Overview of tinnitus

including the role of hearing aids in tinnitus management

A presentation for ENT specialists

PIP_Tinnitus_Presentation V1.00/2014-03/XPl Phonak AG / uncontrolled copy

28.08.15

Slide 1

Objectives
To describe the key features of tinnitus
To show how tinnitus is a substantial health burden
To reveal the role of hearing loss in tinnitus
To present the options for management, including the central role of hearing aids

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Slide 2

What is tinnitus?
Perception of sound but no external source
Usually experienced as buzzing, hissing or

ringing

Not fully-formed sounds

e.g. speech or music

Not sound hallucinations experienced

during bouts of mental illness

Occurs in one or both ears, or arising

within the head

It can have a profound effect on the sufferer

perceived severity of tinnitus

correlates closer to psychological and
general health factors, such as pain or
insomnia, than to audiometrical
parameters
(Zoger et al, 2006)

Langguth B, et al. (2013) Lancet Neurol.12:920-930; Zger S et al. (2006) Psychosomatics. 47:282-288.

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Slide 3

Sound features of tinnitus

Sounds experienced in tinnitus can vary according to several criteria:
NOISE CRITERIA

POSSIBLE FEATURES

Onset

Sudden, gradual

Pattern

Pulsatile, intermittent, constant, fluctuating

Site

Right or left ear, both ears, within head

Loudness

Wide range, varying over time

Quality

Pure tone, noise, polyphonic

Pitch

Very high, high, medium, low

Langguth B, et al. (2013) Lancet Neurol.12:920-930.

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Slide 4

Evaluating tinnitus severity

Tinnitus is highly variable. Some patients

At the other extreme, some patients suffer

are able to cope with the noise and their

lives continue as normal.

so much that daily living is difficult and

they are unable to work. Others suffer a
level of impairment between these two
levels.

Langguth B, et al. (2013) Lancet Neurol.12:920-930.

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Slide 5

The burden of tinnitus

SCALE OF
PROBLEM

IMPACT

TINNITUS RISK
FACTORS

A GROWING
PROBLEM

Tinnitus affects

Tinnitus limits

Hearing

Increasing size

10%15% of the
general
population
worldwide
This is an

estimated 280
million people

daily living in
1%2% of
people with
tinnitus

impairment
Increasing age

of the elderly
population

Gender (male)

Frequency of

Exposure to

noise

Geocze L, et al. (2013) Braz J Otorhinolaryngol.79:106-111; Langguth B, et al. (2013) Lancet Neurol.12:920930; Roberts LE, et al. (2010) J Neurosci. 30:14972-14979.

noise exposure
in work and
leisure
environments

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Slide 6

Peripheral events lead to central neurological changes

A range of peripheral events can lead to central neuronal changes that manifest as tinnitus
Other factors can be involved in either the development or the persistence of tinnitus

HEARING LOSS
CENTRAL
NOISE TRAUMA

AUDITORY
PATHWAY

OTOTOXIC
DRUGS

TINNITUS ONSET

TINNITUS
PERSISTENCE

NEURONAL
ABNORMALITIES

AUDITORY
NERVE
ABNORMALITIES
Langguth B, et al. (2013) Lancet Neurol.12:920-930.

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Slide 7

Brain response to auditory deprivation

Patients with tinnitus exhibit enhanced auditory sensitivity
DECREASED
SOUND INPUT

INCREASED
SOUND
SENSITIVITY

This is caused by hyperactivity of the auditory central nervous system

Homeostatic pathways cause increased central gain (i.e. sensitivity) in response to

auditory deprivation to:

1. Maintain
2. Ensure

central nervous system activity during low sensory input

nerve activity is modulated to respond to changes in sensory input

In patients with tinnitus and hearing loss, the tinnitus pitch and the hearing loss frequency

spectrum are usually matched

Hebert S, et al. (2013) J Neurosci 33:2356-2364; Langguth B, et al. (2013) Lancet Neurol.12:920-930; Norena
AJ, Farley BJ. (2013) Hearing Res 295:161-171.

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Slide 8

Tinnitus is a balance of sensory input and spontaneous

activity
The decreased input from the cochlea, due to outer hair cell damage, results in
readjustments in the central auditory system resulting in abnormal neural activity including
hyperactivity, bursting discharges and increases in neural synchrony.

AUDITORY
DEPRIVATION
AND CENTRAL
GAIN

ALTERED
SPONTANEOUS
NEURONAL
ACTIVITY

TINNITUS

Norena AJ, Farley BJ. (2013) Hearing Res 295:161-171.

Kaltenbach JA. (2011) Tinnitus: models and mechanisms. Hear Res. June; 276 (1-2) : 52 60.

