Taming TBI-Associated Tinnitus Regardless of the tinnitus sound (itself), tinnitus can be especially challenging for clients when paired with traumatic brain injury and post-traumatic stress. Research offers insight into how clinicians can help clients manage this co-occurrence. Features
Free
Features  |   December 01, 2015
Taming TBI-Associated Tinnitus
Author Notes
  • Marc Fagelson, PhD, CCC-A, is professor and director of audiology in the Department of Audiology and Speech Language Pathology at East Tennessee State University. He is an affiliate of ASHA Special Interest Group 6, Hearing and Hearing Disorders: Research and Diagnostics. fagelson@mail.etsu.edu
    Marc Fagelson, PhD, CCC-A, is professor and director of audiology in the Department of Audiology and Speech Language Pathology at East Tennessee State University. He is an affiliate of ASHA Special Interest Group 6, Hearing and Hearing Disorders: Research and Diagnostics. fagelson@mail.etsu.edu×
Article Information
Hearing Disorders / Attention, Memory & Executive Functions / Traumatic Brain Injury / Features
Features   |   December 01, 2015
Taming TBI-Associated Tinnitus
The ASHA Leader, December 2015, Vol. 20, 52-54. doi:10.1044/leader.FTR3.20122015.52
The ASHA Leader, December 2015, Vol. 20, 52-54. doi:10.1044/leader.FTR3.20122015.52
Even before she returned from Iraq, Ms. H began to notice that routine noises—the stacking and washing of dishes, the sound of sirens, the application of brakes—were painfully loud. This tolerance issue arose when Ms. H suffered a blast injury in 2005; at the time, she served as a lead gunner for an armored unit in Iraq. Upon waking following the blast, she heard the tinnitus she hears today.
We first saw Ms. H in the tinnitus clinic of the Mountain Home VA Medical Center in 2006. She reported struggling with many aspects of life outside the military, and tinnitus was clearly a complicating factor. When she came to our clinic for services, her tinnitus was so strident and constant that it interfered with her concentration, communication and sleep. She even started questioning the reliability of her own senses; indeed, many blast-exposed people express frustration that they cannot monitor the environment accurately.
As a result of the blast, Ms. H also had mild traumatic brain injury (mTBI) and mild bilateral high-frequency hearing loss. She was also receiving mental health services for post-traumatic stress disorder (PTSD). Tinnitus, however, was her main complaint, causing her stress, anxiety, insecurity in her environment, and an overall reduced quality of life.
A refresher on tinnitus: It is the listener’s experience of a sound generated internally, not in the environment. People do not, however, imagine tinnitus. Scanning studies confirm its presence in the central nervous system. Tinnitus-related activity stimulates the auditory pathway and other neural centers the same way as external sound.
Patients with tinnitus often report that it affects or is affected by their psychological state. This tie may be even stronger when tinnitus is triggered by a traumatic event associated with the TBI and PTSD. In one study of 150 veterans, Kathleen Carlson and colleagues found TBI-PTSD co-occurrence rates of 33 to 39 percent, as reported in a 2011 article in the Journal of Head Trauma Rehabilitation. Our research with veterans, published in the American Journal of Audiology in 2007, indicated that PTSD could aggravate tinnitus. Likewise, tinnitus may exacerbate PTSD, as suggested in research on Cambodian refugees led by Devon E. Hinton and published in the Journal of Traumatic Stress in 2006.
Certainly tinnitus, PTSD and TBI appeared interrelated for Ms. H. Her tinnitus was rated as more severe than tinnitus that affects clients without TBI and PTSD. It was particularly troublesome for her in that, at times, the tinnitus seemed to trigger traumatic memories of the blast that preceded its onset. As clinicians, how can we better understand this relation between tinnitus, PTSD and TBI to better intervene with patients like Ms. H?
Trauma and memory
Episodes that produce TBI are often violent and traumatic. Some consequences of traumatic exposure appear immediately. Others may emerge over time or appear insidiously. Tinnitus clearly fits both profiles: It may appear immediately after exposure, and it may worsen or change over time. In either case, the person with tinnitus may associate it with the event, focusing on its importance as a reminder of the event or as a warning signal tied to it.
Some studies indicate that people remember trauma-related sensory elements with great detail and show improved performance on memory tasks related to items associated with the trauma, such as a gun or a dented car (see sources below). This trauma-memory connection could exacerbate tinnitus severity.
Traumatic events also produce long-term brain changes and physiological responses, report David M. Diamond and colleagues in a model they describe in a 2007 Neural Plasticity article. Blood levels of stress hormones such as cortisol increase at the same time that memory-related N-methyl-D-aspartate receptors are activated in the brain. This co-occurrence could lead to a person “learning” the sensory scene of a threatening environment as an element of a durable survival response.
The perceived importance of tinnitus resulting from traumatic exposure could result in its being heard consistently and in great detail. Memories of the event may trigger it, or it may trigger recall of the event on its own. The Diamond model supports the observation that trauma-associated tinnitus impairs performance of daily tasks that require concentration or divided attention.

