A review of current tinnitus treatments and reported clinical outcomes, and an outline of a treatment model (including a case study) utilizing a multidisciplinary approach in an outpatient otology setting.
|This article was submitted to HR by Julie Daugherty, MS, NP-C, and Jack Wazen, MD, FACS, of the Silverstein Institute, Sarasota, Fla. The authors can be contacted via the Institute’s Web site, www.earsinus.com.|
The multi-dimensional nature of tinnitus, which includes neurological, audiological, and emotional factors, and the condition’s often complicated treatment regimens have been described many times in the literature. Success in reducing tinnitus is enhanced only when all identifiable factors contributing to tinnitus disturbance are addressed during treatment. Basic techniques such as education, counseling, active listening, reassurance, and empathetic support must be utilized concomitantly with any pharmacological or other treatment protocol to ensure optimal outcomes.
This article provides a review of current tinnitus treatments and reported clinical outcomes, then outlines a treatment model for tinnitus patients utilizing a multidisciplinary approach in an outpatient otology setting. To demonstrate how to incorporate this multidisciplinary approach, a tinnitus patient case study is also presented.
Reviewing the Evidence
A review of the literature over the past decade reveals multiple tinnitus treatment modules with variable clinical outcomes. This review affirms the challenges experienced by scientists in tinnitus research and the great effort that has been put forth to find a successful treatment with consistent results. Treatments either focus on reversing the maladaptive changes that have occurred in the auditory processing centers of the brain or are directed at reducing the patient’s emotional response to their tinnitus. Often, effective treatment requires a multidimensional approach.
Several pharmacological therapies have been tried in an attempt to reduce tinnitus disturbance. Unfortunately, most studies evaluating the efficacy of these drugs have demonstrated variable success. It has been proven that alprazolam offers therapeutic relief in some patients with tinnitus. However, sensitivity to this medication differs considerably in individuals, requiring careful dosage titration.1 In a randomized double-blind trial, gabapentin was no more effective than placebo in relieving subjective tinnitus.2 Intratympanic perfusion of corticosteroids and gentamicin has been shown in studies to be effective in reducing tinnitus in some patients with Ménière’s disease.3,4 Tricyclic antidepressants (nortriptyline and amitriptyline) have been effective in reducing tinnitus loudness. Research shows that these medications significantly reduce subjective complaints of tinnitus when compared to placebo.5,6
Other treatments focus on the psychological elements associated with tinnitus. Research shows that more than 70% of patients with tinnitus have related emotional distress.7 Cognitive Behavioral Therapy (CBT) has been utilized in the treatment of tinnitus. The goal of CBT in tinnitus treatment is to first recognize and then correct any maladaptive thought patterns about tinnitus.8 Studies demonstrate CBT is about 60% effective in reducing tinnitus disturbance.9,10
A third class of treatments use acoustic therapy as a main intervention. According to Folmer and Carroll,11 the purpose of sound therapy is to decrease a patient’s perception of tinnitus by increasing external sound. Research evaluating sound generators (hearing aids, in-the-ear, and tabletop noise maskers) in tinnitus treatment shows that 76% of patients report at least moderate relief of their tinnitus.11
However, the most effective sound therapy is usually paired with some form of counseling.12 Tinnitus Retraining Therapy (TRT) is a combination of counseling and low-level broadband noise therapy. Since 1990, TRT has been utilized as an effective treatment for tinnitus and has been beneficial in 70% to 85% of patients.13
Alternatively, transcranial magnetic stimulation (TMS) has been investigated as a possible treatment for tinnitus. TMS presumably works by altering cortical reorganization associated with tinnitus. Results of current studies using TMS demonstrate only temporary improvement in tinnitus perception.13-15
The Neuromonics® Tinnitus Treatment, a patented, FDA-cleared therapy for tinnitus sufferers, has been available in the United States since 2005.16 Originally invented in Australia by Paul Davis, PhD, the Neuromonics Tinnitus Treatment uses a portable listening device to deliver a customized acoustic neural stimulus. Patients are vigilantly guided by a trained clinician through a comprehensive treatment program for approximately 6 months or longer.
The treatment targets three identified neurological processes responsible for tinnitus disturbance:
- Auditory changes leading to initial perception of tinnitus;
- Attentional processes causing increased conscious awareness; and
- Emotional responses commanding autonomic nervous system response leading to disturbance from tinnitus.
Daily self-treatment using the customized acoustic therapy, along with extensive counseling and education, gradually desensitizes the patient, offering reduced tinnitus awareness and disturbance. In the third clinical trial, 91% of subjects reported an improvement in tinnitus disturbance after 6 months of therapy and the results remained very consistent at 12 months.17 Further, a controlled study was performed comparing subjects receiving the Neuromonics Tinnitus Treatment versus broadband noise and counseling, and counseling only. Results after 6 months showed 86% of patients using the Neuromonics Tinnitus Treatment had clinical improvement in tinnitus disturbance compared to 47% and 23% of patients respectively for the broadband noise and counseling, and counseling only groups (as measured by the Tinnitus Reaction Questionnaire).18
|FIGURE 1. Outline of our current treatment model and a description of our tinnitus treatment algorithm at the Silverstein Institute, Sarasota, Fla.|
For the past year, we have offered the Neuromonics treatment in our otology practice. Our tinnitus treatment center, located at the Silverstein Institute in Sarasota, Fla, has developed a new treatment model using the Neuromonics device. We use a multidisciplinary team consisting of physicians, audiologists, a nurse practitioner, and a psychologist, offering a comprehensive treatment approach. We work collectively to achieve one goal: alleviate the patient’s tinnitus disturbance. Figure 1 and the remainder of this section provide an outline of our current treatment model and a description of our tinnitus treatment algorithm.
