Tech Topic | June 2016 Hearing Review
By creating a Tinnitus Toolbox based on best-practice solutions, hearing care professionals are better able to take their tinnitus evaluation results and tailor a management plan that best suits each and every patient with tinnitus.
Editor’s Note: This is Part 2 of a 2-part series designed to provide hearing care professionals with a guide for successfully navigating treatment options for their patients presenting with tinnitus. Part 1, which dealt with the components of tinnitus assessments and questionnaires, was published in the May 2016 edition of The Hearing Review and online at www.hearingreview.com.1
After completing the evaluation, a typical outcome may be a diagnosis of hearing loss and a subsequent fitting of hearing instruments with no further tinnitus rehabilitation provided. Often, simply measuring, acknowledging, and counseling the patient regarding their tinnitus is sufficient relief to the patient.
However, when it comes to patients with very bothersome tinnitus, often the negative connotations of their tinnitus are so impactful on their daily lives that additional counseling and resources are necessary to assist in slowing and eventually stopping the vicious cycle that tinnitus can cause. Beyond traditional amplification, management options can range from amplification with tinnitus features to Tinnitus Retraining Therapy (TRT), Acoustic Desensitization or other sound therapy approaches, Cognitive Behavioral Therapy (CBT), and other management options such as medical or holistic approaches.2-4 We discuss below some of these options in further detail.
Tinnitus-specific Hearing Instruments and Fitting. The “Big 6” global hearing instrument manufacturers (Widex, Phonak, Signia/Sivantos, GN ReSound, Starkey, and Oticon) all manufacture hearing instruments to assist with tinnitus management. Having several manufacturers, styles, levels of technology, and compatible assistive devices to choose from is a useful advantage for patients looking for the right tinnitus management solution. On the other hand, it can also be overwhelming to have so many choices. Table 1 provides a comparison of the tinnitus-specific hearing instruments offered by each manufacturer as of December 2015, as well as a brief summary of the tinnitus management options.
Given all of the tinnitus management options available in modern hearing instruments, fitting technologies can provide an efficient way to verify hearing instruments with tinnitus management programs and devices. In addition to all of the “Big 6” companies offering products for tinnitus, some also offer counseling tools and training to their customers.
One other tinnitus management tool that is helpful for counseling is in the AURICAL® PMM and MADSEN® Astera² Tinnitus Tab (Figure 1).
If a tinnitus evaluation is completed via the MADSEN® Astera², this information is carried into the AURICAL® PMM, as well. A tinnitus marker overlay is available to designate the pitch and intensity of the perceived tinnitus. For example, the markers are also available in Real Ear and Coupler modes. This makes it easier for you to use existing tinnitus measurement data in the fitting and verification process, as well as a potential counseling tool.
Tinnitus Retraining Therapy (TRT). Pioneered by Jastreboff and Hazell,5 TRT is an extensively researched and well-known tinnitus management method that forms the foundation for many other forms of tinnitus management. TRT includes utilizing patient education and sound therapy to reduce the perception of the tinnitus.2,5 While TRT has been extensively researched and proven to be successful when patients follow the entire recommended protocol, hearing care professionals performing aural rehabilitation currently cannot bill for these services. This can be problematic, as a true TRT program can take anywhere from 18 to 24 months to complete, which includes patient visits with the clinician on a regular basis.
Neuromonics®. The premise of the therapy method provided by Neuromonics is that, by embedding a narrow-band noise within a musical selection at a low volume (either classical or ambient), the patient is able to, over time, habituate to their tinnitus.6,7 This eventually leads to utilizing their device only on an as-needed basis.
The Neuromonics management tool (of which there are several options) resembles an MP3 music player with headphones. This is advantageous because you can use the device on patients with or without a hearing loss. However, there are models of the device now available that are used on an as-needed basis, with programming completed based on the general audiometric configuration, and patients can leave the clinic with the device in hand. This alternative model reduces the follow-up time needed.
However, there can be some limitations of the device based on the patient’s hearing. For example, preferred patients are those with normal hearing, and there is still some concern relative to benefit received by people with more significant hearing losses. The more traditional Neuromonics treatment model takes approximately 6 to 8 months to complete, with the patient listening to the device 2 to 4 hours every day.4 This management plan usually includes follow-up with the patient by the hearing care professional.
