Read on to learn about tinnitus treatment.
Tinnitus is a symptom rather than a disease and it has many causes. This maybe something easy to treat like an ear canal blocked with cerumen (ear wax) or tinnitus may be due to a more problematic ear condition which cannot be easily treated.
If you have tinnitus the first step in dealing with the problem is an assessment by your family doctor or GP who may be able to cure the problem if it is simply one of an ear canal blocked by wax by syringing the ear canal and removing the wax. If the family doctor is unable to treat the ear problem causing the tinnitus he or she will refer you for an assessment by a specialist ENT surgeon or audiologist at a specialist tinnitus clinic. Full assessment includes a detailed history of the tinnitus symptoms, examination of the ear by a specialist doctor, an audiogram (hearing test) possibly an MRI scan of the ear and auditory nerve.
Once a diagnosis has been made then the specialist can advise on treatment of the tinnitus. If the tinnitus is the result of a particular ear condition or disease then treating the underlying problem will help to cure or reduce the severity of the tinnitus. In many cases of tinnitus there is no easy or quick remedy, but nearly all cases of tinnitus can be greatly improved or even cured with the correct management, but this can take time and perseverance. The best place to start with treatment is at the specialist clinic. The medical staff will be able to advise on a treatment plan. This initially involves treating any underlying ear disease or problem.
Deal with deafness
The first step in treating tinnitus is dealing with any deafness or hearing loss. It is important to treat hearing loss, often with hearing aids, because struggling to hear properly may even worsen the symptoms of tinnitus. It has been found that reducing even slight deafness relieves the workload of the hearing centres of the brain and the brain then takes less notice of the tinnitus. An improvement in hearing also means that sounds that were previously inaudible can now be heard and these will help to mask the tinnitus sounds.
The next step in tinnitus treatment is usually sound therapy.
Masking and Sound therapy
Tinnitus sufferers find that their symptoms are worst during silence. Filling this silence with therapeutic sounds usually helps to relieve the persistent noise of the tinnitus. There are many studies that have shown that sound therapy can help to manage or treat tinnitus. Everyone is different and it is a matter of trying diffferent therapeutic sounds. No one type of sound therapy has been shown to be better than others. It is best not to limit yourself to a single method or a particular device. Rather, try out different types of sound therapy and obtain the knowledge and develop the skills to use sound and sound devices in adaptive ways to manage any life situation disrupted by tinnitus. This can be accomplished by learning the different ways that sound can be used to manage reactions to tinnitus, and developing and implementing custom sound-based management plans that address your unique tinnitus problem and needs.
Effective therapeutic sound can be produced by environmental sound, by tapes, CDs, MP3 players and iPods, by table-top/bedside soothing sound generators, by sounds downloaded to and played by a computer, or by wearable sound generators. These are also called maskers or white noise generators. Maskers are worn in the ears, and usually produce a constant white noise or a gentle rushing sound or a processed sound designed to be pleasant to listen to and which helps relieve the tinnitus. Most resemble hearing aids, and fit behind or in the ear canal. The type of sound therapy that is suitable for you depends on your preferences and particular situation.
Audiologists and ENT specialist report that generally people get on best with a sound that is pleasant to listen to and that does not require or demand too much attention. This article covers sound therapy in more detail below.
If you are going to manage and treat tinnitus it is vital to gain a full and detailed understanding of the condition. Effective management usually involves some form of counselling. This is usually carried out by hearing therapists, audiologists or ENT (ear nose and throat) doctors. Counselling is a talking treatment that teaches you in detail about tinnitus, how to establish ways of coping with it and how to manage it effectively. It is surprising just how effective this can be. Simply talking about your tinnitus and how it affects you on a daily basis can help you to gain a deeper understanding of the condition and lessen the effect of its symptoms on your quality of life. This article covers talking therapy in greater detail below.
Tinnitus retraining therapy
Tinnitus retraining therapy (TRT) is a well established regimen that involves a combination of sound therapy and counselling to enable people to overcome their tinnitus. TRT involves a process called habituation. This involves retraining the way that your brain reacts and responds to the tinnitus noise. The aim is to help you start to tune out of it and become less aware of it.
In the UK, very few ENT specialists use TRT in its full form but many hearing therapists, audiologists and doctors, use the principles of TRT in a less structured way. It is important to note that TRT should only be performed by those who have been trained in using the technique. TRT is covered in more detail below.
Cognitive behavioural therapy
Cognitive behavioural therapy (CBT) is the phrase psychologists use for treatments that enable people to overcome problems such as anxiety, depression and post-traumatic stress disorder (PTSD). Our thoughts and behaviour affect the way we feel. Our thoughts affect our behaviour. CBT can help you to manage, overcome and treat your tinnitus. CBT therapy works by improving thinking, behaviour and thought processes to relieve and manage the symptoms of tinnitus and any associated symptoms of distress, anxiety or depression. If you are suffering from tinnitus and you have a limited knowledge about the condition, then you may have distressing thoughts or ideas that lead to emotional upset or anxiety. The thoughts or beliefs that you have may be incorrect and correcting them usually help to ease your emotional distress and unnecessary worry. CBT is covered in more detail below.
Self-help is used by many to manage their tinnitus, sometimes with great beneficial effect. These methods include:
- Dealing with stress and tension - stress and anxiety will often aggravate or intensify tinnitus worse so regular relaxation and exercise may help you deal with tension.
- Tinnitus interactive support groups - if you suffer from tinnitus then talking to others with the same problem can be an effective way to help you deal with the symptoms and to make friends.
- Soothing and calming music – playing music is a good means to help you to relax and can be a great way to drift off to sleep if you have tinnitus related insomnia.
See below for more on self-help
Pharmacotherapy and drugs
Unfortunately there is currently no specific medication which will completely cure tinnitus, but many drugs to treat tinnitus have been studied. A surprising number have been found to provide relief. See below for detailed information. Medication such as anti-depressants or in extreme cases anxiolytics (drugs for anxiety e.g. alprazolam or diazepam) may be prescribed to relieve depression or severe anxiety in combination with talking therapies and counselling. Medication is covered in more detail below.
Making changes to your lifestyle
It is possible to improve tinnitus symptoms by changing or improving your diet and lifestyle:
- Dietary changes that may help tinnitus include – reducing or giving up drinks and foods containing caffeine (coffee, tea, coca cola, pepsi, red bull and carbonated drinks with caffeine added and chocolate), quinine (found in tonic water) and alcohol. Some tinntius sufferers find that these drinks may temporarily worsen their condition.
- A diet low in salt. This is sometimes advised by ENT specialits. A low salt diet and/or diuretics are frequently suggested as a treatment for Merniere's disease. This middle ear problem includes tinnitus as a symptom, along with deafness and vertigo.
- Stop smoking – nicotine is well known to adversly affect the blood supply to the middle ear and the sensitive sensory cells.
- Take up or increase your exercise levels – start exercising or increase your physical activity levels further if you are already exercising. If you suffer from severe tinnitus and are unable to work, then it is vital to maintain an physically and mentally active lifestyle.
- Keep your brain working - mental activity and keeping busy usually helps tinnitus. Keeping busy is an excellent distraction and keeping mentally active has been found to help relieve tinnitus.
- Do not hide away and become a hermit. Research the best ways to mask and distract yourself from your tinnitus – surround your environment with soothing and pleasant sounds; by turning on the radio or stereo system to play soft gentle music. Try listening to relaxation cds or music. Enjoy external sounds such as the noise of the rain, the ocean waves (if you are lucky enough to live by the sea) or the sounds of the birds or city life depending on where you live. It is important not to withdraw from life.
A bit about tinnitus
Tinnitus (which is pronounced TIN-ih-tus or tih-NITE-us) is a noise or sound heard by the sufferer inside the head with no outside source producing the sound.
In medical terminology: tinnitus is defined as the aberrant perception of sound without any external stimulation. Tinnitus may be described as either subjective or objective. Subjective tinnitus, the most common type, occurs in the absence of any physical sound reaching the ear and is audible only to the patient. Objective tinnitus, which affects a minority of patients (1%), is generated in the body and reaches the ear through conduction in body tissue and is audible to the patient as well as the clinician (also referred to as somatosounds).
Tinnitus takes many forms: it can be a whistling sound, while for other sufferers, it is ringing, hissing, static, crickets, screeching, sirens, whooshing, roaring, pulsing, ocean waves, buzzing, clicking, dial tones, chirping, humming, or even music. The noise may seem to come from both ears or only one, from inside the head, or from a distance. It may be constant or steady, pulsating or intermittent.
Picture below: Auditory pathways and tinnitus
Above: Sound waves pass down the external ear canal to the ear drum (tympanic membrane), and then to the middle and inner ear, where the tiny hair cells within part of the cochlea transform the transmitted sound waves into minute electrical messages which are then transmitted via the auditory nerve to the auditory cortex of the brain. If the sensitive hair cells within the cochlear are injured or damaged — e.g. by loud noise or ototoxic medications - the auditory cortex does not perceive the expected messages. The nerve cells in the auditory cortex therefore experience abnormal activity. This abnormal neuronal activity produces an illusion of sound, which is experienced by the sufferer as tinnitus.
Assessment in more detail
Since tinnitus is a symptom of a problem, the first thing you should do is to try to find out the underlying cause. If you develop symptoms of tinnitus, it’s important to see your doctor. They will take a medical history, carry out a physical examination, and perform a series of tests to try to find the source of the problem.
She or he will also ask you to describe the sounds or noise that you are hearing (including its sound quality and pitch), and whether it is intermittent or constant, pulsatile or steady) and the situations, times and places in which you experience it.
When carrying out a medical examination it is important to give special attention given to checking factors associated with tinnitus such as blood pressure, kidney function, medications/drug intake, diet and allergies, emotional stress, noise exposure, and diseases involving the auditory system. Tinnitus can be associated with conditions that occur at all levels of the auditory system. Some of these conditions are impacted wax (in the outer ear canal); ear infection, middle ear tumors, otosclerosis, vascular problems (in the middle ear); Menieres disease, ototoxic medications, circulation disorders, noise-induced hearing loss (inner ear); and, at the central level, the auditory (8th cranial nerve) and other tumors, migraine, and epilepsy.
Your physician will review your medical history, your current and past exposure to noise, and any supplements, drugs or medications that you taking or have taken in the past. Tinnitus can be a side effect of many medications, especially when taken at higher doses.
Musculoskeletal factors — tooth grinding (bruxism), jaw clenching, previous trauma or injury, or muscle tension in the neck region — may make tinnitus more noticeable or troublesome, so your doctor may ask you to tighten muscles or move the neck or jaw in certain ways to see if the sound changes. If tight muscles are contributing or part of the problem, massage therapy may help to ease it.
Tinnitus that is continuous, steady, and high-pitched (the most common type) generally indicates a problem in the auditory system and calls for an audiogram (hearing test) which is carried out by an audiologist. Since tinnitus can be associated with a number of diseases or conditions that can affect any level of the auditory system, the audiological evaluation can yield extensive useful information regarding the diagnosis and options for treatment.
Pulsatile tinnitus is different and requires a thorough evaluation by an otolaryngologist (ENT or an ear, nose, and throat specialist) or neurotologist, especially if the noise is frequent or constant.
Scans may be needed. MRI or CT scans will check for an abnormality of a blood vessel or vessls and also check for tumors. It is vital to review your general health since this may affect the impact and severity of your tinnitus. This is therefore an excellent time to conduct a thorough review of your diet, physical activity levels, sleep, and stress level — and then take steps to improve these important factors.
It is also possible to reduce the impact of tinnitus by treating anxiety, insomnia, pain and depression, anxiety, with psychological treatments and/or medication. If you are exposed to loud noises in the environment either at home or at work, then it is very important to reduce the risk of hearing loss (or further hearing loss) and worsening tinnitus by using protectors such as ear muffs, earplugs or earmuff-like or custom-fitted devices.
Can tinnitus actually be measured?
It is not possible to measure Tinnitus objectively. Rather, the doctor or audiologist relies on information that you provide when describing the symptoms of your particlar tinnitus problem. The audiologist or doctor will ask you questions like:
- Which ear is involved? Right? Left? or Both?
- Is the noise constant?
- Are you aware of it more at certain times of the day?
- Can you describe the sound or the noise?
- Does the noise or sound have a pitch to it? Low pitch? High pitch? Varies?
- How loud does the sound seem?
- Is it soft or loud ?
- Does the noise fluctuate or change?
- Do you notice any circumstances, activities or conditions that make the tinnitus better or worse, e.g., after exposure to noise or loud noise, after having a drink containing caffeine, when taking certain medications?
