Tinnitus Treatment E-Book

• Herausgeber: Thieme Medical Publishers
• Kategorie: Fachliteratur
• Sprache: Englisch

Veröffentlichungsjahr: 2022

Beschreibung

The quintessential clinical guide for audiologists on tinnitus and hyperacusis patient management

Since publication of the first edition in 2005, new developments have impacted the treatment paradigm for tinnitus, such as sensory meditation and mindfulness. Tinnitus Treatment: Clinical Protocols, Second Edition, by world-renowned tinnitus experts and distinguished authors Richard S. Tyler and Ann Perreau provides comprehensive background information, up-to-date strategies, essential tools, and online supplementary materials grounded in years of clinical experience and research. It fills a gap in graduate education and available materials to empower audiologists to effectively treat patients suffering from bothersome to severely debilitating symptoms associated with tinnitus or hyperacusis.

The textbook includes 15 chapters, starting with three chapters on tinnitus models, treatment approaches, and self-treatment options. The next three chapters summarize counseling approaches for audiologists and psychologists, including introduction of the three-track psychological counseling program for managing tinnitus. Chapters 7 and 8 discuss the use of hearing aids in patients with hearing loss-related tinnitus and sound therapy using wearable devices. Chapter 9 covers smartphone apps for tinnitus assessment, management, and education and wellness, including discussion of limitations. The last six chapters provide guidance on tinnitus management topics including treating children, implementing outcome measures, hyperacusis treatment, and future directions.

Key Features

• New relaxation/distraction tactics including meditation, mindfulness, guided imagery, biofeedback, progressive muscle relaxation, art and music therapy, exercise, and exploration of new hobbies
• Treatment guidance for patients with tinnitus associated with Meniere's disease, vestibular schwannoma, unilateral sudden sensorineural hearing loss, and middle ear myoclonus
• Discussion and research-based evidence covering Internet-delivered self-help treatment strategies
• New supplemental videos, brochures, handouts, questionnaires, and datasheets enhance knowledge, scope of practice, and incorporation of effective approaches into clinical practice

This is a must-have resource for every audiology student and advanced courses, as well as essential reading for all audiologists who feel underprepared in managing tinnitus and/or hyperacusis.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

Leseprobe

To access the additional media content available with this e-book via Thieme MedOne, please use the code and follow the instructions provided at the back of the e-book.

Tinnitus Treatment

Clinical Protocols

Second Edition

Richard S. Tyler, PhD

Professor of Otolaryngology and Professor of Communication Sciences and DisordersRoy J. and Lucille A. Carver College of MedicineDepartment of Otolaryngology–Head and Neck SurgeryUniversity of IowaIowa City, Iowa, USA

Ann Perreau, BA, MA, PhD

Associate Professor of Communication Sciences and DisordersAudiology Clinic CoordinatorRoseman Center for Speech, Language, and HearingAugustana CollegeRockland Island, Illinois, USA

83 Illustrations

ThiemeNew York • Stuttgart • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available from the publisher.

© 2022. Thieme. All rights reserved.

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ISBN: 978-1-68420-171-6

Also available as an e-book:

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eISBN (epub): 978-1-63853-686-4

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Contents

Videos

Foreword

Preface

Acknowledgments

Contributors

1Neurophysiological Models, Psychological Models, and Treatments for Tinnitus

Phillip E. Gander and Richard S. Tyler

1.1What Is Tinnitus?

1.2Neurophysiological Models of Tinnitus

1.3Psychological Models of Tinnitus

1.4Categories of Tinnitus Treatments

1.5Counseling in the Treatment of Tinnitus

1.5.1Be Supportive

1.5.2Provide Information

1.5.3Components of Counseling

1.5.4Examples of Counseling Treatment Protocols

1.6Sound Therapies for Treating Patients’ Reactions to Tinnitus

1.6.1Counseling for Sound Therapies

1.6.2Use of Hearing Aids

1.6.3Music Therapy

1.6.4Hyperacusis

1.7Obstacles to Tinnitus Treatment

1.7.1Negative Beliefs by Clinicians or Patients

1.8Conclusion

Appendix 1.1 Tinnitus

2Treating Tinnitus in Patients with Otologic Conditions

David M. Baguley and Manohar L. Bance

2.1Treating Tinnitus in Patients with Meniere’s Disease

2.1.1Treatment Protocol

2.2Treating Tinnitus in Patients with a Vestibular Schwannoma

2.2.1Treatment Protocols

2.3Treating Tinnitus in Patients with Unilateral Sudden Sensorineural Hearing Loss

2.3.1Early Intervention

2.3.2Information Regarding Mechanisms

2.3.3Hearing Therapy

2.3.4Treating Tinnitus Associated with Middle Ear Myoclonu

2.4Other Relevant Conditions

2.5Conclusion

3Internet-Delivered Guided Self-Help Treatments for Tinnitus

Gerhard Andersson and Eldre Beukes

3.1Background

3.1.1Tinnitus and Self-Help Material

3.2Internet-Delivered Guided Self-Help

3.2.1Technical Functionality of the Internet Platform

3.2.2Conducting Assessments

3.2.3Theoretical Foundation of the Intervention

3.2.4The Intervention Content

3.2.5Supporting Patients

3.2.6Fostering Adherence

3.3Evaluation of Internet-Interventions for Tinnitus and Potential Problems

3.3.1Effects of the Internet-Based Self-Help for Tinnitus

3.3.2Problems Related to Dropouts and Compliance

3.3.3Security and Technical Concerns

3.4Conclusion

Appendix 3.1 Suggested Self-Help Resources for Tinnitus

Appendix 3.2 Tinnitus Self-Treatment Brochure

4Tinnitus Activities Treatment

Ann Perreau, Richard S. Tyler, Patricia C. Mancini, and Shelley A. Witt

4.1Introduction

4.1.1Patient Expectation Nurturing

4.1.2Picture-Based Counseling

4.1.3Patient-Centered Approach to Care

4.2Discussion

4.2.1Thoughts and Emotions

4.2.2Hearing and Communication

4.2.3Sleep

4.2.4Concentration

4.3Conclusion

Appendix 4.1 Tinnitus Primary Functions Questionnaire (12-Item Version)

Appendix 4.2 Things You Can Do for Your Tinnitus

Appendix 4.3a Tinnitus Diary

Appendix 4.3b Tinnitus Diary Example Case

Appendix 4.4 Strategies to Improve Hearing and Communication

Appendix 4.5 A Guide to a Good Night’s Sleep for Tinnitus Patients

Appendix 4.6 Strategies to Improve Your Sleep

Appendix 4.7 Strategies to Improve Concentration

Appendix 4.8 Daily Listening Diary

5Three-Track Tinnitus Protocol: Counseling Emphasizing the Patient, the Clinician, and the Alliance

Anne-Mette Mohr

5.1Introduction

5.2Protocol

5.2.1Making the Initial Contac

5.2.2The First Session: The Contract

5.2.3Working in the Tracks

5.3Conclusion

6The Psychological Management of Tinnitus-Related Insomnia

Laurence McKenna and Elizabeth Marks

6.1Introduction

6.2The Cognitive Behavioral Model

6.2.1Cognitive Behavioral Therapy and Insomnia

6.2.2The CB Model, Tinnitus, and Sleep

6.3Group Therapy

6.4Selection and Definitions

6.5Assessment

6.5.1Questionnaire Measures

6.5.2Sleep Diaries

6.6Group Structure

6.7Treatment Protocol: Key Components

6.7.1Group Support

6.7.2Psychoeducation

6.7.3Individual Goal Setting

6.7.4Creating an Individualized Sleep Program

6.7.5Sleep Titration

6.7.6Stimulus Control

6.7.7Motivation and Video Modeling

6.7.8Relaxation

6.7.9Cognitive Restructuring (Cognitive Therapy)

