A multidisciplinary approach to management of tinnitus and hyperacusis

By Roger A. Ruth and Robin Hamill-Ruth

Tinnitus, or chronic ringing or buzzing in the ears, and hyperacusis, a potentially disabling intolerance of moderate to loud sounds, occur commonly in the adult population. Estimates are that from 40 million to as many as 50 million people in the United States experience some degree of tinnitus and/or hyperacusis. Despite the frequency of their occurrence, these complaints frequently go unrecognized or, at best, are poorly understood by most healthcare professionals. Tinnitus is estimated to affect between 10% and 20% of the overall population of the United States.1 Tinnitus complaints are often associated with some degree of hearing loss. Accordingly, prevalence increases with age; nearly a third of the population older than 70 years report significant tinnitus. Somewhere between 20% and 45% of tinnitus sufferers also have complaints of hyperacusis.2 A small number of patients complain of hyperacusis alone. Approximately three-quarters of those who experience tinnitus are not significantly bothered by it. For the remaining 25%, tinnitus exerts an undesirable influence on their daily life. As many as 10 to 12 million people in the United States are sufficiently debilitated by their tinnitus and/or hyperacusis that some form of intervention is warranted. It is for these patients that multidisciplinary management strategies have been developed. In our experience, this type of approach is often necessary and most helpful for patients with complex symptomatology. Tinnitus may best be viewed as a dynamic, complex, multidimensional experience. The mechanisms of tinnitus are not yet thoroughly understood. However, it seems probable that most forms of chronic tinnitus are induced or triggered by peripheral disorder resulting in an imbalance of activity in the central auditory pathways. This, in turn, produces abnormal spontaneous activity resulting in the tinnitus perception. TINNITUS, HYPERACUSIS, AND CHRONIC PAIN Maintenance of the tinnitus percept almost certainly involves both auditory and non-auditory structures within the central nervous system. The degree of annoyance associated with the tinnitus perception is related to these central factors. In this sense, tinnitus and hyperacusis have a
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...tinnitus may best be viewed as a dynamic, complex, multidimensional experience...

number of characteristics that are similar to a variety of chronic pain syndromes.3,4 (See Table 1.) For example, anxiety and depression, sleep disturbance, withdrawal from social activities, and social isolation are found in both patient groups.5 In addition, tinnitus, hyperacusis, and chronic pain can each be a manifestation of peripheral damage and subsequent central nervous system control. The emotional component associated with tinnitus, hyperacusis, and chronic pain supports the involvement of the limbic or sympathetic nervous system in the maintenance of these conditions. Furthermore, with each syndrome, changes in the peripheral nervous system can induce alterations in the central nervous system that are perpetuated beyond the time of normal healing. Very little literature addresses the coincidence of tinnitus/hyperacusis and chronic pain. However, sleep disturbance, depression, tinnitus, hyperacusis, and some types of headaches have all been associated with disturbance of the serotonergic system.6 The level of distress and dysfunction caused by tinnitus/hyperacusis and chronic pain appears to be related to emotional and psychosocial factors as well as coping abil-

Table 1. Similarities between tinnitus and/or hyperacusis and chronic pain.

v Both are subjective perceptions. v Both may change in quality and character over time. v Both systems have well developed efferent control mechanisms. v Both can be masked or interfered with by appropriate sensory stimulation or medications. v Both are under control of central mechanisms. v Both may result from inappropriate re-organization of neural pathways. v For both, treatment of the peripheral system alone is generally unsuccessful. v Both may be associated with hypersensitivity to sensory stimulation. v Both receive strong contributions from non-sensory areas of the brain. v Both are heterogeneous disorders with different
causes and pathologies.
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ities. We have observed a significant number of patients presenting with tinnitus and/or hyperacusis in addition to some form of current or previous chronic pain experience. Tinnitus/hyperacusis and chronic pain have overlapping dysfunctional symptoms and behaviors, such as the need for good coping abilities. A multidisciplinary model of evaluation and treatment for management of severe tinnitus and hyperacusis, which parallels that used with chronic pain patients, was developed and implemented at the University of Virginia Medical Center. MEMBERS OF THE MULTIDISCIPLINARY TEAM Our approach involves the disciplines of audiology, otology, pain medicine, and pain psychology. The intake evaluation strategies are listed in Table 2.

