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Tinnitus Handbook
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What is Tinnitus?
FIG 1. THE AUDITORY SYSTEM
Sound
waves
Outer
Tinnitus is a highly common condition
in which people perceive a sound or
noise which does not have a legitimate
external source. It is a symptom which
approximately 10-15% of the population report experiencing on a regular
basis.
10-15%
FIG 2. POPULATION LIVING
WITH TINNITUS
Tinnitus Handbook
Middle
Inner
Although many people think of tinnitus
as ringing in the ears, a huge variety of
sounds can be perceived, ranging from
single tones to complex tones, even
musical sounds. Although a common
condition, the level of upset caused by
tinnitus can vary significantly. For those
who do find their tinnitus distressing,
the experience can be life altering. Although no single clinically proven cure
exists for tinnitus there are a number of
well established paths which can offer
an improvement to symptoms for many
patients. Treatment paths range from
information, support, counselling and
various forms of treatment and therapy.
What causes Tinnitus?
‘What exactly is causing my tinnitus?’
is the first question that any individual distressed by tinnitus will ask. Most
people will perceive tinnitus at some
point in their lives, albeit this may be
temporary. Tinnitus may arise spontaneously without any clear cause only
to disappear as suddenly as it began.
Many individuals believe this is just a
function of the normal hearing system.
Tinnitus is known to occur as a concomitant of almost all the dysfunctions
that involve the human auditory system
[1], [2] but is most often associated with
a sensory-neural or congenital hearing
loss. Common risk factors include administration of certain medications,
middle ear disease, abnormalities in
the vascular system, and ear surgery.
Many theories have attempted to explain tinnitus and most focus on defects within the ear, especially the inner
ear. If this was consistently the case
however, we would still struggle to explain why many people with tinnitus
have normal hearing and conversely,
there are many people with hearing
loss who do not have any tinnitus. Ultimately tinnitus is a matter of perception. To better understand tinnitus, we
must therefore consider more of the
auditory system and incorporate an
understanding of the hearing pathways
within the brain – the so called ‘central
auditory system’.
Tinnitus Handbook
The auditory system is a sensory system which is responsible for the sense
of hearing. It is divided into the peripheral auditory system and central auditory system. The peripheral system as
seen in Fig 1 consists of the outer, middle and inner ear and this is where the
first stage of sound transduction occurs
and feeds directly into the nervous system. The re-encoded sound travels
down the vestibulocochlear nerve to
the central auditory system.
Numerous mechanisms and models
have been proposed as contributors
to tinnitus [3], [4]. Cochlear damage
is believed to be the initiating factor
which leads to altered patterns of neural activity along the central auditory
pathway [5]. Some suggest that after
cochlear damage a cascade of changes occur in central auditory pathways,
and some of these may serve as ‘neural
codes’ for tinnitus [4].
Are there different
types of Tinnitus?
Tinnitus is broadly categorised into
‘objective’ and ‘subjective’ tinnitus.
Objective tinnitus, although quite rare,
is an audible noise that emanates from
the ear and is often measurable audiologically. Subjective tinnitus, the most
common form of tinnitus, is described
as a sound or noise that has no external source and is audible only by the
patient. Studies have shown that subjective tinnitus is most often associated
with a high-frequency (noise or age-related) hearing loss [6].
Tinnitus may present itself unilaterally,
experienced in one ear only, or bilaterally, experienced in both ears, which is
more common. Unilateral tinnitus warrants further investigation as it is more
likely to be a sign of an underlying pathology. Some patients perceive the
tinnitus sound centrally, finding it difficult to pinpoint the exact location.
Tinnitus is often qualitatively described
as a single noise or tone, or as having
two or more components. The noise
may also be continuous or pulsatile.
Although ‘tinnitus’ derives from the
Latin word for ‘ringing’, it can take a
variety of qualitative forms including,
buzzing, whistling, hissing, whooshing,
or humming.