6.7.10Worry Period

6.7.11Sleep Hygiene

6.7.12Sound Enrichment

6.7.13ClockWatching

6.8Conclusion

Appendix 6.1 Relaxation Listening for Sleep

7Optimizing Hearing Aid Fittings for Tinnitus Management

Grant D. Searchfield and Alice H. Smith

7.1Introduction

7.2Benefits, Modes, and Mechanisms

7.3Clinic Protocol

7.3.1Audiometry and Evaluation

7.3.2Aural Rehabilitation and Goal Setting

7.3.3Instruction

7.3.4Counseling

7.3.5Sensory Management: Selection of Hearing Aids and Their Features

7.3.6Perceptual Training

7.3.7Appointment Scheduling and Follow-Up

7.4Conclusion

8Combining Sound Therapy with Amplification

Grant D. Searchfield, Mithila Durai, and Tania Linford

8.1Introduction

8.2Sound Therapy Framework

8.2.1The Presence of Sound Effec

8.2.2The Context of Sound Effect

8.2.3Reaction to Sound Effect

8.2.4Adaptation to Sound

8.2.5WHO International Classification of Functioning, Disability, and Health

8.3.7Negative Effects

8.3.8Perceptual Training

8.3.9Follow-Up

8.3.1Audiometry and Evaluation

8.3.2Aural Rehabilitation and Goal Setting

8.3.3Instruction

8.3.4Counseling

8.3.5Sensory Management: Selection and Use of Different Sounds

8.3.6Device Selection and Fitting

8.3.10New and Emerging Concepts

8.4Conclusion

9The Clinical Relevance of Apps for Tinnitus

Ann Perreau, Elizabeth Fetscher, and Michael Piskosz

9.1Introduction

9.2Apps for Tinnitus Assessment and Management

9.2.1Apps for Education and Information on Tinnitus

9.2.2Apps forWellness

9.2.3Limitations and Risks Associated with Smartphone Apps

9.3Conclusions

10Distractions, Relaxation, and Peace with Tinnitus: Guided Imagery, Meditation, Mindfulness, and More

Ann Perreau, Courtney Baker, and Richard S. Tyler

10.1Introduction

10.2Meditation

10.3Mindfulness

10.4Guided Imagery

10.5Biofeedback

10.6Progressive Muscle Relaxation

10.7Art Therapy

10.8Music Therapy

10.9Exercise

10.10A New Hobby

10.11Conclusions

11Tinnitus in Children

Mohamed Salah Elgandy and Claudia Coelho

11.1Introduction

11.2Prevalence

11.3Etiology of Tinnitus in Children

11.4Factors that may Promote Tinnitus in Children

11.4.1Age

11.4.2Gender

11.4.3Hearing Loss

11.4.4Temporary Threshold Shifts

11.4.5Motion Sickness

11.4.6Hyperacusis

11.5Criteria of Tinnitus in Children

11.6Impact of Tinnitus on Children and Parents

11.7Evaluation

11.7.1History

11.7.2Physical Examination

11.7.3Audiological

11.7.4Laboratory Evaluations

11.7.5Radiological

11.8Preventing Tinnitus in Children

11.9Treatment Options

11.9.1Medical Treatment

11.9.2Surgical Treatment

11.9.3Counseling

11.10Conclusion

12Measuring Tinnitus and Reactions to Tinnitus

Ann Perreau, Patricia C. Mancini, and Richard S. Tyler

12.1Introduction

12.2Measuring Tinnitus

12.2.1Psychoacoustic Measurements

12.2.2Measuring Reactions to Tinnitus

12.3Measuring Quality of Life

12.3.1Measuring Related Problems

12.4Conclusions

Appendix 12.1 Data Sheet

Appendix 12.2 Tinnitus Handicap Questionnaire

Appendix 12.3 Tinnitus Intake Questionnaire

Appendix 12.4 Meaning of Life and Happiness Questionnaire

Appendix 12.5 Ordered References for Tinnitus Outcome Measures

13Hyperacusis

Richard S. Tyler, Ann Perreau, and Patricia C. Mancini

13.1Introduction

13.2Terminology

13.3Causes

13.4Mechanisms

13.5Measuring Hyperacusis

13.6Questionnaires

13.7Treatments

13.7.1Counseling—Hyperacusis Activity Treatment

13.7.2Introduction

13.7.3Thoughts and Emotions

13.7.4Hearing and Communication

13.7.5Sleep

13.7.6Concentration

13.7.7Hearing Protection

13.7.8Sound Therapies

13.7.9Using Hearing Aids to Help with Hyperacusis

13.8Conclusion

Appendix 13.1 Hyperacusis Problems Questionnaire

Appendix 13.2 Hyperacusis Intake Questionnaire

Appendix 13.3 Hyperacusis Disability and Handicap Scales

Appendix 13.4 Life too Loud? Let’s Talk Hyperacusis

Appendix 13.5 Hyperacusis Activities Treatment

Appendix 13.6 Sound Therapy Treatment Protocol for Hyperacusis

Appendix 13.7 Hyperacusis Listening Diary Example Case

14Navigating Future Directions in Tinnitus Treatment

Fatima T. Husain

14.1Introduction

14.1.1What Should a Clinician Tell a Patient About Novel Treatment Methods?

14.2.2Magnetic Stimulation and Tinnitus

14.2.3Caveats

14.2.4Electric Stimulation

14.2.5Electric Stimulation and Tinnitus

14.2.6Caveats

14.3Vagus Nerve Stimulation

14.2Neuromodulation—Magnetic Stimulation, Electric Stimulation

14.2.1What Is Magnetic Neuromodulation?

14.3.1Vagus Nerve Stimulation and Tinnitus

14.3.2Caveats

14.4Neurofeedback

14.4.1Neurofeedback and Tinnitus

14.4.2Caveats

14.5Conclusions

15Establishing a Tinnitus and Hyperacusis Clinic

Patricia C. Mancini, Shelley A. Witt, Richard S. Tyler, and Ann Perreau

15.1Introduction

15.2Structuring Clinical Services

15.2.1Group Educational Session

15.2.2Individual Sessions

15.3Different Treatment Levels for Different Tinnitus and Hyperacusis Patients

15.3.1Tinnitus

15.3.2Hyperacusis

15.4Billing for Tinnitus Services

15.5Conclusion

Appendix 15.1 Shared Medical VisitWaiver

Appendix 15.2 Tinnitus Intake Questionnaire

Appendix 15.3 Tinnitus Treatment Fact Sheet

Index

Videos

Video 1.1:

Tinnitus patient interview 1

Video 1.2:

Tinnitus patient interview 3

Video 4.1:

Tinnitus Activities Treatment introduction counseling

Video 4.2:

Tinnitus Activities Treatment summary session

Video 4.3:

Tinnitus diary

Video 5.1:

Patient interview 1 with Anne-Mette Mohr

Video 5.2:

Patient interview 2 with Anne-Mette Mohrr

Video 5.3:

Patient interview 3 with Anne-Mette Mohr

Video 6.1:

