Tinnitus at its worst can have a devastating impact on a patient's lifestyle. Sleep disruption, limited social interaction, irritability, lack of concentration, inability to work, breakdowns in relationships, depression, drug dependency, and even suicide are among the possible consequences of severe tinnitus.
On the other hand, some people contacting your private practice may be no more than mildly curious about their tinnitus.
There are also clients who are concerned about hearing damage and think that the tinnitus may indicate that they are losing their hearing. They may even blame the tinnitus for their inability to hear.
It is with this complex and varied group of patients that the dilemma starts for the private practitioner. What type of evaluation is necessary? How much detail is required and, most importantly for a private practice, how much time do I need to allow to see the tinnitus patient?
HOW MUCH TIME FOR AN APPOINTMENT?
To book out half a day for a tinnitus patient is impractical. If patients fail to report to the appointment or have wax occluding the ear canal or fall into the “mildly curious about tinnitus” category, too much time is wasted. Our practice's compromise is to allow 1.5 hours.
Ninety percent of the patients coming to us have already received the necessary medical clearance from an ear, nose, and throat specialist or a general practitioner. Therefore, none of these patients have any medical cause for their tinnitus, such as wax or middle ear conditions.
Another time saver is to send patients a package of information prior to the appointment and have your office staff well versed in tinnitus inquiries.
Some time ago we produced a video in-house that explains what happens at an appointment and interviews some tinnitus patients. This is particularly useful for new clinic staff. Another approach is to allow new support staff to sit in on an appointment so that they are well informed about what takes place during the 90 minutes a patient attends.
Because tinnitus has various causes—some medically correctable, others requiring the fitting of a hearing aid or a sound generator—counseling after the evaluation is also an unknown variable in terms of time. Most important in evaluating a client is the interview, which must be structured to cover all audiologic aspects and information relating to the tinnitus and its effects on the person's lifestyle.
WHAT SHOULD YOU ASK?
At our clinic, we use the Tinnitus Handicap Inventory [THI],1 which our clients complete while in the waiting room prior to their appointment. Also to be gleaned at the interview is information related to noise exposure, onset of tinnitus, severity, lifestyle effects among other factors relating to tinnitus, and a full audiologic history. Table 1 sets out a checklist.
The case history sets the scene for the rest of the appointment, alerting the clinician as to whether the time set aside for the appointment will be adequate. The history identifies the main problems associated with the tinnitus and the impact these issues are having on the patient's lifestyle. It also highlights the emotional status and degree of deafness and indicates the patient's suitability for therapy. In addition, the history reveals whether the main problem is tinnitus or hearing loss or phonophobia or hyperacusis.
The minimum for an assessment of a tinnitus patient is first an assessment of hearing, including air conduction, bone conduction, impedance, and speech recognition. We also measure distortion product otoacoustic emissions (DPOAEs), loudness discomfort levels, speech in noise and quiet, and measurements of tinnitus pitch, loudness, and minimum masking levels.
The assessment battery is set out in Table 2. Electrophysiologic measures should be performed where indicated. The order of the tinnitus assessment is important, as is the premise that masking the audiogram where indicated should be delayed until the tinnitus measures are completed.
Equipment for obtaining measures of the tinnitus can vary from an audiometer to a tinnitus synthesizer. The audiometer will give less precise measures, but the acoustic details of the tinnitus are unimportant in our overall goal of counseling and treating the patient.
DISCUSSION OF RESULTS
The discussion of audiometric test results is important, particularly the DPOAE results, which usually show some outer hair cell damage even when the audiogram reveals no evidence of hearing loss. Speech results can assist in demonstrating the effect the hearing loss, even a very high-tone loss, has on speech discrimination.
Loudness discomfort level (LDL) results are useful in cases where clients report they have been using hearing protection in situations where most people do not perceive a problem with loudness discomfort. (If LDLs are below normal levels, a desensitization program using low levels of noise through sound generators may need to be completed prior to other treatments.)
DIGITAL HEARING AIDS AND TINNITUS
New digital hearing aids and combination sound generators/hearing aids offer the most flexibility and options when fitting the tinnitus patient. Apart from active feedback-control and noise-reduction strategies, digital instruments are reportedly judged by patients to provide greater comfort.
The goal of fitting tinnitus patients is not to focus solely on improving speech discrimination, but rather on providing sound enhancement to a sensorily starved auditory system. Digital hearing aids address the issue of amplification and also provide a multitude of fine-tuning adjustments, especially important in cases where hyperacusis is an issue.
The ability to adjust many parameters is valuable. Multiple programs are useful for the tinnitus patient, as quiet environments can be programmed to amplify soft environmental sounds while, in very noisy environments, noise suppression can be activated in another program.
Completely-in-the-canal aids may work well in some cases. Generally, however, when hearing up to 1000 Hz is normal, a behind-the-ear or larger in-the-ear instrument works better, as more acoustic venting is possible and exacerbation of the tinnitus is avoided. When patients report an increase in their tinnitus following the fitting of hearing aids, increasing the venting will usually alleviate the problem.
