Tinnitus: help is available

Tinnitus is among the top three most accepted conditions for Australian veterans.¹ Not all veterans with tinnitus are bothered by it, but for about one in five, it substantially affects their physical and mental wellbeing.^2-4

Tinnitus is often associated with hearing loss, anxiety and depression,⁵ insomnia, poor concentration, hyperacusis (increased sensitivity to everyday sounds), and reduced social enjoyment, all of which impair daily functioning and quality of life.^6-8 Some people report feeling overwhelmed, exhausted, hopeless and suicidal.⁹

A range of management options, (for example cognitive behavioural therapy (CBT), hearing services referral, talking and sound therapies, relaxation and mindfulness-based therapies, education and group support) may be needed to help patients with tinnitus that is troublesome and distressing.^4, 6, 11

Tinnitus is complex, multifactorial and not fully understood.^2, 12 Research suggests that tinnitus most often develops because of maladaptive neural changes in auditory pathways and attentional, memory, cognitive and emotional areas of the brain. This usually happens after an actual or potential physical or psychological injury occurs; much the same way that cognitive-affective processes play a key role in the experience and maintenance of chronic pain.^9, 12-15

Military personnel are often exposed to hazardous occupational noise, including gunfire and other acoustic traumas, somatosensory system disturbances and emotional stress during service, putting them at high risk of developing tinnitus.¹² Traumatic brain injury (TBI), especially blast-induced TBI, concussion, hearing loss and PTSD can lead to or exacerbate tinnitus.^3, 16 This is reflected in the large number of veteran disability claims for tinnitus.

Although there is no medical or pharmacological cure for tinnitus, an approach that addresses cognitive, behavioural, attentional and social factors can help to reduce the perceived severity of tinnitus, and improve quality of life.^9, 14

Refer patients with tinnitus to an audiologist

Most people with tinnitus, particularly those with troublesome tinnitus and no visible ear pathology on examination, have a degree of hearing loss.⁴ Some people with tinnitus may not be aware they have hearing loss. Trouble communicating and the resultant frustration and distress might be more to do with undiagnosed hearing loss.¹⁷

Untreated hearing loss is also associated with an increased risk of cognitive decline and dementia, social isolation,^18-20 depression and irritability.^21, 22 Treating hearing loss can lessen the intrusiveness of tinnitus. The additional benefits of treating hearing loss include improving quality of life and cognition.^4, 22, 23

Offer to refer patients who report tinnitus that is troublesome or hearing difficulties and have not seen an audiologist recently, for an assessment or review, or to discuss devices to help with tinnitus.^4, 6, 11 An audiologist can conduct impedance audiometry and tympanometry to assess hearing deficits and middle ear and eardrum function, provide tinnitus rehabilitation and counselling, and fit hearing aids and assistive listening devices as needed.¹¹

Audiology Australia can help you find an audiologist, keeping in mind some audiologists specialise in tinnitus, at: https://audiology.asn.au/Home

Under the Repatriation Transport Scheme, DVA funds transport assistance for eligible Veteran Card holders to approved treatment locations. For further information, go to: www.dva.gov.au/about-us/overview/overview-dva-benefits-and-services

Offer to refer distressed patients to a psychologist early

CBT is strongly recommended if tinnitus is troublesome and distressing.^{2, 4, 24, 25} The aim of CBT is to reduce tinnitus-related distress and improve quality of life. It may not reduce the loudness of tinnitus or eliminate the noise. CBT works by the psychologist identifying negative or irrational thinking that results in distress, (see Figure 1) and challenging, modifying and replacing those thoughts with more helpful and realistic beliefs.^4, 24 Treatment also includes learning relaxation techniques and healthy sleep hygiene.⁴ Internet or smartphone-based tinnitus treatments that include CBT have also been shown to be effective.^26-28

Depression can affect the severity or tolerance of tinnitus, tinnitus can trigger depression, and tinnitus can also be an independent comorbidity in depressed people.^25, 29 Depression often overlaps with anxiety disorders, substance misuse, in particular alcohol misuse, and sleep disturbances.³⁰ Some patients with troublesome tinnitus may also experience social phobias and adjustment disorders.^25, 31

Psychological interventions, including CBT and interpersonal therapy, delivered by a psychologist trained in the relevant approach, are strongly recommended as first-line therapies for treating depression, with pharmacological support only if necessary.³⁰

Some veterans with tinnitus may have multiple comorbid mental health issues and complex needs that require careful treatment planning.^32, 33

Medicines are a rare cause of tinnitus

Although there are many medicines reported as causing tinnitus, there is acceptable evidence for only a small number (and then in those medicines, tinnitus occurs only rarely) (see Table 1).³⁸ Risk of ototoxic effects from medicine use is higher with older age, long-term use, renal or liver impairment, and when ototoxic medicines are used in combination with each other. Most ototoxic effects are temporary and dose-dependent.^34, 39

