The Effect of Different Counselors on Treatment Outcome of Tinnitus Retraining Therapy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Tinnitus retraining therapy (TRT) is one of the most effective treatment modalities of tinnitus based on the neurophysiological model proposed by Jastreboff and Hazell. This study was performed to evaluate the effect of counselor factor on treatment outcomes of TRT. SUBJECTS AND METHOD: The total of 78 patients who had TRT from three different counselors in a tinnitus clinic of tertiary referral center from Jan 2015 to Dec 2015 were included in this study. Their medical records were retrospectively reviewed to evaluate the therapeutic response to TRT. RESULTS: Among 78 patients who were followed-up for more than 6 months, 47, 20, and 11 patients were treated by counselors A, B, C (all ENT specialists), respectively. Counselor A had 15-year-experience of TRT counseling, whereas counselor B and C were well trained but beginners of TRT counseling. Initial clinical characteristics including Tinnitus Handicap Inventory (THI) and tinnitus Visual Analogue Scale (VAS) scores of the patients among three groups were not significantly different. Treatment responses evaluated via THI and most of the tinnitus VAS scores after at least 6 months after TRT were significantly improved in all three groups (p<0.05) with no significant difference between the senior (A) and junior (B, C) group. CONCLUSION: TRT seems to be an effective treatment modality of tinnitus even in this short term follow-up study. Treatment outcomes of TRT may not depend on the counselors once they are well trained and follow the same protocol.

Tinnitus Retraining Therapy / 한양의대학술지

According to the Jastreboff's neurophysiological model of tinnitus, if negative associations are attached to the tinnitus signal, tinnitus is perceived to be a threat or a danger and it activates the autonomic nervous and limbic systems. Consequently patient's awareness of tinnitus is heightened and so patient perceives it to be louder and more persistent. Jastreboff and Hazell started tinnitus retraining therapy (TRT) based on the neurophysiological model of tinnitus. The purpose of TRT is blocking tinnitus from activating the sympathetic nervous and limbic systems (habituation of reaction) and from reaching the cerebral cortex (habituation of perception). TRT is composed of two components directive counseling that tries to reclassify tinnitus into the meaningless stimuli and sound therapy that decreases the relative strength of the tinnitus signal. Physicians try to put patient's tinnitus into the territory of meaningless stimuli through retraining the brain (habituation of reaction). Because the brain habituates all unimportant stimuli, if habituation of reaction is fully achieved, habituation of perception will follow automatically. In most clinical results, clinical success rates of TRT approach or exceed 80% improvement. Early improvement can be achieved during the first few months, followed by additional progressive improvement. It should be recommended that the patient continue treatment at least 18 months.

Small-Group Counseling in a Modified Tinnitus Retraining Therapy for Chronic Tinnitus

OBJECTIVES: The authors have treated chronic tinnitus patients using a combination of a simplified tinnitus retraining therapy (TRT) and medications, which we called modified TRT. In this clinical setting, we have attempted small-group counseling to find a time-effective equivalent of individual counseling. The aim of the present study was to evaluate the effectiveness of small-group counseling by comparing the treatment outcomes between individual and small-group counseling. METHODS: The patients who had distressing chronic tinnitus with normal hearing or mild hearing loss were included. The subjects were placed into the small-group (group 1:4) or the individual (group 1:1) counseling group, and underwent a modified TRT composed of a single session of directive counseling and ambient sound stimulation. In addition, alprazolam (0.25 mg) and ginkgo biloba extract (80 mg) were administered orally to the subjects for 3 months. The 3- and 6- month outcomes were assessed using the follow-up rates and tinnitus severity scores: awareness, tinnitus handicap inventory (THI), loudness, annoyance, and effect on life. The treatment responses were classified as improvement, no changes, and worsening. RESULTS: Of the total 149 patients (77 in group 1:1; 72 in group 1:4), 104 patients completed the protocol at 3 months, and 55 patients at 6 months. The follow-up rates were similar in both groups. Over the period of 6 months, all scores declined significantly except the loudness score at 3 months in both groups. Treatment responses showed no between-group differences. The success rate based on THI was 70% in group 1:1, and 64% in group 1:4 at 6 months. CONCLUSION: The small-group counseling of our modified TRT was comparable to the individual counseling for tinnitus relief. We suggest that this protocol can be implemented effectively in any crowded otolaryngology clinics.

