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Managing Patient—and Audiologist—Expectations for Tinnitus Treatment

Tyler, Richard PhD; Perreau, Ann PhD, CCC-A

doi: 10.1097/01.HJ.0000554348.15704.4f
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Dr. Tyler, left, is a professor of otolaryngology–head and neck surgery and of communication sciences and disorders at the University of Iowa, where he organizes an annual International Conference on Management of the Tinnitus and Hyperacusis Patient. Dr. Perreau is an associate professor of communication sciences and disorders and the audiology clinic coordinator at Augustana College.

A recent survey conducted by Husain, Gander, Jansen, and Shen1 stresses an important reminder to hearing care providers: Tinnitus patients need our help. Highlighting the needs and expectations of patients with tinnitus, Husain, et al., compared these results with the expectations of audiologists providing treatment and explored opportunities to improve the training of audiologists involved in tinnitus treatment.

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PATIENT EXPECTATIONS

The survey included 230 patients who sought treatment to eliminate their tinnitus (57%) or at least decrease its loudness (63%). Their primary complaint was tinnitus (86%), not hearing loss (14%), even though all likely had some degree of hearing loss. In fact, Kochkin, Tyler, and Born2 noted that 44 percent of patients reporting tinnitus did not admit they had hearing loss. Although many patients with tinnitus likely have mild hearing loss, patients in this survey reported tinnitus as their biggest problem and more noticeable than hearing loss.

The patients’ primary treatment expectation was medications (29%). Notably, 25 percent expected hearing aids and 17 percent expected sound therapy. Interestingly, most patients (37%) had no expectations for treatment of their tinnitus. In contrast, the 68 audiologists who completed the survey defined success for their tinnitus patients as decreased awareness of one's tinnitus (77%), improved thoughts and emotions (e.g., reduced stress or anxiety; 63%), and increased knowledge about tinnitus (63%).

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TREATMENTS RECEIVED

About 96 percent of the patients saw a health care provider to manage their tinnitus, including audiologists (70%) and family care physicians (44%). Although several questionnaires3,4 are available for audiologists and physicians to set goals for tinnitus therapy and document treatment outcomes, only 60 percent of the audiologists used questionnaires or outcome assessments. Additionally, the patients seldom received specialized counseling for tinnitus. Instead, a majority of patients (77%) received basic information about tinnitus, though this clearly did not address their concerns as over half of the patients (53%) felt that the audiologists did not spend adequate time discussing tinnitus. Similarly, more than half of the patients (57%) reported that the audiologist or physician did not fully answer their questions. Finally, 70 percent of audiologists did not consider specialized counseling for tinnitus as an integral part of their offerings for tinnitus treatment.

Interestingly, about 40 percent of audiologists discussed diet during the patient session. This is noteworthy, as no changes in diet have been recommended for tinnitus treatment,5 and dietary supplements have not shown to be helpful.6,7

About 43 percent of patients with tinnitus also reported hyperacusis. The two were first linked by Tyler and Conrad-Armes in 1983.8 This shows the importance of teaching counseling and sound therapy for hyperacusis as well.9

One shortcoming of the survey was the suggestion of specialized counseling as tinnitus retraining therapy (TRT) or cognitive behavioral therapy (CBT). TRT uses directive, not collaborative counseling, and the use of the mixing point has been challenged.10 Although portions of CBT have been included in counseling activities, we have argued its use is overstated.11 Another issue is that habitation was a focus of success. However, habituating as a goal is only one approach. Optional counselling foci, such as acceptance and ownership of one's tinnitus, were not asked.

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NEED FOR AWARENESS AND TRAINING

Both patients and audiologists emphasized the need for more information about tinnitus. Fortunately, there has been more interest in recent years in enabling both patients12 and audiologists13 to improve tinnitus awareness and management. Specifically, patients are seeking help, but they are unsure of where to begin.

Nearly all patients (94%) reported that they go online to get information about tinnitus, indicating that the internet is the patients’ main source for information on this condition. Consistent with this finding, 75 percent of the audiologists surveyed noted that their clinic was not well known for helping tinnitus patients. Although over 66 percent of audiologists thought a group counseling session or support group would be beneficial for tinnitus patients, they have yet to include any of these activities in their practice. Furthermore, about 59 percent of the audiologists wanted more graduate school training on tinnitus management, suggesting that audiologists also want more resources on tinnitus.

