This document is intended for two groups of audiologists

• Those having special interests in or responsibilities for patients with troublesome tinnitus.
• Those who may only occasionally be asked about tinnitus: if you are in this group, please read the summary advice on the last two pages.
  

   

  Introduction

  Over the last 15 or so years there have been some important developments in the understanding of tinnitus. Collectively, they have led to perhaps the most plausible and therapeutically helpful trains of theory explaining the mechanisms of generation of tinnitus, the distress it sometimes causes and how this can be reduced. These have been combined by Jastreboff into his neurophysiological model¹ of tinnitus. The critical difference between this model and most of its predecessors is the emphasis it places on the central nervous system as the main factor governing whether or not the tinnitus causes distress.

  In this document we give much consideration to the Jastreboff model and its clinical applications^2,3,4. This is because it is a major contributor to the new developments referred to. However, this does not mean that this model is necessarily the most correct description of tinnitus mechanisms: or that NBM or TRT relegates other forms of counselling or management to second-class treatment. Indeed, in suitably skilled hands, other forms of psychological counselling and treatments of similar duration are similarly effective. On the other hand, by comparison, most physical or “interventionalist” treatments have been disappointing. Nevertheless, for completeness, this document will include a brief review of their current status.

  Arising from this model is a management strategy, which we will refer to as Neurophysiologically-Based Management (NBM). The original, but now very restrictively defined, form of NBM is known as Tinnitus Retraining Therapy (TRT)⁴. NBM and TRT have the objective of reducing both the distress associated with tinnitus and the perception itself. As a form of systematic, repeated and skilled counselling over a long period, the evidence for their high degree of effectiveness is mounting^3-5 although as yet the data are not specific to any of the particular components of such therapy. We consider this general line of management to offer a much more effective and logical means of helping people with tinnitus than has been available in most ENT and audiology clinics up to about 1995.

  A repeat attendance, 12-36 month regime of NBM or of TRT is only needed by quite a small minority of people with tinnitus, perhaps the 10% or so who are severely troubled by it according to epidemiological data⁶ or as few as

  1-5%⁷ 5%⁸ or 9%⁹ according to clinical studies. However, many of the therapeutic concepts arising from the neurophysiological model of tinnitus are also very pertinent to the advice to be given to people with less than severe tinnitus. We will therefore describe here the principal features of the model so that they can be utilised by audiologists for all people with tinnitus, whether the patient is seen as a tinnitus referral or just incidental.

  The model would additionally be appropriate as a basis for counselling given by general practitioners, nurses and lay counsellors. It could also provide a more helpful approach for what is said by family and friends of those with tinnitus and by journalists and the media: audiologists may at times be able to influence beneficially the information and advice these people give.

  Finally, to prevent any misunderstanding, we wish to explain that our use of the term “audiologists” refers to all professional groups concerned with hearing disorders, including audiological physicians and scientists and private hearing aid dispensers, but particularly the two groups in the National Health Service most commonly involved in tinnitus management – hearing therapists and medical technical officers (audiology).

   

   

  Mechanisms of Tinnitus

  Many disorders which involve the auditory system directly or indirectly can lead to the emergence of tinnitus. Troublesome tinnitus is commonly associated with hearing loss¹⁰ and traditional teaching has been that tinnitus generation is usually due to pathology in the ear. Often it is, but sometimes the pathology is more central. In yet other cases, it is due to detection of normal auditory neuronal noise¹¹ or of normal or abnormal mechano-acoustic vibrations in the body, which have since 1981 been termed somato-sounds¹².

  Interpretation of neuronal signals

  The normal mechanism of hearing is that the brain interprets, as a sound, any change of rate or pattern in the continuous incoming stream of cochlear neuronal signals. Such changes are usually the result of external sounds. A continuous alteration occurs when there is a cochlear disorder, and this can lead to the sensation of tinnitus, arising either spontaneously or as a result of some triggering event. However, if the change in background neural activity is sufficiently slow, the brain has a chance to adapt to the new pattern, unless or until some other factor upsets the adaptation process and triggers the onset of tinnitus.

  Triggers may be some form of trauma directly affecting the ear: or they may be something quite trivial such as a perfectly normal ear syringing, or something not obvious related to the ear such as an emotional upset.

  When a pathological ear is the generator, it used to be assumed that the severity of the tinnitus depended on the loudness or other psychoacoustic characteristics of the abnormal signal coming from the ear – the “otocentric” concept of tinnitus generation, severity and treatment. However, in most cases, both theory¹ and from therapeutic experience and clinical observations, the central processing of these neuronal signals is now thought to be much more important than the characteristics of the abnormal neuronal signals generated by the ear. What matters in the detection of the abnormal tinnitus-related neuronal signals in the auditory pathways is the response of the CNS. This detection process may be further influenced by the patient’s evaluation of the meaning of the tinnitus perception. This is most commonly the critical factor leading to tinnitus distress and then maintaining or increasing it.

  Occasionally the cause of the tinnitus or an exacerbating factor is amenable to treatment. Otherwise, the prime need is to alter the patient’s reaction to the tinnitus and his beliefs about it.

