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28.09.2014

What is progressive tinnitus management, what drugs can cause ringing in the ears - For Begninners

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Chronic tinnitus (as distinct from somatosounds) reflects malfunction somewhere within the auditory system. By learning to self-manage their reactions to tinnitus, patients are empowered by gaining the ability to know how to address any situation in which their tinnitus is bothersome or intrusive. Intervention with PTM specifically involves activities designed to reduce reactions to tinnitus (no attempt is made to alter the tinnitus sound). As mentioned in article 1, epidemiologic studies reveal that chronic tinnitus is experienced by about 10 to 15% of all adults (H.
Tinnitus that is “clinically significant” indicates that the tinnitus causes functional impairment to such a degree that clinical intervention is warranted. The “tinnitus pyramid” (Figure 1) depicts how individuals who experience tinnitus are distributed with respect to how the tinnitus impacts their lives (Dobie, 2004b).
Most patients do not require extensive (or expensive) clinical intervention to learn how to manage their reactions to tinnitus.
The observation that the majority of individuals who experience tinnitus do not require intervention has been supported by numerous subject-recruitment efforts for controlled studies conducted at the Portland VA Medical Center (under the auspices of the National Center for Rehabilitative Auditory Research, NCRAR) to evaluate methods of tinnitus intervention (see article 2). The overall goal of the hierarchical approach used with PTM is to minimize the impact of tinnitus on patients’ lives as efficiently as possible.
The initial evaluation for a patient who complains of tinnitus usually can be conducted by an audiologist and in many cases the audiology assessment (with the possibility of fitting hearing aids) is the only service needed. Clinical evaluations help determine the range and types of services needed to manage the full scope of medical, rehabilitation, and psychosocial aspects of tinnitus. Ideally, every patient complaining of tinnitus would receive a complete head and neck examination from an otolaryngologist, otologist, or neuro-otologist who is knowledgeable about the multiple causes and pre-sentations of tinnitus. Some patients with tinnitus present with behaviors that indicate the need for an evaluation by a psychiatrist, psychologist, or other licensed mental health professional. In addition to the audiology testing, a brief assessment should be performed to determine if intervention specific to tinnitus is warranted. Level 2 is the audiologic evaluation, which includes a brief assessment of the impact of tinnitus on the patient’s life. The Level 2 evaluation always includes a standard audiologic evaluation and brief written questionnaires to assess the relative impact of hearing problems and tinnitus problems.
Patients who report any degree of a tinnitus problem following these basic services are advised to attend Level 3 Group Education. Level 3 provides group education workshops for patients who require tinnitus-specific intervention. Level 3 Group Education is for patients who have attended the Level 2 Audiologic Evaluation and feel that they need additional clinical services to learn how to manage their reactions to tinnitus. Recent evidence supports the use of group education as a basic form of tinnitus intervention. PTM group education has been carefully developed to assist patients in directly addressing those life situations when their tinnitus is problematic. During the first session with the audiologist, the principles of using sound to manage reactions to tinnitus are explained, and participants use the PTM Sound Plan Worksheet (J. Patients who are unable to satisfactorily manage their reactions to tinnitus following completion of PTM Levels 2 and 3 require a full evaluation to determine their needs for further intervention. The audiologic tinnitus assessment includes written questionnaires, a structured interview, and, optionally, a psychoacoustic assessment of tinnitus perceptual characteristics. The audiologic counselling information is essentially the same as what was covered during Level 3 Group Education. During Level 5 the audiologist and psychologist should collaborate with each other and with the patient to determine what is necessary to provide adequate benefit to the patient.
If a patient reaches Level 5, then one-on-one support is needed for the patient to better understand the concepts and receive help in trying to learn how to self-manage reactions to tinnitus. PTM is a program that is efficient for audiologists and psychologists and is designed to work in the best interest of patients to help them learn how to self-manage their reactions to tinnitus without getting involved in expensive therapy. The PTM model is designed for implementation at any clinic that desires to optimize resourcefulness, cost efficiency, and expedience in working with patients who complain of tinnitus.
Level 1: Sam was referred to audiology by primary care for tinnitus and hearing loss complaints. Level 3: Sam attended group education sessions with the audiologist and psychologist and reported that the education was not enough—he was still very troubled by his tinnitus and wanted more assistance. Level 1: Betty was referred to audiology by primary care due to a report of intermittent tinnitus bilaterally. Level 1: Joe was referred to audiology by his psychologist due to reports that he “dislikes” hearing sound and has very bothersome tinnitus.
