Tinnitus, or chronic ringing or buzzing in the ears, and hyperacusis, a potentially disabling intolerance of moderate to loud sounds, occur commonly in the adult population. Estimates are that from 40 million to as many as 50 million people in the United States experience some degree of tinnitus and/or hyperacusis. Despite the frequency of their occurrence, these complaints frequently go unrecognized or, at best, are poorly understood by most healthcare professionals.
Tinnitus is estimated to affect between 10% and 20% of the overall population of the United States.1 Tinnitus complaints are often associated with some degree of hearing loss. Accordingly, prevalence increases with age; nearly a third of the population older than 70 years report significant tinnitus. Somewhere between 20% and 45% of tinnitus sufferers also have complaints of hyperacusis.2 A small number of patients complain of hyperacusis alone.
Approximately three-quarters of those who experience tinnitus are not significantly bothered by it. For the remaining 25%, tinnitus exerts an undesirable influence on their daily life. As many as 10 to 12 million people in the United States are sufficiently debilitated by their tinnitus and/or hyperacusis that some form of intervention is warranted. It is for these patients that multidisciplinary management strategies have been developed. In our experience, this type of approach is often necessary and most helpful for patients with complex symptomatology.
Tinnitus may best be viewed as a dynamic, complex, multidimensional experience. The mechanisms of tinnitus are not yet thoroughly understood. However, it seems probable that most forms of chronic tinnitus are induced or triggered by peripheral disorder resulting in an imbalance of activity in the central auditory pathways. This, in turn, produces abnormal spontaneous activity resulting in the tinnitus perception.
TINNITUS, HYPERACUSIS, AND CHRONIC PAIN
Maintenance of the tinnitus percept almost certainly involves both auditory and non-auditory structures within the central nervous system. The degree of annoyance associated with the tinnitus perception is related to these central factors. In this sense, tinnitus and hyperacusis have a number of characteristics that are similar to a variety of chronic pain syndromes.3,4 (See Table 1).
For example, anxiety and depression, sleep disturbance, withdrawal from social activities, and social isolation are found in both patient groups.5 In addition, tinnitus, hyperacusis, and chronic pain can each be a manifestation of peripheral damage and subsequent central nervous system control. The emotional component associated with tinnitus, hyperacusis, and chronic pain supports the involvement of the limbic or sympathetic nervous system in the maintenance of these conditions. Furthermore, with each syndrome, changes in the peripheral nervous system can induce alterations in the central nervous system that are perpetuated beyond the time of normal healing.
Very little literature addresses the coincidence of tinnitus/hyperacusis and chronic pain. However, sleep disturbance, depression, tinnitus, hyperacusis, and some types of headaches have all been associated with disturbance of the serotonergic system.6
The level of distress and dysfunction caused by tinnitus/hyperacusis and chronic pain appears to be related to emotional and psychosocial factors as well as coping abilities. We have observed a significant number of patients presenting with tinnitus and/or hyperacusis in addition to some form of current or previous chronic pain experience. Tinnitus/hyperacusis and chronic pain have overlapping dysfunctional symptoms and behaviors, such as the need for good coping abilities. A multidisciplinary model of evaluation and treatment for management of severe tinnitus and hyperacusis, which parallels that used with chronic pain patients, was developed and implemented at the University of Virginia Medical Center.
MEMBERS OF THE MULTIDISCIPLINARY TEAM
Our approach involves the disciplines of audiology, otology, pain medicine, and pain psychology. The intake evaluation strategies are listed in Table 2.
The audiologist serves as coordinator of the Tinnitus and Hyperacusis Clinic. Most patients are seen initially by the audiologist. Referrals are then made to the other members of the team as deemed appropriate.
For a patient presenting with less complex problems, the extended consultation provided by the audiologist is often sufficient by itself in helping the person manage his/her tinnitus or hyperacusis. Audiologic management includes hearing remediation if hearing loss is present. Counseling and education are key elements to understanding the problem.7 Teaching addresses such topics as normal hearing, audiologic hygiene (including the influence of loud noise and/or quiet on the severity of tinnitus and hyperacusis), the mechanisms of tinnitus and hyperacusis as they are currently understood, and an in-depth discussion of treatment options.
In addition, tinnitus habituation training and use of acoustic therapies such as hearing aids or noise generators are used to desensitize or cause a re-organization of the central auditory nervous system. These audiologic management strategies are aimed at reducing the magnitude of the tinnitus percept and the influence it has on the patient's life.
The otologist carries out the medical evaluation and, if indicated, the medical and/or surgical management of tinnitus. The otologic evaluation involves a thorough case history and physical examination, and may also include radiologic and laboratory studies. It is extremely important either to rule out or, when appropriate, to treat medical conditions of which the tinnitus may be a symptom. These include acoustic neuroma, meningioma, Meniere's disease, glomus tumor, and vascular lesions.