Discussing sleep hygiene, sound therapy, and relaxation for bed (AW)

Video 7.1:

Demonstration of hearing aid fitting

Video 8.1:

Narrate hearing aids and wearable tinnitus devices

Video 10.1:

Demonstrate mindfulness/meditation exercises

Video 11.1:

Interview child with tinnitus or parents

Video 12.1:

Demonstration of psychoacoustic testing

Video 13.1:

Interview hyperacusis patient 1

Video 13.2:

Interview hyperacusis patient 2

Video 13.3:

Interview hyperacusis patient 3

Video 13.4:

Interview hyperacusis patient 4

Video 15.1:

Narrate group TAT slides

Foreword

Audiologists are expected to have the knowledge and skills necessary to provide appropriate care for individuals with a variety of hearing and balance issues. The field of audiology, however, is so rich and diverse that it is inappropriate to assume that audiologists can be experts in every area. For example, an audiologist can specialize in diagnostics, treatment, research, and/or teaching (to name a few), can pick a specific work environment (e.g., health care, private practice, education, manufacturing), and can even select a specific age group for care (i.e., infants, from birth to 3-year-old children, school-aged children, adults, and/or geriatrics). After choosing a specific area of interest, work setting, and/or age group, audiologists are inundated with a variety of different theories, approaches, devices, and techniques, all available to achieve the same goals. Hence, lies the problem. The field is so rich and diverse that it often leaves the audiologists feeling overwhelmed and less confident of their abilities. Historically, audiologists could rely on their graduate programs to provide them with the knowledge and skills needed to feel confident enough to venture out and to begin practice.

Unfortunately, most graduate programs are still not strong or relevant in the area of treating individuals with bothersome tinnitus and/or hyperacusis. This must change. The field of audiology needs to do a better job of providing audiologists with the tools necessary to feel confident in this area. This book does just that! This book and the supplemental online content contain the most comprehensive background and up-to-date strategies and tools for treating individuals with bothersome tinnitus and/or hyperacusis. This textbook should be read by every audiology student not only as an introduction to this area of interest, but as an advanced classroom resource. In addition, any practicing audiologist who feels underprepared in managing tinnitus and hyperacusis should be strongly encouraged to use this textbook and the supplemental materials as a guide. You could not ask for a more talented set of authors who not only contribute to the most current research on tinnitus and hyperacusis, but who are also working in the trenches side by side with their patients providing this much-needed service. Audiologists are the most suitable to work with this patient population. Audiologists need to be providing tinnitus and hyperacusis management services on a much more common basis. This is the textbook to provide the knowledge and confidence that audiologists are lacking. You hold in your hand the only needed resource to begin your work. Read it, watch the online videos, go through the handouts, then have faith in yourself and start implementing these ideas with your tinnitus and hyperacusis patients. If you do this work, you will end up feeling more satisfied in your career than you ever have felt before. If I (along with the authors of this textbook) can do this work, so can you.

Shelley A. Witt, MA/CCC-A

Department of Otolaryngology–Head and

Neck Surgery

University of Iowa

Iowa City, Iowa, USA

Preface

In this second edition, we hope to provide the most comprehensive background and up-to-date strategies for treating tinnitus and hyperacusis patients. The textbook is useful for audiology students as an introduction and as an advanced classroom resource for tinnitus management. Also, because many audiologists and clinicians do not receive sufficient training in assessing and treating tinnitus and hyperacusis, we hope this textbook is valuable in providing additional tools and guidance for practicing clinicians.

Since the first edition of 2005, new developments and areas of interest have emerged that impact treatment. For example, sensory meditation and mindfulness is an approach to treat several chronic health conditions, including tinnitus, which is now included in our second edition. We have also reviewed smartphone apps that have emerged in recent years as a helpful tool for managing tinnitus, but caution is needed. Additionally, hyperacusis, an abnormal sensitivity to sounds, is reported by many patients and is included in this new edition. Although there is now a plethora of “information” available via the Internet and many self-help books for patients to help with tinnitus treatment, this textbook provides helpful information on important topics pertaining to tinnitus that is grounded in years of clinical experience and research. We strive to meet the needs of audiologists and clinicians who guide tinnitus and hyperacusis patients in their journey by providing relevant and updated information, including varied perspectives from authors around the world who are well-respected clinicians and researchers on tinnitus.

This textbook contains 15 chapters. The first three chapters provide an overview of tinnitus models, treatment approaches, and self-treatment options. Chapter 1 reviews neurophysiological and psychological models of tinnitus and therapy approaches including counseling and sound therapy for tinnitus. Chapter 2 provides guidance on treating patients with tinnitus who are diagnosed from otologic pathology such as Meniere’s disease, vestibular schwannoma, unilateral sudden sensorineural hearing loss, and middle ear myoclonus. Chapter 3 summarizes an emerging topic of Internet-delivered, self-help treatment, and the research evidence that supports effectiveness of self-help strategies such as apps and self-help books.

The next three chapters, Chapters 4 to 6, summarize counseling approaches for audiologists and psychologists. Chapter 4 on “Tinnitus Activities Treatment” describes our counseling and sound therapy program that has been used in tinnitus management for decades and provides helpful suggestions for audiologists and clinicians to implement this picture-based and customized therapy approach. Chapter 5 introduces the “Three-Track Tinnitus Protocol,” a psychological counseling program that outlines the three components of the Patient–Tinnitus Track, the Patient–Life-World Track, and the Clinician–Patient Track in managing tinnitus. Chapter 6 provides an overview of psychological management of insomnia, a common problem among tinnitus patients, and reviews the cognitive behavioral model as it applies to insomnia.

Chapters 7 to 10 describe approaches to managing tinnitus using amplification, sound therapy, and meditation and mindfulness. Chapter 7 describes the benefits of hearing aids in the management of tinnitus for patients who have hearing loss, incorporating research evidence, and outlining new hearing aid technology and fitting strategies. Chapter 8 reviews sound therapy using wearable devices including the mechanisms for sound therapy effectiveness in treating tinnitus and provides a fitting protocol for audiologists and clinicians based on the individual’s goals. Chapter 9, a new chapter in the second edition, explores smartphone apps for tinnitus, including apps for assessment and management of tinnitus, and apps for education and wellness, and reviews the limitations associated with apps used for managing tinnitus. Chapter 10, a new chapter, describes several options for relaxation or distraction from tinnitus, including meditation, mindfulness, guided imagery, biofeedback, progressive muscle relaxation, art therapy, music therapy, exercise, and exploration of new hobbies. Many of these relaxation techniques are demonstrated in the chapter, and research and clinical reports are included.

The last five chapters provide guidance on specific topics related to tinnitus management such as treating children with tinnitus, implementing outcome measures, treating hyperacusis, and navigating future directions in tinnitus treatment. Chapter 11 provides a thorough review of etiologies, diagnoses, and treatment options when working with children with tinnitus. Special attention is paid to the prevention of tinnitus through education and awareness on hearing protection and ototoxic medications. Chapter 12 summarizes the methods for measuring tinnitus and reactions to tinnitus, including use of psychoacoustic measures of tinnitus, questionnaires, diaries, and scales on associated problems for depression, anxiety, and sleep. Chapter 13 reviews hyperacusis by introducing its symptoms, causes and mechanisms, and diagnosis and treatment including counseling, sound therapy, medications, and use of hearing protection in noisy situations. Common complaints of patients with hyperacusis are reviewed to illustrate the everyday experiences of patients and ways these complaints can be addressed by the clinician and audiologist. Chapter 14 explores emerging treatments of tinnitus, such as vagus nerve stimulation and transcranial magnetic stimulation, and explains the neural networks for tinnitus to demonstrate the application of these treatments. The final chapter, Chapter 15, provides an overview for audiologists and clinicians who wish to expand their professional services and establish a tinnitus and hyperacusis clinic. We outline group educational and individual counseling sessions, structuring the clinic, and billing for services.