Key words: assessment, counseling, education, hearing disorders, quality of healthcare, rehabilitation, screening, tinnitus, treatment, triage. In spite of the growing magnitude of the problem of tinnitus in veterans, most VA medical centers (VAMCs) do not provide clinical management for the condition [14].
Presently, no accepted standard of practice exists for the clinical management of tinnitus, either within or outside of the VHA. This article proposes a basic model for efficiently managing tinnitus patients at all levels of clinical need.
The proposed model is designed for application at any audiology clinic that desires to optimize resourcefulness, cost efficiency, and expedience in its practice of tinnitus management. Dobie reviewed 69 randomized clinical trials that had been conducted to assess the efficacy of various treatments for tinnitus [17].
The reports by Dobie reveal that the literature does not provide definitive evidence to support any particular form of tinnitus intervention. Numerous causes of tinnitus have been identified, many of which involve head and neck injuries or diseases or systemic diseases. Patients should also receive a general physical examination consistent with an ideal standard of tinnitus clinical management. The mechanism(s) of tinnitus is still unknown; thus, no rational basis exists upon which to select a drug to control tinnitus [25].
Many forms of tinnitus therapy recommend the use of sound in some manner to reduce the effects of tinnitus. Hearing aids have been long recognized to reduce the bothersome effects of tinnitus [28-30]. The primary treatment modality with Tinnitus Masking is the use of wearable ear-level devices-tinnitus maskers, hearing aids, or combination instruments [33-34].
Psychological forms of treatment for tinnitus have included progressive muscular relaxation training, biofeedback, hypnosis, and cognitive-behavioral intervention [45,53].
Tinnitus research has been conducted at the Portland VAMC (PVAMC) since 1995 (under the auspices of the NCRAR since 1997). Our randomized clinical trials, described in the following paragraphs, are a systematic effort to develop and document structured forms of tinnitus management for veterans. Before attending the intake evaluation, each of the 172 study candidates completed written tinnitus questionnaires, including the Tinnitus Handicap Inventory (THI) [70], Tinnitus Handicap Questionnaire (THQ) [71], and Tinnitus Severity Index (TSI) [72].
Mean ± standard deviation (SD) scores from Tinnitus Handicap Inventory (THI) for patients at baseline and ongoing treatment appointments.
Mean ± standard deviation (SD) scores from Tinnitus Handicap Questionnaire (THQ) for patients at baseline and ongoing treatment intervals. Mean ± standard deviation (SD) scores from Tinnitus Severity Index (TSI) for patients at baseline and follow-up treatment intervals.
Numbers and percentages of patients in each treatment group (Tinnitus Masking and Tinnitus Retraining Therapy [TRT]) who made statistically significant improvement (0.05 level of significance) based on a 20-point reduction in total index score of Tinnitus Handicap Inventory (THI). The investigators hypothesized that the majority of veterans with clinically significant tinnitus would be treated effectively using group counseling that was adapted from the structured TRT counseling protocol.
Mean ± standard deviation scores from Tinnitus Severity Index (TSI) for patients in three treatment groups at baseline and 1, 6, and 12 months posttreatment (usual care received no treatment).
A further possibility for tinnitus group therapy is to provide the educational program as a videotaped presentation. We are accumulating research evidence that supports the efficacy and efficiency of providing clinical tinnitus services with a progressive intervention approach. Level 1 of tinnitus progressive intervention would involve screening for clinically significant tinnitus-separating persons who do require clinical services from those who do not.
Note that we avoid the word “treatment,” which might be interpreted by patients to mean that a circumscribed course of treatment will permanently quiet or eliminate their tinnitus.
Approaching the top of the pyramid are people who have progressively more severe problems caused by tinnitus. The model is designed to be maximally efficient to have the least impact on clinical resources, while still addressing the needs of all patients who complain of tinnitus. However, many patients require referral for additional evaluations, and some patients require tinnitus-specific intervention.


Members of the tinnitus management team administer a variety of assessment instruments and then, for difficult cases, meet as a group to integrate results into a plan of care tailored to the individual needs of the patient. Involvement of prosthetics and sensory aids staff (at VA, military, and some other hospitals and clinics) ensures that appropriate technology will be available to patients with tinnitus.
The education consists primarily of teaching patients how to use sound and coping techniques to manage their reactions to tinnitus.
