Tinnitus Treatment options
Most of the people who come to the OHSU Tinnitus Clinic have tinnitus in a severe form. Tinnitus is when a sound, like ringing or a high pitched noise, is heard without anything to cause it. Severe tinnitus is when the patient hears these noises and is greatly disturbed, such as when the sound interrupts or prevents normal sleep, or when it interferes with reading, concentration, work activity, recreational pursuits, etc. Some people have tinnitus that is mild and does not interfere with routine activities. These people may have concerns about whether the tinnitus will get worse or will damage their hearing. For these people, it is only necessary to caution them against exposure to loud sounds. Repeated exposures to loud sounds can make tinnitus worse and cause hearing loss.
The Tinnitus Clinic treats patients with all kinds of tinnitus - mild to severe. We have seen over 9,000 patients with severe tinnitus, and work with each patient to manage the condition and help the patient with the most advanced treatments and technologies available to patients with tinnitus.
Our treatment programs can reduce the severity of chronic and bothersome tinnitus, but the process is very time consuming. The time required for patient evaluation, education, reassurance, and counseling, as well as for designing and initiating an individualized treatment program can take more than four hours during the first 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.
Acoustic TherapiesAcoustic Therapy is one of the most successful categories of treatments offered at our clinic. It is the addition or changing of specific types of sounds which can reduce how the patient hears or perceives (senses) the tinnitus. Acoustic Therapy is available in the following forms:
Cassette tapes - broad band (2kHz-12kHz) or pink noiseCDs - broad band, pink noise, or natural masking sounds
Bedside units - The patient sets the frequency and volume of background sound; can be used with or without headphones. Each unit has a timer which can be set before bedtime.
Sound pillows - These special pillows have small speakers built into a comfortable pillow, and can be plugged into a CD, cassette player, or sound machine
Wearable Acoustic Therapy devices are available in three different styles and types:
- A standard hearing aid makes environmental sounds louder, which often reduces the perceived loudness of tinnitus.
- An ear level sound generator can be used for those patients who have tinnitus without significant hearing loss.
- A tinnitus instrument is a combination of a hearing aid and a sound generator. The two components are packaged in a single case but with independent volume controls.
"Why would I want to replace one sound with another?
This question has several answers:
- Tinnitus is often a high-pitched, shrill tone that can be extremely annoying. Sound generators produce sounds like rain or the ocean, which are more pleasant to listen to and can muffle the sound of high-pitched tinnitus.
- Because masking-type sounds are like background noise, they can be ignored more easily than tinnitus sounds.
- Since the masking-type sounds are generated by an external source (unlike tinnitus, which is generated within the patient's brain), patients can more easily adapt to them and ignore those sounds.
Goals of Acoustic TherapyThe goal of Acoustic Therapy is not necessarily to completely cover or mask the tinnitus sound. In fact, complete masking is not possible for some patients. Wearing sound generators usually gives patients immediate relief from tinnitus. Sound generators can help patients to concentrate, sleep, feel less anxious, and improve the quality of their lives. There is also some evidence to suggest that wearing sound generators for 6 or more hours per day over an extended period of time (6 months to 2 years) will make it easier to "re-train" the parts of the brain that hear and sense sounds (auditory) and will result in a permanent reduction of tinnitus loudness and severity. This is a major component of Tinnitus Retraining Therapy or "TRT."
Comprehensive Treatment Programs
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 because of or linked to tinnitus. However, most patients report that sleep problems, whatever the cause, increases 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. Some medications can be effective because they promote sleep and can also reduce anxiety experienced by many tinnitus patients, even with a small dosage before bedtime. If patients are interested in trying a medication for tinnitus relief, they should discuss the possibility with their doctor. 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 because of the 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 tricyclic antidepressants. Tricyclic antidepressants can elevate mood and also improve sleep. Some serotonin reuptake inhibitors (SSRIs) can also be effective antidepressant medications for patients with tinnitus.
Antidepressant or anti-anxiety medications should be used with some type of therapy or counseling. Patients who do not wish 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.
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Tinnitus Retraining Therapy (TRT), also known as habituation therapy, was developed by Dr. Pawel Jastreboff in the mid-1980s.
Approximately 75% of all the people who experience tinnitus are not bothered by it, and the sound/symptoms of tinnitus is treated like any other sound to which they easily get used to. 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 or TRT was developed. This therapy is based on basic principles of how the brain works for each individual.
