Viewers of the Eye & Ear Foundation’s June 12th webinar, “Tinnitus Treatment Options: To Audiology and Beyond” were treated to an overview of tinnitus treatment options and lifestyle changes that help patients with tinnitus. Presenter Lori Zitelli, AuD, CH-TM, Managing Audiologist in the UPMC Department of Audiology and an Adjunct Instructor at the University of Pittsburgh School of Health & Rehabilitation Sciences has undergone TRT Jastreboff Training. She was also recently asked to chair an American Academy of Audiology committee on tinnitus guidelines. In her words, “I’m in deep with tinnitus and really wouldn’t have it any other way.”
What is Tinnitus?
Tinnitus is an auditory phantom perception that is not related to external sounds. It can manifest as ringing, buzzing, hissing, or chirping. “There is no right or wrong way to describe your tinnitus because everyone perceives it differently,” Dr. Zitelli said. A lot of people describe it as a high-pitched sound.
Because we do not know exactly where tinnitus originates in the brain, it is difficult to evaluate and treat. Early theories focused on the outer hearing system – the ears. More recent theories focus on the brain.
Risk Factors
Identifying risk factors for tinnitus include:
- Hearing loss
- Noise exposure
- Certain pharmaceuticals
- Depression
- High stress levels
- Age
Although an estimated 50 million Americans report tinnitus, most do not suffer from it, Dr. Zitelli said. Of this number 70% experience tinnitus, 24% seek medical treatment, and 6% are debilitated.
“A lot of our treatment goals focus on moving people from a category where they’re bothered into one where they’re not bothered by it,” Dr. Zitelli said.
Tinnitus Retraining Therapy
UPMC employs a Tinnitus Retraining Therapy (TRT) approach. Developed by the Drs. Jastreboff at Yale in the late 1980s, TRT is a method of achieving habituation of the emotional response and the body’s physical reaction to sound (combining education/counseling AND sound therapy). Research has shown that it is effective in treating tinnitus for most individuals.
TRT is based on the idea that tinnitus only becomes bothersome to someone when parts of the brain that should not be activated become activated. The body has a reaction as well.
Habituation
One common treatment goal is related to helping someone habituate to their tinnitus. Habituation is the process of repeatedly exposing yourself to something and over time decreasing your response. The brain will tune out eventually if there is no negative meaning to you.
An example is feeling glasses on your face, or if you wear regularly, a wristwatch. We have all likely habituated to the sight of our nose. Our brain tunes it out because it is not worth the effort. The sound of a refrigerator running in the background is fairly easy to habituate to. The longer you are in the room, the less you tend to notice. It is even possible to habituate to things that might seem extremely loud, like people in Chicago living near the El train.
“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.
Sound Therapy
There are many ways to provide sound therapy to someone with tinnitus.
- Masking
- Exposing the person to an external noise that is loud enough to partially or completely cover the tinnitus
- Soothing
- Goal is to feel “better” or less stressed when you hear the sound
- Contrast reduction
- Make the environment 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 unimportant sound that can be ignored
If you want to pursue an evaluation for tinnitus, an appropriate first step would be an appointment with an Ear, Nose, and Throat physician. Schedule an appointment with one of UPMC’s ENT providers for an evidence-based approach to evaluation of tinnitus by calling 412-647-4327 for the Eye & Ear Institute in Oakland or 412-621-0123 for the Shadyside Medical Building.
Other Causes
Although ear and hearing problems are common in people with tinnitus, tinnitus can be linked to many other causes and comorbidities.
- Mental health disorders
- Head/neck/jaw dysfunction
- TMJ issues
- Sleep disturbances
- Middle ear muscle spasms
The prevalence of psychiatric disorders (especially anxiety and depression) is high in patients with tinnitus. In a recent systematic review, 33% of people with tinnitus had depression, and 45% had a lifetime prevalence of anxiety.
Which came first, the tinnitus or depression/anxiety? Did stress cause and worsen tinnitus or did tinnitus cause and exacerbate stress? “We can’t really say,” Dr. Zitelli said, but there is “definitely a link.” If the mental health issues are not treated, they present a barrier to coping.
Cognitive Behavioral Therapy
Cognitive Behavioral Therapy (CBT) is one well-established treatment option for tinnitus. It is a specific type of psychotherapy that aims to change how people think, feel, and behave. It has been used a lot in research related to chronic conditions like pain, anxiety, depression, insomnia, and has been adapted to be applied to tinnitus as well. Patients work with someone certified to provide this type of therapy – usually a mental health provider.
CBT is focused on the relationship between thoughts, emotions, and behaviors. They all interact and impact each other. An example Dr. Zitelli provided is if you are sitting at home reading on the couch as it is getting dark outside. You are all settled on comfy cushions, with a nice glass of wine, and a good book. Then you hear the floorboards creak.
There are two possible paths. If your son lives with you and is coming home soon, you will think, “Oh, he’s home safe, that’s good,” a positive emotion with no change in behavior. On the other hand, if you live alone and are not expecting visitors, a thought generated might be, “There is an intruder in my house.” You will probably be afraid and feel something negative, which could cause you to leap up and run for the door.
