Guidelines

HNO 2019 · 67 (Suppl 1):S10–S42https://doi.org/10.1007/s00106-019-0633-7Published online: 7 March 2019© Springer Medizin Verlag GmbH, ein Teil vonSpringer Nature 2019

R. F. F. Cima1,2 · B. Mazurek3 · H. Haider4 · D. Kikidis5 · A. Lapira6 · A. Noreña7 ·D. J. Hoare8,9

1 Faculty of Psychology and Neuroscience, Department of clinical Psychological Science, ExperimentalHealth Psychology, Maastricht University, Maastricht, The Netherlands

2 Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands3 Tinnituscenter, Charité—UniversitätsmedizinBerlin, Berlin, Germany4 ENT department, Hospital Cuf Infante Santo, Lisbon, Portugal5 1st Department of Otolaryngology, National and Kapodistrian University of Athens, Athens, Greece6Malta University, Valetta, Malta7 Sensory systems and neuroplasticity, Aix-Marseille Université, Marseille, France8National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Ropewalk House,University of Nottingham, Nottingham, United Kingdom

9Otology and Hearing Group, Division of Clinical Neuroscience, School of Medicine, University ofNottingham, Berlin, Germany

Amultidisciplinary Europeanguideline for tinnitus:diagnostics, assessment, andtreatment

Contributors

Adrian Agius, Alain Londero, Allison Clarke,Angela Brandão, Annick Gilles, AntonioRomero-Garcia, Aristides Sismanis, BertholdLangguth, Chris van den Dries, ChristopherR. Cederroth, Daniela Ivansic, David Stockdale,Deborah Hall, Diogo Ribeiro, Domenico Cuda,Don McFerran, Dyon Scheijen, ElizabethMarks, Emile de Kleine, Fioretti Alessandra,Gerhard Hesse, Giovanna Baracca, GordonSun, Helen Pryce, Isabel Diges, Jan Bulla,Joaquim Ferreira, Joost van Tongeren, JuliaHodson, Kneginja Richter, Loes Schenk-Sandbergen, Luca Del Bo, Lucy Handscomb,Magdalena Sereda, Mary Mitchell, MatthijsKillian, Michael Golenhofen, MyriamWestcott,Niklas Karl Edvall, Nuno T Cunha, ParisConstas, Paul Van de Heyning, Peter Byrom,Pim van Dijk, R. Arnold, R. Hofman, RemoArts, Saba Battelino, Sandra Cummings, SarahMichiels, Susanne Nemholt Rosing, ThomasNikolopoulos, Tijana Bojić, Tobias Kleinjung,Tony Kay, Vasco de Oliveira, William Sedley,and Yahav Oron.

4 Date: 18 February 20184 Version: 1.34 Date of revision: 18 February 2023

Contents

Chapter 1 General introduction1.1 Motivation for the guide-

line1.2 Aim of the guideline1.3 Delineation of the guide-

line1.4 Intended users of the

guideline1.5 Main classifications for

subjective tinnitus1.6 Epidemiology of tinnitus1.7 Pathophysiology of tinni-

tus1.8 Mechanisms of tinnitus

awareness and distress1.9 Theoreticalmodels of tin-

nitus in more detailChapter 2 Methods2.1 Introduction2.2 Preparatory work2.3 Development of the Eu-

ropean clinical guideline2.4 Consultation rounds and

consensusChapter 3 Diagnostics, assessments,

and outcomes

3.1 Introduction3.2 Minimum patient assess-

ment3.3 Further assessment3.4 Assessment by question-

nairesChapter 4 Treatmentoptionsandre-

ferral pathways4.1 Available treatments and

evidence4.2 Referral options and cri-

teria, triage anda stepwiseproposal

Chapter 5 Patient information andsupport

5.1 Confirming knowledgeand dispellingmyths. Keymessages to prepare thepatient for treatment andbeyond

5.2 Information that shouldbe given to patients

5.3 Further information andsupport

Appendix A Pulsatile tinnitus man-agement

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Members of the Guideline SteeringGroup

Member (role) Position and institute(s)/affiliations Clinical field/researcharea of interest

Memberships and conflict of interest

Rilana F.F. Cima,PhD (Chairof SteeringGroup)

Assistant Professor, Maastricht Uni-versity, Clinical Psychological Science,Section of Behavioural MedicineClinical Psychologist/Research Coordi-nator, Adelante Centre for Rehabilita-tion and AudiologyThe Netherlands

Tinnitus, CBT, clinical tri-als, experimental studies,fear-avoidance, associa-tive learning, patient-profiling, standards inhealth care

Member of the Dutch National Guideline Committee forTinnitusExpert on advisory board of the Superior Health Council ofBelgium: Prevention, Diagnosis and Therapy of TinnitusRilana Cima is funded by the Innovational Research Incen-tives Scheme “Veni-grant” from The Netherlands Organiza-tion for Scientific Research for her research in tinnitusChair of the TINNET Project Working Group I: Clinical

Haúla Haider,MD

ENT/Lecturer at Nova Medical SchoolENT Consultant at Hospital Cuf InfanteSantoPortugal

TinnitusENT surgeryPhD student with thesison: Presbycusis, tinnitusand quality of life

Member of ENT Portuguese Association, Member of Otoneu-rologic Portuguese AssociationHas received funding from Jmellosaude for PhDCo-Chair of the TINNET Project Working Group I: Clinical

Dimitris Kikidis,MD, PhD

Otolaryngologist, Clinical Fellowand Research Associate, Universityof AthensGreece

Neurotology, tinnitus,balance disorders, earsurgery

Has received funding as Co-Principal Investigator in twoEuropean-funded projects, one for public health policy inregard to hearing aids and one for regeneration of outer haircells of the cochlea

Alec Lapira, MD ENT Specialist/Audiological PhysicianLecturer Malta UniversityAdjunct Professor, Nova SE UniversityMalta

Tinnitus, balance disor-ders, voice rehabilitation

Member of the ENT Association of MaltaFellow of the American Academy of AudiologyMember of the International Society of AudiologyMember of the International Association of Physicians inAudiology

Birgit Mazurek,MD, PhD

Head and Director of the TinnitusCentre Charité—UniversitätsmedizinBerlinGermany

Tinnitus, ENT, CBT, tinni-tus research

Member of the German ENT SocietyMember of the Berlin ENT SocietyMember of the German Society of AudiologyMember of the ADANOMember of the German Tinnitus-Liga e.V. and scientific boardmemberHead of the German Tinnitus Foundation CharitéMember of the EUTI

ArnaudNoreña, PhD

Professor, Head of Team: SensorySystems and NeuroplasticityFrance

Rehabilitationmedicine,otolaryngology, speechand language pathology,psychophysicsPsychophysics

Member of French National Centre for Scientific Research

Derek J. Hoare,MRes, PhD

Associate Professor in Hearing Sci-ences, NIHR Nottingham BiomedicalResearch Centre, Hearing Sciences,Division of Clinical Neuroscience, Uni-versity of NottinghamUK

Tinnitus, hyperacusis,audiology, paediatrics,psychological therapy,evidence synthesis

Chair of the British Society of Audiology Tinnitus and Hyper-acusis Special Interest Group. Was site PI on a clinical trial ofAcoustic CR® NeuromodulationDerek Hoare is funded by the National Institute for HealthResearch (NIHR) Biomedical Research Centre programme.However, the views expressed in this document are those ofthe authors and not necessarily those of the NIHR, the NHS orthe Department of Health and Social Care

Appendix B Method for the develop-ment of an implementa-tion plan

Appendix C Somatosensory tinnitusAppendix D Characteristics and psy-

chometricsofexisting tin-nitus health-related qual-ity-of-life instruments

Appendix E Cognitive therapy andcognitive behaviouraltherapy

Chapter 1: General introduction

1.1 Motivation for the guideline

Tinnitus involves the percept of a soundor sounds in the ear or head without anexternal source. Most individuals expe-riencing tinnitus have a neutral reactionto the percept. However, for some it be-comes a problem. Bothersome (distress-ing) tinnitus might be better describedas a negative emotional and auditory ex-perience, associated with, or describedin terms of, actual or potential physi-

cal or psychological harm [10]. Objec-tive tinnitus is defined as the perceptionof a sound which has a physical sourcegenerated in or near the ear. An exter-nal observer can perceive objective tinni-tus. Subjective tinnitus does not involvean identifiable sound source so cannotbe heard by examination. It is causedby anomalous activity in the auditorysystem. Subjective tinnitus is a highlycomplex condition with a multifactorialorigin and, therefore, heterogeneous pa-tient profiles. In most people, tinnitusis not traceable to medical causes. In

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Table 1 Frequent tinnitus comorbidities

Hearing and vestibular disorders Hearing loss (H90.5)Disturbance of auditory perception (H93.2)Hyperacusis (H93.2)Vestibular disorders (H81)

Mood disorders Adjustment disorder (ICD-10: F43.2)Dysthymia (ICD-10: F34.1)Depressive episode (ICD-10: F32.0, F32.1, F32.2, F32.3):Recurrent depressive episodes (ICD-10: F33.0, F33.1,F33.2, F33.3)

Anxiety disorders Phobic disorders (ICD-10: F40.)e. g., specific phobia (ICD-10: F40.2)Anxiety disorder (ICD-10: 41.)Generalised anxiety disorder (ICD-10: F41.1)Anxiety and depressive disorder, mixed (ICD-10: F41.2)

Reaction to severe stress and adjust-ment disorders

Acute reaction to burdening (F43.0)Posttraumatic stress disorder (ICD-10: F43.1)Somatoform disordersSomatisation disorder (ICD-10: F45.0)Hypochondriasis (ICD-10: F45.2)Psychological factors and behavioural factors in anotherclassified disease (ICD 19: F54)Insomnia (G47)

most cases there is no available curativetreatment [7, 45]. Standard treatment,assessment, and referral-trajectories arepoorly defined, not well established, andoften insufficient. The lack of standardguidelines likely leads to untreated, un-der-, as well as over-treated patients [15,21, 26, 34, 56]. This leads to increas-ing complaints, prolonged suffering, andloss of societal participation, health-careoveruse, and endless referral trajectories,resulting in an enormous psychological,societal, andeconomicburden inEurope.There is therefore a need for a Europeanharmonised guideline for the assessmentand treatment of tinnitus. Through de-velopment and implementation of thisguideline, we anticipate that assessmentand treatment of tinnitus will be sig-nificantly more effective, leading to re-duced suffering and frustration for pa-tients, their families, and clinicians alike.

1.2 Aim of the guideline

The main goal of this guideline is to es-tablish uniformity in the assessment andtreatment of adult patients with subjec-tive tinnitus. In addition, this guidelineaims to establish consistency in policy tooptimise referral trajectories and reduceover- and under-assessment and treat-ment. Guidance for detailed clinical def-inition and characterisation of cases is

also included. Experts fromdifferent dis-ciplines from across Europe have joinedforces to develop standardisation proce-dures for easy, practicable, and mean-ingful patient profiling. The guidelineshould be used as a tool to support shareddecision-making with patients to facili-tate individualised care.

1.3 Delineation of the guideline

Tinnitus is a common auditory symp-tom, which may result in serious burdenparticularly when there are comorbidi-ties. Tinnitus can present inmany forms.It is necessary that clinicians identify allrelevant tinnitus-related factors duringtinnitus assessment. Treatment shouldbe proposed based on an assessment thataccounts for tinnitus as part of a com-plex system with intricate interactionsbetween its constituent factors. A classi-fication protocol should identify tinnitusclinically relevant patient profiles and of-fer a rational path to individualised treat-ment.