COUNSELING, FITTING, AND FOLLOW-UP
In our practice, we have adopted the following protocol.
If there is a medical issue, such as unilateral hearing loss, unilateral sudden-onset tinnitus, or a conductive hearing loss, patients are referred to their general practitioner and a report and test results are sent directly to the physician. These patients are encouraged to return if there is no medical contraindication to fitting or if there is no medical treatment available for their condition.
When there are no medical issues (and most of our patients are referred through a medical practitioner), treatment may involve one of the following options:
1. Discussing the tinnitus and using environmental noise to habituate to the tinnitus.
2. Fitting of sound generators in cases where there is no aidable hearing loss and the tinnitus is causing lifestyle disruption.
3. Fitting of hearing aids in cases where the hearing loss is aidable.
The fitting of sound generators first and then hearing aids (or using one of the new combination instruments in cases where sound sensitivity needs to be treated before the hearing loss) is appropriate for patients with abnormally low LDLs.
Combination instruments are fitted in cases of both clinically significant tinnitus and hearing loss. By “clinically significant,” I mean any tinnitus that will not respond to habituation using environmental noise (even if this is through a hearing aid) and that disrupts the person's lifestyle. Note that bilateral fittings are always recommended, as bilateral stimulation is necessary to prevent the tinnitus from shifting to the opposite side and to provide neural stimulation bilaterally.
PROTOCOL AND THERAPY
In our clinic, we work with Tinnitus Retraining Therapy.2 It sets out a fitting protocol and counseling regime that can be easily implemented in most practices.
Other clinics may successfully offer cognitive or psychological approaches. A uniform approach by all clinicians in a practice is desirable since cases may need to be taken over by another clinician. Although client case continuity is the aim in most practices, this is not always possible, so seeing other clinicians' clients will occur.
One of the biggest concerns of any clinician interested in taking on tinnitus work is the extensive counseling and time-consuming appointments required in treating tinnitus. Some practices bundle a fitting fee with the costs of overheads and time for seeing the client. But, in cases where no devices are fitted and the sessions consist of counseling only, individual appointments will need to be billed. Our practice offers 6 months of sessions for a set fee. Some patients require only one appointment, others require many.
THREE CASE STUDIES
The following case studies show how three very different tinnitus patients were managed.
Mia is a 21-year-old female, who noticed tinnitus for the first time after attending a disco. It was on her third visit to the disco that the tinnitus continued and it was 2 months before she sought help. Mia's audiologic history was unremarkable apart from a history of ear problems as a child.
Her audiogram was “normal.” However, her DPOAEs showed weak emissions in the high frequencies. Speech in noise was poor (50% at a signal-to-noise ratio of 10 dB). Her tinnitus was matched to a pure tone at 6000 Hz with a sensation level 2 dB above threshold.
Mia had noticed that her tinnitus was louder when she was under stress and after going out socially. She was also concerned about losing her hearing. Mia required one appointment, which involved discussing the results and giving instructions about avoiding silence and using environmental noise to habituate to the tinnitus. Recommendations were also made to avoid loud noise or, when that was not possible, to use hearing protection in noisy environments.
Barry is a 50-year-old real estate agent. His tinnitus started for the second time during a very stressful period at work. He noticed his tinnitus was louder when he manipulated his jaw and began monitoring his tinnitus by this action. He also started blaming his tinnitus for his inability to hear.
His audiogram showed a significant hearing loss, which warranted the fitting of hearing aids. Of significance in the history was his 3 years in the army during which he was exposed to noise from jet aircraft, weapons fire, and explosions.
Counseling about avoiding further hearing damage, habituating to the tinnitus, and the relationship that stress may have had to his awareness of the tinnitus were all useful points in reaching a satisfactory outcome. Barry required four appointments in his first 6 months, no more than most hearing aid clients. The sound enrichment provided by his hearing aids and his knowledge about the tinnitus quickly allowed Barry to turn around with regard to his preconceived ideas about the permanency of his tinnitus.
Jack, 65 years old, noticed tinnitus when he retired. He presented at his first appointment with files of information, much of it downloaded from the Internet. It was evident very early in the appointment that 1.5 hours would be totally inadequate for answering all his questions and performing all the necessary tests. Jack was rebooked for a further appointment of the same length and given a few sound-enrichment ideas to work on in the meantime.
Clearly, a small percentage of tinnitus patients will require more than the usual time, so it may be helpful to have support staff schedule patients who may require more time at the end of the day.
Tinnitus work can and should be part of the work of all private audiology practices. The clinician needs to attend a training course on tinnitus treatment, as this topic is often not covered adequately in training programs. Tinnitus work is an area of clinical practice in which the clinician plays an important role and can often make a significant difference in the lives of tinnitus patients.