While Searching for Tinnitus Cures, Interventions Aimed at Management Matter

By Marc Fagelson, PhD, and Heather Malyuk, AuD

The effects of tinnitus, such as interference with sleep and concentration, and anxiety and emotional distress, can be difficult to predict and manage for an individual patient. These effects involve contributions from mind and body that are unique to each patient. At present, no reliable or durable cure is available for chronic tinnitus. Tinnitus is a symptom and not a disease; unfortunately, the underlying conditions producing tinnitus in most cases defy uncomplicated explanation and cannot be altered in a way that would eliminate the sensation. However, the fact that tinnitus effects can be managed without the phantom sound’s complete remission (elimination) should influence the choices made by patients and providers as they interpret the tinnitus experience and the ways in which it affects quality of life.

Patients seeking relief from tinnitus may harbor counterproductive beliefs that span a spectrum of unrealistic expectations. Some patients report the expectation that if they receive a treatment, it is reasonable to expect remission of their tinnitus. Other patients express the belief that the lack of a cure precludes any chance for improvement. Because patients’ expectations may be based on the terminology used by providers and peers, there is value in clarifying some of the more commonly used terms.

Patients who seek tinnitus “treatment” are often confounded by the myriad approaches — especially on the internet — that purport to cure the sensation, or the sound itself. One way to address this situation is to differentiate the term “tinnitus treatment,” associated with a cure and the “fixing” of an underlying otologic or neural mechanism, from “tinnitus management,” in which the tinnitus sensation and its effects are targeted with no intent of shutting off (curing) the tinnitus. In other words, an intervention that purports to provide tinnitus treatment has as its objective a substantial decrease or the elimination of the tinnitus sound. By comparison, an intervention that targets the patient’s response to the tinnitus, or their reaction to its presence, would more reasonably be called a tinnitus management strategy. Differentiating these terms is central to both the expectations of the patient and the goals of the clinician. If patient and clinician are in clear agreement on the objectives of the intervention, then both parties will be able to identify strategies that reduce tinnitus distress and annoyance, while also reducing the frustration that arises when confronting the well-known lack of a consistent and easily accessible cure for most tinnitus cases.

The term “cure” implies not only permanent remission of the symptom but also repair of the underlying mechanism that produces the symptom. It follows that a permanent reduction in tinnitus loudness could be considered a partial cure if, presumably, the intervention associated with such an improvement permanently reduced the tinnitus by modifying the neural activity associated with tinnitus. In contrast, the effects of tinnitus can be reduced without any change to the tinnitus sound. Such cases would be consistent with symptom management, and the intervention employed would not be expected to eliminate or reduce the sensation. Indeed, many interventions promote symptom management and implementation of associated lifestyle strategies to support a patient’s coexistence with tinnitus.

When patients seek tinnitus-related services, their expectations must be identified and any effects of tinnitus on their lifestyle and emotional state assessed. Many audiologists work with patients who have received inaccurate and counterproductive information from a variety of sources: the internet, well-intentioned providers, friends, and family. Providers who work with patients bothered by tinnitus must be prepared to correct inaccurate beliefs, in addition to planning a reasonable course of action that considers each patient’s unique situation and challenges.

The Cochrane Collaboration has published at least 14 review articles of different tinnitus interventions (see http://www.cochrane.org/search/site/tinnitus for a full list), including, among others, cognitive behavioral therapy (CBT), antidepressants, hyperbaric oxygen treatment, gingko biloba, and hearing aids. CBT, which clearly does not purport to cure tinnitus, currently provides the strongest evidence for tinnitus management according to Cochrane reviews, which are systematic reviews of primary research in human health and health policy and are internationally recognized as the highest standard in evidence-based healthcare. Additional evidence exists for various forms of counseling and sound therapy. Pharmacological and invasive medical procedures, such as scans and brain implants, are specifically not recommended in the American Academy of Otolaryngology – Head & Neck Surgery Foundation’s Clinical Practice Guideline: Tinnitus (Tunkel et al., 2014).

Despite the lack of a reliable cure, individuals provide responses on tinnitus handicap scales across numerous studies confirming that, indeed, they can navigate their tinnitus. The lack of a cure should not preclude providers from understanding their patients’ needs and challenges through careful interviewing, completion of validated intake instruments, and consideration of otologic (usually hearing loss) or other potentially contributing factors (such as anxiety/depression). Additionally, lack of a cure should not preclude patients maintaining hope for improvement over time.

Physicians would be more likely than audiologists and psychologists to implement a treatment intended to “fix” the physiologic mechanisms associated with tinnitus. Kleinjung (2011) reminds us that in cases of hearing loss and tinnitus, hearing loss should be managed or treated prior to tinnitus intervention. Surgery for a conductive hearing loss, such as loss related to otosclerosis or chronic otitis media, may resolve or reduce tinnitus. Cochlear implantation may also reduce tinnitus, although in some instances the surgery produces or worsens tinnitus in a patient; in any case, the procedure is not indicated as a tinnitus treatment.

With regard to medical interventions designed specifically to reduce tinnitus, the procedures are invasive and, for the most part, still experimental. Surgical implantation of electrodes, similar to those for Parkinson’s disease, has the potential to reduce or abolish tinnitus. Transcranial magnetic stimulation, previously demonstrated as an effective intervention for depression, and electrical stimulation in the head and neck area may provide tinnitus relief for some patients, but evidence does not support these methods for routine clinical implementation. Although the goal of these treatments is primarily to cure, the expense and potential for negative side effects normally preclude their use.

