At an ENT clinic where I once worked, a 78-year-old woman was evaluated whose main complaint was ringing in her ears. She was found to exhibit a very mild high frequency loss, and was counseled regarding the strong relationship between sensorineural hearing loss and ringing in the ears. She was further advised that amplification might provide some relief from the ringing she was experiencing, as well as potentially benefiting her hearing and communication. “Let me get this straight,” she said matter of factly. “You’re saying I have some hearing loss in the high tones and ringing in my ears?” She was assured that she had understood correctly. “What a relief!” she exclaimed. “I was so afraid that I had tinnitus!”
The lesson that we clinicians learned from this client was the importance and impact of information about tinnitus as part of tinnitus management. For this particular woman, just finding out that “tinnitus” was a harmless symptom of an unknown cause in the auditory system—rather than a fearsome disease—was enough to achieve the primary goals of tinnitus management. These are to reduce the perception of tinnitus by the individual and, ultimately, to reduce the impact of tinnitus on their daily life.
Hearing care professionals encounter tinnitus sufferers on a nearly daily basis, as tinnitus affects approximately 10% to 15% of the overall population. Approximately 20% of that population suffers from clinically treatable tinnitus.1,2 In addition, approximately 80% of all tinnitus sufferers have hearing loss, and the hearing care professional can often be the first point of contact. MarkeTrak VIII3 suggests there are 30 million people with tinnitus, and the incidence of tinnitus for people ages 65-85 is as high as 26.7%. Additionally, increased prevalence is correlated with degree of hearing loss, although people with all levels of hearing loss (including those with normal hearing) can have tinnitus.
Tinnitus is the perception of sound in the absence of an acoustic stimulus, and varies greatly in its perceptual characteristics from person to person. Because there is not a singular identifiable and treatable cause of tinnitus, there is also not a simple solution.
Not surprisingly, there are different approaches to treating tinnitus, such as medical management (in cases where the tinnitus can be addressed medically), educational counseling, and sound therapy, each having a unique approach to tinnitus management. Within the different tinnitus management programs, education regarding tinnitus is a key component. In addition, sound may be incorporated into the protocols. In recent years, hearing instruments that combine the benefits of amplification with tinnitus sound generators (TSG) have become available, increasing the clinician’s flexibility in using sound as part of tinnitus management, particularly with many clients also experiencing hearing loss.4 This article reviews some of the more well-established tinnitus management programs, such as sound therapy, Tinnitus Retraining Therapy (TRT), and Progressive Tinnitus Management (PTM), and discusses how sound enrichment and wireless streaming using the latest hearing aid technology can play a beneficial role in achieving the goals of these tinnitus management programs.
In almost all tinnitus management programs, sound therapy plays a significant role. Although counseling alone can be used without sound therapy, it is often not as effective as using a combined approach. Counseling-only treatments are not intended to change or reduce the acoustic perceptions of the tinnitus, but rather change the reactions to tinnitus and the negative effects it may bring.5 This can be beneficial in regard to improving one’s reactions to tinnitus, but may not be enough for some tinnitus sufferers.
Sound therapy’s main intention is to divert an individual’s attention away from the tinnitus. By introducing sound into their environment, we are able to minimize the contrast between the tinnitus and the background environment (Figure 1). For example, in a quiet room, tinnitus is easily detected, since there is a large discrepancy between the loudness of the tinnitus and quietness of the environment. By enriching the environment with sound, we increase the loudness of the background environment, therefore making the tinnitus less prominent and noticeable. Sound therapy can have immediate effects, helping to reduce tinnitus audibility (eg, masking/partial masking), which can also potentially result in taming the underlying tinnitus. Sound stimulation may also reverse or modify the abnormal cortical reorganization thought to be responsible for tinnitus.6 Many different instruments can be used for sound therapy. For example, with most ear-level devices, a broadband white-noise generator is used, and some devices have proprietary signals that can be used in place of, or in conjunction with, the white noise. However, users are limited to the sound sources available within these devices.