Tinnitus Handbook
Some patients report experiencing tinnitus exclusively in quiet environments,
whilst many others experience it even
in noisy environments. Many individuals report daily variability in the overall
intrusiveness of the condition, whilst
some individuals report a similar daily
variance in the pitch and quality of their
tinnitus.
The Impact of
Tinnitus
The initial onset of tinnitus is quite often associated with stress, which can
lead to negative thoughts and emotions, particularly if the tinnitus persists
[7]. Tinnitus also becomes a problem
when it is perceived as a threat, appears continuously intrusive, or when
patients have difficulty coping [8]. Tinnitus can lead to a repeating cycle of
annoyance, mood changes, fear, and
anxiety, all of which are associated with
tinnitus severity [9].
The Vicious Cycle.
FIG 3. THE VICIOUS CYCLE
For about 20% of people with tinnitus,
the tinnitus signal is classified by the
brain as ‘important’, associated with
something negative. This normally
happens when tinntus is first experienced – an unpleasant or traumatic
event occurs at the same time. Anxiety and annoyane caused by the event
are linked to the tinnitus, which in turn
causes the tinnitus to be considered a
more significant problem. Continious
tinnitus can lead to further anxiety and
stress in many individuals.
Tinnitus Handbook
Once a negative connection has been
established it may be difficult to break.
Should tinnitus symptoms persist, this
can trigger emotions such as a sense of
fear, danger and unhappiness. These
emotions can negatively affect the limbic system and the autonomic nervous
system, further compounding the negative association. This cycle of symptoms is commonly known as the vicious
cycle.
Can my Tinnitus
be cured?
A patient’s first step in determining the
approrpiate treatment for their symptoms should be to consult a qualified
medical practitioner. In some circumstances, where the origin of tinnitus is
clearly identified by the medical practitioner, proper management with clinical guidance can help reduce and in
some cases eliminate the tinnitus. This
result howevr is more common where
tinnitus symptoms are a direct result of
dietary habits or have arisen as a side
effects of a specific medication etc. As
a minimum, by consulting a qualified
medical practitioner, a tinnitus suffer
can reduce the risk of overlooking other, more serious causes for their tinnitus, which may require early treatment.
For most tinnitus patients however,
there is no clinically proven cure available for their symptoms. In the search
for a suitable treatment, tinnitus sufferes should be duly cautious when
assessing advertised treatments which
guarantee a cure or even a specific
reduction in symptoms. Although a
cure for tinnitus remains illusive, there
are many treatment options available
which may help patients to understand
their tinnitus and provide relief.
Tinnitus Handbook
In assessing treatments, a distinction
should be drawn between clinically
proven treatments which have received
regulatory approval prior to sale, or
are offered by qualified medical practitioners and those products or treatments which have not met the required
efficacy and safety standards. As an example, tinnitus patients may be familiar with advertisements claiming that
certain vitamins, herbs or other substances provide relief or even eliminate
tinnitus. It is important to note that
there are no proven benefits to these
claims at this time, and there is a risk
of negative side effects. Again, where
in doubt, patients should seek to consult a qaulified medical practitioner to
avoid potential risks.
Can treatment results
be guaranteed?
As tinnitus has a signifcant variety of
causes, types and impacts, it is unlikely
that a single solution will be developed
which will consistently address all types
of tinnitus in a consistent manner. Furthermore, the reaction of an individual to a treatment is also strongly influenced by their personality, biology
and enivironmental context. It is more
likely therefore, that a range of tinnitus
treatments will be needed to address
symtoms of different tinnitus sufferes.
While some treatments may offer an
average or mean improvement to patients, based on clinical trial results, this
should not be confused with a guaranteed similar result. Where a guaranteed result is advertised, again patients
should be duly cautious of such advertisements.
Can my tinnitus be
treated?
Tinnitus treatments and management
tools do exists which have been proven to deliver credible results to many
patients. Most importantly, there are
treatments which have met the regulatory standards needed to demonstrate
clinical efficacy and safety prior to sale.