Each tinnitus treatment team member has a specific function, which we will describe below:
Physician. The physician conducts the initial consultation, which is centered on gaining in-depth understanding of the patient’s tinnitus complaints and determining the underlying cause. During this appointment, the physician performs a comprehensive review of the patient’s medical, family, and psychosocial history and their current medication regimen, and a thorough physical examination. Audiological imaging using magnetic resonance (MR) or contrast-enhanced computed tomography (CT) is performed when deemed medically necessary.
Psychometric testing is used to measure any tinnitus-related psychological distress. At the Silverstein Institute, we use the Tinnitus Handicap Inventory (THI) and the Tinnitus Reaction Questionnaire (TRQ). These self-report measures quantify the impact of tinnitus-related disturbances in the patient’s daily life. All collected data is reviewed by the physician, and the patient’s tinnitus etiology is confirmed. Medical or surgical intervention is initiated for any treatable causes; for instance, patients with conductive hearing loss may require surgical intervention. If the patient’s tinnitus causes significant disturbance, the physician discusses the treatment options with the patient and treatment is initiated.
Audiologist. The audiologists perform the audiological testing and tinnitus matching. Hearing aids and maskers are fitted as needed.
Nurse practitioner. The Neuromonics treatment is administered by a nurse practitioner. The Neuromonics clinician must be knowledgeable about tinnitus etiology and current treatment options and be motivated to work with tinnitus patients. Tinnitus patients seeking treatment frequently have accompanying emotional distress. They need firm support and encouragement to remain optimistic through their treatment. Similar to audiologists, nurse practitioners are patient advocates providing education and counseling, and stimulating an open discussion of the patient’s emotions relating to their tinnitus disturbance. These skills are essential when facilitating successful treatment with the Neuromonics treatment program.
Psychologist. Lastly, the psychologist is consulted to assist in the treatment of patients with severe tinnitus disturbance. An important member of any tinnitus treatment team, the psychologist focuses on addressing cognitive distortions relating to tinnitus and identifying significant anxiety or depression. Our psychologist specializes in psychodynamic and cognitive behavioral therapy.
In order to demonstrate the success of our treatment model, we present a case report for a tinnitus patient using the Neuromonics Tinnitus Treatment.
A 59-year-old male was referred by his primary doctor for complaints of constant tinnitus (high-pitched buzzing) AU x 18 days after attending a rock concert. He denied subjective hearing loss, pain, drainage, and pressure or fullness in his ears. There was no history of prior noise exposure or family history of hearing loss. The past medical history was non-contributory.
The audiogram revealed an asymmetrical high-frequency sensorineural hearing loss worse in the left ear, with normal speech discrimination and type “A” tympanograms. The auditory brainstem responses were normal bilaterally. The electrocochleography showed no responses in either ear. The tinnitus was matched at 1500 Hz and 70 dB in the left ear. The initial TRQ score was 26 and THI was 24, indicating significant tinnitus disturbance.
A course of steroids was prescribed and the patient returned after 2 weeks with no improvement. He reported increasing anxiety and sleep disturbance from his tinnitus and was using Valium (5 mg) for sleep. He also tried acupuncture without relief. An MRI of the brain/internal auditory canals was then ordered. The results were negative. Amitriptyline (25 mg) was prescribed, and he was fitted with a masker. The patient also joined the local tinnitus support group. On follow-up, his sleep disturbance improved, but he continued to experience significant tinnitus disturbance during waking hours.
The patient was then enrolled in the Neuromonics treatment protocol. He returned after 2 weeks of treatment and then at least every 2 months for counseling and support. In the first phase of treatment (2-month duration), the Neuromonics device was programmed to deliver an acoustic neural stimulus that provided a high level of interaction with the patient’s tinnitus perception. During this phase, the patient experienced relief of his tinnitus only while using the device (treatment duration of 2 to 4 hours per day). After 2 months of therapy, his TRQ score decreased to 13 and his amitriptyline was discontinued.
|FIGURE 2. Treatment protocol as outlined in the Neuromonics Tinnitus Treatment.|
During the second phase of treatment (4-month duration), the acoustic neural stimulus changes to deliver an intermittent or lower level of interaction with the patient’s tinnitus perception, thus allowing desensitization to occur. In this phase, the patient’s tinnitus awareness and disturbance continued to diminish and he reported forgetting to use his device as he was unaware of his tinnitus. At treatment completion (6 months), his TRQ score had decreased further to 6, indicating no significant tinnitus disturbance. THI score was also reduced from 24 (pre-treatment) to 16. The patient stated he had received significant relief from his tinnitus, gained a sense of control over his tinnitus, and had greatly improved sleep. He also described that he had a large improvement in his ability to cope with his tinnitus and generally felt more relaxed.
