The Tinnitus-Traumatic Brain Injury Link What is the role of the audiologist in patient care, treatment and coping strategies? All Ears on Audiology
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All Ears on Audiology  |   August 01, 2016
The Tinnitus-Traumatic Brain Injury Link
Author Notes
  • Candice “Evie” Ortiz, AuD, CCC-A, is an audiologist at the Walter Reed National Military Medical Center in Bethesda, Maryland. candice.e.ortiz.civ@mail.mil
    Candice “Evie” Ortiz, AuD, CCC-A, is an audiologist at the Walter Reed National Military Medical Center in Bethesda, Maryland. candice.e.ortiz.civ@mail.mil×
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Hearing Disorders / Attention, Memory & Executive Functions / Traumatic Brain Injury / All Ears on Audiology
All Ears on Audiology   |   August 01, 2016
The Tinnitus-Traumatic Brain Injury Link
The ASHA Leader, August 2016, Vol. 21, 16-17. doi:10.1044/leader.AEA.21082016.16
The ASHA Leader, August 2016, Vol. 21, 16-17. doi:10.1044/leader.AEA.21082016.16
About 10 to 15 percent of the global population experiences tinnitus, a figure on the rise as the population ages and as combat veterans sustain blast and hearing-affecting injuries. Since 2008, tinnitus has been the most compensated injury in the U.S. veteran population, with the numbers increasing every year.
Of those experiencing tinnitus, only 3 to 5 percent suffer enough to seek medical attention. Why is there a difference between those who report having tinnitus and those who seek help for it from a medical professional? There are many possible reasons for this difference.
A person’s reaction to tinnitus dictates how well they can manage or get used to its presence. Of the many people who say they hear sounds that cannot be explained by external sources, a subset accepts it as a facet of life and shrugs it off; their quality of life is unaffected.
Another subset, however, is so bothered by the presence of tinnitus that they complain of difficulty sleeping, concentrating and relaxing. These same people frequently report a feeling of helplessness when asked if they can control their reactions to tinnitus.
Why the difference? The key may be their response to their tinnitus.

Of those experiencing tinnitus, only 3 to 5 percent suffer enough to seek medical attention. Why is there a difference between those who report having tinnitus and those who seek help for it from a medical professional?

Body system interactions
Reactions involve two major body systems: the limbic system, which is our emotional powerhouse, and the autonomic nervous system (ANS), which regulates key involuntary body functions. When the limbic system associates a feeling with an experience, the ANS reacts accordingly.
For example, when you first move into a new home, you may have restless nights as you adjust to the sounds within that home, like the automatic ice maker dropping a load of ice in the freezer. If you are unfamiliar with the clang of the ice falling into the holding tray, your limbic system may worry that an intruder is trying to enter your home. The ANS responds, perhaps with an increased pulse, clammy palms and a heightened sense of awareness. Falling back to sleep may prove to be a challenge.
Now fast-forward a few months: You are settled in your new home and have adjusted to the sounds the house makes. The ice drops in the freezer; however, you barely notice it because your brain has habituated to the sound, your limbic system knows there is no intruder, and your ANS does not experience a fight-or-flight response. This process is similar to the acclimatization we hope the limbic system and ANS can achieve with tinnitus awareness and perception.
Modifying the response
Treatment for bothersome tinnitus involves modifying the way the brain and body react to its presence—just like we know that the ice drops in the freezer, but we do not always hear or attend to it. Similarly, the goal is to have the person barely notice the tinnitus and be less affected by it.
Sound therapy is a management technique that can modify people’s reaction to tinnitus. Sound therapy distracts the brain, reduces the perception of tinnitus loudness, and/or reduces stress levels.
The technique uses an external sound to facilitate habituation at a subconscious level by reducing the contrast between the loudness of the tinnitus and the listener’s environment. It teaches the brain to think of tinnitus as an unimportant sound, which promotes habituation and/or desensitization, allowing the person to—eventually—“forget” about its presence.

In post-TBI tinnitus, it may be more difficult for the brain to desensitize itself to auditory symptoms because of the reorganization occurring within the central nervous system.

Tinnitus and TBI
Mitigating the perception and disruption of tinnitus takes time and effort. But what about tinnitus that occurs along with traumatic brain injury (TBI)? The effects of TBI—an alteration in brain function caused by an external force, typically from a violent blow or jolt to the head or body—can include varying degrees of brain cell dysfunction, bruising, bleeding and torn brain tissues. Physical symptoms of TBI can include headaches, hearing difficulties, dizziness/loss of balance, auditory hallucinations and tinnitus. Every year, nearly 1.7 million Americans sustain a TBI.
So now we are faced with people who have tinnitus and an injured brain that is trying to heal itself. The healing process often leads to increased spontaneous firing rates in the auditory cortex, increased bursting events, and elevated activity within the inferior colliculus—all of which exacerbate tinnitus perception.
In post-TBI tinnitus, it may be more difficult for the brain to desensitize itself to auditory symptoms because of the reorganization occurring within the central nervous system. Many people with TBI report a new and heightened awareness of “noise” and report new difficulties ignoring input. This heightened awareness creates a challenge to the sound therapy techniques used to mitigate tinnitus.
The patient must be willing to use sounds—not be in silence—to employ sound therapy techniques successfully. This process often requires behavioral health evaluation and treatment, as well as a good working relationship among audiologists, behavioral health specialists and neurological health professionals to ensure that the patient’s health symptoms are being properly managed.
Capturing the momentum
With the spotlight on tinnitus and TBI in the news and on social media, audiologists need to consider ways to address these prevalent, co-occurring conditions:
  • What resources are available? ASHA, for example, offers a Practice Portal page on TBI that includes discussion of signs and symptoms, assessment and treatment. A new page on tinnitus will soon be added to the portal as well. Patient education handouts on tinnitus are available for downloading.

  • Do we have enough support within the neurology and behavioral health communities to form multidisciplinary teams to aid in treatment/management of patients with complex diagnoses and symptom presentations?

  • If not, how do we foster these relationships in a manner that stimulates other disciplines to want to consider atypical, but necessary, affiliations in order to provide exemplary patient-focused care?

With the incidence of tinnitus and TBI increasing every year, I hope audiologists join the effort to find a solution for the management of tinnitus, not only in typically functioning people but also in the more complex person with TBI.
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August 2016
Volume 21, Issue 8