The Management of Tinnitus

Neurology Primer The Management of Tinnitus John P. Preece, PhD, Department of Communicative Disorders, University of Rhode Island, Kingston, RI. Richard S. Tyler, PhD, Department of Otolaryngology-Head & Neck Surgery, Department of Speech Pathology & Audiology, University of Iowa, Iowa City, IA. William Noble, PhD, School of Psychology, University of New England, Armidale, NSW, Australia. Hearing loss in the elderly is a frequently acknowledged problem. Prevalence of hearing loss clearly increases with age, to as high as 50% of persons older than 70 years. Less recognised is an often-related problem, tinnitus. We are concerned here about pathological tinnitus: that which lasts more than five minutes more than once a week. In this article we review the prevalence of tinnitus as a function of age, and its causes and mechanisms. We also describe problems commonly associated with chronic tinnitus and some treatment options. We conclude with some special considerations for the elderly patient. Key words: tinnitus, prevalence, counseling, sound therapy. Introduction Hearing loss in the elderly is a frequently acknowledged problem. Prevalence of hearing loss clearly increases with age, to as high as 50% of persons older than 70 years. 1 Less recognised is an often-related problem, tinnitus. Tinnitus is the perception of sounds that seem to come from the ears or from within the head but which have no external source. The great majority of people experience low-level tinnitus from time to time, but this is not problematic and may not lead to troublesome ear noises. In some people, however, it can become a disturbing phenomenon. Tinnitus is often triggered by intense sound exposure or may be associated with pathological conditions within the cochlea. Tinnitus also might be associated with cardiovascular disorders, and Nondahl, et al. suggested that high total cholesterol might influence tinnitus. 2 Some medications commonly taken by older people have been associated with tinnitus, including anti-inflammatories (including aspirin), antibiotics, antidepressants, antihistamines and antihypertensives. 3 Considering many of these causes, it would be expected that the incidence of tinnitus would rise with increasing age. Tinnitus can be debilitating, and can be associated with other symptoms such as depression, insomnia, reduced concentration and headache. 4 Dauman and Tyler used the terms normal tinnitus and pathological tinnitus as a classification system. 5 We are concerned here with only pathological tinnitus: that which lasts more than five minutes more than once a week. In this article we review the prevalence of tinnitus as a function of age, and its causes and mechanisms. We also describe problems commonly associated with chronic tinnitus and some treatment options. We conclude with some special considerations for the elderly. Prevalence There have been several surveys of the prevalence of tinnitus, some of which divide the data into age groups. Table 1 summarises the findings of eight studies of tinnitus prevalence, from the U.S., 2,6,7 the U.K., 1,8,9 Sweden 10 and Australia. 11 Prevalence estimates vary, perhaps because of variable wording of the particular survey questions that were asked. For example, the data of Nondahl, et al. 2 included only persons with significant tinnitus, defined as tinnitus of at least moderate severity or that which caused difficulty in falling asleep; the question posed by Sanchez, et al. 11 was Do you ever get noises in your head or ears which usually last longer than five minutes?. In contrast, the data of Hinchcliffe 8 and of Leske 6 included anyone who responded that they had ever noticed ringing or other noises over the past few years. It can be seen in Table 1 that prevalence ranges vary from 6 10% in the Nondahl, et al. 2 study, to 27 45% in the Leske 6 study. Overall, there seems to be a gradual increase in prevalence of tinnitus with age until about 70 years. Tinnitus might be more prevalent among females than males, 6,2 and although reasons for this are unclear, there are many sex-related differences in the auditory systems. Table 2 (page 26) lists the likely reasons for the rise in tinnitus prevalence among the elderly. Causes We classify tinnitus as either sensorineural or middle-ear in origin. 12 Middle-ear tinnitus is associated with blood flow or muscle abnormalities. Sensorineural tinnitus arises in the nervous system. Almost anything that causes hearing loss can also cause tinnitus. More common causes include noise exposure, aging (presbycusis), medications, head injury, middle-ear disease (such as otosclerosis) and Meniere s disease. Frequently, a specific cause cannot be determined in an individual case. Stress is sometimes implicated as a trigger. Tinnitus may be caused by a variety of mechanisms. We assume that tinnitus, like the perception of all sound, results from nerve-fibre activity in the temporal lobe of the cortex. This increase in activity might result from: 22 GERIATRICS & AGING June 2003 Vol 6, Num 6