1.4 Intended users of the guideline

This guideline was established for everyhealth professional involved in tinnitusassessment and treatment, including butnot limited to: general practitioners; ear,nose, and throat doctors (ENT); neurol-

ogists; audiologists; psychiatrists; psy-chologists; maxillofacial doctors; nurses;therapists; basic and clinical researchers.It was designed to be accessible to re-searchers, tinnitus patients and theirsignificant others, patient organisations,policy-makers, and any other relevantstakeholders.

1.5 Main classifications forsubjective tinnitus

Acute, sub-acute, and chronictinnitusTinnitus is acute if the patient has ex-perienced it for less than 3 months andis considered sub-acute after 3 months.It is termed “chronic” when the patienthas experienced it for 6 months or more.Assessing whether tinnitus is acute orchronic is relevant to the choice of cer-tain treatments.

Possible comorbiditiesComorbidities can be pre-existent or in-ducedby tinnitus. Frequentlypsycholog-ical, psychosomatic, and/or psychiatriccomorbidities are associated with tinni-tus [42, 68, 77]. Anxiety, depression,and insomnia are commonly found inpatients with tinnitus. The higher thelevel of distress, the more likely comor-bid disorders are present [24, 44]. Onsuspicion of psychological comorbidity,further assessment and treatment shouldbe undertaken by appropriate specialists(psychologist, psychosomatic specialist,psychiatrist, or neurologist). A list ofcomorbidities that may be observed intinnitus patients is given in . Table 1.

Profile of severityTinnitus severity can be graded usingmulti-item tinnitus questionnaire scoreswhere there is a valid grading systempro-vided. It can also be (more subjectively)graded according to structured medicalhistory. For example, the structured tin-nitus interview by Biesinger et al. [8]allows tinnitus severity to be classifiedinto one of four grades based on level andfrequency of impairment (see . Table 2for an adapted version of this gradingsystem).

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Table 2 Tinnitus grading system

Grade Description

1 No distress, no impairment

2 Tinnitus impairs (e. g. emotion, cognition, attention, task performance) occasionally/occurs under stressful situations and mainly in silence

3 Tinnitus regularly impairs (e. g. emotion, cognition, attention, task performance)occurs in several situations

4 Tinnitus constantly leads to impairment (e.g. in emotion, cognition, attention, taskand daily life interference) occurs in all situations

Characteristics of tinnitusTinnitus can be any sound but it istypically ringing, buzzing, hissing, ortonal. Some patients experience mul-tiple sounds. For some the sound ispersistent in quality and for others itchanges. It can be constant or intermit-tent, and heard in one or both ears orinside the head. The sound might bepulsatile (either synchronous with theheartbeat or not) or non-pulsatile, andboth may be objective or subjective (seeAppendix A for further information onpulsatile tinnitus).

1.6 Epidemiology of tinnitus

Studies of tinnitus prevalence are not freeof methodological problems; they usedifferent definitions of tinnitus, or ad-dress selected age or professional groups.Most studies report conservative tinni-tus prevalence rates to be between 10and 19% of adults [6, 23]. The phantomauditory sensation of tinnitus is chroni-cally perceived by roughly one in threeof elderly adults [1, 59]. Tinnitus is com-monly associatedwith hearing loss, noiseexposure, ageing and stress [27, 31, 55,58, 67] and less oftenwith other otologic,neurologic, infectious, and drug-relatedeffects and other comorbidities [76]. Inthe tinnitus population the prevalenceof hyperacusis (reduced tolerance to ev-eryday sounds) is 40–86% according todifferent studies [2, 35].

1.7 Pathophysiology of tinnitus

Mostofourknowledgeontinnituspatho-physiology originates from animal re-search. Firstly, tinnitus is related to“aber-rant” neural activity (that is not producedbyphysicallymeasurable sounds fromtheenvironment) that is generated at some

level of the auditory system. Secondly,the tinnitus-related signal is interpretedas an auditory percept and can be associ-atedwith distress. Tinnitus has been sug-gested to result from an increased firingrate, increased synchronybetweenneuraldischarges, or an aberrant pattern of os-cillatory activity (possibly resulting in anincreaseofneuralfiringsynchrony; [62]).In most cases, tinnitus is believed to beassociated with some degree of cochleardamage. There can be cochlear dam-age not detected by a standard audio-gram. Indeed, it has been shown thathigh-threshold cochlear fibres (that areactivated well above absolute threshold)canbe uncoupled from their correspond-ing inner hair cells and/or degeneratedaftermoderate noise trauma [50, 51, 73].

One can distinguish between the pe-ripheral and centralmechanisms that canresult in the generation of the tinnitus-related activity. Many mechanisms mayaccount for cochlear tinnitus (related tocochlear aberrant spontaneous activity):activation of N-methyl-D-aspartate re-ceptors [25, 66], shift in the operatingpoint of outer hair cells [19, 48, 61], de-couplingofouterhair cell stereocilia [49],and increase in the endo-cochlear po-tential [63]. Central forms of tinnitusare then thought to result from aber-rant neural discharges produced by cen-tral changes which may be triggered byhearing loss. Many central mechanismsthat can account for the generation of thetinnitus-related activity have been pro-posed [20]. The vast repertoire of mech-anisms involved inhomeostatic plasticitymay account for central hyperactivity af-ter hearing loss. The reorganisation ofthe cortical tonotopic map may also playa role in tinnitus generation, by increas-ing synchronyof discharges between cor-tical neurons. This mechanism is likely

not involved in tinnitus inpeoplewithouthearing loss [43] or those with a pantonalhearing loss.

Somatosensory inputs can modulateneural activity in the cochlear nucleus[69–71]. The excitatory modulation ofthese inputs on the auditory pathway isenhanced after hearing loss and can beresponsible for the noise-induced centralhyperactivity (potentially associatedwithtinnitus) after noise trauma [18, 75].

Finally, the thalamusmayplay a directrole in generating tinnitus-related activ-ity. The reduction of sensory inputs isthought to hyperpolarise thalamic neu-rons, which leads to the generation ofburstsofactionpotentials inthe thalamusand cortex. This activity can be main-tained by the cortico-thalamic pathwayand the activation of the reticular nu-cleus sending inhibitory inputs back tospecific nuclei of the thalamus [52, 53].

1.8 Mechanisms of tinnitusawareness and distress

Tinnitus is not necessarily associatedwith distress. Indeed, 6–20% of peoplewith tinnitus consider it bothersome[59]. This indicates a partial dichotomybetween mechanisms generating the tin-nitus-related signal and those responsiblefor tinnitus distress. It has been pro-posed that non-auditory brain regionsevaluate the tinnitus-related signal. Ifthe tinnitus-related activity is not nega-tively reinforced, this neural activity isblocked fromreaching consciouspercep-tion (i. e. habituation occurs). If, on theother hand, the tinnitus-related activityis negatively reinforced (e. g. becausetinnitus is concomitant to a life event orassociated with negative thoughts), thelimbic and autonomic nervous systemsare activated, attention is directed totinnitus, and tinnitus-related distressdevelops. This model postulates thattinnitus awareness and tinnitus-relateddistress result from the mechanisms ofconditioned reflex [37, 40]. Anothermodel suggests that tinnitus-related ac-tivity (enhanced activity in the gammafrequency range) becomes a consciouspercept only if it is associated with co-activation of self-awareness and saliencebrain networks, i. e. anterior cingulate

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Auditory & other cortical areasPerception & evaluation (consciousness, memory, attention)

AuditorySubconscious

Detection/processing

Limbic systemEmotions

Auditory peripherySource

Reactions

Autonomic nervous system

3

2

1

Fig. 18 The neurophysiologicalmodel of tinnitus

Selective attention & monitoring

Conscious process

Negative automatic thoughts

Arousal &distress

Beliefs

Distortedperception

Safetybehaviours

Tinnitusdetection

Tinnitus related neuronal activity

Fig. 28 The cognitivemodel of tinnitus

cortex, ventromedial prefrontal cortex,insula, amygdala and parahippocam-pus [17]. A somewhat different modelsuggests that irrelevant information istuned out by an inhibitory gating mech-anism. Whereas the thalamic reticularnucleus, activated by subcallosal regions(nucleus accumbens and ventromedialprefrontal cortex), is supposed to blockthe activity of sensory thalamus through

its inhibitory influence, in this model itis supposed that the inhibitory gatingmechanism may not block irrelevantinformation properly (including the tin-nitus-related activity) if part of the circuitsuch as the subcallosal regions is lesioned[46, 47, 64].

1.9 Theoretical models of tinnitusin more detail

Habituation theoryHabituation theory [29] proposes thatthe negative interpretation of the tinni-tus signal, and related heightened auto-nomic arousal levels, leads to dysfunc-tional cognitive processing and therebydistress. Hallam et al. [29] proposed thatfor most people repeated perception ofthe tinnitus sound teaches them that itis not worthy of attentional resources.In other words, to function effectively,the brain selects which stimuli to pay at-tention to and which stimuli to ignore.Hallampurported thatmost people learnthat the tinnitus sound is of low infor-mational value and thus not requiringa reaction. Consequently, tinnitus doesnot pose a problem formost people livingwith it. However, tinnitus-related distressdoes occur when these attentional pro-cesses aremalfunctioning, which ismorelikely at times of increased stress andarousal, which in turn strains cognitiveresources.

Habituation theory has remainedlargely theoretical, although tinnitustreatment approaches such as relaxationtherapy, attention diversion techniques(directing attention away from tinnitus),and stress reduction by means of cog-nitive restructuring methods (aimed ataltering beliefs about the tinnitus) havebeen based on its main premises. Totreat tinnitus distress (or facilitate habit-uation to tinnitus), it was recommendedthat stress and arousal levels be reducedand to try and change the meaning ofthe tinnitus signal for the patient [28].Research to date has yielded mixed ev-idence for the validity of habituationtheory [7].

Neurophysiological modelTheneurophysiologicalmodel of chronictinnitus (. Fig. 1) is based on the premisethat conditioned fear responses elicitedby the tinnitus sound are the cause of thetinnitus becoming bothersome [36, 37].This reasoning stems from animal re-search in which conditioning paradigmswere used to induce tinnitus-like fear-ful behaviour in rats [38, 39]. The neu-rophysiological model distinguishes be-

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Source of tinnitus

Tinnitus perception

Recovery

Disability;Generalisation ofsensitivity, Social

withdrawal, Anxiety &Depressed mood

Avoidance &Task interference

Heightenedawareness

Tinnitus-relatedFear

CatastrophicMisinterpretation

of the sound

Acceptanceof tinnitus asbenign signal

No avoidanceExposure to

normal activity

Fig. 39 The fear-avoid-ancemodel of tinnitus(based on the fear-avoid-ancemodel of chronic pain[74])

tween three stages. Stage 1 involves gen-eration of the auditory stimulus in theauditory periphery. Stage 2 involves de-tection of the tinnitus-related signal; andStage 3 involves the perception evalua-tion of tinnitus. The neurophysiologicalmodel is mainly a model of tinnitus gen-eration/detection, based on neurophysi-ological mechanisms.

Cognitive modelMcKennaet al. [57]propose a conceptualcognitive (behavioural) model of tinni-tus distress whereby negative cognitivemisinterpretations of the tinnitus signal,distress, and bodily arousal are provokedleading to inaccurate evaluations of sen-sory activity and distorted perceptions(. Fig. 2). It is proposed that the result-ing hypervigilance and distorted percep-tion of the tinnitus sound contribute toa feedback cycle that exacerbates neg-ative thinking and thus distress. Themodel attributes a fundamental role tothe negative evaluation of tinnitus. Thenegative evaluation of the tinnitus can beviewed as comprising primary and sec-ondary appraisals. For example, a per-son might initially appraise the tinnitusas being threatening to their health, andthen make a secondary appraisal of theirability or inability to cope with it.

Evidence exists that cognitive pro-cesses, such as interpretation, attention,and memory, are indeed involved inchronic tinnitus suffering [5, 16, 60,65, 72], and the validity of the cog-nitive model is currently being testedpsychometrically [30].