CBT treatment helps people focus on identifying thought patterns that are not productive, replacing automatic negative thoughts with more realistic, less harmful, and more productive thoughts and associations.
There are multiple CBT options. If in Pittsburgh, ask your PCP for a recommendation or schedule a consultation with the UPMC Audiology Department to get a list of options. Alternatively, there is a self-guided online option for $950.
Mindfulness Based Stress Reduction
Mindfulness Based Stress Reduction (MBSR) is effective for many individuals. It teaches people to accept chronic symptoms or conditions. MBTSR is a modified version that includes specific education related to tinnitus. It involves using all the senses to be in the present moment where something is not good or bad, it just is.
UPMC offers MBSR classes. There is also an eight-week online option for $225.
Somatosensory Tinnitus
Some individuals can modulate their tinnitus by doing specific movements of their temporomandibular joint, head and neck, eyes, and limbs. In general, temporomandibular disorders are thought to be important risk factors for developing tinnitus. About 60-80% of people have this kind of tinnitus.
If you suspect you might have it, there is a recently published flowchart that your audiologist can use to assess the probability with fairly good accuracy.
Michiels, S., Cardon, E., Gilles, A., Goedhart, H., Vesala, M., Van Rompaey, V., … & Schlee, W. (2022). The rapid screening for somatosensory tinnitus tool: a data-driven decision tree based on specific diagnostic criteria. Ear and Hearing, 43(5), 1466-1471.
If you feel that you may have somatosensory tinnitus, consider a team approach:
- ENT & Audiology
- Start with an ear evaluation
- Dentist
- Treat TMJ disorders (e.g., splint)
- Physical Therapist
- Exercises
- Relaxation of muscle tension
- Cervical manipulation
- Others?
- Injection of anesthetics (e.g., lidocaine)
- Laser therapy, transcutaneous electrical nerve stimulation, magnet therapy
Treating TMD has been shown to improve symptoms associated with tinnitus.
- Bite splints
- CBT
- Home exercises
- Muscle stretching
- Massaging of the affected muscles
- Thermotherapy with moist heat
An average of 69% of patients reported improvement or resolution of their tinnitus after treating their TMJ disorder!
UPMC experts can help. Physical therapists at the UPMC Rehabilitation Institute can develop a management plan for TMD.
Biosensory Treatment
A researcher named Susan Shore who has a lab in Ann Arbor, MI, has developed a biosensory treatment device for tinnitus specifically for people with somatosensory tendencies. A recent study in JAMA detailed some recent trial results which are promising. They are pursuing FDA approval. There is no expected timeline, but Dr. Zitelli will be keeping an eye out.
Sleep Disturbances and Insomnia
Sleep disturbances and insomnia are highly prevalent in people with tinnitus. Consider evaluating your sleep strategies:
- Create a consistent bedtime routine
- Make your bedroom a haven for sleep (eg sleep on comfortable mattress, maintain a cool and dark bedroom)
- Establish a positive association between your bed and sleep
- Avoid bright light exposure in the evening and night
- Watch your caffeine, nicotine, and alcohol intake
- Be mindful of what you eat before sleep
- Try to exercise regularly
- Stay awake during the day
- Take some time to relax
Additional sleeping tips:
- Go to bed only when sleepy at night
- Use the bed and bedroom only for sleep and sex (i.e., no reading, tv watching or worrying)
- Get out of bed and go in another room whenever unable to fall asleep or return to sleep
- Arise at the same time every morning, regardless of the amount of sleep from the previous night
If you feel that sleep is a significant issue for you, consider a formal evaluation with the UPMC Sleep Medicine Center.
In the meantime, you can use sound to distract your brain. Dr. Zitelli said there is no recommendation for a specific type of sound, because what the research supports is whatever you like is best for you. A pretty wide variety of sounds is available: white noise, pink noise, nature sounds, music, and fractal tones, among others. The American Tinnitus Association has a sound library to check out.
The Middle Ear
Muscles in your middle ear may contract randomly, causing the perception of tinnitus.
- Often called “Tensor Tympani Syndrome” (although either one or both of the middle ear muscles can be involved) or “Middle Ear Muscle Myoclonus”
- Subjects frequently report clicking, snapping, fluttering, buzzing
- Largely considered to be rare – exact prevalence likely unknown
- Pace of contractions can vary – if rapid, can sound continuous
This is difficult to evaluate in the clinic since nothing can bring it on – much like bringing your car to the mechanic. Along with a lack of consensus related to diagnosis, there unfortunately is also a lack of consensus for treatment strategies. There is a pretty modest level of evidence available right now.
Medical therapy
- Anxiolytics
- Antiepileptics
- Botox
Surgical treatment
- Division of muscles
Therapeutic decisions are best made on an individual basis. Please consult with your ENT provider, Dr. Zitelli said.
Bottom Line
The American Tinnitus Association has created resources for individuals with tinnitus. Their patient navigator page is designed to help people who do not know what to do about their tinnitus.
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 do not hesitate to reach out to the UPMC Dept of Audiology (412-647-2030) if you want to discuss options for tinnitus management. They will be glad to meet with you.