Tinnitus and Hyperacusis

See the Treatment section of the Tinnitus evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.

Assessment of tinnitus and/or hyperacusis may result in recommendations for management options and/or referral to medical professionals, as appropriate. Management of tinnitus and/or hyperacusis is often an interdisciplinary endeavor (e.g., audiologist, otolaryngologist, psychiatrist, psychologist, primary care physician). Intervention may address a patient's concerns regarding thoughts and emotions, sleep, concentration, and hearing.

See the ASHA resource titled Person-Centered Focus on Function: Tinnitus Management [PDF] for an example of functional goals that are consistent with the World Health Organization's (WHO) ICF framework (WHO, 2001).

Management Options for Tinnitus

In general, there is no cure for tinnitus. Some individuals with tinnitus do not find it bothersome. For others it can be debilitating, causing emotional distress and negatively impacting quality of life. Tinnitus management may include one or more of the following options.

Informational and Educational Counseling

Patients presenting with tinnitus that is bothersome and persistent will require educational and informational counseling. The AAO-HNSF guidelines provide a recommendation for education and counseling (Tunkel et al., 2014). It may be helpful to include the patient's support system (e.g., family, significant others) in the counseling portion of tinnitus management.

The audiologist or related practitioner may provide information related to the patient's specific case of tinnitus and potential management strategies. The patient may also be made aware of unverified claims and "cures" that may mislead them as they research tinnitus online. See ASHA's page on Health Literacy for more information on communicating with patients and family members. Audiologists and related practitioners may also consider professional referrals to address the psychosocial aspects of tinnitus.

Cognitive Behavioral Therapy (CBT)

Cognitive behavioral therapy (CBT) is a specific type of therapy that focuses on modifying problem emotions, thoughts, and behaviors. CBT may be applicable to patients with tinnitus to help reduce negative responses and improve quality of life (Hesser, Weise, Westin, & Andersson, 2011). CBT may be used in combination with other tinnitus management strategies. The AAO-HNSF guidelines provide a recommendation for CBT (Tunkel et al., 2014).

Amplification/Hearing Aids

Some individuals with hearing loss also complain of tinnitus. A properly fitted hearing aid may alleviate bothersome tinnitus through amplification and/or masking effects (Kochkin & Tyler, 2008; McNeill, Távora-Vieira, Alnafjan, Searchfield, & Welch, 2012; Shekhawat, Searchfield, & Stinear, 2013). The AAO-HNSF guidelines on tinnitus provide a recommendation for hearing aid evaluation (Tunkel et al., 2014). Hearing aids may be beneficial when used independently or in combination with a sound generator as an optional programmable feature (Henry, Frederick, Sell, Griest, & Abrams, 2015). Hearing aids that are fit specifically for amelioration of tinnitus may require individualized programming.

See ASHA's Hearing Aids For Adults Practice Portal page for more detailed information on hearing aid fitting.

Sound Therapy

Sound therapy refers to the use of sound to relieve bothersome tinnitus. It is inclusive of several strategies and products (e.g., wearable devices, external devices, accessories to hearing aids). Sound therapy uses external noise to distract, mask, habituate, or neuromodulate (i.e., reduce neural hyperactivity that may be an underlying cause of tinnitus) the perceived subjective tinnitus. A secondary benefit of sound therapy is to provide a relaxation effect, which may aid in habituation. Sound therapy may be considered as an important component of a comprehensive tinnitus management plan (Hoare, Searchfield, El Refaie, & Henry, 2014).

Wearable Devices

Wearable masking devices may be used alone or in combination with hearing aids. Several different styles are available, and some offer frequency adjustment for the patient to use as needed. Some wearable devices are worn for a prescribed number of hours each day and introduce sounds that have been customized for the patient and their tinnitus.

Nonwearable Devices

Nonwearable devices include any environmental device that provides background sound that can be used by patients to reduce their perception of bothersome tinnitus. Examples include

  • bedside devices providing white noise/nature sounds;
  • digital downloads of relaxing music/noise/nature sounds delivered through headphones or pillow speakers;
  • fans; and
  • radios.