Tinnitus Handbook
Due to the subjective nature of this disorder and the variety of factors which
may influence treatment, the results
experienced by patients may vary significantly in response to different treatments. It is therefore important that
patients work with qualified medical
practitioners to understand the options
available to them and what may offer
the best results for their tinnitus.
Currently both pharmacologic and
non-pharmacologic treatments as described below are used for managing
tinnitus. These range from different
forms of Sound Therapy; Tinnitus Retraining Therapy, Cognitive Behavioural
Therapy, Neuro-feedback, and various
forms of Electrical Stimulation. These
therapies tend to provide symptomatic
relief, but tend not to be overly effective in eliminating tinnitus. The chosen
treatment modality is often a function
of the severity of the condition. There
are a diverse range of available treatments, the benefit and limitations of
which have been discussed in numerous articles [10]. Pharmacological treatment of tinnitus has proven ineffective,
although some medications have been
reported to relieve symptoms [11].
There are currently no pharmacological agents specifically recommended
for the purpose of treating tinnitus [12].
What forms of
treatment / therapy
are there?
New approaches to tinnitus management are surfacing all the time. The
goal of all treatment plans should be
to break the vicious cycle and reduce
the negativity associated with the patients tinnitus. This may be achieved
through a reduction in patient stress responses and/or a reduction in tinnitus
symptoms. As with any treatment plan,
it should be understood that results
take time. Again it is therefore prudent to consult with a qualified medical practitioner prior to commencing
treatment. Some immediate relief may
be achieved from treatments, but ultimately long-term treatment should aim
to improve the patients quality of life
by reducing the perceived severity or
impact of symptoms.
Tinnitus Handbook
Reassurance
It may be difficut to believe, but reassurance and explanation are all that
many people with tinnitus require.
When tinnitus begins and tinnitus sufferes first perceive noise which others
are unable to hear, it is common to be
anxioius and fearful. This anxiety usuallly settles after the brain acclimatises
to this new sensation, as a result of the
process of habituation. Reassuring a
tinnitus sufferer can help promote habituation. Simply understanding what
is causing the problem can be a great
help in hastening this problem [13].
Complementary Therapy
Many complemantary or alternative
therapies have been tried by people
with tinnitus, including accupuncture,
reflexology, craniosacral therapy, homoeopathy, herbalism, aromatherapy,
massage, osteopathy (include cranial
sacral therapy), biofeedback, hypnosis, magnets, oxygen yoga, prayer, and
meditation.
Few of these therapies have been subjective to rigorous scientific scruting.
However for some individuals these
treatments help to provide relief from
their tinnitus and can certainly help
people to relax which in turn has a positive impact.
Psychological treatments
It known that tinnitus can cause emotional disturbance and, conversely,
emotional disturbance can exacerbate tinnitus. Because of this, various
psychological treatments are offered,
most commonly Cognitive Behavioual
Therpay (CBT). CBT encourages you
to examine how your thought processes may be adversely affecting your behavious and how to change your ways
of thinking with the aim of bringing
about improvements. Researach has
shown that CBT certainly helps reduce
the impact of tinnitus.
An intervention like Cognitive Behavioural Therapy (CBT) by itself does
not influence the subjective loudness
of tinnitus or improve the associated
depression, but it may effectively increase an individual’s quality of life by
increasing the patient’s ability to deal
with chronic tinnitus [14]. The goal of
CBT in tinnitus treatment is to recognise and then correct any negative
thoughts and emotions an individual
has about their tinnitus.
Relaxation
Many people who practice regular relaxation says it reduces the loudness of
their tinnitus. It’s much easier to ignore.
It helps to break down the vicious circle
of stress and anxiety many people find
accompanies their tinnitus.
Tinnitus Handbook
Although it sounds easy, learning to
relax is a skill. Its takes practice and
effort. Relaxation therapies such as
biofeedback aim to manage stress by
changing the body’s reaction to it by
teaching individuals to manage their
automatic body functions such as muscle tension and body temperature.