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Slide 9

Tinnitus and hearing loss

Most patients with tinnitus have some degree of hearing loss

75%90%
OF PATIENTS
WITH
OTOSCLEROSIS
HAVE TINNITUS

ABOUT 80%
OF PATIENTS
WITH IDIOPATHIC
SENSORINEURAL
HEARING LOSS
HAVE TINNITUS

Hearing loss is a hidden disability and to

have tinnitus is sort of like a double
whammy
Family physician with moderate tinnitus, Canada

Axelsson A, Ringdahl A (1989) Br J Audiol 23:53-62; Ayache D, et al (2003) Otol Neurotol 24:48-51; NosratiZarenoe R et al (2007) Acta Otolaryngol 127:1168-1175; Sobrinho PG et al. (2004) Int Tinnitus J 10:197-201;
Schaette R et al. (2012) PLoS One 10.1371/journal. pone.0035238.

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Slide 10

Tinnitus and distress: a vicious cycle

Experiencing sound in the absence of an external stimulus can be emotionally upsetting
This reaction can make the sounds appear worse
This results in a vicious cycle of worsening tinnitus and increasing distress

TINNITUS

EMOTIONAL
DISTRESS

Schaette R. (2012) Phonak Focus 42.

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Slide 11

Other psychological associations with tinnitus

Tinnitus is associated with increased levels of psychological problems

24/90 (26.7%) versus 5/90 (5.6%) for age-matched controls without tinnitus

HYPOCHONDRIA

HYPERACUSIS

ANXIETY

TINNITUS

COGNITIVE
IMPAIRMENT
Andersson G, McKenna L. (2006) Acta Otolaryngol Suppl. 556:39-43; Belli H, et al. (2012) Gen Hosp
Psychiatry. 34:282-9; Jackson J, et al. (2013) Int J Audiol. E-pub ahead of print; Langguth B, et al. (2013)
Lancet Neurol.12:920-930.

DEPRESSION

SLEEP
PROBLEMS
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Slide 12

Anxiety and depression correlate with severity of tinnitus

TINNITUS (ALL SEVERITIES),
N=80

HIGH-RISK OF CHRONIC,
DISABLING TINNITUS, N=144

Current minor depression (SCID)

0.42

<0.0001

0.43

<0.0001

Major depression (SCID)

0.41

0.0002

0.39

<0.0001

Current anxiety disorder (SCID)

0.12

NS

0.28

0.0010

0.01

NS

0.26

0.0023

0.42

<0.0001

0.48

<0.0001

Depression (HADS)

0.30

0.0079

0.38

<0.0001

Anxiety (HADS)

0.35

0.0018

0.45

<0.0001

Total (HADS)

0.36

0.0014

0.46

<0.0001

Current multiple anxiety disorders

(SCID)
Current depression and/or anxiety
disorders (SCID)

r = correlation coefficient between severity of tinnitus and prevalence of depression and anxiety (higher r = stronger correlation)
HADS: Hospital Anxiety and Depression Scale; NS: non statistically significant; SCID: Structured Clinical Interview for DSM-III-R

Zger S et al. (2006) Psychosomatics. 47:282-288.

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Slide 13

Other tinnitus-associated problems

SLEEP PROBLEMS

COGNITIVE
IMPAIRMENT

HYPERACUSIS

Sleep disturbance is

Patients with tinnitus can

Hyperacusis is an

common in patients with

tinnitus
In particular, the time taken

to achieve sleep may be

lengthened in tinnitus
patients
Insomnia and tinnitus-

associated distress can work

together in a worsening
spiral to adversely affect
psychological wellbeing

exhibit depressive
functioning and/or anxious
vigilance
Cognitive performance can

be worse among tinnitus

sufferers versus controls in
the absence of depression
and anxiety

oversensitivity to certain
sound frequencies or
volumes
It is common among tinnitus

sufferers and may be a

consequence of tinnitus
In an age-matched control

study, 60% of tinnitus

sufferers reported
hyperacusis, compared to
20% of controls
Hyperacusis is measureable

in tinnitus ears with and

without hearing loss
Andersson G, McKenna L. (2006) Acta Otolaryngol Suppl. 556:39-43; Bastos de Magalhaes SL, et al. (2003) Int Tinnitus J. 9:79-83; Belli H, et al. (2012) Gen
Hosp Psychiatry. 34:282-9; Hebert S, et al. (2013) J Neurosci. 33:2356-2364; Jackson J, et al. (2013) Int J Audiol. E-pub ahead of print; Langguth B, et al. (2013)
Lancet Neurol.12:920-930; Wallhusser-Franke E, et al. Sleep Med Rev. 17:65-74.