- Does the tinnitus disturb your sleep? Your work? Your ability to concentrate?
- How distressing or annoying is it? Extremely so? Not terribly troublesome?
In reviewing the answers to these questions, the audiologist or physician can provide you with information that will increase your and their understanding of your tinnitus. Understanding a medical condition better is often a great relief to the sufferer. Knowing the cause of your tinnitus is also a great comfort as well, now that you no longer have to live with the uncertainty of the diagnosis. When your tinnitus is "demystified," your stress level (which may make tinnitus worse) is usually reduced, and you have a feeling of greater hope and control. You are able to "take charge" by anticipating, preventing, and changing situations that make your tinnitus worse.
Treatment in detail
Treating the disease or problem that is producing the tinnitus is the best way to cure tinnitus. If you are fortunate, your tinnitus may be the result of an easy to treat or curable problem or disease. If this is the case then a doctor or specialist can perform a procedure or operation to cure the tinnitus. Unfortunately, many sufferers do not have a readily identifiable cause of their tinnitus. In other cases the cause is determined but medical or surgical treatment is not available yet to treat the condition . If this is the case then the next step is to manage the tinnitus itself. This can be easy or it may take considerable time and effort to discover a treatment that works.
The types of treatment available are: sound therapy (including tinnitus maskers), counselling, cognitive behavioural therapy, tinnitus retraining therapy, neuromonics, progressive tinnitus management, self-help, drug therapy, vitamin therapy, biofeedback, hypnosis, electrical stimulation, relaxation therapy, habituation therapies and informational products and programmes like Tinnitus Miracle.
Other more experimental treatments include: Auditory perceptual training, deep brain stimulation, ear canal magnets, electromagnetic stimulation, hyperbaric oxygen therapy,hypnotherapy, intra-tympanic injection with corticosteroids, low power laser therapy, repetitive transcranial magnetic stimulation, sequential phase shift sound cancellation treatment, teflon insertions, transcutaneous electrical nerve stimulation (TENS), transmeatal laser irradiation and vagal nerve stimulation (whilst playing a high-pitched sound).
Audiologists and otolaryngologists (ENT surgeons) will work together to identify the underlying cause and develop an effective treatment programme. Tinnitus patients are all different and therapies that work for one individual may not help another.
There is a common belief that tinnitus is incurable or untreatable and therefore a surprisingly small number of patients (1%) contact physicians or hearing care professionals for help despite its high prevalence. Yet, there are several methods of tinnitus management designed to alleviate the distress associated with tinnitus. Management is best undertaken by a multidisciplinary team comprising an audiovestibular physician or an otolaryngologist, a hearing therapist, an audiologist and a clinical psychologist.
Series of detailed technical articles about tinnitus treatment:
- Tinnitus treatment - introduction
- The prevention of tinnitus and noise-induced hearing loss
- Counselling for tinnitus treatment
- Cognitive behavioural therapy for tinnitus
- Auditory training in tinnitus
- Tinnitus retraining therapy
- Tinnitus treatment with sound therapy and stimulation
- Neuromonics tinnitus treatment
- Middle ear implantable devices in tinnitus treatment
- Cochlear implants and tinnitus treatment
(more to be added soon)
Correction of hearing loss
- Hearing loss is common: in the UK, 6% of adults have significant hearing impairment.
- Hearing impairment in adults usually occurs gradually
- Progressive loss of hearing, especially in one ear, may not be noticed by the patient
- The degree of disability depends upon the severity of the hearing loss and if it is bilateral
- Profound deafness, in one ear only, allows normal communication except when someone is speaking on that side
- A moderate bilateral high-frequency hearing impairment causes substantial problems in discriminating voices over a noisy environment
- Commonly the diagnosis can be established from a simple history and a few clinical findings: a clear view of the tympanic membranes and use of tuning fork tests
Important characteristics of hearing loss are whether the onset was gradual and over what time period, whether it fluctuates, whether it is in one or both ears and how it affects the patient’s quality of life. Associated symptoms might be tinnitus, dizziness or vertigo, ear ache and discharge from the ear.
Hearing loss may be categorised as conductive or sensorineural based upon the anatomical location of the problem. In conductive deafness, there is obstruction to the passage of the sound waves at any point between the outer ear and the foot plate of the stapes in the middle ear. This is the path of sound waves through the eardrum and ossicles to the cochlea. In a normally hearing ear, vibrations of the footplate of the stapes are transduced into a travelling wave within the fluids and along the basilar membrane of the cochlea. Malfunction or disease within the cochlea or auditory nerve is termed sensorineural. In some conditions there may be a mixed hearing loss, a combination of both forms of deafness.
Conductive hearing causes
- Wax impaction
- Otitis media with effusion (OME)
- Eustachian tube dysfunction
- Ear infections
- Perforations of the tympanic membranes
- Chronic Suppurative Otitis Media
This is probably the most common cause. Frequently the patient has used cotton buds and wax becomes more deeply impacted down the ear canal. The Weber test is referred to the blocked ear. Management entails removal of the wax, by syringing in general practice or by microsuction in a specialist clinic. The use of proprietary ear drop to soften wax for a few days beforehand is helpful. An eardrum which is known or suspected to be perforated or particularly weak should not be syringed.
Sensorineural hearing loss causes
Any adult patient who is found to have an unexplained hearing loss, either symmetrically in both ears, or, as is more common, with a significant asymmetry, requires imaging with an MRI scan of the internal auditory meatuses (IAMs) and posterior fossa to exclude the possibility of a vestibular schwannoma (commonly called an acoustic neuroma) in the deafer ear.
Sensorineural hearing loss causes:
- Noise-induced hearing loss
- Merniere’s disease
- Hereditary hearing loss
- Drug-induced hearing loss
Hearing aids, devices and cochlear implantation
Hearing aids can be useful for all types of hearing loss. If mid to high frequencies (2000–4000 kHz) show hearing thresholds down to 35 dB or below, hearing aids may be helpful. However, the ability to discriminate speech can be poor in severe sensorineural hearing loss even at adequate amplification. This limits the benefit of conventional acoustic hearing aids for some patients.
A large range of digital hearing aids are available. Digital signal processing algorithms aim to optimise the benefit to users. Functions available in modern hearing aids include feedback reduction systems enabling the fitting of open moulds (useful for those who get ear infections and those who need high-frequency gain only). Teleloop settings are helpful for theatres, lectures and television. Devices differ in placement. Behind-the-ear (BTE), open fit or mini-BTE (over the ear), in-the ear (ITE), in-the canal (ITC) and completely in the canal (CITC) are all available.
Bone-conduction hearing aids transmit sound via a bone vibrator held against the mastoid with a band or on the arm of a pair of spectacles. They are useful for the patient who has a conductive or only moderate sensorineural deafness and when a traditional hearing aid with an ear canal insert is unsuitable.
Surgical alternatives exist for hearing with electrical devices. A bone-anchored hearing aid system (BAHA) with a titanium implant screwed into the temporal bone, onto which an external abutment is attached protruding through the skin, allows a sound processor (hearing aid) to be clipped onto it with the sound being transmitted through bone to the cochlea.
Cochlear implantation involves the surgical placement of electrodes within the cochlea to stimulate the auditory nerves directly. Implantation can be undertaken in patients with very severe or profound bilateral deafness who cannot derive benefit from acoustic hearing aids but who have a suitable cochlea and auditory nerves which can be stimulated. The treatment for hearing loss has several approaches depending on the location of the lesion and the degree of deficit across frequencies based on audiologic evaluation. Lesions in the external and middle ear result in conductive hearing loss, which is treated with medical or surgical treatment.
Hearing loss due to inner ear or eighth cranial nerve lesions result in a sensorineural deficit treated through amplifying the signal. The decision to provide patients with amplification is based on the degree of hearing loss and the individual’s self-perceived communication difficulty. For some individuals, a mild hearing loss has a severe impact on their ability to function, and for others, a moderate-to-severe hearing loss has little impact on their perceived day-to-day function
Treatment for temporary or reversible hearing loss (deafness) usually depends on the cause of the hearing loss. Treatment for permanent hearing loss includes using hearing devices or hearing implants.
Treatment for reversible hearing loss
This depends on its cause. It is often possible to treat it successfully.
Hearing loss caused by:
- Ototoxic medicines (such as aspirin or ibuprofen) the deafness often improves after you stop taking the medicine.
- An ear infection, such as a middle ear infection (otitis media), often clears up on its own, but you may need antibiotics (such as amoxicillin).
- An injury to the ear or head may heal on its own, or you may need surgery.
- Otosclerosis, acoustic neuroma, or Merniere's disease may require medicine or surgery.
- An autoimmune problem may be treated with corticosteroid medicines, generally prednisone (a corticosteroid).
- Earwax is treated by removing the wax. This easily done by a nurse or doctor using ear syringing. You usually need to put ear-drops (such as olive-oil ear drops) into the outer ear for a few days to soften the wax (cerumen). Do not use a cotton swab or a sharp object to try to remove the wax. This may push the wax even deeper into the ear or may cause injury.
Permanent hearing loss
For individuals who have sensorineural hearing loss, their deafness is unfortunately permanent. The reason for this is that when the very sensitive hair cells within the cochlea (the delicate spiral,coiled tube inside the inner ear) are damaged, they are not able to recover and remain broken for the remainder of the sufferer's lifespan. However, if you are deaf, there are several remedies that can improve your quality of life. Some of these are covered below. It is often helpful to contact services for deafness support and hearing impairment. In the case of permanent hearing loss, such as age-related (known as presbycusis) and noise-induced deafness, hearing aids and devices will usually improve how well you are able to hear and communicate. These devices include:
Modern hearing aids are discrete, very small and can be worn inside the outer ear canal. The tiny microphone picks up sound which is amplified by the tiny amplifier. Inside hearing aids there are clever devices that are able to differentiate between background noise, such as traffic, and foreground noise, such as conversation.
Unfortunately, hearing aids are not suitable for everyone. For example, they may not be effective if you have very severe deafness. Your family doctor, GP, ENT specialist or audiologist will be able to advise you about whether a hearing aid is suitable for you.
- Hearing loss treatment and hearing aids - non-technical article
- Hearing aids in detail - technical
- Hearing Loss
Cochlear implantation involves the surgical placement of electrodes within the cochlea to stimulate the auditory nerves directly. Implantation can be undertaken in patients with very severe or profound bilateral deafness who cannot derive benefit from acoustic hearing aids but who have a suitable cochlea and auditory nerves which can be stimulated.The fundamental structure of a hearing aid is composed of a microphone, amplifier, and receiver. The microphone receives the acoustic signal and converts it to an electric or binary signal, depending on analog or digital technology, respectively. This signal is then passed through the amplifier that intensifies the signal and then converts it back into an acoustic signal through the receiver and is funneled to the eardrum.
Electrical promontory stimulation (EPS) seems to be a promising tinnitus treatment, providing significant relief. Research on EPS shows at least temporary and partial tinnitus suppression. Immediate relief of tinnitus has been reported in approximately 82% of patients and longer term tinnitus suppression in 45% of these patients. Rubinstein et al. also described the effect of high-frequency EPS on tinnitus, and the authors advocated that the effect should be investigated with an implantable device. There are indications that cochlear implants may provide long-term tinnitus suppression in individuals with severe sensorineural hearing loss. Cochlear implants have been reported to provide tinnitus relief in up to 90% of patients. There is evidence that deafferentation of the auditory pathway plays an important role in causing tinnitus, and that the effect can be reversed by electrical stimulation of the auditory system via EPS or through cochlear implants. A particularly new indication for cochlear implants is single-sided deafness (SSD) with concomitant incapacitating tinnitus.
Read more about cochlear implants, electrical promontory stimulation and tinnitus here: Cochlear implants and tinnitus treatment
Read on: There is hope, tinnitus treatment is possible
Virtually all sound therapies are combined with some form of counselling. Many tinnitus sufferers get relief from listening to background sounds, such as distant traffic, wind in the trees or waves breaking on the seashore. These sounds can be generated through hearing aids and sound globes. Sound globes are portable devices which sit on the bedside/tabletop and provide a variety of soothing sounds. Patients with insomnia due to tinnitus may benefit from a pillow speaker or a radio with a time switch. Some sound generators and most compact disc players, mp3 players, etc., can be plugged into a pillow speaker.
Those who suffer from tinnitus usually find that it is more troublesome when there is no external noise (e.g. in the silence of the night). They usually find that the presence of external sounds makes tinnitus less troublesome. The deliberate use of any noise to minimise the awareness of tinnitus or to ease the distress caused by it is known as sound therapy. In Tinnitus Retraining Therapy (TRT), the phrase sound enrichment is occasionally applied. The therapeutic use of sound is also frequently applied when treating hyperacusis (the over-sensitivity to noise) as well as tinnitus.
