This article integrates the highlights of the authors’ clinical experiences derived from existing protocols for tinnitus diagnosis and treatment with the evolving discipline of palliation medicine. Specifically, it demonstrates how the inclusion of principles of palliation medicine contributes to the efficacy of treatment.
The symptom of tinnitus, an aberrant auditory sensory perception, can be a horribly annoying problem for those who are sufferers and a frustrating problem for the physicians, audiologists, and others who are challenged to help these patients find relief from the sounds they are hearing in their head or ears. To some extent, tinnitus is pervasive; reportedly, 12 million people in the United States are troubled by tinnitus. In fact, tinnitus so commonly accompanies presbycusis, the hearing loss that occurs with aging, that many people think tinnitus is just “to be expected as part of growing older.”
In this article, the term tinnitus refers to subjective idiopathic tinnitus of the severe disabling type (SIT), a neurotologic disorder of the cochleovestibular system, which is acute or chronic in its clinical course, with interference in the life style of the patient.
Despite attempts over many years to identify an underlying cause of tinnitus and its site of lesion and to elucidate the pathophysiology that would explain why tinnitus occurs, tinnitus remains a disorder that must be categorized as idiopathic. Even though the biologic substrate for tinnitus is not well defined and there is no medical or surgical treatment reliably known to eradicate the symptom completely once it has become manifest, patients who have tinnitus can be helped by those doctors and other professionals who have the empathy, inclination, and expertise to offer treatments that can in many ways ameliorate the anguish of patients who have tinnitus.
At the Tinnitus Clinic of the Department of Otolaryngology, State University of New York, Downstate, and at the Martha Entenmann Tinnitus Research Center, Inc., since 1979, experience has been amassed with 10,000 patients who have SIT. Although the authors and their colleagues have varying levels of success in offering treatment for their patients, the basic tenet of their program is the age-old adage, “first, do no harm.” Thus, in a sense, although the authors accept the fact that eradication of the symptom of tinnitus may not be an achievable goal for many patients who come to them seeking help, they do aim to provide palliation.
Palliation has been defined as treatment given to relieve symptoms. Palliation also implies a treatment consisting of disguising or concealing a disease. Palliative medicine is oriented to relief of the symptom rather than the underlying causal pathologic condition, with the intention of improving the quality of life (QOL) for the patient. Palliation medicine for otolaryngology has been limited and has focused primarily on symptoms associated with malignant disease of the head and neck (eg, pain control, relief and maintenance of function of the food and air passageways, hospice care).
A palliative approach for the patient who has SIT can be considered in terms of tinnitus relief achieved with combined treatment protocols, highlighted by medication and instrumentation, to achieve and maintain a QOL consistent with the goals of the individual patient (ie, maintenance of auditory function and communication abilities, physical integrity of the cochleovestibular system and normal brain function, normal behavioral psychologic responses in the presence of tinnitus, adequate sleep, participation in social activities).
Palliation for SIT combines a holistic, compassionate, symptomatic, and interdisciplinary approach to achieve at least a modicum of relief and is based on the application of varying regimens that have been developed, with information coming from advances in the understanding of auditory, brain, neural pathway, and psychodynamic functions.
Concepts and protocols for tinnitus diagnosis and treatment
The following concepts of palliative medicine from the literature, when integrated with those that have evolved from the authors’ clinical experiences with SIT protocols of diagnosis and treatment, are resulting in increasing success in achieving relief for the patient who has SIT.
Principles of palliative care for subjective idiopathic tinnitus of the severe disabling type
The evolution of the discipline of palliation medicine is well established in the twenty-first century and has witnessed the inclusion of nonmalignant disease, beyond quality-of-life (QOL) issues and hospice care for malignant disease, by application of clinical experiences for pain relief in nonmalignant conditions; in patients who have chronic diseases, symptoms, or injury; and in therapies directed to QOL issues.
The statement of principles developed by the Task Force on Surgical Palliative Care and the Committee on Ethics of the American College of Surgeons (ACS) in 2005 reflects this evolution to a broad range of patients receiving surgical care.
