Robert E. Sandlin,
Ph.D.
Adjunct Professor of Audiology
San Diego State University
San Diego, California
and
Robert J. Olsson, M.A.
Clinical Director
California Tinnitus & Hyperacusis Therapy Center
San Diego, California
Introduction:
Fifty million Americans experience some form of
tinnitus. Twelve million have sought professional
intervention. Tinnitus is a significant and common
problem across the USA. For individuals with tinnitus,
something is occurring within the auditory system, or
elsewhere in the neural pathways, which gives rise to
the perception of an acoustic-like sensation, for which
there is no known external cause. There are two types of
tinnitus; objective tinnitus, wherein the patient and
the practitioner can hear the ongoing tinnitus, and,
subjective tinnitus, heard only by the patient. By far,
the most prevalent of the two is subjective tinnitus.
Some estimates indicate that 95 percent of all tinnitus
is subjective.
Since the audiologist has interest in conditions and
anomalies that affect the auditory system, and since
tinnitus is such a condition, it seems logical that our
scope of training should provide differential diagnostic
and therapeutic intervention management for tinnitus.
However, many audiologists do not have an extensive
background in the clinical management of tinnitus. This
is not an indictment of audiologists as a professional
body. Audiologists have strong clinical backgrounds in
the assessment of hearing loss with regards to the type
and degree of hearing loss, diagnostic testing and
interpretation, prevention of hearing loss and in the
provision of rehabilitative practices and devices for
the hearing impaired. Tinnitus management is a
relatively new arena for the audiologist and therefore,
this paper serves to explore some of the issues
associated with tinnitus management by the audiologist.
Based on a thorough understanding of tinnitus, a
definitive and defensible audiologic diagnosis can be
made and a plan of rehabilitation formulated. It is not
the purpose of this article to encourage audiologists to
consider clinical involvement with tinnitus patients.
Rather, our purpose is to offer an overview of major
therapeutic approaches used in the treatment of this
disorder.
At this time, there is no single therapeutic approach to
the treatment of tinnitus that is sufficiently
compelling to warrant its exclusive use above all
others. There are no test batteries for tinnitus that
provide reliable, clinical predictors of cause or
treatment. Perhaps this uncertainty keeps many
audiologists from being involved in treating the
tinnitus patient. For others, the obstacle may be the
depth of the psychic involvement of tinnitus sufferers
with their condition, for tinnitus is as much an
emotional issue as it is a 'hearing' issue.
Three Realities in Tinnitus Treatment:
There are three realities that one must be aware of in
the treatment of tinnitus. First, there is no consensus
as to what causes the problem. This is not to suggest
that a rational answer for the mechanisms of tinnitus is
not of interest, but rather that is not germane to our
discussion of tinnitus treatment. Second, there is no
known cure. Third, all present forms of therapeutic
intervention treat the symptoms of the disorder, not the
cause of the disorder.
Given these clinical limitations, what are the current
therapeutic practices used by those who treat the
tinnitus patient? Rather than offering an exhaustive
analysis of each modality, we will discuss specific
approaches related to both medical and non-medical
intervention processes. Parenthetically, it has been our
observation that the therapeutic modality chosen is most
often determined by the professional and clinical
backgrounds of the practitioner. Medical models seem to
be supported by physicians. Non-medical models appear to
be supported by other non-physician professionals. For
example, psychologists rely on counseling, whereas
audiologists generally employ some form of
sound/auditory therapy.
Medical Management:
Medical models typically include the use of drugs to
attempt to control the subjective loudness of the
ongoing tinnitus, or (more commonly) to reduce the
intensity of the patient's response to it. For the most
part, specific drugs seem to be the medical treatment of
choice. Anti-anxiety and anti-depression medications
reduce negative behaviors brought on by the presence of
tinnitus. Other drugs used in the treatment process may
include lidocaine, tocanide (oral cognate of lidocaine),
Lasix, Misolene, Tegratol and others. Sandlin and Olsson
(1999) reviewed the value of drug use and the risks
assumed by the patient.
