As part of an expert group that developed clinical practice guidelines for severe and profound hearing loss, I was asked to look into the literature on tinnitus management for this target group. I was surprised to discover how little evidence exists. I also found that clinical guidelines did not specifically recommend a management based on the severity of hearing loss.
Most guidelines for tinnitus management focus on normal hearing or mild to moderate hearing loss. Individuals with severe and profound hearing loss can be similarly affected by tinnitus and as you can imagine, special care is needed for this group. In this blog post, I provide some background and guidance on how to manage tinnitus in those with severe and profound hearing loss.
Let us start with the basics. Tinnitus is defined as the involuntary perception of sound in the absence of an external source, which is often perceived within one or both ears or the head.
The origin of tinnitus is still not completely understood, but it is most likely caused by a degree of overactivity within the nerve and brain systems related to hearing function. Tinnitus is commonly associated with hearing loss, noise exposure, aging and stress.1,2
The burden of tinnitus
Tinnitus is a very common symptom in our society. About 10-15% of the world population experiences tinnitus,1,3 which means many of us have either experienced tinnitus or know someone who does. However, not all individuals with tinnitus need help. It is estimated that about 20% of individuals experiencing tinnitus need clinical intervention.1 Usually, the burden of tinnitus is not the audible noise but the negative/emotional response it evokes.
Although tinnitus is not considered an actual disease, it changes how a person perceives their own hearing. Different grades of severity or decompensation exist, which can range from mild to catastrophic.3 The decompensation can result in stress, anxiety, depressive symptoms, sleep problems and overall loss of well-being.
Tinnitus and hearing loss
Hearing loss is strongly associated with tinnitus. In about 80-90% of tinnitus cases, some form of hearing loss is present. Vice versa, about 50% of hearing-impaired individuals also suffer from tinnitus.1 Tinnitus burden seems to be independent of the severity of hearing loss and these percentages are similar between the different groups of hearing loss.
This means that many of the patients with severe to profound hearing loss who come to audiology clinics experience bothersome tinnitus.
There is not one single type of tinnitus patient or intervention. Tinnitus is a highly complex condition with very individual patient profiles that need special care. Tinnitus has a strong impact on well-being, with 38% of a group of individuals with severe and profound hearing loss reporting that tinnitus negatively impacted their quality of life.4
In recent years, great effort from the clinical and scientific community has been made to publish clinical practice guidelines on tinnitus management.1,5,6 These guidelines are helpful for tinnitus management, but they are mostly independent of severity of hearing loss. As mentioned earlier, tinnitus in the presence of severe and profound hearing loss is largely excluded in all the existing tinnitus guidelines.6
How to manage tinnitus for individuals with severe and profound hearing loss
In the case of tinnitus in clients with severe and profound hearing loss, management should be provided early in the rehabilitation process. First, it is important to exclude issues like excessive cerumen in the ear canal or other underlying medical conditions that can be diagnosed by an Ear Nose and Throat (ENT) doctor. Red flags like sudden onset of hearing loss and/or tinnitus should be referred to an ENT doctor as an emergency case.
A thoroughly conducted tinnitus history is a crucial part of the diagnostic assessment. This should be done in the beginning to determine the burden of tinnitus and the affected domains of life. The use of standardized questionnaires, such as the tinnitus handicap inventory (THI) , is strongly recommended to guide tinnitus intervention based on the individual’s needs. Such questionnaires should also be used to monitor the progress of the tinnitus management.5
For those with severe and profound hearing loss and tinnitus, it is strongly recommended that hearing loss be addressed first. On top of improving quality of life and reducing the burden of communication, in most cases, fitting a hearing aid also provides relief of tinnitus burden7,8,9 In cases where the hearing loss is not aidable with hearing aids, cochlear implants should be considered as an alternative.1,5 Many CI candidates (67-100%) complain about tinnitus before implantation, and in 28-51%, the tinnitus improved after the surgery.3
Sound therapy for tinnitus is usually used to shift the attention away from the tinnitus to a more neutral sound (noise) to create habituation to the tinnitus so it is perceived as ‘usual’ background noise. Any type of sound is suitable to reduce tinnitus symptoms and sound therapies might provide acute relief.10 The evidence supporting the benefit of sound therapy as an isolated treatment, however, is sparse.8,10
In the case of severe and profound hearing loss, sound therapy has a limited benefit for managing tinnitus. To make the noise audible, the volume levels need to be respectively high. The sound generators in modern hearing aids should not be activated in programs that are dedicated for speech understanding to not drown out speech signals or other important signals e.g. warning sounds.11
A separate program focusing on the noise generator can be set up to be used (e.g. at home to get some short-term relief of tinnitus). Other home-based alternatives such as radio, TV or other music options can be used as well. Also here, the volume level should be set so that important sounds can still be perceived.