  The vicious circle

  Tinnitus is a real sensation, but of oto-neurological origin. While it is not a psychological disorder, the problems it causes are in the psychological domain. These include anxiety concerning its cause, prognosis and feared influence on lifestyle and work. Tinnitus can also cause or exacerbate tension, frustration, loss of concentration, sleep disturbance and depression. These, often together with over-attention to the tinnitus, set up vicious circles of increasing tinnitus, which in turn cause greater anxiety, thereby increasing the tinnitus and so on, as illustrated in the diagram

   

  

   

  In addition, pre-existing or coincident psychological and emotional problems may lead to an increased perception of the tinnitus and anxiety about it, as also can external stresses. Patients may need assistance for these circles to be reversed, by appropriate information, counselling and support. Some degrees of habituation usually occur spontaneously but the traditional approach of telling patients that nothing can be done about tinnitus, and that it inevitably continues and has to be “put up with”, can have a devastating effect on this possibility. Clinicians, among them audiologists, have thus sometimes been responsible for worsening the effects of tinnitus.

  Jastreboff’s Neurophysiological Model

  The most important features of Jastreboff’s model¹ and its clinical applications, which we believe can be utilised beneficially in counselling all people with tinnitus, including the following:

   

• Although the ear is probably the most common source of disorder that generates the abnormal train of neuronal signals that under lie most forms of tinnitus, it is usually unimportant with respect to the “severity” of the tinnitus, ie the extent and nature of its adverse effects on the patient.
• The degree of distress depends on the way in which the neuronal signal is processed in the brain, including parts of it outside the auditory system.
• This process involves neuronal networks and filters responsible for selective hearing.
• These networks and filters have plasticity. This means they can react, sometimes as a form of conditioned response, to the apparent potential threat of any new of strange sound. This enhances the detection of such new patterns of auditory neuronal signal.
• In turn, the links between the central auditory pathways and the limbic and autonomic nervous systems may lead to a variety of unpleasant and physical responses to the new sound.
• These processes can be reversed by appropriate counselling to reduce or remove the anxieties and fears caused by tinnitus.
• As people come to terms with their tinnitus, lose much of their fear of it and learn to reduce the attention they give to their tinnitus, so the neuronal pathways and filter settings change, leading to the gradual habituation to tinnitus which is the general rule. Counselling aims to speed up and enhance the habituation process.
• The counselling must be encouraged, giving confidence, hope and expectation of worthwhile improvement at least and possibly even virtual elimination of tinnitus.
• Habituation can be further assisted by decreasing the tinnitus-to-noise ratio. This may be done by increasing the acoustic input to the patient, either by enriching the patient’s acoustic environment or by reinforcing it by means of wearable sound generating or amplifying instruments or both. Such sound therapy makes it easier for the person to disregard (or filter out) the tinnitus signal.
• Sound therapy also counteracts the big enemy of the person with tinnitus – quietness. In the quiet, and particularly if there is hearing loss, the central auditory system increases its sensitivity in order to detect any faint sounds. This increases the apparent loudness of the tinnitus, and also that of external sounds – thus causing the over-sensitivity to sounds, hyperacusis, which accompanies tinnitus in about 40% of cases.
• If the added sound is loud enough to render the tinnitus sound inaudible, to completely “mask” it, this may delay habituation however. You cannot habituate to something you cannot perceive. Nevertheless, some patients find such masking very helpful, and in others it may be all they want.
  

  Tinnitus Retraining Therapy (TRT)

  As practised ^2,3,4 by its originators, TRT normally involves repeat sessions over six to 24 months, or even longer. It has two main elements: counselling and sound therapy. The counselling is the more important, indeed is essential. The therapy employs techniques that are mostly not new to management and treatment of tinnitus, but entail a methodical, rationalised and prolonged use of them, carried out with explanation of and illustration by Jastreboff’s neurophysiological model.

  Giving the patient information

  As with most other forms of tinnitus counselling neurophysiologically based counselling aims primarily at teaching patients the real meaning of tinnitus. This aims to remove anxiety and inappropriate beliefs about it, and reduces the tendency for tinnitus to be seen as a threat, which view would tend to enhance the persistence and severity of the tinnitus. The initial responsibility for this rests on the otologist, but this has to be repeated and extended by audiological and/or other staff to whom most of the therapeutic work will usually be delegated. In prolonged distress or a period of initial severe distress, the counselling may need to be supplemented or even preceded by anti-depressants, sedative or anxiolytic drugs. The counselling should be a combination of different sorts, tailored to the individual: directive, reactive, person-centred and cognitive.

  Directive counselling aims to impart clear information about the mechanism of hearing and tinnitus and how the tinnitus can be influenced adversely or beneficially.

  Reactive counselling – the practitioner responds to questions and comments by patients about their previous and new experiences with tinnitus.

  Person-centred counselling deals with the stresses on the person concerned, and focuses on their own needs and ways of dealing with problems in their life, many of which may have nothing to do with tinnitus and nevertheless react adversely with it. This kind of counselling brings o the front patients’ own strengths and coping strategies, which may be very individual. Additionally, it is very helpful to use a cognitive form of counselling, which identifies and challenges patient’s unduly gloomy or false beliefs and attitudes. However, if the counsellor tries to encourage the questioning and rationalising of the many fears and false ideas too soon, or without the support of other types of counselling, the patient may resist – apparently wanting their misery acknowledged first before they are ready to dispel their fears.