Fear-avoidance modelThe fear-avoidance model of chronic tin-nitus (. Fig. 3) offers explanatory predic-tions about both the cognitive processesas well as the behavioural mechanismsof tinnitus [11, 12]. It predicts that indi-viduals perceiving the tinnitus signal aresubject to automatic emotional and sym-pathetic responses. These symptoms aremisinterpreted as harmful or threaten-ing. If the signal persists, the coincidingthreatening (alarm) states, which indi-cate malignance of the signal, elicit con-ditioned (both classic and operant) fearresponses, i. e. fear, increased attention,andsafety-seeking (avoidanceandescapebehaviours). Safety behaviours becomenegatively reinforced through instant de-creased fear, which is adaptive in theacute phase. In other words, by avoidingor not exposing themselves to tinnitus-related perceptions, patients learn thattheir fear instantly diminishes. However,through persistent avoidance of the tin-

nitus, tinnitus-eliciting, or tinnitus-in-creasing stimuli, fear and fear responsessuchashypervigilanceandsafety-seekingare maintained. Avoidance behaviourssubsequently lead totask interferenceandfunctional disability [9, 33, 41, 54]. Themaintained high threat value of the tin-nitus leads to increased tinnitus severityanddistress, feeding into an endless cycleof increased disability [14].

A feature of the fear-avoidance modelis that itpredictsbothamaladaptivepath-way and an alternative more adaptivepathway. In the more adaptive pathway,a positive or neutral evaluation of thetinnitus (the system accepts it as beingbenign)results innofearorlowfearoftin-nitus, distress, or avoidance behaviours.

These models differ in explaininghow classic and operant learning prin-ciples contribute to tinnitus suffering.Nonetheless, there exists a large con-ceptual overlap between them. Inboth the neurophysiological model andMcKenna’s conceptual cognitive (be-havioural) model it is hypothesisedthat effortful conscious alteration ofnegative interpretations will decreasearousal and distress because of tinni-tus. Both models place less importanceon the behavioural processes. The fearavoidance model, which is based on

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Stage WHAT HOW WHY

Preparatory phase:Inventory of Clinical opinions across

Europe

Consensus meeting WG 1:Open invitation: What should be the

scope and aim of the group?

European state of the art andpossibilities on consensus are

unknown1

2

3

4

5

Snapshot of current situation in EuropeProcedure

• Pan-European Survey Clinicians• Scoping of existing guidelines

Not known what is currentclinical opinion/usual practice

across Europe

Description ofstate of the art

Analysis:Data from European cliniciansReview of existing guidelines

Need for description of barriers,facilitators, and state of the artin guidelines/practice across

Europe

Draft of European Guideline forassessment and treatment

Consultation round 1 (within TINNET)• WG 1 members

• MT members of TINNET• Chairs /co-chairs other working groups

Agreement is needed on whatis best choice and actionable

for different patients

Final adaptive and actionable EuropeanGuideline for assessment and treatment

of tinnitus

Consultation round 2 (outside TINNET)clinicianspatients

other stakeholders

Broad clinical foundation forand consensus on European

guideline

Fig. 48 Individual stages in the development of current guideline:a roadmap.WGworking group,MTmanagement team

associative learning principles, offersboth explanatory predictions about cog-nitive processes of change and predic-tions about behavioural mechanisms.This fear-avoidance approach integratesprevious cognitive conjectures withina behavioural framework. This mayprove helpful, both for discovering newvenues for investigations and as a meansof discovering why the cognitive as wellas the behavioural treatment approachesare consistently found to be beneficial. Italso offers a means of discerning whichcomponents work best and for whom.

Empirical data support the fear-avoidance model. Accumulating ev-idence indicates that a cognitive be-havioural treatment, based on this fear-avoidance notion—which targets re-ap-praisal of, and exposure to, the tinnitus-sound—significantly reduces tinnitusdistress, decreases tinnitus suffering, andimproves quality and daily functioning

of tinnitus patients [3, 4, 13, 120]. How-ever, the cause–effect relationships ofspecific learning mechanisms are stillunknown [11, 22, 32, 41].

Chapter 2 Methods

2.1 Introduction

Tinnitus is a complex condition witha multifactorial origin. Consensus onclinically relevant patient profiles, stan-dard treatment, assessment, and referraltrajectories has not been reached thus far.Additionally, inconsistent results in tin-nitus studies, in experimental research,clinical trials, observational and cross-sectional research, represent a barrierto efficient standards in health care fortinnitus. Even though chronic tinnituscomplaints represent enormous socioe-conomic relevance [13, 80–82], researchfunding is still limited. Hence, there is

increasing need for a European guide-line for the assessment and treatment oftinnitus patients. The purpose of thischapter is to describe the methods usedto develop this guideline.

Duration and validityThis guideline consists of five chapterscontaining several modules. Some or allthese modules may need revision or ex-tension in the future. The current guide-line steering group aims to pursue re-as-sessment and maintenance of the guide-line within 5 years of the initial publica-tion.

ImplementationDuring the development of this guide-line, the practicality and feasibility ofthe implementationof recommendationsacross Europe were considered at everystage (. Fig. 4). Consensus was reachedat the beginning of the project that a Eu-

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Table 3 Summary of barriers and facilitators identified from a pan-European survey

Barriers

1 Lack of knowledge about or non-existence of specialised tinnitus clinics or teamsmakesit difficult for tinnitus patients to find their way to the most appropriate professionals ina country

2 Lack of time or other resources for adequate counselling

3 Lack of time or other resources for professionals responsible for tinnitus patients to beable to adequately assess the distress level of tinnitus patients

4 Lack of multidisciplinary teams and/or availability of psychologists in southern and east-ern European countries

5 High variation in available treatment options; more medical–pharmacological treatmentin southern and eastern countries. Counselling–rehabilitative approaches more avail-able in northern countries. When many treatment avenues are seen as viable, it may bedifficult to reach consensus on what works for whom

6 The use of self-report instruments is much less common in southern and eastern coun-tries

7 There are differences in how patients pay for treatment. If regulatory bodies in healthcare in a country are unwilling or unable to hold to the restrictions or recommenda-tions stated in a guideline, the chances of implementationof this guideline drasticallydecrease

Facilitators

1 Common ground in expert opinion that tinnitus is a central auditory symptom. Thisoffers options for discussions on the definition of tinnitus in a European guideline

2 Consensus across regions on what conditions are relevant to or associatedwith tinnitus.Harmonisations such as these are to be highlightedwhere possible to facilitate imple-mentation of a standard guideline

3 Although someminor differences in procedures were reported, most experts agree thatotoscopy and pure tone audiometry are used. This finding facilitates discussions on diag-nostics to include in the guidelines

4 The most commonly used questionnaire irrespective of region is the Tinnitus Handi-cap Inventory. This might facilitate discussions on assessmentmethods to recommendwithin a guideline

5 The percentage of respondents satisfiedwith current tinnitus health care in their countryin southern and eastern Europe was low; less than half of respondents reported theywere satisfied. Health-care professionals are likely to be positive towards progressiveguidelines and towards changes in health care for tinnitus

ropean guideline was to be as adaptive aspossible, with the possibility that it canbe tailored to resources and needs dic-tated by the participating countries1. Thepracticability of these recommendationsand guidelines will need testing beyondthe initial publication of the guideline;a method and criteria for the develop-ment of an implementation plan are pro-vided in Appendix B.

1 Belgium, Cyprus, Czech Republic, Denmark,Finland, France, Germany, Greece, Israel, Italy,Lithuania, Malta, The Netherlands, Norway,Poland, Portugal, Romania, Serbia, Slovenia,Spain, Sweden, Switzerland, Turkey, UnitedKingdom.

ResponsibilityThe responsibility tomaintain the guide-line, for reassessment purposes and pos-sible future revisions or extensions, lieswith Drs. Rilana Cima and Derek Hoare.

2.2 Preparatory work

Activities, meetings, and studies per-formed for the development of thisEuropean guideline were supported bythe TINNET—COST Action BM1306(2014–2018), which aimed to estab-lish a pan-European tinnitus network(researchresearch.net). Consensus wasreached in the preparatory phase thatthe main aim of the TINNET WorkingGroup 1 (WG1) was to develop a con-sensus-based meaningful, adaptive, andactionable European guideline for the

assessment and treatment of tinnituspatients.

European guideline steering groupformationIn 2015 a selection of WG1 membersof TINNET were nominated to becomemembers of a guideline steering groupfor the development of this guideline.The group consists of representatives ofall specialties and fields thought to bestakeholders in the clinical practice oftinnitus health care across Europe. Allsteering group members are responsiblefor the integral text of this guideline.

Clinical demands and bottleneckanalysis (Stage 1)During the first preparatory (consensus)meeting with theWG1members of TIN-NET, the chair (R.C.) inventoried clinicaldemands and possible bottlenecks. Afterthis first meeting a roadmap was createdfor the agreed different stages of devel-opment of this guideline (. Fig. 4).

Understanding the state of theart (Stages 2 & 3): a pan-EuropeansurveyTinnitus remains a scientific and clinicalproblem. In spite of increasing knowl-edge about its management and treat-ment, little impact on clinical practicehas been observed. There is evidencethat prolonged, obscure and indirect re-ferral trajectories persist in usual tinnituscare.

It is widely acknowledged that effortsto change professional practice are moresuccessful if barriers are identified andimplementation activities are systemati-cally tailored to the specific determinantsof practice. The first step towards thedevelopment of meaningful and action-able European guidelines for the assess-ment and treatment of tinnitus patientsinvolved scoping the existence and cur-rent knowledge of standards in tinnituscare. Here, we addressed this by per-forming a pan-European survey of ex-perts, clinicians, and policy-makers togain insight into the status quo of expertviews on treatment and assessment, stan-dards, and guidelines in tinnitus healthcare throughout Europe.

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Table 4 Summary of recommendations from a systematic reviewof clinical practice guidelinesfor tinnitus

Summary of recommendations regarding the assessment of subjective tinnitus

– Conduct a physical examination to exclude possible (physical) causes of tinnitus

– Conduct an audiological assessment

– Establish the degree to which a patient experiences subjective tinnitus as bothersome ordistressing using a validated and reliable questionnaire such as the Tinnitus Questionnaire,Tinnitus Handicap Inventory, or Tinnitus Functional Index

– In situationswhere patients appear to be experiencing a degree of distress or difficulties re-lated to living with tinnitus, consider making a referral for an assessment by a psychologist orpsychiatrist

– Variations exist in recommendations regarding the use of imaging studies (e. g. magneticresonance imaging)

Summary of therapeutic recommendations regarding the treatment of subjective tinnitus

– Provide information about tinnitus and treatment options

– Use hearing aids only when patients have a diagnosed hearing loss

– Specialised cognitive behavioural therapy for tinnitus should be offered to patients

– There is a lack of consensus on the use (or otherwise) of sound therapy for tinnitus

– Prescribed and herbal medicines and dietary supplements should not be used for the soletreatment of tinnitus

– Transcranial magnetic stimulation is not recommended as a treatment for tinnitus

Table 5 Levels of evidence (Oxford)

Level Therapy/prevention, aetiology/harm

1a Systematic review (SR) of randomised controlled trials (RCTs)

1b Individual RCT (with narrow confidence intervals)

1c All or none effects

2a SR (with homogeneity) of cohort studies

2b Individual cohort study (including low-quality RCT; e. g. <80% follow-up)

2c “Outcomes” research; ecological studies

3a SR (with homogeneity) of case–control studies

3b Individual case–control study

4 Case series (and poor-quality cohort and case–control studies)

5 Expert opinion without explicit critical appraisal, or based on physiology, bench re-search or “first principles”

Survey results showed that there aresignificant differences in reports onnational health-care structure, tinnitusdefinitions, characteristics of the tinnituspatient, andmanagement, treatment, anddiagnostic options, particularly notablewhen comparing northern, southern,and eastern European countries. Resultsindicate seven important barriers to betaken into consideration if a Europeanclinical guideline is to be implementable(. Table 3). Additionally, five facilitatorswere defined. Overall, the findings ofthis study confirm the need for a Eu-ropean guideline to provide consistencyand promote equity of access to servicesfor all tinnitus patients.