Clinical Application of Tinnitus Retraining Therapy on Subjective Tinnitus

OBJECTIVE: Subjective tinnitus is heard only by the patient and is usually considered to have no acoustic source. Treatments of subjective tinnitus include medication, Tinnitus retraining therapy (TRT), psychological treatment, and electrical suppression. TRT is one of the most effective treatment for subjective tinnitus. However, TRT is not commonly done in Korea. The aim of this study was to investigate the effect of TRT on subjective tinnitus. METHODS: A case-control study was conducted between March 2010 and October 2011. A total of 148 patients who were diagnosed as subjective tinnitus were included in this study. In TRT group, TRT was given with hearing aids or sound generator and medications. The result of Tinnitus was evaluated by tinnitus handicap inventory (THI), visual analogue scale (VAS) and tinnitogram. RESULTS: At 3 months, TRT group showed significantly improvement at 15.2+/-14.2 of THI, 8.1+/-2.1 by emotional score of THI, and 18.1+/-15.5 by length of noticeable time. CONCLUSION: TRT group showed better result than medication group according to THI and VAS. TRT showed good effect on emotional score of THI and length of noticeable time. However, TRT needs more time and effort of physician.

Vestibular Rehabilitation Therapy: Review of Indications, Mechanisms, and Key Exercises

Vestibular rehabilitation therapy (VRT) is an exercise-based treatment program designed to promote vestibular adaptation and substitution. The goals of VRT are 1) to enhance gaze stability, 2) to enhance postural stability, 3) to improve vertigo, and 4) to improve activities of daily living. VRT facilitates vestibular recovery mechanisms: vestibular adaptation, substitution by the other eye-movement systems, substitution by vision, somatosensory cues, other postural strategies, and habituation. The key exercises for VRT are head-eye movements with various body postures and activities, and maintaining balance with a reduced support base with various orientations of the head and trunk, while performing various upper-extremity tasks, repeating the movements provoking vertigo, and exposing patients gradually to various sensory and motor environments. VRT is indicated for any stable but poorly compensated vestibular lesion, regardless of the patient's age, the cause, and symptom duration and intensity. Vestibular suppressants, visual and somatosensory deprivation, immobilization, old age, concurrent central lesions, and long recovery from symptoms, but there is no difference in the final outcome. As long as exercises are performed several times every day, even brief periods of exercise are sufficient to facilitate vestibular recovery. Here the authors review the mechanisms and the key exercises for each of the VRT goals.

Short Term Effect of Mixed Tinnitus Retraining Therapy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The long-term effect of tinnitus retraining therapy (TRT) is excellent while its short-term effect is known to be inferior to tinnitus making (TM). In this regard, we mixed TRT (mTRT) by combining TRT and TM to improve the short-term effect of TRT. This study evaluated the short-term effect of the mTRT and also compared the clinical efficacy between mTRT and TM. SUBJECTS AND METHOD: Twenty patients who underwent mTRT due to chronic subjective tinnitus were included in this study. Sound therapy of the mTRT was performed with mixed noise of broadband noise and narrow band noise. The broadband noise was used for TRT and the narrow band noise was used for TM. During the first month of mTRT, sound therapy was mainly composed of narrow band noise. During the second month, the proportion of broadband noise was gradually increased to 2/3. After 3 months, only the broadband noise was applied. Tinnitus Handicap Inventory (THI), Visual Analog Scale (VAS) on annoyance and the tinnitus awareness duration (hr/day) was checked as the outcome measures. The outcome was also compared between mTRT and TM. RESULTS: The THI score decreased significantly from 41.8+/-24.3 to 27.3+/-25.6 after mTRT. The VAS (from 5.9+/-1.4 to 4.7+/-1.8) and the tinnitus awareness duration (from 18.5+/-8.2 to 12.6+/-10.7) also showed a significant improvement after treatment. When the treatment outcome was compared between mTRT and TM, there was no significant difference. CONCLUSION: mTRT seems to be effective in relieving the discomfort of tinnitus. Similar short-term outcomes can be expected from mTRT as they did in TM.

Tinnitus: Characteristics, Causes, Mechanisms, and Treatments

Tinnitus-the perception of sound in the absence of an actual external sound-represents a symptom of an underlying condition rather than a single disease. Several theories have been proposed to explain the mechanisms underlying tinnitus. Tinnitus generators are theoretically located in the auditory pathway, and such generators and various mechanisms occurring in the peripheral auditory system have been explained in terms of spontaneous otoacoustic emissions, edge theory, and discordant theory. Those present in the central auditory system have been explained in terms of the dorsal cochlear nucleus, the auditory plasticity theory, the crosstalk theory, the somatosensory system, and the limbic and autonomic nervous systems. Treatments for tinnitus include pharmacotherapy, cognitive and behavioral therapy, sound therapy, music therapy, tinnitus retraining therapy, massage and stretching, and electrical suppression. This paper reviews the characteristics, causes, mechanisms, and treatments of tinnitus.