Nonwearable masking devices may be especially helpful for those individuals who have difficulty sleeping due to bothersome tinnitus.

Tinnitus-Specific Management Programs

There are several management programs specific to tinnitus, including those described below.

Tinnitus Retraining Therapy (TRT)

Pawel J. Jastreboff (1990) wrote about the neurophysiological model of tinnitus. Based on this model, tinnitus retraining therapy (TRT) is a habituation-based intervention that includes a combination of directive counseling and sound therapy. The TRT protocol involves a structured case history followed by assignment of the patient into one of five categories differentiated by their specific type of tinnitus. Category assignment directs intervention. All patients receive directive counseling and education specific to tinnitus and auditory physiology, among other topics. Some type of sound input/enriched sound is often included.

Progressive Tinnitus Management (PTM)

The progressive tinnitus management (PTM) approach focuses on the patient learning to self-manage their negative reactions to tinnitus. PTM uses a clinical service structure in which a patient progresses to higher (more intensive) levels of intervention only as needed. A significant aspect of PTM involves educating the patient on the use of individualized coping skills as well as some elements of CBT. The five levels of PTM have been described in detail (Henry, Schechter, Zaugg, & Myers, 2008; Henry, Zaugg, Myers, Kendall, & Turbin, 2009).

Tinnitus Activities Treatment (TAT)

Tinnitus activities treatment (TAT) is an intervention using individualized counseling. Four areas are considered, including "thoughts and emotions, hearing and communication, sleep, and concentration" (Tyler, Gogel, & Gehringer, 2007, p. 425). Low-level partial masking sound therapy as well as patient homework activities (based on the four problem areas outlined above) are also integral to this approach.

Other/Alternative Tinnitus Management Options

In making prudent recommendations for a person complaining of tinnitus, a clinical practitioner should remain current in their knowledge of the various management options available and should carefully review supporting or opposing scientific evidence (or lack thereof).

See the Treatment section of the Tinnitus Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.

A variety of other tinnitus management options are currently being used and/or studied. Examples include the following approaches:

  • Biofeedback training—learning to monitor one's own physiological response to tinnitus in an attempt to gain some voluntary control of the response.
  • Hypnotherapy—introducing an altered state of consciousness to allow for positive suggestion to bring about subconscious change.
  • Myofascial trigger point therapy—working with a skilled practitioner to release muscle contraction at trigger points (for patients with tinnitus and chronic pain in areas around the ear).
  • Neuromodulation—introducing specific therapeutic sound presentations and sequences, often administered through a neuromodulation device.
  • Psychotherapy, such as
    • mindfulness traininglearning to attend to thoughts and feelings that one is having in the current moment without judgment and with acceptance; and
    • relaxation training—developing skills and techniques for relaxation and stress management.
  • Self-help options—using resources such as Internet-guided programs providing CBT or mindfulness and stress management for tinnitus.
  • Transcranial magnetic stimulation—a noninvasive procedure using magnetic fields to stimulate nerve cells in the brain.
  • Vagus Nerve Stimulation—stimulation of the vagus nerve with an electrical stimulator implanted under the skin and used in conjunction with audio tone therapy.

Appropriate Referrals

Appropriate referrals for a patient with tinnitus may include a variety of health care professionals. In cases where a medically treatable cause is identified, medical, surgical, psychiatric, or dental treatment may be recommended by the appropriate medical professionals (e.g., surgical excision of a tumor, medication for an infection). Based on an audiologist's own knowledge and skills, it may be appropriate to refer out for specific tinnitus management techniques, such as TRT. Psychological referrals may be necessary for counseling and CBT. Effective treatment of depression, anxiety, and insomnia may help to reduce the severity of tinnitus and improve a patient's quality of life (Folmer, 2002).