Systematic review of existingguidelinesA systematic review was performed tocollect all available guidelines and iden-tify fields of agreement and remainingopenquestionsabout tinnitusassessmentand treatment. The tinnitus assessments(diagnostics and measures), processesand treatment options recommended bythe respective guidelines were comparedand summarised. Methods are describedin brief here and are reported in full byFuller et al. [79].

Selecting guidelines for the review.Guidelines were considered eligible forinclusion if they fit the definition, and no

publication date or language restrictionswere imposed. Guidelines on objectivetinnitus, referral pathways, or a spe-cific type of assessment or treatmentprocedure were excluded. Guidelineswere identified through a systematicsearch for “tinnitus” and “guideline”using Medline, PubMed, and the Cu-mulative Index to Nursing and AlliedHealth Literature, as well as the EMBASEdatabases. In addition to these, the Na-tional Guideline Clearinghouse (www.guideline.gov), National Institute forHealth and Clinical Excellence (NICE;https://www.nice.org.uk/), Guideline In-ternational Network (GIN; http://www.g-i-n.net/), and Google were searched,and a hand-search of reference lists ofany included guidelines was undertaken.International expertswere also contactedto ask if they were aware of any guide-lines that had not already been identifiedfrom the search results. Final searcheswere conducted on 2 May 2016. Tworeviewers independently screened eachsearch result. Five documents fitting thedefinition of guidelines were included,from the USA, Germany, Sweden, TheNetherlands, andDenmark. Data extrac-tion was conducted in a structured wayby two independent reviewers and thequality of each guideline was evaluatedusing the AGREE II tool [78].

Findings. The absence of guidelines formost countries contributes to the expla-nation for the variations that exist in as-sessment and treatment of tinnitus inter-nationally. Across guidelines, differencesin recommended assessment procedurestend torelate to specific techniques, ques-tionnaires, diagnostic tests, or types ofscanningtechniquesrather thantotheas-sessmentof tinnitusseverity, hearing loss,psycho-social problem(s), and the pres-ence of severe physical pathology caus-ing the tinnitus. Consensus exists on theneed to exclude a physical cause of tin-nitus, conducting an audiometric assess-ment of the patient, using standardisedquestionnaires tomeasure degrees of tin-nitus-related distress and, when relevant,making referrals for further psychologi-cal assessment. Summary recommenda-tions emerging from the systematic re-view are provided in . Table 3.

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Table 6 Levels of recommendation

Strength of recommenda-tion

Valence of re-commendation

Description

Strong recommendationMost or all individuals will bebest served by therecommended course ofaction

For Level 1a, 1b, or 2a evidence that the desir-able effects of an intervention outweigh itsundesirable effects

Against Level 1a, 1b, or 2a evidence that the unde-sirable effects of an intervention outweighits desirable effects

Weak recommendationNot all individuals will be bestserved by the recommendedcourse of action

For Level 2b, 2c, or 3a evidence that the de-sirable effects of an intervention probablyoutweigh its undesirable effects

Against Level 2b, 2c, or 3a evidence that the unde-sirable effects of an intervention probablyoutweigh its desirable effects

No recommendation Not applicable Only level 3b, 4, or 5 evidence available, orhighest level of evidence shows no cleartrade-off between desirable effects of anintervention and its undesirable effects, orindividual patient’s reactions to undesirableeffects are likely to be so different that itmakes little sense to think about typicalvalues and preferences

2.3 Development of the Europeanclinical guideline

Results from the survey and the system-atic review of guidelines were used to se-lect and evaluate the modules includedin Chap. 3, “Diagnostics, assessments,and outcomes”, and Chap. 4, “Treatmentoptions and referral pathways”.

InclusionWe included assessmentmethods anddi-agnostic tools where there was evidenceof their use and indication that they areclinically useful (see Chap. 3 for furtherdetails). Treatment methods (treatmentelements or protocols, devices, or pro-cedures) were included if high-level re-search evidence (randomised clinical tri-als, meta-analyses) was available and/oraneedexisted that theguideline informedclinical practice (i. e. practices identifiedin the survey results; see . Table 4).

ExclusionTreatment methods (treatment elementsor protocols, devices, or procedures)were not included when not supportedbyhigh-level researchevidenceandwhenonly weak evidence was available (casereports, case control, and retrospectivestudies), and/or the need existed thatthe guideline informed clinical practice

(i. e. practices identified in the surveyresults). Further assessment methods,diagnostic tools, treatment methods(treatment elements or protocols, de-vices, or procedures) may be includedin future revisions or extensions of thisguideline if new research evidence be-comes available or a need to inform newpractices is identified.

Levels of evidenceQuality of evidence for the treatmentmethods (treatment elements or proto-cols, devices, or procedures) included inChap. 4 was guided by the Oxford Centreof Evidence method2 (see . Table 5).

Levels of recommendationThe recommendation level for eachtreatment method (treatment elementsor protocols, devices, or procedures)included in Chap. 4 was guided by theGRADE system3 (. Table 5), wherebyonly high-level evidence (Levels 1a–2b;randomised controlled trials [RCTs]and systematic reviews) was consideredin making a recommendation for oragainst treatment. Where only low-

2 http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/.3 http://www.gradeworkinggroup.org/.

level evidence existed (2c-5), we au-tomatically make a judgment of “norecommendation” (see . Table 6).

2.4 Consultation rounds andconsensus

Consensusmethod on the drafts ofthe clinical European guidelineInitial drafts of this guideline were sub-jected to review in two consultationrounds. The comments from each roundwere aggregated and addressed acrossthree consensus meetings of the steeringgroup (held in July and November 2017,and in January 2018).

Consultation round 1 involved onlymembers of TINNET, being:4 Members of WG14 Members of the TINNET manage-

ment committee4 Representatives of all other TINNET

working groups

Consultation round 2 involved stake-holders outside TINNET, being:4 Patient representatives/associations4 Professional associations/national

professional representatives4 Committee members of existing

national guidelines4 Policy-makers4 EU commission members

Contributors inbothconsultationroundswere invited to comment on consecutivedrafts of the guideline. For each com-ment submitted, contributors were askedto rate whether they felt their commentreflected what they considered to be anessential change to the guideline (ratedas 1), or was a recommend change (ratedas 2), or was simply a note for the authorto consider (rated as 3).

Consensus meetingsIn the consensus meetings, steeringmembers voted whether to implementa change to the guideline based on thecomment. Contributors received feed-back on all comments. The feedbackincluded whether the change was madeor not. Where changes were not madein response to a comment (i. e. therewas author consensus not to imple-

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Table 7 Some known conditions associatedwith tinnitus

Site of affection Associated conditions

Outer ear Wax blockage of outer ear channelOtitis of outer ear channelObliterative exostoses

Middle ear Otitis media with effusionOtosclerosis

Inner ear PresbyacusisNoise-induced hearing lossMénière’s diseaseSudden hearing lossAcoustic neuromas

Muscular Palatal myoclonusTensor tympanimyoclonusPatency of eustachian tube

Cardiovascular Glomus jugular or glomus tympanicumMitral or aortic stenosis

Pharmacological Benzodiazepines withdrawalInduction from ototoxic drugs

Metabolic HyperthyroidismDiabetesHypertension

Haematologic Anaemia

Arthrogenous Dysfunction of temporomandibular jointCervical dysfunction

Impairment of cognitive–emotionalreaction system

Concentration disturbance– Attentional problems– Memory deficit– Executive function deficit

Loss of control/helplessness/resignationDysfunctional thoughts: catastrophising

– Fear reactions– Safety behaviours (avoidance)

Psychological/psychiatric – Psychological trauma– Distress– Major affective event– Depression– Anxiety/panic disorder

Trauma – Traumatic brain injury– Neurosurgical

ment a change based on the comment),a rationale for the decision was provided.

In total, 395 comments on the firstdraft were submitted in consultationround 1 by 33 within-TINNET contrib-utors. In the second consultation round,an additional 25 outside-TINNET con-tributors submitted 265 comments onthe second draft.

AuthorisationAll contributors were asked to indicateif they did not want their details to beincluded in the contributor list of thefinalversion of the guideline.

Chapter 3 Diagnostics,assessments, and outcomes

3.1 Introduction

Many factors can contribute to the on-set of tinnitus. It is a symptom asso-ciated with multiple medical disorders(. Table 7). In addition to hearing-re-lated causes, other potential causes mustbe individually identified or excluded. Inmost cases, the aetiologyof tinnitus isun-known, andmany clinical approaches arededicated to helping patients cope withtheir tinnitus rather than to treating thecause [37, 62, 84].

When referring patients for a specificdiagnostic algorithm, for example in thecase of acute tinnitus, the medical ne-cessity as well as financial cost must beconsidered in each individual case. In-stead of using rigid diagnostic steps, itis recommended to choose a diagnosticpathway based on the patient’s historyand on basic diagnostics (for an exampleof a diagnostic pathway, see the Tinni-tus Research Initiative flowchart at www.tinnitusresearch.org).

The following sections outline rec-ommended progressive levels of diag-nostics and assessment of tinnitus. Thecontent and structure of these sectionswere informedbymultiple sources in twosteps. First, the authors reviewed diag-nostics andassessments that are currentlyused across Europe [15], and the recom-mended diagnostics and assessments in-cluded in existing national clinical prac-tice guidelines (USA, Denmark, Sweden,Germany, and The Netherlands; Fulleret al. [79]). An initial proposalwas there-after agreed by consensus of the authorsbasedonknowledgeofcurrentuse inclin-ical practice specifically for tinnitus, andtherefore of the need to provide endorse-ment of those procedures considered safeand clinically useful (and exclude thosethat were considered not). This sectionwas heavily revised according to com-ments received in both rounds of expertconsultation.

3.2 Minimum patient assessment

A comprehensive patient history is thefoundation of diagnosis, accurately grad-ing tinnitus severity and identifying rele-vant comorbidities. To exclude treatablemedical conditions, e. g. otitis media,otosclerosis, wax blockage of outer earchannel, or acoustic neuroma amongother putative causes, a detailed tinnituscharacterisation should include whethertinnitus is objective (can be heard byan external observer) or subjective (canonly be heard by the patient), per-ceptional characteristics of the tinnitussound (tonality, pitch, loudness), tempo-ral properties (pulsatile or not, constant,intermittent, or fluctuating), location (inone or both ears, or in the head), andseverity (assessed by score on suggested

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measures, see Sect. 3.4 “Assessment byquestionnaires”).

It is crucial to perform a detailed clin-ical examination/history of the tinnituspatient. There are causal diagnostics andseverity-oriented diagnostics.

Tinnitus history and clinicalexamination1. Tinnitus history

jOnset: Since when is tinnitusperceived; what are importantassociated clinical factors (noisetrauma, stress, recent events, acuteillness, other); was it a sudden onsetor did symptoms start graduallywith a continuous increase?

jModulation: Can the tinnituspercept be modulated by: orofacial,cervical or eye movements, headpositions, movements of the jaw,tension of jaw muscles, physicalexertions?

jSeverity/impact of the tinni-tus: Is the tinnitus bothersome/interfering with daily life (sleepdifficulties, task interruptions,fearful reactions, cognitive-atten-tional problems, negative affect).A questionnaire should be usedto establish the degree to whicha patient experiences subjectivetinnitus as bothersome or distress-ing (see Sect. 3.4 for more details).Furthermore, the level of tinni-tus awareness is of importance:Can tinnitus be perceived onlyin silence or also in noise; is thetinnitus easily masked or amplifiedby ordinary background noise; arethere changes in tinnitus loudness?

