Tinnitus is an invisible condition affecting 10 percent to 15 percent of adults (Hoffman and Reed, 2004). Chronic tinnitus is defined as the persistent perception of sound when there is no external source (Jastreboff, 1990). It generally is accepted that tinnitus is manageable and not bothersome for about 80 percent of those who experience it (Davis and Refaie, 2000; Hoffman and Reed, 2004; Jastreboff and Hazell, 1998). That is, most people who experience tinnitus tend to ignore it and are not interested in receiving specialized clinical services. For the remaining 20 percent, however, tinnitus disturbs sleep, impairs concentration, and/or causes negative emotional reactions—all to different degrees. These 20 percent are the ones in greatest need of clinical services (Figure 1). People with tinnitus most likely have had noise exposure that caused peripheral auditory damage, resulting in both tinnitus and hearing loss (Axelsson and Barrenas, 1992). And that is where we, the audiologists, come in.
The Role of the Audiologist
Audiologists across the nation are inundated with the number of patients seeking help for tinnitus complaints. Tinnitus care should include evaluation, management, and follow-up of patients’ symptoms; however, we may not have been trained adequately in our graduate programs to know how to treat a tinnitus patient and may be unaware of clinical resources that are available. In addition, we’re bombarded with a plethora of new products, devices, and “cures” that will fit every tinnitus patient type. Although many therapies for tinnitus are available, most do not have the support of rigorous scientific research. There is no cure for tinnitus, and, despite claims that are ubiquitous on the Internet, no method has been shown to permanently suppress the perception of tinnitus. To help patients, it is therefore necessary to mitigate the functional effects of tinnitus (Davis and Refaie, 2000). Where do we get this information, though?
As audiologists, it is emphasized that we are to provide clinical care based on scientific evidence. But what does this really mean? And how do we differentiate “strong” from “weak” evidence? Figure 2 shows the different levels of evidence—the bottom step indicating the weakest and the top step being the strongest level (Liddle et al, 1996). Anecdotal evidence is labeled weak evidence, but that’s not to say it is not valuable information, especially with respect to tinnitus. We rely heavily on our patients to tell us how they react to their tinnitus, which suggests how to design their best management options. This type of evidence is especially important when providing patient-centered care.
Audiologist opinions are extremely valuable when considering clinical tinnitus care options—as clinicians, we develop a sense of what will or will not work for a particular patient. Taking this into account, we can’t fully rely on gut-level opinion to care for our patients. Moving up the steps, we get to case reports and then observational studies. These provide good descriptive and qualitative information for us as clinicians, but we need to remember these types of studies might be describing atypical features identified in one person or summarizing a sample population. Our next step includes clinical trials, such as randomized controlled trials (RCTs) or masked trials, which provide strong evidence in support of a particular treatment or management because they minimize bias. This is important! The different comparison groups of these types of studies allow researchers to determine any effects of treatments with control groups, which eliminate alternate explanations, or experimental results that could result from experimental errors or experimenter bias. Clinical trials are considered the gold standard and are used to test efficacy and effectiveness of interventions. This is what we need, right?
At the topmost step sits systematic reviews. These are a type of literature review that use precise methods to collect and assess research studies, and then, synthesize their findings. Systematic reviews provide a complete and exhaustive summary of every piece of current and relevant information. We need these reviews to tell us what we should be considering or not considering for our patients. We’ve made it to the top—great! Now where do we go?
Here Is What We Know
A wealth of information is available from systematic reviews, RCTs, and clinical practice guidelines for tinnitus that can direct our care plans. This includes the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) guidelines (Tunkel et al, 2014), reviews of all existing guidelines to date (Fuller et al, 2017), relevant Cochrane reviews (e.g., Hobson et al, 2010; Martinez-Devesa et al, 2010), and recent RCTs (e.g., dos Santos et al, 2014; Henry et al, 2017a and 2017b). I’ve summarized the main points from these articles for you here and in an upcoming American Journal of Audiology article, Henry and Manning (in press).
Tinnitus in 10
So, what do we do for that 20 percent of the population with tinnitus that seeks our help? How can we provide research-based tinnitus care despite the overwhelming amount of information thrown our way?
Here are 10 ways you can implement this research evidence for tinnitus care in your clinic.
1. Perform a Case History
I know what you’re thinking—well, of course I’m going to do this. It goes without saying that it is critical for tinnitus patients to be able to speak about what they are perceiving and how they are feeling. Not only does a thorough case history give us details as to other medical or hearing concerns, it helps patients become involved in their own care. Our best information comes from the patients themselves, and they are, in fact, collaborators in determining the best course of clinical action. No case history model is better than any other. Langguth et al (2007) described a sample case history that includes questions about tinnitus onset, perception, and manifestation.
