Tinnitus patients represent one of the most perplexing clinical populations served by hearing healthcare professionals. During the past three decades many tinnitus-management procedures have come and gone.
The complex and multiple factors inherent in tinnitus may, in part, explain why certain “treatments” appear to provide relief for some patients but not for others. The fact that most tinnitus is idiopathic and there are multiple etiologies also may account for some of this variability. Unquestionably, there is a significant placebo effect, and undoubtedly there are many patients for whom apparent beneficial effects may simply have been caused by a coincidental disappearance or lessening of the symptom for unrelated reasons.
Tinnitus patients, because of their ever-increasing number and the negative effect of tinnitus on their quality of life, deserve our continued effort. But there are so many conflicting and unsubstantiated claims of so-called “cures” or “treatments” found in the professional literature, the Internet, and the mainstream media in ubiquitous advertisements that hearing healthcare professionals must be vigilant both in the pursuit of better management procedures and in critically evaluating “evidence” in an unbiased and scientific manner. Indeed, while anecdotal reports may form level 5 or 6 evidence,1 a pervasive symptom like tinnitus deserves more controlled investigation.
Thus, when David Kirkwood asked me to guest-edit this special issue of The Hearing Journal, I was excited about the opportunity to present new potential concepts that are in various stages of development as viable approaches for tinnitus-patient management. Yet, at the same time, I was hesitant to provide a forum for promoting treatments that have little or no evidence base.
Ultimately, I decided to accept this challenge, because I felt it afforded an opportunity to present information, some with good evidence, some lacking in clear-cut evidence but containing a logical scientific rationale; some that appears rather foreign, exotic, or “far out” to those of us trained in Western medicine; and some that has been widely advertised but has not achieved widespread acceptance in scientific circles.
While this issue is by no means an exhaustive compilation of all the novel strategies available, I have attempted to provide a representative cross-section of approaches. However, the inclusion of an article in this special issue should not be interpreted as an endorsement of the approach it discusses by either me, as guest editor, or The Hearing Journal.
In my quest to find interesting and worthy articles, I was determined to find approaches representing a range of levels of scientific evidence. I didn't want to qualify or disqualify potential authors on the basis of their academic degree or publication record. However, I did ask for two things from all the authors: a rationale for why their treatment approach might work and data verifying that their treatment does work.
As you read these articles—and I hope you will read them all—you will find a wide disparity in scientific merit. Nonetheless, all of the approaches discussed have met with some degree of reported success and some degree of failure. So, I leave it up to you to determine if the authors met their obligations.
While the articles selected cover a wide range of approaches to tinnitus management, they can generally be divided into four (not always discrete) treatment categories: acoustic, behavioral, pharmacologic, and electromagnetic.
In the acoustic category, you will find papers by Reavis, Chang, and Zeng, using temporally patterned sounds; Viire, using sounds matched to one's tinnitus; and David, Naftali, and Katz, using binaural beats and principles of entrainment. Each of these represents a significant departure from traditional masking and sound-enrichment approaches.
In the pharmacologic category, Centore reviews pharmacological management; Keate discusses the ingredients in a ginkgo biloba-based Ring Stop treatment; and Latino describes the highly advertised homeopathic treatment called Quietus.
For a new behavioral approach, Gans explains the use of a group-based therapy called Mindfulness Based Tinnitus Reduction. And in the electromagnetic category, Dornhoffer and Mennemeier provide an up-to-date critique of repetitive transcranial magnetic stimulation.
Since the focus of this issue is on new approaches to tinnitus management, you will not find individual papers specifically devoted to those treatments that currently appear to be the most used and best established, namely Tinnitus Retraining Therapy (TRT), Neuromonics acoustic desensitization, masking, cognitive-behavioral therapy (CBT), amplification, and the use of special acoustic stimuli, such as fractal tones, now contained within certain hearing aids. Therefore, for readers who have not been exposed to these more widely accepted approaches, my colleague Jennifer Henderson Sabes and I offer an overview.
None of the approaches described in these papers are likely to provide the “cure” for all, or even most, tinnitus sufferers. In the meantime, scientists will continue to pursue the elusive cure. At least two recent papers2,3 provide hope that we are closing in on the actual site of lesion, an essential piece of knowledge for developing the “cure.” Until then we must continue to maintain an open, but critical mind for tinnitus-management procedures.
Robert W. Sweetow, PhD, the guest editor of this special issue on new approaches to the management of tinnitus, is Professor of Otolaryngology at the University of California, San Francisco (UCSF) and a consultant for Widex.
The long-time director of audiology at UCSF, Dr. Sweetow is a leading authority on tinnitus. He created and, for the past 15 years, has run the Tinnitus Clinic at UCSF and has personally treated tinnitus patients for 30 years.
He wrote the first paper on the use of Cognitive-Behavioral Therapy with tinnitus, which was published in Ear and Hearing in 1986. He has also written dozens of other articles and book chapters on tinnitus, including the chapter on Cognitive-Behavioral Modification in the 2000 Tinnitus Handbook, edited by Richard S. Tyler, PhD, and the chapter on tinnitus in the 1996 third edition of Hearing Disorders, edited by Jerry L. Northern, PhD.
He was guest editor of a special issue on tinnitus published in Seminars in Hearing and as chair of the American Academy of Audiology Task Force on Tinnitus, he authored the task force document, Audiologic Guidelines for the Diagnosis & Management of Tinnitus Patients in 2002.
He has also given numerous instructional courses on tinnitus patient management. Next April at AudiologyNOW! 2011, he and Dr. Steven Cheung will give a featured session presenting “A New Integrated Model of Tinnitus Perception and Management.”
Dr. Sweetow has twice been awarded research grants by the American Tinnitus Association and served on the ATA Scientific Advisory Committee for 6 years. He has been associate editor of The International Tinnitus Journal since 1995.
He is also prominent in audiology beyond the area of tinnitus. He is currently president of the Academy of Rehabilitative Audiology and serves as assistant or associate editor of Journal of the American Academy of Audiology, Trends in Amplification, and Seminars in Hearing. In 2008, he received the American Academy of Audiology Distinguished Achievement Award. In 2002, he was presented with an Oticon Focus on People National Award in the practitioner category.
1. Cox R: Evidence-based practice in provision of amplification. JAAA
2. Cheung SW, Larson PS: Tinnitus modulation by deep brain stimulation in locus of caudate neurons (Area Lc). Neurosci
3. Rauschecker JP, Leaver AM, Mühlau M: Tuning out the noise: Limbic-auditory interactions in tinnitus. Neuron