It is not exactly clear how sound therapy works. Some scientists and specialists believe that it results in physical alteration in the sensitivity of the anatomy of the audiology centre of the brain while others think it simply works as a psychological distraction or by helping relaxation. It is possible that it is a combination of these components. However, it is is clear is that most people with tinnitus use it in some form or other. The therapeutic use of sound may be a part of a broader tinnitus management programme at a clinic or hospital or it may be utilised as a self-help treatment.
When the degree of benefit produced by sound therapy and counselling has been compared by researchers, some studies have shown that sound therapy may be less important than counselling in improving tinnitus symptoms. There is debate about this issue. Specialists generally advice that the therapeutic use of sound is one tool amongst many in the management and therapy of tinnitus. However, sound therapy is very easy to do, does not require professional assistance, can used by all tinnitus sufferers and is excellent if you are unable to obtain or access professional help.
Sound therapy can be produced by environmental sound, by tapes and CDs, by table-top or bedside sound generators, by sounds downloaded to and played by a computer, or by wearable sound generators (also called maskers). Your particular circumstances and preferences will determine the most suitable form of sound therapy. Most tinnitus sufferers find that the ideal therapeutic sound is one that is pleasant to listen to and that does not demand excessive attention.
Many with tinnitus are aware that some background noise, for example noise from traffic, the conversation and bustle of a busy office, the sound of the ocean, wind blowing through the trees, make tinnitus less apparent. Simply opening a window with the right amount of noise outside can provide all the sound therapy required.
CDs, iPods, tapes and mp3 players
There are numerous tapes and CDS of nature sounds and relaxing music and nature sounds available. Many local libraries have them available for loan, so that they can be tested. The British Tinnitus Association produces a good-quality recording of the seashore which can be ordered on-line or by phone. There is a good range of nature sounds can be downloaded from web sites to be played on iPods, iPhones mp3 players or other portable devices. Some of these are available for free. For example, the web site www.peterhirschberg.com has a piece of software called ‘aire freshener’ which is free to download for personal use.
Table top and bedside sound generators
These portable machines sit on the table top or by the bed and produce a wide variety of gently soothing sounds. The volume can be altered to suit your needs and hearing. At bed-time the presence of a gentle relaxing sound often aids sleep if you are troubled by insomnia The sound may be left playing at a quiet level overnight and can be a soothing distraction from tinnitus if you happen to wake up during the night. It is even possible to plug some sound generators and most CD players, mp3 players, iPods etc into a speaker inside a pillow or into a sound pillow. Thus causing less disturbance to a nearby partner. However, many people without tinnitus also enjoy listening to soothing sounds at night!
Sound machines that provide a steady background of comforting noise are useful. Fish tanks, fans, low volume music, indoor waterfalls, etc. can also be helpful. Fans, humidifiers, dehumidifiers and air conditioners in the bedroom may also help cover the internal noise at night.
Picture 1 Example of environmental sound generator used in sound therapy
Wearable sound generators (also known as white noise generators, or maskers)
Masking devices were initially usd as a treatment for tinnitus because sufferers noticed that their tinnitus was more troublesome when it was quiet. White noise maskers are used to carefully obscure rather than completely obliterate the tinnitus, by producing a gentle rushing noise. The obliteration of tinnitus is seen as being counterproductive in terms of the habituation process, as one cannot habituate to tinnitus which is not audible due to masking. White noise generators are worn behind the ear or in the ear. If the patient has a hearing loss as well as tinnitus, the masker and the hearing aid may operate together as one instrument.
Maskers look like hearing aids and are worn in the ear or behind the ear. They make a gentle constant white noise that is able to "mask", or cover up the tinnitus. The masking sound works as a distraction and is often found to be easier to tolerate than the tinnitus. This may be because it is an external sound and is prefered to the internal noise coming from inside a sufferers head. Maskers are an optional part of many forms of tinnitus therapy, and it is important that they are fitted by a tinnitus specialist as part of a tinnitus management programme. The precise characteristics of your tinnitus is described to the audiologist. They are then able to decide the nature of the masking sound that will provide the greatest benefit.
If you suffer from deafness in addition to tinnitus the hearing aid and masker can operate as one device. Maskers help some people with tinnitus but not all. Like a hearing aid a thorough assessment by an audiologist can determine whether a white noise generator will benefit you. Most people prefer the maskers that are worn behind the ear because they do not block the ear canal. It is vital that when the maskers are worn you do not feel that the masker is blocking your hearing.
Hearing aids and sound therapy
If you are deaf, hearing aids are likely to be of benefit. They provide a form of therapeutic sound therapy by giving easier access to everyday environmental sounds. Most individuals are aware their tinnitus is not as troublesome when their hearing aids are switched on. It is a good idea to use hearing aids with CDs and tapes, or bedside/table-top sound generators. The addition of a loop system can help improve clarity.
How to use sound therapy
The aim of tinnitus therapy is to enable people to habituate to (become accustomed or used to) their tinnitus, so that it is ‘filtered out’ most of the time by the brain, even though it is still present. Specialists advise that habituation is probably best achieved if you use sound therapy at a level that is just below your tinnitus most of the time. Some sufferers use masking (loud noise which drowns out the tinnitus) to provide some temporary relief, but this approach does not allow habituation, and the tinnitus may appear louder when the masking is turned off.
Will I need to use sound therapy for ever?
Most people discover that sound therapy is helpful whilst their tinnitus is intrusive, but becomes less important as they become accustomed to their tinnitus. Those who use maskers often use them only until they feel they can manage their tinnitus better, and bedside sound generators may no longer be necessary once a better sleeping pattern has developed.
How do I get sound therapy?
A list of suppliers for CDs, tapes, websites, bedside/table-top sound generators, and sound pillows can be obtained from the British Tinnitus Association. Wearable sound generators and bedside sound generators may be provided by your Audiology or ENT Clinic, however, provision of equipment within the UK NHS varies from clinic to clinic. Tinnitus management is also available in the private sector, in which case sound generators can be bought directly from the clinic.
What Sound Therapies help tinnitus?
There are a number of sound therapies and devices that are available – some over-the-counter, others through an audiologist or other healthcare provider:
- Counter-top devices, including environmental sound machines and tabletop water fountains
- CD-based systems
- Hearing aids
- Ear-level masking devices, which look like hearing aids, but produce white noise (a wide bandwidth of sound)
- Combination units that combine hearing aids with maskers Ear-level sound generators used in tinnitus retraining therapy (TRT), which look like maskers but produce a much lower volume of sound
- Music therapy, including the new Neuromonics system
Consult with an audiologist. That’s the best way to ﬁnd the right option for you. Even though sound therapy is an extremely important part of any effective rehabilitation program for tinnitus, it’s important to know that it’s often not enough. For example, when we combine sound therapy with counseling, such as with tinnitus retraining therapy, the effectiveness is roughly double that of sound therapy alone or counseling alone.
Sound therapy for unilateral tinnitus
If you are only deaf on one side then you only require a hearing aid on that side. With a tinnitus masker, treating only the ear which has tinnitus may work. However, it is sometimes the case that treating one ear effectively leads to tinnitus developing on ther other side. The reason for this is probably that the tinnitus has been bilateral but was only apparent on the louder side, until the masker was used. When the worst affected ear was treated, the less powerful tinnitus on the alternate side became noticeable. Audiologists comment that sufferers often obtain more satisfactory results using bilateral masking devices. Tinnitus retraining therapy uses bilateral stimulation. This is due to the fact that the whole auditory system requires stimulation. It is important to note that within the brain the ears are interconnected via the brainstem.
Research has shown that music can be helpful in the treatment of anxiety and pain. Music aids relaxation and has beneficial effects on the primitive part of the emotional brain known as the limbic system.Therefore music is a potentially good therapy for tinnitus. The problem with a lot of music is what is known as its tonal content. There is a tendency for music to emphasize the low frequencies and to have less volume in the higher frequencies. An analysis of an average tinnitus sufferer reveals that most have better hearing in the low frequency areas and worse hearing in the high frequency regions. This also happens to be where the tinnitus is most dominant. If music therapy is to work then it needs to deal with this potential mismatch.
Neuromonics has been developed to overcome this mismatch. Neuromonics employs music that has been altered and that is delivered through high-ﬁdelity earphones. The music produced matches the tinnitus suffere's particular hearing and tinnitus levels. Neuromonics results in the total spectrum of music listened to to be low level, comfortable, yet still audible. The neuromonics protocol sarts with and then builds on the principles of tinnitus retraining therapy. It also uses masking. It has been utilised and researched by its creators, Drs. Peter Hanley and Paul Davis, in Australia for over 10 years. It is is now also used in the US as well. The two Australian researchers report a very high success rate. The big advantage of the neuromonics therapy is that it can enable a patient to habituate his or her tinnitus in six or seven months. this is much quicker than the 18 to 24 months usually needed for tinnitus retraining therapy.
How to discover whether sound therapy can help your tinnitus?
This is possible by carrying out an experiment with masking at home. This is easily done by tuning a radio between stations. If the static sound produced covers your tinnitus, or makes it less noticeable (i.e. if it partially masks it), then you have discovered that masking can be of benefit. Alternatively, if the sound from a shower drowns out your tinnitus, then you have a pretty good idea that a masker can help you. However, in practice, the only way to know with any degree of certainty is to try a sound therapy for several weeks. There are many sound therapy choices available today for tinnitus: environmental sound devices, CDs, water fountains, hearing aids, and computer programs, plus the more individualized and precise therapies offered by masking, tinnitus retraining therapy and Neuromonics. Any one of these, or a perhaps a combination of, may well help to relieve your tinnitus to some worthwhile extent. You do not have to just "learn to live with your tinnitus", as too many are advised by misinformed health professionals.
Different types of sounds used in sound therapy
The progressive tinnitus management (PTM) programme describes three types of sound (soothing, interesting, and background) that can be used to manage reactions to tinnitus.
Soothing sound is any sound that provides an immediate sense of relief from stress or tension that is caused by tinnitus. The use of soothing sound has its origin in the method of tinnitus masking, which originally was described by Vernon (1976). This type of tinnitus masking is still used, and relies on the use of ear-level “maskers” that generate a broadband noise. The use of sooting sound with tinnitus masking is intended to provide an immediate sense of relief—not to “mask” tinnitus, as the name would seem to imply. However, soothing sound for tinnitus management is not just limited to the use of ear-level maskers and broadband noise. Any sound that produces a sense of relief (or that the individual considers soothing) can be used as soothing sound. When using soothing sound, it is important that the sufferer focuses on obtaining a sense of relief from stress and tension rather than focusing on how much their tinnitus is masked. Progressive tinnitus management audiologists have therefore decided to abandon use of the term “masking” altogether, because whether or not the tinnitus is masked is completely irrelevant to the utilization of soothing sound in tinnitus therapy.
Interesting sound is used to actively divert attention away from the tinnitus. The use of interesting sound for tinnitus management has not been a part of any formal method of therapy for tinnitus. However, distraction is a concept that is used for the management of pain and anxiety. The use of interesting sound follows the basic pain model. In essence, using interesting sound to manage reactions to tinnitus is intended to shift the individual's attention away from the tinnitus and onto some other sound. Sufferers therefore gradually learn to “actively listen” to sounds that they find interesting or entertaining, which achieves the distraction objective.
Some individuals do not experience a satisfactory sense of relief from sound and so they are tempted to abandon its use altogether. It is important to emphasise that even if sound does not provide immediate relief (or if it is not interesting), it still can be extremely effective in managing reactions to tinnitus by reducing the contrast between tinnitus and the acoustic environment. This enables the brain to allow the tinnitus to go unnoticed.
Read more about sound therapy in detail here: Tinnitus treatment with sound therapy and stimulation
Tinnitus counselling is a talking therpay in which the cause and nature of tinnitus is carefully and clearly explained. The adverse effect of tinnitus on a person's daily life is explored and together with the counsellor the sufferer develops a good understanding of how to manage and control the tinnitus. The specialist or therapist works towards providing assistance with overcoming the most debilitating and distressing psychological effects of tinnitus sounds.
Tinnitus retraining therapy (TRT) is a specilised type of tinnitus counselling which is extremely effective at reducing the intensity and degree of tinnitus. TRT is made up of a combination of detailed explanation, counselling and the carefully controlled use of hearing aid devices and/or white noise generators. TRT takes time to work (sometimes as long as 18-24 months). However research has shown that it has excellent long-term results. In a large percentage of individuals TRT will be very effective, but it may not completely get rid of the tinnitus sounds.