The pain-management physician evaluates the patient for the presence of head and neck pain complaints, such as temporomandibular joint dysfunction, myofascial neck and shoulder complaints, or cervical spine disease. Treatment for these conditions coincides with the management of tinnitus and/or hyperacusis. Often the pain complaint, which may compound the patient's distress, can be readily managed.
In addition, attention is paid to other treatable co-morbidities, including sleep disorder, depression, and the presence of ototoxic medications (e.g., high-dose, non-steroidal anti-inflammatory drugs, loop diuretics), which may contribute to the severity of the tinnitus and/or hyperacusis. Many tinnitus/hyperacusis patients arrive at our clinic after having seen multiple healthcare professionals over a number of months or longer. It is not uncommon for these individuals to be on numerous medications, including antidepressants, sleep aids, anxiolytics, and even narcotics. The pain-management physician is actively involved in simplifying and focusing the medical regimen. For some patients, this function is often vital to the overall success of efforts to manage more severe tinnitus and/or hyperacusis symptoms.
The pain-management psychologist evaluates the patient's emotional, cognitive, and behavioral functioning. Particular effort is directed toward identification of barriers to successful treatment, such as mood disorders and deficient coping strategies. Treatment modalities include supportive and cognitive-behavioral interventions, which incorporate education about pacing of activities with energy conservation, sleep hygiene, behavioral planning to increase functioning, stress management, and realistic goal setting. Self-regulation techniques such as biofeedback are used to help increase body awareness, shift perceived locus of control, manage autonomic arousal, and facilitate the reintegration of the patient with his/her life. The focus is on “wellness” rather than “illness.”
Figure 1 illustrates the multidisciplinary model used in our tinnitus/hyperacusis clinic. The paradigm depends on a high level of communication among all participants. In addition, it is imperative that the audiologist, otologist, pain-management physician, and pain-management psychologist have a fundamental understanding of the role and contribution of each member of the tinnitus/hyperacusis team. The majority of our referrals are routed through the audiology clinic. About half of these are self-referrals and half derived from various healthcare professionals.
TINNITUS/HYPERACUSIS AND CHRONIC PAIN
In preliminary studies of chronic pain patients, the incidence of tinnitus and hyperacusis was found to be significantly higher than would be predicted in the general population. For example, 70% of patients suffering from headache or facial pain reported tinnitus and/or hyper-acusis.8 Of patients with tinnitus and/or hyperacusis, virtually all (91%) felt their head pain was worsened by the audiologic complaint. Likewise, a similar number reported that their tinnitus or hyperacusis was exacerbated by the presence of head pain. Of those patients studied with myofascial pain or fibromyalgia, 67% reported tinnitus and/or hyperacusis.9
We have identified a large number of tinnitus and hyperacusis patients who have depression and sleep disturbance. In addition, many have coincident pain complaints, particularly myofascial, head, neck, and shoulder pain, or degenerative spine disease. Use of medications and injections to manage these complaints has, in most cases, served to decrease perceived dysfunction and distress. This, in turn, allows for the delivery of more efficacious audiologic tinnitus management, particularly when treating more refractory patients.
An example of such a patient is shown in Figure 2. The patient is a 64-year-old woman referred by her primary-care physician. She had a 14-month history of virtually incapacitating tinnitus and hyperacusis and had been told by her primary-care physician and several specialists that she should “just ignore it and it would go away.” She reported significant sleep disorder, problems concentrating, intolerance of social situations, and excruciating scalp tingling and pain. She also had a long history of interstitial cystitis, anxiety disorder, depression, and hypothyroidism.
Audiologic evaluation revealed hearing essentially within normal limits through 3000 Hz with mild-to-moderate, precipitous, high-frequency hearing loss bilaterally. She reported tinnitus in both ears centered around 4000 Hz and resembling a hissing sound. She also reported severe hyperacusis.
Extensive education and counseling were provided along with tinnitus habituation therapy. In-the-ear noise generators were fitted bilaterally. She was placed on Baclofen for neuropathic pain, myofascial pain, and sleep disturbance. Counseling was also provided for pacing of daily activities, relaxation, and mood monitoring.
After 1 year of treatment, her symptoms were much improved. She was no longer experiencing severe tinnitus or hyperacusis and her pain symptoms were largely resolved. She was also sleeping much better and had returned to her usual social activities.
Generally, the patients who enter our program have undergone months or years of unsatisfactory “doctor shopping” and extensive evaluation to rule out associated central nervous system pathology (e.g., acoustic neuroma). For these patients, many previous efforts at traditional medical treatment had failed. In addition, most have been told at some point that the medical community has nothing to offer and they will “just have to learn to live with it.”
Through the combined expertise of audiology, otology, and pain management within a multidisciplinary tinnitus/hyperacusis treatment model, the functional goals of these often-complex patients can be achieved.