In addition to the textbook, we have developed new supplemental materials to both demonstrate the techniques discussed in the book and to provide helpful tools in tinnitus and hyperacusis management. Some chapters in the book offer appendices, which have been carefully selected to help the audiologist and clinician in implementing treatment protocols and procedures in their clinical practice. Apart from the appendices, there are multiple videos such as interviews of patients with tinnitus and hyperacusis, counseling and sound therapy demonstrations, mindfulness and meditation exercises, psychoacoustic testing, and hearing aid fittings for tinnitus patients. We also included handouts on counseling; relaxation and sound therapy; questionnaires on tinnitus, hyperacusis, and quality of life; and datasheets on psychoacoustic testing for clinicians and audiologists to use in clinical practice. The brochures and slides for Tinnitus Activities Treatment used in our clinics at the University of Iowa and at Augustana College are also available as appendices. All videos are available on Thieme MedOne. We acknowledge the efforts of the reviewers for this book, including researchers, clinicians, and audiology students, who provided valuable inputs for the final product.

Richard S. Tyler, PhD

Ann Perreau, BA, MA, PhD

Acknowledgments

Many have helped with my career and my interest in tinnitus and hyperacusis.

Jim Stouffer helped me appreciate the importance of good science. Bill Yovetich helped me move beyond my stuttering. Arnold Small, David Lilly, Jim Curtis, and Paul Abbas provided a detailed background to the field. Ross Coles opened a switch on tinnitus. Then Johnathan Hazell, Pawel and Margarette Jastreboff, and Jean-Marie Aran opened up the widespread diverse perspectives. Jack Vernon and Mary Meikle showed me how much they cared about their patients. Peter Wilson opened up cognitive behavior therapy for tinnitus for me. Carol Bauer and Bob Dobie brought in the medical perspective. Jay Rubenstein and Paul Van de Heyning convinced me cochlear implants could help. Dick Salvi and Josef Rauschecker searched for mechanisms. Bill Noble and Dennis McFadden helped with the science. Bob Levine opened up somatosensory issues. And Ann and Shelley … a thoughtful, dedicated team … WOW … and there were many more…

Every author in this book has influenced my strategies. We do not have to agree, but listen … and learn and adapt from our different perspectives; and it is helpful that we all have different perspectives. So many people are moving this forward in so many directions.

Thank You! All of you. I dedicate this book to You!

Richard S. Tyler, PhD

This book is shaped by many individuals who have had a hand in my work. To my mentors at the University of Iowa: Carolyn Brown, Paul Abbas, Chris Turner, and Ruth Bentler, thank you for your guidance in my early years. I thank Kathy Jakielski, who has supported me since the day of our first meeting at Augustana College. I appreciate so many colleagues, Shelley A. Witt, Hua Ou, and Smita Agrawal, who have had such a profound impact on me as an audiologist and scholar. To the patients and research participants at the Tinnitus and Hyperacusis Clinic at the University of Iowa and Augustana College Roseman Center for Speech, Language, and Hearing, you give me inspiration and motivation every day! I am grateful for years of mentorship and involvement of students from undergraduates to doctoral candidates in CSD and audiology who have contributed to my work and research over the years. I thank Courtney Baker who assisted with editing and recording of the supplemental videos and was an integral part of creating this new edition. Finally, thanks to Richard S. Tyler for making this dream a reality and helping me achieve this milestone!

I also acknowledge Annette Schneider who assisted with the final proofs of the book.

Ann Perreau, BA, MA, PhD

Contributors

Gerhard Andersson, PhD

Professor

Department of Behavioural Sciences and Learning

Department of Biomedical and Clinical Sciences

Linköping University

Linköping, Sweden

David M. Baguley, BSc, MSc, MBA, PhD

Professor of Hearing Sciences;

Consultant Clinical Scientist (Audiology)

NIHR Nottingham Biomedical Research Centre, Hearing Sciences

Division of Clinical Neuroscience, School of Medicine

University of Nottingham

Nottingham, UK

Courtney Baker, BA

Doctoral of Audiology Student

Northwestern University

Evanston, Illinois, USA

Manohar L. Bance, MB, ChB, MSc, MM

Professor of Otology and Skull Base Surgery

Department of Clinical NeuroscienceUniversity of Cambridge

Cambridge, UK

Eldre Beukes, PhD

Department of Speech and Hearing Sciences Lamar University

Beaumont, Texas, USA;

Vision and Hearing Sciences Research Centre Anglia Ruskin University

Cambridge, UK

Claudia Coelho, MD, PhD

Department of Otolaryngology–Head and Neck Surgery

University of Iowa

Iowa City, Iowa, USA;

College of MedicinePostgraduate Program in Medical SciencesUniversity of Vale do Taquari

Univates

Lajeado, Rio Grande do Sul, Brazil

Mithila Durai, BSc, MAud (Hons), PhD

Research Fellow (Audiology)

School of Population Health The University of Auckland

Auckland, New Zealand

Mohamed Salah Elgandy, MD

Department of Otolaryngology–Head and Neck Surgery, Zagazig University

Az Zagazig, Ash Sharqiyah, Egypt;

Department of Otolaryngology–Head and Neck Surgery University of Iowa

Iowa City, Iowa, USA

Elizabeth Fetscher, AuD

Communication Sciences and Disorders Illinois State University

Normal, Illinois, USA

Phillip E. Gander, PhD

Associate Research Scientist

Department of Neurosurgery University of Iowa

Iowa City, Iowa, USA

Fatima T. Husain, PhD

Professor

Department of Speech and Hearing Science, Neuroscience Program

The Beckman Institute for Advanced Science and Technology

University of Illinois at Urbana-Champaign

Champaign, Illinois, USA

Tania Linford, BSc, MAud

Professional Teaching Fellow;

Audiologist

Hearing and Tinnitus Clinic

Audiology, School of Population Health The University of Auckland

Auckland, New Zealand

Patricia C. Mancini, PhD

Associate Professor

Department of Speech-Pathology and Audiology;

Full professor

Speech-Pathology and Audiology Sciences Post-Graduate Program

Federal University of Minas Gerais

Minas Gerais, Brazil

Elizabeth Marks, PhD

Clinical Psychologist and Lecturer

Department of PsychologyUniversity of Bath

England, UK

Laurence McKenna, MClin Psychol, PhD

Consultant Clinical Psychologist

Royal National ENT & Eastman Dental HospitalsUCLH & UCL

London, UK

Anne-Mette Mohr, MA, Candidate of Psychology

Clinical Psychologist;

Director

House of Hearing

Private Practising Clinical Psychologist

Psykologcentret NordvestCopenhagen, Denmark

Ann Perreau, BA, MA, PhD

Associate Professor of Communication Sciences and Disorders

Audiology Clinic Coordinator

Roseman Center for Speech, Language, and Hearing

Augustana CollegeRockland Island, Illinois, USA

Michael Piskosz, BA, BS, MS

Product Manager

Oticon Medical, LLCSomerset, New Jersey, USA

Grant D. Searchfield, BSc, MAud(Hons), PhD, MNZAS

Associate Professor;