The following principles of palliative care for subjective SIT are recommended, reflecting modification and clinical application of the principles of palliative care proposed by the ACS:
- 1.
Respect the dignity and autonomy of patients who have tinnitus, patients’ surrogates, and caregivers.
- 2.
Respect and honor the right of the competent patient or surrogate to choose among treatments, including those that may or may not provide tinnitus relief.
- 3.
Communicate effectively and empathetically with patients, their families, and caregivers.
- 4.
Identify the primary goals of care from the patient’s perspective, and address how the professional attempting tinnitus relief can achieve the patient’s objectives and present the realities and limitations of what is and is not known about tinnitus.
- 5.
Do the best one can to achieve tinnitus relief, establish the medical significance of the tinnitus, and differentiate in treatment recommendations among the components of all sensations (ie, sensation, affect behavioral response to the sensation, psychomotor response to the sensation).
- 6.
Recognize, assess, discuss, and offer access to services of neurology, psychology or psychiatry, social issues, tinnitus patient support groups, and national and international tinnitus organizations.
- 7.
Provide access to therapeutic support when such support can realistically be expected to improve the QOL as perceived by the patient.
- 8.
Recognize the physician’s responsibility to discourage treatments that are unlikely to achieve the patient’s goals.
- 9.
Arrange for continuity of care by the patient’s primary or specialist physician or audiologist, alleviating the sense of abandonment that patients may feel when “curative” therapies are not available. Do not tell a patient, “You have to live with it.”
- 10.
Maintain a collegial and supportive attitude toward others entrusted with the care of the patient.
Principles of palliative care for subjective idiopathic tinnitus of the severe disabling type
The evolution of the discipline of palliation medicine is well established in the twenty-first century and has witnessed the inclusion of nonmalignant disease, beyond quality-of-life (QOL) issues and hospice care for malignant disease, by application of clinical experiences for pain relief in nonmalignant conditions; in patients who have chronic diseases, symptoms, or injury; and in therapies directed to QOL issues.
The statement of principles developed by the Task Force on Surgical Palliative Care and the Committee on Ethics of the American College of Surgeons (ACS) in 2005 reflects this evolution to a broad range of patients receiving surgical care.
The following principles of palliative care for subjective SIT are recommended, reflecting modification and clinical application of the principles of palliative care proposed by the ACS:
- 1.
Respect the dignity and autonomy of patients who have tinnitus, patients’ surrogates, and caregivers.
- 2.
Respect and honor the right of the competent patient or surrogate to choose among treatments, including those that may or may not provide tinnitus relief.
- 3.
Communicate effectively and empathetically with patients, their families, and caregivers.
- 4.
Identify the primary goals of care from the patient’s perspective, and address how the professional attempting tinnitus relief can achieve the patient’s objectives and present the realities and limitations of what is and is not known about tinnitus.
- 5.
Do the best one can to achieve tinnitus relief, establish the medical significance of the tinnitus, and differentiate in treatment recommendations among the components of all sensations (ie, sensation, affect behavioral response to the sensation, psychomotor response to the sensation).
- 6.
Recognize, assess, discuss, and offer access to services of neurology, psychology or psychiatry, social issues, tinnitus patient support groups, and national and international tinnitus organizations.
- 7.
Provide access to therapeutic support when such support can realistically be expected to improve the QOL as perceived by the patient.
- 8.
Recognize the physician’s responsibility to discourage treatments that are unlikely to achieve the patient’s goals.
- 9.
Arrange for continuity of care by the patient’s primary or specialist physician or audiologist, alleviating the sense of abandonment that patients may feel when “curative” therapies are not available. Do not tell a patient, “You have to live with it.”
- 10.
Maintain a collegial and supportive attitude toward others entrusted with the care of the patient.
Palliation medicine and tinnitus: a biophysiologic model
The landmark neuroscience contributions of Eric Kandel to the understanding of mind and memory are considered to provide, in part, a biophysiologic model to explain the symptomatic relief with palliative medicine, particularly with combined therapies of counseling and drug therapy for control of anxiety and medication, both of which are significant for the patient who has SIT. Specifically, it has been demonstrated that “talk” therapy and listening to the patient involve the brain pathways within the frontal lobes that are involved primarily in cognitive processing (ie, “thinking.”) Neural processing is primarily “top down.” Fluorodeoxyglucose (FDG) positron emission tomography (PET) brain nuclear medicine imaging has demonstrated an increase in activity in the caudate nucleus in patients who have obsessive-compulsive disorder.
