Publications

APS Bulletin • Volume 10, Number 5, September/October 2000

Publications

Management of Tinnitus and Hyperacusis Using a Multidisciplinary Pain Model

Robin J. Hamill-Ruth, MD; Roger A. Ruth, PhD; Dania Cyd Chastain, PhD; Andrew Cook, PhD

Tinnitus, or chronic ringing or buzzing in the ears, and hyperacusis, a disabling increase in sensitivity to noise, occur commonly in the adult population and yet the complaints are frequently unrecognized by healthcare professionals. Tinnitus is estimated to effect 13% to 20% of the overall population of the United States (Coles & Sook, 1998). These complaints, often associated with hearing loss, increase with age, with 27% to 34% of the population older than 70 years reporting significant tinnitus (Ruth & Hall, 1999). Twenty percent to 45% of tinnitus sufferers also will have complaints of hyperacusis. A small number of patients complain only of hyperacusis.

Tinnitus and hyperacusis have a number of characteristics that are similar to chronic pain syndromes (Moller, 2000). For example, anxiety and depression, as well as sleep disturbance, withdrawal from social activities, and social isolation, are found in both patient groups (Sanchez, Boyd, & Davis, 1999). In addition, tinnitus, hyperacusis, and chronic pain can each be a manifestation of peripheral as well as central nervous system pathology. With each syndrome, changes in the peripheral nervous system can induce changes in the central nervous system that are perpetuated beyond the time of normal healing. Little in the literature addresses the coincidence to tinnitus/hyperacusis and chronic pain. However, sleep disturbance, depression, tinnitus, hyperacusis, and some types of headaches have all been associated with disturbance of the serotonergic system (Simpson, Hopkins, & Davies, 1999). Emotional and psychosocial factors, as well as coping abilities, impact the level of distress and dysfunction caused by tinnitus/hyperacusis and chronic pain. Given their associate coincidental dysfunctional symptoms and necessary coping abilities, a multidisciplinary model of evaluation and treatment for the management of severe tinnitus and hyperacusis, which parallels that used with chronic pain patients, was developed and implemented. Aspects of the intake evaluation and management strategies are listed in the Table.

Multidisciplinary management

Audiologic management includes hearing remediation if hearing loss is present. Counseling and education are key to the understanding of the problem (Hall & Ruth, 1999). Teaching includes information about normal hearing; audiologic hygiene, including the influence of loud noise and quiet on the severity of tinnitus and hyperacusis; the mechanisms of tinnitus and hyperacusis as they are currently understood; and an in-depth discussion of treatment options. In addition, tinnitus retraining and use of noise generators (hearing aid-like devices that produce white noise) are used to desensitize the central auditory nervous system.

The pain management physician evaluates the patient for the presence of head and neck pain complaints, such as temporomandibular joint dysfunction, myofascial neck and shoulder complaints, or cervical spine disease. Treatment for these coincides with the management of the tinnitus and hyperacusis. Often, the pain complaints, which may compound the patient’s distress, can be readily managed. In addition, attention is paid to other treatable comorbidities, including poor sleep hygiene, depression, and the presence of ototoxic medications (e.g., high-dose nonsteroidal anti-inflammatory drugs, loop diuretics, etc.), which may contribute to the severity of the tinnitus and hyperacusis.

The pain psychologist evaluates the patient’s emotional, cognitive, and behavioral functioning. Particular effort is directed toward identification of barriers to successful treatment, such as mood disorders and coping deficits. Treatment modalities include supportive and cognitive-behavioral interventions, which incorporate education about pacing of activities with energy conservation, sleep hygiene, behavioral planning to increase functioning, stress management, and realistic goal setting. Self-regulation techniques with biofeedback are used to help increase body awareness, shift perceived locus of control, manage autonomic arousal, and facilitate reintegration of the patient with his or her life. The focus is on ”wellness“ rather than ”illness.“

This paradigm depends on high-level communication between the primary three participants: the audiologist, the pain physician, and the pain psychologist.

Tinnitus, hyperacusis, and chronic pain

In preliminary studies of chronic pain patients, the incidence of tinnitus and hyperacusis was found to be significantly higher than would be predicted in the general population. Seventy-nine percent of headache and facial pain patients studied reported tinnitus and/or hyperacusis (Hamill-Ruth, Chastain, Cook, & Ruth, 1999b). Sixty-three percent of the tinnitus and 91% of the hyperacusis patients felt their head pain was worsened by the audiologic complaint. Sixty-three percent of those with tinnitus and 91% with hyperacusis reported increased audiologic complaints with head pain. Interestingly, all of the hyperacusis patients reported worsened headache pain with hyperacusis, but only 18% of tinnitus patients felt that the tinnitus aggravated the head pain. Of those patients studied with myofascial pain or fibromyalgia, 67% reported tinnitus and 61% reported hyperacusis (Hamill-Ruth, Chastain, Cook, & Ruth, 1999a). Fifty-eight percent to 64% of the patients with tinnitus or hyperacusis exacerbated by the muscular pains felt that the audiologic complaint worsened the muscle problem, while 42% of tinnitus and 64% of hyperacusis patients felt the same. In general, hyperacusis was found to be at least as limiting as the pain complaint in both groups, while the tinnitus was generally less bothersome than the hyperacusis.

Tinnitus retraining and use of noise generators with good patient compliance can significantly decrease severity of tinnitus. To date, the program has identified a significant number of tinnitus and hyperacusis patients that have depression and sleep disturbance. In addition, most have coincident pain complaints, particularly myofascial head, neck, and shoulder pain or degenerative cervical spine disease. Use of medications and injections to manage these complaints has decreased perceived dysfunction and distress. Psychological treatment, management, and training of patients’ self-regulation techniques is the oil that makes the ”machine“ run well. Any segment of the management triad, without the others, would likely be less efficacious, particularly when treating the more refractory patients.

Conclusions

Generally, the patients that enter the program have undergone years of unsatisfying ”doctor shopping“ and extensive evaluation to rule out associated central nervous system pathology (e.g., acoustic neuroma). Many previous efforts at traditional medical treatment have failed. In addition, most have been told at some time in their course that the medical community has nothing to offer and they will ”just need to learn to live with it.“ By using tinnitus retraining therapy within a multidisciplinary pain treatment model program, such complex patients’ functional goals can be approximated and achieved.

References

Robin J. Hamill-Ruth is associate professor of anesthesiology and critical care medicine and director at the Pain Management Center at University of Virginia Health Systems, Charlottesville.

Roger A. Ruth is professor of audiology and otolaryngology and director of communication disorders, division of audiology, department of otolaryngology, head and neck surgery, University of Virginia Health Systems, Charlottesville.

Dania Cyd Chastain is assistant professor of anesthesiology and pain medicine and director of pain psychology at the Pain Management Center at University of Virginia Health Systems, Charlottesville.