This is probably okay for most patients, where the tinnitus is not having an impact on their lifestyle, physical or emotional state. But what about the patients where the tinnitus is their primary complaint? Perhaps they even have normal hearing. How are they handled?

While survey findings vary, it is believed that about 10% of U.S. adults have tinnitus, and of this group, about 7% consider it a big, or very big problem. So, if these data are correct, we would predict that roughly 1 out of every 100 adult patients who walk in your door need more than your passive acknowledgement of their tinnitus. Unfortunately, most audiologists have not had much training in the evaluation, treatment and management of the tinnitus patient. We’re going to help fix that this month here at 20Q.

Christopher Spankovich, PhD, is an Associate Professor and Vice Chair of Research for the Department of Otolaryngology and Communicative Sciences at the University of Mississippi Medical Center. He is a clinician-scientist with a translational research program focused on prevention and treatment of acquired forms of hearing loss, tinnitus, and sound sensitivity.

You probably know Dr. Spankovich from his numerous publications, some of them here at 20Q. He is known internationally for his lectures and workshops on the topics of tinnitus, sound sensitivity, and implications of lifestyle and diet on hearing health. He was recognized by the American Academy of Audiology as a Jerger Future Leader of Audiology, serves on the Academy’s Practice Policy Advisory Committee, and is an Associate Editor for Audiology Today and the International Journal of Audiology.

While Chris has conducted considerable research related to tinnitus, and lectures frequently on the topic, he also is in the clinic each week seeing his caseload of tinnitus patients. Just the right kind of guy to write a 20Q article on developing a practical management tool for this disorder.  

Gus Mueller, PhD
Contributing Editor

Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q

20Q: Tinnitus - Developing a Practical Management Protocol

Learning Outcomes 

After this course, readers will be able to:

• Discuss the audiologist’s role in tinnitus management and list effective approaches.
• Describe key components of the case history and diagnostic evaluation for a patient whose chief complaint is tinnitus.
• List 5 factors to address in audiological tinnitus management and ways audiologists can incorporate them into a clinical protocol.

      Christopher Spankovich    

1. I am not ever sure about what to do with tinnitus patients. Is there really anything audiologists can do?

2. Are audiologists the most appropriate providers for patients with tinnitus?

As audiologists, we are trained in the anatomy and physiology of the auditory-vestibular system, neuroanatomy/neurophysiology, acoustics and psychoacoustics, differential diagnostics, aural rehabilitation, counseling, and treatment of hearing and balance dysfunction using non-medical interventions. No pharmacological or surgical interventions exist for treating tinnitus for the vast majority of patients. The lack of medical intervention for tinnitus has led to the common experience of patients being told by physicians and other providers, “You will learn to live with it”. This statement often results in the patient feeling dismissed and hopeless. In reality, most patients simply want a knowledgeable clinician to sit down with them and explain what tinnitus is (and what it is not), why they are experiencing tinnitus (often related to hearing loss), and give them recommendations to help reduce the difficulty they are experiencing. That all seems like it’s part of an audiologist's scope of practice to me.

3. So, how do we treat tinnitus?

Good question. Currently, in most cases, we don’t. Rather, most approaches commonly used by audiologists are not treating tinnitus, that is, the approaches are not seeking to disrupt the tinnitus signal through some type of neuromodulation. But rather, approaches treat the patient’s reaction and interpretation of the tinnitus percept, which might lead to reduced reaction and reduced perception. Now, we could get picky and say that brain regions involved in gating our attention, perception, and stress-based response to tinnitus may change, but really we are not curing a person’s tinnitus or removing the signal. Yet, there are a few treatments currently available that seek to modulate the tinnitus signal and there are others that are being developed.For example, Susan Shore’s lab at the University of Michigan is exploring the application of somatosensory stimulation paired with sounds. Their findings are showing some success in both animal and human experiments - you can read more about that here. However, currently, no large randomized blinded placebo-controlled studies exist.

