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:


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 (art. Tinnitus)

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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




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