SoundCure®. Similar to some of the Neuromonics products, SoundCure is designed to be used on an as-needed basis and is also programmed using the patient’s audiometric configuration.8 However, instead of an embedded narrow-band noise in a musical track, the system uses a low-rate click stimulus that, when listened to for an extended period of time, significantly reduces the perception of tinnitus to the patient.9 According to the research generated by the University of California, Irvine, the click rate is synchronous with the neural firing patterns that occur naturally in the auditory cortex in response to temporally patterned sounds.
As this device can be one of the more cost-effective management options, in particular for patients with no hearing loss, it is a viable option to use not only as a standalone treatment, but can also be used in conjunction with other products. However, the clinician should keep in mind that they are still fitting to a pre-set configuration and not to the actual hearing loss of the patient.
Sound Applications. The use of applications or “apps” is also gaining popularity for patients who have no hearing loss or those who are bothered by tinnitus when they sleep. Smartphone or tablet users can download these apps for free, or with a minimal purchase fee.
While there are several options, the authors have noted that two Apps with easy to use features are “Relax Melodies” and “White Noise Baby.” As of this writing, these two apps both record a 5-star rating from 34,001 customer reviews in the Apple App store (Relax Melodies) and 78 customer reviews (White Noise Baby), respectively. While both offer a variety of nature sounds, noise, and music to choose from, one feature they share in common is the timer option. This is a beneficial feature because patients can program the application to turn off automatically, both for assisting in falling asleep or timing how long they are using the program. Most apps are supported by both Apple and Android products, increasing their versatility and discrete use. As with most products used for tinnitus treatment, when recommending these apps, hearing care professionals should keep in mind that patients should have the sound source at a level that does not mask the tinnitus, but rather assists in providing a means for habituation.4
Cognitive Behavioral Therapy (CBT). Often considered a more traditional approach, CBT services are provided by a licensed psychologist or psychiatrist. Cognitive Behavioral Therapy aims to harness the patient’s ability to become more aware of their negative thoughts towards tinnitus, which in turn allows for more positive thinking and “owning” of their current situation.10 This requires research by the clinician to find a provider with whom they are comfortable referring patients. If no local provider that specifically treats patients with tinnitus is available, providers who have experience with pain management can be an alternative referral source, as patients who deal with chronic pain can have many similarities with patients that have tinnitus. In some cases, well-trained audiologists themselves administer CBT to their tinnitus patients.11
Mindfulness-based Tinnitus Relief. While having CBT is an option, patients who cannot attend therapy during standard business hours, or who do not have a local CBT provider, will need to have another method of intervention available. An example of such an alternative is “Mindfulness Based Tinnitus Relief.” Developed and mediated by Jennifer Gans, PsyD, this 8-week online course is done as a group discussion, with guided readings, meditations, and group discussions.12
Supplements and Medical Management. Over-the-counter medications, such as “T-Gone” and “Arches Natural Products,” after many peer reviewed studies, have been shown to provide nothing more than a placebo effect.11,13 This also includes herbal medications such as Zinc and Ginko Biloba.
Some prescription medications hold potential for tinnitus relief; however, so far there appears to be a lack of replication of positive results in the literature. Of current interest are Alprazolam, Cyclandelate, and Eperisone—which are Selective Serotonin Reuptake Inhibitors (SSRIs). While they have produced mixed results, if the patient has a common co-morbid psychiatric disorder such as depression, anxiety, insomnia, PTSD, etc, this can be an option for those under a physician’s care.14
Holistic Approach. As with medical management approaches, holistic therapy approaches also have not been proven to “cure” tinnitus. However, as tinnitus is often associated with the “vicious cycle” described in Part 1 of this article, any management option that is not harmful to the patient and can help reduce their anxiety and stress should not be automatically discounted.2,15 Possible options include massage therapy, meditation, or acupuncture.
Some holistic treatment providers claim that they can “cure” tinnitus; proper counseling from a hearing care professional on what effective tinnitus management options are currently available is recommended. Additional holistic options, such as wearable magnets or ultrasonic tinnitus treatment devices, are available for purchase, but again there is currently no literature to support their claims of tinnitus relief beyond the placebo effect.3
Imaging Studies. In the last 5 to 7 years, there have been several fMRI research studies that explored the use of minimally invasive approaches, such as laser treatments, Transcranial Magnetic Stimulation (TMS), and Transcranial Direct Current Stimulation (tDCS).3 These studies focus on the neural activity in the auditory cortex and surrounding areas, most commonly the left temporoparietal (LTA). Utilizing these various stimulations, there has been a slight positive correlation in perceived loudness of the tinnitus. At this time, the authors are unaware of studies that have duplicated these promising results or that have a control group associated with the study.