2. Thorough audiological history andprioritisation: Assessment of hearingloss, perceived “ear fullness” (pres-sure), sensitivity to normal sound (orhyperacusis), problems in balance/dizziness/vertigo

3. Medical history: ear, nose andthroat, orthopaedic, cervical, dental,jaw, internal medicine (thyroid,hypertension, anaemia), mentaldisorders (psychological, psychiatric)

4. Presence of comorbidities/drughistory/medications; ototoxic drugs(e. g. chemotherapy, antimalarialdrugs); long-term pharmacological

consumption (e. g. antidepressants,anxiolytics)

5. Relevant personal history, occu-pational history, hobbies/leisureactivities, noise exposure, head/neck trauma, social support status,education, recent life events

Essential primary diagnostic stepsConduct a thorough physical–medicalassessment to exclude possible (physical)causes of tinnitus:

Complete ear, nose, and throat exam-ination, especially otoscopy (preferablymicro-otoscopy) to exclude presence ofwax, tympanic membrane rupture, otitismedia with effusion, chronic otitis me-dia, retro-tympanic mass or any otherpathology.

Special consideration should be givenin rare tinnitus causes (e. g. palatalmyoclonus, temporomandibular joint[TMJ] disorders).

A comprehensive diagnostic investi-gation should include pure tone audiom-etry, speech audiometry, and evaluationof the perceptional quality of tinnitus(e. g. loudness, pitch, and minimummasking estimations), sound tolerance,tympanometry, and acoustic reflex in-cluding auscultation of the ear andcarotid artery in pulsatile tinnitus, asclinically indicated. Care must be takenin performing loudness-based tests, par-ticularlywhere there is evidence of recentfluctuations in loudness or intensity ofthe patient’s tinnitus.

3.3 Further assessment

Further investigations or referralsin special casesOnly to be considered if clinically indi-cated:4 Auditory brainstem responses and/or

magnetic resonance imaging (MRI)in cases of unilateral tinnitus and/orasymmetric hearing loss consider

4 High-frequency audiometry in casesof tinnitus with normal hearing atstandard (conversational) frequencies

4 Further sound tolerance assessment(e. g. loudness discomfort level) forsound sensitivity grading or hearingaid settings

4 Residual inhibition to evaluate short-term effects of sound on the tinnitus

4 Transient-evoked otoacoustic emis-sions and/or distortion productotoacoustic emissions in cases ofnormal standard audiogram andsuspicion of cochlear dysfunction

4 Caloric testing, and vestibular evokedmyogenic potential, as indicated incases of dizziness, vertigo, or balanceproblems

4 Functional cervical diagnostics ina quiet environment for detecting tin-nitus modulations in somatosensorytinnitus. Consider imaging of cervicalspine in cervical pathology associatedwith somatosensory tinnitus (seeAppendix C for further informationon somatosensory tinnitus)

4 Dental examination (includingTMJ) in a quiet environment fordetecting tinnitus modulations inTMJ dysfunction or bruxism

4 MRI of the brain in abnormal audi-tory brainstem response or abnormalvestibular evoked myogenic potential

3.4 Assessment by questionnaires

Tinnitus severity in terms ofdistress/impactTinnitus severitycanbedefinedasa func-tion of the level of distress or impactthat tinnitus has on the individual. Fora small proportion of patients (5–8%)tinnitus is severely distressing and there-fore disabling [83]. Since distress refersto the general aversive state, instrumentstomeasure this construct usually includesub-domains which are hypothesised tocontribute to tinnitus severity. These in-struments are therefore hybrid in thattheymeasure several concepts as ameansof capturing tinnitus distress.

There are several instruments in usefor assessing level of severity of tinnituscomplaints. In a review on disease-spe-cific health-related quality-of-life (HR-QoL) instruments used to measure out-comes in tinnitus trials, six commonlyused HR-QoL tinnitus instruments wereidentified [89].

The Tinnitus Handicap Inventory(THI; [94]) was developed to measurethe impact of tinnitus on daily life. It hasthree subscales; functional, emotional,

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and catastrophic responses to the tinni-tus. Both the overall questionnaire andthe functional and emotional subscalesshow good internal consistency. How-ever, a unifactorial structure was foundin subsequent validation studies [90].

The Tinnitus Questionnaire (TQ;[88]) has six domains; emotional dis-tress, cognitive distress, intrusiveness,auditory andperceptual difficulties, sleepdisturbances, andsomatic complaintsbe-cause of the tinnitus. The TQ items areinternally consistent; the subscales lackinternal consistency, however.

The Tinnitus Reaction Questionnaire(TRQ; [95]) was developed to measuredistress related to tinnitus. It has foursub-scales: general distress, interference,severity, and avoidance of the tinnitus.

TheTinnitusSeverityIndex(TSI; [92])was introducedasameasureofhowmuchtinnitus negatively impacts a patient’s lifeand how bothersome patients perceivetheir tinnitus tobe. Twoitemsspecificallymeasure how much tinnitus interfereswith daily life activities.

TheTinnitusHandicapQuestionnaire(THQ; [91]) was intended to measurepatients’ perceived degree of handicapdue to tinnitus. The THQ has three do-mains: physical health/emotional status/social consequences, hearing and com-munication, and personal viewpoint ontinnitus. Seven items specifically addressthe interference of the tinnitus on dailyactivities; four of which address hearingdifficulties, two items address social in-teractions and one item addresses sleepdifficulties because of the tinnitus. TheTHQ subscales fail on internal consis-tency however.

The Tinnitus Severity Questionnaire(TSQ; [85]) is a short, unified measure,with two items specifically addressing in-terference of the tinnitus, one item onsleeping habits and one on impairmentof concentration.

More recently, the Tinnitus Func-tional Index (TFI) was developed asa new measure of the severity and neg-ative impact of tinnitus, both for useas a diagnostic tool and for measuringtreatment-related changes in tinnitus[93]. The TFI is a multi-domain ques-tionnaire, measuring tinnitus-relateddistress/severity as a function of pre-

dominantly psychological constructs,such as attention, worry, anxiety, de-pression as well as the more functionalconstructs such as hearing, social life,and activity level [86].

The TQ and the THI are widely usedin clinical practice and clinical trials [87].Additionally, almost all existing clinicalpractice guidelines [79] recommend us-ing the Hospital Anxiety and DepressionScale [96] to assess negative affect coin-ciding with or reactionary to tinnitus.

Appendix D summarises the charac-teristics and psychometric properties ofthe seven tinnitus-specific instrumentsdescribed here.

Recommendation

Tinnitus patients who report com-plaints/show decompensation (grade 2and higher; see. Table 2) should beevaluatedwith at least one measure oftinnitus-related disability, such as theTQ or THI.

Chapter 4 Treatment optionsand referral pathways

4.1 Available treatments andevidence

Informed knowledgeClinicians should educate patients withtinnitus about treatment strategies. Foran extended presentation of the informa-tion that shouldbe conveyed, seeChap. 5.

Drug/pharmacological

Weak recommendation against

There is no evidence for the effective-ness of drug treatments specifically fortinnitus but evidence for potentiallysignificant side effects. Recommenda-tion is based on systematic reviews andrandomised trials.

It is common that treatment of acutetinnitus is given according to treatmentof acute sudden hearing loss. However,in both cases the evidence base for treat-ment is scarce [99]. Therefore, if tinnitusoccurs acutely without hearing loss, thestandard cortisone therapy is not recom-

mended. Present psychosomatic factorscan play a decisive role [118]. Thera-peutic approaches such as intratympanicsteroid treatment have no effect on tinni-tus [168]. Any increase in tinnitus sever-ity or distress in chronic tinnitus shouldnot be treated as new-onset tinnitus. Thisshould be regarded and treated as a fluc-tuation of chronic tinnitus [119].

For chronic tinnitus, many classes ofdrugs have been used or trialled, includ-ing various anti-arrhythmics, anticon-vulsants, anxiolytics, glutamate receptorantagonists, antidepressants, muscle re-laxants, and others [45], with little evi-dence of benefit over harm [169]. TheCochrane review of antidepressants fortinnitus [100] identifiedsixRCTs(610pa-tients) on the topic. Only one study wasjudged to be of high quality. This studycompared the effect ofParoxetine (a sero-tonin re-uptake inhibitor) with placebo,finding no significant difference in effectbetween groups. No effect was seen fortrazadone (serotonin antagonist and re-uptake inhibitor) and a small effect wasseen for tricyclic antidepressants, but thereviewers concluded this couldhave beendue tomethodological issues in the stud-ies. Side effects were commonly reportedincluding sedation, sexual dysfunction,anddrymouth. Nonetheless, antidepres-sants are often successfully applied in thetreatment accompanying depression andanxiety, not for improvement of the tin-nitus.

Jufas andWood [131] provided a sys-tematic review of benzodiazepines fortinnitus also finding six clinical trialswhich examined the use of diazepam,oxazepam, and clonazepam. There weremixed results across studies andmethod-ological issues which reduced confidencein the estimate of effect they reported.Thus, they concluded that benzodi-azepine use for subjective tinnitus doesnot have a robust evidence base and thatthese drugs must be used with cautionbecause of serious side effects.

No drug can generally be recom-mended for the treatment of chronictinnitus. However, psychiatric comor-bidities associated with tinnitus (anx-iety, depression) may need drug treat-ment. Antidepressants should not be

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prescribed to tinnitus patients withoutthe diagnosis of depression.

Hearing loss interventionsCochlear implants.Despite the relativelylimitednumberofcochlearimplantusers,there are many studies of their effects ontinnitus. In a systematic review of theeffects of cochlear implantation on tinni-tus in patients with bilateral hearing loss,five studies were found which reportedon changes in tinnitus after implantation[157]. Based on tinnitus questionnairescores, the review found total suppres-sion of tinnitus in 30–37% of patients,a decrease in 29–72% of patients, nochange in 0–30% of patients, and a wors-ening in 0–25% of patients across stud-ies. Of course, RCTs are not applicable inthis context. Small case–control studies(3b) have shown the efficacy of cochlearimplantation in patients with unilateraldeafness and persistent, bothersome tin-nitus. Hence, larger studies are necessaryto confirm these findings.

No recommendation for (tinni-tus); recommendation for (deaf-ness)

Cochlear implantation is recommendedonly for patients meeting the hearingloss criteria for candidacy. Recommen-dation for tinnitus based on evidencefor safety but low-level evidence of ef-fectiveness

Hearing aids. Hearing loss is one ofthe most prevalent chronic diseases andcauses of disability [176]. The conse-quences of hearing loss in the overallhealth condition of the people suffer-ing from it are significant. It has beensuggested that the reduced physical andmental activity and secondary socialisolation caused by hearing loss [98]increase the risk of cognitive decline/dementia [138], mental illness [140] anddepression [105, 140]. Although tinnitushas been strongly associatedwithhearingloss, the degree of hearing loss cannotlinearly predict tinnitus severity. Only50% of patients with hearing loss expe-rience tinnitus including many patientswho are profoundly deaf [133, 156]. In

addition, 10% of tinnitus sufferers havenormal pure tone audiometry [161, 162].Furthermore, tinnitus occurs in differentpercentages in groups of patients withvarious causes of hearing loss rangingfrom 30% (in ototoxicity) to 90% (inacoustic trauma). The significant benefitof hearing aids for hearing difficultieshave been demonstrated in RCTs [111,128, 144].