an increase in spontaneous activity of neurons in the auditory system above the normal spontaneous activity level; a decrease in spontaneous activity reducing the effectiveness of an inhibitory circuit; 13 an edge between normal and absent activity; 14 a correlation of neural activity among nerve fibres or; 15 a reassignment of neural best frequencies and therefore a greater than normal representation of certain bestfrequency fibres in the brain following hearing loss. 16 Although the effects of hearing loss due to aging can be seen in the cochlea, it is important to understand that tinnitus might arise in the brain stem or in the brain. 12 Treatments Although many people who experience problematic tinnitus seem to habituate to it, 17 for others it can be debilitating. 4 The areas of difficulty can be categorised broadly into problems with concentration, emotional well-being, hearing and sleep. Not all patients have difficulties in all of these areas, and the level of difficulty in each area can vary widely across patients, and even between episodes within the same patient. There are many possible treatments for tinnitus, divided broadly into strategies that reduce the tinnitus and those that help the patient cope with the tinnitus. In a small minority of cases, tinnitus involves abnormal blood flow or middle-ear muscle movement, 18 and surgical treatment can be considered. In extremely debilitating cases of sensorineural tinnitus, sectioning of the auditory nerve has been utilised. Unfortunately, this procedure completely eliminates hearing and is largely ineffective at eliminating the tinnitus. Numerous medical treatments have been tried, but none has been shown to be effective in controlled studies. 19 Although there are no currently accepted medical treatments for tinnitus per se, the tinnitus sufferer should be evaluated for the possibility of a treatable associated condition, such as high blood pressure. Some complementary therapies, such as acupuncture, have been attempted, but the results have not been promising. 19 Counseling Counseling can form a major part of effective treatment of tinnitus. 20-23 Counseling can be divided into the following areas: providing information; changing the way the patient thinks about tinnitus and; providing coping strategies. For many patients, counseling that provides information the demystifying of tinnitus, in a sense provides some relief. 24 Tyler and Baker referred to this as educational counseling, 4 and topics for discussion may include prevalence, possible causes and potential treatments of hearing loss and tinnitus. 23 Many patients find comfort in learning that tinnitus is relatively common and that there are causal factors. They need to know that tinnitus is real and not just something in their heads. It is important not to mislead the patient to believe there is a cure that works for everybody, but rather to explain there are strategies that can reduce the effect of tinnitus on their lives. Specific characteristics of an individual s tinnitus, obtained through pitch and loudness matching, can be discussed. Degree of handicap also can be assessed. 25 Although we cannot make the tinnitus go away, we can change the way our patients think about and react to it. This forms the basis for cognitive-behavioural therapy. 20,26 Patients often develop unrealistic and unhelpful thoughts about Table 1 Prevalence of Tinnitus for Various Age Groups Hinchcliffe 8 Leske 6 Coles 9 Axelsson 10 Brown 7 Davis 1 Sanchez 11 Nondahl 2 Age % Age % Age % Age % Age % Age % Age % Age % 18 24 21 18 24 27 17 30 4 20 29 8 18 44 2 17 30 10 25 34 27 25 34 27 35 44 24 35 44 31 31 40 5 30 39 6 31 40 9 45 54 27 45 54 33 41 50 8 40 49 9 41 50 11 55 64 39 55 64 38 51 60 12 50 59 19 45 64 5 51 60 15 48 59 7 65 74 37 65 74 45 61 70 16 60 69 20 65 74 9 61 70 19 70 74 5 60 69 10 75 79 41 71 80 14 70 79 21 >75 8 71 80 18 75 79 7 70 79 9 >80 18 80 84 9 80 92 6 >84 9 Ages are in years and percentages are rounded to the nearest whole number. 24 GERIATRICS & AGING June 2003 Vol 6, Num 6