Drug therapy with selective serotonin receptor inhibitors (SSRIs) has been identified to work primarily in subcortical “nonthinking” brain regions (ie, neural processing is primarily “bottom up.”) For SIT, this rationale is hypothesized to provide, in part, an explanation for the relief from SIT reported with combined therapies directed to the sensory and affect components of the SIT—specifically, the ultimate influence on the processes involved in the establishment of paradoxical auditory memory, the initial process in transformation of an aberrant auditory sensory stimulus (SIT) to an affect behavioral response (ie, the final common pathway for tinnitus). The differences in relief for SIT are based on the underlying molecular genetics involved in sensory, affect, and cognitive processing, which reflect the individuality of each patient who has SIT and the heterogeneity of tinnitus in general and SIT in particular.
Quality of life
QOL issues for a particular symptom or disease are individual and subjective for each patient. Reports of QOL in patients who have tinnitus should always differentiate between SIT and other clinical types of tinnitus (CTTs).
QOL determinants for SIT have been individual in the authors’ clinical medical audiologic neurotology experience with SIT in excess of 10,000 patients since 1979, originating in the Tinnitus Clinic of the Department of Otolaryngology, State University of New York, Downstate, and ongoing at the Martha Entenmann Tinnitus Research Center, Inc. The authors’ experience has been marked by the heterogeneity and diversity of influences and end points for SIT QOL issues, including physical, psychologic, and social components. For SIT, QOL issues are highlighted by interference in sleep, concentration, communication, performance at work, and interference in social activities with family and friends, with accompanying or resultant anxiety or depression and interference in speech expression and memory. Most important in evaluating reports of QOL issues and tinnitus is the clinical diagnosis of the type of tinnitus. In this article, tinnitus refers to subjective SIT.
In the authors’ experience, a team approach of the primary physician and otology-neurotology, audiology, and neuropsychology or psychiatry specialists with a resultant stable personality increases the efficacy of modality(ies) of therapy attempting relief from SIT and the resultant QOL for the patient who has SIT.
Significant determinants have been identified to influence the clinical course of the SIT, the efficacy of therapies attempting tinnitus relief, and the resultant QOL of the patient who has SIT. Included are the following:
- •
Affect/behavioral response to the presence of SIT: the antecedent or associated behavioral affect response of anxiety and depression to the presence of the SIT is the most significant determinant for the QOL in most patients who have SIT.
- •
Parameters of tinnitus identification of quality of tone and/or noise, intensity, location, masking effect(s), and duration: intensity is the most frequent complaint influencing the QOL (ie, the higher the intensity, the greater is the report of interference in QOL). The next most frequent complaint has been duration (ie, the longer the duration, the greater is the report of interference in QOL). Individual, occasional, and less frequent has been the report of influence of the quality of the SIT (single or multiple, tone or noise, and location) on SIT QOL. Sociodemographic factors associated with SIT include age, stress, and noise exposure; antecedent neuropsychiatric disease (eg, anxiety; depression; posttraumatic stress disorder [PTSD]; traumatic brain injury [TBI]; metabolic disease of sugar, thyroid, or hyperlipidemia; cardiovascular disease); identification, treatment, or control of hypertension or arrhythmias; and neuropsychiatric disease (eg, anxiety, depression, cerebrovascular or neurodegenerative central system [CNS] disease). Age alone has not been a significant factor for SIT except when associated with neuropsychiatric disease and neurodegenerative CNS disease.
- •
Neurotologic-associated conditions: Neurotologic conditions associated with SIT, as identified by the patient’s history, physical examination and cochleovestibular testing, have been identified and are known to influence the clinical course of the SIT adversely. When not identified and controlled, such conditions have been reported to influence adversely the QOL of the patient who has SIT. Included are the presence of hyperacusis, sensorineural hearing loss, fluctuation in aeration of the middle ears, secondary endolymphatic hydrops (SEH), noise exposure, and stress.
