Treatments used in the management of tinnitus are aimed either at reducing the intensity of the tinnitus directly or at relieving the annoyance and distress caused by tinnitus (Han et al., 2009). Audiologists are generally concerned with the latter and management of tinnitus in clinic typically involves a combination of strategies: (1) habituation of perception, which aims to alleviate the intrusiveness of the tinnitus signal and (2) habituation of reaction, a psychological approach, which aims to adjust any negative and irrational reactions to tinnitus (Hobson et al., 2012).
1. Habituation of Perception
Sound Therapy or Sound Enrichment
Table-top or body-worn in-ear sound generators can present broadband noise, such as white or pink noise, or relaxing environmental sounds, such as rain or waves, which are intended to be relaxing and to alleviate the intrusiveness of the tinnitus signal. The main principle of sound-enrichment is that the therapeutic sound should be perceived as less disturbing than the tinnitus sound (Langguth et al, 2013).
Tinnitus Retraining Therapy
Tinnitus Retraining Therapy, or TRT, is a combination treatment of both counselling and sound therapy that was developed by Pawel Jastreboff and Jonathan Hazell in the 1980s. TRT is based on the neurophysiological model of tinnitus and its implementation is based on the plasticity of the brain and its natural tendency to eliminate (habituate) reactions to unimportant stimuli (Jastreboff & Hazell, 2004). Put simply, sound therapy induces habituation by reducing the strength of the tinnitus signal, while counselling aims to encourage the patient to reclassify their tinnitus into a neutral category to further facilitate habituation.
Hearing aids are cited to offer relief from tinnitus in some patients who have hearing loss (Andersson et al., 2011) and are widely used in Audiology clinics. Amplification compensates for the absence of auditory input in the frequency range of the hearing deficit. However, the 2013 literature review by Langguth et al. cite research that observes the limitation of hearing aids in the high-frequency range and the issue of dead regions in the cochlea. Research suggests that hearing aids may only provide benefit to tinnitus patients whose tinnitus is of a frequency that is within the amplification capabilities of a hearing aid and this is often less than 6kHz. However, hearing aids often help to enhance speech and environmental sounds, thereby drawing attention away from tinnitus (Han et al, 2009).
2. Habituation of Reaction
Counselling and Education
Patient counselling and education should form the foundation of all tinnitus treatments and can incorporate the provision of information, which should aim to explain and demystify the condition and correct any false beliefs, as well as empower and encourage patients to cope with the emotional consequences of tinnitus (Langguth et al., 2013).
Cognitive Behavioural Therapy
Cognitive-Behavioural Therapy, or CBT, aims to reduce the tinnitus-related disability by modifying dysfunctional cognitive, emotional and behavioural responses to tinnitus (Langguth et al, 2013). The main components of CBT include relaxation training, mindfulness training, psychoeducation, imagery training and attention-control techniques.
Research demonstrates an association between tinnitus and psychological disorders, with some studies reporting a high prevalence of tinnitus in patients with psychiatric illness, depressive disorder and anxiety when compared with the general population (Milerová et al, 2013). Relaxation therapy has long been judged to play an important part of a multi-strategy tinnitus in the psychological treatment of tinnitus, but appears to offer little benefit to tinnitus on its own (Baguley et al., 2013a).
In a health service that always faces the challenge of time restraints and long waiting lists, self-help interventions are becoming more frequently used in the clinical setting. CBT has been researched historically mainly in the face-to-face setting, but more recent literature has investigated the efficacy of self-help tinnitus treatments. A systematic review by Nyenhuis et al. (2013) concluded that self-help interventions are effective in the reduction of tinnitus distress and depressiveness in tinnitus patients, however, it is not known with any certainty as yet, how this efficacy compares with face-to-face treatments. Therefore, self-help CBT treatments are recommended in the healthcare setting to support tinnitus patients who are unable or unwilling to attend face-to-face counselling, which still remains the preferred method of administering CBT.
Tinnitus is difficult to assess and research. It is therefore a challenge to treat successfully. Research using human subjects, particularly trials, is scarce and the use of multi-disciplinary treatment approaches or combination rehabilitation strategies complicate the process of drawing scientific conclusions on the efficacy and value of each intervention (Baguley et al, 2013b). However, animal research and neuroimaging techniques have improved understanding of the pathophysiological mechanisms of the different types of tinnitus (Langguth et al., 2013). Despite the lack of research on tinnitus that is truly isolated from other influencing factors, a multidisciplinary approach that includes all of the treatment strategies discussed above remains the preferred treatment strategy for tinnitus. Indeed, while the benefits of such treatments may be small in most cases, and the perception of tinnitus is not eradicated, they do appear to have a significant and positive effect on quality of life (Baguley et al, 2013b).
Andersson, G., Keshishi, A. & Baguley, D. 2011. Benefit from hearing aids in users with and without tinnitus. Audiol Med. 9. pp73-78.
Baguley, D., Andersson, G., McFerran, D. & McKenna, L. 2013a. Tinnitus: A Multidisciplinary Approach. Wiley-Blackwell, UK.
Baguley, D.M., McFerran, D. & Hall, D. 2013b. Tinnitus. The Lancet. 382, pp1600-1607.
Han, B.I., Lee, H.W., Kim, T.Y., Lim, J.S. & Shin, K.S. 2009. Tinnitus: Characteristics, Causes Mechanisms, and Treatments. Journal of Clinical Neurology. 5, pp11-19.
Hobson, J., Chisholm, E. & El Refaie, A. 2012. Sound therapy (masking) in the management of tinnitus in adults (Review). The Cochrane Database of Systematic Reviews. Issue 11. Art. No.: CD006371. DOI: 10.1002/14651858.CD006371.pub3.
Jastreboff, P.J. & Hazell, J.W. 2004. Tinnitus Retraining Therapy. Cambridge University Press, New York.
Langguth, B., Kreuzer, P.M., Kleinjung, T. & De Ridder, D. 2013. Tinnitus: Causes and Clinical Management. Lancet Neurology. 12, pp920-930.
Milerová, J., Anders, M., Dvořák, T., Sand, P.G., Kniger, S. & Langguth, B. 2013. The influence of psychological factors on tinnitus severity. General Hospital Psychiatry. 35, pp412-416.
2013. A Systematic Review and Meta-Analysis on the Efficacy of Self-Help Interventions in Tinnitus, Cognitive Behaviour Therapy, 42:2, pp159-169.