4. Remind me, what is a randomized blinded placebo-controlled study?

A placebo is a substance that has no active substance to result in a real therapeutic effect. This helps to control for the psychological effect of receiving a treatment. Placebo effects are more commonly associated with conditions that have significant psychophysiological underpinnings. A randomized blinded placebo-controlled trial assigns participants to either the therapeutic agent or a placebo agent (preferably identical to the therapeutic agent except for the active substance) randomly, with both the participants and potentially the researchers blinded (double blind) to the assignments. Work in tinnitus research has suggested a placebo effect as high at 40% (Duckert & Rees, 1984). In other words, 4 out of 10 tinnitus patients that are provided an M&M candy for their tinnitus, and told this will help treat their tinnitus, will report tinnitus reduction.

5. Alright, then how do we treat a patient’s reaction to tinnitus?

Better question. As mentioned previously, numerous management approaches exist. Common examples include tinnitus retraining therapy (TRT), tinnitus activities treatment (TAT), cognitive behavioral therapy (CBT), and other psychological-based therapy approaches. There also are numerous proprietary devices, such as those from Neuromonics, Desyncra, Levo, etc. Even the simple fitting of amplification with basic counseling can be effective for many patients with tinnitus complaints (Kochkin et al., 2011; Searchfield et al., 2010). There are differences among these approaches. For example, TAT, developed by Rich Tyler and colleagues at the University of Iowa, is significantly influenced by strategies used in cognitive behavioral therapy. TAT considers four areas: thoughts and emotions, hearing and communication, sleep, and concentration. TAT typically uses Partial Masking Sound Therapy, with a noise or music set to the lowest level that provides relief. A picture-based approach facilitates engagement of the patient, and provides thorough and structured counseling. The patient is engaged through the use of homework and activities to demonstrate understanding and facilitate progress (Tyler et al., 2007). On the contrary, tinnitus retraining therapy gives greater emphasis to the subconscious reflexive pathway sustaining the reaction to and perception of the tinnitus. TRT, through educational counseling on the neurophysiological model of tinnitus and sound therapy, attempts to achieve habituation to the reaction and perception of the tinnitus percept (Jastreboff & Jastreboff, 2000; Jastreboff & Hazell, 1993).

6. You mentioned Cognitive Behavioral Therapy (CBT), can I do that?

I am not aware of any state licensure language in audiology that includes CBT within the scope of practice. Now, that does not mean we cannot utilize principles from CBT. But, at least here in the United States, we (audiologists) cannot market or perform CBT without leaving ourselves open to litigation. One of my audiology mentors, Robert Sweetow, uses the term adjustment-based counseling. That being said, if you pursue the appropriate credentials (degree in behavioral therapy, necessary hours, and licensure) you can perform CBT.

7. You’ve provided examples of several tinnitus management approaches. Which is the best?

Recently, a number of studies have attempted to determine what factors may influence patient outcomes (e.g., Scherer & Formby, 2019; Tyler et al., 2019; Theodoroff et al., 2017; Henry et al., 2017, to name a few). First, understand that there is a limited relationship between psychophysical measures of tinnitus and tinnitus distress (Henry & Meikle, 2000). In other words, the pitch match, loudness match, or minimum masking level for the patient has very little correlation to self-perceived tinnitus difficulty. Second, it is very difficult to control for prior knowledge and counseling components of tinnitus management. That is, if a patient has already searched Google or communicated with a knowledgeable provider, this can affect patient expectations for a research study. Third, there is a significant clinician effect. In other words, a more knowledgeable and experienced clinician can have a greater influence on outcomes (Henry et al., 2016).  But, let me answer your question directly. In general, research has shown that when comparing masking, formal management approaches, hearing aids, hearing aids with sound generators….all work to some extent when compared to wait-list controls.  However, none necessarily work better than others. 

8. You mean it doesn't matter what I do?

No, that's not what I mean. It does matter. These studies are examining group differences and have limitations. For example, how well the clinicians were trained in specific approaches may vary. For the individual patient, one approach vs. another may make the difference! It is you as the provider that makes the difference. Your knowledge and experience with various management approaches to tinnitus and the ability to be flexible and tailor your approach to the individual is what makes the difference.