It has also been suggested that hear-ing aids reduce tinnitus awareness, andthereby stress [109], and reduce centralauditory gain [152] and homeostatichyperactivity [177], implicating them intinnitus. It has been hypothesised [109]that increasingbandwidth (the frequencyrange of sounds amplified) may improveeffectiveness. Combination hearing aids(including amplification and sound gen-erator in the same device) are anotheroption for patients who may benefitfrom both amplification and passivesound stimulation. Yet there is minimalhigh-level evidence for the efficacy ofhearing aids for tinnitus in systematicreviews; Hoare et al. [124] included justone RCT [151] which found hearingaids to be beneficial but equally effectiveto sound generators for tinnitus. Twosubsequent RCTs compared hearing aidswith combination hearing aids [116] andconventional hearing aids with combi-nation hearing aids or deep-fit hearingaids [117] in patients with hearing lossand tinnitus. Both trials concluded thatall devices offered some equivalent ben-efit for tinnitus. Hesse [119] includedlower-level evidence studies in theirsystematic review but found study re-sults to be contradictory and concludedthat convincing prospective studies arerequired.

Weak recommendation for

Hearing aids are recommended for themanagement of hearing loss and shouldbe considered as an option for patientswith tinnitus and hearing loss. Rec-ommendation is based on evidenceof effectiveness and safety in RCTs ofhearing aids for hearing loss and tinni-tus, and systematic reviews consideringhearing aids for tinnitus.

Hearing aids should not be offeredto tinnitus patients without hearingloss. Tinnitus might be a parameter tobe considered in hearing aid fitting andconsequent relevant decision-making.

NeurostimulationNeurostimulationtreatmentsarehypoth-esised to alter tinnitus-generating neuralfiring. They can be invasive or non-inva-sive, and use electromagnetic, electrical,or sound stimuli. However, the preciseneural mechanism by which changes oc-cur at both local and network levels isnot fully understood [123, 158]. More-over, with non-invasive treatments, theprecise area of the brain to be stimulatedis unknown. Non-invasive treatmentsinclude transcranial electrical stimula-tion, vagus nerve stimulation (transcuta-neous), repetitive transcranial magneticstimulation (rTMS), and acoustic coor-dinated reset (CR)neuromodulation. In-vasive treatments include vagus nervestimulation (implantable device), corti-cal surface stimulation, and deep brainstimulation.

Transcranial electrical stimulation.Tran-scranialdirectcurrentstimulation(tDCS)delivers low-level direct current (about0.5–2mA) via scalp electrodes to thecortex. Thereby, some current is con-ducted through the scalp and someflows into the cerebral cortex where itis hypothesised to increase or decreasecortical excitability (depending on thepolarity) in the brain regions whereit is applied. It was first proposed asa treatment for tinnitus by Fregni et al.[112]. Themost recent systematic reviewof tDCS included 17 studies but onlytwo RCTs [166]. It concluded that therewas insufficient evidence to determinewhether tDCS was effective for tinnitus.The review called for further RCTs oftDCS and studies involving variations tothe stimulation protocol. Many RCTs oftDCS have subsequently been conducted[101, 102, 149, 163, 172], which reportit to be safe but with little or no effecton tinnitus.

Transcranial alternating current stim-ulation (tACS) involves the delivery ofalternating current (constant polaritychanges) between electrodes placed on

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the skin over cortical regions of interest.It is hypothesised to affect up- and down-regulation of synapses, possibly affectingchange in oscillatory cortical activity.There are few studies investigating tACS.One randomised study concluded thereare no effects on tinnitus [172].

No recommendation

There is evidence for safety but no evi-dence for the effectiveness of transcra-nial electrical stimulation for tinnitus.Recommendation is based on system-atic review and RCTs.

Vagus nerve stimulation. Stimulation ofthe vagus nerve is a means of stimulat-ing the cholinergic nucleusbasalis, whichin turn has been shown to induce sus-tained changes in cortical organisation.By this mechanism, vagus nerve stim-ulation, paired with sound stimuli (topromote reorganisation in the auditorycortex), is a hypothesised treatment fortinnitus. Experimental studies have ex-amined the safety and efficacy of vagusnerve stimulation, both direct (i. e. im-planted electrode) and transcutaneous,paired with acoustic stimulation for tin-nitus [108, 129, 134, 136, 178]. Tyleret al. [171] conducted a prospectiverandomised double-blind controlled pi-lot study of the effects of direct vagusnerve stimulation paired with tones ontinnitus. They reported high compliance,mild, well-tolerated adverse effects, butno significant between-group differencein tinnitus at the end of their 6-weekrandomisation period.

No recommendation

There is evidence for safety but insuffi-cient evidence that vagus nerve stimu-lation treatments have effects on tinni-tus. Recommendation is based on thelack of RCTs or systematic review.

Repetitive transcranial magnetic stim-ulation.Repetitive transcranialmagneticstimulation (rTMS) uses strong electriccurrent generated within a coil to createfast-oscillating magnetic fields. Whenused in treatment, the coil is placed nextto the head over the target brain area.

It is hypothesised that the energy fromthe magnetic fields penetrates the skullto cause depolarisation of the superficialcortical neurons; rTMS for tinnitus hasbeenstudiedextensively. Themost recentsystematic review [165] included15 stud-ies and concluded on a significant effectof treatment. However, high variabilityin study design and reported outcomeswas noted and thus the review concludedthe need for large-scale trials and repli-cation studies. Safety was not reported inthis review. A Cochrane review [143] in-cluded five RCTs and concluded that (1)there was limited support across studiesthat rTMS was beneficial, and (2) therewas insufficient information to concludeit was safe in the long term.

Recommendation against

No consistent evidence that repetitivetranscranial magnetic stimulation is ef-fective for tinnitus and no evidence thatit is safe in the long term. Recommen-dation is based on systematic reviews.

Acoustic coordinated reset (CR®) neu-romodulation. Acoustic CR® neuro-modulation is a sound therapy involvinga randomised sequence of four “phaseresetting” tones adjusted to the pa-tient’s dominant tinnitus pitch that arehypothesised to generate a lasting desyn-chronisation of the pathological brainrhythms causing tinnitus. A systematicreview of acoustic CR® neuromodula-tion included eight studies [175]. Itconcluded that the available evidenceindicates the treatment to be safe butthat there is insufficient evidence of itseffectiveness for clinical implementationof this treatment. The review also con-cluded that the hypothesised mechanismof effect is unproven.

No recommendation

Acoustic CR® neuromodulation is safebut there is no high-level evidence of ef-fectiveness. Recommendation is basedon systematic review.

Invasiveneurostimulation treatments.Invasive forms of tinnitus treatment arehighly experimental and span vagus

nerve stimulation with an implanted de-vice, chronic electrical vestibulocochlearnerve stimulation, brain surface (ex-tradural) implanted electrodes, and deepbrain neural stimulator implantation.That they are invasive means they arenot a viable option for widespread use.Research to date is limited to a smallnumber of cases and in each the preciseneural mechanism by which changesoccur at both local and network levelsis not fully understood (for a compre-hensive review, see Hoare et al., [123]).There are no RCTs or systematic reviewsto date.

No recommendation

There is no high-level evidence for theeffectiveness or safety of invasive treat-ments for tinnitus. Recommendationis based on lack of RCTs or systematicreview.

Cognitive behavioural therapy

Strong recommendation for

There is high-level evidence for the ef-fectiveness and safety of CBT for tin-nitus. Recommendation is based onsystematic review and one further RCT.

Cognitive behavioural therapy ap-proaches share the premise that humansuffering (psychological distress) andresulting problems are based in mal-functioning information processing,emotional reactivity, and behaviouralmechanisms (see Appendix E for fur-ther general information on CBT). TheCBT approaches have led to a plethoraof evidence-based cognitive behaviouraltreatments formental and somatic healthdisorders [127]. Cognitive behaviouraltherapy is an integrative and pragmatictherapy where the aim is to modifydysfunctional behaviours and beliefsto reduce symptoms, increase daily lifefunctioning, and ultimately promoterecovery from the disorder [110]. Con-fusion often exists about the differencesbetween cognitive therapy and CBT.Since CBT stems from the convergenceof two distinct theoretical schools, theradical behavioural school (first wave)

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and the cognitive school (second wave),CBT entails a diversity of both cognitiveand behavioural principles andmethods,and usually a combination of these areused in therapeutic sessions. Therefore,bothcognitiveandbehavioural treatmentelements can be found when reviewingCBT procedures in general and thus intinnitus intervention/treatment researchas well.

Cognitive behavioural theory andtreatment have been applied in tinni-tus research for decades and the resultsof the effectiveness of CBT approachesfor tinnitus have been shown to varyin decreasing tinnitus severity/distress,tinnitus-related fear, tinnitus disability,and tinnitus-related cognitive problemsand in improving daily life functioning[13, 120, 126, 139, 141]. Establishing theeffectiveness of CBT in tinnitus healthcare and research is difficult becausepatients report to suffer in various lifedomains. In addition to general prob-lems with daily functioning because ofconcentration difficulties and sleep de-privation, despair, depression, fear, andworry are amongst the most incapaci-tating. Disagreement still exists on whattinnitus-related domains and outcomesto measure, why, and how [122], andin the research literature there is asof yet no standardisation of outcomeselection. Additionally, often the inves-tigated tinnitus CBT approaches varyin number of treatment sessions, hoursspent in therapy, group versus individualformats, face-to-face versus Internet- orbook-based self-help therapies, combi-nations of different treatment elements,and tinnitus diagnostics and outcomeassessments.

Since the most recent Cochrane re-view of CBT for tinnitus was published[139], anewCochraneCBTreviewproto-col has been published [22]. This reviewwill include more recent RCTs and com-ply with the latest Cochrane standards.

Themost recently published review ofCBT interventions for tinnitus was a his-torical and narrative overview in whicha range of study designs in addition toRCTs were included, but one in whichneither a risk of bias assessment was un-dertaken, nor a meta-analysis conducted[84]. These methodological issues make

it harder to draw conclusions about thestrengthof any treatment effects and risksofbias intheevidence included inthenar-rative synthesis. Cognitive behaviouraltherapy for tinnitus (CBT4T) often in-cludes a combination of several elements(such as education, counselling, expo-sure,mindfulness, relaxation, hearing re-habilitation). In a large RCT it was foundthat specialised CBT for tinnitus showedsignificant better groupdifferences in im-provement in quality of life (d= 0.24),decreasing severity of tinnitus (d= 0.43)andtinnitusdisability(d= 0.45), aswellasdecreasing depressive and anxious symp-toms, when compared with general audi-ological counselling and diagnostics only[13].

Despite the afore-mentioned limita-tionsandtheneedtobecautiousabouttheexact effectiveness of CBT for tinnitus ingeneral, at present, a specialised stepped-careCBT4T[13] is theonlyavailable ther-apeutic health-care intervention for tin-nitus supported by a high-quality clinicaltrial. Stepped-care CBT4T has been im-plemented across several Dutch clinicalcentres as the cost-effective treatmentop-tion. Additionally, stepped-care CBT4Tis generally well received by patients andis potentially a cost-effective means forreducing the reactivity [80]. The treat-ment can be defined as a stepped-care4multimodal CBT4T approach in whichaudiological diagnostics, treatment andconsultation as well as CBT-treatmentelements are combined.

Self-help CBT interventions (Inter-net-based or otherwise) appear effica-cious indecreasing tinnitusdistresswhencompared with passive control condi-tions, and less so when compared withactive face-to-face CBT treatment [147].Additionally, treatment attrition in trialsof self-help (Internet-basedorotherwise)CBT interventions is high. Nonetheless,CBT in a self-help format might be a use-ful alternative to support tinnituspatientswho are unable or unwilling to take partin a face-to-face CBT treatment.

4 A stepped-care approach is a framework fororganising health services based on individualpatients’ needs, with a gradual increase in theintensityof thecareateach level [174].