According to Dr. Jastreboff:
- The processing of information occurs on several levels for each sensory system, each level contributing to the final stage when a signal reaches the portion of the brain that processes it.
- The auditory (hearing) system is closely connected with the part of the brain that controls emotions and the automatic response of the body to danger
- Connections within the nervous system are continuously changing, resulting in the increasing of important signals, and decreasing in response to unimportant signals
- Sounds that are new, or associated with a negative experience, are treated as significant, and start an emotional response that triggers the body to prepare for "fight or flight." The repetition of these sounds results in an increase of perception and in a resistance of the body to ignore those signals. The repetition of signals not associated with positive or negative feelings or actions results in the disappearance of a response to their presence, i.e., in habituation
- The detection of sound occurs on a pattern-matching principle, allowing for nearly complete perception of a signal even when it becomes highly distorted.
As a result, the main point of the theory of tinnitus based on these principles is the idea that non- hearing systems, particularly the brain systems that deal with emotion (limbic system), and the nervous system which controls all body functions and triggers the "flight of fight" reaction are a key part of each case of troublesome tinnitus. The auditory (hearing) pathways play a secondary role. According to this model, the annoyance of tinnitus is determined totally by the limbic and autonomic nervous systems.
In the majority of cases of patients with tinnitus, the continued presence of tinnitus combined with a lack of any positive or negative association (causing fight or flight, or annoyance) ends up with the patient getting used to the tinnitus noise - habituation. 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 (it is "all in your head"), 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 increases the first responses of the autonomic nervous system evoked by fear. As tinnitus is commonly present all the time, and when it is linked to a strong emotional response, this results in the tuning of the brain networks detecting the tinnitus signal itself. As a result, this increases the time an individual is aware of the tinnitus and further enhances the negative (fight or flight) emotional responses and the reaction of the nervous system, thus increasing annoyance. It should be noted, though, that the it is the limbic and nervous system responses that result in the annoyance felt by the person with tinnitus - the actual volume or pitch of the tinnitus doesn't matter for the most part.
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From the patient's point of view, the most important question is: What can be done to remove tinnitus-evoked annoyance? To our knowledge there is no drug, procedure, or surgery that can totally remove the source of tinnitus without profound side effects. Even in cases with significant inner ear changes, attempts to solve the problem by destroying the cochlea or the auditory nerve would not be consistently helpful in fixing the tinnitus problem, and would make 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 and the level where tinnitus is perceived -- the cerebral cortex (part of the brain). The idea is to block tinnitus-related brain activity from reaching the level of the cortex where it is perceived, and from activating the limbic and autonomic nervous systems. If this is blocked, the patient becomes habituated to the tinnitus perception and any reactions that are caused by the tinnitus.
Everyday experience and research show that we are consciously aware of only a small portion of incoming sounds. Although other sounds make changes in the brain activity within the hearing centers of the brain, these sounds are is filtered out by the centers before reaching the level of conscious perception - these sounds become "background noise". 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 pathways of the brain that process sounds (auditory pathways). In the absence of sound there are high levels of chemical and electronic activity in the auditory nerve, as well as in other activities 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. While the patterns of electrical activity within the auditory nerve closely reflect the sound that reaches our ear, this activity undergoes a lot of processing in the brain before reaching the cortex, where perception of the sound occurs. Our brain sorts sounds by importance, giving important sounds high priority to our attention and filtering out (habituating) unimportant sounds. The rules controlling sorting change 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.
So if we can train the brain to classify tinnitus-related neuronal activity as representing an unimportant signal, the process of habituation will occur automatically. To achieve this, it is necessary to remove the negative feelings and actions that are attached to the perception of tinnitus.
Signals that make you feel fear, indicate danger, or that are associated with any unpleasant situation cannot be habituated. To avoid unpleasant situations, we must not get used to (habituate) sounds that provide warning! The decreased negative association of tinnitus is achieved through 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 body's systems 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 model of tinnitus and we use the principles of TRT to successfully treat our patients.
How to Make an Appointment
To schedule an appointment, or to get more information about our program, services, or doctors, at the OHSU Tinnitus Clinic, please call 503 494-7954 or email us at email@example.com.
Clinic hours (Pacific Coast Time - USA) are Monday to Friday from...
8:00 AM to 12:00 PM
1:00 PM to 4:30 PM
We are closed Saturday and Sunday. We are located on the OHSU Marquam Hill Campus in the Hatfield Research Center (HRC)