Tinnitus and Hyperacusis Rehabilitation
Dr. Hashir Aazh, Tinnitus & Hyperacusis Therapy Specialist Clinic, Audiology Department, Royal Surrey County Hospital, Egerton Road, Guildford, GU2 7XX, UK. E-mail: hashir.aazh@nhs.net
Tinnitus is the sensation of sound without any external acoustic sound source. Hyperacusis is an intolerance to everyday sounds that causes significant distress and impairment in social, occupational, recreational, and other day-to-day activities (Aazh et al, 2016). The Tinnitus & Hyperacusis Therapy Specialist Clinic (THTSC) at the Royal Surrey County Hospital is an audiologist-led service. THTSC offers a mixture of interventions comprising: (1) education, (2) Cognitive behavioural therapy (CBT), (3) hearing aids (4) sound therapy, and (5) client-centred counselling. A brief description of each intervention and its evidence base is given below.
1) Education
The content of the educational sessions at THTSC is informed by simplified Tinnitus Retraining Therapy (Aazh & Moore, 2016; Aazh et al, 2008). There are two systematic reviews supporting the efficacy of educational sessions in combination with sound therapy in the management of tinnitus (Phillips & McFerran, 2010). However, the evidence base for the efficacy of education alone in management of tinnitus or hyperacusis is poor.
2) Cognitive Behavioural Therapy (CBT)
CBT is a psychological intervention that aims to help the patient to modify their unhelpful, erroneous cognitions and safety-seeking behaviours (Beck, 1976). CBT involves helping the patient to identify, challenge and modify their unhelpful thoughts in response to tinnitus or environmental sounds (Aazh & Allott, 2016; Aazh et al, 2011). The CBT techniques at THTSC comprised: Socratic questioning, guided discovery, behavioural experiments, education and filling in diaries of thoughts and feelings between the sessions.
There is a wide range of research supporting the efficacy of CBT in the management of tinnitus (Grewal et al, 2014). The author is aware of only one published research study on hyperacusis management that reports some benefits from CBT (Juris et al, 2014).
3) Hearing aids
Patients are offered hearing aids if they have tinnitus combined with self-reported hearing difficulties and a hearing loss that could be helped with hearing aids. Despite their widespread use, there seem to be conflicting results with regard to the effectiveness of hearing aids in the management of tinnitus. While several authors have recommended the use of hearing aids in tinnitus management a recent Cochrane systematic review concluded that there is currently no evidence to support or refute their use as a routine intervention for tinnitus (Hoare et al, 2014).
4) Sound therapy
All patients were offered bedside sound generators (SGs) to use at night. For use during the day, patients were offered the combination devices. Research supporting the effectiveness of sound therapy for tinnitus or hyperacusis is limited, as in most studies sound therapy has been offered in combination with educational sessions.
5) Client-centred counselling:
Client-centred counselling was developed by Carl Rogers (Rogers, 1951) and emphasises respecting and trusting the patient’s capacity for growth, development and creativity (Rogers, 1951). Empathic listening is a key counselling skill that is used throughout the therapy sessions to build a good patient-clinician relationship and offer emotional support to patients. Empathy means to understand and feel another person’s perspectives. Use of client-centred counselling in the management of tinnitus and hyperacusis as well as in the process of aural rehabilitation has been recommended by several authors (Tyler et al, 2001; Aazh, 2015; Aazh, 2016; Aazh & Moore, 2017).
94% of the patients seen at THTSC rated counselling as effective. This was followed by education, hearing tests, and CBT, which 91%, 88% and 85% of the patients rated as effective, respectively. This is in contrast with the bedside SGs, hearing aids and WNGs, which only 75%, 64% and 53% of patients rated as effective, respectively (Figure 1) (Aazh et al, 2016).
A comparison of scores for responders with tinnitus only and those with hyperacusis (with or without tinnitus) showed that there were no significant differences for education (p=0.32), counselling (p=0.14), CBT (p=0.05), bedside SGs (p=0.16), WNGs (p=0.29) or hearing aids (p=0.26).
Figure 1 here
Fig 1: The percentage of patients who ranked each intervention as effective.
In order to gain practical skills in offering specialist rehabilitative approaches for management of tinnitus and hyperacusis in children and adults visit http://tinnitustherapy.org.uk/
References
Aazh, H. 2015. Feasibility of conducting a randomised controlled trial to evaluate the effect of motivational interviewing on hearing-aid use Int J Audiol, 1-9.
Aazh, H. 2016. Patients’ Experience of Motivational Interviewing for Hearing Aid Use: A Qualitative Study Embedded within a Pilot Randomised Controlled Trial. J Phonet and Audiol, 2, 1-13.
Aazh, H. & Allott, R. 2016. Cognitive Behavioural Therapy in Management of Hyperacusis: A Narrative Review and Clinical Implementation. Auditory and Vestibular Research, 25, 63-74.
Aazh, H. & Moore, B.C. 2016. A comparison between tinnitus retraining therapy and a simplified version in treatment of tinnitus in adults. Auditory and Vestibular Research, 25, 14-23.
Aazh, H. & Moore, B.C. 2017. Audiological Rehabilitation for Facilitating Hearing Aid Use: A Review. J Am Acad Audiol, 28, 248-260.
Aazh, H., Moore, B.C. & Glasberg, B.R. 2008. Simplified form of tinnitus retraining therapy in adults: a retrospective study. BMC Ear Nose Throat Disord, 8, 7.
Aazh, H., Moore, B.C.J., Lammaing, K. & Cropley, M. 2016. Tinnitus and hyperacusis therapy in a UK National Health Service audiology department: Patients’ evaluations of the effectiveness of treatments. Int J Audiol, 55, 514-522.
Aazh, H., Moore, B.C.J. & Prasher, D. 2011. Providing support to school children with hyperacusis. British Journal of School Nursing, 6, 174-178.
Beck, A.T. 1976. Cognitive therapy and the emotional disorders. New York: International Universities Press.
Grewal, R., Spielmann, P.M., Jones, S.E. & Hussain, S.S. 2014. Clinical efficacy of tinnitus retraining therapy and cognitive behavioural therapy in the treatment of subjective tinnitus: a systematic review. J Laryngol Otol, 128, 1028-33.
Hoare, D.J., Edmondson-Jones, M., Sereda, M., Akeroyd, M.A. & Hall, D. 2014. Amplification with hearing aids for patients with tinnitus and co-existing hearing loss. Cochrane Database Syst Rev, 1, Cd010151.
Juris, L., Andersson, G., Larsen, H.C. & Ekselius, L. 2014. Cognitive behaviour therapy for hyperacusis: A randomized controlled trial. Behav Res Ther, 54c, 30-37.
Phillips, J.S. & McFerran, D. 2010. Tinnitus Retraining Therapy (TRT) for tinnitus. Cochrane Database Syst Rev, 3, Cd007330.
Rogers, C. 1951. Client-Centered Therapy. UK: Constable and Company Limited.
Tyler, R.S., Haskell, G., Preece, J. & Bergan, C. 2001. Nurturing patient expectations to enhance the treatment of tinnitus. Seminars in Hearing, 22, 15-21.