Overview of tinnitus –
including the role of hearing aids in tinnitus management
• A presentation for ENT specialists
PIP_Tinnitus_Presentation V1.00/2014-03/XPl © Phonak AG / uncontrolled copy
4/8/2015
Slide 1
Objectives
• To describe the key features of tinnitus
• To show how tinnitus is a substantial health burden
• To reveal the role of hearing loss in tinnitus
• To present the options for management, including the central role of hearing aids
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Slide 2
What is tinnitus?
• Perception of sound but no external
source
• Usually experienced as buzzing, hissing or
ringing
–
Not fully-formed sounds
e.g. speech or music
–
Not sound hallucinations experienced
during bouts of mental illness
–
Occurs in one or both ears, or arising
within the head
• It can have a profound effect on the
sufferer
“… perceived severity of tinnitus
correlates closer to psychological and
general health factors, such as pain or
insomnia, than to audiometrical
parameters …”
Langguth B, et al. (2013) Lancet Neurol.12:920-930; Zöger S et al. (2006) Psychosomatics. 47:282-288.
(Zoger et al, 2006)
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Slide 3
Sound features of tinnitus
Sounds experienced in tinnitus can vary according to several criteria:
NOISE CRITERIA
POSSIBLE FEATURES
Onset
Sudden, gradual
Pattern
Pulsatile, intermittent, constant, fluctuating
Site
Right or left ear, both ears, within head
Loudness
Wide range, varying over time
Quality
Pure tone, noise, polyphonic
Pitch
Very high, high, medium, low
Langguth B, et al. (2013) Lancet Neurol.12:920-930.
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Slide 4
Evaluating tinnitus severity
• Tinnitus is highly variable. Some patients
are able to cope with the noise and their
lives continue as normal.
Langguth B, et al. (2013) Lancet Neurol.12:920-930.
• At the other extreme, some patients suffer
so much that daily living is difficult and
they are unable to work. Others suffer a
level of impairment between these two
levels.
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Slide 5
The burden of tinnitus
SCALE OF
PROBLEM
IMPACT
TINNITUS RISK
FACTORS
A GROWING
PROBLEM
• Tinnitus affects
• Tinnitus limits
• Hearing
• Increasing size
10%–15% of the
general
population
worldwide
• This is an
estimated 280
million people
daily living in
1%–2% of
people with
tinnitus
impairment
• Increasing age
of the elderly
population
• Gender (male)
• Frequency of
• Exposure to
noise
Geocze L, et al. (2013) Braz J Otorhinolaryngol.79:106-111; Langguth B, et al. (2013) Lancet Neurol.12:920930; Roberts LE, et al. (2010) J Neurosci. 30:14972-14979.
noise exposure
in work and
leisure
environments
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Slide 6
Peripheral events lead to central neurological changes
• A range of peripheral events can lead to central neuronal changes that manifest as tinnitus
• Other factors can be involved in either the development or the persistence of tinnitus
HEARING LOSS
CENTRAL
NOISE TRAUMA
AUDITORY
PATHWAY
OTOTOXIC
DRUGS
TINNITUS ONSET
TINNITUS
PERSISTENCE
NEURONAL
ABNORMALITIES
AUDITORY
NERVE
ABNORMALITIES
Langguth B, et al. (2013) Lancet Neurol.12:920-930.
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Slide 7
Brain response to auditory deprivation
• Patients with tinnitus exhibit enhanced auditory sensitivity
DECREASED
SOUND INPUT
INCREASED
SOUND
SENSITIVITY
• This is caused by hyperactivity of the auditory central nervous system
–
Homeostatic pathways cause increased central ‘gain’ (i.e. sensitivity) in response to
auditory deprivation to:
1. Maintain
2. Ensure
central nervous system activity during low sensory input
nerve activity is modulated to respond to changes in sensory input
• In patients with tinnitus and hearing loss, the tinnitus pitch and the hearing loss frequency
spectrum are usually matched
Hebert S, et al. (2013) J Neurosci 33:2356-2364; Langguth B, et al. (2013) Lancet Neurol.12:920-930; Norena
AJ, Farley BJ. (2013) Hearing Res 295:161-171.
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Slide 8
Tinnitus is a balance of sensory input and spontaneous
activity
The decreased input from the cochlea, due to outer hair cell damage, results in
readjustments in the central auditory system resulting in abnormal neural activity including
hyperactivity, bursting discharges and increases in neural synchrony.
AUDITORY
DEPRIVATION
AND CENTRAL
GAIN
ALTERED
SPONTANEOUS
NEURONAL
ACTIVITY
TINNITUS
Norena AJ, Farley BJ. (2013) Hearing Res 295:161-171.
Kaltenbach JA. (2011) „Tinnitus: models and mechanisms“. Hear Res. June; 276 (1-2) : 52 – 60.