9. Sounds good, but it would be nice if there were a simple, step-based process to do this?

You lucked out. I happen to have some simple recommendations that can help with the vast majority of tinnitus patients. Where you start depends on the patient. First, what was the referral source? Is the patient coming from an otolaryngology colleague down the hall, primary care physician, or self-referral? This can significantly influence my history intake, counseling, testing, and recommendations.

An obvious starting point is a thorough case history. In the case history, we want to review these areas:

• Patient’s tinnitus history
  • onset: gradual vs. sudden
  • percept quality: ring, buzz, pulsing, etc.
  • localization: ear, head, etc. 
  • correlation: associate in time with a specific factor
• Audiologic and Medical history
  • hearing status
  • balance status
  • use of amplification 
  • medical history: co-morbidities, medications, etc.
• Psychological history
• Lifestyle 
  • diet
  • exercise
  • sleep
  • other  

We also want to know how the tinnitus is impacting the patient’s quality of life and function. Numerous inventories exist. I prefer the Tinnitus Functional Index (Meikle et al. 2012) and the Tinnitus Handicap Inventory (Newman et al. 1988). Another questionnaire I recently have incorporated into my clinic is the Tinnitus and Hearing Survey (Henry et al. 2015).

10. I have not heard of the Tinnitus and Hearing Survey - can you elaborate?

The Tinnitus and Hearing Survey was developed by Jim Henry and colleagues at the National Center for Rehabilitative Auditory Research (NCRAR) in Portland, Oregon. You can access the survey here. It is very common for patients to have a chief complaint of tinnitus. Then spend the next 15 minutes describing how the tinnitus is affecting their ability to follow conversations, understand speech, and so on. The Tinnitus and Hearing Survey helps to differentiate patients that have a primary complaint of hearing loss rather than tinnitus.

11. All of that information really helps with the case history. What's next?

The next part is likely something you do in your clinic every day, diagnostics. Testing can include comprehensive audiologic examination, immittance measures, otoacoustic emissions, auditory evoked potentials, and a tinnitus assessment. I do not perform every test on every patient. The diagnostic evaluation is really dependent on the patient, his or her history, and where the results lead. And of course, medical necessity is a consideration. For example, if the patient is not coming directly from an audiology or ENT colleague and does not have a recent hearing test, or does, but complains of a change in hearing, I will start with a comprehensive audiogram. The results of that test may lead to immittance measures (depending on if there is asymmetry and the need for reflexes, or air-bone gaps and the need to determine middle ear function). The results may indicate that other testing is needed to contribute to a differential diagnosis (site of lesion) and determination of the need for a medical referral. If the patient just had an audiogram from a reliable referral source, and does not complain of a change in hearing, then I often consider the routine diagnostic battery unnecessary. 

12. How do you perform a tinnitus assessment?

This is typically your next step, but I first want to point out that a tinnitus evaluation is, in general, a psychophysical measure of a patient’s tinnitus percept. In other words, it is subjective. It is not an objective measure of tinnitus. No clinical objective measure of tinnitus exists. The tinnitus assessment (CPT code 92625) includes a pitch match, loudness match, minimum masking level, and optional residual inhibition. In brief, the procedures are as follows:

• The pitch match involves a forced choice paradigm where two pitches are played to the patient (above their threshold) and the patient is directed to choose which pitch is closer to their tinnitus pitch. The procedure brackets back and forth around the perceived pitch.
• The loudness match involves playing a sound in ascending levels (commonly the pitch-matched sound) until the patient reports that the external sound matches the tinnitus percept in loudness.
• The minimum masking level involves playing noise (often white noise) in ascending levels until the patient reports the noise suppresses or masks the perception of the tinnitus. 

Numerous approaches exist for each and it is a good idea to repeat each component several times.  Further, some proprietary applications may suggest specific strategies.

