The disability caused by tinnitus is believed to be one of the most common chronic medical conditions in adults – on par with diabetes, lower back & neck pain and knee problems. And, hearing care professionals encounter patients with tinnitus on an almost daily basis.
In fact, according to South Korean researchers, tinnitus, like hearing loss, is one of the few chronic medical conditions adversely affecting all five measures of health-related quality of life surveys: mobility, self-care, performance of usual daily activities, pain and/or discomfort and anxiety and/or depression. Further, tinnitus, a symptom described as the perception of sound in the absence of an external stimulus, is a relatively widespread condition with studies indicating 5% to 30% of the population deals with the condition.
Tinnitus Research Suggests Millions Impacted
A recent JAMA Otolaryngology Head & Neck Surgery study, published online July 21, indicated that tinnitus affects nearly 10% of the adult population in the U.S and more than half of individuals with tinnitus do not discuss it with their doctor. The situation, moreover, is confounded by the fact that recent evidence-based tinnitus management guidelines, published in 2014 by the American Academy of Otolaryngology- Head & Neck Surgeons (AAO-HNS), are not routinely followed by physicians.
Jay Bhatt & Harrison Lin of the Department of Otolaryngology at the University of California- Irvine and Neil Bhattacharyya of Harvard Medical School were the authors of the JAMA study published last week. Using the 2007 National Health Interview Survey (NHIS) data, more than 75,000 adults over the age of 18 were queried about the prevalence, duration, severity and regularity of their tinnitus as well as their history of workplace & recreational noise exposure.
Results indicated that 10.5% of men and 8.8% of women reported tinnitus. Fifty-six percent of respondents reported their tinnitus had been a problem for more than five years, while 27% had dealt with their tinnitus for more than 15 years.
According to the researchers, of those experiencing tinnitus, 36% reported nearly constant tinnitus, 15% had noticeable symptoms at least once per day, and 14.6% had noticeable tinnitus once per week. Bedtime seemed to be a relatively common situation where tinnitus become problematic, as 38.4% of respondents said tinnitus was noticeable during that time of day. Additionally, the subjective severity of the respondents was notable, as 7.2% believed their tinnitus was a “big or very big” problem, 20.2% believed it was a “moderate” problem, and 41.6% reported it was a “small” problem.
Considering about 72% of respondents said that had either “no” problem or a “small” problem with their tinnitus, for many patients with persistent tinnitus, the severity of symptoms may be tolerable and, therefore, do not require any intervention. On the other hand, Bhatt et al’s data suggests tinnitus management options are not adequately addressed in a large segment of the population who may be suffering from it.
Many Physicians Don’t Follow Tinnitus Guidelines
Perhaps the most interesting aspect of this study was the lack of adherence on the part of physicians to follow recent evidence-based tinnitus management guidelines. These AAO-HNS guidelines are designed to address patients with tinnitus that has persisted more than six months.
These guidelines were intended to provide a framework for how patients with tinnitus are evaluated and managed in the clinic, as they are intended to provide evidence — both for and against – the use of education, counseling, sound therapy, cognitive behavioral therapy, medications, dietary supplements, and other various management approaches. The guidelines recommend that clinicians should not use medical therapy, including anti-depressant, anticonvulsants and intratympanic medications for routine management of tinnitus because there is insufficient data supporting their effectiveness.
In the Bhatt et al study, it was reported that 49.5% of individuals with tinnitus discussed it with their physician. Their survey also found 84.8% of patients had never tried any form of remedy, and that the most common intervention discussed by physicians was medication – a recommendation not supported by the 2014 AAO-HNS guidelines for routine cases of tinnitus.
It is also noteworthy that even though the AAO-HNS tinnitus guidelines recommend that a hearing aid evaluation is an appropriate management option, it was rarely discussed by physicians.
Although not supported by solid evidence, the guidelines also encourage physicians to present sound therapy (masking devices) as an option, but according to this study it too was rarely made available to patients.
According to UC-San Francisco clinical psychologist & founder of MindfulTinnitusRelief, Dr. Jennifer Gans:
“This study shines light on tinnitus as a major public health concern and with awareness comes more critical investigation and better management recommendations from doctors on the front-line of care. The search for better tinnitus management forces us to step outside-of-the-box and to look at how mental habits and erroneous thinking may in fact be preventing us from healing. While we cannot look, at this time, to a pill or operation to “cure” tinnitus, there are multiple effective management tools to help shift tinnitus from the ‘bothersome’ category into the non-bothersome’ category. What I have found in my work is that it is the ‘stories’ and often erroneous thoughts in which we wrap our experience with tinnitus that keeps it stuck in the ‘bothersome’ category. When we start to unravel this knot of beliefs, we can then allow the natural habituation process to take place. Mindfulness and cognitive behavioral counseling may not be as easy to administer as a pill or surgical intervention, but what we are learning is that the management of bothersome tinnitus involves changing one’s perspective. Therapy emphasizing mindfulness and a cognitive shift or ‘letting go’ of suffering around the tinnitus sensation allows the brain to relax enough to allow the natural habituation process to take place.”
Given that more than 50% of the individuals in this recent survey reported persistent tinnitus that had lasted more than five years, and fewer than one on four patients who discussed their tinnitus with their physician received management recommendations consistent with the 2014 evidence-based AAO-HNS guidelines, the audiology community has ample opportunities to provide effective long-term tinnitus management strategies, including the recommendation of hearing aids and sound relief devices.
Long-term management strategies supported by the AAO-HNS tinnitus guidelines also support the use of non-device strategies, including cognitive behavioral therapy, support groups, multidisciplinary education and mindfulness stress relief training that could be employed by hearing care professionals in their intervention strategies with patients suffering from tinnitus.
Richard Tyler, tinnitus researcher at the University of Iowa said, the Bhatt et al article “highlights the confusion about helpful treatments available to tinnitus patients, many such approaches like Tinnitus Activities Treatment include Cognitive Behavioral Training (CBT). In the US, audiologists (who provide tinnitus management services) provide counseling and sound therapy. They do not market themselves as providing a full 10-week CBT therapy.”
Dr. Tyler went on to say that “the article does highlight the different primary functions associated with tinnitus, including thoughts and emotions, hearing, sleep and concentration. We (audiologists) need to do a better job alerting the general public that help is available.”