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Slide 9
Tinnitus and hearing loss
Most patients with tinnitus have some degree of hearing loss
75%–90%
ABOUT 80%
OF PATIENTS
WITH
OTOSCLEROSIS
HAVE TINNITUS
OF PATIENTS
WITH IDIOPATHIC
SENSORINEURAL
HEARING LOSS
HAVE TINNITUS
“Hearing loss is a hidden disability and
to have tinnitus is sort of like a double
whammy”
Family physician with moderate tinnitus, Canada
Axelsson A, Ringdahl A (1989) Br J Audiol 23:53-62; Ayache D, et al (2003) Otol Neurotol 24:48-51; NosratiZarenoe R et al (2007) Acta Otolaryngol 127:1168-1175; Sobrinho PG et al. (2004) Int Tinnitus J 10:197-201;
Schaette R et al. (2012) PLoS One 10.1371/journal. pone.0035238.
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Slide 10
Tinnitus and distress: a vicious cycle
• Experiencing sound in the absence of an external stimulus can be emotionally upsetting
• This reaction can make the sounds appear worse
• This results in a vicious cycle of worsening tinnitus and increasing distress
TINNITUS
EMOTIONAL
DISTRESS
Schaette R. (2012) Phonak Focus 42.
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Slide 11
Other psychological associations with tinnitus
• Tinnitus is associated with increased levels of psychological problems
–
24/90 (26.7%) versus 5/90 (5.6%) for age-matched controls without tinnitus
HYPOCHONDRIA
HYPERACUSIS
ANXIETY
TINNITUS
COGNITIVE
IMPAIRMENT
Andersson G, McKenna L. (2006) Acta Otolaryngol Suppl. 556:39-43; Belli H, et al. (2012) Gen Hosp
Psychiatry. 34:282-9; Jackson J, et al. (2013) Int J Audiol. E-pub ahead of print; Langguth B, et al. (2013)
Lancet Neurol.12:920-930.
DEPRESSION
SLEEP
PROBLEMS
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Slide 12
Anxiety and depression correlate with severity of tinnitus
TINNITUS (ALL SEVERITIES),
N=80
HIGH-RISK OF CHRONIC,
DISABLING TINNITUS, N=144
r
P
r
P
Current minor depression (SCID)
0.42
<0.0001
0.43
<0.0001
Major depression (SCID)
0.41
0.0002
0.39
<0.0001
Current anxiety disorder (SCID)
0.12
NS
0.28
0.0010
0.01
NS
0.26
0.0023
0.42
<0.0001
0.48
<0.0001
Depression (HADS)
0.30
0.0079
0.38
<0.0001
Anxiety (HADS)
0.35
0.0018
0.45
<0.0001
Total (HADS)
0.36
0.0014
0.46
<0.0001
Current multiple anxiety disorders
(SCID)
Current depression and/or anxiety
disorders (SCID)
r = correlation coefficient between severity of tinnitus and prevalence of depression and anxiety (higher r = stronger correlation)
HADS: Hospital Anxiety and Depression Scale; NS: non statistically significant; SCID: Structured Clinical Interview for DSM-III-R
Zöger S et al. (2006) Psychosomatics. 47:282-288.
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Slide 13
Other tinnitus-associated problems
SLEEP PROBLEMS
COGNITIVE
IMPAIRMENT
HYPERACUSIS
• Sleep disturbance is
• Patients with tinnitus can
• Hyperacusis is an
common in patients with
tinnitus
• In particular, the time taken to
achieve sleep may be
lengthened in tinnitus
patients
• Insomnia and tinnitus-
associated distress can work
together in a worsening spiral
to adversely affect
psychological wellbeing
exhibit depressive
functioning and/or anxious
vigilance
• Cognitive performance can
be worse among tinnitus
sufferers versus controls in
the absence of depression
and anxiety
oversensitivity to certain
sound frequencies or
volumes
• It is common among tinnitus
sufferers and may be a
consequence of tinnitus
• In an age-matched control
study, 60% of tinnitus
sufferers reported
hyperacusis, compared to
20% of controls
• Hyperacusis is measureable
in tinnitus ears with and
without hearing loss
Andersson G, McKenna L. (2006) Acta Otolaryngol Suppl. 556:39-43; Bastos de Magalhaes SL, et al. (2003) Int Tinnitus J. 9:79-83; Belli H, et al. (2012) Gen Hosp
Psychiatry. 34:282-9; Hebert S, et al. (2013) J Neurosci. 33:2356-2364; Jackson J, et al. (2013) Int J Audiol. E-pub ahead of print; Langguth B, et al. (2013) Lancet
Neurol.12:920-930; Wallhäusser-Franke E, et al. Sleep Med Rev. 17:65-74.
