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  1. Cognitive Aspects of Tinnitus Patient Management : Ear and Hearing
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Although many therapies for tinnitus are available, most do not have the support of rigorous scientific research. There is no cure for tinnitus, and, despite claims that are ubiquitous on the Internet, no method has been shown to permanently suppress the perception of tinnitus. To help patients, it is therefore necessary to mitigate the functional effects of tinnitus Davis and Refaie, Where do we get this information, though?

As audiologists, it is emphasized that we are to provide clinical care based on scientific evidence. But what does this really mean?

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Figure 2 shows the different levels of evidence—the bottom step indicating the weakest and the top step being the strongest level Liddle et al, We rely heavily on our patients to tell us how they react to their tinnitus, which suggests how to design their best management options. This type of evidence is especially important when providing patient-centered care. Audiologist opinions are extremely valuable when considering clinical tinnitus care options—as clinicians, we develop a sense of what will or will not work for a particular patient. Moving up the steps, we get to case reports and then observational studies.

These provide good descriptive and qualitative information for us as clinicians, but we need to remember these types of studies might be describing atypical features identified in one person or summarizing a sample population. Our next step includes clinical trials, such as randomized controlled trials RCTs or masked trials, which provide strong evidence in support of a particular treatment or management because they minimize bias.

This is important! The different comparison groups of these types of studies allow researchers to determine any effects of treatments with control groups, which eliminate alternate explanations, or experimental results that could result from experimental errors or experimenter bias. Clinical trials are considered the gold standard and are used to test efficacy and effectiveness of interventions. This is what we need, right? At the topmost step sits systematic reviews. These are a type of literature review that use precise methods to collect and assess research studies, and then, synthesize their findings.

Systematic reviews provide a complete and exhaustive summary of every piece of current and relevant information. We need these reviews to tell us what we should be considering or not considering for our patients. Now where do we go? A wealth of information is available from systematic reviews, RCTs, and clinical practice guidelines for tinnitus that can direct our care plans.

Hearing and Tinnitus Tips from an Audiologist

So, what do we do for that 20 percent of the population with tinnitus that seeks our help? How can we provide research-based tinnitus care despite the overwhelming amount of information thrown our way? It goes without saying that it is critical for tinnitus patients to be able to speak about what they are perceiving and how they are feeling. Not only does a thorough case history give us details as to other medical or hearing concerns, it helps patients become involved in their own care.

Our best information comes from the patients themselves, and they are, in fact, collaborators in determining the best course of clinical action. No case history model is better than any other. Langguth et al described a sample case history that includes questions about tinnitus onset, perception, and manifestation. Modifying questionnaires such as this one to suit your clinical needs is encouraged.

In general, the case history should address pulsatile, unilateral, or recent-onset tinnitus, hearing complaints especially asymmetric, unilateral, or sudden-onset hearing loss , exposures to noise or ototoxic medications, balance disorders, emotional disorders, cognitive difficulties, and insomnia Tunkel et al, Tinnitus has different connotations that need to be distinguished due to their clinical implications.

Duration refers to how long they have experienced tinnitus. Temporal manifestations refer to the timing of how they hear the tinnitus. We all experience spontaneous tinnitus, that sudden-onset tone that usually lasts less than a minute. This is normal. Others experience temporary, occasional, intermittent, or constant tinnitus.

These individuals need to be screened as to which type they have. This is important to decide if an ear, nose, and throat ENT physician referral is warranted, what types of tests should be performed, and what type of management options might be of benefit Henry et al, A summary of these five categories is given in Figure 3.

The Tinnitus Screener is short, quick, and efficient, and can be included as part of the case history. More than 50 million people in the United States have reported experiencing tinnitus, and of that number, an estimated 12 million seek medical intervention Tunkel et al, The great majority of those patients reporting tinnitus and seeking help have primary tinnitus, i. Some patients have tinnitus suspected as secondary, i. Secondary tinnitus can be associated with auditory system disorders e.

Remember the tinnitus screener? This little tool will help you define the type of tinnitus and give you indications of secondary tinnitus refer to Figure 3. Once categorized, the screener helps to steer you toward primary or secondary tinnitus.

For example, individuals categorized as temporary and occasional tinnitus should be asked about events or situations that cause the tinnitus onset, which might indicate secondary tinnitus. Intermittent and constant tinnitus may be more associated with SNHL. If medical, refer to an ENT. Oftentimes, our patients may think they have a true, primary concern of tinnitus. If so, the patient has determined that this is a tinnitus problem, not a hearing problem.

We need to help them identify the true difficulty. The Tinnitus and Hearing Survey THS is another quick tool that helps to distinguish a tinnitus problem from a hearing problem Henry et al, b. The THS contains three sections. Section A has four items that address the most common tinnitus problems and are written so as not to be confused with a hearing problem. Section B focuses on four possible hearing concerns that would not be confused with a tinnitus problem.

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Cognitive Aspects of Tinnitus Patient Management : Ear and Hearing

It should be noted that the scores obtained for Sections A and B should not be used for decision making. Rather, these scores, combined with the audiologic assessment, provide the information needed to determine what services might be appropriate for the patient with respect to both tinnitus and hearing loss. The systematic reviews and clinical guidelines all state that an evaluation should occur to assess the whole health of the patient. Because up to 90 percent of individuals with tinnitus also have hearing loss Johnson, ; Schechter et al, , any patient reporting tinnitus should receive an audiologic assessment.

Any hearing problems should be addressed before providing intervention for bothersome tinnitus. Randomized controlled trials have confirmed what audiologists already know: bothersome tinnitus is mitigated often through the use of hearing aids for those with hearing loss dos Santos et al, ; Henry et al, a; Henry et al, a.

Bothersome tinnitus is normally the secondary reason to fit hearing aids, but in some cases, it can be the primary reason. Although research has not proved the value of hearing aids as intervention for patients who have bothersome tinnitus but are not hearing aid candidates, anecdotal evidence is fairly abundant that this may be effective. Remember that clinical trials are needed to support a particular intervention.

Good news—studies are in progress to test this anecdotal evidence. Regardless of whether these patients receive hearing aids, they should receive basic information about tinnitus during the appointment, and brief tinnitus counseling as time allows. Patients who receive hearing aids should be asked during their follow-up appointment if they would like to receive intervention for the types of problems described in the THS Tinnitus section Section A.

This is always the biggest question—what is the best treatment option for tinnitus? Unfortunately, there is no evidence of any treatment that eliminates, or even reduces, the perception of tinnitus. According to systematic reviews, Cognitive Behavioral Therapy CBT is considered the most evidence-based method of tinnitus intervention Hobson et al, ; Martinez-Devesa et al, Log in to view full text.

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If you're not a subscriber, you can:. Colleague's E-mail is Invalid. Your message has been successfully sent to your colleague. Save my selection. Despite the availability of several management procedures for tinnitus, many audiologists seem reluctant to engage in long-term rehabilitation of patients.

Tinnitus patients are somewhat similar to chronic pain patients in that both groups suffer from intractable symptoms. A technique which has been effectively utilized in helping pain patients cope with their problems is cognitive-behavioral therapy.

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This approach can be applied with considerable success to tinnitus patients with the emphasis placed on treating the patient's reaction to tinnitus rather than the tinnitus itself. To accomplish this, maladaptive behaviors and thought patterns must be identified and then systematically altered via a program specifically designed for the individual.

This procedure is analogous to many precepts governing aural rehabilitation. Address reprint requests to Robert W. Sweetow, Ph. You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page. Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent.

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