Table 2. Intake evaluation and management strategies for tinnitus/hyperacusis multidisciplinary management team.
Audiology:

v Point of entry and team leader v History and evaluation of severity v v v v v

and functional impact (Visual Analog Scales, Tinnitus Handicap Inventory, questionnaires, etc.) Comprehensive hearing evaluation Tinnitus/hyperacusis assessment (pitch and loudness match, maskability, LDLs, etc.) Education and directive counseling Acoustic therapy (hearing aids, noise generators, sound machines, etc.) Tinnitus Habituation Therapy

v Assessment of overall discomfort, mood, etc. v Sleep assessment v Recommendations for management of associated symptoms v Pain v Sleep disturbance v Anxiety v Depression v Active patient participation in design v Cognitive Risk Profile v Evaluation of mood, motivation, barriers to treatment success v Counseling to facilitate shift in locus of control v Pacing strategies v Cognitive restructuring v Increased focus on function,
decreased focus on symptoms Pain psychology:

of treatment plan, including prioritization of treatment options

v Medical history and physical examination v Radiological and laboratory studies v Medical or surgical management,
if indicated

Otology:

Audiologist
The audiologist serves as coordinator of the Tinnitus and Hyperacusis Clinic. Most patients are seen initially by the audiologist. Referrals are then made to the other members of the team as deemed appropriate. For a patient presenting with less complex problems, the extended consultation provided by the audiologist is often sufficient by itself in helping the person manage his/her tinnitus or hyperacusis. Audiologic management includes hearing remediation if hearing loss is present. Counseling and education are key elements to understanding the problem.7 Teaching addresses such topics as normal hearing, audiologic hygiene (including the influence of loud noise and/or

v History and physical examination

quiet on the severity of tinnitus and hyperacusis), the mechanisms of tinnitus and hyperacusis as they are currently understood, and an in-depth discussion of treatment options. In addition, tinnitus habituation training and use of acoustic therapies such as hearing aids or noise generators are used to desensitize or cause a re-organization of the central auditory nervous system. These audiologic management strategies are aimed at reducing the magnitude of the tinnitus percept and the influence it has on the patients life.

Pain medicine:

Otologist
The otologist carries out the medical evaluation and, if indicated, the medical and/or surgical management of tinnitus. The otologic evaluation involves a thorough case history and physical examination, and may also include radiologic and laboratory studies. It is extremely important either to rule

...our approach involves the disciplines of audiology, otology, pain medicine, and pain psychology...
out or, when appropriate, to treat medical conditions of which the tinnitus may be a symptom. These include acoustic neuroma, meningioma, Menieres disease, glomus tumor, and vascular lesions.

Pain-management physician
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The pain-management physician evaluates the patient for the presence of head
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strategies. Treatment modalor hyperacusis, virtually all (91%) felt their ities include supportive and head pain was worsened by the audiologic cognitive-behavioral intercomplaint. Likewise, a similar number ventions, which incorporate reported that their tinnitus or hyperacusis education about pacing of was exacerbated by the presence of head activities with energy conpain. Of those patients studied with myofasservation, sleep hygiene, cial pain or fibromyalgia, 67% reported tinbehavioral planning to nitus and/or hyperacusis.9 We have identified a large number of increase functioning, stress tinnitus and hyperacusis patients who have management, and realistic depression and sleep disturbance. In addigoal setting. Self-regulation tion, many have coincident pain comtechniques such as biofeedplaints, particularly myofascial, head, neck, back are used to help and shoulder pain, or degenerative spine increase body awareness, disease. Use of medications and injections shift perceived locus of conFigure 1. Chart illustrating the multidisciplinary model to manage these complaints has, in most trol, manage autonomic employed by the Tinnitus and Hyperacusis Clinic at the cases, served to decrease perceived dysarousal, and facilitate the University of Virginia. function and distress. This, in turn, allows reintegration of the patient for the delivery of more efficacious audiwith his/her life. The focus and neck pain complaints, such as temologic tinnitus management, particularly is on wellness rather than illness. poromandibular joint dysfunction, when treating more refractory patients. Figure 1 illustrates the multidisciplinary myofascial neck and shoulder complaints, model used in our or cervical spine disease. Treatment for tinnitus/hyperacuthese conditions coincides with the mansis clinic. The paragement of tinnitus and/or hyperacusis. adigm depends on Often the pain complaint, which may a high level of comcompound the patients distress, can be munication among readily managed. all participants. In In addition, attention is paid to other addition, it is treatable co-morbidities, including sleep imperative that the disorder, depression, and the presence of audiologist, otoloototoxic medications (e.g., high-dose, nongist, pain-managesteroidal anti-inflammatory drugs, loop ment physician, diuretics), which may contribute to the and pain-manageseverity of the tinnitus and/or hyperacument psychologist Figure 2. This graph summarizes pre- and post-treatment evalusis. Many tinnitus/hyperacusis patients have a fundamenation of symptom severity on a Visual Analog Scale for a 64-yeararrive at our clinic after having seen multal understanding old patient. The unfilled arrows represent the patients assessment tiple healthcare professionals over a numof the role and conof a particular condition before treatment and the filled arrows ber of months or longer. It is not tribution of each indicate those obtained at 1 year uncommon for these individuals to be on member of the tinnumerous medications, including antinitus/hyperacusis depressants, sleep aids, anxiolytics, and CASE STUDY team. The majority of our referrals are even narcotics. The pain-management An example of such a patient is shown in routed through the audiology clinic. physician is actively involved in simplifyFigure 2. The patient is a 64-year-old About half of these are self-referrals and ing and focusing the medical regimen. woman referred by her primary-care physihalf derived from various healthcare proFor some patients, this function is often cian. She had a 14-month history of virfessionals. vital to the overall success of efforts to tually incapacitating tinnitus and manage more severe tinnitus and/or hyperacusis and had been told by her priTINNITUS/HYPERACUSIS hyperacusis symptoms. mary-care physician and several specialists AND CHRONIC PAIN that she should just ignore it and it would In preliminary studies of chronic pain Pain-management psychologist go away. She reported significant sleep dispatients, the incidence of tinnitus and The pain-management psychologist evalorder, problems concentrating, intolerance hyperacusis was found to be significantly uates the patients emotional, cognitive, of social situations, and excruciating scalp higher than would be predicted in the and behavioral functioning. Particular tingling and pain. She also had a long hisgeneral population. For example, 70% of effort is directed toward identification of tory of interstitial cystitis, anxiety disorder, patients suffering from headache or facial barriers to successful treatment, such as depression, and hypothyroidism. pain reported tinnitus and/or hypermood disorders and deficient coping Audiologic evaluation revealed hearacusis.8 Of patients with tinnitus and/

