Direct Intervention vs. Indirect Approaches: Tackling Tinnitus Head-On
If you talk to your primary care physician, ask your friends and neighbors, or dare to search the internet, you will come across a never-ending sea of options for treating tinnitus. You will find everything from white-noise generators to acupuncture.
For the most up to date information on tinnitus, please visit www.excellenceinaudiology.org.
Regardless of the exact treatment, all tinnitus treatments fall into one of two categories: Direct or Indirect Treatment.
Direct and Indirect treatment are terms often used in the context of healthcare and therapy to describe different approaches to addressing a patient’s condition or symptoms. The primary difference between these two approaches is how they target the actual underlying pathology. While Direct treatment involves directly addressing the underlying cause or symptoms of a condition, Indirect treatment focuses on addressing symptoms or triggers associated with a condition rather than directly targeting the underlying cause.
The underlying cause of tinnitus in the vast majority of patients (over 90%) is the progressive breakdown of the neural integrity of the ear-to-brain connections. Thus, Direct treatment of this condition would be to focus on neural preservation by stimulating remaining neurons and slowing the progression of the pathology.
Direct Treatment for Tinnitus
Today’s prescriptive hearing treatment technology employs advanced techniques to directly stimulate the brain and compensate for missing neural signals, while also mitigating the ‘central gain’ related to the perception of tinnitus. This method of direct treatment can be achieved through modern technology that utilizes artificial intelligence (AI) to present sound to the brain through acoustic or electric means.
- Prescriptive Technology with AI: Using modern technology, we can offer patients cutting-edge treatment that enhances signal processing and tailors auditory input to an individual’s specific needs. This new technology can analyze incoming auditory activity and adjust the stimulation parameters to optimize sound perception. This approach aims to mimic the brain’s natural processing of sound, thus addressing the issue of central gain, which is the brain’s tendency to amplify weak auditory signals. In the AAO-HNS report, it was noted that this form of treatment had a “preponderance of benefit” with no significant risks or harms.
- Cochlear Implants: Cochlear implants are surgically implanted devices that bypass damaged receptor hair cells in the inner ear and directly stimulate the auditory nerve with electrical impulses. They consist of an external microphone and speech processor that capture sounds, convert them into electrical signals, and transmit them to an implanted electrode array. This direct stimulation helps individuals with hearing loss receive auditory input that would otherwise be compromised.
- Currently, cochlear implant surgery is reserved only for those patients with tinnitus who have significant hearing loss and do not receive any benefit from prescriptive technology. What's even more worrisome is that certain reports indicate that tinnitus worsened after cochlear implant surgery in 10-15% of patients.
- Perhaps the most controversial form of direct treatment for tinnitus is surgical removal of the auditory nerve. The AAO-HNS does not recommend this procedure for several reasons highlighted below.
- Surgical Removal of the Auditory Nerve: Surgery to sever the auditory nerve as a treatment for tinnitus is a relatively uncommon and highly invasive procedure. Severing the auditory nerve is typically considered a last resort when all other treatments have failed, and the tinnitus is severely impacting a person’s quality of life.
There are some key points to consider regarding this procedure:
- High Risk – Severing the auditory nerve is a high-risk procedure that is likely to result in permanent hearing loss. It is usually reserved for extreme cases of tinnitus where other treatments, such as direct treatment, and/or cognitive-behavioral therapy, have not been effective.
- Unpredictable Outcomes: The effectiveness of the surgery in relieving tinnitus can vary from person to person. Some individuals may experience relief from the tinnitus, while others may not experience any improvement or may even have worsened symptoms.
- Hearing Loss: Since the auditory nerve carries signals from the inner ear to the brain, severing it will result in complete hearing loss in the affected ear. This procedure is usually only considered for individuals who have already experienced significant hearing loss in that ear.
- Balance Issues: Severing the auditory nerve can also affect balance because it is closely connected to the vestibular system, which helps control balance. Post-surgery balance issues are common, and rehabilitation may be necessary.
- Risks and Complications: Like any surgery, there are risks and potential complications associated with severing the auditory nerve, including infection, cerebrospinal fluid leakage, and injury to nearby structures.
Indirect Treatment for Tinnitus
Many Indirect treatment options for tinnitus exist. While some of these treatments can serve to enhance the impact of Direct treatment, many of them have limited or no scientific backing.
- Sound Therapy: Often, ‘sound therapy’ will be recommended to patients. This entails using an external sound generator to help them mask or ignore the phantom sounds in their head. For instance, they can use a fan, a white noise generator, or a sound-generating app on their smartphone while attempting to sleep. Some available noise generators can even be worn at ear level (and appear to look like a traditional hearing aid). The goal of this indirect treatment is to make the tinnitus less noticeable or bothersome. The AAO-HNS considers this indirect treatment a viable option but warns against promoting false hope to patients by offering this intervention with uncertain efficiency.