13. Wait, what about residual inhibition?

Don’t worry, I was getting to that. Residual inhibition involves playing the sound you used in the minimum masking level test, 10 dB above the minimum masking level for 1 minute. The patient is instructed to report after the masking sound is discontinued when the tinnitus percept returns to the level prior to the noise. The phenomenon of sustained suppression of tinnitus despite removal of the masking has been related to neural adaptation. Though, anecdotally, many patients have limited residual inhibition and some may experience a brief exacerbation of their tinnitus. You’ll find a nice review of this by Henry et al. 2005.

14. I will take a look at that paper. What's next in terms of our protocol?

That was the evaluation. Next we need to counsel the patient and provide management options. I recommend addressing 5 factors: 1. tinnitus source, 2. habituation and behavioral factors, 3. sound therapy options, 4. distraction, and 5. lifestyle.

15. How do you address the tinnitus source?

It is important the patient be provided a basic, or even more than basic, explanation of tinnitus neuroscience including the role of the auditory pathway and non-auditory pathways. Now, I cannot provide you an overview of tinnitus neuroscience here, but you can find more detail in a recent course I presented on AudiologyOnline, Principles of Tinnitus Evaluation and Management.

In brief, I explain normal hearing, with the goal of the patient recognizing we don’t hear with our ears, but rather, we hear with our brain. I then review the patient’s test results and if there is evidence of a hearing deficit (most often there is), I review what part of the pathway is implicated. Next, we talk about how peripheral changes can result in central compensatory effects. And, I explain how non-auditory regions of the brain involved in salience, attention, memory, and our stress response are critical in the interpretation of the tinnitus percept and even determine if a patient perceives tinnitus. I like how Ryan and Bauer (2016) summarize tinnitus neuroscience: 

“Tinnitus is a spectrum-based percept, most commonly a consequence of changes in auditory and non-auditory neural networks following damage to the cochlea. Homeostatic compensatory mechanisms occur after hearing loss and these mechanisms alter the balance of excitatory and inhibitory neurotransmitters. In many individuals with hearing loss, chronic tinnitus and related phenomena emerge. Some people with tinnitus are disturbed by this subjective sensation. When auditory network dysfunction is coupled with limbic-gating dysfunction, an otherwise meaningless auditory percept such as tinnitus may acquire negative emotional features.” 

I also try to normalize tinnitus. Tinnitus is a normal experience. One example is the classic study of Heller & Bergman. In 1953, they reported on tinnitus experience in persons with hearing loss and healthy young adults without hearing loss or tinnitus. Participants were placed in a sound-treated room for 5 minutes and then questioned on what they experienced; 94% of the normal hearing young adults (without tinnitus normally) reported the perception of ringing, buzzing, humming, etc.  

Another way to explain this is by using an analogy to pain. Pain is a normal response that motivates the individual to withdraw as a means of protection and prevention of future experiences. Pain elevates from a symptom to a disorder when it becomes chronic and interferes with a person’s quality of life and general function. Pain is psycho-physiological. Now read this paragraph again except replace the word "pain" with "tinnitus." 

Finally, I also want to normalize the patient's reaction. It makes sense for a patient to find tinnitus to be annoying and bothersome and to report an immediate negative aversive reaction. If you started to experience ringing or buzzing in your ears, your first reaction would not be, “Oh good, this must mean that I am developing super hearing" or, "this is a sign I am healthier, or I’m going to live longer.” No, of course not, your first reaction would be, “What is wrong? This is not my normal."  If you were driving your car down the road and your engine started making a banging noise, you would not perceive this as positive. You would immediately think something was wrong with your car.  Now, your car makes hundreds of sounds, but not until something is perceived as abnormal does your brain take notice.

16. Looks like I have some reading to do on tinnitus neuroscience. How about habituation and behavioral factors?

Here we address the common recommendation “to learn to live with it."  In reality, there is truth to that statement. Unfortunately, in most cases the follow-through of explaining what that means is not effectively translated to the patient. Habituation is when a new stimulus becomes “well known” and loses relevance. Many examples exist. I commonly give the example of a watch on the wrist, ring on the finger, or shoes on your feet. All day those things are touching you, but most of the day you don’t feel them. It is not that the signal is turned off, but your brain is filtering it. When you point out the item, the person can then feel them, because they have forced their brain to read that signal. I follow-up with examples using environmental sounds (e.g., air conditioning, refrigerator, etc). 

