Our treatment programs can reduce the severity of chronic and bothersome tinnitus, but the process is very time consuming. The time required for patient assessment, education, reassurance, and counseling, as well as for designing and initiating an individualized treatment program can take more than four hours during the initial visit. Follow-up appointments can take between two to three hours. The Tinnitus Clinic Staff is willing and able to spend this amount of time with each patient in order to effectively treat chronic, severe tinnitus.

In addition to Acoustic Therapies there are a number of other treatments that provide relief for tinnitus patients. In order to determine which treatments are likely to be effective for a particular patient, we consider individual differences in hearing, tinnitus, medical, and psychosocial histories and conditions. A treatment that is effective for one patient will not necessarily be successful for all patients.

For example, many tinnitus patients have trouble sleeping. Their insomnia may or may not be attributable to tinnitus. However, most patients report that sleep disturbances, whatever their cause, increase the severity of tinnitus. For these patients, getting a good night’s sleep will reduce the annoyance caused by tinnitus.

Some patients with tinnitus and insomnia benefit from the use of prescription medications. Benzodiazepines such as Xanax (alprazolam), Ativan (lorazepam), or Klonopin (clonazepam) can be effective because they promote sleep and can also reduce anxiety experienced by many tinnitus patients. A small dosage (0.25 or 0.50 mg) of these medications taken before bedtime can help patients to sleep. In a controlled study conducted at this Clinic, higher doses of Xanax reduced the loudness of tinnitus for 13 of 17 patients who received the medication. Only one of 19 patients in the placebo group reported a reduction of tinnitus loudness. However, higher doses (1.5 mg per day or more) of Xanax or other benzodiazepines are not recommended for most patients. If patients are interested in trying these medications, they should discuss the possibility with their physician. Other prescription medications that can help patients to sleep include Ambien and Trazodone. Some patients benefit from over-the-counter remedies such as melatonin, Tylenol P.M., Excedrin P.M., kava, or even a glass of milk.

Some tinnitus patients also have major depression. Again, the depression may or may not be attributable to tinnitus. However, successful treatment of depression can reduce the severity of tinnitus. For patients who are interested in trying antidepressant medication, we recommend that they talk with a psychiatrist about tricyclics such as Pamelor (nortriptyline) or Elavil (amitriptyline). Tricyclic antidepressants can elevate mood and also improve sleep. Selective serotonin reuptake inhibitors (SSRIs) such as Paxil, Zoloft, or Effexor are also effective antidepressant medications.

Antidepressant or anti-anxiety medications should be used in conjunction with some type of psychotherapy or counseling. Patients who do not wish to or need to use medications can benefit from counseling that helps them to manage stress or depression, and to develop relaxation techniques and coping strategies.

We work with each patient to develop an individualized treatment program based on the patient’s history and current needs. An appropriate combination of medical intervention, Acoustic Therapy, medication, and counseling can reduce sleep disturbances, anxiety, and depression for many patients with tinnitus. In most cases these treatments will reduce the annoyance caused by tinnitus and will improve the quality of life for these patients.

Tinnitus Retraining Therapy (TRT) and the neurophysiological model of tinnitus were developed by Dr. Pawel Jastreboff in the mid-1980s and were published in 1990 (Jastreboff, PJ. Phantom auditory perception (tinnitus): mechanisms of generation and perception. Neurosci. Res. 8:221-254, 1990).

Approximately 75% of all the people who experience tinnitus are not bothered by it, and they treat tinnitus like any other sound to which they easily habituate. An important fact is that there is often no difference in the physical characteristics of the tinnitus sound perceived by people who suffer because of it and those who are not bothered by it. This observation is one of the findings responsible for the development of Dr. Jastreboff’s model of tinnitus, and based on the model, Tinnitus Retraining Therapy. The model is based on basic, well-established neurophysiological and psychological principles. According to Dr. Jastreboff:

1. the processing of information occurs on several levels for each sensory system, each level contributing to the final stage when a signal reaches the cortex
2. the auditory system is closely connected with the part of the brain that controls emotions and the automatic response of the body to danger
3. connections within the nervous system are continuously modified, resulting in the enhancement of significant signals, and a decrease of neuronal response to irrelevant signals
4. sounds that are new, or associated with a negative experience, are treated as significant, evoke an emotional response that triggers the body to prepare for "fight or flight." The repetition of these sounds results in enhancement of their perception and in a resistance of their perception to be suppressed by other signals. The repetition of signals not associated with positive or negative reinforcement results in the disappearance of a response to their presence, i.e., in habituation
5. the detection of sound occurs on a pattern-matching principle, allowing for nearly complete perception of a signal even when it becomes highly distorted.

Consequently, the main point of the theory of tinnitus based on these neurophysiological principles is the postulate that nonauditory systems, particularly the limbic system (involved in emotion), and the autonomic nervous system (which controls all body functions and triggers the "flight of fight" reaction) are an essential part of each case of troublesome tinnitus. The auditory pathways play a secondary role. According to this model, the annoyance of tinnitus is determined exclusively by the limbic and autonomic nervous systems.