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Slide 14
Tinnitus management options
Currently, there is no cure for tinnitus, but management is possible
EVIDENCE BASED
TINNITUS
MANAGEMENT
APPROACHES
e.g. TINNITUS
RETRAINING THERAPY
HEARING AIDS
DRUGS
TINNITUS
COUNSELLING
SOUND THERAPY
Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Langguth B, et al. (2013) Lancet Neurol.12:920-930;
Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762
COGNITIVE
BEHAVIOURAL
THERAPY
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Slide 15
Hearing aids are central to tinnitus management
• Reports of the use of hearing aids in the
management of tinnitus go back over 60
years
• Because hearing loss is often associated
with tinnitus, at least partial restoration of
hearing should help to reduce the central
gain in auditory perception that is a
feature of tinnitus
• A recent scoping review of studies of
hearing aids in tinnitus revealed that 17/18
publications showed improvements in
tinnitus symptoms by fitting hearing aids
“The majority of studies reviewed
support the use of hearing aids for
tinnitus management. Clinicians
should feel reassured that some
evidence shows support for the
use of hearing aids for treating
tinnitus …”
Shekhawat et al, 2013
Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762
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Slide 16
Interventional studies of the benefits of hearing aids
• A scoping review identified 11
interventional studies of hearing aids
• Six types of tinnitus evaluation were used:
–
THI x 4; THQ x 1; TRQ x 1; TSI x 1; TQ
x 1; VAS x 3
• Up to 50% reduction in tinnitus severity
• 10/11 studies showed improvements
>10%
Tinnitus measurement tool
THI: Tinnitus Handicap Inventory; THQ: Tinnitus Handicap Questionnaire; TRQ:
Tinnitus Reaction Questionnaire; TSI: Tinnitus Severity Index; TQ: Tinnitus
Questionnaire; VAS visual analogue scale (various)
Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762
4/8/2015
Slide 17
Patient and hearing-care professional surveys of the benefits of hearing
aids
Scoping review identified 4 survey studies
STUDY 1
STUDY 2
STUDY 3
STUDY 4
• Binaural hearing
• 65.5% of
• Fitting a hearing
• Audiologist-
aids provided
benefit in 66%
(47/71) of
tinnitus patients
patients with
frequent tinnitus
reported
improvements
with hearing aids
• 41.4% reported
disappearance of
symptoms
Shekhawat GS, et al. (2013).J Am Acad Audiol. 24:747-762
aid was the most
frequently
reported benefit
of visiting a
specialised
tinnitus clinic
• Reported by
34.9% of
patients
reported tinnitus
relief after fitting
a hearing aid
–
Minor to major
relief in 60% of
cases
–
Major relief in
22% of cases
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Slide 18
Masking level and tinnitus reduction
• Retrospective study of 70 patients with
tinnitus in Australia
• Tinnitus severity measured using the
tinnitus reaction questionnaire (TRQ)
• Overall, 51% of patients experienced
“clinically significant” change (≥40%
change in TRQ score)
McNeill C, et al. (2012) Int J Audiol. 51:914-919.
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Slide 19
Psychological and behavioural support
INTERVENTION
DESCRIPTION
Counselling and
education
•
•
Delivered in person, to groups and via the internet
Variable results may depend on personal characteristics
•
Designed to modify maladaptive behavioural and emotional
responses
One-to-one and group settings, delivered by psychologists or
psychiatrists, or via internet
Statistically significant reductions in severity of tinnitus symptoms
(P<0.05)
Cognitive
behavioural
therapy
•
Relaxation therapy
•
•
May help reduce tinnitus symptoms and depressive symptoms
Hoare DJ, et al. (2011) Laryngoscope 121:1555-1564; Langguth B, et al. (2013). Lancet Neurol.12:920-930
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Slide 20
Drug options for tinnitus management
DRUG CLASS
EXAMPLES OF DRUGS USED IN TINNITUS
Antidepressants
tricyclics, selective serotonin reuptake inhibitors
Antipsychotics
sulpiride
Mood stabilisers
gabapentin, valproate
Sedatives/hypnotic
benzodiazepines
s
• No approved drugs (European Medicines Agency [EMA] or US Food and Drug
Administration [FDA])
• Some psychopharmacological agents may help reduce the severity of psychological issues
associated with tinnitus, and some may also lessen tinnitus symptoms
Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Langguth B, et al. (2013) Lancet Neurol.12:920-930
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Slide 21
The need for multidisciplinary care
• Tinnitus management should include hearing aids with appropriate frequency ranges
together with psychological support and education
• This requires a multidisciplinary care team
–
GP, ENT specialist, psychologist/psychiatrist and hearing-care professional
• As a leading supplier of hearing aids, Phonak can be another member of your team,
helping your patient to have the optimal hearing aid for their situation
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Slide 22
Thank you.
Contact information
Phone:
Email:
Website:
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Slide 23