  Helpful strategies

  Also helpful in such cases is⁽ⁱ⁾ the teaching of distraction and thought-blocking techniques, and avoidance of over-attention to the tinnitus to encourage the breaking of vicious circles,⁽ⁱⁱ⁾ the use of relaxation, sleep and stress management techniques, and⁽ⁱⁱⁱ⁾ the investigation and treatment of underlying emotional disturbances. While assisting in the promotion of habituation, these other techniques often give good symptomatic relief and also help the patient to develop coping strategies. They may be provided within the department by suitably trained audiologists or through other departments and services. Further referral to an appropriate psychological or psychiatric professional may sometimes be indicated. Contact with the local British Tinnitus Association group or with the RNID Tinnitus help line may also be helpful. Useful further assistance can result from appropriate written material and handouts, which are available from the BTA.

  Sound enrichment

  The sound therapy element of TRT or NBM supplements the counselling - by providing background sound at a level just below that of the tinnitus, usually for six to 24 hours per day but particularly during the quietest times of day and night including when asleep. As appropriate for each particular patient, the sound may be delivered by a hearing aid together with added sound in the environment; or more often by a Wearable noise generator (WNG: formerly called “a masker”, but now used just below the completely masking level); or by any of the variety of other non-wearable or environmental sound sources; or by combinations of these.

  It must be stressed that TRT or NBM is not just a palliative, but therapy that aims to enhance the natural processes of habituation and therefore bring lasting benefits. The first stage of this is reduction of the distress caused by the patient’s reaction to the tinnitus, which may be followed later by actual reduction of its perception, eg. of its loudness.

  TRT or not TRT?

  Exactly what does and what does not constitute TRT was until 1998 the subject of considerable uncertainty. However, it now seems best to regard it as the strictly prescribed therapy used by Jastreboff and Hazell, and taught by them in their TRT courses held in the USA and in London, and outlined in the annual four-day European Instructional Courses on Tinnitus and its Management. They insist that TRT requires at least the following components to be fulfilled:

   

• Individual assessment of the patient according to the neurophysiological model
• Categorisation of patients according to the model
• A specific treatment protocol adjusted to each patient individually
• One-to-one directive counselling tailored to each individual case
• Use of sound therapy according to the model, not necessarily involving use of noise generators or hearing aids
• A series of follow up visits involving further individual one-to-one counselling, over a period up to two years. (Editorial note: a single visit, or just one follow-up suffices for some patients; and the treatment given still amounts to TRT according to Jastreboff ⁴ – what he describes as Category 0 patients)
• The ability by the professional to answer all patient’s questions on basis of the neurophysiological model
  

  If not TRT, NBM

  The treatment’s originators ask that the clinical results from anything less than or different from the above should not be quoted as results of TRT. On the other hand, many audiologists now provide related therapies, which they have described as TRT. More correctly they should be described as NBM, but as containing some, most or all of the essential components of TRT.

  Results of TRT and Related Treatments

  Prior to 1998, reports on the outcome of TRT have mainly been anecdotal, though encouraging. However, in 1998 Jastreboff⁴ published results from an uncontrolled series of 152 consecutive patients at the University of Maryland Tinnitus and Hyperacusis Center. In the 129 patients receiving the full treatment, 81% showed significant improvement. The other 23 patients received initial counselling only, of whom only 17% improved. Those other 23 could not really be regarded as an adequate control group though, because their selection was far from random and involved some factors likely to reduce their success rate.

  Data is also available from a study by McKinney et al⁵ carried out at the former RNID Tinnitus and Hyperacusis Centre in London. One hundred and twenty-four patients with little or no hearing loss and no hyperacusis were given TRT over one year. A year later, 75% of them were found to have improved by 40% or more. In addition, their results suggest that WNGs set as close to the volume of the tinnitus as possible without complete masking occurring are more effective than WNGs set at a just audible level, and that directive counselling may be more effective if used in conjunction with WNGs set at the higher of these two levels. At very least, this study strongly reinforces existing belief that prolonged, intensive and skilled counselling is a great help to tinnitus patients, and suggests that sound therapy is a useful adjunct to such counselling.

  Sheldrake et al¹³ also showed good results from repeated counselling, yet only in about three fifths of her cases did this amount to TRT as now defined, the earlier cases having been treated with less specific counselling and with masking. Slightly better results occurred in the later cases but her report gives insufficient detail, eg of possible changes in the amount of counselling and follow-up and in treatment–entry criteria, to permit constructive comparisons to be made between earlier and later treatments.

  Another study of relevance is that of Dineen et al¹⁴ looking at results of four forms of “tinnitus management training” closely related to TRT. Considerable improvements in coping ability and reductions in annoyance and distress were found at follow-up after 12 months. None of the management strategies, namely counselling, relaxation and low-level noise, was more effective than any other. However, low-level noise did appear to influence beneficially the cognitive reaction to tinnitus, though not its actual perception.

