Many of us have a ringing or a buzzing in our ears from time to time, often after exposure to a loud noise. Tinnitus is that same kind of ringing or buzzing, but it never goes away. It usually but not always accompanies hearing loss. The more severe the hearing loss, in general, the more severe the tinnitus. Many people learn to manage it or ignore it—but for a small percentage it becomes debilitating.
Tinnitus can affect job performance, result in insomnia, and, as Sergei Kochkin, the executive director of the Better Hearing Institute wrote in a 2011 report accompanying a survey on tinnitus sufferers, it “can contribute to psychological disorders, such as depression, suicide ideation, post-traumatic stress disorder, anxiety and anger. The constancy of tinnitus and the perceived lack of control can provoke fear, which exacerbates the problem, leading to an ever increasing cycle of distress.” A quarter of the respondents in Kochkin’s survey reported that their tinnitus was disabling or nearly disabling.
The American Tinnitus Association estimates that 40 to 50 million Americans have tinnitus, and that two million are so debilitated by it that they can’t function on a normal day-to-day basis.
Many of them are veterans. Almost one million veterans received disability payments for tinnitus in 2012. It’s the largest single category for disability claims in the military, with hearing loss a close second. The third largest category is post-traumatic stress disorder, which itself may be accompanied by tinnitus and may exacerbate it. Traumatic brain injury is also often accompanied by tinnitus.
The military has a vested interest in finding a way of alleviating tinnitus. Dr. James Henry, a research scientist the National Center for Rehabilitative Auditory Research at the VA Medical Center in Portland, Oregon, has been working on the problem since 2006, developing five progressively more refined treatment protocols. Dr. Henry, like others, emphasizes that there is no cure for tinnitus. The goal is management.
When he and his colleagues initially announced that they were looking for participants in a clinical trial for tinnitus management, in 2006, they received 800 responses. Sixty-four percent of the callers declined to enroll when they heard about the time they would need to invest. These presumably were those who were bothered by tinnitus but not enough to participate in a multi-week, multi-meeting trial.
Progressive Tinnitus Management is a five-step program, with gradually declining numbers of participants at each level. Level 1 of the PTM program is triage, providing guidelines intended for health care providers about referring patients to an audiologist. Because so many people with chronic tinnitus also have hearing loss, Level 2 is correction of that hearing loss with hearing aids. The VA provides hearing aids at no cost. If there is no hearing loss, the audiologist may fit the patient with an ear level “sound generator.”
Level 3 involves five group-therapy sessions with an audiologist and a psychologist. Participation drops off drastically at this stage, in part because of the stigma among the military of psychological evaluations. The researchers now realize they have to urge patients to attend the workshops, which in many ways are the core component of PTM—the component that teaches tinnitus sufferers how to manage tinnitus on their own.
The audiologist focuses on showing patients how to use sound (either soothing sound, background sound, or “interesting” sound, which engages the patient and helps take his mind off the tinnitus). The psychologist, using cognitive behavioral therapy, teaches relaxation exercises, “cognitive restructuring” (putting a more positive spin on negative thoughts about tinnitus) and diversion (activities to take their mind off tinnitus). Patients are also given a self-help workbook, “How to Manage Your Tinnitus.” The book is not available to the general public, but it’s available as a free download from the NCRAR website: http://www.ncrar.research.va.gov/Education/Documents/TinnitusDocuments/I....
Dr. Henry found that 95% who attend the Level 3 workshops, those who were not helped at the first two levels, succeed in managing their tinnitus. A small minority go on to Levels 4 and 5. In Level 4, after a multidisciplinary evaluation, the researchers propose a program tailored for the veteran, which includes one-on-one sound management therapy as well as one-on-one meetings with a psychologist. Level 5 is a more intensive version of Level 4.
Dr. Henry’s ongoing studies now include the use of PTM for veterans with tinnitus and traumatic brain injury. Since these patients tend to be scattered around the country, the study is measuring the effectiveness of using the telephone for evaluations and consultative procedures, supplemented by materials like workbooks delivered by mail. The study compares the effectiveness of this treatment on veterans with mild TBI, moderate or severe TBI, and those who have bothersome tinnitus but no TBI.
PTM is a variation on the theme of management that has proven effective: using hearing correction, masking, CBT and relaxation training. Whether PTM is actually more effective than any of these alone is the subject of a randomized clinical trial he and his colleagues are conducting at three VA centers, with three hundred patients. Patients who qualify for the study and receive hearing aids or and other audiology services are then told about the study and the five-part educational therapy program. Those who opt for the five sessions are offered the chance to receive either “immediate care" or to wait six months, during which time they receive “usual care.” Usual care, the control group, includes a hearing test, fitting with hearing aids if necessary, or fitting with ear level noise generators, or a combination of the two. There is a minimum amount of counseling. Full results of the trial will be available at the end of the year but preliminary data analyses suggest that including counseling makes a measurable difference, Dr. Henry says.
Prevention is also a major undertaking by the military. Lt. Col. Mark Packer, the director of the Lackland Center for Hearing Excellence, notes that active duty soldiers need to be able to hear each other and the enemy—but of course they also need protection from the everyday noises of war: gunshots, explosions, the noise of heavy machinery. Much of this noise is random, leaving little time to pop in earplugs. In the early years of the Gulf War and Afghanistan, the military issued double-sided earplugs, one side for use in normal circumstances and the other in louder conditions. No one wore them. Now the military uses a single sided earplug, which shuts down if the noise reaches a certain decibel level. At lower decibels, the solder can hear as well as he could without the earplugs.
For a soldier returning from war, tinnitus may seem a small thing when compared to the disabling injuries we more often hear about. Some on-line comments drip with disdain: “Disability??? I've had Tinnitis for 40 years and no one's compensated me. It's nothing; a minor, persistent, insistent, perpetual, always-present nothing. Deal with it. I'll believe a cure when I can't hear it anymore.”
Major Jim Stevens, a 62-year-old Air Force officer, was treated for hearing loss and tinnitus at Walter Reed. His tinnitus is constant, he said in an email, but it came on gradually and he thinks for this reason he was able to adjust to it. He did take a tinnitus management class at Walter Reed, where he realized how severely others were affected by it: “I was surprised to hear the other students describe all manner of problems they experience including inability to focus on reading, sleeping, conversation, etc. One lady related she experienced physical pain.”
Despite research showing that programs like PTM, mindfulness meditation, and CBT are effective in managing tinnitus, many sufferers continue to look for a quick fix, trying everything from ear candling to the neti pot, which irrigates the nasal passages with salt water. In February of this year, the Center for Hearing Loss Help released a comprehensive list of the drugs, herbs and chemicals people use for tinnitus. They numbered 563, sold under 1,131 brand names. Tinnitus is a profitable business.
Correction (3/21/14): The Center For Hearing Loss Help lists drugs that are associated with tinnitus, that can cause tinnitus. Those drugs are not intended to cure tinnitus.