The Eye & Ear Foundation’s June 3rd webinar covered a topic that affects an estimated 50 million Americans. “Living with Tinnitus: Clinical Evaluation and Management Strategies” was presented by Lori Zitelli, Au.D., CH-TM, Managing Audiologist, UPMC Center for Audiology and Adjunct Instructor of Audiology at the University of Pittsburgh School of Health & Rehabilitation Sciences. One of Dr. Zitelli’s special interests is tinnitus treatment; she heads up the Tinnitus Treatment Program.
What is Tinnitus?
What is tinnitus? It is an auditory phantom perception that is not related to external sounds. Some people hear it within their ears, while others feel like the noise is in their head. Sounds have been described as ringing, buzzing, humming, hissing, chirping, or whooshing.
The problem is we do not know exactly where tinnitus comes from. A lot of different things can cause it. Early theories focused on the ears, while subsequent theories focused on the brain. Now most people believe that it originates in the central auditory system, even when hearing damage is the triggering factor.
Risk Factors
There are multiple risk factors for tinnitus:
- Hearing loss
- Noise exposure (musicians, dentists, construction workers, hunters, service members/veterans) – What is tricky about this is that it is not just about the sound you are exposed to, but how long you are listening to it
- Certain pharmaceuticals – Certain types of chemotherapy agents can cause tinnitus, as can diuretics, but if you take any medication and look far enough down on the list of possible side effects, you are likely to see tinnitus somewhere
- Age – Over time, people are more likely to develop hearing loss and tinnitus
- High stress levels
Types
Bothersome tinnitus is typically treatable. The type you have will be determined by a healthcare professional. There are two kinds of tinnitus: primary and secondary.
Primary Tinnitus is treated by an audiologist. It is associated with sensorineural hearing loss (SNHL) and is idiopathic. This means you do not necessarily know what is causing it; it is not linked to anything specific. There is no “cure.” Management is habituation, or the process of the brain learning to tune things out over time. A lot of people are able to do that very successfully, Dr. Zitelli said.
Secondary Tinnitus is treated by a physician. This kind is associated with a specific underlying cause or condition other than SNHL. Management is treating the underlying condition medically or surgically.
Diagnosis
If you want to pursue an evaluation for tinnitus, the first step will be an appointment with an Ear, Nose, and Throat doctor. Schedule with one of UPMC’s ENT providers for an evidence-based approach to evaluation of tinnitus. Following an appointment with a physician, you will complete a series of evaluations with an audiologist.
Through a case history – in which you describe how your tinnitus impacts you – and subjective questionnaires – measuring your self-perceived handicap – and more specific questions, your tinnitus will be evaluated.
Then psychoacoustic measures of tinnitus, audiometric testing, and Loudness Discomfort Levels will provide more information about your tinnitus perception, ability to tolerate environmental sounds, and your peripheral hearing status.
There are several ways to classify the perception of tinnitus:
- Loudness (0-10 scale)
- Pitch (low, medium, high)
- Spectral quality (tonal, hissing, chirping, etc.)
- Number of sounds heard
- Lateralization (unilateral, bilateral, middle of head, asymmetry)
- Maskability/suppression (complete masking, partial masking, no masking)
- Modification/modulation
- Residual inhibition (none, partial, total)
- Exacerbation – relates to how loud sounds in your environment interact with your tinnitus
Impact
Although an estimated 50 million Americans report tinnitus, most do not suffer from it. This is an important distinction, Dr. Zitelli said. Of the people who have it, 70% are experiencing it, 24% are seeking medical treatment, and 6% are debilitated by it (meaning it affects their ability to sleep, relax, concentrate, socialize, and work).
Thirty one percent of people with tinnitus classified it as not being a problem. It was a small problem for 41.6%, a moderate problem for 20.2%, and a big problem for 7.2%. The numbers from both surveys line up well, Dr. Zitelli said, with the percentage of people who need to seek treatment.