  A very different minimal-cost management of tinnitus patients in the NHS has been reported by Windle -Taylor et al (1996)⁸ .The principal ingredient was careful counselling, both directive and person centred, to help the patient to find his/her own solutions through a process of self-examination and a building of awareness. In a cohort study of 100 patients with tinnitus as their primary symptom, at least 60 attained a new state that was acceptable to them.

  There is the pioneering work of Goebel and his colleagues (1998)¹⁵ . One hundred and fifty five chronic tinnitus sufferers were given intensive psychological treatment over 7-12 weeks as in-patients in a specialist clinic. They were compared with 79 waiting list controls who, in fact changed little over the waiting time of around six months. A year after the end of the treatment, 30% of the patients reported more than 20% decrease in tinnitus loudness; 56% indicated a decrease in tinnitus discomfort of more than 20%; and 62% rated their coping ability as improved by more than 20%.

  Most recently, (2002 & 2003)^22,,23,24 Andersson et al in Sweden have carried out three randomised, controlled trials of Internet based cognitive, behavioural therapy for distress associated with tinnitus. The Internet is promising in that it can reach many people at long distances and at low cost.

  Rationale for Neurophysiologically–based Management

  The results quoted above suggest that there is at least something common to TRT and the other reported treatments, which is an effective treatment for a substantial proportion of patients. Nevertheless, as is only to be expected, TRT does not work for all patients, and in many others it is only partially successful. Moreover, what the data do not tell us about TRT is (i) whether it is better than other forms of similarly intensive, prolonged and skilled counselling, (ii) what component(s) of the counselling are critically important, (iii) to what extent the sound therapy component brings additional benefit, and to what extent the details of how this was given may be correct or necessary, and (iv) how much of the neurophysiological theory is either necessary to the treatment or even correct.

  Benefits of counselling

  Putting all this together, it is evident that intensive counselling does benefit many people with tinnitus. But whether it needs to be exactly, or at all, along the lines of the Jastreboff model is unproven. Provided it included the principal points listed in the document, considerable variations on it would probably make little difference, and might even be better. Nevertheless, strict application of the model was of course used in the Hazell, Jastreboff and McKinney studies and in part of Sheldrake’s, and the only certain way of obtaining similarly good results from NBM must be to precisely replicate their TRT counselling and sound therapy procedures. However, to adopt the rigidly now may be unnecessarily laborious, expensive and restricting, as well as inhibiting the possible discovery of variations, or of different therapeutic methods altogether, yielding even better or more cost-effective results. On the other hand, the general concepts of the neurophysiological model are very plausible, more so in the writers’ opinion than most other theories of tinnitus mechanisms. They also offer the therapist, doctor or counsellor a more rationalised, systematised and constructive basis for the management of patients with tinnitus than generally seems to be applied in the NHS or elsewhere.

  The same goes both for sound enrichment in the patient’s general environment, and for its reinforcement by one or two WNGs, hearing aids or both. This probably brings some specific benefit as well as helping the patient to cope: it also provides a good recurrent opportunity for further counselling of the patient. WE therefore recommend that audiologists should embrace the general concepts of the neurophysiological model and utilise them in a flexible way for the benefit of the patients, although not necessarily going as far as to follow the unjustifiably dogmatic strictures and considerable expense¹⁶ of present day TRT. In any event, it must be recognised that the majority of patients with tinnitus seen in audiology departments will only need one session of counselling, together with advice on sound enrichment and reinforcement, and hearing aiding if applicable. This is equivalent to Jastreboffs ⁴ treatment Category 0, ie those with only slightly troublesome tinnitus. Less than about 10%, those in his treatment Categories 1&2 (severe tinnitus without hyperacusis) are likely to need the full TRT regime, or NBM equivalents of it.

  Other forms of Counselling and Psychological Treatments

  Our advocacy of neurophysiological-based management should not be taken to imply any lesser place for some of the other very successful lines of treatment^8,15 , especially other programmes of recurrent counselling or of psychological management such as cognitive therapy. Nor does this new therapy reduce the need for further research, eg in the pharmacological field.

  Hyperacusis

  A patient with hyperacusis experiences auditory discomfort from (unamplified) sounds that previously were not particularly uncomfortable or which other people tolerate without difficulty. Sometimes it is over-sensitivity to any loud sound, sometimes only to sounds of a particular type eg high frequency sounds. The discomfort may be severe, affecting the patient’s whole lifestyle: more often the discomfort is only slightly troublesome, but perhaps enough to reduce the acceptability of the hearing-aid fitting they may otherwise need.

  Hyperacusis occurs in about 40% of people with tinnitus^4,17,18 and is probably another manifestation of the increase in central gain⁴ that is believed to occur with increasing tinnitus or when the brain tries to compensate^17,18 for a diminished input from a damaged or degenerating cochlea. In other cases, the discomfort from loud sounds may simply be due to the unpleasant distortion of hearing often associated with cochlear disorders. Hyperacusis may occur both in individuals with normal hearing and in those with hearing loss. In the latter, it can co-exist with loudness recruitment, perhaps thereby accounting for the phenomenon of over-recruitment.