Another form of sound therapy is a tabletop sound generator, which offers different sound options, such as running creeks, birds chirping, soothing ocean waves, as well as other nature-type sounds. Many tabletop sound generators are able to use different sound cards, allowing the user to change the sound signal at their convenience. Tabletop sound generators can be used to enrich a quiet room with sound, therefore diverting attention away from the tinnitus. They are often used in the bedroom to help one sleep, but can be used to enrich multiple environments with sound. A limitation to tabletop sound generators is that they are not always conveniently portable, nor discreet, like an ear-level device, and therefore when and where they can be used is somewhat limited.
With the recent popularity of smartphones and the applications that can be downloaded with them, a number of tinnitus applications, or “apps,” are now available. Typically, these offer different types of noise (ie, white, pink, brown, etc), as well as nature-like sounds, that can be downloaded for a minimal cost and played over the external speaker or via headphones. Although the portability of the smartphone is quite convenient, if the user has a hearing loss, it is not taken into account, and thus the sound therapy signal provided by these phones may not be maximized.
More commonly used in treating tinnitus are open-fit hearing instruments. These hearing instruments have been beneficial to a number of tinnitus sufferers, since the open ear canal allows for more natural sound to enter, and therefore provides a form of “natural” sound therapy.7,8 Hearing street noise or people talking can enrich one’s environment with sound, therefore making the tinnitus harder to detect.
Although many people benefit from using hearing instruments alone for tinnitus management, there are a number of people for whom amplification alone is not sufficient. For these individuals, a combination unit, which incorporates both a hearing instrument and a tinnitus sound generator, can be very useful. It allows hearing professionals to address both the hearing loss using amplification, and the tinnitus more specifically using either white noise or a proprietary signal designed for tinnitus management.
In addition, some of today’s technology can be combined with wireless accessories that allow the user to wirelessly stream any sound source that may be beneficial to their tinnitus management plan. Various hearing instrument manufacturers offer products that can be used in this way—for example, the ReSound Unite™ accessories, such as the Mini Microphone and/or TV streamer (Figure 2), that have the ability to wirelessly stream numerous sound signals to the AleraTS™ hearing instruments. This means that virtually any sound source could be used for sound therapy in a convenient manner. Users can upload any sound source to an MP3 player or computer-based music database, such as iTunes, connect it to the ReSound Unite Mini Microphone or TV streamer via a stereo plug, and have that sound source wirelessly streamed to their hearing instruments. This allows them to choose and use the sound signals that are most beneficial and therapeutic to them.
In these cases, one would not be limited to listening only to white noise, but could stream other types of noise, such as pink, red, violet, blue, etc, which differ in their spectral shape, and could provide more benefit, depending on the characteristics of the tinnitus. In addition, other sound signals, such as nature-like sounds, music, or speech, could be used. It is important to remember that individual differences can influence the effectiveness of specific sound over others. Sounds used for sound therapy can vary in their temporal, spectral, and emotion-evoking characteristics.
Searchfield and colleagues6 showed that a rain sound signal was preferred over a white-noise sound signal when it came to masking the tinnitus. Some argue that more dynamic sounds, like a rain sound, are better at helping to mask tinnitus compared to less dynamic sounds like white noise.9 In addition, music was the least favored when it came to masking the tinnitus due to the cognitive stimulation and the attention it brings. However, when measuring these three sound signals in relation to decreasing tinnitus annoyance, music was preferred over white noise, with rain once again being the most preferred.4 Sound therapy can be used in a variety of ways to help enrich one’s acoustic environment. For example, depending on the time of day or the environment (eg, work versus home), a particular sound source might be preferred over another. Wireless streaming offers flexibility with sound therapy never seen before, and allows for true customization of any tinnitus management program, according to the user’s needs and preferences.
Tinnitus Retraining Therapy
Tinnitus Retraining Therapy is a tinnitus management program based on the neurophysiological model of tinnitus, which educates the tinnitus patient to better understand the mechanisms involved with tinnitus and their reactions to tinnitus, and ultimately helps them habituate to the tinnitus, from an emotional and perceptual perspective. Habituation is the process of retraining the brain from conditioned responses. In TRT, the habituation process turns the tinnitus from a negative signal back into a neutral signal, diminishing any negative emotions toward the tinnitus.