Advanced tinnitus counseling
When amplification and sound therapy are not enough to reduce the burden of tinnitus, advanced counseling (i.e., tinnitus-specific) is recommended. Advanced counseling like Cognitive Behavioral Therapy (CBT) or Tinnitus Retraining Therapy (TRT) cannot cure the tinnitus, but it can help to adopt coping mechanisms to lessen the burden.
Especially in the case of anxiety or depressive symptoms, these specific counseling techniques are highly recommended.3 Depending on the type of counseling, the focus might be on understanding tinnitus, learning to relax and/or learning tinnitus confrontation techniques. Cognitive-behavioral therapy (CBT) is currently the gold standard of tinnitus therapy as a lot of studies show the clinical effectiveness of this approach.1,12,13
Key take-aways for audiologists
For your clients with severe and profound hearing loss, it is of utmost importance that tinnitus interventions are delivered in a format that is accessible. As most of these advanced approaches are based on verbal counseling, face-to-face sessions are recommended.
Not every audiologist is a specialist for CBT or other types of tinnitus. Building up a referral network with tinnitus experts, psychologists and other disciplines can help you provide the appropriate management.
To learn more on tinnitus management for those with severe and profound hearing loss, I recommend you read the full text of our recent publication, Guidelines for Best Practice in the Audiological Management of Adults with Severe and Profound Hearing Loss.
The podcast, ‘The Audiologist’, just launched a new series based on content in the severe and profound guidelines. It delivers informative interviews with the experts who created them.
Maren Stropahl will be one of the experts interviewed in coming weeks and will further discuss tinnitus care for those with severe and profound hearing loss.
In the first interview of the series, Laura Turton, clinical audiologist and editor of the guidelines, explains how the guidelines can be implemented in clinical practice. Find the first podcast in the series here!
- Cima, R.F.F., Mazurek, B., Haider, H., Kikidis, D., Lapira, A., Noreña, A., & Hoare, D.J. (2019). A multidisciplinary European guideline for tinnitus: diagnostics, assessment, and treatment. Hno; 67(1), 10-42.
- Shore, S., Zhou, J., & Koehler, S. (2007). Neural mechanisms underlying somatic tinnitus. Progress in brain research, 166, 107-548.
- Baguley, D., McFerran, D., & Hall, D. (2013). Tinnitus. The Lancet; 382(9904), 1600-1607.
- Carlsson P-I, Hjaldahl J, Magnuson, A., et al. (2015). Severe to profound hearing impairment: quality of life, psychosocial consequences and audiological rehabilitation. Disabil Rehabil; 37(20): 1849–1856
- Tunkel, D. E., Bauer, C. A., Sun, G. H., Rosenfeld, R. M., Chandrasekhar, S. S., Cunningham Jr, E. R., … & Whamond, E. J. (2014). Clinical practice guideline: tinnitus. Otolaryngology–Head and Neck Surgery, 151(2_suppl), S1-S40.
- Tinnitus: assessment and management NICE guideline Published: 11 March 2020 www.nice.org.uk/guidance/ng155
- Tutaj, L., Hoare, D.J. & Sereda, M. (2018). Combined amplification and sound generation for tinnitus: a scoping review. Ear Hear; 39(03):412–422
- Sereda, M., Xia, J., El Refaie, A., Hall, D.A. & Hoare, D.J. (2018). Sound therapy (using amplification devices and/or sound generators) for tinnitus. Cochrane Database Syst Rev; 12(12):CD013094
- 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; (01): CD010151
- Schad, M. L., McMillan, G.P., Thielman, E.J., Groon, K., Morse-Fortier, C., Martin, J.L., & Henry, J.A. (2018). Comparison of acoustic therapies for tinnitus suppression: A preliminary trial. International Journal of Audiology; 57(2), 143-149.
- British Society of Audiology (BSA) (2020). Fitting of combination hearing aids for subjects with tinnitus. Available at: https://www.thebsa.org.uk/ resources/practice-guidance-fitting-of-combination-hearing-aids-for-subjects-with-tinnitus/. Accessed June 23, 2020
- Hoare, D.J., Kowalkowski, V.L., Kang, S. & Hall, D.A. (2011). Systematic review and meta-analyses of randomized controlled trials examining tinnitus management. Laryngoscope; 121(07):1555–1564
- Hesser, H., Weise, C., Westin, V.Z., Andersson, G. (2011). A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioral therapy for tinnitus distress. Clin Psychol Rev; 31 (04):545–553