Where there are pragmatic barriersand/or lack of resources, an initial stepof CBT treatment might be performedby a competent non-psychological pro-fessional provided there is appropriatesupport.

Tinnitus retraining therapy

No recommendation

There is evidence for safety but littlehigh-level evidence for the effective-ness of TRT. Recommendation is basedon availability of one RCT and two sys-tematic reviews.

One widely used treatment is tinnitusretraining therapy (TRT), which is basedon the neurophysiological model of tin-nitus [37]. Tinnitus retraining therapyis a specific implementation of gen-eral tinnitus habituation therapy, whichutilises directive counselling to decreasethe negative tinnitus-evoked reactionsand sound to decrease the strength oftinnitus signal [130]. The principal goalof TRT is to achieve habituation of tin-nitus through the retraining of the brain[130, 164]. It means that owing to thehigh level of plasticity of the centralnervous system, it is possible to reducethe responsiveness to repeated stimu-lation with neutral sound stimuli andtrough the counselling [164]. In this pro-cess, the limbic system and autonomicnervous system are the main systemsresponsible for negative tinnitus-evokedreactions, because those areas are acti-vated when one stimulus is associated inthe category of unpleasant or dangerousstimuli, which results in reactions ofstress, anxiety, panic attack, or loss ofwell-being (fight, flight, or freeze). But,tinnitus without negative associationleads to the extinction of a responseto tinnitus. Thus, the goal of TRT isto prevent tinnitus from activating thelimbic system and automatic nervoussystem—habituation of reaction—andwhen the habituation of reaction is fullyachieved, the patient does not experiencenegative tinnitus-evoked reaction. Afterthis, the cerebral cortex—habituation ofperception—is automatically activated,because the brain habituates to all unim-

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Guidelines

Table 8 Categories of tinnitus retraining therapy for patientswith tinnitus andhyperacusis

Category Impacton life

Tinnitus Subjectivehearing loss

Hyperacusis Prolonged soundinduced exacerbation

Treatment

0 Low Present Not present Not present Not present Abbreviated version of counselling

1 High Present Not relevant Not present Not present Full counselling and sound therapy withsound generators

2 High Present Significant pres-ence

Not present Not present Full counselling and sound therapy withcombination instruments

3 High Not rele-vant

Not relevant Present Not present Full counsellingwith stress issues relatedto hyperacusis and sound therapy usingsounds generators and hearing aids

4 High Not rele-vant

Not relevant Present Present Full counselling, sound therapy with soundgenerators set at the threshold

portant stimuli. If the patient achievesthis habituation of perception, tinnitus isblocked before it reaches the conscious-ness level and the patient does not heartinnitus [164].

Based on a medical evaluation oftinnitus, patients are placed into oneof five general categories that guide thetreatment recommended (. Table 8).Each one of five categories is associatedwith a specific variant of TRT treatment,and all patients receive counselling andsound therapy, with substantial differ-ences. Sound therapy has an importantrole in TRT. Specifically, sound therapyacts by providing the auditory systemswith constant neutral signs with soundgenerators, hearing aids, or backgroundnoise. This decreases the contrast be-tween tinnitus-related neural activityand background activity. Furthermore,the sound therapy interferes with thedetection of tinnitus signal and decreasesthe gain within the auditory pathways[119, 135, 164].

The Cochrane review of TRT [153]found only one trial that met their in-clusion criteria, concluding that the trialwas of low quality and no final conclu-sions concerning the efficacy of TRT canbe drawn. The same single study wasalso included in a more recent system-atic review of CBT and TRT, although inthis review the study was rated as highquality [113].

Sound therapy

No recommendation

There is evidence for safety but littlehigh-level evidence for the effective-ness of sound therapy. Recommenda-tion is based on RCTs and a systematicreview.

Acoustic stimulation may be the old-est approach aimed at improving tinni-tus. It is at least the most “natural” one,as tinnitus patients can experience everyday that an external acoustic source canmask their tinnitus. This simple and in-tuitive approach has been (and is still)widely used. Importantly, this approachis not aimed at treating the causes oftinnitus but simply at helping to man-age the consequences of tinnitus. It isused in different ways. Other acous-tic approaches have been developed tointerfere with the tinnitus causes. Forthese methods, the assumptions relativeto the tinnitus mechanisms are critical.All these methods assume that tinnitusresults fromcentral changes after hearingloss that can be reversed by appropriateacoustic stimulation.

In general, acoustic stimulation hasbeen shown to modestly improve tin-nitus condition in several independentlow-quality studies. It is unclear whetheracoustic stimulation might improve tin-nitus through some interaction withtinnitus mechanisms, through the par-tial or complete masking of tinnitus,and/or through certain cognitive in-fluences (diversion, stress managementetc.). Tinnitus is a highly heterogeneous

entity and acoustic stimulation may bevery beneficial for some patients whilecompletely ineffective for others. The“central” model of tinnitus assumes thatthe central changes due to sensory de-privation involved in tinnitus generationare reversible. However, some changesresulting fromsensorydeprivationmightbe difficult to reverse, especially whensensory deprivation has been present formany years. It may not be possible tocompensate fully for deprived inputs bymeans of acoustic stimulation. Indeed,the cochlea (and/or cochlear nerve) canhave nonfunctional areas, which arecalled “dead regions”. The presence of“dead regions” prevents any acousticstimulation from activating the audi-tory centres within the correspondingprojecting areas.

Tinnitusmasking therapy.Many studieshave shown that tinnitus masking ther-apy (TMT) can provide some relief forcertain tinnitus subjects. However, onlya few of the studies included placebocontrols [126] and the different stud-ies are not always comparable, as theyused different questionnaires and proto-cols, with some studies even using theirown custom questionnaires. Henry et al.[115] compared the efficacy of TMT andTRT, finding that both methods led toself-reported improvements in tinnitus,but that TRT was superior to TMT inreducing tinnitus-related distress, espe-cially in the group of patients for whom“tinnitus is a very big problem.” Most ofthe improvement induced by TMT wasachieved during the first 3–6 months oftreatment, while TRT induced a steady

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improvementover the course of the treat-ment (18 months). A more recent study,however, showed that TMT and TRThad similar effects on tinnitus when bothwere associated with counselling [170].Finally, a randomised controlled studyshowed that TRT (masker+ counselling)significantly improved tinnitus handicap[151].

Neuromonics approach. Neuromonicstreatment consists of an acoustic stimu-lation combining music and broadbandnoise [106, 107, 114]. The spectrumof this combination is customised toprovide an equalised stimulation overthe audible frequency range. In addi-tion to providing stimulation within thedeprived sensory region, the acousticstimulation is also designed to pro-mote relaxation and relief. These effectsare reinforced and complemented bycounselling. Patients undergoing Neu-romonics treatment are permitted tocompletely mask their tinnitus in theearly stages of the treatment to maximiserelief and relaxation (2 months). Thisinitial stage is also intended to maximisethe amount of stimulation of the de-prived sensory region. In a second stage(4 months), the patients are discouragedfrom masking their tinnitus to facilitatedesensitisation [107]. In an RCT bythe manufacturers, this method was re-ported to significantly improve tinnitus.The study design included two groupswith different modules of Neuromon-ics intervention, but participants self-adjusted the prescribed treatment forwhat they felt worked best, such that theintervention was no longer different be-tween groups and their data were pooled.Overall, however, theyreportedclinicallysignificant changes in tinnitus severityat 6 months for 86% of Neuromon-ics patients. Few independent studiesof Neuromonics have been conducted.Of note, Newman and Sandridge [145]compared the cost-effectiveness and costutility of Neuromonics versus ear-levelsound generators at about one third ofthe cost. Both interventions resulted inreduced tinnitus handicap score withno difference in improvement betweengroups.

Notchedmusic stimulation.Arecentap-proach investigated the effects of notchedmusic on tinnitus, the notch (1 octavewidth) being chosen to correspond tothe tinnituspitch [148, 167]. Thenotchedmusic was intended to reduce tinnitus-related cortical activity within the notch,possibly through increasing lateral inhi-bition [150]. After 12 months of regularlistening, this approach was reported toreduce self-reported tinnitus loudness,by around two points on a ten-pointscale (eight subjects were treated withthe notched music). The authors in-terpreted this approach as reversing the“maladaptive cortical reorganisation bythe notched music training”.

Customised music stimulation. It hasbeen suggested that tinnitus may resultfrom the central changes accompanyinghearing loss [146]. An implication ofthis model is that an appropriate acous-tic stimulation may reverse the centralchanges due to hearing loss, includingthose involved in tinnitus generation.In this context, hearing aids may im-prove the tinnitus condition by restoringsensory inputs thereby reversing thetinnitus-related central changes due tohearing deprivation. Recently, an RCTinvestigated the effects of their ownproduct aimed at reversing the tinnitus-related central changes using a cus-tomised music stimulation [137]. Tin-nitus severity was significantly reducedaccording to the THQ questionnaire (by34%). Tinnitus severity estimated fromthe TFI, however, was not changed bythe method.

Sound therapy (including masking,music, environmental sound) may beuseful for acute relief purposes but isnot considered an effective interven-tion with long-term results.

Dietary and alternative therapies

Recommendation against

There is evidence that dietary and al-ternative therapies (e.g. Ginkgo biloba,melatonin, zinc, or other dietary sup-plements) have no proven efficacy andpose potential harm in the manage-ment of tinnitus. Recommendation is

based on RCTs and systematic reviewswith methodological concerns.

Ginkgobiloba. Ginkgo biloba is the mostcommonly used herbal supplement fortinnitus. The two latest systematic re-views included three RCTs on Ginkgobiloba for tinnitus as a primary complaint[121, 173]. ACochrane review, first pub-lished in 2004 andmost recently updatedin2013, concludedthatGinkgo bilobawasnot effective [121]. A second systematicreview included five RCTs, with mosttrials having low methodological rigour[173]. The results were favourable to-ward Ginkgo, but the authors stated thata firm conclusion about efficacy was notpossible. A meta-analysis pooled datafrom six RCTs and concluded that therewas no benefit of Ginkgo over placebo[159]. Ginkgo biloba can interact withother blood thinners to cause seriousbleeding and can worsen bleeding riskin patients with underlying clotting dis-orders [155].

Melatonin. Melatonin is a hormone se-creted by the pineal gland that is involvedwith regulation of the sleep–wake cycle.Three RCTs, with a total of 193 partici-pants, studiedmelatonin to treat tinnitus,and each demonstrated benefit with thegreatest improvement in those patientswith severe tinnitus and insomnia [154].However, giventhesmallnumberofover-all patients studied and themethodologi-cal limitations, including lackofaplacebogroup in the largest trial, these resultsshould be interpreted with caution. Al-though another study demonstrated po-tential benefit for patients with concomi-tantsleepdisturbancedue totinnitus, thisstudy lacked randomisation, blinding, orplacebo control [142]. Only one studyreported possible adverse effects ofmela-tonin, which included bad dreams andfatigue [160].

Dietary supplements. Three RCTs ofzinc as a treatment for tinnitus, witha total of 205 participants, showed in-consistent results [97, 103, 104]. It wassuggested that benefit couldbe associatedwith underlying zinc deficiency.

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Guidelines

Several other dietary supplementshave been used for tinnitus, includ-ing lipoflavonoids, garlic, homeopa-thy, traditional Chinese/Korean herbalmedicine, honeybee larvae, and othervarious vitamins and minerals. Evi-dence for the efficacy of these therapiesfor tinnitus does not exist [155].

No recommendation

There is evidence for safety but littlehigh-level evidence for the effective-ness of acupuncture. Recommendationis based on systematic review.

