Tinnitus Treatment: A Comprehensive Approach

By Tricia Scaglione and Sara Downs

This article is a part of the September/October  2024, Volume 36, Number 5, Audiology Today issue.

A 62-year-old man named Michael (pseudonym) was referred to Dr. Sara Downs by his psychiatrist for bilateral tinnitus evaluation and treatment. Despite pharmacological and cognitive behavioral interventions with mental health specialists, no improvement was observed, leading to a referral to an audiologist specializing in tinnitus management. Dr. Downs, trained in tinnitus retraining therapy (TRT) and certified in mind-body medicine (MBM) by the Center for Mind-Body Medicine (CMBM.org), utilizes a modified TRT approach integrating MBM techniques.

Michael, presenting in despair with suicidal thoughts, insomnia, panic attacks, and general anxiety, underwent a comprehensive tinnitus evaluation. Audiological findings revealed mild symmetric high-frequency hearing loss (>25 dB HL) bilaterally, with normal middle ear status indicated by tympanometry. Distortion product otoacoustic emissions (DPOAEs) showed abnormal outer hair cell function consistent with his sensorineural hearing loss. Acoustic reflex thresholds were deferred due to the patient’s reported bothersome tinnitus during the appointment.

The patient completed the Tinnitus Reaction Questionnaire (TRQ) to assess tinnitus distress, yielding a baseline score of 89 out of 104, indicating severe distress (Wilson et al, 1991). Additionally, he self-assessed his level of tinnitus habituation (ability to adapt and cope with his symptoms) using the 4 Stages of Habituation chart (American Tinnitus Association, 2018), reporting an initial stage 1 (no habituation) out of 4 (full habituation). This correlates with his complaint of tinnitus significantly affecting his sleep, concentration, and overall sense of calmness.

For tinnitus sufferers, consulting both an otolaryngologist and an audiologist is recommended to assess the need for further evaluation and management, especially if symptoms are distressing.

Michael’s case is not unusual. With approximately 27 million individuals experiencing tinnitus symptoms in the United States according to the 2014 National Health Interview Survey (Steinmetzger et al, 2024), there’s a pressing need for hearing-health-care providers to adeptly identify and counsel patients seeking tinnitus support. Although there are about 18,508 audiologists in the United States (DataUSA, n.d.), it remains unclear how many offer tinnitus services. However, with only 360 professionals enrolled in the American Tinnitus Association (Downs, 2024) and 589 completing the Certificate Holder–Tinnitus Management (CH-TM) course (Stafford, 2024), there appears to be a shortage of audiologists equipped to address the patient population with tinnitus.

Medical Assessment

For tinnitus sufferers, consulting both an otolaryngologist and an audiologist is recommended to assess the need for further evaluation and management, especially if symptoms are distressing. Based on the otolaryngologist’s assessment, additional tests such as imaging studies or carotid ultrasound may be ordered, along with an audiometric evaluation. Collaborative care with various specialists, including general practitioners, mental health therapists, dental/oral specialists, neurologists, physical therapists, and sleep medicine physicians, may also be recommended, depending on associated symptoms.

Audiological Assessment

Although an evidence-based protocol for performing an audiological assessment in patients with tinnitus does not exist, various guidelines are available for clinician guidance, including the American Academy of Audiology Audiologic Guidelines for the Diagnosis and Management of Tinnitus Patients (Sweetow et al, 2001). Audiological assessments typically involve thorough history taking, which covers tinnitus-specific questions beyond onset, such as laterality, tonality, perceived triggers or alleviating factors, impact on quality of life, perception of sound sensitivity, and past pursued management options. Subjective questionnaires that assess the patient’s perceived distress level or handicap from tinnitus can be easily administered and scored before or during the patient’s visit. In addition to the TRQ, examples of frequently used validated self-report questionnaires include the Tinnitus Handicap Inventory (Newman et al, 1996) and the Tinnitus Functional Index (Meikle et al, 2012). Clinicians may also include the Tinnitus and Hearing Survey (Henry et al, 2015) to identify if hearing loss or tinnitus is the patient’s primary concern. If there are suspicions of mental health issues, subjective screening tools can also be used. 

Otoscopy is conducted to examine the outer ear for issues such as cerumen impaction. Middle ear dysfunction may contribute to tinnitus perception; therefore, impedance testing is recommended. Caution is advised when assessing acoustic reflex thresholds because high stimulus intensity may temporarily worsen symptoms. DPOAEs, including ultra-high-frequency assessment, are valuable for evaluating outer hair cell function, particularly when hearing thresholds appear normal (< 25 dB HL), but DPOAEs indicate subclinical abnormalities (Jedrzejczak et al, 2022).

A thorough audiometric evaluation covering 250–8,000 Hz, including interoctaves, is essential. Ultra-high-frequency audiometric thresholds should be assessed when high-pitched tinnitus is reported despite normal hearing in standard frequencies (Savastano, 2008; Henry et al, 2020). These findings serve as counseling tools, helping understand tinnitus perception and guide audiological monitoring plans. 

Although psychoacoustic (tinnitus) assessments do not objectively confirm the presence of tinnitus, the results often offer validation to patients and inform counseling (Taylor and Mattson, 2016). Some tinnitus management devices require such assessments for baseline and monitoring. Psychoacoustic testing may involve assessing loudness discomfort levels, tinnitus pitch and loudness matching, minimal masking levels, and residual inhibition testing (Sherlock and Formby, 2005; Henry, 2016; Henry et al, 2019). Current Procedural Terminology code 92625 (tinnitus assessment) may be used for reimbursement. Additional diagnostic tests, such as auditory evoked potentials or vestibular testing, may be suggested based on patient symptomology or audiometric findings.