Therapists offer strategies to divert the
individual attention away from their tinnitus-related symptoms. Although this
may not eliminate tinnitus, the main
aim is to improve an individual’s quality of life [15], by providing them with
behavioural and relaxation techniques.
Medication
The focus of research has shifted from
drugs that act on the ear to drugs that
act on the audiory pathways in the
brain. Although alot of these trials
have been reported on in newspapers,
internet etc, they are still experimental.
It is not yet known whether or not they
will have any effect and it is possible
that some of the drugs being tried will
have quite a few side effects.
Sound Therapy
Dental treatment
Sound therapy can be introduced in
many ways by means of everyday items
including TVs, radios, portable music players, fans and table-top sound
generators and sound pillows. Sound
therapy helps to reduce the perceived
strength of the tinnitus signal making
it more difficult to separate the tinnitus
from the background noise. Overtime,
less importance and priority is placed
on the tinnitus as the brain habituates
to it.
TMJ disorder is a very common disorder which arises from the temporomandibular joints and associated structures.
It is also known as temporomandibular
pain dysfunction or craniofacial disorder. Symptoms of TMJ include pain,
tenderness, abnormal bite, headaches
and facial sensitivity. Tinnitus can also
be a symptom of temporomandibular joint dysfunction. In most cases,
changing to a soft diet, jaw muscle exercises or use of anti-inflammatory or
analgesic drugs can help. For those
that grind their teeth, dental treatment
or bite realignment can help relieve the
symptoms of TMJ pain and associated
tinnitus for some individuals [16].
Hearing aids
It has long been good clinical practice
to offer hearing aids to individuals with
tinnitus who have associated hearing
loss. The aim is to increase the stimulation the auditory system in the brain
gets from external sounds so that the
tinnitus doesnt seem as intrusive and
the brain pays less attention to it. Also,
if there is a hearing loss, the individual may strain to hear which in turn can
make them more aware of their tinnitus. It is now possible to have a hearing aid fitted for even a very mild loss
and individuals often benefit in terms
of their tinnitus, however the benefits
or relief experienced tends to be temporary.
Tinnitus Handbook
Transcutaneous Electrical
Stimulation (TENS)
Transcutaneous Electrical Stimulation
(TENS) machines are commercially
available devices which apply pulsed
electrical stimuli to provide pain relief.
In a review of tinnitus, indicated Electrical Stimulation (ES) as a possible treatment modality for patients with severe
tinnitus [18].
ES for suppression of
tinnitus has been researched for many
years and it has been indicated as a
promising area of investigation [19].
Tinnitus Retraining Therapy (TRT)
Tinnitus Retraining Therapy (TRT) which
was developed by PJ Jastreboff in the
1990’s, is a commonly used habituation
programme which combines sound
therapy with directive counselling.
Sound is used to make the tinnitus less
noticeable as opposed to masking it
out, and it is used in conjunction with
an intense form of direct counselling
based on the Jasstebroff’s ‘neurophysiological model’ [13]. The combination
of sound therapy and counselling with
TRT is designed to lead to habituation,
which means that the tinnitus-related
neuronal activity is blocked from reaching the limbic and autonomic nervous
system and consequently there are no
negative reactions to the tinnitus [17].
Mutebutton™ Multisensory Tinnitus
Treatment
This treatment combines synchronous
audio and lingual (tongue) stimulation
to promote neuroplasticity amongst
patients. The signals are co-ordinated
through the mutebutton control device, which plays relaxing music and
audio tracks through the recommended Bluetooth headphones while sending corresponding signals through the
tonguetip™ intra-oral device.
Tinnitus Handbook
The aptly named ‘tonguetip’ rests on
the tip of the patient’s tongue, delivering stimulation to lingual nerves.
This synchronous stimulation promotes
neuroplasticity to reduce the symptoms
of tinnitus. The mutebutton system has
been shown to gradually reduce the illusory sounds of tinnitus.
Who should I consult
regarding my
tinnitus?
Although most cases of tinnitus are
harmless, seeking medical attention is
very important. A GP or Medical Professional can inform you about what
treatment options are available. Because tinnitus is unique from person to
person, it is important to find a treatment plan that is individulised for your
personal needs and works best for you.