  Moderate degrees of hyperacusis associated with tinnitus (Jastreboff Category 3) can usually be much improved by a combination of neurophysiologically based counselling, explanation of hyperacusis and its lack of relation to noise damage, and acoustic desensitisation. The latter involves general enrichment of the patient’s sound environment, particularly during the quietest periods of the day or night, and use of a wearable noise generator, starting at a just audible level and later increasing gradually over weeks or months according to one treatment method. The patient should also be advised not to constantly wear earplugs or earmuffs, since they are liable to reduce the sound levels reaching the ear to levels that are too low: they may be necessary though when severely uncomfortable sound levels are experienced or expected.

  Review of the More Interventionalist Treatments

  Drugs

  No specific drugs for treatment of chronic tinnitus that are both frequently effective and non-toxic have yet been developed, but research continues.

  On the other hand, sedatives, anxiolytics or anti-depressants are often needed for treating the background state of the patient. Such drugs without counselling are rarely going to be effective though.

  Tinnitus of recent and sudden onset may sometimes be helped by the emergency treatments used by otologists for sudden deafness.

  Surgery

  Middle-ear surgery, other than simple drainage or aeration procedures, is seldom justified for tinnitus per se. It may aggravate it – even if the surgery leads to an improvement in hearing ability. Destructive surgery, of the end-organ or cochlear nerve, seems rarely to be justified, may not work and may even make the tinnitus worse.

  Hearing aids

  One of the things to consider is whether to fit a hearing aid or aids, or improve or extend an existing fitting. Rather smaller than usual degrees of hearing loss can usefully be aided and thereby help the tinnitus also, especially if explained to the patient that it is a treatment for the tinnitus as well. To this end, the patient’s acoustic environment should also be enriched, particularly at the quietest times, by addition of background noise at a level that becomes clearly audible when amplified by the hearing aid. Where possible and appropriate, fittings should be non-occluding and binaural. Poor hearing-aid fittings can lead to frustration, loudness discomfort and anxiety, and thus are liable to make tinnitus worse.

  “Maskers”

  “Tinnitus maskers”, in their original usage, have proved disappointing in perhaps half of those treated in this way. Moreover complete masking, better described as suppression, may inhibit the process of habituation. Nevertheless, some patients still find a WNG useful as a masker to provide temporary symptomatic relief, ie comfort while the masking effect takes place. Such masking can be used to supplement to NBM, but in some cases it may provide all the help the patient wants.

  Diet

  Dietary regimes are occasionally helpful. This should start with careful questioning to detect possible tinnitogenic dietary components (eg caffeine),

  Drinks or medication: and be followed by dietary exclusion trials to confirm or disprove the potential benefits for that individual.

  Electrical stimulation

  Direct electrical stimulation of the cochlea may temporarily reduce or abolish tinnitus. But, as yet, no sufficiently effective and painless means of external or indirect electrical stimulation has been developed.

  Hypnotherapy and alternative medicine

  Hypnotherapeutic techniques can be of indirect help, by aiding relaxation. Methods of alternative medicine, including acupuncture and herbal preparations, only rarely seem to have any beneficial effect on tinnitus, but can be of worthwhile supportive value if the patient believes they are helping.

  The Changing Approach

  The lack of a “quick fix” has frequently resulted in a negative feeling in he medical profession towards tinnitus. This has led to a not uncommon view by doctors and in the public that tinnitus is untreatable. This results either in the giving of depressing advice or no advice at all, which for distressed tinnitus patients only makes things worse.

  Although NBM techniques can sometimes take a long while to achieve their effect (up to twenty four months or even longer), by making use of them Audiology Departments can now offer an organised and often effective line of treatment for most patients with distressful tinnitus. More encouraging and informative counselling (ENT, GP or lay) would also do much to prevent or alleviate such distress at the outset.

   

  Training Courses and Further Information

   

• More detailed instruction on all aspects of tinnitus and its therapy, including NMB, is available in the four-day European Instructional Course on Tinnitus and its Management held annually in Cambridge.
• Intensive three-day TRT courses are being run in London (and in the USA). While the number of patients who need and can be provided with the full treatment as taught may be quite limited, the course provides a generally useful and intensive training in how to manage patients utilising the principles of the neurophysiological model.
• Two-day counselling courses with special references to tinnitus are run by the BTA in Nottingham for professionals and lay people. Local hospital or college courses on counselling skills may also be available.
• Courses on techniques of relaxation training, aimed at both professional and laypersons who work with people troubled by tinnitus, are run in Birmingham.
  

  Further information on tinnitus is available on the Internet^{19. 25}, in recent textbooks ^18,20 and in a review of psychological treatments given in a recent critique of TRT²¹ The RNID Tinnitus Helpline newsletter Tinnitus Focus is also very useful, it is available free to tinnitus professionals on application. All those audiologists intending to offer some form of NBM should read some of the paperss and chapters quoted here, of which the Jastreboff (1998) reference⁴ is considered to be the most concise and informative.

   

  Qualifications for Tinnitus Work

  For audiologists taking special responsibilities for tinnitus patients the most important qualifications would be training, experience and interest. Over and above basic audiological qualifications and at least five years of clinical audiological experience, the minimum additional training desirable would be attendance at one of the tinnitus introductory courses and, if possible, a counselling training course. This should be supplemented by reading some of the references quoted in this update. In addition, arrangements should be made to sit in on six to twelve tinnitus management clinics with an audiologist already experienced in this work.

