Tinnitus: what a GP needs to know

An audiologist sums up tinnitus facts, red flags, causes/risk factors, therapy, online resources – and what not to tell your patients.

---

Please do not tell your patients there is no cure for tinnitus or advise them to learn to live with it.

For tinnitus patients who are anxious and distressed, these all too common responses by medical professionals serve to invalidate what can be a frighteningly catastrophic and traumatic experience.

Although neuroscience research has not (yet) been able to stop tinnitus emergence in the brain, informing patients that tinnitus is a common and benign neurological phenomenon while referring for audiological assessment provides validation and reassurance.

Effective tinnitus therapy can provide significant benefit and is available from some audiologists and psychologists. All audiologists are trained to provide tinnitus guidance and support, and can recommend tinnitus therapy providers, if needed.

Tinnitus Facts

• Tinnitus is the perception of sound without any external source.
• Tinnitus can be constant or intermittent; it can be heard as a tone or a more broadband sound; it can be a single sound or a complex series of sounds.
• Tinnitus can be perceived in one ear, both ears or in the head. Some people perceive it as an external sound.
• Most commonly, tinnitus is subjective, due to “aberrant” neural activity generated in the central auditory system and interpreted by the brain as sound(s). Less commonly, tinnitus is objective, faintly audible to others and due to a mechanical source within the body. This article will focus predominantly on subjective tinnitus.
• Tinnitus is considered to be associated with a change of hearing or cochlear damage, which may not necessarily be detected by a standard audiogram. As a neurological phenomenon, tinnitus can persist even when a change in hearing is temporary.
• Tinnitus can be influenced by somatosensory movement of the head, neck or jaw.
• Tinnitus can be heard by 90%+ of the population with attentive listening in silence¹ so is actually an enhanced naturally occurring phenomenon.
• 15-20% of people report constant tinnitus.
• Habituation is the process by which the brain subconsciously filters away frequent background, non-threatening sensory input. Most people with tinnitus spontaneously habituate to their tinnitus over time.
• About 2% report their tinnitus is distressing. Why do some people become distressed while others habituate to their tinnitus without much effort?

Tinnitus in children is common:²

• 12 – 36% of children with normal hearing and up to 66% of children with a hearing loss report tinnitus.
• Sleep in children with tinnitus is affected in 38 – 79% of cases.
• Half of all children reporting tinnitus have had difficulties with attention, concentration and listening to teachers².
• One third of children reporting tinnitus had a possible or probable emotional/anxiety disorder².

Ideally, ask all children attending with fluctuating middle ear pathology or hearing concerns whether they hear noises in their ears or head, and, if so, does it bother them.

Red flags for GPs³

Indications for referral:

• Pulsatile tinnitus
• Tinnitus associated with significant vertigo
• Unilateral tinnitus
• Tinnitus associated with an asymmetric hearing loss
• Tinnitus causing significant psychological distress
• Tinnitus in association with significant neurological symptoms and/or signs

Although many tinnitus patients do not fit into any of these categories, clinicians involved in tinnitus care are firmly of the opinion that all patients with these symptoms should at the very least receive an audiological assessment.³ Unilateral tinnitus, particularly with an asymmetric sensorineural hearing loss, should be referred for an ENT specialist investigation to exclude acoustic neuroma/vestibular schwannoma.

Tinnitus causes and aggravating/risk factors:

• Hearing loss, change in hearing, noise damage. In adults, exposure to sudden or prolonged sounds is the most commonly reported factor related to the onset of tinnitus.
• Outer/middle ear/inner pathology, which can affect the hearing eg. wax against the tympanic membrane, otitis media, Meniere’s Disease.
• Neurological conditions, head injury eg. acoustic neuroma, migraine.
• Medications: ototoxic drugs, including some chemotherapy drugs, some SSRIs.
• Somatosensory triggers can cause/aggravate tinnitus eg bruxism, jaw clenching, TMJ dysfunction, neck problems, whiplash etc.
• Stress, anxiety, depression, fatiguewill exacerbate tinnitus prominence, intensity and restrict spontaneous tinnitus habituation.
• Hyperacusis is an abnormal sensitivity or intolerance (a heightened sense of volume and physical discomfort) to everyday loud/impact sounds. Hyperacusis is due to an involuntary sense of threat from those sounds, often from anxiety that they may exacerbate pre-existing aural symptoms such as tinnitus or hearing loss, or cause damage or be painful. Large-scale prevalence research has identified the development of hyperacusis in about 50% of help-seeking tinnitus patients^3,4.
• Pre-existing misophonia, which is an involuntary, strongly aversive response to certain specific sounds, irrespective of their volume. It may develop when those trigger sounds become perceived as an intolerable intrusion into one’s sense of personal space. Exposure to trigger sounds in people affected by misophonia can result in excessively high levels of annoyance, anger and intrusion.
• Tonic Tensor Tympani Syndrome (TTTS) is an involuntary myoclonus which can develop in the tensor tympani muscle in the middle ear, causing a range of symptoms in and around the ear from the resultant tympanic membrane tension, alterations in middle ear ventilation and, in severe cases, trigeminal nerve inflammation. Most common symptoms are a sensation of aural blockage, objective humming/buzzing tinnitus, dull earache, a sharp stabbing aural pain and tympanic membrane flutter.^5-10 TTTS symptoms can be easily misdiagnosed as Eustachian tube dysfunction.