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Slide 14

Tinnitus management options

Currently, there is no cure for tinnitus, but management is possible

EVIDENCE BASED
TINNITUS
MANAGEMENT
APPROACHES
e.g. TINNITUS
RETRAINING THERAPY

HEARING AIDS

DRUGS

TINNITUS

SOUND THERAPY

Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Langguth B, et al. (2013) Lancet Neurol.12:920-930;
Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762

COUNSELLING

COGNITIVE
BEHAVIOURAL
THERAPY
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Slide 15

Hearing aids are central to tinnitus management

Reports of the use of hearing aids in the

management of tinnitus go back over 60

years
Because hearing loss is often associated

with tinnitus, at least partial restoration of

hearing should help to reduce the central
gain in auditory perception that is a feature
of tinnitus
A recent scoping review of studies of

hearing aids in tinnitus revealed that 17/18

publications showed improvements in
tinnitus symptoms by fitting hearing aids

The majority of studies reviewed

support the use of hearing aids for
tinnitus management. Clinicians
should feel reassured that some
evidence shows support for the
use of hearing aids for treating
tinnitus
Shekhawat et al, 2013

Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762

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Slide 16

Interventional studies of the benefits of hearing aids

A scoping review identified 11

interventional studies of hearing aids

Six types of tinnitus evaluation were used:

THI x 4; THQ x 1; TRQ x 1; TSI x 1; TQ

x 1; VAS x 3

Up to 50% reduction in tinnitus severity

10/11 studies showed improvements

>10%

Tinnitus measurement tool

THI: Tinnitus Handicap Inventory; THQ: Tinnitus Handicap Questionnaire; TRQ:
Tinnitus Reaction Questionnaire; TSI: Tinnitus Severity Index; TQ: Tinnitus
Questionnaire; VAS visual analogue scale (various)

Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762

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Slide 17

Patient and hearing-care professional surveys of the benefits of hearing

aids
Scoping review identified 4 survey studies
STUDY 1

STUDY 2

STUDY 3

STUDY 4

Binaural hearing

65.5% of

Fitting a hearing

Audiologist-

aids provided
benefit in 66%
(47/71) of
tinnitus patients

patients with
frequent tinnitus
reported
improvements
with hearing aids
41.4% reported

disappearance of
symptoms

Shekhawat GS, et al. (2013).J Am Acad Audiol. 24:747-762

aid was the most

frequently
reported benefit
of visiting a
specialised
tinnitus clinic
Reported by

34.9% of
patients

reported tinnitus
relief after fitting
a hearing aid

Minor to major
relief in 60% of
cases

Major relief in
22% of cases

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Slide 18

Masking level and tinnitus reduction

Retrospective study of 70 patients with

tinnitus in Australia
Tinnitus severity measured using the

tinnitus reaction questionnaire (TRQ)

Overall, 51% of patients experienced

clinically significant change (40%

change in TRQ score)

McNeill C, et al. (2012) Int J Audiol. 51:914-919.

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Slide 19

Psychological and behavioural support

INTERVENTION

DESCRIPTION

Counselling and
education

Delivered in person, to groups and via the internet

Variable results may depend on personal characteristics

Designed to modify maladaptive behavioural and emotional

responses
One-to-one and group settings, delivered by psychologists or
psychiatrists, or via internet
Statistically significant reductions in severity of tinnitus symptoms
(P<0.05)

Cognitive
behavioural
therapy

Relaxation therapy

May help reduce tinnitus symptoms and depressive symptoms

Hoare DJ, et al. (2011) Laryngoscope 121:1555-1564; Langguth B, et al. (2013). Lancet Neurol.12:920-930

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Slide 20

Drug options for tinnitus management

DRUG CLASS

EXAMPLES OF DRUGS USED IN TINNITUS

Antidepressants

tricyclics, selective serotonin reuptake inhibitors

Antipsychotics

sulpiride

Mood stabilisers

gabapentin, valproate

Sedatives/hypnotic
benzodiazepines
s
No approved drugs (European Medicines Agency [EMA] or US Food and Drug

Administration [FDA])
Some psychopharmacological agents may help reduce the severity of psychological issues

associated with tinnitus, and some may also lessen tinnitus symptoms

Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Langguth B, et al. (2013) Lancet Neurol.12:920-930

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Slide 21

The need for multidisciplinary care

Tinnitus management should include hearing aids with appropriate frequency ranges

together with psychological support and education

This requires a multidisciplinary care team

GP, ENT specialist, psychologist/psychiatrist and hearing-care professional

As a leading supplier of hearing aids, Phonak can be another member of your team,

helping your patient to have the optimal hearing aid for their situation

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Slide 22

Thank you.

Contact information
Phone:
Email:
Website:

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Slide 23