What Is the Best Approach to Tinnitus Management?
Numerous protocols and approaches are used by audiologists in the management of tinnitus, including but not limited to Tinnitus Retraining Therapy (TRT), Tinnitus Activities Treatment, and Progressive Tinnitus Management. Additional psychological approaches include Cognitive Behavioral Therapy (CBT), Mindfulness-Based Tinnitus Stress Reduction, Acceptance and Commitment Therapy, and many others. These approaches both used by audiologists and mental health professionals have many common components to their counseling and recommendations. The approach with the most literature-based evidence is CBT. The question remains, among audiologist-lead management approaches for tinnitus, which is the most effective?
Results from a randomized clinical trial were recently published in the JAMA Otolaryngology-Head & Neck Surgery. The trial, performed in U.S. military hospitals, compared comprehensive TRT (counseling and ear-level sound generators), partial TRT (only counseling component with placebo sound generators; sound was at first audible but then tapered off over a brief time), and standard of care (basic counseling and enriched sound environment). Participants were randomized to one of the treatments, with approximately 50 participants in each group. Baseline scores on the Tinnitus Questionnaire, Tinnitus Functional Index, Tinnitus Handicap Inventory, and visual analog scale were compared to scores 18 months post treatment.
The results showed that approximately 50 percent of the participants showed clinically meaningful reduction in their tinnitus, but there was no significant difference between treatments. In other words, basic counseling and recommendations for an enriched sound environment are effective at the group level and following a specific protocol may not be necessary.
However, there were numerous limitations of this study. First, the standard of care component was based on ASHA-preferred practice recommendations with a patient-centered approach that included counseling on tinnitus, relationship to hearing loss, and use of sound enrichment. It is arguable if this is the standard the average patient with tinnitus receives. More often or not patients with tinnitus are told there is no medical treatment and they will need to learn to live with it and likely advised to keep sound around. Second, there is a significant clinician effect with tinnitus counseling. The providers in the study were not initially proficient, nor routinely provided TRT. Third, there was significant attrition in the study due to military operations, such as deployment. Finally, though no group differences were observed, it is plausible that individuals may find greater benefit from one management approach versus another. Identifying factors for triage of tinnitus patients to the appropriate level and management approach is an important consideration.
Scherer et al. (2019) Effect of tinnitus retraining therapy vs standard of care on tinnitus related quality of life, JAMA Otolaryngology-Head & Neck Surgery. May 23, 2019.