Where are we Now?

There is a difference between people who experience tinnitus and people who experience from tinnitus. Tinnitus is very common: 30 percent of adults in Britain have experienced tinnitus of short duration and about 10 to 15 percent of the population have experienced prolonged tinnitus. Looking at people who seek treatment, 8 percent consult their GP and 3 percent visit a hospital.

Looking for the cause

Where are we now regarding mechanisms of tinnitus? If the ear was the cause of tinnitus and you treated the ear, you could get rid of tinnitus, but we have moved on a bit from there. Although the cochlear hair cells are still implicated in all forms as sensorineual hearing loss, there are different theories about how they are involved in generating a tinnitus signal. The management of tinnitus depends on the mechanism, but most people coming into tinnitus clinics will have tinnitus of sensorineual origin.

Early thinking

When people first looked at tinnitus management, they wanted some kind of pharmacological sure. A cure for tinnitus would be wonderful and various drugs have been tried that night work temporarily for some people, but to date we do not have a pill we can give to everybody with tinnitus to take it away. That may change, and we hope it does, but that is the situation today.

Electrical stimulation of the nerve has also been tried. In people with the latest generation of cochlear implants, 80 percent find their tinnitus suppressed. People with brainstem implants (an electrode pad is put into the brainstem rather than the cochlear) find similar results, but this is obviously not something you can use for people with normal hearing. Many other treatments have been tried and some do help with stress and anxiety, things like biofeedback are known to help with relaxation, but a lot of therapies and devices do not do what they claim.

At the moment there is no surgical or medical cure that works for everybody. So the best we can do is offer people with longstanding, distressing tinnitus a way of habituation to it.

What is habituation?

Habituation means more than 'getting used to' or 'developing tolerance of' tinnitus. With regard to tinnitus, it means tinnitus affecting one less and becoming less aware of tinnitus.

We all experience tinnitus. When we put on a new pair of shoes, a new scarf or tie, it is a new sensation, but soon after we don't see or feel it because we have habituation to it.

You can measure habituation in single cells and you can measure it in animal behavior. You can train animals to habituate. People whose tinnitus levels fluctuate find it more difficult to habituate, because every time they hear tinnitus there will be a strong reaction to it. Only when a person 'I have that before, it is not meaningful', can habituation start.

We can help with habituation. People have looked at different techniques, psychologists have suggested various ways, including relaxation, and have come up with a good cognitive behavioral therapy that works very well. If you can identify what people think about tinnitus, if they are anxious and depressed by it, and if you can change that, perhaps you can change the way they respond to it.

Masking out the noise

Masking has been tried, giving people a wide-band noise louder than their tinnitus and hoping they hear that rather than their tinnitus, but it is very difficult to mask tinnitus and any benefit is short term.

Complete masking however evolved into 'partial masking for the tinnitus retraining level' which means setting the level of the noise generator at or just below the level when it mixes with tinnitus. People hear the tinnitus as well as the sound therapy, thus reducing the contrast between tinnitus and background noise, and the tinnitus becomes less obvious. It has also been suggested that people do well with sound therapy because it gives them a feeling of control over their tinnitus.

The combination approach

In a research study conducted by Ross Dineen in Australia, where one group received information about tinnitus plus sound therapy, a second group given information about tinnitus and relaxation, and the third group received information, sound therapy, relaxation and behavioral therapy, the biggest change measure by response to tinnitus came from the third group. We cannot cure tinnitus, nor can we get rid of it for all the people all the time by all of the approaches we have at the moment.

Today's recipe for tinnitus treatment is a mixture of cognitive and behavioral management, sound therapy and relaxation techniques - a combination approach.

By Catherine M^cKinney, Audiological Scientist, Head of Audiological Services, Guy's and St. Thomas' Hospital, London.

Reprinted from Quiet - Journal of the British Tinnitus Association. Autumn 2000