Table 2 Reasons for Increase in Prevalence of Tinnitus With Age Aging of the auditory system might directly cause tinnitus. Hearing loss due to aging might indirectly cause tinnitus. Accumulation of noise exposure over the years might cause tinnitus. (This may be related to the previous point that prevalence of hearing loss increases with age. Some types of noise-induced tinnitus may not arise until years after removal from the noise.) 35 Tinnitus might become more noticeable as external sounds become less audible with advancing hearing loss. Accumulation of aging effects on the overall physiological health of the patient. Elderly more likely to have other diseases, some of which might be associated with tinnitus (e.g., cardiovascular disease). Older people might not be able to habituate to low-level tinnitus, therefore making it more likely to be problematic. 17 Increased use of prescription drugs, some of which may cause or increase tinnitus. 5 their tinnitus. Helping them think about tinnitus in a less negative way can be very useful. To date, this procedure is the only treatment shown to be effective in controlled studies. 26,27 It is essential that the patient be empowered with ways to learn to live with their tinnitus, as well as provided with information and help for them to restructure their thoughts. Coping strategies may include the recognition of what situations make their tinnitus worse, and how they can sometimes avoid these situations. Knowing what situations make their tinnitus less noticeable, and how they can increase the occurrence of these situations is also helpful. Other strategies may include having a plan (such as watching a movie or performing a captivating hobby) to implement when their tinnitus is worse, and being able to relax on a regular basis and whenever necessary. Hearing Aids Although the use of hearing aids is not a therapy for tinnitus per se, most people with tinnitus also have impaired hearing and can benefit from hearing aids (see Amplification: The Treatment of Choice for Presbycusis, May 2003, Vol.6, No.5). In many cases, the improved communication allowed by amplification relieves stress, which in turn reduces the severity of tinnitus. In addition, hearing aids amplify background noises, which can mask tinnitus or allow a habituation to low-level sounds. 28 Some people report that the background sounds distract them from the tinnitus and they find this more pleasant. Other Sound Therapies Many patients use a variety of background sounds to compete with, blend with or mask their tinnitus. 29 Table 3 lists some of the many different types of sound therapies, from the use of sounds encountered incidentally in the environment, to the deliberate use of music or broadband noise to help mask tinnitus. Specific sounds may be prescribed as a treatment for tinnitus. Everyday sounds include fans, car engines, the static from a radio and electric motors. Music should be relaxing and in the background. 30 Tinnitus retraining therapy uses a noise that is set to a mixing point at which the tinnitus is heard just above the noise. This level is where the noise and tinnitus blend or mix together. 31 Noise also may be used to completely mask or partially mask the tinnitus. 29 These sounds can be tailored to disrupt tinnitus but to minimally interfere with other sounds. At least part of the benefit comes from the patient being able to control the external sound, creating a replacement for the tinnitus. In some Table 3 Categories of Sound Therapy Sound Therapy Everyday Sounds Music Retraining Masking Rationale Attention Attention Habituation Perception Long-term Goal Not attend to tinnitus Not attend to tinnitus Not attend to tinnitus Not attend to tinnitus When heard, refocus When heard, refocus When heard, not react When heard, not react Counseling Shift attention Shift attention Decrease fear Provide control Type of Sound Environmental Music Noise Noise 26 GERIATRICS & AGING June 2003 Vol 6, Num 6

patients there is a residual benefit, with the reduction in tinnitus continuing for a short time after the removal of the masker. 32 Special Considerations in Aging Many older people are healthy and active, and no special considerations are needed for their treatment of tinnitus. However, here we will consider a few of the issues requiring special attention that may occur in the elderly. The use of hearing aids, tinnitus noise generators or a combination of hearing aids and noise generators can require fine coordination for manipulation of gain controls and battery replacement. It has been reported that hearing aid use decreases somewhat with increasing age. 33 One possible explanation for the decrease in usage could be that the patients experience increasing difficulties with the handling of the devices. For older people, recall of verbal material declines. 34 Hence, there is increased likelihood that more effort may be needed to follow lengthy instructions or advice, as offered in counseling sessions, and a greater chance that material forming a counseling episode may not be recalled or recalled accurately. Programs need to be tailored to take this factor into account, such as by scheduling multiple, short sessions. Written materials are also helpful. Many elderly persons live alone and have restricted social lives. This can make normal tinnitus problematic. There may be few distractions to reduce the salience of the tinnitus. In these cases, management might include appropriate recreation and lifestyle changes. The usefulness of background sounds could be part of this discussion. Conclusions Tinnitus is a common problem in the elderly, due to the aging process itself, an accumulation of a lifetime s noise exposure and the increased use of medications. Although there is no cure for tinnitus, there are beneficial interventions. The most helpful treatments include counseling and some form of sound therapy. Hearing aids improve communication and therefore reduce stress, indirectly helping to reduce the effects of tinnitus. Acknowledgements: We wish to acknowledge grant support provided by the Rhode Island Geriatric Education Center (Preece) and the Obermann Center for Advanced Studies, The University of Iowa (Tyler and Noble). References 1. Davis, A. Hearing in adults. London: Whurr, 1995. 