Director

Hearing and Tinnitus Clinic;

Deputy Director

Eisdell Moore Centre, Faculty of Medical and Health Sciences University of Auckland

Auckland, New Zealand

Alice H. Smith, MA AuD

Professional Teaching Fellow;

Team leader

Hearing and Tinnitus Clinic, Audiology, School of Population Health

The University of Auckland

Auckland, New Zealand

Richard S. Tyler, PhD

Professor of Otolaryngology and Professor of Communication Sciences and Disorders

Roy J. and Lucille A. Carver College of Medicine

Department of Otolaryngology–Head and Neck Surgery University of Iowa

Iowa City, Iowa, USA

Shelley A. Witt, MA/CCC-A

Department of Otolaryngology–Head and Neck Surgery University of Iowa

Iowa City, Iowa, USA

1 Neurophysiological Models, Psychological Models, and Treatments for Tinnitus

Phillip E. Gander and Richard S. Tyler

Abstract

This chapter provides an overview of different models of tinnitus according to the two major categories of neurophysiological and psychological models. These models lead to different approaches to tinnitus treatment and the implementation of sound therapy and counseling protocols, which are summarized accordingly.

Keywords: neurophysiological, psychological, treatment, sound therapy, counseling

1.1 What Is Tinnitus?

A clear definition of tinnitus is from the study by McFadden.1 Tinnitus:

●Is a perception of sound (it must be heard).

●Is involuntary (not produced intentionally).

●Originates in the head (not hearing or overly sensitive to an external sound).

The patient’s reaction should also be considered. It is helpful to distinguish:

●Tinnitus that is problematic from that which is not.2

●How often the tinnitus occurs and how long an episode is (e.g., whether it occurs once a month for 10 s or is present daily).

Tinnitus has been classified in several ways, such as its presumed site of generation and whether it is audible to someone other than the patient (objective tinnitus) or the patient alone (subjective tinnitus). An objective tinnitus, heard by the examiner, may be of middle ear origin or a spontaneous otoacoustic emission arising from the sensorineural system and can occasionally be identified by physical examination to direct treatment options, such as in vascular causes. However, the terms subjective and objective are not particularly helpful in understanding or treating most forms of tinnitus. Instead, it is more useful to classify tinnitus in a manner analogous to hearing loss according to site of injury or generation3; that is, whether it is middle ear, sensorineural, or central tinnitus. A thorough physical examination and treatment of identified ailments, when possible, are important first steps in patients with tinnitus. However, a physical examination will typically not reveal a clear cause, that is, idiopathic tinnitus. Importantly, in all cases a distinction can be made between (1) the tinnitus and (2) the reaction to the tinnitus, which has become known as the psychological model of tinnitus.4 Regardless of the classification, the treatments described in this book are applicable to all types of tinnitus. See Appendix 1.1 for an overview of this chapter.

The overall impact of tinnitus on a patient is influenced by the characteristics of tinnitus and of that particular patient.5 For example, tinnitus is more likely to be annoying if it is louder or has a screeching quality. Some authors have incorrectly suggested that psychoacoustic factors are unimportant or unrelated to tinnitus annoyance. Psychoacoustic factors are indeed relevant,6,​7 although they are only one thing to consider in understanding the effect tinnitus has on a patient. An absence of high correlation between loudness and annoyance does not mean that loudness is not important. Stouffer and Tyler8 concluded that patients with soft tinnitus are not under as much stress as those who report a loud tinnitus. Also, patients who are under stress or have not had adequate sleep find the tinnitus more annoying.

Tinnitus is not a personality disorder, but psychological factors are involved in the development and maintenance of this problem (see, e.g., Folmer et al,9 Fowler and Fowler,10 Nondahl et al11). Although patients with severe tinnitus can have clinical depression, in our experience, serious psychological problems are rare among most tinnitus patients. Very few of us, after all, would not be bothered at all if we constantly heard an unwanted sound that we had no control over.

1.2 Neurophysiological Models of Tinnitus

A likely cause for tinnitus is maladaptive plasticity of the central nervous system.12 In essence, in response to some (typically unknown) causes, mechanisms that keep the nervous system in balance (i.e., homeostasis) lead to changes that result in the perception of tinnitus. In the normal auditory system, increases in neural activity evoked by acoustic stimuli are the basis for sound perception. Under conditions of a hearing loss, there is a decrease in input to the auditory system in the frequency range of the loss. Normal operation of the nervous system is to restore activity levels that have changed due to this decrease in input, to keep homeostasis.13 A mechanism for this restoration is modification of the sensitivity of neurons to their input and their resultant output activity by increasing the neural response gain.14 The increase in gain also leads to an increase in spontaneous activity in the absence of acoustic stimulation. Therefore, neurophysiological models have logically nominated this increase in spontaneous activity as a mechanism of tinnitus. Wherever the site of origin, most probably this activity change is transmitted to and results in an increased spontaneous rate in the auditory cortex. Table 1.1 reviews a few of the neurophysiological models that have been proposed over the years (for reviews, see Cacace,15 Eggermont,16 Eggermont and Roberts,17,​18 Jastreboff,19 Salvi et al,20 and Vernon and Moeller21). Some of these are specific to precise anatomic or physiological sites; others are more general models referring to processing principles.

Table 1.1 Examples of neurophysiological models of tinnitus

Kiang, Moxon, and Levine25

Edge between normal and absent hair cells and subsequent neural activity

Tonndorf29

Decoupling of stereocilia between the hair cells and tectorial membrane

Eggermont26

Moeller27

Cross-talk (interneural synchrony) between nerve fibers

Hazell30

Tinnitus is a result of automatic gain control system of central nervous system (e.g., normally increasing the sensitivity in quiet), linked to outer hair cells

Penner and Bilger31

Spontaneous otoacoustic emissions

Jastreboff19

Discordant inner and outer hair cell damage (damaged outer hair cells with reasonably intact inner hair cells)

Salvi et al20,​28

Increase in central neurons tuned to similar frequencies following reorganization of peripheral hearing loss

Llinás et al32

Abnormal neural oscillatory connection between thalamus and cortex

Noreña and Eggermont33

Eggermont and Roberts17

Cochlear damage leads to reduced inhibition in auditory system resulting in increased neural synchrony, spontaneous firing, and burst firing

Kaltenbach, Zhang, and Zacharek34

Hyperactivity of dorsal cochlear nucleus

Noreña35

Schaette and McAlpine36

Zeng37

Homeostatic plasticity after hearing loss results in neural hyperactivity from increased central gain

Leaver et al38

Rauschecker et al39

Failed “noise cancellation” system in frontostriatal network that gates and interprets neural noise

Roberts, Husain, and Eggermont41

Basal forebrain cholinergic attention system involved in tinnitus prominence and maintenance

De Ridder, Vanneste, and Freeman42

Multiple brain networks that interact with tinnitus “core” subnetwork

De Ridder et al43

Hearing loss reduces input and brain fills in missing information to resolve uncertainty

Sedley et al22

Brain reinterprets increased neural noise as a sound

In general, many of these models are insightful and clever. For models to be useful, they should be testable or should lead to a broader understanding and eventually a testable hypothesis. Unfortunately, many of these models are mutually exclusive22 and so it becomes difficult to separate testable hypotheses that usefully contribute to broader understanding.