- Counseling and Education: Educating a patient on their medical condition must always be a part of the therapeutic process. Tinnitus counseling focuses on educating individuals about their condition, helping them understand the underlying causes, and teaching coping strategies to reduce anxiety and stress associated with tinnitus. The AAO-HNS notes that education has a preponderance of benefit over harm and values the role of education in counseling patients.
- Cognitive-Behavioral Therapy (CBT) (aka ‘talk therapy’) is a common approach within counseling to address the emotional impact of tinnitus. CBT is a widely recommended and very effective form of psychotherapy that focuses on addressing and changing negative thought patterns and behaviors to improve mental health and well-being. CBT is based on the idea that our thoughts, feelings, and behaviors are interconnected, and by identifying and modifying unhealthy thought patterns and behaviors, individuals can experience significant improvements in their psychological and emotional functioning. Clinicians are encouraged to recommend CBT to patients experiencing persistent and bothersome tinnitus.
- Tinnitus Retraining Therapy (TRT): TRT is a form of Indirect therapy that combines counseling and sound therapy. It aims to desensitize individuals to the tinnitus sound, reducing its perceived loudness and distress. TRT often involves wearing hearing devices that emit low-level noise to habituate the brain to the tinnitus sound. Much conflict surrounds the efficacy of TRT, including a history of poorly designed studies and a recent report in the Journal of the American Medical Association (JAMA), which found no outcome difference in the group with vs. without TRT.
- Medications: Some medications may be prescribed to alleviate the symptoms of tinnitus, especially if an underlying medical condition is contributing to it. However, there is no single medication that consistently works for tinnitus, and their effectiveness varies from person to person. The consensus of the AAO-HNS is not to recommend medication for the specific treatment of tinnitus.
- In some cases, medications may be prescribed to help manage tinnitus-related conditions, such as anxiety or depression. The medications might include antidepressants (to help with the emotional distress that tinnitus can cause), anxiolytics (anti-anxiety drugs to reduce the anxiety associated with tinnitus), and hearing loss medications (to improve blood flow to the inner ear).
- Lifestyle Changes: Making lifestyle changes can indirectly help manage tinnitus. Reducing exposure to loud noises, managing stress, regular exercise, and avoiding excessive caffeine and alcohol consumption can all have a positive impact on tinnitus symptoms. Often, your hearing healthcare provider will ask you to keep a ‘log’ of daily activities to help uncover triggers that can worsen the experience with tinnitus.
- Herbal Supplements: There are many unfounded claims about herbal supplements and treating tinnitus. Below are two lists of supplements: one with evidence of decreasing the experience of tinnitus and the other with no scientific validity.
- Herbal Supplements with Strong Evidence to Decrease Tinnitus
- Vitamin B12: A deficiency in Vitamin B12 has been associated with deficits in neural function throughout the brain, especially in older individuals. If you have a Vitamin B12 deficiency, supplementation is recommended for many reasons, including enhanced cognitive performance and the potential to reduce tinnitus.
- Melatonin: A high level of scientific data exists to corroborate the notion that melatonin can reduce the experience of tinnitus. Although the mechanism is not well understood, it stands to reason that increased sleep can reduce the stress and anxiety related to tinnitus and, therefore, decrease the experience of tinnitus.
- Herbal Supplements with Limited Evidence to Decrease Tinnitus
- Ginkgo Biloba: Ginkgo Biloba is an herbal supplement that has been suggested to improve blood flow to the inner ear. To date, no scientific studies exist to back up these claims.
- Zinc: Zinc deficiency has been linked to tinnitus in some cases; thus, it stands to reason that zinc supplementation may be helpful if you have a deficiency. The jury is out on this supplement.
- Magnesium: Magnesium is involved in nerve function and has been studied for its potential role in reducing tinnitus symptoms, particularly in cases related to noise-induced hearing loss.
- Coenzyme Q10 (CoQ10): CoQ10 is an antioxidant that may help improve circulation and reduce oxidative stress in the inner ear. Some people have reported a reduction in tinnitus symptoms when taking CoQ10.
- Omega-3 Fatty Acids: Omega-3 fatty acids, found in fish oil supplements, have anti-inflammatory properties, and may support overall ear health.
- Herbal Supplements with Strong Evidence to Decrease Tinnitus
- Acupuncture: Acupuncture is an alternative Eastern medicine practice that involves inserting thin needles into specific points on the body to stimulate various physiological responses. Acupuncture may vary from person to person, depending on the specific cause of their tinnitus. When performed by a trained and licensed practitioner, acupuncture is considered safe and can be very effective. Limited data exists to support any claim that acupuncture can reduce the experience of tinnitus.
As a rule, when it comes to treatment options for tinnitus, the more salacious and outrageous the claim is, the less likely it is to be true! Also, any marketing that claims the treatment of tinnitus is quick and easy (i.e., take this pill, and your tinnitus will go away) is generally suspect.
To get the most current and accurate information about hearing treatments and recommendations from AAO-HNS, I recommend you check GetTinnitusTreatment.com for up-to-date medical recommendations and consult with your local Excellence In Audiology-approved tinnitus treatment provider.