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ing essentially within normal limits through 3000 Hz with mild-to-moderate, precipitous, high-frequency hearing loss bilaterally. She reported tinnitus in both ears centered around 4000 Hz and resembling a hissing sound. She also reported severe hyperacusis. Extensive education and counseling were provided along with tinnitus habituation therapy. In-the-ear noise generators were fitted bilaterally. She was placed on

Baclofen for neuropathic pain, myofascial pain, and sleep disturbance. Counseling was also provided for pacing of daily activities, relaxation, and mood monitoring. After 1 year of treatment, her symptoms were much improved. She was no longer experiencing severe tinnitus or hyperacusis and her pain symptoms were largely resolved. She was also sleeping much better and had returned to her usual social activities.

SUMMARY Generally, the patients who enter our program have undergone months or years of unsatisfactory doctor shopping and extensive evaluation to rule out associated central nervous system pathology (e.g., acoustic neuroma). For these patients, many previous efforts at traditional medical treatment had failed. In addition, most have been told at some point that the medical community has nothing to offer and they will just have to learn to live with it. Through the combined expertise of audiology, otology, and pain management within a multidisciplinary tinnitus/hyperacusis treatment model, the functional goals of these often-complex patients can be achieved.
Roger A. Ruth, PhD, is Professor of Audiology and Otolaryngology and Director of Communication and Balance Disorders, University of Virginia Health Systems, and Professor of Audiology and Director of the Electrophysiology Lab, Department of Communication Sciences and Disorders, James Madison University. Robin Hamill-Ruth, MD, is Associate Professor of Anesthesiology and Critical Care Medicine and Director of the Pain Management Center, University of Virginia Health Systems. Correspondence to the first author at Division of Communication and Balance Disorders, Department of Otolaryngology-HNS, University of Virginia Health Systems, P.O. Box 800713, Charlottesville, VA 22908-0713; e-mail rar6k@hscmail.mcc.virginia.edu. REFERENCES
1. Davis A, Rafie EA: Epidemiology of tinnitus. In Tyler R, ed. Tinnitus Handbook. San Diego: Singular, 2000: 1-23. 2. Ruth RA, Hall JW III: Patterns of audiologic findings for tinnitus patients. In Hazell JWP, ed. Proceedings Sixth International Tinnitus Seminar. London: The Tinnitus and Hyperacusis Center, 1999: 442-445. 3. Moller AR: Similarities between severe tinnitus and chronic pain. JAAA 2000;11:115-124. 4. Folmer RL, Griest SE, Martin WH: Chronic tinnitus as phantom auditory pain. Otolaryngol Head Neck Surg 2001;124(4):394-399. 5. Sanchez L, Boyd C, Davis A: Prevalence and problems of tinnitus in the elderly. In Hazell JWP, ed. Proceedings Sixth International Tinnitus Seminar. London: The Tinnitus and Hyperacusis Center, 1999: 58-63. 6. Simpson JJ, Hopkins PC, Davies WE: Does loignocaine interact with serotonin (5-HT) function? In Hazell JWP, ed. Proceedings Sixth International Tinnitus Seminar. London: The Tinnitus and Hyperacusis Center, 1999: 254-260. 7. Hall JW III, Ruth RA: Outcome for tinnitus patients after consultation with an audiologist. In Hazell JWP, ed. Proceedings Sixth International Tinnitus Seminar. London: The Tinnitus and Hyperacusis Center, 1999: 378-380. 8. Hamill-Ruth R, Chastain DC, Cook A, Ruth RA: Incidence of tinnitus and hyperacusis in patients with chronic headache. Proceedings Eighteenth Annual Scientific Meeting of the American Pain Society 1999:93. 9. Hamill-Ruth R, Chastain DC, Cook A, Ruth RA: Incidence of tinnitus and hyperacusis in patients with myofascial pain. Proceedings Eighteenth Annual Scientific Meeting of the American Pain Society 1999:103.

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