  Later, if continuing in this field, attendance first at one of the European Tinnitus Courses, and perhaps eventually at one of the special TRT courses, would be valuable. Attendance at up-date courses in London and at regional or subsequent tinnitus-interest group meetings would be important.

   

  References

  1) Jastreboff, P J (1990) Phantom auditory perception (tinnitus): mechanisms of generation and perception. Neuroci.res. 8:221-254

  2) Jastreboff, P J and Hazell, J W P (1993) A neurophysiological approach to tinnitus: clinical implications. Br.J Audiol. 27: 1-11

  3) Jastreboff, P J, Gray W I and Gold S L (1996) Neurophysiological approach to tinnitus patients. Am J Otol. 17: 236-240

  4) Jastreboff, P J (1998) Tinnitus. Pages 90-95 in “Current Therapy in Otolaryngology – Head and Neck Surgery” Ed.G. Gates. Mosby: St Louis

  5) McKinney, C., Hazell, J W P and Graham, R (1998) A comparison of the principal components of tinnitus retraining therapy. Abstract of paper to the Israel meeting of the European Union’s P A N (protection against noise) programme.

  6) Coles, R R A (1984) Epidemiology of tinnitus: (1) Prevalence. J. Laryng. Otol. Supple. 9: 7-15

  7) Goebel, G (1998) A review of the effectiveness of psychological therapies in chronic tinnitus. Pages 85-100 in “Tinnitus- Psychosomatic Aspects of Complex Chronic Tinnitus” Ed. G Goebel. Quintessence:London

  8) Windle-Taylor, P C., Evans, C., Talbot-Hole, J., Donovan, D M.,Taylor, H., and Lavers, V (1996). The clinical management of tinnitus: realities of hospital practice, with special reference to person-centred counselling. Pages 548-553

  in “Proceedings of the Fifth International Tinnitus Seminar 1995” Eds. G E Reich and J A Vernon. American Tinnitus Association: Portland.

  9) Vesterager, V., Nilsson, P and Sibelle, P (1996) A programme for systematic treatment of tinnitus: a follow-up study. Pages 546-547 in “Proceedings of the Fifth International Tinnitus Seminar, 1995” Eds. G E Reich and J A Vernon, American Tinnitus Association, Portland

  10) David, A C., Coles, R R A., Smith, P A and Spencer, H S (1992) Factors influencing tinnitus report in Great Britain. Pages 239-243 in “Proceedings of the Fourth International Tinnitus Seminar, Bordeaux 1991” Eds. J-M Aran and R Dauman. Kugler: Amsterdam

  11) Heller, M F and Bergman, M (1953) Tinnitus aurium in normally hearing persons. Ann. Otol.Rhinol. Laryngol 62:72-83

  12) Anon (1981) Definition and classification of tinnitus. Appendix 1 in “Tinnitus: Ciba Foundation Symposium 85” Eds. D Evered and G Lawrenson. Pitman:London

  13) Sheldrake, J B., Jastreboff, P J and Hazell, J W P (1996) Perspectives for total elimination of tinnitus perception. Pages 531-536 in “Proceedings of the Fifth International Tinnitus Seminar 1995” Eds. G E Reich and J A Vernon American Tinnitus Association: Portland

  14) Dineen, R., Doyle, J., Bench, J and Perry A (1998) The influence of training on tinnitus perception: an evaluation 12 months after tinnitus management training. Brit. J Audiol in the press

  15) Goebel, G., Hiller, W., Reif, W and Fichter, M (1998) Integrative behavioural medicine in-patient treatment concept for chronic tinnitus. Evaluation of therapy and long term effects. Pages 113-146 in “Tinnitus –Psychosomatic Aspects of Complex Chronic Tinnitus” Eds. G Goebel, Quintessence:London

  16) The Wessex Institute for Health Research and Development (1998)

  “Tinnitus Retraining Therapy” Development and Evaluation Committee Report No 83, University of Southampton

  17) Jastreboff, P J and Hazell, J W P (1998) Treatment of tinnitus based on a neurophysiological model. Chapter 22 in “Tinnitus: Treatment and Relief” Ed. J A Vernon. Allyn and Bacon: Boston

  18) Coles, R R A (1997) Tinnitus. Chapter 18 in Vol. 2, 6^th

  ed. S D G Stephens. Butterworth – Heinemann: Oxford

  19) Internet. Hazell, J W P and Jastreboff, P J Information on Tinnitus and TRT for patients and professionals. http://www.tinnitus.org

  20) Jastreboff, P J and Hazell, J W P (2004) Tinnitus Retraining Therapy – Implementing the Neurophysiological Model Cambridge University Press

  21) Wilson, P H., Henry, J L., Andersson, G., Hallam, R S and Lindberg, P (1998) A critical analysis of directive counselling as a component of tinnitus retraining therapy. Brit. J. Audiol. 32: 273-286

  22) Andersson, G and Kaldo-Sandstrom, V (In press) Internet-based cognitive behavioural therapy for tinnitus, Journal of Clinical Psychology.