TRT reflects a general rule that we do not react to the absolute, but to the relative strength of a stimulus compared with the background.10 For example, the fan of a ventilation system in a very quiet room will sound much louder than if that same fan is blowing in a crowded room with people talking and music on (eg, a cocktail party), even though the intensity of the ventilation fan has not changed. The same holds true with tinnitus. If we increase the intensity of the background environment, and thus stimulate more background neuronal activity, then the tinnitus signal will not be perceived to be as strong, even though the tinnitus signal itself has not changed.
TRT also discusses in-depth the role of the limbic system and the autonomic nervous system (ANS) in regard to tinnitus. The limbic system is greatly connected to our sensory systems, and can elicit both positive and negative reactions, depending on sensory input. This can strongly influence our emotional state. The ANS, which is strongly connected to the limbic system (emotional state), is responsible for automatic body functions, such as heart rate, breathing, and hormonal levels. When put under duress, where a fast reaction is required (fight or flight), the ANS is automatically stimulated and prepares itself for physical or mental activity.
Relative to tinnitus, inappropriate stress is put on these systems due to the negative association of the tinnitus, which is often due to the fact that the person suffering doesn’t understand what is happening to them, even though in most cases, the tinnitus itself is harmless. When these systems are highly stimulated, a vicious cycle involving the auditory system, limbic system, and ANS takes place (Figure 3). One of the goals of TRT is to break this vicious cycle, and sound therapy is often a vital component of this treatment program.
Within TRT, sound therapy can provide a weakening of the tinnitus signal by decreasing the contrast between the tinnitus signal and the background neuronal activity. This can facilitate perceptual changes to the tinnitus. However, there are strict rules as to what sounds should be used to increase the background environment.
Some of the abiding principles of sound therapy within TRT are:
- The external sound being used should not provoke any negative reactions or irritate or annoy the user;
- It is important to maintain the perceptual characteristics of the tinnitus;
- Sounds should not diminish attention from or interfere with other important signals of interest, such as speech, or affect daily activities; and
- Sounds should not fully mask the tinnitus (the tinnitus signal should be audible), as this will prohibit habituation from occurring (you can’t habituate to something you can’t hear).
TRT follows the rules that sounds used for sound therapy should have stable continuous amplitudes, as this is easier to habituate to than changing or fluctuating sounds. Users also should have the ability to change the volume of the sound to optimize habituation, and having some control may help in turn to make the sound more non-threatening and therapeutic. In addition, broadband noise is often suggested, as it stimulates a wide range of neurons with the auditory system. And lastly, with open-fit instruments, environmental sounds can enter the ear naturally, helping to enrich the sound environment.
Many of these requirements can be addressed by using the broadband white noise TSG feature within the ReSound AleraTS. For those users who do not enjoy the sound of white noise, wireless streaming allows the use of any type of continuous stable sound (eg, pink, red, blue, violet, steady nature-like sounds, etc), offering flexibility to address the unique needs and preferences of each tinnitus sufferer. It also provides numerous options to maximize the requirements of TRT and increase the chances of successful outcomes.
Progressive Tinnitus Management
Similar to TRT, Progressive Tinnitus Management uses sound, as well as counseling, as a vital role in helping to achieve the goals of the management plan. PTM is a patient-centered approach to tinnitus management that uses specific evaluation procedures and emphasizes the appropriate use of sound encompassed within a five-step hierarchical plan. Although it has a structured approach on how to use sound, it is very flexible in regard to what sounds can be used within the management plan.
The five levels of management with PTM are as follows (an individual can go through one level or all levels according to their needs):
- Triage. Making the appropriate referrals according to the needs and concerns of the individual;
- Audiologic evaluation. Relevant diagnostic testing, including hearing aids if appropriate;
- Group education. Discussion of self-management strategies within a group setting;
- Tinnitus evaluation. Provides an in-depth interview to determine if further individualized management is necessary; and
- Individualized management. A customized tinnitus management program.