Almost 70% of patients with severe tinnitus and more than 90% of patients with severe tinnitus and hyperacusis report one or more symptoms consistent with TTTS.⁵  TTTS symptoms in these patients appear to be induced as a primary phenomenon from a central nociceptive ‘protective’ response to sounds or other stimuli subconsciously perceived as potentially aggravating their tinnitus, or potentially painful or potentially threatening/damaging to their ear/hearing.^5,6

TTTS is also considered to be the major cause of referred symptoms in and around the ear in patients with TMJ dysfunction.¹⁰

Where to refer your tinnitus patients

A list of therapy providers will become available on the Tinnitus Australia website https://www.tinnitusaustralia.org.au/. Tinnitus Australia is an emerging and growing group made up of different health professionals and people with tinnitus, who are dedicated to providing a comprehensive tinnitus information resource for medical/health professionals and the public, as well as providing training programs and webinars for clinicians. Tinnitus Australia is being modelled on, and works collaboratively with the British Tinnitus Association.

The aim of tinnitus therapy is to reduce the negative emotions associated with tinnitus, reduce tinnitus distress and promote habituation. Achieving a more satisfactory level of tinnitus habituation will reduce both tinnitus prominence and intensity.

An overview of tinnitus therapy

Clinical evaluation of tinnitus:

Commonly used audiological measures include:

• Tinnitus frequency match
  • Tinnitus volume match at the tinnitus frequency
  • Minimum masking level

Measures can validate the patient’s experience but tinnitus is a neural signal so does not readily conform to acoustic measures. Tinnitus loudness and other sensory characteristics of tinnitus do not correlate with tinnitus severity.

Tinnitus severity is the adverse effect the tinnitus has on the patient’s life. There are a range of questionnaires designed to investigate these effects in detail. The Tinnitus Reaction Questionnaire (TRQ)¹¹ used in our clinic was developed and normed in Australia and correlates with the Beck Depression Inventory and the State-Trait Anxiety scale.

At our clinic, we evaluate from a psychological perspective why a person hasn’t spontaneously habituated to their tinnitus. Our aim is to triage the guidance and support required for our patients to be ready and open for a self-managed habituation process. For some, acknowledging and sitting with the trauma of their tinnitus onset or escalation using an Acceptance and Commitment Therapy (ACT) approach is needed before any process can commence. In extreme cases, an adjustment disorder, causing patients to freeze and lock them in a persistent state of distress, can develop, requiring appropriate psychological/psychiatric referral and diagnosis. Treatment may not be effective so, sadly, some patients are not ever able to become ready for tinnitus habituation therapy.

Personalised explanation of tinnitus, tinnitus perception and tinnitus reaction

For most patients, once they are able to understand how their brain evaluates and filters sounds (including tinnitus) subconsciously in the central auditory pathway, the links with their limbic system and how their thoughts/beliefs may have influenced their tinnitus experience, they have a possible pathway for reversal of a strong tinnitus reaction.  

Habituation strategies

• If a hearing loss is present, amplification from hearing aid fitting supports both a hearing loss and reduces tinnitus awareness.
• Sound enrichment: tinnitus is more noticeable in silence. The use of low volume broadband sounds (eg white noise, sea/rain sounds) day and night, with no need for attentive listening, is recommended. The rationale is not to mask the tinnitus, but “fill in the silence” taking the edge off the tinnitus, at both an auditory and neurological level.
• CBT strategies address fears and challenge inappropriate beliefs about tinnitus.
• Active distraction strategies to reduce hypervigilance to tinnitus (and external sounds with hyperacusis patients).

Sleep Management: sleep hygiene, sound enrichment and tinnitus distraction strategies.

Stress management

High levels of distress and fatigue may make it difficult for a patient to absorb information and implement proactive self-management strategies.

• Stress/panic management: breathing techniques; imagery; active relaxation; mindfulness training; Acceptance and Commitment Therapy (ACT)
• Trauma management: the tinnitus can be a reminder of a traumatic event (eg MVA, head injury); the tinnitus experience can be so distressing it is a traumatic event
• Grief counselling for loss of a perceived healthy body image; acknowledgement and management of suffering. Hyperacusis patients struggle with sounds in the environment being pervasive, unavoidable and unpredictable. Significant hyperacusis will result in distress and suffering from sound-induced pain and lifestyle/social/employment constraints.

Referral to a psychologist is indicated for patients with significant symptoms of anxiety, depression, PTSD, critical incident stress or adjustment disorder.