The perceived importance of tinnitus resulting from traumatic exposure could result in its being heard consistently and in great detail.

Management strategies
The confluence of physical, psychological and social effects in clients with TBI, PTSD and tinnitus requires a multidisciplinary approach to management. Multiple senses, including vision, may be impaired. Polytrauma teams providing audiology, speech-language pathology, neurology, nutrition, otolaryngology, optometry, occupational therapy, physical therapy and pharmacology services may be best prepared to manage patients.
As with any client seen in a tinnitus clinic, those with TBI require full audiometric evaluation and services targeting hearing loss. For some patients, management of hearing loss can minimize the impact of tinnitus.
Certain hearing aid-fitting strategies can help those with tinnitus and minimal hearing loss. Grant D. Searchfield’s chapter “Hearing Aids and Tinnitus” in the 2005 book “Tinnitus Treatments: Clinical Protocols” suggests one option is to fit hearing aids that contain masking circuitry. However, Searchfield stresses that it is often effective to program devices to prioritize (in addition to speech audibility) patients’ awareness of environmental sounds. This adjustment can facilitate control regarding monitoring and responding to environmental sounds, fostering a sense of security and improving a patient’s functioning across listening situations.
In our clinic, more than 50 percent of clients with trauma histories report that hearing aids reduce tinnitus annoyance. Nearly all, regardless of hearing loss severity, report better communication, more environmental awareness and increased activity levels.
Also shown to be beneficial for both TBI and tinnitus is cognitive behavioral therapy, or CBT—a type of psychotherapy that challenges negative thoughts and misinterpretations of events with the goal of changing counterproductive behavior patterns (see sources below). This intervention addresses clients’ mental health needs and offers coping strategies specific to their challenges. It teaches them new ways to react to and cope with the tinnitus sensation, and as a result many patients report reduced tinnitus intrusiveness. CBT is also used as a frontline intervention for PTSD.
Sound management
So, given this array of interventions, how did we manage Ms. H’s needs as related to tinnitus exacerbated by TBI and PTSD? After several hours of tinnitus-related counseling, we fitted her with a pair of mild-gain hearing aids and instructed her how to use them for improved communication, awareness of environmental sounds, localization and the possibility of tinnitus relief. She originally wanted to forego hearing aids, but a few weeks post-fitting she reported that the devices improved her sense of security.
Ms. H also reported that her activity level was higher and that communication difficulties were less pronounced. Though she continued hearing tinnitus, its intrusiveness decreased. We urged her to continue counseling in the mental health clinic and to return to audiology for more focused tinnitus counseling and routine checks on her hearing aids.
Ms. H’s care illustrates how interprofessional management that includes appropriate hearing aids and aural rehabilitation can help mitigate the disruptions associated with co-occurring TBI, PTSD and tinnitus. This approach greatly improved her quality of life and ability to function. As with any intervention, it is essential to convey realistic expectations and help restore clients’ sense of control of their environment. The needs of people with TBI are great, and the call to audiologists and speech-language pathologists to participate in their care is correspondingly urgent.
Sources
Carlson, K. F., Kehle, S. M., Meis, L. A., Greer, N., MacDonald, R., Rutks, I. … Wilt, T. J. (2011). Focus on clinical research and practice, part 1; prevalence, assessment, and treatment of mild traumatic brain Injury and posttraumatic stress disorder: A systematic review of the evidence. Journal of Head Trauma Rehabilitation, 26(2), 103–115. [Article] [PubMed]
Carlson, K. F., Kehle, S. M., Meis, L. A., Greer, N., MacDonald, R., Rutks, I. … Wilt, T. J. (2011). Focus on clinical research and practice, part 1; prevalence, assessment, and treatment of mild traumatic brain Injury and posttraumatic stress disorder: A systematic review of the evidence. Journal of Head Trauma Rehabilitation, 26(2), 103–115. [Article] [PubMed]×
Cima, R. F. F., Maes, I. H., Joore, M. A., Scheyen, D. J. W. M., El Refaie, A., Baguley, D. M. … Vlaeyen, J. W. S. (2012). Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: A randomised controlled trial. Lancet, 379, 1951–1959. [Article] [PubMed]
Cima, R. F. F., Maes, I. H., Joore, M. A., Scheyen, D. J. W. M., El Refaie, A., Baguley, D. M. … Vlaeyen, J. W. S. (2012). Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: A randomised controlled trial. Lancet, 379, 1951–1959. [Article] [PubMed]×
Diamond, D. M., Campbell, A. M., Park, C. R., Halonen, J., & Zoladz, P. R. (2007). The temporal dynamics model of emotional memory processing: A synthesis on the neurobiological basis of stress-induced amnesia, flashbulb and traumatic memories, and the Yerkes-Dodson Law. Neural Plasticity. Online publication.