To date, there is no large body of evidence that
warrants adapting one particular form of drug therapy.
Each of the drugs mentioned above has proven beneficial
to some. The general wisdom suggests that drugs
constitute an ongoing process that permit the patient to
derive some prolonged benefit. Brummet (1997) cautions
the practitioner about possible consequences of drug use
to control tinnitus. Most patients are treated with
non-medical approaches.
Surgical Management:
Some, but very few, physicians have previously elected
to perform surgery to eliminate or reduce or control
tinnitus. Surgical management of tinnitus has not
produced consistent, acceptable results. Surgically
sectioning the auditory nerve of the offending ear, more
often than not, does not solve the problem. For some,
the subjective loudness of the tinnitus, as perceived in
the post-operative period, is the same. For others, the
tinnitus is exacerbated. Another form of surgical
control of tinnitus involves microvascular surgery to
eliminate or reduce vascular compression (i.e.'vascular
loops') in the area of the VIII cranial nerve, theorized
by some to be a frequent cause of tinnitus (Vernon,
1998). Another surgical approach involves direct
electrical stimulation of structures deep in the brain
(Shi & Martin, 1999).
Non-Medical Management:
Although there are many non-medical treatment
modalities, only a few have received widespread
acceptance The three most common, and most promising,
non-medical methods of treatment are masking, tinnitus
retraining therapy (also known as habituation therapy)
and cognitive therapy. Alternative non-medical
treatements include; biofeedback, psychological
counseling, nutritional controls, acupuncture, gingko
biloba, and Vitamin B 12. For an overview and
comprehensive listing of herbs and vitamins purported to
assist in the management of tinnitus, the reader is
referred to the March 2000 issue of Tinnitus Today,
published by the American Tinnitus Association (ATA). It
should be noted that gingko biloba, despite its
enthusiastic cohort of supporters, has been rather
clearly shown to have no more benefit than a placebo
(Drew & Davies, 1999). For a more comprehensive overview
of treatment, the reader is referred to the book by
Vernon (1998), Tinnitus - Treatment and Relief,
available from the ATA (published by Allyn and Bacon).
Maskers and Combination Devices:
Masker use, as described by Dr. Jack Vernon, (1977,
1978, 1979, 1981) has proven to be effective for some,
but not for all. Masking involves using an external
signal (i.e., masking noise) sufficient to mask or
'cover' the ongoing tinnitus. The rationale is that an
external acoustic stimulus is easier for the patient to
ignore than the constant, ongoing tinnitus. Johnson
(1998) reported the use of masker devices was effective
about 35 to 40% of the time for those who investigated
their use. Although not an impressive number in
isolation, tinnitus sufferers who were in the 35 to 40%
group find masker devices to be a godsend.
A combination device, an instrument containing both a
hearing aid and a noise generating circuit, increased
success rates to about 70%. That is, for those tinnitus
patients having tinnitus and hearing loss sufficient to
interfere with speech understanding, the combination
device provided more relief than a masker device alone.
The combination device also provided more relief than a
hearing aid alone.
Maskers and combination devices continue to be used by
tinnitus patients, suggesting that these instruments
continue to be a valuable therapeutic modality, which
provides relief and reduces the high stress level often
associated with tinnitus.
Tinnitus Retraining Therapy
Dr. Pawel Jastreboff
(www.tinnitus-pjj.com/) is recognized as the person
who conceived and popularized the use of Tinnitus
Retraining Therapy. In essence, Dr. Jastreboff
postulated that acoustic, or acoustic-like perceptions,
could be habituated to if they were not considered to be
a harbinger of disease, danger or mental stress. For
example, grandfather clocks ticks day in and day out.
Yet those who live in a house with a grandfather clock
have habituated to its ticking. Literally, they do not
perceive it. Similarly, the refrigerator motor goes on
and off many times during the day, yet one is not
consciously aware of it. If you are sitting in front of
a computer as you read this, you are probably not aware
of its cooling fan. This ability to habituate to a
number of sensory experiences is an integral part of
human behavior.