GP Resources

• Tinnitus Australia https://www.tinnitusaustralia.org.au/
• British Tinnitus Association (BTA): https://www.tinnitus.org.uk/
• BTA guidelines for GPs: https://www.tinnitus.org.uk/guidance-for-gps
• iCBT is a comprehensive free online self-help CBT program for Tinnitus, the result of collaborative work between UK audiologists, hearing scientists and clinical psychologists based on clinical practice and research. www.icbt4tinnitus.com
• Tinnitus Association of Victoria (TAV) is a support group and website provides advice https://www.tinnitus.org.au/
• Tinnibot – a tinnitus support app currently in development, provides access to an 8 week CBT program and soundscapes, with the potential to link to local psychological support, chatbot and online support groups.
  • On apple store: https://apps.apple.com/au/app/tinnibot/id1510756641
  • On google play: https://play.google.com/store/apps/details?id=com.tinnibot
• Joey Remenyi is a vestibular audiologist who provides an online therapy program: https://www.seekingbalance.com.au/. She utilises CBT, ACT and mindfulness therapy, emphasising neuroplasticity concepts and drawing on her own lived experiences with tinnitus and vertigo, as well as her background as a yoga practitioner and teacher. Her recent book: Rock Steady: Healing Vertigo or Tinnitus with Neuroplasticity
• Inner Ease Tinnitus Centre. Dani Fox is an audiologist, qualified teacher and yoga and meditation teacher. She provides an online mindfulness meditation course for tinnitus and other sound intolerances: 4d89ee_f51f34b8c5e14c7bb8b666a7b01d5937.pdf (filesusr.com)
• Resources for medical practitioners: Resources for Medical Practitioners | Inner Ease Tinnitus Centre
• T-Minus is a free app that has been developed by a musician with tinnitus, with input from audiologists, using tinnitus retraining, masking, music and fractal tones to create a unique library of tinnitus therapy tracks. T-Minus also features audio and masking controls and contains news, links, tips for managing tinnitus and FAQ
• Hyperacusis desensitisation progam: Hyperacusis & Misophonia – DWM Audiology
• Cima, R.F.F., Mazurek, B., Haider, H. et al. A multidisciplinary European guideline for tinnitus: diagnostics, assessment, and treatment. HNO 67, 10–42 (2019). https://doi.org/10.1007/s00106-019-0633-7

References

1. M.F Heller and M Bergman. Tinnitus Arium in normally Hearing Persons. Annals of Otology, Rhinology & Laryngology 62, no 1 (1953): 73-83, https://doi.org/10.1177/000348945306200107
2. Tinnitus in Children – A Medical Perspective. Dr Veronica Kennedy (UK Consultant Audiovestibular Physician) http://bapa.uk.com/userfiles/Veronica%20Kennedy%20Tinnitus%20in%20Children%20-%20Medical%20%20Perspective%20BAPA%20Jan%2016.pdf
3. British Tinnitus Association guidelines for GPs: https://www.tinnitus.org.uk/guidance-for-gps
4. Schecklmann M, Landgrebe M, Langguth B, the TRI Database Study Group (2014) Phenotypic Characteristics of Hyperacusis in Tinnitus. PLoS ONE 9(1): e86944.
5. M Westcott et al. Tonic Tensor Tympani Syndrome (TTTS) in Tinnitus and Hyperacusis Patients: A Multi-Clinic Prevalence Study. Noise and Health Journal, Mar-Apr 2013, Volume 15, Issue 63 pp117-128.
6. Westcott M: “Middle Ear Myoclonus and Tonic Tensor Tympani Syndrome”. Chapter in “Tinnitus: Clinical and Research Perspectives” edited by D M Baguley, M Fagelson, Plural Publishing Inc, 2015.
7. Noreña AJ, Fournier P, Londero A, Ponsot D, Charpentier N. An Integrative Model Accounting for the Symptom Cluster Triggered After an Acoustic Shock. Trends Hearing 2018 Jan-Dec; 22: 2331216518801725
8. Bance M, Makki FM, Garland P, Alian WA, van Wijhe RG, Savage J. Effects of tensor tympani muscle contraction on the middle ear and markers of a contracted muscle. Laryngoscope 2013;123:1021Y7.
9. Aron M, Floyd D, Bance M. Voluntary Eardrum Movement: A Marker for Tensor Tympani Contraction? Otol Neurotol. 2014 Apr 19. [Epub ahead of print]
10. Ramirez LM, Ballesteros LE, Sandoval GP. Topical Review: Temporomandibular disorders in an integral otic syndrome model. Int J Audiol 2008: 47(4): 215-227
11. Wilson P H, Henry J, Bowen M, Haralambous G. Tinnitus Reaction Questionnaire: Psychometric Properties of a Measure of Distress Associated With Tinnitus. J Speech Lang Hear Res, February 1991, Vol. 34, 197-201. doi:10.1044/jshr.3401.197