Sometimes it also is appropriate to screen for mental health conditions that can interfere with successful self-management of reactions to tinnitus. Patients who require amplification are fitted with hearing aids, which often can result in satisfactory reduction in reactions to tinnitus with minimal education and support specific to tinnitus (J. Patients who report a severe problem with reduced sound tolerance are scheduled for STEM, which then becomes the focus of clinical management. Level 3 is the first level within PTM for which patients receive focused intervention for a tinnitus problem. Group education has been shown to be effective as part of a hierarchical tinnitus management program at a major tinnitus clinic (C. Such an in-depth evaluation is not warranted for the great majority of patients who are able to self-manage reactions to tinnitus with the information and support provided in Levels 2 and 3. The questionnaires and interview are the key to determining how the tinnitus impacts the patient’s life and if individualized support from an audiologist is indicated. If ear-level devices are involved in the management program, then appointments with an audiologist are essential to ensure that the devices are working properly and that the patient is using the devices in a manner that is optimal for tinnitus management.
However, for Level 5, the overview of PTM 31 audiologist uses a book to facilitate the counselling (Progressive Tinnitus Management: counselling Guide) (J. Occasional appointments with both providers may be helpful for clarifying the goals of the interventions and emphasizing a team approach to providing tinnitus care. Use of these recommendations should lead to more widespread and consistent tinnitus assessment and intervention by clinicians. She obtained the information needed to self-manage her reactions to tinnitus by optimizing her lifestyle and using low level sounds in her environment when the tinnitus was bothersome. Joe learned from the audiologist how to use sound to decrease his awareness of tinnitus and to continue increasing his tolerance to sound. Our clinical trials and screening methodology support the commonly reported observation that most individuals who experience tinnitus do not require intervention. Use of these recommendations should lead to more widespread and consistent tinnitus assessment and treatment by audiologists.
He concluded that none of these studies demonstrated replicable, long-term reduction in tinnitus impact on lifestyle. With that caveat in mind, we will now review various methods of treatment for tinnitus that are most commonly reported in the literature and have been used in clinical practice. An otologic evaluation is essential when symptoms are consistent with an acoustic neuroma or when the tinnitus is pulsatile or objective in nature [21]. Because so many drugs have been taken for so many different conditions, anecdotal evidence of correlative tinnitus relief has accumulated. Patients with hearing loss and tinnitus often receive the secondary benefit of tinnitus relief when using hearing aids [31]. These types of therapy are not intended to remove or reduce the perceived tinnitus in any way but rather to help one cope with the effects of tinnitus on quality of life.
Because of the anecdotal reports of tinnitus relief with the use of these various methods, numerous studies have been conducted to attempt to verify the reports. Our long-term objective is to develop a tinnitus management program for veterans that is documented for treatment efficacy. Of course, the concern exists that some patients have tinnitus that requires medical attention. A section follows that outlines the most common referral concerns for tinnitus patients and describes how referrals should be handled at each of the five levels of progressive intervention.
Most likely, the majority of individuals who inquire about tinnitus services could have their needs met through an effective screening process.
Such an outcome typically is what patients want, and they often are not interested in receiving clinical services if those services will not cure their tinnitus. Learning these concepts is universally important and is particularly necessary for anyone who experiences tinnitus to minimize the potential for exacerbation of the tinnitus symptom.
However, just experiencing tinnitus is not justification for receiving therapy that is designed to address reactions to tinnitus. Because of the multiple dimensions of problematic tinnitus, clinical services are optimized by using an interdisciplinary approach. The scope of care depends on the severity of perceived tinnitus and medical and psychological issues. It therefore is critical to determine how much of the patient’s complaint is due to a hearing problem and how much is due specifically to the tinnitus.
More specifically, patients learn how to develop and implement individualized plans for using therapeutic sound and apply principles of cognitive-behavioral therapy (CBT) to manage their tinnitus.
Tinnitus disproportionately affects the populations most likely to have low health literacy: older adults and low-income individuals (S. Level 1 Triage provides guidelines for all clinics where patients with tinnitus are likely to be encountered.
If they fail the screening, then they should participate in the sound tolerance evaluation and management (STEM) protocol, as indicated on the figure.
Special procedures have been developed for selecting sound-generating devices for tinnitus management using therapeutic sound, including ear-level noise generators and combination instruments, and personal listening devices. Audiologists can help patients with tinnitus feel less concerned about this stigma if they explain the goals of CBT. During the CBT workshops he learned the importance of staying active to distract himself from his tinnitus. The lack of VA tinnitus services reflects the fact that research evidence for all forms of tinnitus treatment remains equivocal and that no one method is as yet proven to be any more effective than another [17-19].
Before describing the model, we will first review various methodologies that are used for tinnitus management. Even when these symptoms are not present, the ideal standard for tinnitus management would be for every tinnitus patient to receive a complete examination by an otolaryngologist or otologist [22]. In some cases, tinnitus relief is the primary goal of hearing aids, especially if the patient is a marginal hearing aid candidate.