Jastreboff's (1987, 1994a, 1994b, 1990) account of the
model goes something like this:
First, there is the perception of the stimulus. At the
cortical level, a decision is made as to whether overt
action of any kind is mandatory. If the conscious brain
deems the stimulus does not demand some purposeful
behavior, it can be habituated to (i.e., dismissed) if
there are frequent occurrences of the same stimulus.
Suppose, however, that tinnitus serves as the stimulus?
The conscious brain attempts to make some rational
decision. 'Have I heard this before? What causes it? Is
it some sort of precursor indicating I am going deaf? Do
I have a serious disease? I haven't heard this sound
before and I must attend to it until I understand its
cause.' The cortex, failing to find an answer for the
tinnitus' presence, labels the sound a threat. The
limbic system (the brain's emotional control system) is
thus alerted and activated to the tinnitus, and the
tinnitus becomes a more significant problem for the
patient.
Emotional involvement with tinnitus can produce
psychological and physiological behaviors. Sleep
disturbance, irritability, anger, loss of concentration
and anti-social consequences are often reported. If
these negative behaviors produced by the limbic system
persist over time, then the autonomic nervous system may
also become involved.
A self-perpetuating cycle of events takes place in the
brain. The subconscious brain continues to maintain the
conscious brain's awareness of the tinnitus. The
conscious brain continues to involve the subconscious
brain, including the limbic and autonomic nervous
systems, as it seeks a resolution that is not
forthcoming. This cycle, in turn, serves to increase the
subjective loudness and importance of the perceived
sound.
Jastreboff suggests two things that are important in the
control of the tinnitus:
1- The patient must habituate to the tinnitus itself,
and
2- The patient must habituate to the emotional
consequences of the tinnitus.
To habituate to the tinnitus, it is necessary to reduce
the contrast between the ambient noise level and the
subjective level of the ongoing tinnitus. To accomplish
this task, bilateral noise generators are used These are
acoustically similar to, but much quieter than, tinnitus
maskers. Depending on the individual patient
requirements and categorization, the level of the noise
produced by the generators may be increased equal to the
loudness of the tinnitus. This makes it more difficult
for the conscious brain to concentrate on the ongoing
tinnitus.
To habituate to the emotional consequences, directive
counseling is used. The essence of this directive
counseling, according to Jastreboff, is to make certain
the patient understands what tinnitus is, demystifies it
as much as possible, and realizes that it not an
indicator of a serious physical or psychological
problem. To achieve this change of thinking, it is
necessary to reinforce one's understanding of the
disorder. To do so, the patient must be adequately
counseled. This is accomplished through a prearranged
and individually scheduled series of follow-up
appointments wherein the clinician and the patient
review the patient's current status.
Jastreboff maintains that the Tinnitus Retraining
Program treatment program typically achieves its
greatest success within 18 to 24 months. Importantly,
this does not mean that nothing positive happens until
then. Rather, it indicates that it probably will take 18
to 24 months to achieve maximal results.
Clinics throughout the world, our own included, report
success rates in the 80-90% range with tinnitus
retraining therapy. Success is determined by the
following criteria:
1. Tinnitus awareness is reduced by 20%.
2. The impact of tinnitus on the quality of life is
reduced 20%.
3. Tinnitus annoyance is decreased by 20%.
The success criteria listed above represent minimal
levels of improvement. The majority of patients exceed
the 20% level of change.
Cognitive Therapy
One of the common threads found in therapeutic
approaches to tinnitus treatment is the effective use of
counseling intervention. One such counseling
intervention process is Cognitive Therapy. 'Cognition'
refers to thought processes. 'Therapy' refers to some
form of management intended to create change in the
thinking process. Therefore, the purpose of cognitive
therapy is to alter the negative thinking of the patient
and bring about a more realistic assessment and
understanding of the problem. Sweetow (1986) reports on
management of the tinnitus patient using cognitive
therapy as a therapeutic base.