Erlandsson and Hallberg reported on the QOL and its association with tinnitus-related factors (psychologic, psychosomatic, and audiologic) based on a sample of 122 patients who attended a hearing clinic for distress as a result of tinnitus. Six of 13 variables included in the model proved to be significant regressors and to explain 65% of the variance. The 6 predictor variables were as follows:
- 1.
Impaired concentration
- 2.
Feeling depressed
- 3.
Perceived negative attitudes
- 4.
Hypersensitivity to sounds
- 5.
Average hearing level (best ear)
- 6.
Tinnitus duration (the shorter the duration of tinnitus, the more negative was the impact on QOL)
The three most significant predictors were directly related to perceived psychologic distress and explained most of the variance in QOL in the patients who had tinnitus and were included in this study. An unexpected finding was that fluctuations in tinnitus, vertigo, headache, or perceived social support did not prove to belong to the significant regressors.
A recent report highlights the significance of the impact of tinnitus on QOL in older patients who have tinnitus. In a population-based study, in self-reported data using the Medical Outcomes Study Short Form Health Survey (SF-36) from 2800 subjects who were aged 53 to 97 years, with 669 subjects having a mild, moderate, or severe level of tinnitus, the most significant negative effects of tinnitus showed up in the domains of physical pain and stress, as opposed to the mental and emotional domains. When looking at the SF-36 data, mean scores for all eight domains (physical functioning, role-physical, bodily pain, general hearing perceptions, vitality, social functioning, role-emotional, and mental health index) worsened with the severity of the subject’s tinnitus, as did mean scores for the two summary indexes (Physical Summary and Mental Component Summary). A significant ( P <.05) linear trend was observed for the role-physical, bodily pain, vitality, and Physical Component Summary index. Almost 25% of the population had tinnitus, with 9.4% reporting moderate to severe tinnitus. The researchers concluded that “quality of life is diminished in participants with tinnitus, and the effect increases with severity.”
Reports of QOL in patients who have tinnitus should always differentiate between SIT and other CTTs.
Tinnitology
Tinnitology is a new distinct discipline that has been identified, defined, and developed since 1991. It has become a multidiscipline of professionals dedicated to the study of tinnitus and to the translation and integration of clinical otology with the behavioral and basic sciences for tinnitus diagnosis and treatment. Specifically, basic scientists, clinicians, and audiologists are attempting to understand how an aberrant auditory sensation (ie, tinnitus) is transformed into an affect behavioral response. Tinnitology is evolving as an integrated multidiscipline of basic science, auditory science, neuroscience, and clinical medicine. Modalities of treatment recommended at this time are resulting in tinnitus relief (ie, palliation) in an increasing number of cases.
Definitions and classification
Definitions of “tinnitus” are dynamic, reflecting what is and is not known of auditory science, sensory biophysiology, the cochleovestibular system (peripheral and central), the brain (structure and function), and human behavior. Originally the definition focused on its subjective nature and was defined as the perception of an aberrant auditory stimulus unrelated to an external source of sound.
In 1992, tinnitus was defined as a sensory disorder of auditory perception reflecting an aberrant auditory signal produced by interference in the excitatory or inhibitory process(es) involved in neurotransmission. This definition reflected the integration of clinical efforts of observation with neuroscience and nuclear medicine to identify underlying mechanisms of tinnitus and to establish the medical significance of tinnitus.
In 2006, tinnitus was defined as a clinical conscious awareness, varying in degree of consolidation, of an aberrant auditory paradoxical memory originating in response to an interference in the homeostasis between dyssynchrony and synchrony within the synaptic circuitry of the neural substrates involved, and thus interfering in the precision, specificity, and complexity involved in synaptic transmission for normal neuronal and interneuronal function.
A tinnitus classification system has been recommended differentiating between an otologic and neurotologic clinical site of lesion. The otologic classification is based on the integration of the clinical history and otologic physical examination. The neurotologic examination is based on extrapolation of correlates of electrophysiologic testing of the cochlear vestibular system, peripheral or central in location. The neurotologic or otologic classification primarily provides a basis for the diagnosis of SIT and the selection of a suitable system method for tinnitus treatment and tinnitus control. It offers a method for standardizing the reporting of SIT data for its diagnosis and treatment.