However, patients with more troublesome tinnitus are advised to wear ear-level devices (sound generators, hearing aids, or combination instruments) to optimize the habituation process.
Regardless of the form of treatment, certain counseling topics would be considered universal for tinnitus patients. Second, no form of tinnitus treatment can claim unequivocal research evidence demonstrating consistent success.
Our efforts run in two parallel tracks to address the needs of veterans with (1) severe tinnitus and (2) mild-to-moderate tinnitus.
Study participants were veterans who required long-term, individualized treatment for their tinnitus.
It was therefore critical to select only veterans with tinnitus of enough severity to warrant the long-term treatment that would be provided.
Each questionnaire provides an index score, with higher scores reflecting greater perceived tinnitus handicap.
When patients began treatment with lower index scores (reflecting a less severe tinnitus problem), the benefits of TRT compared with masking were more modest. Therefore, the participants in this study did not have as severe a tinnitus condition (on average) as did those in the trial just described. The group, which focuses on providing useful information for reducing tinnitus impact on lifestyle, has consistently benefited the attendees. The educational program should therefore inform all patients of symptoms that suggest acoustic neuroma, Meniere's disease, or tinnitus that may be correctable through medical or surgical means. Considering that reducing the loudness of tinnitus normally is not an option, the next best thing is to help patients live more comfortably with their tinnitus. Patients need to be informed that although tinnitus cannot be cured they can learn to manage their reactions to it, thereby improving their quality of life. However, the condition is “clinically significant” for only about 20% of those who experience tinnitus (A. Intervention for tinnitus typically requires audiology and mental health services but may involve medical and prosthetic services.
For example, pulsatile tinnitus often has an identifiable site, for which there are many potential causes. Untreated PTSD can impede rehabilitation efforts, including the clinical management of tinnitus.


Level 1 Triage on the flowchart includes a large rectangular text box that describes the criteria for referring patients who complain of tinnitus. The STEM protocol should resolve the hyperacusis problem, at which time the patient should be evaluated to determine if further tinnitus services are needed. The tinnitus triage guidelines can be used to help guide referral practices for clinicians encountering patients reporting tinnitus. The workbook provides detailed information and instructions for developing individualized action plans to self-manage reactions to tinnitus using therapeutic sound and coping techniques.
Some patients may require psychiatric management to address persistent or more serious mental health symptoms that may become evident at any level of PTM.
Included in that education is a thorough explanation of the different ways that sound can be used to manage reactions to tinnitus.
Some clinics employ health psychologists or clinical psychologists who specialize in auditory disorders, and who may be especially adept at responding to the psychological needs of patients with tinnitus. His sound tolerance recovered over a six-month period to the degree that tinnitus became the primary problem.
We will then describe results of our prospective trials that are building research support for the progressive intervention approach. Regardless of the form of treatment, sound is used in one way or another to distract attention from the tinnitus and to reduce the brain's perceived need for stimulation [27]. Most importantly, all patients should be advised to avoid exposure to loud noise, which is well known to cause damage to the auditory system and to potentially cause or exacerbate tinnitus [47]. Electrical stimulation is not a method that is presently useful in clinical practice to treat tinnitus but is considered a promising area of investigation. Herbal remedies also have been used in the attempt to reduce tinnitus symptoms-extract of ginkgo biloba has received the greatest attention.
Tinnitus sufferers therefore do not have the benefit of referring to any standardized guidelines when seeking help for their condition.
First, veterans who require clinical management for their tinnitus have widely varying levels of need, thus requiring a program that addresses these different levels.
Results of these studies are promising, but further studies are needed to validate the results, to improve efficiency of treatment, and to develop methods to most appropriately triage tinnitus patients into a management program.
These findings suggest that TRT may be most effective for patients who have the most serious difficulty with their tinnitus, and that treatment of 1 to 2 years may be necessary to achieve maximum benefit of therapy. This group, along with the availability of a structured tinnitus counseling protocol, provided the impetus for conducting this randomized clinical trial. The focus of PTM is to teach patients how to manage their reactions to tinnitus, which can make a meaningful difference in quality of life. Henry, Zaugg, Myers, Kendall, et al., 2009) until they are able to independently manage their reactions to tinnitus. Furthermore, individuals who do require intervention have different levels of need, ranging from brief counselling to individualized, ongoing therapy— thus the rationale for progressive clinical services.
