Tinnitus Clinical Practice Guidelines from American Academy of Otolaryngology, Head and Neck Surgery Foundation: What Audiologists Should Know

Carolyn Smaka: Thanks for your time today, Rich.  You were part of the panel that authored the new tinnitus clinical practice guidelines from the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF).  It was great to see your name – along with audiologists Jim Henry and Craig Newman – as part of that panel.  The list of authors looked like quite a collaboration among disciplines.

Rich Tyler:  Yes, it was an important collaboration, not just in producing the guidelines, but also in the overall management of tinnitus patients.  As you mention, these guidelines are coming from AAO-HNSF, a medical professional association, and many of the recommendations and referrals in the document include audiologists.  Tinnitus care is a great opportunity for otolaryngology and audiology to work together as highlighted by the guidelines. 

Carolyn:  Can you give us an overview of what’s in the guidelines?

Rich:  The guidelines are quite comprehensive, and cover many of the options considered for evaluating and treating tinnitus patients.  They include a systematic and reasonable approach to reviewing the literature, and consider multiple points of view and strategies that have been developed over the years.  The guidelines come out in strong favor of an audiological evaluation.  They also come out very strongly in favor of providing brochures, self-help books, sound therapy devices, and hearing aids for patients bothered by their tinnitus.

Carolyn: What kind of impact do you think these guidelines will have?

Rich: These guidelines will inform not only otolaryngologists, but also other physicians in general, about how we can help their tinnitus patients.  Too often tinnitus patients are still told, “There’s nothing that can be done” for them, and that is not true.  These guidelines should help steer the medical profession to make referrals for their patients with tinnitus, either to an otologist when there are medical concerns, or to an audiologist when there are not. 

Carolyn: Is there anything new or surprising in the guidelines in terms of audiological management strategies?

Rich: The audiological management strategies for measuring and managing tinnitus, interestingly, have not changed much since the 1980s (e.g., Tyler & Babin, 1986; Tyler & Bentler, 1987; Bentler & Tyler, 1987; Tyler, Schum & Stouffer, 1989). Generally, someone that has tinnitus should receive a very thorough audiological work-up. Hearing aids should be recommended when appropriate, because they often help tinnitus patients.  Sound therapy can be helpful for many.   In the last few years, a variety of different sounds are now available from many manufacturers.  This is very important, because it gives patients choices.  Individual differences for choosing calming background sounds can vary widely amongst patients.  Although the guidelines indicate that there is not strong evidence from controlled studies showing the benefit of sound therapy, they went ahead and recommended that it should be considered anyway.  I think the evidence is lacking because some of the trials have not been well done or have used inappropriate sound therapy techniques (for example, some with too high-levels of partial masking).  Regardless, the recommendation is to consider sound therapy for patients with tinnitus. This is good.  We can help many patients with sound therapy.

The guidelines also indicate that there is evidence supporting the use of self-help books.  There are several self-help books available for tinnitus patients including the Consumer Handbook on Tinnitus, Tinnitus: A Self-Management Guide for the Ringing In Your Ears, Davis (1995), and others. They provide a level of detail and background for tinnitus patients and their partners that would not be available in brief diagnostic counseling sessions.  These books can sometimes educate the clinician wanting to learn more about tinnitus as well.

Carolyn: What about non-audiological treatments or management?  Any word on things like acupuncture or dietary supplements, for example?

Rich: The guidelines say that there is no recommendation with respect to acupuncture.  There were some people on the panel that thought it was helpful, but others who did not find any support for it.  Therefore, the guidelines did not come to any conclusion about acupuncture. 

The guidelines recommend not prescribing medications and not prescribing dietary supplements to treat tinnitus.  In my experience, there are some physicians who do prescribe medications or supplements.  They feel that it is worth a try as long as it is not harmful, and it is better than having nothing to offer a patient who may feel overwhelmed. Perhaps there are some subgroups that do benefit from some pills.  However, one should keep in mind that some medications and supplements have undesirable side effects.   Additionally, some tinnitus sufferers continually search for that magic pill, never accepting and dealing with their tinnitus. Overall, members of the committee believe that there is no evidence supporting any dietary supplement or medicine at this point.  They are very clear about not recommending it.  Although the practice of prescribing these things has been accepted for many years by some physicians, they might now feel more comfortable saying no to medications and dietary supplements.