In the age of apps and tinnitus-specific technologies, it can be a challenge for hearing care professionals to stay up-to-date on what resources are available to expand beyond treating a patient’s hearing loss with hearing instruments. In addition to a selection of hearing instruments with tinnitus features, a multitude of assessment, evaluation, and counseling tools are available for clinicians who would like to add tinnitus care to their practice.
By creating a Tinnitus Toolbox based on best-practice solutions, hearing care professionals are better able to take their tinnitus evaluation results and tailor a management plan that best suits each and every patient with tinnitus. Clinicians who are interested in adding tinnitus care to their practice can also view a series of courses, white papers, and reference materials available at http://www.audiologysystems.com/tinnitus.
Young B, Boorazanes M, Sanchez C. The tinnitus toolbox guide to support the full patient journey. Hearing Review. 2016;23(5):24-26. Available at: https://hearingreview.com/2016/04/the-tinnitus-toolbox-guide-to-support-the-full-patient-journey
American Academy of Audiology (AAA). Audiologic guidelines for the diagnosis & management of tinnitus patients. October 8, 2007. Available at: http://www.audiology.org/publications-resources/document-library/tinnitus.
Folmer RL, Theodoroff SM, Martin WH, Shi Y. Experimental, controversial, and futuristic treatments for chronic tinnitus. J Am Acad Audiol. 2014;25:106-125.
Sweetow RW, Sabes JH. An overview of common procedures for the management of tinnitus patients. Hear Jour. 2010;63(11):11-15.
Jastreboff PJ, Hazell JW. A neurophysiological approach to tinnitus: Clinical implications. Brit J Audiol. 1993;27(1):7-17.
Davis PB, Paki B, Hanley PJ. Neuromonics tinnitus treatment: third clinical trial. Ear Hear. 2007;28(2):242-259.
Sinopoli T, Davis PB, Hanley PJ. Tinnitus: Addressing neurological, audiological, and psychological aspects with customized therapy. Hearing Review. 2007;14(9):32-35. Available at: https://hearingreview.com/2007/08/tinnitus-addressing-neurological-audiological-and-psychological-aspects-with-customized-therapy
Perry B, Strom KE. Novel sound therapy: SoundCure harnesses research on brain science in fighting tinnitus. Hearing Review. 2012;19(08):52-54. Available at: https://hearingreview.com/2012/08/novel-sound-therapy-soundcure-harnesses-research-on-brain-science-in-fighting-tinnitus
Tyler R, Stocking C, Secor C, Slattery WH III. Amplitude modulated “s-tones” can be superior to noise for tinnitus reduction. Am J Audiol. 2014;23:303-308.
Hoare DJ, Searchfield GD, Refaie AE, Henry JA. Sound therapy for tinnitus management: Practicable options. J Am Acad Audiol. 2014;25:62-75.
Henry JA, Zaugg TL, Schechter MA. Clinical guide for audiologic tinnitus management I: Assessment. Am J Audiol. 2005;14:21-48.
Gans, J. Mindfulness basedtinnitus stress reduction: Unraveling the Gordian Knot of tinnitus. Hearing Review. 2015;22(7):28.
Dobie RA. A review of randomized clinical trials in tinnitus. Laryngoscope. 1999;109(8):1202-1211.
Shi Y, Robb MJA, Michaelides EM. Medical management of tinnitus: Role of the physician. J Am Acad Audiol. 2014;25:23-28.
McKenna L, Andersson G. Changing reactions to tinnitus. Hearing Review. 2007;14(9):12-19. Available at: https://hearingreview.com/2007/08/changing-reactions-to-tinnitus
Correspondence can be addressed to Hearing Review or Dr Young at: [email protected]
Original citation for this article: Young B, Boorazanes M, Sanchez C. The Tinnitus Toolbox Guide to Support the Full Patient Journey, Part 2. Hearing Review. 2016;23(6):28.?