Modifying questionnaires such as this one to suit your clinical needs is encouraged. In general, the case history should address pulsatile, unilateral, or recent-onset tinnitus, hearing complaints (especially asymmetric, unilateral, or sudden-onset hearing loss), exposures to noise or ototoxic medications, balance disorders, emotional disorders, cognitive difficulties, and insomnia (Tunkel et al, 2014).
2. Define Your Patients’ Tinnitus Type
Tinnitus has different connotations that need to be distinguished due to their clinical implications. What does it truly mean when a patient says, “I have tinnitus?” As clinicians, we need to break their perception down into duration and temporal manifestations. Duration refers to how long they have experienced tinnitus. Temporal manifestations refer to the timing of how they hear the tinnitus. We all experience spontaneous tinnitus, that sudden-onset tone that usually lasts less than a minute. This is normal. Others experience temporary, occasional, intermittent, or constant tinnitus. These individuals need to be screened as to which type they have. Why? This is important to decide if an ear, nose, and throat (ENT) physician referral is warranted, what types of tests should be performed, and what type of management options might be of benefit (Henry et al, 2016).
A great tool to use when defining a patient’s tinnitus type is the Tinnitus Screener (Henry et al, 2016). A summary of these five categories is given in Figure 3. The Tinnitus Screener is short, quick, and efficient, and can be included as part of the case history.
3. Distinguish Between Primary and Secondary Tinnitus
More than 50 million people in the United States have reported experiencing tinnitus, and of that number, an estimated 12 million seek medical intervention (Tunkel et al, 2014). The great majority of those patients reporting tinnitus and seeking help have primary tinnitus, i.e., tinnitus that is idiopathic and may/may not be associated with sensorineural hearing loss (SNHL) (Tunkel et al, 2014).
Some patients have tinnitus suspected as secondary, i.e., the tinnitus appears to be associated with an identifiable underlying cause (other than SNHL) or organic condition. Secondary tinnitus can be associated with auditory system disorders (e.g., cochlear abnormalities including Meniere’s disease, middle-ear diseases including otosclerosis and Eustachian tube dysfunction, or cerumen impaction) or nonauditory system disorders (e.g., intracranial hypertension, myoclonus, or vascular anomalies causing pulsatile tinnitus).
Remember the tinnitus screener? This little tool will help you define the type of tinnitus and give you indications of secondary tinnitus (refer to Figure 3). Once categorized, the screener helps to steer you toward primary or secondary tinnitus. For example, individuals categorized as temporary and occasional tinnitus should be asked about events or situations that cause the tinnitus onset, which might indicate secondary tinnitus. Intermittent and constant tinnitus may be more associated with SNHL. Along with your case history, you’ll be able to decide if this is an auditory or medical concern. If medical, refer to an ENT.
4. Identify the True Problem
Oftentimes, our patients may think they have a true, primary concern of tinnitus. Have you ever heard “I can’t hear during group conversations because of my tinnitus” from one of your patients? If so, the patient has determined that this is a tinnitus problem, not a hearing problem. We need to help them identify the true difficulty. The Tinnitus and Hearing Survey (THS) is another quick tool that helps to distinguish a tinnitus problem from a hearing problem (Henry et al, 2015b). The THS contains three sections. Section A has four items that address the most common tinnitus problems and are written so as not to be confused with a hearing problem. Section B focuses on four possible hearing concerns that would not be confused with a tinnitus problem.
It should be noted that the scores obtained for Sections A and B should not be used for decision making. Rather, these scores, combined with the audiologic assessment, provide the information needed to determine what services might be appropriate for the patient with respect to both tinnitus and hearing loss. The THS further provides two items (Section C) to screen for a sound tolerance problem (hyperacusis and/or misophonia).
5. Perform an Audiological Evaluation
I don’t have specific rules for you here. You, the audiologist, are the expert, so perform the tests you believe will help you decide the best path for your patient’s management. The systematic reviews and clinical guidelines all state that an evaluation should occur to assess the whole health of the patient. Because up to 90 percent of individuals with tinnitus also have hearing loss (Johnson, 1998; Schechter et al, 2002), any patient reporting tinnitus should receive an audiologic assessment. Any hearing problems should be addressed before providing intervention for bothersome tinnitus. All of the information you’ve collected so far in your case history, tinnitus screener, and THS, in conjunction with your evaluation, will now prepare you, and your patient, for the treatment discussion.