Classification based on epidemiology is further recommended to differentiate between clinical and subclinical tinnitus and auditory and nonauditory tinnitus (ie, whether the auditory system is the primary site of origin of the lesion of the tinnitus complaint [auditory tinnitus] or whether it is secondarily involved [nonauditory tinnitus]). Other system(s) may use the auditory system to express the dysfunction. Clinically manifest tinnitus is an auditory threshold perception that the patient is experiencing. Subclinical tinnitus refers to the tinnitus as an abnormal subthreshold auditory sensation. Tinnitus may be subclinical in nature and become clinically manifest with a “trigger” event. Such an event may be that of noise exposure or inflammation, for example.
Principles of clinical tinnitology
The following principles of tinnitology reflect the realities of the authors’ experiences for tinnitus diagnosis and treatment at this time. To be informed and to share information with the patient are principles of palliative medicine.
Principles have evolved from attempts at establishing accuracy for the clinical diagnosis of tinnitus and for attempting tinnitus relief in 2007 through 2008, which have been called “principles of tinnitology” and include the following:
- 1.
There is no cure for tinnitus at this time.
- 2.
Treatment efficacy is based on the accuracy of the tinnitus diagnosis.
- 3.
Not all tinnitus is the same. It is necessary to differentiate tinnitus in patients with the symptoms of SIT from tinnitus that is occasional or tinnitus that is present and not disabling.
- 4.
Tinnitus is not a unitary symptom. There are different CTTs and clinical subtypes of tinnitus.
- 5.
The masking of tinnitus is reflected in different types of masking.
- 6.
Tinnitus is reflected in its clinical course as a chronic, multifactorial, heterogeneous complaint.
- 7.
Components of tinnitus have been identified based on a clinical translation of basic sensory physiology for tinnitus diagnosis and treatment (ie, sensory, affect, psychomotor).
- 8.
Factors have been identified that influence the clinical course of the SIT. When treated, the result is significant tinnitus relief.
- 9.
Noise is a significant etiology influencing the clinical course of the tinnitus. Increasing noise exposure results in an increase in the intensity of tinnitus.
- 10.
Stress exacerbates the intensity of tinnitus. A stress diathesis model for tinnitus has been hypothesized.
- 11.
Tinnitus has medical significance for each patient who has tinnitus, which requires an attempt to be established.
- 12.
Management realities: although there is no cure for tinnitus at this time, there are systems available for attempting tinnitus relief, which are highlighted by medication and instrumentation.
- 13.
Treatment recommendations are based on a dilemma that has and does exist for the symptoms of tinnitus and aberrant auditory phenomena unrelated to an external source of sound. Specifically, the question is how a sensory phenomenon becomes transposed or translated to one of affect or how the reverse can take place.
- 14.
A final common pathway in the brain has been hypothesized for all CTTs, with the initial process(es) being the establishment of a paradoxical auditory memory for the aberrant auditory stimulus ( Fig. 1 ). “The chief function is the transition of a dyssynchronous auditory sensory signal to affective behavioral response. It is hypothesized that for all sensory systems, the sensory and affect components are linked by memory.”
Fig. 1
Final common pathway for tinnitus, 1995. A reciprocal, innervating, interneuronal network transforms a sensory aberrant stimulus, tinnitus, to one of affect and emotion. The factor of stress and the biophysiologic processes involved modulate the severity of the tinnitus. Amyg, amygdala; B.S., brain stem; Hippo, hippocampus. ( From Shulman A. A final common pathway for tinnitus: the medial temporal lobe system. Int Tinnitus J 1995;1:119; with permission.)
- 15.
The key to efficacy for tinnitus treatment depends on the accuracy of the diagnosis for tinnitus. The completion of a medical audiologic tinnitus patient protocol (MATPP) ( Fig. 2 ), with examination of the cochleovestibular system (ear and brain), improves the accuracy of the SIT diagnosis and efficacy of modality(ies) recommended for attempting tinnitus relief.