Whatever the initial source of tinnitus, it must be perceived in the auditory cortex (see Tyler,23 p. 136; Vanneste and De Ridder24). Broadly, there are three different ways that the mechanism of tinnitus can be coded in the auditory cortex:

●Increased spontaneous activity fed by increase or decrease in activity or edge in activity.25

●Cross-fiber correlation with normal or increased spontaneous activity.26,​27

●More fibers with similar best frequency following hearing loss–induced auditory plasticity.20,​28

Fig. 1.1 shows a schematic representation of how we hear, interpret, and react to sounds. Sound is transformed from acoustic to electrical information in the cochlea. It is transmitted through the brainstem to the auditory centers of the brain within the temporal lobe of each hemisphere. Other parts of the brain are involved in our memory for sounds and our emotional reaction to them. Such neurophysiological models of hearing have existed for decades and were applied to tinnitus as early as 1988,44 and later popularized by Jastreboff.19 Although the mechanism responsible for the source of tinnitus initiation may potentially arise anywhere in the nervous system, its representation in the nervous system must be transmitted to the brain. Wilson45 (pp. 30, 31) suggested that tinnitus is coded in the auditory cortex “by virtue of the pattern of activity over many cells.” Like normal sounds, any reactions patients have to their tinnitus must involve other regions of the brain, such as the amygdala and the autonomic nervous system. Hallam et al46 (p. 44) discussed “neurophysiological models of habituation” and their importance in understanding and treating the emotional components of tinnitus. This model was widely accepted at the time (e.g., Hazell et al,47 p. 74).

Fig. 1.1 A general schematic representation of the process of hearing, interpreting, and reacting to sounds. The mechanism for the initiation of tinnitus may arise anywhere, but its representation eventually occurs in the auditory cortex. Any emotional responses must involve the amygdala and the autonomic nervous system (known connections between these regions are not shown in the diagram).

Noise-induced hearing loss, one of the most common causes of tinnitus, is known to inflict cochlear damage. Early studies of noise-induced hearing loss emphasized that both outer hair cells and inner hair cells are affected (e.g., Liberman and Dodds48). More recently, noise trauma has been found to disconnect inner hair cells from sensory neurons before damage to the inner hair cells is observed, a condition called cochlear synaptopathy.49 This has also been termed “hidden hearing loss” because outer hair cell function, which principally accounts for threshold test results, are unaffected. Importantly, it has been proposed that the change in inner hair cell function could contribute to the generation of tinnitus in some cases.36

While cochlear trauma may be an initiating condition, it is clear that tinnitus must also intimately involve the brainstem and cortex (Tyler,23 p. 136). This can be shown from several observations, including that:

●Sectioning the auditory nerve is often ineffective in reducing tinnitus.50

●Masking can be just as effective in the ear ipsilateral to the tinnitus as in the ear contralateral to the tinnitus (e.g., Tyler and Conrad-Armes51).

●Observing that a person who is convinced about hearing tinnitus in the right ear can suddenly hear the tinnitus in the left ear when the right ear tinnitus is masked.

●Documenting that disorders of the central auditory pathways can cause tinnitus.2

It is of interest, and perhaps a clue, that tinnitus can be influenced by other neurophysiological systems (for reviews, see Cacace,15,​52 Levine et al,53 Sanchez and Rocha54). For example, in some patients, tinnitus can be altered by touches to the hand, jaw movement, pressure to the head, and changes in eye gaze. Whether this is a property of tinnitus in general or just a subgroup can provide important information for treatment approaches.

Of course, because tinnitus can provoke emotional reactions, other neurophysiological systems that are responsible for emotions must also be involved, including the autonomic nervous system and the amygdala. Both Hallam et al46 and Slater and Terry55 described how the autonomic nervous system is involved in tinnitus. This unconscious involuntary control system is for “fight or flight.” The sympathetic system sets up the body for action, and the parasympathetic system operates after the extra alertness is past, to bring the body from its “highly aroused state to its normal state” (Slater and Terry,55 p. 177). The authors emphasized how the “dangers” sensed are typically stress related and reviewed in great detail the neurophysiological responses. They suggested coping strategies (e.g., relaxation techniques) as a treatment for the “inappropriate” autonomic response of tinnitus patients. It has been known for decades that a group of cortical and subcortical structures in the center of the brain (the limbic system) are involved whenever emotions are triggered (for reviews, see LeDoux56 and Mega et al57). Jastreboff19 pointed out that the limbic system, therefore, must be involved in tinnitus patients who have emotional reactions. However, the concept of a single “limbic system” is oversimplified as these structures are involved in different, but related functions.40 More recent evidence indicates that certain structures, such as the amygdala58,​121 may be more important than the whole system.15

We like the way Goodey44 (p. 84) explains tinnitus to his patients:

“Too few messages are passing through the ear to keep the hearing nerve busy and especially in quiet conditions, the electrically active nerve generates its own messages which are heard as tinnitus.”

1.3 Psychological Models of Tinnitus

Physiological and psychological models are inherently linked. One cannot have a change in thinking or behaving without some neurophysiological correlate. Studies, and related conceptual frameworks, that focus on thinking and behaving can be considered psychological. Table 1.2 reviews some psychological frameworks for considering tinnitus treatment.

Table 1.2 Psychological factors considered in treating tinnitus

Cognitive

Have developed inappropriate ways of thinking about tinnitus

Sweetow73,​74

Andersson and Kaldo (Chapter 8), Hallam and McKenna (Chapter 6), Hallam et al46

Habituation

Bothersome tinnitus is failure to habituate

Hallam et al46

Hallam75

Hallam and McKenna (Chapter 6)

Attention

Failure to shift attention away from tinnitus

Hallam and McKenna (Chapter 6), Hallam et al46

Hallam75

Learning

Responses to tinnitus are learned

Jastreboff and Hazell76

Bartnik and Skarz’yn’ski (Chapter 10) also McKenna,57 Hallam et al46

Acceptance

I accept it, is not good or bad

Mohr77

Ownership

I own the tinnitus; it is mine

Mohr and Hedelund78

These models are certainly not mutually exclusive. For example, Hallam et al,46 in their habituation model, noted that an organism needs to analyze (or attend to) new and potentially important stimuli. How we think about tinnitus influences our inclination to attend to it. External events can reinforce or inhibit our behavior. Learning theory, particularly classical conditioning, has been proposed as an important factor in the reaction to tinnitus (e.g., Jastreboff,59 McKenna60). Hallam et al46 (p. 44) suggested that “habituation can be delayed by intense, aversive and unpredictable stimuli to which affective significance has been attached by learning.”

1.4 Categories of Tinnitus Treatments

We can categorize tinnitus treatments in two ways. First, a treatment can focus on the tinnitus directly, reducing its magnitude or eliminating it completely. This can be approached by medications as described by Baguley in Chapter 2 (also see Dobie,100 Elgandy and Tyler,61 and Murai et al62) or electrical suppression (e.g., Dauman,63 Dobie et al,64 Elgandy et al,65 Hazell et al,66 Quaranta et al,67 Rubinstein and Tyler,68 Tyler et al,69 and Zwolan et al70) or neuromodulation.71,​72 Important insights in these approaches are discussed by Husain in Chapter 14.