For behavioral factors, I want to consider any maladaptive thoughts or behaviors that the patient is demonstrating. These include negative automatic thoughts such as all or none thinking, discounting the positive, etc. For example, a patient loves to go to live music shows, but experienced a spike in his or her tinnitus after a show, and now has stopped going because if they go it will make their tinnitus worse. Addressing this concern with a realistic assessment and alternative strategies (e.g. musicians' earplugs) often can get the patient back to doing the things they enjoy.

17. Where does sound therapy fit into this protocol?

There are many options for sound therapy - everything from simply enriching the environment with sound and avoiding silence, to the use of ear-level devices, including hearing aids. If a patient has hearing difficulty, I often recommend hearing aids. Hearing aids stimulate the pathway responsible for generating the tinnitus percept with real sound, reducing the contrast of ambient sound and tinnitus percept. Hearing aids also improve hearing, reduce listening fatigue and change the focus of the treatment from treating tinnitus to treating the auditory system. At night, I commonly recommend using a soothing sound in the room. The patient can consider the use of a sound pillow (pillow with a speaker in it) or another similar device. The sound is preferably one that does not engage active listening, but rather passive listening. It should not be a sound the patient finds annoying or bothersome. It should be set at a level that provides relief, but does not necessarily mask the tinnitus. The idea is to have a sound that helps take the edge off the tinnitus perception. The brain will usually be able to put that sound to the background (i.e. habituate). If the brain can do that with one sound, it can do it with the tinnitus percept.

18. Sounds reasonable, what about distraction?

Simple, you tell the patient “just stop focusing on your tinnitus.” Ha—that of course doesn’t work.  That is like me telling you, “Don’t think of a number right now.” You just thought of the number 7, didn't you? Rather, what I do say is that if the tinnitus is bothering, don’t just sit there and listen to it, put on some sound and distract yourself. Put on your favorite funny movie, call up a friend, go cook something, or go for a run. Do something you enjoy and something positive. Also, try not to make the tinnitus a central focus of your day-to-day activities. Get off tinnitus list servs, leave the tinnitus Facebook groups, and stop Googling potential cures. The patient now has you as a resource.

19. You mentioned addressing lifestyle. How do we do that?

Keep in mind that things like eating healthy and exercising will not cure tinnitus. But, they are also not going to make it worse.  Eating healthy, exercising, improving sleep hygiene can all help improve overall health, reduce stress levels, and potentially reduce the risk for further hearing loss—something I talked about here at 20Q a few years back (access those articles here and here). I tell the patients, if you want to view the tinnitus as an alarm, fine.  View it as an alarm to start taking better care of yourself and enjoying life. If you feel better, lose a little weight, are getting out more, and engaging more in your life, guess what you will not notice as much? Now granted, this approach doesn’t always help, but ask yourself how often have you seen a tinnitus patient that is a vegan, marathon-running, yoga fanatic?

20. You really think I can implement all this in my practice?

To quote the movie “Waterboy”, “You can do it.” First, the majority of your patients likely have tinnitus, though it may be a minimal factor in their lives (only about 20-25% of persons with tinnitus have issues with it). Begin to discuss these concepts with this group of patients as preparation to apply your skills to more complex cases.

Second, you need to do your homework: 1.) Read up on the neuroscience of tinnitus and on various management approaches. 2.) Watch online training material on the topic. 3.) Attend workshops and professional meetings with tinnitus topics. 4.) Find a colleague that is more advanced in tinnitus management and see if you can shadow him or her. 

Third, if a case seems above your skillset, when in doubt, refer out.  