What is counselling?
Counselling is a talking therapy that takes place between the client and the therapist. It has different definitions. A simple one is that it is a talking treatment involving a working relationship with between you and a counsellor that gives you an opportunity to talk openly and discuss problems or difficulties that you are facing in your life.
Can counselling help tinnitus?
Yes. Having the opportunity and time to talk freely to someone who actively listens and show understanding can be enormously reassuring, helpful and of great comfort. Your tinnitus counsellor is also trained to enable you to identify how other issues and factors in your life are aggravating your tinnitus. There are different ways of obtaining counselling, all of which can help if you have tinnitus and want to talk about it. These are: medical counselling, private counselling, lay counselling and group counselling.
To talk to someone who has a specialist understanding of tinnitus, you really need medical counselling. Most medical counselling is delivered in specialist tinnitus clinics in hospitals. Your GP may refer you to your local ear, nose and throat (ENT) department initially. If the ENT specialist think it’s appropriate, you may be referred to a tinnitus clinic. Tinnitus clinics are normally staffed by hearing therapists or specialised audiologists. Successful medical counselling is based on knowing the nature and causes of tinnitus and how to manage it. If you have tinnitus, medical counselling can help in several ways by:
- Relieving your fears.
- Helping you understand your tinnitus, which can help you accept it.
- Showing you that tinnitus is a common complaint.
- Encouraging you to accept that most people eventually learn to live with their tinnitus, and ignore it.
- Showing you that your tinnitus can be managed quite effectively using simple techniques.
Medical counselling is an essential part of tinnitus retraining therapy (TRT), which tries to reduce tinnitus distress. UK NHS hospital tinnitus clinics may refer a person with tinnitus to a clinical psychologist. Some clinics may already have a clinical psychologist in their team for tinnitus management. Some private healthcare providers also offer medical counselling services.
Private counselling involves talking to a counsellor who either practises independently, or through an agency such as a counselling centre. You usually have to pay and most counsellors will not have specialist knowledge about tinnitus. Private counselling may be useful if aspects of your life are making you feel unhappy or anxious, such as bereavement or relationship difficulties. Stress can make your tinnitus seem worse, whereas talking about difficulties in your life can indirectly make your tinnitus seem better. The experience and qualifications of counsellors can vary greatly, so make sure your counsellor is recognised by the British Association for Counselling and Psychotherapy. You may be able to see an independent counsellor through the NHS. Some GPs employ counsellors on a sessional basis to work with their patients. Sessions may be free or offered at a reduced rate.
Lay counselling may be helpful if you have tinnitus. A lay counsellor is not a qualified counsellor, but may have undergone some counselling training, or have some personal knowledge or experience of tinnitus. They could be a member of a local tinnitus self-help group or work on a helpline. You may be able to work through your feelings about your tinnitus in different ways and receive practical and emotional support face-to-face or over the telephone.
Sometimes, your therapist may suggest you participate in a group session. A group of you meets the therapist for a number of sessions. During these sessions, you are taught how to discover your hidden beliefs and how to challenge negative thoughts. The people in the group will have at least two things in common – they have tinnitus and they are upset by it.
Read about tinnitus counselling in detail here: Counselling for tinnitus treatment
Cognitive behavioural therapy
Cognitive behavioural therapy (CBT) is used to identify and alter negative behaviour and thought patterns. The focus of cognitive therapy is on the interpretation that people place upon events rather than the events themselves. If tinnitus per se caused psychological distress, then everyone experiencing tinnitus would experience similar psychological distress, which is clearly untrue. Whereas some patients with tinnitus feel that it indicates the presence of a catastrophic illness, others interpret it as a feature of aging and some patients see their tinnitus in a more positive light. CBT addresses the negative distorted beliefs which surround tinnitus and helps the patient to use structured thinking that results in less anxiety. CBT is believed to be an effective treatment for tinnitus.
What is cognitive behavioural therapy (CBT)?
CBT examines your thought patterns, beliefs and the way you do things, in order to understand why you react in certain ways. Therapy may be provided on a one-to-one basis or in a group session. The professionals most likely to offer and use CBT are clinical psychologists or psychotherapists.
How can CBT help me if I have tinnitus?
What you think about your tinnitus affects how you feel about it. The more attention you pay to your tinnitus, the worse you may feel. Although not designed as a tinnitus-specific treatment, CBT can help you in a number of ways: It can teach you coping techniques to deal with negative feelings and distress. Your thoughts and feelings can become more positive. By changing how you think about tinnitus and what you do about it, your distress is reduced, you start to tolerate the noises and they eventually become less noticeable.
What happens in a course of CBT?
You are usually asked to keep a diary of the times that your tinnitus noises are most annoying or distressing, making a note of the nature of the distress and any thoughts that go with it. For example, you might write: ‘Tonight I feel upset and scared about the cause of my tinnitus noises. I worry about my health’. The therapist will help you look at the reasons behind your strong reactions to your tinnitus. Your therapist will discuss your thoughts with you and suggest different ways of doing things. Throughout CBT, you are encouraged – and given help – to challenge your ways of thinking. A therapist will not try to force a set of beliefs on you, but will help you find the best way of approaching your tinnitus.
Tinnitus retraining therapy
Tinnitus retraining therapy (TRT) is designed to help a person retrain the brain to avoid thinking about tinnitus. It uses a combination of counselling together with a non-masking white noise which decreases the contrast between tinnitus and the surrounding environment. Randomised, controlled clinical studies with no treatment and placebo groups are required to ascertain the effectiveness of TRT for the treatment of tinnitus.
What is tinnitus retraining therapy (TRT)?
TRT is based on the neurophysiological model of tinnitus developed in the late 1980s by Pawel Jastreboff and Jonathan Hazell. The neurophysiological model of tinnitus suggests that it is the limbic system – the subconscious part of the brain responsible for our emotions – that gives importance and meaning to the tinnitus signal.
According to this model, we perceive the tinnitus signal to be a threat or a danger and this provokes an emotional response. Our awareness of tinnitus is heightened and so we perceive it to be louder or more persistent.
TRT is the term given to tinnitus treatment that combines counselling and low-level sound therapy. It does not work directly on your tinnitus, but on your awareness and understanding of it. In time, as your awareness of the sounds is reduced, you will only notice it when you focus on it. This is known as ‘habituation’ and is the ultimate goal of TRT. Results and their time-frame can vary from one person to another.
Tinnitus retraining therapy is one approach by which habituation to tinnitus and hyperacusis can be induced. It is logically based on the neurophysiological model described by Jastreboﬀ (1990). Considering the complexity of tinnitus and hyperacusis, it is logical and straightforward, both in treating the patient, and in teaching the technique to health care professionals. The key problem with persistent tinnitus and hyperacusis is an aversive conditioned reﬂex response, similar to that evoked by security issues, or threats to wellbeing. For as long as this response to internal neuronal activity (in tinnitus) or external sounds (in hyperacusis) is established in the subconscious, it continues to evoke unpleasant alteration of limbic and autonomic function, whenever the signal is detected. Habituation to continuous meaningless sounds occurs rapidly, but does not occur where the sound has a negative, invasive, or threatening message. The goal of TRT is to habituate or block completely any reaction of the limbic or autonomic nervous system to tinnitus, or, in hyperacusis, to sound in the environment, which is causing annoyance. The technique requires a speciﬁc approach in which tinnitus and hyperacusis is ﬁrst categorised, and an individual programme of retraining on a one-to-one basis is designed for each patient, dependent on 5 diﬀerent treatment categories. All treatments involve directive counselling/teaching, training in sound enrichment of the environment and avoidance of silence. Some categories involve the use of instruments (either noise generators or hearing aids), ﬁtted and used in the speciﬁc context of the neurophysiological model. The vital component for both professionals and patients is a complete understanding of the model.
How does TRT work?
TRT works through a combination of two main elements: counselling and sound therapy.
When we talk about TRT (Tinnitus Retraining Therapy), this is not simply an abstract learning exercise. In the subconscious part of the brain concerned with hearing, beyond the inner ear, (but before conscious perception of sound takes place), subconscious filters, or networks of nerve cells (neuronal networks) are programmed to pick up signals on a ‘need to hear' basis. Think again of the way we invariably detect the sound of our own name, or a distant car horn, or a new baby stirring in sleep, whereas we may be unaware of the sound of rain pounding on the roof or surf beating on a sea shore. Retraining therapy involves reprogramming or resetting these networks which are selectively picking up 'music of the brain' in the auditory system. Tinnitus retraining first involves learning about what is actually causing the tinnitus. As a result of this and other therapy including sound therapy, the strength of the REACTION against tinnitus gradually reduces. This reaction controls the setting of subconscious filters which are constantly looking for threats. With strong reactions, the filters are constantly monitoring tinnitus, but without a reaction, habituation occurs, as it does to every meaningless sound that is constantly present. Firstly the disappearance of the reaction means that sufferers no longer feel bad, or distracted, and normal life activities can be resumed – sleep, recreation and work, as before. Secondly as the auditory filters are no longer monitoring the tinnitus it is heard less often and less loud. As a result it can finally become a friend instead of an enemy. Think, now, how much of this treatment depends on being able to believe that tinnitus results from normal compensatory changes in the hearing mechanism, rather than irreversible ear damage. While it is important to have a proper examination by an ear specialist, those professionals who themselves believe that tinnitus is an 'ear' phenomenon cannot help your tinnitus. We are in a difficult situation where the classical training of tinnitus being due to inner ear damage is still very dominant. Few have an understanding based on the Jastreboff neurophysiological model (Jastreboff P.J. 1990).
Wearable sound generators (WSGs)
Wearable sound generators (which look similar to hearing aids), have an important role to play. Tinnitus masking was at one time thought to be useful in that it simply made tinnitus inaudible. In fact, this proved to block tinnitus habituation, as it must be audible for habituation to occur. Habituation to any signal cannot occur in the absence of its perception. Imagine trying to habituate your response to spiders, which you hate, simply by avoiding them. Much better long-term results can be obtained if wide band noise is used at low intensities while the tinnitus can be heard at the same time. WSGs contain many frequencies, and therefore gently stimulate all the nerve cells in the auditory pathways allowing them to be more easily reprogrammed, (increasing their plasticity). They must be fitted and instruction given by a trained professional. Wrong use, including one-sided use, can make sufferers worse.
Silence is not golden
Emergence of tinnitus is often dependent on silence. Most tinnitus is first heard at night in a well soundproofed bedroom, or a quiet living room (Heller and Bergman 1953). Persistence of tinnitus depends not only on the meaning attached to it, but also to the contrast it creates with the auditory environment. Contrast contributes greatly to the intensity of any perception. Thus a small candle in the corner of a large darkened room seems to be dazzlingly bright, until the room lights are switched on making it virtually invisible. Everyone, especially tinnitus patients should avoid extreme silence, and retraining programmes will always use sound enrichment (see instructions on this website). Make sure there is always a pleasant, non-intrusive background sound (like a large slow fan, or an open window, and purchase a device for generating nature sounds). Choosing what sound is right for you may take some time. Nature sounds are always the best, as they are already habituated, and usually produce feeling of relaxation, calm and well-being. Avoid masking tinnitus, but have some sound present during day and night. Remember filters are working 24 hours a day, even when asleep, and so should sound enrichment. Many tinnitus patients have decreased sound tolerance and for this reason often seek very quiet environments. They are their own worst enemy! In all cases, sound enrichment should be practiced, using unobtrusive sound sources, to break the silence. At the present moment TRT is available in relatively few centres, but the techniques are spreading and gradually being learned and used in an increasing number of ENT and audiology departments around the world. In 2002, 800 professionals had attended TRT training courses around the world.
Middle ear implantable devices
Rehabilitation with hearing aids has shown effectiveness in reducing tinnitus. However, in some individuals with severe high-frequency hearing loss, classical hearing aids are not always able to amplify the high frequencies sufficiently and provide enough power. Active middle ear implants are an alternative to conventional hearing aids that allow more power delivered to the cochlea, especially at high frequencies, and can also be used when middle ear ossicles are damaged.
A totally implantable piezoelectric device, known as the Esteem Hearing implant , was developed by St. Croix Medical, Inc. (now Envoy Medical Corporation) (Picture 1).
Picture 1: Envoy piezoelectric device - “Esteem”
Electromagnetic transduction devices consist of a magnet and an energizing coil. The magnet is attached to the ossicular chain, tympanic membrane, or the inner ear (round window or oval window). Specific experiences with regard to the influence on tinnitus have not been published.