Second, it is possible to treat a patient’s reaction to tinnitus. Medications can be used to treat patients with depression and anxiety and to help with sleep problems. Baguley in Chapter 2 highlights how some of the more common medical conditions influence the counseling strategy. Medications for some patients are important, but they are not specific to tinnitus and will not be reviewed here. Counseling and sound therapy are two treatments that have been in common use since the early 1980s. Appendix 1.1 provides a summary of treatment options.

1.5 Counseling in the Treatment of Tinnitus

Whether we spend 1 minute or 60 minutes with a patient, talking with and listening to the patient are the cornerstones of the current treatment. Counseling for tinnitus patients is often performed by audiologists without a strong theoretical background in the many counseling strategies available. Psychologists frame different counseling approaches (and there are literally hundreds) using very specific guidelines. Table 1.3 provides a few examples of these frameworks, taken from an excellent summary by Flasher and Fogle.79

Table 1.3 Psychological counseling approaches

Existential therapy

Concerns with individual’s overall existence in life, and how one deals with problems. Considers uncertainty, meaning, and isolation (see Chapter 5)

Cognitive therapy

Thoughts influence behavior, erroneous ways of thinking are identified, and steps for coping and correcting thoughts are identified (see Chapters 3 and 4)

Humanistic therapy

Promotes personal growth and positive support in a nondirective fashion (see Chapters 5 and 15)

Behavioral therapy

Focus is on changing the ways in which patients behave (see Chapters 3, 4, and 5)

These theoretical frameworks are also not mutually exclusive, but we suspect that tinnitus counseling would benefit from a deeper understanding of the theoretical background of different counseling approaches. Those clinicians who have some training in these approaches will put themselves in a better position to serve their tinnitus patients.

1.5.1 Be Supportive

We, and others,80,30,81 have noted how important it is to be supportive and to offer positive encouragement to the tinnitus patient (e.g., Coles and Hallam,80 Hazell,30 and Tyler et al81).

Whatever counseling strategy is adopted, providing reasonable hope and demonstrating that you are knowledgeable, sympathetic, and sincerely care will likely be helpful. A new and comprehensive approach to this is provided by Mohr in Chapter 5.

1.5.2 Provide Information

Most of the therapies designed for tinnitus provide information. Whichever neurophysiological or psychological model you adhere to, providing information helps patients better understand their problems and feel less victimized and puts them in a position of moving forward in treatment. Table 1.4 outlines the kinds of information that can be provided.

Table1.4 General categories of information typically provided to tinnitus patients

Hearing

How we hear

Anatomy and physiology of hearing

Hearing loss

Anatomy and physiology of hearing loss

Consequences of hearing loss

Tinnitus epidemiology

Prevalence of tinnitus

Causes of tinnitus

Common problems associated with tinnitus

Tinnitus mechanisms

Spontaneous activity of nerves

Neurophysiological models (see Table 1.1)

Central nervous system

Role of the brain in perceiving and reacting to sound

Habituation

Effect of repeated exposure to stimuli

Consequences of fearful stimuli

Consequences of not habituating to tinnitus

Attention

Factors that contribute to attention

Learning

Factors that contribute to learning

Sleep

Factors that influence sleep

Concentration

Factors that contribute to concentration

Auditory training

Things that influence our hearing and understanding

Lifestyles

How our overall lifestyle, including eating, exercise, and activities, influences our health

Self-image

How our self-image influences our beliefs and reactions

Treatment options

Variety of treatment options available for hearing loss, including hearing aids, cochlear implants, and auditory training

Treatment options for tinnitus

Variety of treatment options available for tinnitus, including coping strategies, relaxation therapy, cognitive behavior therapy, and sound therapies

The relative importance of each of these topics is unclear. It is unlikely that discussing any of them would have a negative impact, and thus, the question really is which to include or exclude, and how much time to spend on each topic. Obviously, too much information can be overwhelming for some patients, and it is possible to provide the information in too much detail or without sufficient clarity. This may prevent a patient from engaging in the other aspects of the treatment. We have proposed using pictures to facilitate the counseling process.82

Many of the counseling components of treatment focus primarily on providing information about hearing, hearing loss, and tinnitus (e.g., Bentler and Tyler,83 LaMarte and Tyler,84 Sheldrake et al,85 Tyler and Babin,3 and Tyler and Baker86). Some researchers, such as Hallam,75 include discussions about habituation and attention in their approaches (see Chapters 3, 4, 5, and 10 of this book), whereas others focus more on brain mechanisms and learning. All of the clinicians writing in this book provide information on their particular counseling approach, and the diversity of topics and emphasis is evident. For example, Chapter 9 shows how Apps can be used by patients to facilitate the transfer of information in conjunction with clinic visits.

1.5.3 Components of Counseling

Briefly, there are three components of most successful counseling programs:

●Changing thoughts.

●Changing behavior.

●Understanding an individual patient’s needs.

Changing Thoughts

Providing information can change the way patients think about their tinnitus. However, simply lecturing a patient is not enough, even if the information is useful. Understanding what caused the tinnitus, how the patient learned to react to it, and how the patient can help himself or herself is important. This is a key part of treatments that include aspects of cognitive therapy (see Hallam et al87; see also Chapters 3, 4, 9, and 10 in this book), even for young children (see Chapter 11).

Changing Behavior

Sometimes it is possible to change behavior simply by providing information. However, it is usually more effective to practice the desired behavior. Some coping strategies involve changing behavior; others deal with emotional reactions. Providing specific tasks to engage in is part of changing behavior. Chapters 3, 4, 9, and 13 offer numerous examples of engaging the patient in behavior management.

Understanding an Individual Patient’s Needs

A broader perspective on tinnitus treatment involves understanding the individual patient, how the person views tinnitus, what support the patient has, and how tinnitus fits into the bigger picture of the patient’s overall life. Listening, as opposed to providing information, is the first step. The Tinnitus Three-Track Tinnitus Protocol, as discussed in Chapter 5, is a wonderful example of this.

1.5.4 Examples of Counseling Treatment Protocols

Several counseling treatment protocols and strategies have been proposed. Most contain some aspect of providing information. Several go beyond that. Tyler and Baker86 suggest that counseling needs to consider all of the patient’s difficulties. They recommend that the major emphasis of counseling address the emotional problems related to tinnitus. Hazell30 (p. 113) suggests that “it is fruitless and unrealistic to approach the tinnitus in isolation.” Table 1.5 summarizes some of these protocols and strategies.

Table 1.5 Tinnitus treatment counseling strategies

Tyler and Baker86

Tyler and Babin3

Tyler et al88

Informational counseling

Providing information

Considering emotional problems related to tinnitus

Clark and Yanick89

Informational counseling

Understanding individual patient needs

Sweetow73,​74

Cognitive behavioral therapy

Providing information

Sleep

Changing attitude and self-esteem

Diversionary tactics (attention)

Coping strategies

Cognitive behavior therapy

Hallam75

Habituation therapy

Habituation

Attention

Relaxation

Modifying the environment

Coles2

Habituation therapy

Providing information

Coles and Hallam80

Habituation therapy

Relaxation

Habituation of reaction to tinnitus

Hazell30

Masking therapy

Providing information

Consideration of all the patient’s problems (e.g., business, financial, and domestic)

Reassurance

Attention

Relaxation

The use of diaries

Modifying the environment

Slater and Terry55

Guided therapy

Providing information

Attention

Activities

Habituation

Lifestyle changes (being positive and active)