It is strongly recommended that when
individuals become aware of their tinnitus they consult their doctor if it is
troubling them. If a person is very distressed and anxious about their tinnitus, a doctor may prescribe mild sedatives or sleeping medication. This
sometimes also results in a lessening
of the severity of the tinnitus noise. If
a simple cause (such as hardened earwax) can be ruled out, the doctor usually refers the person onwards to an
Ear, Nose and Throat (ENT) specialist.
An MRI scan or other procedures may
be carried out to ensure that there is
no serious underlying illness, but in
most cases, no discernible cause for
the tinnitus can be found. Occasionally, tinnitus is associated with Ménière’s
Disease, a disorder of the middle ear,
for which medication can be helpful.
Surgical intervention to treat tinnitus is
rare. As a result, ENT specialists tend
to have little or no ongoing role in
managing tinnitus.
Tinnitus Handbook
Audiologists and hearing therapists,
who may be of assistance in relation
to hearing difficulties, can also help in
tinnitus management. There are some
audiological (hearing-related) tests that
may be carried out to provide more information regarding your tinnitus.
The individual with troublesome tinnitus needs reassurance and encouragement in the early stages, as well
as information to aid understanding.
Knowing that others experience the
same symptoms and have reached a
stage where they are no longer affecting day-to-day life, can be reassuring.
Psychological support may be necessary, and counselling helps many at
this acute stage. An audiologist may
recommend a hearing aid which, while
improving hearing, may subdue the
tinnitus noise at the same time. Other
forms of ‘noise generators’ which help
to soften the tinnitus are also available.
Measuring
Tinnitus
It is widely acknowledged that there
are a lack of objective tools to measures and quantify tinnitus. Various
measures can be used to determine
the presence and severity of tinnitus
[20]. A thorough clinical examination,
including a complete patient history,
audiological assessment and in some
cases further investigation, is paramount in determining potential causes.
Although no single cure exists, there
are compelling treatment options available which can improve the patient’s
quality of life. In addition to seeking
advice from a qualified clinician, patients may benefit from talking to other
tinnitus sufferers and from the supports
offered by National Tinnitus Groups.
The assessments of tinnitus severity
and its impact also depend on valid
and reliable self-report instruments.
Self-report measures are increasingly used in tinnitus research and in the
management of tinnitus patients. The
use of robust outcome measures is of
great importance. There are a number
of validated questionnaires and inventories for the assessment of tinnitus impact.
Visit: www.TinnitusAwareness.ie .
Getting Support
Above all else, it is important for individuals who suffer from tinnitus to know
that they are not alone. Although the
perceived noise may be illusory, tinnitus is reported in roughly 10% - 15% of
the population.
Tinnitus Handbook
For more information on available
tinnitus support groups
Disclaimer
This handbook is not designed to and
does not provide personal medical advice, professional diagnosis, opinion,
treatment or services to you or to any
other individual. The Tinnitus Handbook is provided for general information and for educational purposes only.
The information provided is not a substitute for medical or professional care,
and you should not use the information
in place of a visit, call consultation or
the advice of your physician or other
healthcare provider. The makers of this
handbook are not liable or responsible
for any advice, course of treatment,
diagnosis or any other information,
services or product you obtain having
read this handbook.
If you believe you have any other health
problem, or if you have any questions
regarding your health or a medical
condition, you should promptly consult your physician or other healthcare
provider. Never disregard medical or
professional advice, or delay seeking it,
because of something you read in this
book. Never rely on information in this
book in place of seeking professional
medical advice.
Tinnitus Handbook
Appreciating that medical research is
constantly advancing, the information
in this handbook should not be considered current, complete or exhaustive,
nor should you rely on such information to recommend a course of treatment for you or any other individual.
Reliance on any information provided
in this handbook is solely at the discretion of the reader.
References
[1] Naughton, P., (2004), “The quest for
quiet: people’s experience of tinnitus in
Ireland”, A Research Study for the Irish
Tinnitus Association.