Educational counseling, including appropriate use of sound, is provided during Level 3 (group education) and Level 5 (individualized management) with PTM. At these points, there are three classifications of sound discussed in regard to tinnitus treatment.
- Soothing sounds. These sounds help produce a sense of relief from the stresses of the tinnitus.
- Background sounds. These sounds help in reducing the contrast between the tinnitus and the background acoustic environment. In addition, these sounds aid in passively diverting attention away from the tinnitus.
- Interesting sounds. In contrast to background sounds, these sounds aid in actively diverting attention away from the tinnitus.
Within the three classifications of sounds, three assortments of sound are recommended for optimal results: Environmental sounds, such as nature sounds, appliances, fans, and broadband noise, as in TSG devices; music of all sorts can be used; and speech of all varieties is also acceptable. From here, patients are instructed to recognize the situation where their tinnitus is most bothersome and construct a sound plan to manage that situation. The plan can be modified as needed to achieve maximum results. As time progresses and greater comfort using these sounds has been achieved, patients can apply these strategies to other troublesome situations.10 One of the key elements of PTM is that the patient plays a very active role in identifying problems and contributing input on ways to best manage these concerns. They take a very hands-on approach to any lifestyle changes and what sounds are best for them in helping to alleviate their tinnitus. Having the capability to wirelessly stream the sounds that are most therapeutic and beneficial to their progress puts the user in control, which is consistent with the practices of PTM.
Most ear-level devices offer only white noise or proprietary sound files that may not always be preferred by a user, or may not be an appropriate sound source for a particular tinnitus management plan. By having the ability to wirelessly stream different types of environmental, music, or speech sounds using today’s advanced technology, users can truly customize and optimize the PTM management program.
It is important to note that there are multiple effective programs to treat tinnitus. It is not the intention of this article to recommend one treatment program over another, but rather to offer insight into the role sound plays in these different treatment programs, and how wireless streaming capabilities offer a unique flexibility never seen before. Note that the requirements of using sound can vary greatly from treatment to treatment, but the ability to wirelessly stream different sound signals allows hearing health professionals to maximize any treatment program to accommodate the unique needs of each individual tinnitus patient.
Correspondence can be addressed to HR or Michael Piskosz, MS, at .
- Davis A, Refaie AE. Epidemiology of tinnitus. In: Tyler R, ed. Tinnitus Handbook. San Diego: Singular; 2000:1-23.
- Jastreboff PJ, Hazell JWP. Treatment of tinnitus based on a neurophysiological model. In: Vernon JA, ed. Tinnitus Treatment and Relief. Needham Heights, Mass: Allyn & Bacon; 1998:201–217.
- Tyler R, Kochkin S, Born J. MarkeTrak VIII: The prevalence of tinnitus in the United States and the self-reported efficacy of various treatments. Hearing Review. 2011;18(12):10-26. Available at: www.hearingreview.com/issues/articles/2011-11_01.asp.
- Piskosz M, Kulkarni S. An innovative combination device to assist in tinnitus management. Hearing Review. 2010;17(11):26-30. Available at: www.hearingreview.com/issues/articles/2010-10_04.asp. Accessed January 20, 2012.
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- Del Bo L, Ambrosetti U, Bettinelli M, Domenichetti E, Fagnani E, Scotti A. Using open-ear hearing aids in tinnitus therapy. Hearing Review. 2006;13(9):30-32. Available at: www.hearingreview.com/issues/articles/2006-08_05.asp.
- Parazzini M, Del Bo L, Jastreboff M, Tognola J, Ravazzini P. Open ear hearing aids in tinnitus therapy: an efficacy comparison with sound generators. Int J Audiol. 2011;50(8):548-553.
- Henry JA, Rheinsburg B, Zaugg TL. Comparison of custom sounds for achieving tinnitus relief. J Am Acad Audiol. 2004;15(8):585-598.
- Jastreboff PJ, Hazell JWP. Tinnitus Retraining Therapy: Implementing the Neurophysiological Model. Cambridge, UK: Cambridge University Press; 2008.