2. Nondahl DM, Cruickshanks KJ, Wiley TL, et al. Prevalence and 5-year incidence of tinnitus among older adults: The epidemiology of hearing loss study. J Am Acad Audiol 2002;13:323-31. 3. Royal National Institute for the Deaf. Drugs and tinnitus. RNID Factsheet. www.rnid.org.uk/html/factsheets/tin_dr ugs.htm, 2001. 4. Tyler RS, Baker LJ. Difficulties experienced by tinnitus sufferers. J Speech Hear Disord 1983;48:150-4. 5. Dauman R, Tyler RS. Some considerations on the classification of tinnitus. In: Aran JM, Dauman R, editors. Proceedings of the fourth international tinnitus seminar, 1991 Aug 27-30, Bordeaux, France. Amsterdam/New York: Kugler Publications, 1992. 6. Leske MC. Prevalence estimates of communicative disorders in the U.S.: Language, learning and vestibular disorders. ASHA 1981;23:229-37. 7. Brown, SC. Older Americans and tinnitus: A demographic study and chartbook. In: Johnson RC, Hotto SA, editors. GRI Monograph Series A, #2. Washington: Gallaudet University, 1990. 8. Hinchcliffe R. Prevalence of the commoner ear, nose and throat conditions in the adult rural population of Great Britain. Br J Preventive Med 1961;15:128-40. 9. Coles RRA. Epidemiology of tinnitus: Prevalence. J Laryngol Otol 1984; (Suppl 9):7-15. 10. Axelsson A, Ringdahl A. Tinnitus: A study of its prevalence and characteristics. Br J Audiol 1989;23:53-62. 11. Sanchez L, Boyd C, Davis AC. Prevalence and problems of tinnitus in the elderly. In: Hazell J, editor. Proceedings of the Sixth International Tinnitus Seminar, 1999 Sept 5-9, Cambridge. Cambridge: The Tinnitus and Hyperacusis Centre, 1999. 12. Tyler RS. Comments on animal models of tinnitus. In: Evered D, Lawrenson G, editors. Tinnitus. London: Pitman Books Ltd., 1981:136. 13. Eggermont JJ. Tinnitus: Some thought Where to Get Advice? In addition to a consultation with an audiologist and otolaryngologist, patients could be directed to a selfhelp resource for tinnitus sufferers. One such resource that could be recommended is: American Tinnitus Association P.O. Box 5 Portland, OR 97207-0005, USA 800-634-8978 http://www.ata.org about its origin. J Laryngol Otol 1984; (Suppl 9):31-7. 14. Kiang NYS, Moxon EC, Levine RA. Auditory-nerve activity in cats with normal and abnormal cochleas. In: Wolstenholme GEW, Knight J, editors. Sensorineural hearing loss. London: Churchill, 1970:241-68. 15. Moller AR. Pathophysiology of tinnitus. 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JM, Martini A, et al., editors. Handbook of audiological medicine. London: Martin Dunitz, 2003:571-8. 24. Sanchez L, Stephens D. Survey of the perceived benefits and shortcomings of a specialist tinnitus clinic. Audiology 2000;39:333-9. 25. Tyler, RS. Tinnitus disability and handicap questionnaires. Seminars in Hearing 1993;14:337-84. 26. Henry JL, Wilson PH. An evaluation of two types of tinnitus cognitive intervention in the management of chronic tinnitus. Scand J Behaviour Therapy 1998;27:156-66. 27. Davies S, McKenna, L, Hallam, RS. Relaxation and cognitive therapy: A controlled trial in chronic tinnitus. Psychology Health 1995;10:129-44. 28. Vernon JA. Attempts to relieve tinnitus. J Am Audiol Soc 1977;2:124-31. 29. Vernon JA, Meikle MB. Tinnitus masking. In: Tyler RS, editor. Tinnitus handbook. San Diego: Singular, 2000:313-56. 30. Davis PB, Wilde RA, Steed LG. Clinical trial findings of the acoustic desensitisation protocol: a habituationbased rehabilitation technique. Seventh International Tinnitus Seminar 2002: 74-7. 31. Jastreboff PJ, Hazell JWP. A neurophysiological approach to tinnitus: clinical implications. Br J Audiol 1993;27:7-17. 32. Feldmann H. Time patterns and related parameters in masking of tinnitus. Acta Otolaryngologica 1983;95:594-8. 33. Humes LE, Wilson DL, Barlow NN, et al. Longitudinal changes in hearing aid satisfaction and usage in the elderly over a period of one or two years after hearing aid delivery. Ear Hear 2002;23: 428-38. 34. Craik FIM, Jennings JM. Human memory. In: Craik FIM, Salthouse TA, editors. The handbook of aging and cognition. New Jersey: Lawrence Erlbaum Associates, 1992:51-110. 35. Coles R. Medicolegal issues. In: Tyler RS, editor. Tinnitus handbook. San Diego: Singular, 2000:399-417. 28 GERIATRICS & AGING June 2003 Vol 6, Num 6