Future Directions

Tinnitus presents several challenges for clinicians because there is generally no cure, and there is a lack of consensus and standardization regarding definition, objective measurement, assessment, and management. Future responses to these difficulties may include

  • standardized training for students, audiologists, and other practitioners;
  • collaboration among tinnitus experts to define important outcomes of focus for clinical trials; and
  • standardized procedures for the diagnosis, assessment, and management of tinnitus.

Management Options for Hyperacusis

Hyperacusis can be debilitating, causing emotional distress and negatively influencing an individual's quality of life. Intervention may include one or more of the following options (see subsections below).

Informational and Educational Counseling

Patients presenting with complaints of hyperacusis will require education and counseling. It may be helpful to include the patient's support system (e.g., family, significant others) in the counseling portion of hyperacusis management.

Education may include information relating to the patient's specific case of hyperacusis as well as potential management strategies. See ASHA's web page on Health Literacy for more information on communicating with patients and family members. Professional referrals may also be considered to address the psychosocial aspects of hyperacusis.

Cognitive Behavioral Therapy (CBT)

Referral to a trained and licensed professional for psychotherapy may be appropriate. Cognitive behavioral therapy (CBT) is a specific type of therapy that focuses on modifying problem emotions, thoughts, and behaviors. Treatment of depression, anxiety, and insomnia may also be necessary.

Sound Therapy

Sound therapy for hyperacusis requires the patient to listen to low-level sounds for long periods of time to encourage habituation. "Over time, gradual increases of the level and/or duration of the sound treatment should be implemented along with positive reinforcement by the clinician" (Pienkowski et al., 2014, p. 428). Sound therapy options for hyperacusis include the following presentations (Pienkowski et al., 2014):

  • Continuous low-level broadband noise
  • Music or environmental sounds
  • Successive approximations to high-level broadband noise
  • Successive approximations to troublesome sounds
  • Gradual increase of maximum output of hearing aid or ear-level sound generator

Hyperacusis-Specific Management Programs

Tinnitus Retraining Therapy (TRT)

The general principles of TRT described in an earlier section may also be used successfully in the management of a patient with hyperacusis (Mraz & Folmer, 2003).

Hyperacusis Activities Treatment

Hyperacusis activities treatment is based on the protocol for TAT, described earlier. The approach includes both individualized counseling and sound therapy specific to hyperacusis.

Hearing Protection

Some individuals with hyperacusis feel that wearing hearing protection to avoid disturbing sounds is helpful; however, this is not advisable when environmental sound levels are safe. Avoiding normal-level sounds in the environment can make the auditory system become more sensitive to these sounds when protection is not used. This increased sensitivity can exacerbate the hyperacusis (Formby, Sherlock, & Gold, 2003). Using hearing protection when exposed to excessive noise is advisable for all individuals.

Appropriate Referrals

Appropriate referrals for a patient with hyperacusis may include a variety of health care professionals. These referrals may include neurology, psychiatry, occupational therapy, psychology, and primary care professionals. The appropriate referrals may depend on whether a specific cause has been identified.

Considerations for Pediatrics

It is important to consider that children may be less able to describe bothersome tinnitus or hyperacusis verbally, and they may use actions or emotional gestures instead (e.g., covering ears with hands, crying). Children may have tinnitus, hyperacusis, or both. Underreporting of tinnitus or hyperacusis is a concern in the care of children.

Tinnitus

Children who experience tinnitus—much like adults who experience tinnitus—will benefit from general education and information about the condition. Allaying a child's fears may be a significant factor in the management of tinnitus. Pediatric audiology specialists will use the assessment and intervention techniques described above as appropriate for the child and for the specifics of the tinnitus.

Hyperacusis

Hyperacusis in children may coexist with conditions such as autism. Hyperacusis can be acquired after severe ear infections and head injuries, and through a variety of other causes. A child with hyperacusis may have normal hearing. Pediatric audiology specialists will use the assessment and intervention techniques described above as appropriate for the child and for the specifics of the hyperacusis. Similar to management of hyperacusis in adults, a goal of managing hyperacusis in children is to help children reduce their fear of and aversion to everyday sounds.

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