[8] Hazell, J., (1998), “Management
of tinnitus”, In H. Ludman & T. Wright
(Eds.), Diseases of the ear (pp. 202–
215). London: Arnold.
[2] Hoffman, H. J. & Reed, G. W., (2004),
“Tinnitus: Theory and management”,
Epidemiology of Tinnitus, 16-41.
[9] Henry, J. L., Dennis, K. & Schechter,
M. A., (2005), “General Review of Tinnitus: Prevalence, Mechanisms, Effects
and Management”, Journal of Speech,
Language and Hearing 48, 1204-1235.
[3] Baguley, D.M, (2002), “Mechanisms
of Tinnitus”, British Medical Bulletin,
63, 195212.
[4] Eggermont, J.J. & Roberts, L.E.,
(2004), “The Neuroscience of Tinnitus”, Trends in Neurosciences, 27(11),
676-682.
[5] Bauer, Carol A., et al., (2008), “Tinnitus and inferior colliculus activity in
chinchillas related to three distinct
patterns of cochlear trauma.” Journal
of neuroscience research 86(11), 25642578.
[6] Nicolas-Puel, Cécile, et al. “Characteristics of tinnitus and etiology of
associated hearing loss: a study of 123
patients. “The International Tinnitus
Journal 8.1 (2002): 37.
[7] Schmidtt, C., Patak, M. & Kroner-Herwig, B., (2000), “Stress and the
Onset of Sudden Hearing Loss and Tinnitus”, International Tinnitus Journal, 6,
41-49.
Tinnitus Handbook
[10] Langguth, B., Biesinger, E., Del Bo,
L., De Ridder, D., Goodey, R., Herraiz,
C. & Searchfield, G. D., (2011), “Algorithm for the diagnostic and therapeutic management of tinnitus”, In Textbook of tinnitus (pp. 381-385). Springer
New York.
[11] Perry, B. P., & Gantz, B. J., (2000),
“Medical and surgical evaluation and
management of tinnitus”, Tinnitus
handbook, 221-241
[12] Dobie, R.A., (1999), “A Review of
Randomized Clinical Trials in Tinnitus”,
The Laryngoscope 109(8), 1202-1211.
[13] McKenna, L., Baguley, D., & McFerran, D., (2011), “Living with tinnitus
and hyperacusis, Sheldon, London
[14] Martinez-Devesa, P., Perera, R. &
Theodoulou, M. (2010), “Cognitive
Behavioural Therapy for Tinnitus”, Cochrane Database System Revision 8(9).
[15] Ireland, C. E., Wilson P. H., &
Tonkin, J. P., (1985), “An Evaluation of
Relaxation
Training in the Treatment of Tinnitus
Management”, Behavioural Research
and Therapy 23(4), 423-30.
[16] Morgan, D. H., (1996), “Tinnitus
Caused by a Temporomandibular Disorder”, Proceedings of the Fifth International Tinnitus Seminar, 653-654.
[17] Jastreboff, P. J. & Hazell, J. W.,
(2006), “The Neurophysiological Model of Tinnitus and Decreased Sound
Tolerance”, Tinnitus Treatment: Clinical
Protocols, 32-36.
[18] Seidman, Michael D., and Gary P.
Jacobson. (1996). “Update on tinnitus”, Otolaryngologic Clinics of North
America, 29(3): 455-465.
[19] Rubinstein, J. T., & Tyler, R. S.,
(2004), “Electrical Suppression of Tinnitus”, In J. B. Snow, Jr. (eds), Tinnitus:
Theory and Management, Lewiston,
NY: BC Decker.
Tinnitus Handbook
[20] McCombe, A. Baugley, D. & Coles,
R. (2001), “Guidelines for the Grading
of Tinnitus Severity: The Results of a
Working Group Commissioned by the
British Association of Otolaryngologists, Head and Neck Surgeons 1999”,
Clinical Otolaryngology & Allied Science 26(5), 388-393.