Audiologists must be aware of certain tinnitus-specific symptoms that indicate the need for medical evaluation services. Breaking the process of learning how to manage tinnitus into small achievable tasks helps to ensure that patients experience initial success. All patients with tinnitus-specific problems are advised to participate in the workshops that comprise Level 3 Group Education.
Mental health professionals who receive tinnitus referrals should have expertise in providing psychological interventions for patients with chronic health conditions and at least be familiar with the nature of tinnitus within the context of comorbid psychological problems.
Some patients also may express a strong desire to simply concentrate on addressing sound tolerance problems rather than tinnitus. PTM counselling thus does not just educate patients about tinnitus—it is designed to teach patients how to self-manage their reactions to tinnitus. Henry et al., 2010a) to develop an individualized “sound plan” to use to manage their most bothersome tinnitus situation. The provision of CBT for chronic problems other than tinnitus often involves six to eight sessions (J.
The referring psychologist learned about tinnitus from the PTM team and incorporated skills taught during PTM into his PTSD treatment. Veterans can claim tinnitus as a service-connected disability, which is occurring with increasing frequency. Certain forms of therapy are well defined and are used routinely in clinics that offer tinnitus management. Although test results may reveal that otologic surgery is an appropriate option, such surgery would be indicated only for a very small proportion of tinnitus patients and results are often unpredictable [23].
Patients should also maintain a background of constant low-level sound that can make the tinnitus less noticeable.
Once the sound tolerance problem is under control, then it is determined whether the patient should continue to receive tinnitus-specific clinical services.
These patients are empowered to make informed decisions about self-management, protecting their ears, and further tinnitus intervention options.
As of September 2005, 339,573 veterans had been awarded a service-connected tinnitus disability (Department of Veterans Affairs [VA] Office of Policy and Planning). Cerumen impaction or significant cerumen on the tympanic membrane can cause temporary tinnitus [24], and its removal may require specialized equipment and medicine expertise.
The use of drugs should be considered for tinnitus patients only when sleep disorder, depression, or anxiety are reported as significant coexisting conditions [17]. Serendipitously, cochlear implants were found to be effective for reducing the sensation of tinnitus [59-61]. The tinnitus research program at the National Center for Rehabilitative Auditory Research (NCRAR) aims to provide evidence to support effective methods of treatment.
Many of the callers expressed the common misconception that their tinnitus caused their hearing difficulties [6,67-69].
Optimally, audiologists who provide tinnitus services should work with an interdisciplinary tinnitus team. In addition, we completed a randomized clinical trial (see article 2) evaluating group education for tinnitus in almost 300 patients that showed significantly more reduction in tinnitus severity for patients in the education group as compared to two control groups (J. The analogy between pain and tinnitus is especially useful in introducing the goals of psychological management for tinnitus. If the screening determines that care is urgently required or if further help is needed following the group session(s), a tinnitus intake assessment (Level 3) should be performed. For their tinnitus disability, these veterans received a combined 1-year compensation of approximately $418,000,000. Physicians also are qualified to evaluate for drug interactions or circulatory abnormalities that could be associated with tinnitus. To date, controlled studies have not identified any effective herbal remedies for tinnitus.
Efficiency and economy are crucial for VA acceptance and implementation of tinnitus programs. These veterans required education about this issue and about their other tinnitus concerns.
This immediate-relief strategy may work best for patients with a more moderate tinnitus problem. Further information about managing reactions to tinnitus is then presented, and the participants revise their sound plan based on the discussion and new information. Patients should be reassured that clinicians do not think tinnitus is a psychological disorder nor do we think it is “in their heads.” It may be important for some patients to hear that clinicians believe their tinnitus is real and very disturbing to them as a validation of their concerns and distress upon introducing the psychologist’s role. Our research has revealed that the great majority of patients who complain of tinnitus also complain of hearing problems (J. By the end of the second session with the audiologist, the participants should have learned how to develop, implement, evaluate, and revise a sound plan to manage their most bothersome tinnitus situation.
They are encouraged to use the Sound Plan Worksheet on an ongoing basis to write additional sound plans to address other bothersome tinnitus situations.
For PTM, only certain components of CBT are taught to minimize the number of group sessions and because other components of CBT, such as education about tinnitus, are provided elsewhere during Level 3 and Level 5. Untreated depression, anxiety, or sleep disorder can negate tinnitus rehabilitation efforts. At all levels, the goal is to minimize the impact of tinnitus on the patient's life as efficiently as possible.
An audiologic examination should be the clinical starting point for all patients who complain of tinnitus, unless urgent medical services are required.




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