Another implantable middle ear device known as Carina™ is shown in Picture 2.
Picture 2: Otologics MET fully implantable middle ear device - “Carina”
Soundbridge is the middle ear implant with the longest clinical experiences, 3,000 patients so far (2009). It was first marked by Symphonix Devices in San Jose, California, as the Vibrant Soundbridge. It has received both European CE-mark in March 1998 and FDA approval in the U.S. in August 2000 [14–16]. However, the company went out of business in 2002 only to return in March 2003 as the Med-EL Vibrant Soundbridge.
The semi-implantable device consists of an outward audio processor which is placed over the implanted coil and magnet. The coil is linked by a golden wire to the floating mass transducer (FMT) (Picture 3). The frequency range is 1,000–8,000 Hz, but technically amplification up to 16,000 Hz is possible.
Picture 3: The “vibrant soundbridge” system
In the last few years, the Vibrant Soundbridge has assumed particular importance through the fact that the FMT can also be implanted in the round window  (Picture 4). The indication here refers to a destroyed middle ear, such as after removal of the petrosal bone, malformations, cholesteatoma, sclerosis of the footplate, etc. The FMT provides a better way to induce sound energy into the cochlea than using the ossicular chain.
Picture 4: Implantation of an FMT into the round window
Neuromonics, developed in Australia, combines acoustic stimulation with a structured programme of counselling and support by a clinician skilled in tinnitus rehabilitation. In neuromonics, the audiologist matches the frequency spectrum of the tinnitus to music which overlaps the sound spectrum of the tinnitus. The music stimulates the auditory pathways deprived by hearing loss and engages the limbic system and the autonomic nervous system.
Read more about neuromonics in detail: Neuromonics tinnitus treatment
Biofeedback is a relaxation technique that teaches people to control certain autonomic body functions, such as pulse, muscle tension, and skin temperature. The goal of biofeedback is to help people manage stress, resulting in a reduction in the severity of tinnitus.
Anxiety, Tension, and Learning How to Relax
It is very common to worry about tinnitus and for this to cause tension, so learning how to relax is part of the relief process. Tinnitus often creates a vicious cycle of tension and worry that keeps the tinnitus worse than it could be. However, you can break this cycle. If you break it, the chain of events will reverse. As a first step, read these notes again to make sure you understand how worrying about your tinnitus and constantly listening to it will feed this vicious cycle. Monitoring your tinnitus and worrying about it will only make it worse. Relaxation Exercises To help relieve the tension in your body, you can use simple relaxation exercises that involve training your body to relax. You can read about such exercises in books, listen to them on CDs, or learn how to do them at relaxation exercise classes, whichever you prefer. Here are some simple examples of relaxation exercises: 1. Find a comfortable position, and breathe in slowly and clench your fist. Feel the tension in your hand and wrist. Now breathe out, and as you do so relax your hand and feel the difference. You can extend this to other parts of your body, such as your other hand, each arm, leg and foot, your back and neck, face movements, and jaw clenching. 2. Breathe slowly and deeply, hold your breath a moment, relax then let it out, wait a moment, then breathe slowly and deeply again, and so on. Once you have learned such breathing and muscle relaxation exercises, you can do them regularly, wherever and whenever you can find the time and space. It will take a bit of practice, but you should quickly start to feel the benefits, and you will gradually learn how to relax your body without having to do the exercises. As you learn to relax your body, you will also find it easier to relax your mind. Some people find that aromatherapy, improved posture, massage, reflexology, craniofacial therapy, yoga, and tai chi have similar relaxing benefits, as can simply resting in a relaxing environment, perhaps with special aromas, dim lights, and soft music. The key is to find what helps you relax the most and easiest, and then practice it often.
Recreation and Health
Having active interests and hobbies can enhance the quality of your life. They can put your tinnitus into a better perspective so you can still enjoy life to the full. It is never too late to learn or to get involved in adult education programmes. Some people have seen the positive side of their tinnitus and have welcomed the push it gave them to do something new, to rekindle old interests, or to take on the challenge of working for a tinnitus support group. How is your general health? Are you getting a good, varied diet, plenty of exercise and rest, and some enjoyable social activity? If you find that certain foods or drinks, or activities or situations aggravate your tinnitus, you could cut down a little, cut them out, or find alternatives. With just a few adjustments, you will find that tinnitus will not stop you carrying on with life the way you want to.
If you have tinnitus, you should not wear any kind of earplugs that make it more difficult for you to hear, except when exposed to very loud noises. They will not help your tinnitus: indeed, they will probably make it seem louder while you are wearing them. Generally, it is not a good idea to wear earplugs if you have hyperacusis (unless you are using earplugs temporarily in a noise that is unbearably loud to you) as they can prevent your ears from becoming desensitised to sounds. On the other hand, you should always use ear protection when you are exposed to very loud sounds, whether you are affected by hyperacusis or not.
Temporary Deafness and Temporary Tinnitus
If you have been exposed to a particularly loud sound, for example, a disco or fireworks, or working around loud noise, you may often experience a dullness of hearing or tinnitus, or both immediately afterwards. Provided you do not let yourself get into a state of great anxiety about it, this will usually disappear after a few minutes or hours. These temporary effects should be taken as a warning, though – there is a risk of permanent damage if you expose your ears repeatedly to such loud sounds.
Sharing your experiences of tiinitus with other people who have the same problem can be an effective way to help you deal with the symptoms and to make friends.
UK: For details of your nearest tinnitus support group in the UK, contact the Action on Hearing Loss tinnitus helpline on 0808 808 0123, or the British Tinnitus Association on 0800 018 0527. Website: http://www.tinnitus.org.uk/
US: The American Tinnitus Association's Support Network consists of dedicated support group leaders and help network volunteers. These volunteers provide compassion, support, experience and perspective, as well as valuable resources for treating your tinnitus. While support groups are not yet available in all states, you are welcome to contact help network volunteers regardless of location. Website: http://www.ata.org/support
It is not possible to cure tinnitus with medication, but in some cases drugs may help reduce the severity of symptoms or complications.
Possible medications include: Tricyclic antidepressants, such as amitriptyline and nortriptyline, have been used with some success. However, these medications are generally used for only severe tinnitus, as they can cause troublesome side effects, including dry mouth, blurred vision, constipation and heart problems.
Alprazolam (Niravam, Xanax) may help reduce tinnitus symptoms, but side effects can include drowsiness and nausea. It can also become habit-forming.
Drug therapy for tinnitus in detail
Although tinnitus is a significant health and economic problem, there are no FDA-approved drugs to treat tinnitus and few drugs reliably suppress or eliminate chronic tinnitus in the majority of patients. The lack of drug therapies is due in part to a limited understanding of the biological basis of tinnitus, the lack of an accepted tinnitus nosology, the heterogeneity of the tinnitus population, the wide range of medical conditions that appear to cause tinnitus and the huge cost associated with developing drugs to specifically treat tinnitus.
Consequently, drugs developed for other medical conditions have generally been evaluated to determine whether they can relieve tinnitus. While several double-blind, placebo-controlled, crossover studies have been carried out in tinnitus patients, many reports suffer from the lack of proper experimental controls and small sample sizes. However, advances have been made in the development of animal models in which to test compounds that can suppress noise- or drug-induced tinnitus. The following sections review many of the drugs used to suppress tinnitus, with a focus primarily on drugs administered systemically rather than locally as oral dosing is most likely to gain widespread acceptance because of convenience, ease of titration and scheduling.
Acamprosate (Campral®) is approved for the treatment of alcoholism in the U.S. and Europe. It presumably blocks excitatory glutamatergic N-methyl-d-aspartate (NMDA) receptors while enhancing γ-aminobutyric acid (GABA)-mediated nerve inhibition. However, some studies indicate that acamprosate enhances NMDA function, while others indicate that the compound enhances NMDA-induced excitability at low concentrations and suppresses it at high concentrations. Other reports suggest that acamprosate has no effect on GABA-mediated currents, and some reports suggest that acamprosate inhibits the binding of taurine to taurine receptors. One paper has been published on the use of acamprosate to treat tinnitus patients, most of whom had mild to profound noise-induced hearing loss. The rationale for treatment assumes that tinnitus arises from excess glutamatergic activity through NMDA receptors and/or hyperactivity resulting from the loss of GABA-mediated inhibition.
In this double-blind study, patients received placebo or acamprosate (333 mg t.i.d.) and rated the loudness and annoyance of their tinnitus before and at monthly intervals of treatment. Acamprosate had no beneficial effects after 30 days of treatment, a modest benefit at 60 days and a significant effect at 90 days.
Approximately 87% of the subjects in the acamprosate group showed some improvement, including three subjects in whom tinnitus disappeared, compared to 44% in the placebo group. A larger clinical trial is currently under way to further assess the encouraging results from this preliminary study (http://clinicaltrials.gov/ct2/show/NCT00596531).
Caroverine (Spasmium-R®) is used as a spasmolytic drug and acts as an antagonist of calcium and non-NMDA and NMDA glutamate receptors (76–80). Because of a limited uptake with oral administration, caroverine is administered intravenously or locally. It has been proposed that cochlear synaptic tinnitus arises from a synaptic disturbance of NMDA or non-NMDA receptors on the afferent dendrites of the spiral ganglion neurons. To test this hypothesis, patients with putative cochlear synaptic tinnitus were enrolled in a single-blind study in which subjects were randomly assigned to a placebo group (i.v. saline) or a caroverine group (a maximum dose of 160 mg i.v.; less if tinnitus reduced or worsened).
Tinnitus loudness (5-point scale) and tinnitus matching (intensity and frequency) were measured before and after treatment and at 1 week post-treatment. Significant responders were those that showed a reduction in loudness of 1 point or more and a 50% reduction in intensity (−3 dB).
Immediately post-treatment, 63% of the caroverine group and 0% of the placebo group showed a significant response. At 1 week post-treatment, 43% in the caroverine group had a significant positive response compared to 3% in the placebo group. The low positive response rate in the placebo group was unusual, because placebo response rates are typically around 40% . While these initial results were encouraging, a subsequent study following the same protocol found no positive effect of caroverine treatment.
Memantine (Namenda®) is currently used in the treatment of Alzheimer’s disease (AD) and has shown positive effects in depression. It acts as a voltage-dependent antagonist of NMDA receptors and reduces excitotoxicity by preventing prolonged influx of calcium. However, memantine is also known to block serotonin (5-HT) and nicotinic acetylcholine receptors. Excitotoxicity mediated by NMDA receptors has been proposed as a mechanism for cochlear tinnitus.
High doses of salicylate, the active ingredient in aspirin, reliably induce tinnitus and augment currents through NMDA receptors on cochlear spiral ganglion neurons. NMDA antagonists applied locally to the inner ear blocked behavioral evidence of salicylate-induced tinnitus. In another behavioral experiment, cochlear application of the selective NMDA antagonist ifenprodil in the first 4 days following noise exposure significantly reduced the probability of developing noise-induced tinnitus.
In contrast to the positive results seen with cochlear application of NMDA antagonists, systemic memantine administration failed to completely suppress salicylate-induced tinnitus in a behavioral model of tinnitus. Likewise, in a prospective, randomized, double-blind, crossover clinical study using the Tinnitus Handicap Inventory to assess efficacy, 90-day treatment with memantine was no more effective than placebo. Moreover, memantine caused side effects in 9% of patients.
AM-101 is a noncompetitive NMDA antagonist that is being evaluated as a treatment for tinnitus. Based on positive results in animal studies, a double-blind, randomized, placebo controlled phase IIb trial of intratympanic delivery of AM-101 is currently being carried out. The study involves patients with acute tinnitus (< 3 months) arising from noise trauma or sudden hearing loss who have not responded to glucocorticoid treatment (http://www.aurismedical.com/p/therapies/am_101.php). Patients with acute tinnitus are being enrolled in a clinical trial with AM-101 (http://clinicaltrials.gov/ct2/show/NCT00860808).
Neramexane, a drug similar to memantine, is being evaluated for AD, drug dependence, depression and pain. Like memantine, neramexane acts as a noncompetitive, voltagedependent NMDA antagonist. It also blocks α9 and α10 nicotinic cholinergic receptors which are expressed on inner hair cells in the inner ear. Developer Merz & Co GmbH is currently conducting a multicenter clinical trial to determine the efficacy of neramexane for treating tinnitus (http://clinicaltrials.gov/ct2/show/NCT00772980).
