Tinnitus treatment an introduction.
Tinnitus is most likely always multi-factorial. However, sometimes, one factor is dominant, and correcting that factor alone may be almost all that a sufferer requires, as far as their tinnitus management is concerned. Clearing the ear canals of wax or debris, surgical correction of hearing loss, the withdrawal of a drug, or facilitating the treatment of a psychiatric disturbance may stop tinnitus from being a problem. However, even in these “dominant factor” situations, other factors helped determine that awareness of tinnitus became a major feature and influence whether the tinnitus persists as a problem, even after the dominant factor has been treated.
In most tinnitus sufferers, several factors are important in their awareness of tinnitus and the distress they experience. Specialists find it helpful to group these factors into three broad categories.
- Changes in sensory input.These usually predisposed to the onset of tinnitus and help maintain it.
- Psychological influences. These include emotional state and emotional associations, lack of understanding and resultant anxiety, and unconscious conditioning (“neurophysiological model”).
- Changes in neural activity within the brain. These have usually been triggered by the above factors, sometimes by direct injury, but then become self-perpetuating and are now regarded as the actual “generators” of tinnitus.
Specialists then view the same three broad categories as distinguishing the avenues available for treating each patient who is troubled by tinnitus.
- Manipulating and where possible normalizing sensory inputs. This applies most often to auditory input where hearing loss may be corrected or compensated, or therapeutic auditory stimulation applied. A lot of attention has recently been focused on somatosensory inputs, their ability to modulate and sometimes trigger tinnitus, and how these effects may be reduced. Visual, olfactory, vestibular, taste, and other sensory inputs may have influences on tinnitus, but have received little study in this context.
- Controlling emotional factors. Successful management of tinnitus almost always requires reduction in concern about implications and often separation from anger about perceived causes. Disassociation of tinnitus from emotional factors, especially depression, anxiety, fear, and anger is essential. Explanation and understanding reduce anxiety and fear and the tendency for a patient to dwell upon their tinnitus. The most sophisticated and validated approach to achieving this “de-concerning” is cognitive behavioural therapy. At a less conscious level, de-conditioning techniques such as tinnitus-retraining therapy and desensitization with music are useful in reducing physiological changes associated with troublesome tinnitus.
- Direct approaches to the central nervous system. Once tinnitus has become intrusive and distressing, then treatment through control of sensory input and psychological factors may be insufficient. Neuroplastic changes within the brain may need to be approached directly as well. The most readily available route is through the bloodstream, providing access for drugs and dietary factors. However, changes within the brain can also be approached directly by surgery, by direct electrical stimulation, and, especially in this context, by transcranial magnetic stimulation. Even if such direct approaches can reverse neuroplastic changes, they almost certainly need to be used in conjunction with the control of sensory input and psychological factors if relapse is to be prevented.
Generally, specialists acknowledge, explicitly or implicitly, that each therapy described needs to be part of a package of care incorporating other approaches if it is to be of long-lasting benefit. In managing sensory input, it is helpful to cover auditory training, sound stimulation and hearing aids, music treatment, middle-ear implantable devices, cochlear implants, treatment directed to the ear, and surgical treatments, all of which may improve or manipulate auditory sensory input.
Some pharmacological and nutritional therapies have their effect by improving inner ear function and auditory input. Treatment of temporomandibular joint dysfunction, cutaneous stimulation, involves and focuses on techniques which probably alter somatosensory influences on tinnitus, as may neuro-biofeedback and lowlevel laser therapy.
Psychological factors are addressed at a conscious level in the following articles on counselling and cognitive behavioural treatment but may also be important components of sensory stimulation such as in music treatment. De-conditioning at an unconscious level is inherent in tinnitus retaining therapy but may also be important in some forms of sound treatment. There are benefits in more holistic approaches. Most of the pharmacological treatments described in the article on medications act directly on the central nervous system as may some non-conventional therapies, nutritional factors, and vitamins. Principals of neuro-modulation are discussed later prior to descriptions of neuro-biofeedback and of direct stimulation both magnetically and electrically.
Some specific treatments for particular problems are also described in the following articles, such as treatment of vestibular schwannoma and microvascular decompression. There is an article devoted to the similarities between treatment of tinnitus and that of pain. Treatment of disorders that are closely associated with tinnitus such as temporomandibular and masticatory disorders can often relieve tinnitus. There is room for more innovation in the treatment of tinnitus. Our improved understanding of the influences of sensory input and psychological factors and the neuroplastic changes, which result, has given us far greater sophistication in managing those who have and feel distressed by their tinnitus. For each person, we have to identify the most helpful ways in which sensory inputs can be manipulated, how best to improve understanding and disassociate emotional factors, and whether there is a place for centrally acting agents and other direct approaches.