Finally, Husain, et al.,1 found that the audiologists who had better access to resources on tinnitus treatment were also more likely to report effective management of their patient's tinnitus and higher patient satisfaction, and more often provided adequate resources to the patient. Thus, better audiologist training on tinnitus management is likely to be the best step in improving patient outcomes.

The bottom line is that 83 percent of the patients assessed the overall effectiveness of their encounter with an audiologist or physician for tinnitus management to be not at all or not very effective. Certainly, this emphasizes that we need to provide more support and counseling to tinnitus patients.

Although it is true that most tinnitus patients want a pill,14 Husain and colleagues1 demonstrated how hearing health care providers can expand services by including tinnitus management. We can help patients by providing specialized counseling for tinnitus, hearing aids, and sound therapy devices using comprehensive and patient-centered care. Patients are seeking our help, and we need to be knowledgeable, nurturing, and equipped to assist them in the best way possible.

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REFERENCES

1. Husain, F.T., Gander, P.E., Jansen, J.N., & Shen, S. (2018). Expectations for tinnitus treatment and outcomes: A survey study of audiologists and patients. Journal of the American Academy of Audiology, 29, 313-336.
    2. Kochkin, S., Tyler, R., & Born, J. (2011). MarkeTrak VIII: Prevalence of tinnitus and efficacy of treatments. The Hearing Review, 18(12),10-26.
      3. Tyler, R.S. & Baker, L.J. (1983). Difficulties experienced by tinnitus sufferers. Journal of Speech and Hearing Disorders, 48(2), 150 154.
        4. Tyler, R., Ji, H., Perreau, H., Witt, S., Noble, W., & Coelho, C. (2014). Development and validation of the Tinnitus Primary Function Questionnaire. American Journal of Audiology, 23, 260-272.
          5. Tunkel, D.E., Bauer, C.A., Sun, G.H., Rosenfeld, R.M. et al. (2014). Clinical practice guideline: Tinnitus. Otolaryngology-Head and Neck Surgery, 151(2S) S1-S40.
            6. Rojas-Roncancio, E., Tyler, R., Jun, H.J., Wang, T.C., Ji, H., Coelho, C., … Gantz, B.J. (2016). Manganese and lipoflavonoid plus(®) to treat tinnitus: A randomized controlled trial. Journal of American Academy Audiology, 8, 661-668.
              7. Coelho, C., Witt, S., Ji, H., Hansen, M., Gantz, B., & Tyler, R. (2013). Zinc to treat tinnitus in the elderly: A randomized placebo controlled crossover trial. Otology and Neurotology, 34(6), 1146-1154.
                8. Tyler, R.S. & Conrad Armes, D. (1983). The determination of tinnitus loudness considering the effects of recruitment. Journal of Speech and Hearing Research, 26(1), 59 72.
                  9. Tyler, R.S., Noble, W., Coelho, C., Roncancio, E., Jun, H.J. (2015). Tinnitus and hyperacusis, In Katz, J., Chasin, M., English, K., Hood, L., Tillery, K. (Eds.) Handbook of clinical audiology, 7th ed., pp. 647-658.
                    10. Tyler, R., Noble, W., Coelho, C., & Ji., H. (2012). Tinnitus Retraining Therapy: Mixing Point and Total Masking Are Equally Effective. Ear Hear. 33:588–594. doi: 10.1097/AUD.0b013e31824f2a6e.
                      11. Tyler, R.S., & Mohr, A.M. (2017). Is CBT for tinnitus overemphasized? The Hearing Journal, Journal Club, 8-10.
                        12. Tyler, R.S., Chang, S.A., Gehringer, A.K., & Gogel, S.A. (2008). Tinnitus: How you can help yourself! Audiological Medicine, 6, 85-91.
                          13. Tyler, R.S., Haskell, G., Gogel, S., & Gehringer, A. (2008). Establishing a tinnitus clinic in your practice. American Journal of Audiology, 17, 25-37.
                            14. Tyler, R.S. (2012). Patient preferences and willingness to pay for tinnitus treatment. Journal of American Academy Audiology, 23, 115-125.
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