Lindberg et al90

Tinnitus behavior therapy

Providing information

Coping

Stouffer et al91

Informational counseling

Various relaxation procedures

Providing information

Keeping diaries

Changing activities

Jastreboff and Hazell76

Retraining therapy

Providing information

“Directive” approach

Davis93

Living with tinnitus

Providing information

Stress management

Sleep

Changing thinking

McKenna60

Habituation therapy

Providing information

Habituation

Relaxation

Reactions to stress

Listening to the patient

Henry and Wilson94,​95

Cognitive behavioral therapy

Providing information

Self-help strategies

Sleep, depression

Attention control

Cognitive behavior therapy

Relaxation

Coping strategies

Relapse prevention

Tyler and Erlandsson96

Refocus therapy

Three tiers of treatment

Attention

Engagement in other activities

Tyler et al97

Tinnitus

Activities

Treatment

Group session

Individual counseling

Thoughts and emotions, hearing, sleep, concentration

Hearing aids

Sound therapy

Henry et al98

Progressive tinnitus

Management

Five levels of treatment

Triage

Audiologic management

Group education

Tinnitus evaluation

Individualized management

Cognitive Behavioral Therapy

Cognitive behavioral therapy has been applied to tinnitus for some time, has been discussed in the literature in great detail, and is arguably the only approach that has been shown to be effective in controlled studies.99,​100,​101 Several general concepts are used in many tinnitus counseling protocols, although not always acknowledged. The “providing information” component is intended to change the way individuals think about their tinnitus. The basic premise of cognitive behavioral therapy94,​95,​73,​74 is the following: Your tinnitus is there. The way that you think about it results in a particular emotional reaction.

Directive Counseling

One approach, directive counseling, or retraining therapy, stands alone, in that it explicitly frowns upon considering individual needs, addressing personal concerns, and providing suggestions for initiating behavioral changes. For example, Jastreboff102 (p. 291) describes it as a “teaching session”: “It is not, and never was, intended to be ... collaborative.” Furthermore, it was never intended to “change a patient’s perception, attention and emotions towards tinnitus ..., to improve a patient’s well-being, everyday life, social interactions and work abilities.”

The directive counseling approach prompted some concerns from several clinicians. For example, Wilson et al103 criticized retraining therapy for its “teaching” approach to counseling, which seemed to disregard standard counseling procedures that include a more interactive approach. Retraining therapy omitted basic principles leading the patient to discover unhelpful thoughts, develop realistic beliefs and attitudes, and modify their emotional response. Kroener-Herwig et al104 went on to criticize many components of retraining therapy, one of which was that it “completely neglected” procedures to help the patient modify behavior. They believed that many tinnitus sufferers require more sophisticated strategies than simply teaching information to them. Instead, they felt that some patients should receive intervention programs to change their beliefs about tinnitus, their emotions, and behavior. McKenna60 questioned the underlying philosophy of Jastreboff’s model, noting that its reliance on a classical conditioning perspective ignores the human component of tinnitus. Recent randomized controlled trials of tinnitus retraining therapy (TRT) have found little to no evidence for its effectiveness beyond standard care.105,​106

1.6 Sound Therapies for Treating Patients’ Reactions to Tinnitus

Sound has been used for decades to treat tinnitus (see Searchfield’s Chapters 7 and 8). Its role can be understood in terms of:

●Reducing the attention drawn to the tinnitus.

●Reducing the loudness of the tinnitus.

●Substituting a less disruptive noise (background sound) for an unpleasant one (tinnitus).

●Giving the patient some control.2,​107

Sound therapies include the use of background sound, hearing aids, total masking, partial masking (including retraining therapy), and music therapy. Most of the chapters in this book include sound therapy directly or indirectly. A recent study has documented that sound therapy can indeed help some patients.108

1.6.1 Counseling for Sound Therapies

Virtually, all sound therapies are combined with some form of counseling, even if it is just providing information. More typically, in addition to basic information about tinnitus, hearing loss, attention, and habituation, specific counseling is included on the use of sound. This is true whether the sound therapy uses hearing aids or partial masking. Bentler and Tyler,83 in their discussion of sound therapies, noted that, regardless of the management regimen chosen, counseling needs to be considered an integral component. Coles2 (p. 395) said that “good counseling will go far toward interrupting the sort of vicious cycles” in addition to the sound therapy. Table 1.6 lists some of the topics that are typically covered in counseling for sound therapy.

Table 1.6 Components of counseling for sound therapy

Rationale behind the use of background sound

Caution about using noise generators that are too intense; may interfere with speech and everyday sound perception, and may damage hearing

Selecting the type of noise generators

Selecting the ear or ears to receive noise generators

Selecting the ear mold(s) to use, if applicable

Trial periods of the background noise

Sources: After Hazell30; Tyler and Bentler.112

Occasionally, sound therapies are represented as if they do not include counseling. For example, Henry and Wilson74 (p. 574) suggest that no specific counseling protocol has been published for partial or total masking. This is at odds with the tinnitus partial masking therapy proposed by Hazell.30 In Hazell’s discussion of masking therapy, detailed counseling strategies are an essential component. In our opinion, no sound therapy should be administered without counseling. Searchfield (Chapter 8) and Perreau et al (Chapter 10) share this perspective.

1.6.2 Use of Hearing Aids

Listening to background sound has been recommended in the treatment of tinnitus for over 50 years.109 Because most patients with tinnitus also have hearing loss, the use of hearing aids to amplify the background noise is a logical step,92,​110 and many clinicians note the benefit (e.g., Bentler and Tyler83 and Searchfield et al111). Chapter 7 provides an excellent detailed strategy for fitting hearing aids for tinnitus patients.

In the late 1970s and early 1980s, several researchers observed that some patients required high levels of noise to mask the tinnitus, or even could not mask the tinnitus completely. Vernon and Schleuning110 stressed that the actual level of the noise should be under the control of the patient. Hazell and Wood113 found that the masking noise can be set so that the patient hears both the masking sound and the tinnitus. They noted that the noise provides a distraction that makes patients concentrate less on the tinnitus itself. Other authors reported that the intensity of the tinnitus can be reduced with the use of noise that did not completely mask the tinnitus, or partial masking.

This approach allowed patients to determine the level of noise they could tolerate. Hazell30 (p. 114) said that the masking sound “is most often effective at an apparent intensity much less than that of the patient’s tinnitus.”

Partial masking is a term that comes from the psychoacoustic literature, referring to the observation that the loudness of a tone can be reduced in the presence of background noise (e.g., Scharf114; Table 1.7).

Table 1.7 Examples of descriptions of partial masking in the literature

Tyler and Babin3

“Both the noise and tinnitus are heard, but the tinnitus is reduced in loudness” (p. 3213)

Patients should “use the lowest level masker that provides adequate relief” (p. 3213)

Coles and Hallam80

“A low level background sound against which the loudness of the tinnitus is reduced” (p. 994)

Erlandsson et al117

Reduced the noise from the complete masking condition until it was “comfortable enough to listen to” (p. 40)

Hazell30

“The masking sound does not completely cover the tinnitus,” and it provides a “distracting background sound” (p. 107)

The “tinnitus tends to ‘break through’ the masking noise” (p. 112)

Coles2

“When the masker is used to provide only a low level of background sound against which the loudness of the tinnitus is reduced” (p. 398)

Tyler and Bentler112

“Sometimes a masker can reduce the tinnitus loudness or annoyance, even though the tinnitus remains audible” (p. 55)

“Partially mask the tinnitus yet produce the lowest SPLs and the least interference with speech” (p. 59)