Diamond, D. M., Campbell, A. M., Park, C. R., Halonen, J., & Zoladz, P. R. (2007). The temporal dynamics model of emotional memory processing: A synthesis on the neurobiological basis of stress-induced amnesia, flashbulb and traumatic memories, and the Yerkes-Dodson Law. Neural Plasticity. Online publication.×
Ehlers, A., Hackmann, A., Steil, R., Clohessy, S., Wenninger, K., & Winter, H. (2002) The nature of intrusive memories after trauma: The warning signal hypothesis. Behaviour Research and Therapy, 40, 995–1002. [Article] [PubMed]
Ehlers, A., Hackmann, A., Steil, R., Clohessy, S., Wenninger, K., & Winter, H. (2002) The nature of intrusive memories after trauma: The warning signal hypothesis. Behaviour Research and Therapy, 40, 995–1002. [Article] [PubMed]×
Fagelson, M. A. (2007). The association between tinnitus and posttraumatic stress disorder. American Journal of Audiology, 16, 107–117. [Article] [PubMed]
Fagelson, M. A. (2007). The association between tinnitus and posttraumatic stress disorder. American Journal of Audiology, 16, 107–117. [Article] [PubMed]×
Goodrich, G. L., Kirby, J., Cokerham, G., Ingalla, S. P., & Lew, H. L. (2007) Visual function in patients of a polytrauma rehabilitation center: A descriptive study. Journal of Rehabilitation Research and Development, 44, 929–936. [Article] [PubMed]
Goodrich, G. L., Kirby, J., Cokerham, G., Ingalla, S. P., & Lew, H. L. (2007) Visual function in patients of a polytrauma rehabilitation center: A descriptive study. Journal of Rehabilitation Research and Development, 44, 929–936. [Article] [PubMed]×
Henry, J. A, Zaugg, T. L, Myers, P. J, & Schechter, M. A. (2008) The role of audiologic evaluation in progressive audiologic tinnitus management. Trends in Amplification, 12(3), 170–187. [Article] [PubMed]
Henry, J. A, Zaugg, T. L, Myers, P. J, & Schechter, M. A. (2008) The role of audiologic evaluation in progressive audiologic tinnitus management. Trends in Amplification, 12(3), 170–187. [Article] [PubMed]×
Kleinjung, T. (2011). Surgical treatment: The ear. In Moller, A., Langguth, B., DeRidder, D., & Kleinjung, T. (Eds.), Textbook of tinnitus (pp. 663–668). New York: Springer-Verlag.
Kleinjung, T. (2011). Surgical treatment: The ear. In Moller, A., Langguth, B., DeRidder, D., & Kleinjung, T. (Eds.), Textbook of tinnitus (pp. 663–668). New York: Springer-Verlag.×
Martinez-Devesa, P., Perera, R., Theodoulou, M., & Waddell, A. (2010). Cognitive behavioural therapy for tinnitus. Cochrane Database of Systematic Reviews 2010, (9).
Martinez-Devesa, P., Perera, R., Theodoulou, M., & Waddell, A. (2010). Cognitive behavioural therapy for tinnitus. Cochrane Database of Systematic Reviews 2010, (9).×
Myers, P. J., Wilmington, D. J., Gallun, F. J., Henry, J. A., & Fausti, S. A. (2009). Hearing impairment and traumatic brain injury among soldiers: Special considerations for the audiologist. Seminars in Hearing, 30, 5–27. [Article]
Myers, P. J., Wilmington, D. J., Gallun, F. J., Henry, J. A., & Fausti, S. A. (2009). Hearing impairment and traumatic brain injury among soldiers: Special considerations for the audiologist. Seminars in Hearing, 30, 5–27. [Article] ×
Safer, M. A., Christianson, S. A., Autry, M. W., & Sterlund, O. K. (1998). Tunnel memory for traumatic events. Applied Cognitive Psychology, 12, 99–117. [Article]
Safer, M. A., Christianson, S. A., Autry, M. W., & Sterlund, O. K. (1998). Tunnel memory for traumatic events. Applied Cognitive Psychology, 12, 99–117. [Article] ×
Searchfield, G. D. Hearing aids and tinnitus. (2005). In Tyler, R. (Ed.), Tinnitus treatment: Clinical protocols (pp. 161–175). Thieme.
Searchfield, G. D. Hearing aids and tinnitus. (2005). In Tyler, R. (Ed.), Tinnitus treatment: Clinical protocols (pp. 161–175). Thieme.×
Sweetow, R. W. (1986). Cognitive aspects of tinnitus patient management. Ear and Hearing, 7(6), 390–396. [Article] [PubMed]
Sweetow, R. W. (1986). Cognitive aspects of tinnitus patient management. Ear and Hearing, 7(6), 390–396. [Article] [PubMed]×
0 Comments
Submit a Comment
Submit A Comment
Name
Comment Title
Comment


This feature is available to Subscribers Only
Sign In or Create an Account ×
FROM THIS ISSUE
December 2015
Volume 20, Issue 12