Dr. David Burns (1980) is to be given much of the credit
in the development of Cognitive Therapy. Cognitive
Therapy is a form of behavioral modification. The
practitioner attempts to modify the ways in which the
patient may react to his or her tinnitus. Dr. Burns
coined the phrase 'cognitive distortions.' These
distortions are defined in the following ways:
1. All or nothing thinking: If performance falls short
of perfect, you see yourself as a total failure.
2. Overgeneralization: You see a single negative event
as a never-ending pattern of defeat.
3. Mental Filter: You see a single negative detail and
dwell on it exclusively.
4. Disqualifying the positive: You reject positive
experiences by insisting that for some reason or
another, they don't count.
5. Jumping to conclusions: You make a negative
interpretation of a particular event,although there is
no evidence to support the negative conclusion.
6. Magnification: You exaggerate the importance of
things or events.
7. Emotional reasoning: You think your negative emotions
reflect the way things really are.
8. Should statements: You try to motivate yourself with
should or shouldn't statements.
The emotional consequence is guilt.
9. Labeling and mislabeling: Instead of describing your
action as an error, you attach a negative label, such as
'I'm no good,' to yourself
10. Personalization: You see yourself as the cause of
some negative event, even though you were not.
It is evident that these distortions of thinking tend to
perpetuate the patient's negative behaviors. Failure to
modify cognitive distortions can have undesirable
consequences and lead to destructive behaviors. Although
Cognitive Therapy was not intended primarily for
tinnitus patients, it has been useful in their
counseling process.
Whether, and to what extent, audiologists should be
involved in cognitive therapy with tinnitus patients is
a controversial topic. There are strong arguments both
for and against. On the one hand, audiologists, more
than anyone else, understand the auditory system, and
provide hearing system rehabilitation. Furthermore,
audiologists engage in counseling routinely. All aural
rehabilitation beyond the provision of hearing aids is
by definition counseling. The hearing aid fitting
process itself involves counseling. On the other hand,
audiologists generally do not have explicit training in
emotionally centered counseling, and need to work within
their scope of practice and licensure.
Summary
The incidence of tinnitus is rather high. Early on,
there was little interest in the clinical management of
this disorder. That is changing. Increased awareness and
interest, spurred on by the American Tinnitus
Association, have contributed greatly to the number of
clinicians, audiologists included, providing therapeutic
programs.
Although the cause, or causes, of tinnitus is unknown,
treating the symptoms of the disorder has been
beneficial. Even though there is no one absolute
therapeutic approach or treatment modality, there are
medical and non-medical intervention programs, which
have proven to be of significant value. It is no longer
defensible to tell a patient to 'go home and learn to
live with it.'
We are convinced that audiologists will find clinical
and research challenges in working with the tinnitus
patient. However, if the audiologist is to diagnose and
manage those with tinnitus, we strongly recommend that
he or she seek sufficient academic and clinical training
prior to the provision of service. Reading a few
articles is a wholly inadequate preparation. In
particular, attempting to implement tinnitus retraining
therapy without proper instruction can leave the patient
in a worse condition.
We feel that at some future date a cure will be found
for tinnitus. It is quite possible that the cure will
come in the form of specific drugs, which are effective
in altering neurochemical behaviors that reduce or
eliminate the onset or awareness of tinnitus without the
serious side effects of the medications now sometimes
employed. We also believe that a compelling therapeutic
approach will emerge.
Regardless of what the future holds, there is a current
need to provide treatment for those who suffer from this
disorder and seek relief. As individuals who have worked
with the tinnitus patient for
several decades, the authors can say without fear of
contradiction that providing tinnitus management therapy
is a demanding challenge that can stimulate your
clinical and intellectual abilities and can greatly
impact and improve the quality of life of your patients.
Direct correspondence or inquiries to:
Robert J. Olsson, M.S. Ed., M. A., Au.D. Candidate, FAAA
California Tinnitus & Hyperacusis Therapy Center
6505 Alvarado Road, Suite 103
San Diego, California 92120
(619) 583 6612
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