Treatment Response of Modified Tinnitus Retraining Therapy with Medical Therapy in the Patients with Tinnitus / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: According to the neurophysiologic model of tinnitus, emotion and autonomic nervous systems are closely related to generation of tinnitus. We performed this study to evaluate the treatment response of modified tinnitus retraining therapy (TRT) with medication in the patients with sensorineural tinnitus. SUBJECTS AND METHOD: Forty-three tinnitus patients who were diagnosed as sensorineural tinnitus through audiologic evaluation and have normal hearing in speech frequency were included in this study. Tinnitus and psychological status were measured by tinnitus questionnaire, Korean version of Brief Encounter Psychosocial Instrument (BEPSI) scale, Beck Depression Inventory (BDI), Spielberger State Trait Anxiety Inventory (STAI). Patients treated with anxiolytics and microcirculation enhancer were Group 1 and those treated with modified TRT and medications were Group 2. Short-term therapeutic response was analyzed and compared between two groups. RESULTS: Loudness, awareness, annoyance and effect on life of tinnitus and tinnitus handicap score were significantly decreased in Group 2. Relief of tinnitus in more than 2 of 4 subjective parameters was achieved in 4 patients (30.7%) in Group 1 and 15 patients (75%) in Group 2. Stress score was also decreased significantly after treatment in Group 2. CONCLUSION: Tinnitus patients in Group 2 treated with medication and modified TRT showed the higher compliance and the response rate of treatment than the patients in Group 1 treated with medication alone. Modified TRT, in addition to medical therapy, should be considered to increase the therapeutic response in patients with sensorineural tinnitus.

The Effectiveness of the Directive Counseling in Tinnitus Retraining Therapy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Tinnitus retraining therapy (TRT) was introduced as a new method for tinnitus management, and it is currently an efficacious therapy in use. In this article, we would like to show the effectiveness of directive counseling in TRT on tinnitus management. MATERIALS AND METHOD: A total of 1, 100 patients who visited tinnitus clinic at the Severance Hospital from 1999 to 2002 were included in this study. Their characteristics and negative associations of tinnitus were investigated. Forty-six patients who were managed with directive counseling were evaluated with questionnaires about the psychoacoustic characteristics of tinnitus and the subjective changes in tinnitus. RESULTS: Tinnitus was developed after stress (35.6%), fatigue (32.0%) and exposure to noise (21.4%), and it was negatively associated with hearing loss (51.8%), continuation of tinnitus (51.6%) and sleep disorder (17.5%). Factors such as awareness, loudness, annoyance, the effect on life tinnitus had were decreased after directive counseling. And the tinnitus handicap inventory (THI) score was also significantly decreased. CONCLUSION: Directive counseling in TRT which includes explanation of neurophysiology of tinnitus should be tried preferentially before habituation occurs.

Clinical Implication and Therapeutic Efficacy of Tinnitus Retraining Therapy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Tinnitus retraining therapy (TRT) has been presented as a new approach to tiniutus management. The aim of this paper is to show the clinical implication method of TRT in our clinic and to evaluate the therapeutic efficacy of TRT based on questionnaires and tinnitograms. MATERIALS AND METHODS: Using the clinical implication method of TRT, 60 patients with tinnitus, who visited Tinnitus Clinic, Kangnam St. Mary's Hospital from May, 1999 to July, 2001, and who had received TRT for their tinnitus, were included for the evaluation of therapeutic efficacy of TRT. Their psychoacoustic characteristics of tinnitus and changes of subjective tinnitus were analyzed. RESULTS: Loudness, awareness, annoyance and effect on life of tinnitus decreased after TRT. Tinnitus handicap score also significantly decreased (p<0.05). Forty-eight patients among the sixty patients (80%) showed relief of their tinnitus in more than 2 of 4 subjective parameters (loudness, awareness, annoyance and effect on life of tinnitus). CONCLUSION: TRT has been shown to be effective in the treatment of subjective tinnitus. Modification of TRT may be necessary for easy application of this therapy in Korea.

Treatment of Tinnitus With Tinnitus Retraining Therapy / 听力学及言语疾病杂志

Nine patients with tinnitus were treated with tinnitus retraining therapy( TRT) between August and November, 1997. The components of TRT included(1)correct counselling, (2)use of appropriate hearing aid, (3)mask with a low level sound, (4)use of relaxation technique. 7 cases demonstrated encouraging results of treatment. This provides a new method for treatment of tinnitus.