Pharmacological agents employed to treat a diagnosed underlying condition such as depression or post-traumatic stress disorder (PTSD) have been known to reduce or eliminate the tinnitus perception for some patients. Such drugs would require prescription by a physician, and, although psychotropic agents such as Xanax (alprazolam) may reduce tinnitus distress, they do so by altering mental health status rather than auditory pathway contributions. It must be noted here that medications, and interactions between medications, have the potential to intensify the tinnitus sensation.

Audiologists and psychologists employ strategies with the understanding that tinnitus can be managed even if it cannot be cured. Returning to Kleinjung’s statement, use of hearing aids for patients with bothersome tinnitus may be the analogous situation for the audiologist. Many investigators (see Searchfield, 2016) outline fitting strategies and provide data supporting the use of hearing aids as an element of tinnitus management. Controlled studies have supported the use of hearing aids for this purpose. Although hearing aids may provide relief in the form of masking and access to environmental sounds, as well as reduced stress and listening effort when conversing, hearing aids do not cure tinnitus — when the patient takes the hearing aids off at night, their tinnitus is usually easy to hear.

Other audiologic, sound-based interventions may purport to change the tinnitus sound or to provide relief in quiet environments. However, if such sound-based interventions could be considered treatment with the objective of providing a cure, then counseling, which is indicated for nearly all sound-based interventions, would not be required. In practice, sound therapy at its best provides a portion of an intervention approach; counseling usually improves outcomes associated with the use of amplification and/or masking sounds. Although tinnitus is obviously a sound experience, the emotional impact of tinnitus may not be related solely to the sound’s psychoacoustic qualities (tinnitus loudness, pitch, and timbre). Sound therapies that fail to consider the nonauditory elements of tinnitus generally do not work as well as those that do. For example, some patients first observe their tinnitus at a time of great stress and physical and/or psychological trauma. In such cases, tinnitus may provoke anxiety and exacerbate (worsen) symptoms associated with the traumatic event; management of the patient’s response to the tinnitus would be far more important than focusing intervention exclusively on the tinnitus sound. Indeed, background noise or masking signals may change the tinnitus sound despite producing minimal effect on the psychological burden experienced by the patient. An intervention that fails to address the effects of tinnitus on emotional state would, for most patients with bothersome tinnitus, fail to address the sensation’s intrusive nature.

Ideally, tinnitus interventions would provide clear and unambiguous relief from the experience by eliminating its perception. Unfortunately, a patient’s tinnitus is rarely abolished consistently or long term. Tinnitus is a neurological event, oftentimes resulting as a by-product of the central nervous system “purposefully” implementing neuroplastic adjustments to auditory system function (Møller, 2008). Ironically, by considering tinnitus a result of neural plasticity, Møller pointed out that the neural mechanisms are merely doing their job — compensating for a change in auditory system function — and producing tinnitus as a form of maladaptive plasticity. It may be that there is nothing to “fix” in the sense that the central nervous system, in producing tinnitus, is carrying out the basic function of adapting to an auditory system whose function changed over time.
Tinnitus is an obstinate and unwelcome intruder for millions of people. Clinicians who provide tinnitus-related services routinely encounter patients who report a help-seeking journey in which they discovered, or were provided, inaccurate or counterproductive information. Patients report their provider could not deliver the cure they wanted, and as a result, they question whether it is reasonable to initiate or continue down a therapeutic avenue. Additionally, many patients struggle to acknowledge the potential for mental health status to influence tinnitus severity, and consequently they reject referrals for CBT and psychological consultations. It is essential for tinnitus clinicians to establish for patients the sense that, although it is unrealistic to expect tinnitus remission, it is likely that the emotional effects of tinnitus can be managed with combinations of sound and counseling. The patient who receives effective counseling, well-fit maskers/hearing aids as appropriate, and who learns to recognize and manage the effects of tinnitus on their state of mind may find relief even as they understand they will coexist with a sensation they do not like.

marc fagelson

Marc Fagelson, PhD, is a professor of audiology in the Department of Audiology and Speech-Language Pathology at East Tennessee State University. He earned undergraduate and master’s degrees at Columbia University in New York City and his PhD at the University of Texas at Austin. His clinical and academic teaching includes hearing science, audiological evaluation, pathologies of the auditory system, and tinnitus management. He coedited Tinnitus: Clinical and Research Perspectives and a companion text, Disorders of Sound Tolerance, with Dr. David Baguley; both books were published by Plural. Dr. Fagelson has more than 40 publications and has presented more than 100 times at conferences and workshops. He opened the James H. Quillen Mountain Home VA Medical Center Tinnitus Clinic in 2001; the clinic has enrolled more than 1,000 patients. Dr. Fagelson provides extensive and collaborative counseling for patients, as well as a variety of sound therapy strategies, to support their ability to manage tinnitus. A substantial proportion of the veterans seen in the clinic experience tinnitus that is complicated by the influence of co-occurring psychological conditions, and in particular post-traumatic stress disorder. This challenging and underserved population is the focus of Dr. Fagelson’s research. He is also a member of the ATA’s Scientific Advisory Committee.

Heather Malyuk, AuD, owner of Soundcheck Audiology in Northeast Ohio, is known internationally as a clinician, public speaker, and educator in the field of music audiology. She received an undergraduate degree in Music History and Literature from the University of Akron and earned her Doctor of Audiology degree from Kent State University. Dr. Malyuk is actively involved with the American Academy of Audiology and recently co-authored the clinical consensus document for Audiological Services for Music Industry Personnel. She serves on the executive council for the National Hearing Conservation Association, and is a member of the Wellness Committee for the College Music Society. In addition to her clinical and educational work, Dr. Malyuk is a consultant for various companies in the audiology sector and is a research scientist with Gateway Biotechnology Inc. and the University of Akron, where she is currently researching cochlear synaptopathy, tinnitus, and the effects of COVID-19 on the music industry.