In the majority of cases the continued presence of tinnitus combined with a lack of any positive or negative association results in habituation of the reaction to the tinnitus signal. Although tinnitus perception may still be possible, there is little or no annoyance or discomfort because of it. This situation is typical for children, or those leaving a loud concert, who tend to treat tinnitus as a natural event. Tinnitus typically does not annoy them.

However, in some cases, the perception of tinnitus is associated with a negative emotion. Patients treat tinnitus as an indicator that something is wrong with their hearing, or their brain, and as a result they start to focus their attention on the tinnitus. Quite frequently this occurs as a result of "negative counseling." All too often healthcare professionals advise patients to check for a brain tumor, or indicate that the tinnitus is basically a psychiatric condition, or tell the patient "nothing can be done with tinnitus" and that the patient has to "learn to live with it." This negative reinforcement of tinnitus perception actually enhances the initial responses of the autonomic nervous system evoked by fear. As tinnitus is commonly continuously present and evokes a strong emotional response, this results in the tuning of the neuronal networks detecting the tinnitus signal itself. Consequently, this increases the time an individual is aware of the tinnitus and further enhances the aversive emotional responses and the reaction of the autonomic nervous system, thus increasing annoyance. Notably, the involvement of the limbic and autonomic nervous systems is responsible for the annoyance evoked by tinnitus; the loudness and pitch of tinnitus are irrelevant to a large degree and normally do not play a significant role.

From the patient's point of view, the crucial question is: What can be done to remove tinnitus-evoked annoyance? To our knowledge there is no drug, procedure, or surgery that can eliminate the source of tinnitus without profound side effects. As evident from the model, even in cases with significant inner ear contribution, attempts to solve the problem by destroying the cochlea or the auditory nerve would not be consistently helpful while making the patient deaf.

If we cannot erase the source(s) of tinnitus, we should turn our attention to what is happening between the source of tinnitus (most frequently at the periphery) and the level where tinnitus is perceived -- the cerebral cortex. The idea is to block tinnitus-related neuronal activity from reaching the level of the cortex where it is perceived, and from activating the limbic and autonomic nervous systems -- to habituate tinnitus perception and tinnitus-induced reactions.

Everyday experience and research show that we are consciously aware of only a small portion of incoming sounds. Although other sounds evoke changes in the neuronal activity within the auditory pathways, this activity is filtered out by the neuronal networks before they reach the level of conscious perception. Similarly, most sounds do not evoke any emotional reaction or activate the autonomic nervous system.

To understand how tinnitus emerges, it is helpful to understand how sound is processed in the auditory pathways. In the absence of sound there are high levels of neuronal activity in the auditory nerve, as well as in other neurons in the auditory pathways, but this activity is random. The nervous system filters out this activity and therefore we do not perceive it as sound. This random activity can be considered "a code for silence."

When we are exposed to a sound the activity within the auditory system increases, and becomes more regular and synchronized. While the patterns of electrical activity within the auditory nerve closely reflect the sound that reaches our ear, this activity undergoes extensive processing in several subcortical centers within the auditory pathways before reaching the cortex, where perception of the sound occurs.

Our brain sorts sounds according to their significance, giving important sounds high priority to our attention and filtering out (habituating) insignificant sounds. Notably, the rules controlling sorting are changing throughout our lives. With proper training we can enhance our perception of some sounds, and we can train our brain to filter out other sounds.

Accordingly, if we can train the brain to classify tinnitus-related neuronal activity as representing a neutral, nonsignificant signal, then the process of habituation will occur automatically. To achieve this, it is necessary to remove the negative associations that are attached to the perception of tinnitus.

Signals that induce fear, indicate danger, or that are associated with any unpleasant situation cannot be habituated. To avoid unpleasant situations, we must not habituate to sounds that provide warning! The decreased negative association of tinnitus is achieved through directive counseling, with emphasis on teaching the patient the basic function of the auditory system and the brain in reference to the perception of tinnitus. This patient education/counseling is effective because a known danger evokes a weaker reaction of the autonomic system than an unknown danger. Decreasing the patient’s negative reactions to tinnitus is a primary goal of the therapy.

The process of retraining can take between 12 to 18 months. However, once tinnitus habituation is achieved, there is no need for continuing the treatment. Another important property of Tinnitus Retraining Therapy is that it cannot create any harm. Dr. Jastreboff and others have reported that more than 80% of their patients using TRT demonstrated significant improvement in tinnitus severity. We have achieved similar results in the OHSU Tinnitus Clinic. Our Director, Dr. William Martin, and Dr. Robert Folmer have both attended and completed TRT training courses taught by Dr. Jastreboff. We agree with most of the elements of his neurophysiological model of tinnitus and we use the principles of TRT to successfully treat our patients.