  23) Andersson, G, Stromgrem, T, and Lyttkens, L (2002) Randomised, controlled trial of Internet-based cogmitive behavioural therapy for distress associated with tinnitus. Psychosomatic Medicine, 64, 810-816

  24) Kaldo-Sansdstrom, V, Larsen, H, C, and Andersson, G (2003) Internest-based cognitive behavioural self-help treatment of tinnitus: Clinical effectiveness and predictors of outcome. Submitted25) British Tinnitus Association website: www.tinnitus.org.uk – downloadable information for patients and professionals

   

  Acknowledgements

  The Working Group wishes to thank Dr Ewart Davies for his particular interest in the content of this document and for his critical but helpful comments. Our thanks are also due to Mr Jonathan Hazell, FRCS for constructive suggestions, even though he disagrees with some of our comments, criticisms and conclusions. Useful comments have also been offered by Dr O P Tungland and Mrs Vera Vaughan.

   

  Appendix - A

  Points to consider in the outline business plan for the development of a tinnitus service

  Introduction

  It will be necessary to put up a case to the purchaser to properly fund a new tinnitus service. Otherwise you may find that you start a service, which you cannot maintain. Responsibility for making or drafting the documents may be devolved to a member of the audiological staff.

  Content

  Below are a number of suggestions on how to present your business case:

  a) Identify workload

  The need for and potential workload of a tinnitus service needs first to be identified in terms of numbers of patients and service hours. The National Study of Hearing has produced information on the prevalence of hearing loss and tinnitus, but you need to assess that against local figures taking into consideration the age structure of the population that you serve and whether or not it is an industrially noisy area or perhaps an old-age retirement area, which may produce bias. You have to remember that historically less patients seek help than require it, so allowance needs to be made for the fact that a service will attract work.

  b) Future monitoring of the workload

  Records of referral will need to be kept, showing:

  (i) Source of referral (ENT, Audiology, GP, or open access)

  (ii) Date of referral

  (iii) Date seen

  (iv) Date discharged

  A review of the new/review ratio will also be needed, and also whether or not any patients require tertiary referral.

  c) A presentation may need to be made on:

  (i) Investigation and diagnosis

  (ii) Therapy and counselling

  d) Effectiveness

  The results of therapy will need to be assessed. This is best done by use of a previously researched questionnaire, asking the patient to score how the tinnitus affects different aspects of his/her life. The patient brings this to the first therapy appointment and it can be repeated later to see if there is a shift in the scoring. It is recognised that this type of visual analogue score has weakness. But if it can be seen to show an improvement in the patient’s condition by a reducing severity score, presentation of such data to interested groups, colleagues or management can be useful in bringing to them an awareness of the benefits of a tinnitus service.

  e) Staff and time requirements

  (i) Medical

  (ii) Audiology professional

  (iii) Hearing therapist

  (iv) Other, including clinical psychologist and lay tinnitus counsellors

  (v) Clerical

  f) Accommodation

  The room(s) to be used needs to be sited close to or within the auditory rehabilitation area, ENT clinic or hearing aid department. If separated from other audiological, a “panic button” is desirable. A display of environmental noise sources and wearable noise generators is also desirable.

  g) Costs

  (i) Staff

  (ii) Equipment

  (a) Capital may be needed for an additional small clinical audiometer and a display of rehabilitative equipment

  (b) Revenue for noise generators, additional hearing aids, production of information leaflets and handouts, training and meeting costs

  Example

  Each tinnitus patient might receive, on average:

  (i) One or two 15-minute consultations in an ENT clinic

  (ii) Audiometry including matching of tinnitus pitch: 20-60 minutes

  (iii) One and a half hours of basic counselling

  (iv) Initial fitting of appropriate sound reinforcement device(s): 60 minutes

  (v) Forty-five minute follow-ups with further counselling, until agreed with the audiologist and patient that such support is no longer required

  (vi) Reports to the referring otolaryngologist or other source, with a copy to the patient’s GP after the first appointment, then periodically to up-date

  The clinical psychology department should be approached for support for difficult cases, but the ENT department may be asked to present a case of need, because the psychology services are usually overloaded. It can also be worthwhile to make local contacts with the British Tinnitus Association, as it has an increasing number of trained counsellors available who can also offer valuable support for the patient.

  Based on a typical district servicing a population of 300,000, current spending on tinnitus amounts to one whole time equivalent member of staff. This is made up of seven therapeutic and two administrative sessions by audiologists, and one session of secretarial support. The average cost of a good service based on NBM has recently been estimated at about £250 per patient referred to the Audiology department’s tinnitus service. This contrasts very favourably with the figure of £1500-£2500 quoted for TRT at a tertiary referral centre in London¹⁶. The main reasons for the difference are probably the use of less expensive and fewer staff and auditory prostheses, and reservation of a multiple attendance regime of NBM to only a small minority^7,8,9 of ordinary ENT departmental tinnitus patients who need it.