“When we see you in clinic, the goal is to move you from the category of bothered to someone who is not bothered,” Dr. Zitelli said. “There are many ways we can try to do that.”
Interestingly, the difference between someone who is experiencing tinnitus and someone who is suffering from tinnitus is related to their reactions, not their perceptions.
Treatment
The common treatment goal for tinnitus is to help someone habituate to their tinnitus. Dr. Zitelli provided some examples of how we already do this in our daily lives. If you wear a watch, you will feel it on your wrist at first. Eventually, you will get to a point in the day when you do not feel it because you have become habituated to it. Likewise, if you get a new refrigerator, it might seem loud at first. You never noticed the old one before. But that is because you got used to it; in a couple of weeks, your brain will probably move the new fridge to the same sound category.
There are many treatment options for tinnitus. Many are not evidence-based, but a few are:
- Counseling/education
- Sound therapy
- Possible others…
- Wait and see what happens
“The goals of educating a tinnitus sufferer are to promote a person’s capacity for self-growth and move them toward acceptance,” Dr. Zitelli said.
Common topics for counseling/education are the goal/outcome of treatment, the basics of the auditory system, the basics of brain function/interaction, habituation, and the role of sound therapy. Once people understand, they feel more empowered.
Behavioral Therapies
Several behavioral therapies are often used in treating tinnitus, with good results:
Cognitive Behavioral Therapy
- Focus on negative, unrealistic, unproductive thoughts that cause maladaptive behaviors
- By correcting these negative cognitions, one can have more positive and realistic thoughts
Mindfulness Based Stress Reduction
- Meditation and yoga program with a focus on mindfulness, a method for facing, exploring, and alleviating suffering by relating to present experiences
Acceptance & Commitment Therapy
- Focus on helping people to accept difficulties that come with life; do not try to control your emotions, just accept your psychological experiences
Sound Therapies
There are many ways to provide sound therapy to a person with tinnitus:
Masking – Exposing the person to an external noise that is loud enough to partially or completely cover the tinnitus
Soothing – The goal is to feel “better” or less stressed when you hear the sound
Contrast Reduction – Make the tinnitus less noticeable by introducing other sounds into the environment
Distraction – Use external sounds to divert the person’s attention away from the sound
Habituation – Help the person’s brain to reclassify tinnitus as an important sound that can be ignored
“Most people are hoping for a quick fix,” Dr. Zitelli said. “We would love to provide that to you. But the brain needs to be exposed to consistent things, and you need time to change your reactions. Most people that go through our process are helped significantly. Generally, it is a process of at least a couple of months. If you stick with it, the odds will be higher.”
Hearing aids can also be a valuable tool in managing bothersome tinnitus. Soothing, contrast reduction, distraction, masking, and stress reduction can all be achieved with hearing aids. They also help with auditory stimulation.
Bottom Line
Some people with tinnitus can do nothing and still improve over time. This is generally more applicable to people who are not bothered by their tinnitus. There is often a small improvement in tinnitus severity up to four months after its onset. While tinnitus generally improves over time, the effects are highly variable across individuals. “We are not sure how clinically meaningful this improvement is,” Dr. Zitelli cautioned.
The best thing to do is contact your UPMC audiologist to discuss treatment options.
UPMC employs a Tinnitus Retraining Therapy (TRT) approach. This is a method of achieving habituation of the emotional response and the body’s physical reaction to sound (combining education/counseling AND sound therapy). It was developed by the Drs. Jastreboff at Yale in the late 1980s. Now they teach others how to employ this type of treatment. Research has shown that TRT is effective in treating tinnitus for most people.
The American Tinnitus Association has resources for individuals with tinnitus.
Takeaways
Dr. Zitelli ended her presentation with three takeaways:
- Tinnitus may be medically manageable, but there are treatment options even if it is not
- Audiologists, physicians, mental health providers, primary care physicians, dentists, physical therapists, and others can all work together to treat tinnitus
- Please contact your UPMC audiologist to discuss treatment options for tinnitus