Gacyclidine is another NMDA antagonist under evaluation for the treatment of tinnitus. In animal behavioral studies of salicylate-induced tinnitus, gacyclidine suppressed tinnitus-like behavior when applied bilaterally to the cochlea. Nine days of intracochlear perfusion of gacyclidine did not have any adverse effects on the guinea pig auditory evoked responses, suggesting that this treatment may be relatively safe. In preliminary studies in unilateral deaf humans perfusion of gacyclidine on the round window membrane for several days resulted in the temporary relief of tinnitus. While the results in the published abstract are encouraging, further work is needed to determine the generality of the findings and if gacyclidine has any long-term benefit.
Alprazolam (Xanax®) is a short-acting triazolobenzodiazepine used to treat anxiety, panic attacks and depression. Alprazolam binds to the benzodiazepine site of the GABAA receptor, where it acts as a GABA agonist by increasing the permeability of chloride ions, leading to hyperpolarization and decreased excitability. Complications associated with alprazolam include drug dependency and difficulty of discontinuing use.
In a prospective, double-blind, placebo-controlled study, alprazolam was administered to patients with tinnitus; the dose was increased until it caused side effects or had an effect on tinnitus. Alprazolam reduced tinnitus loudness, measured with a tinnitus synthesizer and visual analog scale, in 76% of subjects, whereas only 5% showed a reduction in tinnitus loudness in the control group. Although the positive effects of alprazolam observed in this study are encouraging, the study design has been criticized because of the small sample size, drug dosing method, failure to assess emotional effect and the need for replication.
The benzodiazepine diazepam (Valium®) is used to treat anxiety, insomnia, epilepsy, and muscle spasms. It binds to a specific subunit on the GABAA receptor and is a positive allosteric modulator of GABA that increases hyperpolarization and decreases neuronal excitability. However, diazepam can also bind to voltage-gated sodium channels and reduce excitability by slowing sodium channel inactivation. Diazepam was evaluated in a double-blind, triple crossover trial involving 21 tinnitus patients.
The drug had no effect on tinnitus loudness, a result which is surprising considering that its mechanisms of action are similar to those of alprazolam. One possible explanation for the discrepancy is that the dose of alprazolam, but not diazepam, was adjusted for each patient to maximize its effects on tinnitus. Complications associated with diazepam include drug dependency and difficulty of discontinuing use.
Clonazepam (Klonopin®) is a benzodiazepine derivative used as a muscle relaxant, anxiolytic and anticonvulsant. Like other benzodiazepines, it binds to specific subunits of the GABA receptor, where it acts as an agonist, leading to hyperpolarization and decreased excitability. In a retrospective study of medical records from over 3,000 patients taking clonazepam (0.5–1 mg/day for 60–180 days) for vestibular or cochleovestibular disorders, 32% reported an improvement in their tinnitus. The lack of a control group makes it difficult to evaluate the significance of these findings.
In a prospective, randomized, single-blind clinical trial involving 10 patients per group, clonazepam significantly reduced tinnitus loudness and annoyance (visual analog scale) relative to the control group. Because of the small sample size, lack of double-blind and a crossover design, additional studies are needed to evaluate the efficacy of clonazepam. Like other benzodiazepines, drug dependency and difficulty discontinuing use are complicating factors associated with its use in the treatment of tinnitus.
Vigabatrin and tiagabine
Vigabatrin (Sabril®) and tiagabine (Gabitril®), two drugs that act on different aspects of GABAergic neurotransmission, have been studied in an animal model of noise-induced tinnitus. Vigabatrin is used as an anticonvulsant and to treat infantile spasms. It irreversibly inhibits GABA transaminase (GABA-T), the enzyme that catabolizes GABA, thereby increasing GABA levels. Vigabatrin also induces tonic release of GABA by causing the GABA transporter to operate in reverse. Tiagabine is used to treat seizures and panic disorders and acts by inhibiting the uptake of GABA via the GAT-1 transporter, thereby increasing the availability of GABA at its receptor. It has been proposed that tinnitus arises from loss of inhibition in the CNS as a result of cochlear deafferentation caused by noise, aging or ototoxic drugs.
To test this hypothesis, noise-exposed rats with behavioral evidence of tinnitus were treated with vigabatrin or tiagabine. Tiagabine did not suppress noise-induced tinnitus; however, vigabatrin suppressed noise-induced tinnitus, and the tinnitus reappeared when treatment was discontinued. We are unaware of any clinical trials in which vigabatrin has been used to treat tinnitus; however, given the positive animal data, vigabatrin is a potential drug candidate for a clinical study in tinnitus. However, it is known that the drug can cause irreversible visual disturbances, limiting it use in humans.
Lidocaine (Xylocaine®) is generally used as a local anesthetic or to treat cardiac arrhythmias. It is believed to bind to fast voltage-gated sodium channels, reducing the magnitude of the sodium current during depolarization. However, the mode of action of lidocaine is more complex, as it is known to affect calcium-, potassium-, and glycine-induced chloride currents at micromolar concentrations.
In 1935, lidocaine was inadvertently found to suppress tinnitus following nasal administration. Since that time, many clinical studies have shown that intravenous lidocaine suppresses tinnitus in a subpopulation of subjects. High positive response rates (~70%) have been reported in some studies, while others have reported lower response rates (~40%), as well as a large percentage of subjects in whom tinnitus became worse (~30%).
Relatively few patients show large reductions in tinnitus loudness; in those that do, the positive effects tend to be short-lasting. The sites of action of intravenous lidocaine are not well understood, but there is evidence that it affects both the cochlea and CNS.
In one human brain imaging study in which lidocaine either increased or decreased the loudness of tinnitus, the changes in loudness were associated with altered neural activity in the right auditory association cortex.
Tocainide, an analogue of lidocaine that can be taken orally, was evaluated as a potential long-term therapy for tinnitus. While preliminary results were encouraging, several randomized, controlled studies found that tocainide had little benefit for tinnitus.
Potassium channel modulators
Tinnitus is thought to arise from neural hyperactivity. As potassium ion channels play an important role in regulating the resting potential and spontaneous and evoked neural activity, potassium channel modulators may represent potential therapeutic targets for tinnitus therapy. Potassium channel modulators have also attracted attention as potential therapeutic targets for pain, epilepsy, anxiety and other hyperexcitability disorders.
In a preliminary report utilizing a rat behavioral model, the potassium channel modulators flindokalner (BMS-204352; MaxiPost™), and its (R)-enantiomer (R-MaxiPost™) reduced behavioral evidence of salicylate-induced tinnitus in a dose-dependent manner. Both enantiomers are KCa1.1 (BK) positive modulators and Kv7.1 negative modulators. MaxiPost and its (R)-enantiomer modulate Kv7.2-Kv7.5 ion channels positively and negatively, respectively. These results suggest that potassium channel modulators may represent new therapeutic candidates for tinnitus management.
Carbamazepine (Tegretol®) is an anticonvulsant and mood stabilizer used to treat a variety of clinical disorders, including epilepsy, bipolar disorder, schizophrenia, pain and trigeminal neuralgia. The drug binds to voltage-gated sodium channels and stabilizes the sodium inactivation state, thereby reducing neural firing. Its mode of action, however, may be more complex than this, as some reports indicate that carbamazepine enhances outward, voltage-dependent potassium currents, inhibits L-type calcium channels and enhances the release of 5-HT.
The results for carbamazepine in the treatment of tinnitus have been mixed. Several randomized clinical trials reported no beneficial effect of carbamazepine on tinnitus. However, the doses in these studies tended to be low (200 mg/day), and in one study only a single dose was given, which may explain the lack of effect. Other reports have shown that, among those patients who responded positively to intravenous lidocaine, 56% had a good or excellent response to carbamazepine (typically administered at 600–1000 mg daily), whereas those that responded poorly to lidocaine also responded poorly to carbamazepine.
Patients most likely to respond positively to lidocaine were those with cochlear hearing loss. A more recent report found that among positive lidocaine responders, 50% responded positively to carbamazepine (ascending doses of 50–600 mg), carbamazepine had no effect in 29% of lidocaine responders, 15% withdrew because of side effects, and tinnitus worsened in 6% of patients.
These results suggest that carbamazepine may provide tinnitus relief in roughly half the patients that respond positively to lidocaine. A rare group of patients who derive significant benefit from carbamazepine are those who have intermittent “typewriter tinnitus”, which is described as sounding like a typewriter, popcorn or ear clicking. Radiological analysis showed evidence of vascular compression of the auditory nerve on the same side as the clicking. This suggests that there may be a tinnitus subgroup that can be classified on the basis of tinnitus perceptual characteristics, radiological features and response to drug treatment.
Finally, an animal study evaluated the ability of carbamazepine to suppress salicylate (aspirin)-induced tinnitus in rats. Tinnitus was assessed with a behavioral conditioned, licksuppression paradigm. Salicylate-induced tinnitus was significantly reduced by 15 mg/kg of carbamazepine, but not by lower or higher doses. The neural mechanisms by which carbamazepine suppresses salicylate-induced tinnitus are unclear.
Sodium valproate/valproic acid
Sodium valproate (Depakene®) is used in the treatment of seizures, bipolar disorders, mood disorders and depression. Valproic acid has a broad spectrum of action that includes inhibition of GABA-T, inhibition of histone and blockade of voltage-gated sodium channels and T-type calcium channels. One case study found that sodium valproate (200 mg b.i.d.) was effective in suppressing tinnitus. However, another case study reported that sodium valproate induced tinnitus, and that the tinnitus gradually disappeared when treatment was discontinued. Because sodium valproate is sometimes used clinically to treat patients with severe tinnitus, well-controlled clinical trials are needed to assess its efficacy.
Gabapentin (Neurontin®) is widely used in the treatment of seizures, neuropathic pain and migraine. Because of its structural similarity to GABA, gabapentin was thought to bind to GABA receptors; however, its mechanisms of action are not fully understood. Gabapentin does not act directly on GABA, glycine or glutamatergic receptors, or voltage-gated sodium or calcium channels. The drug enhances the stimulated release of GABA, increases GABA levels in patients and, with chronic application, inhibits calcium currents by disrupting calcium channel trafficking.
An early case report and several clinical studies suggest that gabapentin may suppress tinnitus. In addition, an animal study indicated that gabapentin reversibly suppressed behavioral evidence of noise-induced tinnitus in rats. Despite these positive findings, several large, randomized clinical trials found that gabapentin was not significantly different from placebo in treating tinnitus, with the possible exception that it reduced tinnitus annoyance in a subgroup of patients with noise-induced tinnitus (186–189).
The overall trend that has emerged from randomized clinical trials is that gabapentin may be of limited value in treating tinnitus.
Trimipramine (Stangyl®) is classified as a tricyclic antidepressant; however, its mode of action differs from other tricyclic antidepressants in that it is a weak to moderate inhibitor of norepinephrine and 5-HT. However, trimipramine also blocks some dopamine and 5-HT receptors and alters the concentration of dopamine and 5-HT. Trimipramine was evaluated in a double-blind, placebo-controlled, crossover study. Of the 19 subjects completing the study, 47% reported improvement and 37% claimed worsening of their tinnitus with trimipramine, whereas 42% reported improvement and 21% reported worsening with placebo. These results suggest that trimipramine has little or no benefit in the treatment of tinnitus.
Nortriptyline (Aventyl®) is tricyclic antidepressant that is also used to treat chronic fatigue, migraine and chronic pain. Its primary mode of action is to inhibit the reuptake of norepinephrine and, to a lesser extent, 5-HT. Nortriptyline also blocks muscarinic and 5-HT receptors. In a small, single-blind, placebo-washout study involving patients with severe tinnitus and major depression, nortriptyline significantly reduced depression and tinnitus loudness (10-dB reduction).
In a double-blind, placebo-controlled, follow-up study involving subjects with severe tinnitus and severe depression or depressive symptoms, nortriptyline significantly reduced depression scores, tinnitus disability scores and tinnitus loudness (6.4-dB reduction) relative to placebo.
There was a significant correlation between the reduction in tinnitus disability scores and depression scores. These results suggest that nortriptyline is effective in reducing tinnitus loudness and severity in severely depressed tinnitus patients, but has less benefit in nondepressed individuals.
Paroxetine (Paxil®) is an antidepressant that is also used to treat post-traumatic distress disorder, obsessive-compulsive disorder, anxiety and panic disorder. Paroxetine is a potent and highly selective serotonin reuptake inhibitor (SSRI) and shows weak binding to muscarinic acetylcholine receptors.
In a double-blind, placebo-controlled study involving chronic tinnitus patients, few of whom suffered from depression, the paroxetine group showed little difference from placebo on tinnitus loudness matching, Tinnitus Handicap Questionnaire scores and other measures; however the paroxetine group showed a significant improvement in tinnitus aggravation compared with the control group.
