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What is Tinnitus? Fifty million Americans experience some form of tinnitus. Twelve million have sought professional intervention. Tinnitus is a significant and common problem across the USA. For individuals with tinnitus, something is occurring within the auditory system, or elsewhere in the neural pathways, which gives rise to the perception of an acoustic-like sensation, for which there is no known external cause. There are two types of tinnitus; objective tinnitus, wherein the patient and the practitioner can hear the ongoing tinnitus, and, subjective tinnitus, heard only by the patient. By far, the most prevalent of the two is subjective tinnitus. Some estimates indicate that 95 percent of all tinnitus is subjective. Since the audiologist has interest in conditions and anomalies that affect the auditory system, and since tinnitus is such a condition, it seems logical that our scope of training should provide differential diagnostic and therapeutic intervention management for tinnitus. However, many audiologists do not have an extensive background in the clinical management of tinnitus. This is not an indictment of audiologists as a professional body. Audiologists have strong clinical backgrounds in the assessment of hearing loss with regards to the type and degree of hearing loss, diagnostic testing and interpretation, prevention of hearing loss and in the provision of rehabilitative practices and devices for the hearing impaired. Tinnitus management is a relatively new arena for the audiologist and therefore, this paper serves to explore some of the issues associated with tinnitus management by the audiologist. Based on a thorough understanding of tinnitus, a definitive and defensible audiologic diagnosis can be made and a plan of rehabilitation formulated. It is not the purpose of this article to encourage audiologists to consider clinical involvement with tinnitus patients. Rather, our purpose is to offer an overview of major therapeutic approaches used in the treatment of this disorder. At this time, there is no single therapeutic approach to the treatment of tinnitus that is sufficiently compelling to warrant its exclusive use above all others. There are no test batteries for tinnitus that provide reliable, clinical predictors of cause or treatment. Perhaps this uncertainty keeps many audiologists from being involved in treating the tinnitus patient. For others, the obstacle may be the depth of the psychic involvement of tinnitus sufferers with their condition, for tinnitus is as much an emotional issue as it is a ‘hearing’ issue. Three Realities in Tinnitus Treatment There are three realities that one must be aware of in the treatment of tinnitus. First, there is no consensus as to what causes the problem. This is not to suggest that a rational answer for the mechanisms of tinnitus is not of interest, but rather that is not germane to our discussion of tinnitus treatment. Second, there is no known cure. Third, all present forms of therapeutic intervention treat the symptoms of the disorder, not the cause of the disorder. Given these clinical limitations, what are the current therapeutic practices used by those who treat the tinnitus patient? Rather than offering an exhaustive analysis of each modality, we will discuss specific approaches related to both medical and non-medical intervention processes. Parenthetically, it has been our observation that the therapeutic modality chosen is most often determined by the professional and clinical backgrounds of the practitioner. Medical models seem to be supported by physicians. Non-medical models appear to be supported by other non-physician professionals. For example, psychologists rely on counseling, whereas audiologists generally employ some form of sound/auditory therapy. Medical Management Medical models typically include the use of drugs to attempt to control the subjective loudness of the ongoing tinnitus, or (more commonly) to reduce the intensity of the patient’s response to it. For the most part, specific drugs seem to be the medical treatment of choice. Anti-anxiety and anti-depression medications reduce negative behaviors brought on by the presence of tinnitus. Other drugs used in the treatment process may include lidocaine, tocanide (oral cognate of lidocaine), Lasix, Misolene, Tegratol and others. Sandlin and Olsson (1999) reviewed the value of drug use and the risks assumed by the patient. To date, there is no large body of evidence that warrants adapting one particular form of drug therapy. Each of the drugs mentioned above has proven beneficial to some. The general wisdom suggests that drugs constitute an ongoing process that permit the patient to derive some prolonged benefit. Brummet (1997) cautions the practitioner about possible consequences of drug use to control tinnitus. Most patients are treated with non-medical approaches. Surgical Management Some, but very few, physicians have previously elected to perform surgery to eliminate or reduce or control tinnitus. Surgical management of tinnitus has not produced consistent, acceptable results. Surgically sectioning the auditory nerve of the offending ear, more often than not, does not solve the problem. For some, the subjective loudness of the tinnitus, as perceived in the post-operative period, is the same. For others, the tinnitus is exacerbated. Another form of surgical control of tinnitus involves microvascular surgery to eliminate or reduce vascular compression (i.e.‘vascular loops’) in the area of the VIII cranial nerve, theorized by some to be a frequent cause of tinnitus (Vernon, 1998). Another surgical approach involves direct electrical stimulation of structures deep in the brain (Shi & Martin, 1999). Non-Medical Management Although there are many non-medical treatment modalities, only a few have received widespread acceptance The three most common, and most promising, non-medical methods of treatment are masking, tinnitus retraining therapy (also known as habituation therapy) and cognitive therapy. Alternative non-medical treatments include; biofeedback, psychological counseling, nutritional controls, acupuncture, gingko biloba, and Vitamin B 12. For an overview and comprehensive listing of herbs and vitamins purported to assist in the management of tinnitus, the reader is referred to the March 2000 issue of Tinnitus Today, published by the American Tinnitus Association (ATA). It should be noted that gingko biloba, despite its enthusiastic cohort of supporters, has been rather clearly shown to have no more benefit than a placebo (Drew & Davies, 1999). For a more comprehensive overview of treatment, the reader is referred to the book by Vernon (1998), Tinnitus – Treatment and Relief, available from the ATA (published by Allyn and Bacon). Maskers and Combination Devices Masker use, as described by Dr. Jack Vernon, (1977, 1978, 1979, 1981) has proven to be effective for some, but not for all. Masking involves using an external signal (i.e., masking noise) sufficient to mask or ‘cover’ the ongoing tinnitus. The rationale is that an external acoustic stimulus is easier for the patient to ignore than the constant, ongoing tinnitus. Johnson (1998) reported the use of masker devices was effective about 35 to 40% of the time for those who investigated their use. Although not an impressive number in isolation, tinnitus sufferers who were in the 35 to 40% group find masker devices to be a godsend. A combination device, an instrument containing both a hearing aid and a noise generating circuit, increased success rates to about 70%. That is, for those tinnitus patients having tinnitus and hearing loss sufficient to interfere with speech understanding, the combination device provided more relief than a masker device alone. The combination device also provided more relief than a hearing aid alone. Maskers and combination devices continue to be used by tinnitus patients, suggesting that these instruments continue to be a valuable therapeutic modality, which provides relief and reduces the high stress level often associated with tinnitus.
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