Fig. 2
MATPP: diagnosis and treatment. ( From Shulman A. Medical audiologic tinnitus patient protocol. In: Shulman A, et al, editors. Tinnitus diagnosis/treatment. Forest Hills (NY): Martha Entenmann Tinnitus Research Foundation, Inc. p. 109; with permission.)
- 16.
A biochemical marker, the γ-aminobutyric acid-A receptor (GABA-AR) has been identified for a predominantly central type of tinnitus. Its clinical application is a therapy targeting the GABA-AR, which is resulting in long-term tinnitus relief.
- 17.
An electrophysiologic correlate has been identified for a predominantly central type of tinnitus
- 18.
Receptor-targeted therapy (RTT) directed to the GABA-AR called RTT-GABA has resulted in the clinical treatment application for a patient who has the predominantly central type of SIT.
- 19.
Tinnitus is not a phantom phenomenon. Electrodiagnostic, physiologic, and biochemical alterations in neural substrates have been identified, which are significant for different CTTs.
- 20.
The ultrahigh audiometric response can be used for the identification of patients who have SIT and may benefit from acoustic stimulation using ultrahigh-frequency stimulation.
Principles of sensory physiology
The basic tenet of sensory physiology that there are different clinical components for any sensation has been clinically applied for the patient who has SIT. The components are sensory, affect, and psychomotor. For tinnitus the sensory component is the tinnitus symptom itself, the affect component is the behavioral response of the patient who has tinnitus to the presence of the tinnitus, and the psychomotor component is the somatomotor response to the behavioral component of the tinnitus.
Tinnitus is an aberrant auditory sensation. Recommendations for tinnitus relief should specify and differentiate among the components of the aberrant auditory sensation (ie, tinnitus).
In general, for the SIT sensory component, a combination of instrumentation and medication is advised. For the affect component focusing predominantly on anxiety and depression, appropriate anxiolytic and antidepressant medications are recommended. Fear is a significant factor in new patients who have SIT, and appropriate psychiatric medication or psychotherapy is recommended. To be considered is that a significant number of patients, particularly in the geriatric age population, have associated complaints of interference in memory and cognition. Appropriate neurodegenerative drugs or memory enhancers are recommended.
Tinnitogenesis
Tinnitogenesis is a seizure type activity, cortical-subcortical in location, with a resultant aberrant auditory perception. It is an epileptiform auditory phenomenon. It is hypothesized that a disruption in calcium homeostasis reflective of glutamate neurotoxicity results in hyperexcitability in the underlying neural substrate of epileptiform characteristics. This finding has provided a rationale for the innovative recommendation of antiepileptic agents in an attempt to achieve tinnitus relief in appropriate patients who have SIT.
Medical significance of tinnitus
The medical significance of tinnitus is considered to be the spectrum of clinical manifestations reflecting interference in function of the cochleovestibular system or brain, with sensory, affect, and psychomotor components. The sensory component is considered to be the tinnitus sound and quality. The affect component is the patient’s behavioral response to the tinnitus. The psychomotor component is a somatomotor response to the behavioral component of tinnitus.
The otologic and neurotologic etiologies associated with the medical significance of tinnitus have been found to be highlighted by associations with inflammatory disease of the middle ear or mastoid, Ménière’s disease, acoustic tumor, sensorineural hearing loss, and autoimmune inner ear disease.
Tinnitus theories: diagnosis and treatment applications
Hypotheses of mechanisms of tinnitus in the past included changes in temporal firing patterns of neuronal activity, “cross-talk” among eighth nerve fibers, analogy to pain perception, damage to the temporal dysfunction of the inner or outer hair cells, partial damage to interruption of the eighth nerve, damage to the efferent system, imbalanced activity in eighth nerve resulting in tinnitus, and the recent tinnitus dyssynchrony/synchrony theory ( Fig. 3 ) to differentiate between the dyssynchronous signal that is hypothesized to be tinnitus and the synchrony of neuronal activity at the brain cortex that is the function of the perception and conscious awareness of tinnitus (see Fig. 2 ).