Although SSRIs are widely used to treat tinnitus, the authors suggested that antidepressants should not be used to treat nondepressed tinnitus patients. However, in a case study, paroxetine significantly reduced tinnitus and improved mood in a patient with severe depression, anxiety and tinnitus.
Trazodone (Desyrel®) is an antidepressant with a dual mode of action: it is an SSRI and also selectively blocks postsynaptic 5-HT2A and 5-HT2C receptors. In addition to its use as an antidepressant, trazodone is also used to treat insomnia. It main side effects are drowsiness and hypotension.
Trazodone was evaluated in a prospective, placebo-controlled, doubleblind trial involving 83 subjects - approximately half each in the placebo and treatment groups. Subjects were treated with trazodone for 60 days at 50 mg/day. Patients in both the placebo and trazodone arms showed significant improvement in tinnitus loudness, discomfort and quality of life; however, the differences between the placebo and trazodone groups were not statistically significant. Thus, trazodone was not shown to be effective in treating tinnitus using this particular regimen and in this patient population.
Vestipitant/paroxetine combination therapy
Vestipitant and the combination of vestipitant and paroxetine are currently undergoing a phase II clinical trial for the treatment of tinnitus (http://clinicaltrials.gov/ct2/show/NCT00394056); information on the clinical efficacy of these drugs is currently unavailable.
Vestipitant is a novel antagonist of the tachykinin NK1 receptor that binds substance P. Substance P acts as a neurotransmitter and neuromodulator. NK1 receptor antagonists suppress pain. Neurokinin receptors are present in the inner ear and therefore represent a potential therapeutic target for tinnitus. Paroxetine is an SSRI used to treat depression, obsessive-compulsive disorder and anxiety.
Sertraline (Zoloft®) is used to treat major depression, anxiety, obsessive-compulsive behavior and panic disorder. It mainly acts as an SSRI by suppressing the serotonin transporter; however, it also inhibits the dopamine transporter and the σ1 receptor.
In a randomized, double-blind, placebo-controlled study in patients without severe hearing loss but with depression, anxiety and a high risk for developing severe tinnitus, sertraline was shown to be significantly more effective than placebo in reducing tinnitus loudness (12 dB versus 4 dB) and tinnitus severity (4.7 versus 2.7), but not tinnitus annoyance. Collectively, the results suggest that tinnitus patients with depression and anxiety may gain some benefit from antidepressant treatments.
Misoprostol (Cytotec®) is a synthetic prostaglandin E1 (PGE1) analogue that is primarily used to prevent gastric ulcers induced by non-steroidal anti-inflammatory drugs such as aspirin and to induce labor. It also inhibits the release of inflammatory cytokines.
In a small, placebo-controlled, semi-crossover study, tinnitus was improved (reduced severity, improved sleep and concentration) in 33% of subjects during misoprostol treatment (escalating to 800 μg/day), whereas no subjects improved in the placebo group. In a subsequent double-blind, placebo-controlled study, the proportion of subjects showing a > 15-dB reduction in tinnitus loudness was significantly greater in the misoprostol group (800 μg/day) than in the placebo group.
Surprisingly, misoprostol did not show significant benefit on other tinnitus measures. In a third randomized, controlled study involving tinnitus patients with hypertension and/or diabetes, the decrease in tinnitus loudness was significantly greater in the misoprostol group (46% of patients) than the placebo group (14% of patients); surprisingly, the subjective measures of tinnitus were not different. Overall, the studies suggest that misoprostol may provide some benefit to tinnitus patients with minimal risk, but larger studies are needed to confirm these trends before misoprostol can be considered of significant benefit for tinnitus.
The statin atorvastatin (Lipitor®) is used extensively to lower blood cholesterol and prevent strokes. The drug inhibits HMG-CoA reductase, which suppresses the production of mevalonate, in turn reducing the synthesis of cholesterol. Atorvastatin also improves circulation and reduces inflammation and oxidative stress. In a 13- month, randomized, double-blind, placebo-controlled study involving elderly patients with elevated cholesterol, atorvastatin failed to slow the progression of age-related hearing loss and did not significantly reduce tinnitus, although there was a trend toward a beneficial effect that did not reach significance.
The L-type calcium channel blocker nimodipine (Nomotop®) was originally used for the treatment of high blood pressure, but is now primarily used in the treatment of subarachnoid hemorrhage. Nimodipine crosses the blood-brain barrier, dilates cerebral blood vessels and improves cerebral blood flow. The first open-label clinical trial found that nimodipine had positive effects on tinnitus in many patients, but the lack of a placebo control made it difficult to gauge its efficacy. Subsequent behavioral studies in rats showed that nimodipine significantly reduced tinnitus-like behavior caused by high doses of quinine or sodium salicylate. However, a second open-label clinical trial found significant improvement in the subject rating of tinnitus in only 5 of 31 (16%) patients; 17 patients (55%) showed no change and 6 patients (19%) showed marginal to major worsening of their tinnitus. Because there were few positive responders, it was concluded that a large-scale, randomized, placebo-controlled study was not warranted.
Furosemide (Lasix®) is a loop-inhibiting diuretic used to treat congestive heart failure and edema. It inhibits the Na-K-2Cl cotransporter that transports sodium, potassium and chloride ions into and out of cells. The Na-K-2Cl cotransporter is expressed in the inner ear, as well as in the brain. Furosemide also blocks GABAA receptors. The drug has been proposed as a treatment for tinnitus of cochlear origin because it strongly suppresses the endolymphatic potential and other cochlear responses. It has been reported that ~50% of patients note a reduction in tinnitus symptoms following intravenous furosemide treatment; these positive responders were hypothesized to have cochlear tinnitus, whereas those who did not respond were assumed to have central tinnitus. In contrast, patients with presumably central tinnitus (i.e., tinnitus emanating from a surgically ablated ear) did not show a reduction in their tinnitus. Furosemide has also been found to suppress tinnitus in ~40% of patients with Meniere’s disease. However, high doses of furosemide can also induce temporary hearing loss and tinnitus. Thus, the data on the use of furosemide to treat tinnitus and conclusions regarding its central versus cochlear mode of action are difficult to interpret, especially when considering that Na-K-2Cl transporters are present in both the ear and brain.
Amino-oxyacetic acid (AOAA) is an anticonvulsant that potently inhibits GABA-T, leading to the buildup of GABA in the brain, thereby strengthening its inhibitory effects. AOAA also reduces the endocochlear potential in the cochlea. Because of its cochlear effects, AOAA was evaluated as a treatment for tinnitus presumably of cochlear origin. AOAA reduced tinnitus severity in ~20% of patients; however, > 70% of patients experienced severe side effects, thereby ruling out the clinical utility of this compound.
Scopolamine is used to treat motion sickness, nausea and intestinal cramps. It acts as a competitive antagonist of M1 muscarinic acetylcholine receptors, which are widely distributed in the brain and along the auditory pathway. A literature search failed to turn up any clinical report in which scopolamine has been used to treat tinnitus. One animal study, however, suggested that scopolamine might be effective in suppressing salicylate-induced tinnitus. The rationale for using scopolamine is based on the fact that high doses of salicylate significantly increase the expression of the activity and plasticity-related proteins c-fos and arg3.1 in the auditory cortex and amygdala; these proteins were considered putative markers of tinnitus-related neural activity. The amygdala sends axons to the nucleus basalis, which in turn sends cholinergic fibers to the auditory cortex, and scopolamine was proposed as a treatment for salicylate-induced tinnitus as it suppresses the expression of c-fos and arg3.1 in the auditory cortex. However, when behavioral measures of tinnitus were obtained from rats treated with salicylate or salicylate scopolamine, scopolamine failed to suppress salicylate-induced tinnitus. On the basis of these results, it seems unlikely that scopolamine will be effective in treating tinnitus.
Cyclandelate is a vasodilator that is believed to act by blocking the influx of calcium into cells. It is mainly used to treat peripheral vascular disorders, but is sometimes used to treat cerebrovascular disorders. Because some reports suggest that tinnitus arises from vascular insufficiency affecting the labyrinthine or brain, cyclandelate was investigated as a treatment for tinnitus. In an open-label, nonrandomized, multicenter clinical trial in patients with tinnitus, vertigo and visual disturbances, 90 days of treatment with cyclandelate reportedly reduced the severity and frequency of these symptoms, with minimal side effects. However, in a subsequent placebo-controlled, double-blind study, cyclandelate did not significantly change audiometric measures of tinnitus loudness and pitch. The number of positive tinnitus responders was small and not significantly different from the placebo group, and many patients reported side effects. Thus, there is no clear evidence that vasodilators such as cyclandelate improve tinnitus symptoms.
Sulpiride (Meresa®) is an antipsychotic drug that selectively blocks dopamine D2 receptors. Several studies have explored the use of sulpiride to treat tinnitus based on models and data suggesting that dopaminergic pathways in limbic, prefrontal and temporal areas of the cortex contribute to tinnitus severity. In one double-blind, placebocontrolled study, sulpiride significantly reduced subjective ratings of tinnitus and tinnitus visual analog scale scores; the reductions with sulpiride were not significantly greater than those produced by placebo. However, the combination of sulpiride plus melatonin, which interacts with dopamine receptors, reduced tinnitus visual analog scale scores significantly more than placebo. In a single-blind, placebo-controlled study, sulpiride plus hydroxyzine, an antihistamine and anxiolytic, was significantly more effective in reducing tinnitus visual analog scale and tinnitus perception scores than placebo or sulpiride alone. These preliminary studies suggest that D2 antagonists such as sulpiride may help to suppress tinnitus symptoms, but further work is needed to confirm or refute these findings.
The phosphodiesterase type 5 (PDE5) inhibitor vardenafil (Levitra®) prevents the degradation of cyclic GMP found in the vascular smooth muscles of the penis and lungs. Vardenafil is primarily used to treat male impotence and sometimes pulmonary hypertension. While vardenafil is generally well tolerated, common side effects include headache, flushing, nasal congestion and dyspepsia. In a recent clinical report, the rationale for evaluating the effects of vardenafil on tinnitus was based on informal patient reports claiming that their tinnitus improved significantly when taking vardenafil. The efficacy of vardenafil was evaluated in a randomized, double-blind, placebocontrolled study with 21 patients receiving placebo or vardenafil (10 mg b.i.d. for 12 weeks). The major outcome variables relevant to tinnitus (Tinnitus Questionnaire, tinnitus loudness or pitch and other audiometric measure) failed to reveal any clinical or statistically significant improvement. Therefore, vardenafil does not appear to be a suitable treatment for tinnitus.
Extracts derived from the ancient Chinese Ginkgo biloba tree yield EGb-761, the active component, which contains bioactive flavonoids, terpenes and vasoactive compounds. Because of its vasodilating and antioxidant properties, Ginkgo has been used to treat a wide range of disorders, including tinnitus. Several studies have reported that Ginkgo alleviates tinnitus symptoms, particularly in patients with short-duration symptoms. In addition, one behavioral study with rats found that EGb-761 reduced the behavioral manifestations of salicylate-induced tinnitus. However, a growing body of evidence from large, well-controlled, double-blind, placebo-controlled clinical studies clearly indicates that Ginkgo is no more effective in alleviating tinnitus symptoms than placebo.
Melatonin, a naturally occurring circulating hormone produced in the pineal gland and other tissues, binds to melatonin receptors and plays an important role in regulating circadian rhythms. Melatonin is also a potent antioxidant that protects mitochondrial and nuclear DNA and has been found to protect against noise-and drug-induced hearing loss. Because sleep disturbances represent a major complaint and complicating factor in tinnitus, melatonin was evaluated as a treatment for tinnitus in three studies. In the first double-blind, placebo-controlled, crossover study, scores of tinnitus severity measured with the Tinnitus Handicap Inventory improved by approximately the same degree with melatonin and placebo. There was a trend toward improved sleep scores with melatonin, but the effect was not statistically significant. A subsequent openlabel study found statistically significant improvements on the Tinnitus Handicap Inventory and Pittsburgh Sleep Quality Index with melatonin treatment; however, it is difficult to evaluate the significance of these findings because of the lack of a placebo control group and moderate effect size. A more recent, randomized, double-blind, placebo-controlled study found that melatonin reduced subjective ratings of tinnitus and tinnitus loudness more than placebo; these improvements were substantially larger if melatonin was combined with the antipsychotic sulpiride, a selective dopamine D2 antagonist.