6. Use Hearing Aids
Randomized controlled trials have confirmed what audiologists already know: bothersome tinnitus is mitigated often through the use of hearing aids for those with hearing loss (dos Santos et al, 2014; Henry et al, 2015a; Henry et al, 2017a). Bothersome tinnitus is normally the secondary reason to fit hearing aids, but in some cases, it can be the primary reason. Although research has not proved the value of hearing aids as intervention for patients who have bothersome tinnitus but are not hearing aid candidates, anecdotal evidence is fairly abundant that this may be effective.
Remember that clinical trials are needed to support a particular intervention. Good news—studies are in progress to test this anecdotal evidence. Regardless of whether these patients receive hearing aids, they should receive basic information about tinnitus during the appointment, and brief tinnitus counseling as time allows. Patients who receive hearing aids should be asked during their follow-up appointment if they would like to receive intervention for the types of problems described in the THS Tinnitus section (Section A). If they don’t receive hearing aids, intervention should be discussed following any counseling they receive.
7. Focus on the Patient when Choosing Treatment
This is always the biggest question—what is the best treatment option for tinnitus? As mentioned earlier, there are a plethora of treatment options on the market just waiting to “cure” someone’s tinnitus. Unfortunately, there is no evidence of any treatment that eliminates, or even reduces, the perception of tinnitus. According to systematic reviews, Cognitive Behavioral Therapy (CBT) is considered the most evidence-based method of tinnitus intervention (Hobson et al, 2010; Martinez-Devesa et al, 2010). CBT should be provided by a specialist, particularly one who specializes in tinnitus management; therefore, if this is decided as a viable option between you and your patient, a referral will be needed to an appropriate mental health provider, as this is not within our scope of practice. Sometimes a patient does not feel CBT is a good option for them and that is okay. Look back at the evidence you have gathered and decide with the patient what they should try. It is very possible that hearing aids will be the only management option they need. Another patient might need CBT and/or sound therapy. Whatever the decision, make sure it is centered on the patient.
8. Use Sound as Tinnitus Management
There is growing evidence for sound-based therapies, especially in conjunction with CBT (Newman and Sandridge, 2012; Henry and Schechter, 2005). These therapies provide patients with tools to learn how to manage specific situations when their tinnitus is bothersome or intrusive. Sound-based therapy can include hearing aids, hearing aids with a sound option program, and devices that can provide sound (e.g., sound generators, radio, TV, iPod, apps, etc.). Music, noises, audiobooks, and environmental sounds can all be used as management. Yes, sound can be provided in the easiest way possible to patients! Educate them on using sound as a way to not cover or mask their tinnitus, but to manage it. Sound can be used to soothe, distract, or provide background to an otherwise quiet environment. Don’t skimp on the possibilities of using sound for your patient—it’s free, accessible, and everyone has it.
9. Practice Patient Education
Basic educational counseling should be implemented during all appointments—it’s within your scope of practice! Counseling can include information on the auditory system; types of hearing loss; medical causes of tinnitus; theories behind tinnitus generation; management options including stress management, hearing aids, sound generators, and music therapy; and the importance of hearing conservation due to the association of tinnitus, hearing loss, and noise exposure.
Be careful not to bombard them with too much information, and make sure to gauge the patient’s level of tinnitus severity for reaction purposes. Resources are available to audiologists who need counseling material. Progressive Tinnitus Management (PTM) and Tinnitus Retraining Therapy (TRT) are options that have been assessed and studied and also provide counseling materials for clinicians (Henry et al, 2010abc; Jastreboff and Hazell, 2004). Most important, letting patients know there are research-based options and many strategies for them to address their tinnitus goes a long way for those who suffer from bothersome tinnitus.
10. Track Your Patient’s Progress
Validated questionnaires have been used to gauge the impact of tinnitus in everyday life. Make sure to track your patient’s progress over time with validated outcome measures. There are a multitude of self-report questionnaires including but not limited to the Tinnitus Handicap Inventory (THI; Newman et al, 1996), the Tinnitus Handicap Questionnaire (THQ; Kuk et al, 1990), the Tinnitus Retraining Questionnaire (TRQ; Wilson et al, 1991), the Tinnitus Effects Questionnaire (TEQ; Hallam et al, 1988), and the Tinnitus Functional Index (TFI; Meikle et al, 2012). The benefit of use of self-report questionnaires is that they address the perceived impact of tinnitus on daily functions such as concentration, relaxation, hearing, and sleep. When used pre- and post-treatment, self-report questionnaires offer important measures of treatment outcomes.
In summary, tinnitus can be managed effectively when conducting a proper assessment and performing intervention that is based on research evidence. At the very least, both patients and providers should be aware of, and adhere to, systematic reviews and clinical practice guidelines to ensure the provision of evidence-based tinnitus services. Our main goal as audiologists should be to focus on the patient, listen to their needs, and provide tinnitus care that centers on their specific circumstances.