References

Duckert, L.G., & Rees, T.S. (1984). Placebo effect in tinnitus management. Otolaryngol Head Neck Surg, 92(6), 697-699. doi:10.1177/019459988409200618

Heller, M.F., & Bergman, M. (1953). Tinnitus aurium in normally hearing persons. Ann Otol Rhinol Laryngol, 62(1), 73-83. doi:10.1177/000348945306200107

Henry, J.A., Griest, S., Zaugg, T.L., Thielman, E., Kaelin, C., Galvez, G., & Carlson, K.F. (2015). Tinnitus and hearing survey: a screening tool to differentiate bothersome tinnitus from hearing difficulties. Am J Audiol, 24(1), 66-77. doi:10.1044/2014_AJA-14-0042

Henry, J.A., Stewart, B.J., Griest, S., Kaelin, C., Zaugg, T.L., & Carlson, K. (2016). Multisite randomized controlled trial to compare two methods of tinnitus intervention to two control conditions. Ear Hear, 37(6), e346-e359. doi:10.1097/AUD.0000000000000330

Henry, J.A., Zaugg, T.L., & Schechter, M.A. (2005). Clinical guide for audiologic tinnitus management I: Assessment. Am J Audiol, 14(1), 21-48. doi:10.1044/1059-0889(2005/004)

Henry, J.A. & Meikle, M.B. (2000). Psychoacoustic measures of tinnitus. J Am Acad Audiol, 11(3), 138-155.

Henry, J.A., McMillan, G., Dann, S., Bennett, K., Griest, S., Theodoroff, S., Silverman, S.P., Whichard, S., & Saunders, G. (2017). Tinnitus management: Randomized controlled trial comparing extended wear hearing aids, conventional hearing aids, and combination instruments. J Am Acad Audiol, 28(6) 546-561.

Jastreboff, P.J., & Jastreboff, M.M. (2000). Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol, 11(3), 162-177.

Jastreboff, P.J. & Hazell, J.W. (1993). A neurophysiological approach to tinnitus: clinical implications. Br J Audiol, 27 (1) 7-17.

Kochkin, S., Tyler, R., & Born, J. (2011). MarkeTrak VIII: The prevalence of tinnitus in the United States and the self-reported efficacy of various treatments, Hearing Review, 18 (12), 10-27.

Meikle, M.B., Henry, J.A., Griest, S.E., Stewart, B.J., Abrams, H.B., McArdle, R., . . . Vernon, J.A. (2012). The tinnitus functional index: development of a new clinical measure for chronic, intrusive tinnitus. Ear Hear, 33(2), 153-176.

Newman, C.W., Sandridge, S.A., & Jacobson, G.P. (1998). Psychometric adequacy of the tinnitus handicap inventory (THI) for evaluating treatment outcome. J Am Acad Audiol, 9(2) 150-160.

Ryan, D., & Bauer, C.A. (2016). Neuroscience of tinnitus. Neuroimaging Clin N Am, 26(2), 187-196.

Scherer, R.W., Formby, C., & Tinnitus Retraining Therapy Trial Research Group (2019). Effect of tinnitus retraining therapy vs standard of care on tinnitus-related quality of life: a randomized clinical trial. JAMA Otolarngyol Head Neck Surg, epub.

Searchfield, G.D., Kaur, M., & Martin, W.H. (2010). Hearing aids as an adjunct to counseling: tinnitus patients who choose amplification do better than those that don't. Int J Audiol, 49(8), 574-579. doi:10.3109/14992021003777267

Theodoroff, S.M., McMillan, G.P., Zaugg, T.L., Cheslock, M., Roberts, C., & Henry, J.A. (2017). Randomized controlled trial of a novel device for tinnitus sound therapy during sleep. Am J. Audiol, 26(4) 543-554.

Tyler, R.S., Gogel, S.A., & Gehringer, A.K. (2007). Tinnitus activities treatment. Prog Brain Res,166,425-434. doi:10.1016/S0079-6123(07)66041-5

Tyler, R.S., Perreau, A., Powers, T., Watts, A., Owen, R., Ji, H., & Mancini, P.C. (2019). Tinnitus sound therapy trial shows effectiveness for those with tinnitus. J Am Acad Audiol, epub.