Our tinnitus treatment center has observed several patients with similar outcomes to the patient in the case report. We have closely adhered to the treatment protocol as outlined in the Neuromonics Tinnitus Treatment (Figure 2). There are several key features of this treatment protocol that we find particularly noteworthy. First, prior to initiating treatment, it is imperative to review and confirm treatment expectations with the patient. Additionally, allowing the patient to set the treatment goals facilitates individualized and measurable outcomes by both patient and clinician.
Once the treatment is under way, time must be spent with the patient at intervals throughout the treatment in order to provide necessary education and counseling. Addressing cognitive distortions is vital to alleviate the fear and anxiety surrounding tinnitus. This collaborative, rather than directive treatment, approach has been effective in reducing tinnitus disturbance. We are currently participating in a national multi-center study, evaluating the benefits of this treatment up to 36 months post-treatment.
The race is on to find the cure for tinnitus. Researchers globally are working hard with great optimism, gathering the necessary evidence to explain the pathogenesis of tinnitus. Clinicians specializing in tinnitus treatment and their patients suffering from this mystifying symptom eagerly await advances in the treatment of tinnitus. New therapies offer very promising treatment outcomes, and there is an aura of great confidence among leading tinnitus investigators that even greater advancements are on the horizon.
- Johnson R, Brummett R, Schleuning A. Use of alprazolam for relief of tinnitus. Arch Oto-laryngol Head Neck Surg. 1993;119:842-5.
- Picirillo J, Finnell J, Vlahiotis A, Chloe R, Spitznagel E. Relief of idiopathic subjective tinnitus. Arch Otolaryngol Head Neck Surg. 2007;133:390-97.
- Hill S, Digges N, Silverstein H. Long-term follow-up after gentamicin application via the Silverstein Microwick in the treatment of Ménière’s disease. Ear Nose Throat J. 2006;494-98.
- Dodson KM, Sismanis A. Intratympanic perfusion for the treatment of tinnitus. Otolaryngol Clin North Am. 2004;37:991-1000.
- Bayer N, Böke B, Turan E, Belgin E. Efficacy of amitriptyline in the treatment of subjective tinnitus. J Otolaryngol. 2001;30:300-3.
- Dobie R. Depression and tinnitus. Otolaryngol Clin North Am. 2003;36:383-88.
- Lee S, Kim J, Hong S, Lee D. Roles of cognitive characteristics in tinnitus patients. J Korean Med Sci. 2004;19:864-69.
- Tyler R. Tinnitus Treatment: Clinical Protocols. New York: Thieme; 2006:1-22.
- Andersson G, Vretblad P, Larsen H, Lyttkens L. Longitudinal follow-up of tinnitus complaints. Arch Otolaryngol Head Neck Surg. 2001;127(2):175-79.
- Kröner-Herwig B, Frenzel A, Fritsche G, Schilkowsky G, Esser G. The management of chronic tinnitus: comparison of an outpatient cognitive-behavioral group training to minimal-contact interventions. J Psychosomatic Res. 2003;54:381-89.
- Folmer RL, Carroll JR. Long-term effectiveness of ear-level devices for tinnitus. Otolaryngol Head Neck Surg. 2006;134:132-37.
- Henry JA, Jastreboff MM, Jastreboff PJ, Schechter MA, Fausti SA. Guide to conducting tinnitus retraining therapy initial and follow-up interviews. J Rehab Res Dev. 2003;40(2):157-78.
- Fregni F, Marcondes R, Boggio PS, et al. Transient tinnitus suppression induced by repetitive transcranial magnetic stimulation and transcranial direct current stimulation. Eur J Neurol. 2006;13:996-1001.
- De Ridder D, Verstraeten E, Van der Kelen K, et al. Transcranial magnetic stimulation for tinnitus: influence of tinnitus duration on stimulation parameter choice and maximal tinnitus suppression. Otol Neurotol. 2005;26:616-19.
- Smith JA, Mennemeier M, Bartel T, et al. Repetitive transcranial magnetic stimulation for tinnitus. Laryngoscope. 2007;117:529-34.
- Sinopoli S, Davis PB, Hanley P. Tinnitus: addressing neurological, audiological, and psychological aspects with customized therapy. Hearing Review. 2007;14(9):32-35.
- Davis P, Paki B, Hanley P. Neuromonics tinnitus treatment. Ear Hear. 2007;28:242-59.
- Davis P, Wilde R, Lyndall G, Hanley P: Treatment of tinnitus with a customized acoustic neural stimulus: a controlled clinical study. Ear Nose Throat J. 2008;87:330-39.
Citation for this article:
Daugherty J, Wazen J. A new model for tinnitus treatment. Hearing Review. 2010;17(2):26-30.