Like other neurologic symptoms, tinnitus can be considered chronic if it persists for 6 months or more. Approximately 90% of cases of chronic tinnitus are associated with some degree of sensorineural hearing loss.19 Because sensorineural hearing loss is irreversible, most cases of chronic tinnitus cannot be “cured.” Duckro et al20 wrote: “As with chronic pain, the treatment of chronic tinnitus is more accurately described in terms of management rather than cure.”
The goal of management is not necessarily to mask or remove the patient’s perception of tinnitus. In many cases, this is not possible. Successful management enables patients to pay less attention to their tinnitus. An effective management program helps patients to understand and gain control over their tinnitus, rather than allowing it to control them. The ultimate goal is to reduce the severity of tinnitus. Clinicians should strive to help patients progress to where tinnitus is no longer a negative factor in their lives.
Establishing tinnitus severity
Only 25% of people who experience chronic tinnitus consider the symptom to be a significant problem.2 These are the patients most likely to seek treatment. If a patient is not bothered by tinnitus and no active disease processes are detected, no treatments are necessary. The clinician should reassure such patients that tinnitus is a harmless perception of sound and does not usually portend more serious medical conditions.
What differentiates the majority of people not bothered by tinnitus from the minority who perceive it as a significant, even debilitating problem? Is it the matched loudness, pitch, or other qualities of the sound(s) they hear? Several studies have concluded that tinnitus severity is not correlated with any of these psychoacoustic parameters.21-23
Tinnitus severity can be defined and quantified several ways: by how much or how often a patient is bothered by tinnitus; by how much or how often tinnitus detracts from the patient’s enjoyment of life; or by how disabling patients perceive their tinnitus to be. Instruments such as the Tinnitus Severity Index11 can be used to assess tinnitus severity (Figure 2).
Tinnitus management strategies
Once underlying conditions have been treated or ruled out, reassure and counsel patients regarding factors that could exacerbate or improve their condition. If patients understand their tinnitus is nothing more than a perception of sound, they will be better able to pay less attention to it. This process of patient education and counseling helps to “demystify” the symptom of tinnitus and encourages patients to view their tinnitus with a more realistic perspective.
The severity of tinnitus is often associated with problems such as insomnia,24 anxiety,25 and depression.26 Such issues can form a vicious circle, with each one exacerbating the others.23 Tinnitus is not always the starting point of this cycle—many patients experience depression, insomnia, or anxiety before tinnitus. Medication or psychotherapy will often reduce the severity of these symptoms and associated tinnitus (LOE: 2).27-28
Because each patient has a unique medical, psychological, and social history, management programs should be individualized. In fact, the most successful tinnitus management programs employ multimodal strategies designed to address the specific needs of each patient (LOE: 2).27,29
Recommendations should be formulated and explained to the patient: appropriate acoustic therapy; use of hearing protection (all patients should wear earplugs or ear muffs when they are exposed to excessively loud sounds [LOE: 1]);30 and strategies for management of insomnia, anxiety, or depression. As appropriate, provide patients with referral and contact information for physical or psychiatric evaluations, psychological counseling, and other recommended services or products.
Acoustic therapy
Patients should add pleasant sounds (music, relaxation CDs, or a tabletop sound machine) to any environment that is too quiet, and listen to them through speakers or headphones. Patients who experience chronic insomnia because of tinnitus may find relief in using a tabletop sound machine in combination with a pillow embedded with speakers (such as the Sound Pillow, distributed by Phoenix Productions, San Antonio, TX).
Patients with normal or nearly normal hearing might benefit from in-the-ear sound generators (such as those manufactured by General Hearing Instruments, Harahan, LA) that produce a broad-band sound to muffle or mask the tinnitus.31 Significant, aidable hearing loss can often be lessened with hearing aids or combination instruments (hearing aid and sound generator in one unit). Hearing aids not only improve communication ability, the devices can also reduce the perception of tinnitus.32
Follow-up
Encourage patients to ask questions about recommended tinnitus management procedures and to report their progress. Reassess patients at 1 month. If necessary, recommendations can be modified to facilitate patient improvement. Follow-up questionnaires can be mailed to patients 6 and 12 months after their initial appointment to assess the effectiveness of the tinnitus management program.