   

  Appendix – B

   

  Practical advice on developing your tinnitus service

  Different health areas will have an assortment of facilities and management structures, such that in some cases only one or two aspects of this information can be implemented. The audiologists should not be discouraged by this, as gradual growth of some specialised tinnitus service is better than none at all.

  Undertake further study of tinnitus management – see sections on training courses, information and qualifications.

  Support & Supervision. Whilst the chance to help tinnitus sufferers and the independent nature of the work leads to audiologists experiencing a high degree of job satisfaction, it is important to realise that the job may sometimes be isolated, demanding and stressful. The nature of the work, involving continual decision making and helping some very distressed people, creates a tension that needs release. At the same time, opportunities for the exchange of ideas and information with colleagues may be limited. Creating a support structure for audiologists can enable them to “unload” some of the feelings generated by the work, encourage them to examine the way they work, explore new ideas, take a creative approach to problem solving and learn from each other’s experiences.

  Audiologists are usually responsible to an ENT consultant. However, the term “supervision” here is used in the same way as in social work and counselling. Supervision offers a chance to make and monitor plans and is an effective way of sharing information and preventing problems from arising. It should not be seen as “sitting in judgement”.

  Networking with other professionals can provide support, and they are often keen to help. Firstly, an audiologist experienced in tinnitus work may be approached to act as “mentor” for a new worker during the induction period. In such a case the mentor’s role becomes one of support worker and coach. Secondly, special interest groups organised on a regional or sub-regional basis can form an effective means of support. Such groups can help to share ideas and experiences and work on joint projects. If such a group does not already exist, consider initiating one.

  Gain support from one of your ENT consultants in particular, so that any uncertainties or problems can be discussed with him/her.

  Attempt to have two audiologists involved, to give mutual support, and for sharing the workload, sickness cover etc.

  Arrange for specifically referred tinnitus patients to be seen in a separate session from other hearing rehabilitation patients. The timing of the patients can then be decided at your discretion, and their special management is more effective and easier to organise and audit.

  Organise a clear protocol for further referral, eg. to GPs, psychology, relaxation training and ensure that you know when and how to refer, especially for the very small minority about whom you feel concerned regarding their level of distress.

  Questionnaires – there are numerous tinnitus questionnaires available. Some of these are for use prior to appointment to assess the level of distress and provide a baseline. They can then be administered again to measure effectiveness of treatment on its completion. Other questionnaires are intended to be used informally during interview to ensure coverage of all aspects of tinnitus and its effects, and to provide data for use in future appointments.

  Train others – various professionals need to be made aware that your service is provided and what is available. There are frequent reports from patients of negative statements having worsened their tinnitus. These statements come from the press and media, from relatives and friends, and quite often from professionals too. Such negative beliefs can be changed by a positive approach from audiologists and a raised awareness of their services.

  Report back to the referring ENT consultant, with a copy to the patient’s GP, giving a brief outline of the therapy and progress. Doing this both during and on completion of treatment is a good awareness–raising technique.

  ADVICE TO GIVE ON TINNITUS

  The points below are relevant to all audiologists, but are compiled by those who do not have special responsibility for management of tinnitus. If asked questions about tinnitus, explain all or part of the following:

  Tinnitus is not a disease. It is a symptom, like an ache in a joint or a blurring of vision.

  It is usually a symptom of a disorder somewhere in the hearing system, most commonly in the internal ear.

  By far the most common cause of the disorder is nothing more than the slight deterioration of hearing that comes with ageing. Another quite common cause is noise exposure.

  Nevertheless, the patient’s GP or an ear specialist should check its possible cause.

  Tinnitus is a common disorder, present in about 10% of the adult population.

  The noise is harmless in itself; only a minority of those experiencing tinnitus become very annoyed by it. Many simply do not allow themselves to be bothered by it at all. Even in those people who do suffer annoyance from their tinnitus, this gradually reduces with the passage of time, the natural process of habituation.

  Encourage the patient to make positive efforts not to listen to the tinnitus, to use activities and environmental sounds such as those from an electric fan, a radio, a table-top noise generator, a personal stereo to help distract attention from the tinnitus and reduce its intrusiveness.

  Inform the patient that reduction in these fears and anxieties, and in attention to the tinnitus, will promote habituation to the tinnitus and reduction of the tinnitus itself

  Explain the additional habituation training effect of use of low-level noise.

  Avoid using such words as “incurable”, permanent, and certainly “you’ve got to learn to live with it”. These will only worsen the patient’s perception of his or her tinnitus by feeding the vicious circles which tend to increase tinnitus awareness and distress.

  Reassure and positively encourage - for instance: “improvement is usual”, “there are means of helping further, if needed”, “it is unlikely to get worse (or go on getting worse)”.

  Advise on local counselling and self-help facilities. Also on the British Tinnitus Association and the RNID Tinnitus Helpline, and bodies able to help with associated problems, eg. Relate.

  If asked about treatments for tinnitus, explain that there is no “magic wand” that can waft tinnitus away, even temporarily. But that modern methods of management used in many hospitals are helpful to most of those patients needing them.

  If asked about TRT in particular, explain that it is a particular form of NBM and not universally available. In any event, it is not needed for most cases, and is not necessarily any more effective than NBM.

   

  © British Tinnitus Association 2005