Treating Tinnitus Across a Broad Patient Population Requires Multiple Management Options Beyond Just Hearing Aids
Caroline Hamilton, BSc, MSc, Anita Sayers, BSc, MSc and Helen MacMahon, BA, MSc
Tinnitus is the perception of sound in the absence of an external acoustic stimulus. Tinnitus is associated with hearing loss, and thus, hearing aids are considered as a management option for tinnitus. Hearing aids are often the only option provided for tinnitus patients in a clinical setting; therefore, it is interesting and instructive to examine the patient treatment pathway in a clinic with multiple tinnitus management options available. Analyzing the results of 297 patients in a clinical setting where a range of options are available for tinnitus treatment, including hearing aids, neuromodulation, and tinnitus therapy in the form of cognitive behavioural therapy (CBT), there was a considerably low uptake of hearing aids compared to the other treatment modalities that were offered to the patients. This article discusses how and why patients do not opt for hearing aids when provided with multiple tinnitus management options.
Tinnitus and hearing loss; hearing aids as a tinnitus management option
Tinnitus is the perception of sound in the absence of an external acoustic stimulus1,2. Research indicates a correlation between hearing thresholds and tinnitus, with 85-90% of tinnitus sufferers experiencing varying degrees of hearing loss3-6. It is for this reason that hearing aids often serve as a management option for those experiencing tinnitus. However, there are also limitations associated with this treatment pathway for tinnitus,7-9 found in a scoping review of evidence on hearing aids for tinnitus that due to the variability in the quality of evidence (out of the 28 primary research studies that were selected), no consensus was reached in relation to the use of hearing aids as a treatment for tinnitus. While 68% of the studies demonstrated some positive results of hearing aids for tinnitus relief, they showed variability across tinnitus patients. However, 14% of studies demonstrated no change in tinnitus perception. Also noteworthy is that hearing aid compliance may be affected by loudness discomfort and lack of motivation10.
Low uptake of hearing aids in a tinnitus clinic that provides multiple tinnitus management options
Data were collected from 297 tinnitus patients who sought help at the Otologie Tinnitus Care Clinic in Dublin, Ireland, which provides multiple tinnitus management options. Based on their audiological test results, the options that were recommended to the patients included hearing aids, tinnitus therapy in the form of cognitive behavioral therapy, and neuromodulation in the form of the Lenire bimodal stimulation treatment manufactured by Neuromod Devices (device combines sound and electrical tongue stimulation). Prior to the audiological assessment, patients were asked if they believed they had a hearing loss. While 48.8% of respondents answered yes to this question, results of audiological assessments available for 237 patients, indicated that 81% had an actual objective hearing loss. The mean age of the patients within the normal hearing level category was 39.2 years while the mean age of patients with at least a mild hearing loss in the worse ear was 56.6 years. This information highlights a cohort of patients younger in age with tinnitus and within the normal hearing category. While patients in this group may not require amplification at this point, hearing aids may be an option in the future. Based on their audiological and tinnitus profile, as well as a detailed patient history that focused on both their hearing loss as well as their tinnitus, patients were then advised regarding the most ‘suitable’ treatment option. Some patients were deemed suitable for more than one treatment (i.e., Lenire and hearing aids). Following discussion with each of the patients regarding treatment options and prioritizing what was most bothersome to them (i.e., their hearing loss or their tinnitus), 64.7% of the overall cohort of patients were ‘referred’ on for Lenire treatment, 26.3% for tinnitus therapy and 8.4% (25 patients) for hearing aids. These patients who were recommended hearing aids had sufficient hearing loss and difficulties in their daily lives to justify hearing aids. However, only eight of these 25 patients actually purchased hearing aids to treat their tinnitus, representing a very small percentage (~3%) of all 297 patients that came into the clinic seeking tinnitus treatment.
Although historically many tinnitus patients have some form of hearing loss, it was surprising to observe that those actually seeking treatment for their tinnitus were not typically those with sufficient hearing loss to be recommended for a hearing aid. Furthermore, of those who were recommended a hearing aid for tinnitus treatment, only a few purchased devices.
The very low adoption of hearing aids in a tinnitus clinic can be attributed to a number of different factors. Although tinnitus is highly correlated to hearing loss, there are many tinnitus patients whose hearing loss does not cause them concern or impact them to the point where they require amplification. Although hearing aid technology has evolved over the last number of years and many devices include updated tinnitusspecific features, tinnitus patients are often unmotivated to use hearing aids that are originally designed to address hearing loss or are influenced by the taboo towards them11,12.
Another aspect to take into consideration is that tinnitus is a condition that is heterogenous in nature with variations occurring in auditory perception, risk factors, comorbidities, and impact on quality of life13,14. The auditory perception of tinnitus presents itself in myriad forms with variation occurring in the location, frequency, tone, and intensity of the sound15. The impact of tinnitus on quality of life is wide-ranging and habituation to the sound may occur. It is also noted that tinnitus leads to varying susceptibility to psychological factors, such as depression and anxiety, as well as impairment across functional and cognitive abilities16-18. Due to the wide variation and heterogeneity seen in individuals with tinnitus, it is recommended that different tinnitus management and treatment options are provided to reflect this diversity.
Considering that many tinnitus patients are not interested or are not needing to purchase a hearing aid to treat their tinnitus, and due to the heterogenous nature of how tinnitus affects different patients, it is important for hearing clinics to provide multiple treatment options beyond just hearing aids, such as CBT and neuromodulation treatments to help a much larger and diverse patient population suffering from tinnitus. ■
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Caroline Hamilton is the Global Director of Audiology at Neuromod Devices. Anita Sayers is the Head of Tinnitus Care at Otologie. Helen MacMahon is a Clinical Audiologist at Otologie.