Management and Treatment Planning

Treatment decisions should follow the exclusion of medical conditions. Considerations should include underlying hearing loss, tinnitus impact on daily activities (for example, sleep and concentration), mental health conditions (such as anxiety or depression), and severity of tinnitus intrusion as indicated by self-report measures (Karaaslan et al, 2020).

A thorough audiometric evaluation covering 250–8,000 Hz, including interoctaves, is essential.

Tinnitus therapies aim to prompt the nervous system to reclassify the tinnitus signal as neutral rather than intrusive, facilitating the natural habituation process. Treatment plans must be personalized for each case, necessitating audiologists to have a range of tools and resources at their disposal. In addition to standard sound therapy options such as hearing aids, combination units, tabletop sound machines, and smartphone apps, audiologists should establish a professional network for concurrent management of patients with tinnitus, including mental health counseling. Given that optimal bodily function correlates with feelings of calmness, safety, and grounding, audiologists are advised to familiarize themselves with mind-body techniques, such as breathwork, meditation, movement, and mindfulness (Kreuzer et al, 2012). These can be seamlessly incorporated into patients’ treatment plans. 

Michael’s Treatment Plan

After audiological and tinnitus assessments, Michael received counseling on his results, recommendations, the mind-body response to tinnitus, and its prevalence and impacts. The emphasis was placed on demystifying tinnitus and addressing common misconceptions. Due to Michael’s reported sleep difficulties related to tinnitus, sleep hygiene tips were provided. 

Michael was fit bilaterally with combination devices, addressing his hearing loss while providing ear-level sound therapy options. He was instructed on setting the sound therapy to the mixing point, the ideal blending level of tinnitus and external stimuli (Jastreboff, 2011), along with relaxation techniques. These mind-body techniques encompassed breathwork (for example, soft belly breathing, 4-4-8 breaths), in-office biofeedback sessions using thermistor (a type of sensor that measures skin temperature) and autogenic phrases (verbal cues to promote relaxation), movement including daily outdoor walks for 20 minutes, and journaling.

For those familiar with TRT, the inclusion of “journaling” as a treatment method might seem unexpected. However, this patient, who had a highly analytical approach, had already been using a color-coded calendar to track “bad tinnitus days” for two months. Despite counseling against it, he found value in this practice because analyzing the data gave him a sense of control. Consequently, Dr. Downs and the patient agreed to limit journaling to once a day, focusing solely on assessing his coping with tinnitus rather than its characteristics.

Progress and Outcomes

Follow-up appointments were provided in two-week intervals and consisted of Michael’s self-report regarding his adherence to the treatment plan, Dr. Down’s reinforcement of concepts regarding the mechanisms of tinnitus, review of sleep hygiene tips, and answering any of his questions about the protocol. Special emphasis was placed on cultivating a relaxation response to sound therapy through mind-body techniques. Initially, Michael struggled to feel at ease and comply with the recommended breathwork. To address this, Dr. Downs conducted an in-office biofeedback session, showing Michael how deep breathing affected his body temperature. This demonstration motivated Michael to incorporate breathwork into his sound therapy routine. At the subsequent follow-up, Michael was fully compliant with the protocol.

Throughout his treatment, Michael completed self-report assessments regarding his tinnitus and perceived habituation progress. His TRQ score at six weeks showed a notable reduction from baseline (89 out of 104) to 42, exceeding the suggested 20–40 percent improvement threshold for clinical significance (Jastreboff, 1996; Hazell, 1999; Hiller and Haerkötter, 2005). By week 12 and his six-month follow-up, his TRQ scores further decreased to 21 and 0, respectively. Regarding his self-reported habituation stage, Michael progressed from 1 at baseline to 1.5 at six weeks, reaching 3.5 by week 12 and achieving the maximum stage of full habituation (4) at his six-month follow-up.

Michael’s journal entries aligned with his self-report measures, showing a progression from predominantly red (indicating “bad tinnitus days”) to intermittent yellow with red lines, yellow, yellow with green, and eventually all-white days (no tinnitus awareness), marked with a star. After 16 weeks, he entered the maintenance phase and sees Dr. Downs every six months for hearing aid check-ups. Occasionally, he experiences “red spell” days, managing them with sound therapy.

Discussion

Tinnitus affects around 11.2 percent of the U.S. population, but less than 1 percent of audiologists are currently serving these patients (Steinmetzger et al, 2024). There is an opportunity for all clinical audiologists to contribute, from initial consultation and audiometric evaluation to guiding through a complete treatment plan. At the very least, more audiologists are needed to educate patients on managing their tinnitus. Providing this information, along with contact details for local specialists, can offer hope and initiate appropriate treatment. Clinicians can access free resources from the American Tinnitus Association website to support patients.

The potential repercussions of untreated tinnitus, such as disturbances in sleep and heightened anxiety, underscore the urgency of addressing this issue.

For audiologists interested in a more in-depth role in tinnitus management, there are clinician guides and training programs available for guidance. It is imperative to acknowledge the patients’ unique, individual needs when developing their care plan, balancing provider expertise with patient autonomy. Michael’s case highlights the importance of flexibility, integrating stress management, relaxation techniques, sound therapy, and interdisciplinary care.

Conclusion

Tinnitus often manifests as a disruption to the quality of life for individuals seeking audiological assistance. The potential repercussions of untreated tinnitus, such as disturbances in sleep and heightened anxiety, underscore the urgency of addressing this issue. A pressing necessity exists for audiologists to enhance their proficiency in discerning the extent to which tinnitus affects individuals, along with their ability to conduct thorough assessments and develop personalized treatment strategies for this specific patient demographic.