Zinc, an essential trace metal that plays an important role in numerous biological functions, is widely expressed in the auditory pathway, including the dorsal cochlear nucleus, a structure posited to be a major tinnitus generator. Zinc has been proposed as a treatment for tinnitus, particularly in patients with hypozincemia. While positive results have been reported in some patients, most well-controlled, double-blind, placebo-controlled studies have found little or no improvement in tinnitus with zinc therapy, except in a few patients with low zinc serum levels. A clinical trial to evaluate the efficacy of a dietary zinc supplement for treating tinnitus is under way (http://clinicaltrials.gov/ct2/show/NCT00683644).
Summary and outlook for drug treatment of tinnitus
The neural mechanisms that give rise to tinnitus are likely to be just as complex and multifaceted as other neurological disorders, such as epilepsy, pain or depression. The lack of a clinically relevant, objective and valid framework for classifying and distinguishing patients who present with tinnitus symptoms represents a major challenge for clinicians. Efforts are currently under way to develop more clinically relevant schemes for classifying tinnitus patients based on etiology, somatic, audiometric, perceptual and psychological features, as well as brain imaging findings. Advances in classifying tinnitus patients are likely to lead to improved success rates with drugs targeted to specific subpopulations.
For many years, the standard of care for dealing with tinnitus patients has been, “You need to learn to live with it.” Over the past two decades, a small cadre of clinicians has significantly advanced the standard of care by providing patients with sound therapy, counseling and education. While many tinnitus patients demonstrate slow, steady improvement with these methods, most patients would prefer a drug therapy that would rapidly lead to improvement and complete suppression of their tinnitus. Aside from a few exceptional cases, most currently available drugs fail to completely suppress tinnitus, although some drugs have been reported to provide moderate relief of symptoms in a subset of patients. Careful clinical observations, along with data from clinical trials, have provided useful clues for deciding on a rational course of drug therapy for select patients. A rare subgroup of patients who describe their tinnitus as sounding like a typewriter is likely to gain significant tinnitus relief from carbamazepine. For other patients, carbamazepine is likely to be no better than placebo. When a shotgun approach is used to treat all tinnitus patients with antidepressants, the overall success rates have proved disappointing. However, if tinnitus patients with severe depression are treated with antidepressants, tinnitus symptoms often show noticeable improvement. Administering a depression inventory to all patients seeking treatment would help identify those patients likely to obtain tinnitus relief from antidepressant therapy. Not surprisingly, patients with roaring tinnitus often find it difficult to fall asleep. Sleep deprivation adds to the fatigue, emotional burden and stress associated with tinnitus. Melatonin, an over-the-counter sleep aid with antioxidant properties and minimal side effects, may prove helpful in reducing tinnitus symptoms in patients with significant sleep disturbances. Preliminary studies combining melatonin with the dopamine D2 antagonist and antipsychotic sulpiride have yielded promising results, but further work is need to confirm these findings.
Because little is known about the underlying neural mechanisms that cause tinnitus, the clinical approaches to implementing drug therapies for treating tinnitus have been largely hit or miss. The development of behavioral measures of tinnitus in animals, combined with physiological, biochemical, molecular and imaging techniques are likely to provide important insights on the underlying causes of tinnitus. Behavioral methods for detecting tinnitus in animals will allow new or existing drugs to be screened to determine if they can suppress tinnitus. The studies carried out to date suggest that GABA-T inhibitors and potassium channel modulators are potential drug candidates for tinnitus.
The potential market for an FDA-approved drug to treat tinnitus is quite large; however, the acceptance by the medical community of new or old drugs to treat tinnitus ultimately rests on significant positive findings from well-controlled, multicenter clinical trials. Several existing drugs have been reported to provide significant relief from tinnitus; however, many of these studies suffer from small sample size, lack of replication, unusual dosing methods or weak experimental design, thereby hindering the acceptance of these drugs by the medical community. Looking to the future, patients and clinicians may finally receive clear-cut answers from clinical trials currently under way to evaluate the efficacy of neramexane, vestipitant alone and in combination with paroxetine, acamprosate, AM-101 and dietary zinc supplements. Information gleaned from ongoing and future clinical studies may have the potential to revolutionize the treatment of tinnitus.
Drug pumps and injections into the middle ear
A novel drug pump implanted in the ear using NST-001 developed by NeuroSystec
A drug pump which is implanted in the ear is the latest approach for tackling tinnitus. It works by releasing a powerful new medicine that calms the overactive nerves thought to cause the condition.The new therapy, developed by U.S.-based company NeuroSystec, uses a drug known as NST-001. This is thought to block the production of excessive glutamate, in turn reducing this rogue nerve firing.
Researchers claim it may even result in the elimination of tinnitus. Animal research found that when the drug was put into the ear, it cut the sounds of tinnitus. And in a small pilot study on human volunteers in Germany, the majority of patients given the drug reported a significant reduction of tinnitus. When the treatment ended, the condition returned to previous levels.
A new trial is under way at the Hospital Avicenne in France with 24 patients. Because of the need for continual treatment, scientists are focusing on developing a fully implanted drug pump. This has an internal reservoir that they hope will administer the drug for more than a year, after which it will be refilled through the skin via a minor surgical procedure.
Dr Ralph Holme, director of Biomedical Research at the Royal National Institute for the Deaf, says: 'In recent years, there has been research into a number of drugs which aim to reduce the hyperactivity in the brain associated with tinnitus. This particular study is interesting, as it is also testing a new way of administering a drug by pumping it straight into the inner ear.' He added that the glutamate system is increasingly appearing as a possible cause. 'We know from animal studies that reducing levels of glutamate in the ear leads to a lessening of tinnitus.
If it does work in humans, it would, therefore, address a cause, rather than existing treatments which tackle the symptoms. 'The approach may benefit people with relatively new cases of tinnitus, but we do not yet know whether it works in well-established tinnitus. 'If found to be safe, it could also lead to the development of new devices to inject these drugs directly into the ear.'
This studied was terminated in May 2013 and the results are being evaluated.
Draper laboratory tinnitus treatment delivery device
The U.S. Department of Defense has commissioned Draper Laboratory in Cambridge, Mass., to spend the next year fleshing out a concept for a small delivery device inserted near the membrane-covered window—no more than three millimeters in diameter—separating the middle ear from the inner ear. Once at the membrane the device (essentially a polymer capsule, although Draper is not developing any of medicines that might be placed inside) would release a drug into the cochlea, the tubular organ residing in the inner ear that enables us to hear. The plan is to embed wireless communications into the capsule so that a patient or doctor can control the dosage. After the capsule finishes delivering its supply of drugs, it would dissolve.
Although Draper's project is still in the very early stages and years away from any clinical testing, it holds more promise than many of today's most common approaches to tinnitus treatment, which include deep breathing, using background noise to drown out the ringing or simply learning to ignore the bothersome sound.
Steroids injected into the eardrum have shown some promise in helping patients with certain hearing and balance disorders, but the ear begins eliminating these drugs through the eustachian tube (a passageway in the middle ear that acts as a pressure equalizer) as soon as the patient talks, swallows or even sits up. As a result, the patient must endure several injections into their ear and remain immobilized for a time after each injection to get any relief from the malady. "By and large there aren't that many good ways to treat tinnitus," says Lloyd Minor, provost and senior vice president for academic affairs at Johns Hopkins University. Draper's work "is potentially a novel way of delivering drugs to treat tinnitus. In general, we don't have the types of drug-delivery systems that we would like to get medication into the inner ear."
Otonomy, Inc., in San Diego is testing a sustained release dexamethasone (a type of steroid) gel that would be injected into the middle ear, where it would stay in place, dissolving slowly and delivering treatments for hearing and balance disorders.
MicroTransponder, a medical device company spun out from the University of Texas at Dallas in 2007, is looking to broaden the use of its implanted wired neuro-stimulation system for treating epilepsy to likewise help tinnitus patients. The neuro-stimulation approach shows greater promise than those based on delivering medication to the inner ear at this time, says Michael McKenna, an otologist and neurologist at Massachusetts Eye and Ear in Boston.
However, targeted drug therapy is of questionable benefit because tinnitus comes from a variety of causes—including age-related hearing loss, traumatic ear injuries or circulatory system disorders—and has varying degrees of severity, he adds. Perhaps some combination of all these efforts will end up delivering the relief that tinnitus sufferers seek. "Nothing really has been a panacea, so there is the need for further technological development," Minor says. If Draper's technology "works in the way they're hoping it will work, it will potentially be a big advance for the field."
Tinnitus relief remedies and lifestyle changes
Some common and easy remedies such as the following may be of benefit to some individuals. Reducing or avoiding caffeine and salt intake, and quitting smoking may help relieve tinnitus symptoms. Some tinnitus patients have been found to have lower zinc levels and may benefit from zinc supplementation. One study showed melatonin may help tinnitus sufferers, particularly those with disturbed sleep due to the tinnitus. However, this is not yet been verified in controlled studies. Ginkgo Biloba has been touted as a natural tinnitus remedy, but controlled studies to date have not shown it to be effective.
Alternative treatments for tinnitus
Minerals such as magnesium or zinc, herbal preparations such as Ginkgo biloba, homeopathic remedies, or B vitamins are sometimes prescribed for relieving tinnitus.
Procedures such as acupuncture, cranio-sacral therapy, magnets, hyperbaric oxygen, or hypnosis are also occasionally tried. Your doctor might give you clearance to try them for tinnitus given that they generally carry little risk to health.
There are different methods in use for treatment of tinnitus, and before discussing TRT, it may be useful to briefly discuss some of these other main treatments for tinnitus. Traditionally, the goal has been to eliminate the tinnitus source and tinnitus perception, thus, aiming at achieving a cure of the tinnitus. So far, however, this goal is rarely achieved. Many treatments, typically aimed at the cochlea by delivering drugs directly to the cochlea or through the middle ear, have been tried, and some studies of the outcome of such treatments are currently in progress. Another traditional approach for treatment of tinnitus has been aimed at eliminating tinnitus perception. Suppression of tinnitus perception by external sound, labeled “masking,” has been widely promoted. This approach has not been as successful as hoped, with reported effectiveness from zero to 60%. Recently, “masking” has been re-defined as use of any sound which provides some immediate relief for tinnitus. This approach has shown some effectiveness, but it is not clear if it is better that any other type of sound therapy.
Different investigators have used the term “masking” in different ways to describe tinnitus suppression. Auditory masking results from interaction between two traveling waves on the basilar membrane of the cochlea, and as such exhibits phenomena of “critical band” and “V-shaped suppression curve.” None of this is true for tinnitus, it is possible to suppress tinnitus perception equally easy by sound of any frequency, and there is lack of significant dependence on the intensity of the sounds needed to suppress tinnitus from a frequency of the tone. These findings support the hypothesis that tinnitus is a phantom auditory perception without any correspondence to the vibratory activity within the cochlea.
Another approach to suppress tinnitus perception that has been described makes use of electrical stimulation of the cochlea/auditory nerve or, recently, electrical stimulation of the auditory cortex. In the case of the auditory cortex, in addition to direct electrical stimulation, Transcranial Magnetic Stimulation (TMS) has been used. In TMS, impulses of a very strong magnetic field are applied locally to the skull and the induced electrical current stimulates the cerebral cortex. All these attempts to treat patients with tinnitus were partially successful, with an average rate of about 50%. These methods are now under further investigation.
Different classes of treatment have been aimed at decreasing tinnitus-evoked reactions by improving coping strategies, modifying an individual’s thinking about tinnitus, or by using psychotropic drugs to attenuate activity of the limbic system. Psychological approaches have shown effectiveness in the range of 50%, while so far none of the drugs tested have shown significantly positive effects.
Last, but not least, a variety of sound therapies based on the concept of attenuating tinnitus or making it less noticeable have been described. These treatments have shown some effectiveness, but for most of these methods lack of systematic, independent studies have made it impossible to accurately assess their efficacy. Recently, the concept of using sounds where the energy at frequencies around the pitch of a person’s tinnitus were eliminated has been reintroduced. The use of such sounds is based on the hypothesis that utilizing the mechanism of lateral inhibition in the auditory cortex would suppress tinnitus. Lateral inhibition, which occurs commonly in the brain and reflects situation that stimulation of one neuron, is frequently accompanied by inhibition of nearby neurons. In the case of the auditory system, which exhibits tonotopic organization, stimulation with a given frequency can inhibit neurons that respond best to nearby frequencies. Specifically, in case of tinnitus, it has been postulated that by removing the music’s frequencies around a person’s tinnitus pitch, the neurons in this range will be inhibited due to activation of neurons which respond best to nearby frequencies.
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There is hope, treatment of tinnitus is possible