Table 1. Medicines associated with ototoxic effects
Class of medicine	Medicine		Ototoxic effects
Antimalarial drugs8, 34	e.g. quinine-based agents34, 40, 41		Reversible hearing loss, tinnitus and vertigo34, 41
Nonsteroidal anti-inflammatory drugs	e.g. ibuprofen, indomethacin34		Tinnitus occurs only rarely (less than 0.1%)34
	aspirin34, 42		Tinnitus, hearing impairment and vertigo with high doses34 Reversible with short-term use42
Loop diuretics8	e.g. furosemide, bumetanide		Tinnitus, vertigo and hearing loss with high doses (especially with rapid intravenous administration)34
Antibiotics	Aminoglycosides34 e.g. amikacin, gentamicin, tobramycin, streptomycin34		Vestibular (nausea, vomiting, vertigo, nystagmus and gait disturbances) and cochlear (hearing loss, tinnitus and a feeling of fullness in the ear) ototoxicity is dose-related34
	Glycopeptides34 e.g. vancomycin, teicoplanin34		Rarely causes dizziness, vertigo or tinnitus. Risk is higher with prolonged use, in renal impairment, and when given with other ototoxic medicines, such as aminoglycosides or loop diuretics.34, 43 Deafness can be permanent34
	Macrolides8 e.g. erythromycin, azithromycin34		Tinnitus, dizziness or hearing loss is dose-related34
Chemotherapies8	methotrexate34		Vertigo and tinnitus34
	cisplatin, carboplatin34		Hearing loss is dose-related, generally irreversible and more common in elderly patients. Tinnitus is usually reversible34
	vincristine34		Permanent or temporary vertigo and deafness34

Talk with patients about how a multidisciplinary approach can help

Explain to patients:

• Tinnitus is a symptom, not a disease. Management strategies can help reduce the perceived severity and improve quality of life.⁴
• Medical investigation may be needed initially, but tinnitus is rarely an indication of a serious illness.²
• Tinnitus can be temporary, but often it is not.²
• The importance of stopping medicines that are ineffective in treating tinnitus and emphasise the benefits of seeing a psychologist.^2, 24
• The severity of tinnitus may change in response to many factors, including emotional stress, anxiety, general health, pain, lack of sleep or exposure to loud noises or quiet places.^{2, 15, 25, 44}
• Treatments focus on adapting to tinnitus and managing the emotional reaction to tinnitus.⁹
• No single treatment works for everyone. A multidisciplinary approach that involves a range of strategies, including CBT and counselling, self-care, education, mindfulness and relaxation, communication and auditory therapies, and devices such as hearing aids, assistive listening devices and sound therapy can be helpful.^4, 6, 45
• To keep doing the things they enjoy; living life to accommodate tinnitus only amplifies the noise.²
• Making the environment more ‘tinnitus friendly’ by using hearing aids and sound therapy can be helpful.^2, 11

• Hearing aids amplify peripheral and objective sounds and make the tinnitus sounds less noticeable.¹¹
• Sound therapy reduces the starkness of tinnitus and distracts attention away from it. It can be used in combination with a hearing aid with an inbuilt sound generator.^4, 11

• Information can be empowering and help them to feel better about tinnitus. Access Tinnitus Australia at: www.tinnitusaustralia.org.au
• The Veterans’ guide to better hearing may help them gain a better understanding of tinnitus and hearing loss, and treatment options available to them, at: www.dva.gov.au/sites/default/files/files/p04129-guide-to-better-hearing.pdf

References

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3. MacGregor A, Joseph A, Dougherty A. Prevalence of tinnitus and association with self-rated health among military personnel injured on combat deployment. Mil Med. 2020; 185: e1608-e1614.
4. Tunkel D et al. Clinical practice guideline: Tinnitus. Otolaryngol Head Neck Surg. 2014; 151(2S): S1-S40.
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28. Beukes E, Allen P, Baguley D, Manchaiah V, Andersson G. Long-term efficacy of audiologist-guided internet-based cognitive behavior therapy for tinnitus. Am J Audiol. 2018; 27: 431-447.
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30. Malhi G et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry. 2021; 55(1): 7-117.
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32. Van Hooff M et al. Mental Health Prevalence and Pathways to Care Summary Report. Mental Health and Wellbeing Transition Study. Australian Government Department of Defence and Department of Veterans' Affairs. Canberra. 2018.
33. Carlson K et al. Health care utilization and mental health diagnoses among veterans with tinnitus. Am J Audiol. 2019; 28: 181-190.
34. Australian Medicines Handbook. Adelaide. Australian Medicines Handbook Pty Ltd. 2021.
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37. Wegner I, Hall D, Smit A, McFerran D, Stegeman I. Betahistine for tinnitus. Cochrane Database Syst Rev. 2018; 12: CD013093.
38. McFerran D. British Tinnitus Association: Drugs and tinnitus. 2020. Available at: www.tinnitus.org.uk/drugs [Accessed December 2020].
39. Therapeutic Guidelines. eTG complete. Available at: https://tgldcdp.tg.org.au/index#toc_d1e79 [Accessed February 2021].
40. Roche R et al. Quinine induces reversible high-tone hearing loss. Br. J. Clin Pharmac. 1990; 29: 780-782.
41. Alvan G et al. Concentration-response relationship of hearing impairment caused by quinine and salicylate: pharmacological similarities but different molecular mechanisms. Basic & Clinical Pharmacology & Toxicology. 2017; 120: 5-13.
42. Sheppard A, Chen G, Ralli M, Salvi R. Review of salicylate-induced hearing loss, neurotoxicity, tinnitus and neuropathophysiology. ACTA Otorhinolaryngol Ital. 2014; 34: 79-93.
43. Altissimi G et al. Drugs inducing hearing loss, tinnitus, dizziness and vertigo: an updated guide. Eur Rev Med Pharmacol Sci. 2020; 24: 7946-7952.
44. Pan T, Tyler R, Ji H, Coelho C, Gogel SA. Differences among patients that make their tinnitus worse or better. Am J Audiol. 2015; 24: 469-476.
45. Nolan D, Gupta R, Huber C, Schneeberger A. An effective treatment for tinnitus and hyperacusis based on cognitive behavioral therapy in an inpatient setting: a 10-year retrospective outcome analysis. Front Psychiatry. 2020; 11.

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