Carolyn: I’m sure the diverse panel had differing points of view on some of the topics.

Rich:  Yes, and that is not uncommon when you have a diverse committee or task force.  For me, I thought that some of the terminology in place is going to be confusing.  For example, the guidelines make a distinction between tinnitus masking therapy versus Tinnitus Retraining Therapy.  For me, Tinnitus Retraining Therapy is a masking therapy.  Tinnitus masking therapies can include total masking or partial masking.  Tinnitus Retraining Therapy is a partial masking therapy - it uses a high level of partial masking at the mixing point.

Carolyn: What are some other key things for audiologists to know about these guidelines?

Rich: I think it is important to note that counseling is recommended by the guidelines, and that the counseling procedure that has received the most scientific rigor is Cognitive Behavior Therapy.  Cognitive Behavior Therapy was introduced for use with patients with tinnitus by audiologist Robert Sweetow.  That is a good indication that we as audiologists have been providing effective counseling for tinnitus patients. Cognitive Behavior Therapy helps people challenge their thoughts and beliefs, and experience behavior modification techniques that can change the way they think and react to their tinnitus.  Psychologists on the panel provided details about one application of Cognitive Behavior Therapy in the guidelines outlined in an 8 week program.  

There are now several different counseling procedures available for tinnitus, and many of these include the essential components of Cognitive Behavior Therapy.  For example, we developed Tinnitus Activities Treatment that uses Cognitive Behavior Therapy to focus on four areas, depending on individual needs:  thoughts and emotions, hearing, sleep, and concentration.  If someone does not have any sleep problems, they do not get the module focused on sleep.  The Tinnitus Activities Treatment can be implemented in 2 to 6 sessions, instead of 8 sessions for Cognitive Behavior Therapy, and has the potential to be more effective as well, since it focuses on those specific categories. 

These guidelines represent an important summary of a critical evaluation of the evidence supporting different strategies. It emphasized that many things an audiologist can provide – such as counseling, hearing aids and sound therapy – can help these patients.  It sends a message to the medical community about the work that we do and I know we will see more referrals from the medical profession to help these patients.

Carolyn: Excellent.  So it sounds like the guidelines shouldn’t contain any surprises for audiologists?

Rich: That’s right. But we should expect more referrals and we should prepare ourselves to help our tinnitus patients.

Carolyn:  Thanks for that summary, Rich.  Audiologists can access the guidelines here.  You do not have to be a member of the journal to access them.

Rich: Thanks for having me.

References

Bentler, R.A., & Tyler, R.S. (1987). Tinnitus management.  ASHA, 29(5), 27-32.

Davis, P.B. (1995). Living with tinnitus.  Sydney, Australia: Gore & Osment Publications.

McKenna, L., Baguley, D., & McFerran, D. (2010). Living with tinnitus and hyperacusis [Kindle edition]. London: Sheldon Press. 

Tunkel, D.E., Bauer, C.A, Sun, G.H., Rosenfeld, R.M., Chandrasekhar, S.S., Cunningham, E.R.,...Whamond, E.J. (2014).  Clinical practice guideline: Tinnitus. Otolaryngology-Head and Neck Surgery, 151(2S), S1-S40.

Tyler, R.S. (Ed). (2008). The consumer handbook on tinnitus. Auricle Inc., Sedona

Tyler, R.S., & Babin, R.W. (1986). Tinnitus.  In:  C.W. Cummings, J.M. Fredrickson, L. Harker, C.J. Krause & D.E. Schuller (Eds.), Otolaryngology - head and neck surgery (pp. 3201-3217). St. Louis: C.V. Mosby Co.

Tyler, R.S., & Bentler, R.A.  (1987). Tinnitus maskers and hearing aids for tinnitus. Seminars in Hearing, 8(1), 49‑61.

Tyler, R.S., Stouffer, J.L., & Schum, R.  (1989).  Audiological rehabilitation of the tinnitus client.  Journal of the Academy of Rehabilitative Audiology, 22, 30‑42.