Acupuncture. No recommendation canbe made regarding the effect of acupunc-ture in patients with persistent bother-some tinnitus, based on poor-qualitytrials, no benefit, and minimal harm.A systematic review in 2012 on acupunc-ture for the treatmentof tinnitus includednine RCTs, with a total of 431 partic-ipants [132]. However, this systematicreview highlighted the heterogeneityamong study designs as well as theirmethodological limitations using theCochrane tool for assessing risk of bias.Variations in study design included typesof acupuncture intervention, frequency,intensity and duration of treatment ses-sions, selection of other control groups,variability with blinding, and selectionof outcome measures, many of whichwere not validated [132]. The authorsconcluded that the small number ofRCTs of acupuncture for the treatmentof tinnitus, with small sample size andmethodological issues, were insufficientto make conclusions about effectiveness.

4.2 Referral options and criteria,triage, and a stepwise proposal

A stepped-care approach that providesa standard pathway based on patientneed, including the disciplines involved,assessments, and treatments at eachstage, is presented in . Fig. 5. The stepsproposed in the flowchart are based onthe studies executed within the frame-work of the current guideline and theconsensus meetings held within thesteering committee. The barriers andfacilitators of each member-country of

the TINNET project have been takeninto consideration, with a gradual in-crease in the intensity of the care at eachlevel to be implemented according tohealth-care policy, available resourcesand health-care coordination within thespecific country, region, or state. Sug-gested cut-off scores on the THI and TQhave been included as an example. Forother instruments on tinnitus severity,we refer the reader to Chap. 3.

A stepwise multi-disciplinaryapproachOn the basis of the evidence describedat present, we suggest that a CBT-basedapproach, whether in groups or individ-ually, is the most evidence-based choicefor effectively relieving tinnitus com-plaints. Tinnitus treatment aimed at thesound-perception level, such as soundtherapy, including the use of hearingaids prescribed for tinnitus relief only,masking devices, ear-level sound genera-tors, sound perceptual training, or othersound generating technology, however,has not been proven to have an addi-tional effect on counselling or CBT, oras a standalone treatment. Nevertheless,evidence indicates the merits of audi-ological diagnostics, counselling, andeducation to decrease tinnitus sufferingas well. On the basis of the currentevidence, we suggest that the best tin-nitus treatment strategy might be CBTbased. Research suggests that next tootolaryngological/medical diagnostics,an overall CBT-based framework intinnitus management is advisable, fromaudiological diagnostics (assessment ofhearing and prescription of hearing aidsif indicated to increase hearing function)and tinnitus counselling to psychologicaldiagnostics and tinnitus treatment, sinceall studies showed benefits from someform of education, information, and/orcounselling initially for all patients, andfor the more severely impaired a moreintensive CBT treatment. Moreover,tinnitus standard care might be best or-ganised in a multi-disciplinary manner,using a stepped-care approach [13, 174],gradually increasing intensity of treat-ment in steps, so that most patients canbe treated effectively with a fairly shortprocess (diagnostics and information/

education), and additional treatmentsteps can be indicated for those sufferingon a more severe level.

Chapter 5 Patient informationand support

5.1 Confirming knowledge anddispelling myths. Key messages toprepare the patient for treatmentand beyond

It is essential to successful tinnitus treat-ment that patients are empowered to self-care, that they are provided with reliableinformation and learning resources, andthat they are signposted to appropriatesources of support [34]. Patients needto understand tinnitus, how distressingtinnitus is managed, and what sources ofinformation and support are available tothem beyond their treatment sessions.

The provision of information shouldbe timely and fill gaps in knowledge, dis-pel myths, offer hope, and provide keymessages that are a framework for treat-ment. Information should never be neg-ative, e. g. “there is nothing that can bedone” or “you will just have to learn tolive with tinnitus”.

Having information about tinnituscan be very powerful. Many patientsstart their tinnitus journey by looking forinformation on the Internet and whilethere is some accurate and useful infor-mation available on the Internet, there isalso a lot of very unhelpful information[202]. Patients may read “nightmare”stories on the Internet, or hear inaccu-rate “facts” from friends, family, or evena clinician. Dispelling such myths iscrucial.

IntheassessmentdescribedinChap.3,information is gathered about how tinni-tus is affecting the patient in their dailylife, about their understanding of tin-nitus, and their concerns or fears sur-rounding it. This can be used to explorewith them how their beliefs about tin-nitus and the meaning they attach to itinfluences how they think, feel, and reactto it. Health-care professionals should becompassionate to the concerns and fearsexpressed by patients.

There isnocure for subjective tinnitus,but patients can be treated to help them

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Generalpractitioner

ENT/Audiology

Screen for bothersometinnitus and hearing loss

YES bothersome tinnitus(with or without hearing

difficulties)

Physical examinationThorough Audiological

assessmentScreen Tinnitus Severity

(THI/TQ)

No suffering reported bypatient

TQ<30, THl<36

Suffering reported bypatient

TQ>30, THl>36

Specialist TinnitusHealthcare

(Tinnitus clinic, Tinnitus(Audiological) centre,

Psychologist, Psychiatrist )

Tinnitus specific psychological& Comorbidity assessment• Severity/Impact of the Tinnitus• Life inventory•Assessment of other Comorbidities

Grade 3&4Tinnitus regularly /always impairs emotion,cognition, attention, and task-performance,

cognitive and physical areas/ occurs inseveral situations

CBTFor tinnitus

(Intensity/frequencydependent on

Severity)

Grade 2Tinnitus impairs emotion,cognition, attention, andtask-performance once in

a while/ occurs understressful situations

Psycho education

• lifestyle advice• Self-help manual• Online resources

Education onhearing loss and

tinnitus

Assessment TinnitusSeverity

(Medical/physical/otologicalissues solved and/or clarified

Hearing rehabilitationstarted)

NO bothersome tinnitus(with or without hearing

difficulties)

Fig. 59 Criteria for as-sessment and treatment oftinnitus. CBT cognitive be-havioural therapy, THI Tin-nitus Handicap Inventory,TQ Tinnitus Questionnaire

habituate and to reduce the functionalimpact of their tinnitus. The functionalimpact might include sleep disturbance,difficulty concentrating, problems withhearing, and difficulty relaxing. Patientscan learn to manage their reactions totinnitus, thereby improving their qualityof life.

5.2 Information that should begiven to patients

Patient information and resources (e. g.decision aids) need to be sufficient to al-low them to reach a shared decision withthe clinician about their treatment andto fully engage themselves in the processof care [182, 208, 212]. Initial informa-tion and advice need to be given that willenable patients to have immediate strate-

gies to alleviate tinnitus. Treatmentsmayinclude hearing aids, sound-generatingdevices, medicines, and ways to learnhow to cope with tinnitus. Dependingon what is available locally, tinnitus caremight involve the family doctor, an ear,nose and throat (ENT) specialist or anaudiovestibular physician, hearing ther-apists or specially trained audiologists,clinical psychologists, nurses, or otherclinical professionals [15, 21, 34, 187].

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Table 9 Commonmyths/misconceptions and information for patients

Example myth/misconception

Example information

Having tinnitus means youwill go deaf

It should be explained to the patient that this is not the case.Everyone’s hearing deteriorates as they get older, but tinnitusdoes not cause hearing loss. In many cases, tinnitus is caused bypre-existing hearing loss, but not the other way around [204]

Tinnitus is temporary and willgo away

It should be explained that tinnitus can be temporary, but oftenit is not. The attitude of “hoping” or “wishing” it will go awaywhen it does not go away causes additional distress and moni-toring, thus driving tinnitus distress [57]

Tinnitus will get worse overtime

It should be explained that tinnitus can be affected by life sit-uations that make it more bothersome in time. In general, theseverity of tinnitus decreases over time [207]

Hearing aids will make thetinnitus louder

Where there is a hearing loss as well as tinnitus, and the hearingloss can be compensated by hearing aids, the hearing aids mayalso help to address tinnitus. Hearing aids amplify externalsounds, i. e. those in our environment; hearing aids cannot anddo not amplify an internal noise, which is what the tinnitusnoise is [211]

Caffeine makes tinnitus worse This may be the case for a small number of individuals; how-ever, a clinical trial found that caffeine had no effect on tinnitusseverity [213]. In fact, the same study reported a significantnegative effect of caffeine withdrawal, concluding there is noevidence to justify caffeine abstinence as a therapy to alleviatetinnitus. However, the consumption of coffee does influencesleeping patterns. If there are sleeping problems associatedwith tinnitus, then coffee consumption should be limited

Tinnitus means there is a veryserious underlying illness

Although there are many conditions that may cause or exacer-bate tinnitus, it is extremely rare that it is a symptom of a seri-ous illness [179]

Patient information and support top-ics should be tailored to the patient’s needand what is available to them. Topics in-clude:4 What is tinnitus? What causes and

maintains it?4 Pulsatile tinnitus (follows heartbeat)4 Common misunderstandings and

myths4 Hearing loss and hearing aids4 Ear wax removal4 Hyperacusis and tinnitus4 Protecting your hearing4 Habituating to tinnitus4 Relaxation4 Monitoring tinnitus4 Use of sound4 Dealing with sleep problems4 Dealing with emotional conse-

quences of tinnitus4 Self-help and support groups

What is tinnitus? What causes andmaintains it?Even though tinnitus is a symptom andnot a disease, it can lead to illness in

some people. Tinnitus should be ex-plained to the patient as a sensation ofhearing a sound in the absence of anyexternal sound and their reaction to it.It can be reassuring for patients to de-scribe the various ways in which peopleexperience tinnitus. Different patientswill hear different types of sound, for ex-ample ringing, buzzing, whooshing, orhumming, and occasionally tinnitus hasamusical quality. Tinnitusmight be con-tinuous or intermittent. It might seemlike it is heard in one or both ears, in-side the head, or it might be difficultfor the patient to describe where it iscoming from. Tinnitus is very common(about 10–19% of the population) and isreported in all age groups including chil-dren. It is more common in people whohave hearing loss or other ear problems,but it can also be found in people withnormal hearing. Most people find that itdoes not affect them in any way. Somepeoplefinditmoderatelyannoying,whileothers finding it very troublesome [172,189].

It is important to explain that for sub-jective tinnitus, exactly how and why itoccurs is not yet fullyunderstoodbut thatresearch is ongoing. It is thought thattinnitus is the sound of activity withinthe auditory system, which can generallybe heard in a silent environment, but inthe presence of normal environmentalsounds it is “filtered” out by the brainbecause it does not have meaning.

Although an underlying cause of tin-nitus is rarely known, it is commonlylinked to hearing loss. Age-related “wearand tear” in the inner ear is a commoncause of sensorineural hearing loss [204].It can also be linked to exposure to loudsounds such as occupational or leisurenoise [180]. If relevant, it should be ex-plained to the patient that tinnitus is alsoassociatedwithdisorderscausingconduc-tive hearing loss such as ear wax blockageand otosclerosis [204]. With any ear con-dition, the amount of information beingsent to the brain can change. Researchsuggests that tinnitus results from thecompensatory adaptation of the centralauditory system to hearing loss.

Note that tinnitus is sometimesassoci-ated with emotional stress, use of certainmedications, ear infections, ear, head orneck injuries, neurological disorders in-cludingacousticneuroma,metabolicdis-orders including hypothyroidism, hyper-thyroidism, anddiabetes. Patientsshouldbe reassured that tinnitus is rarely an in-dication of a serious disorder.

Some clinicians invite patients toa group tinnitus information session, fol-lowingwhich they can request individualtherapy if they wish [203]. Some patientsfind the group session alone adequateto reassure them and no further treat-ment is needed. Group sessions havethe advantage of considerably reducingpatient waiting times until their firstappointment.

Common myths and misconcep-tions about tinnitusWhere myths or misconceptions abouttinnitus are identified during assessment,it is important to provide information todispel those myths and misconceptions.Some of these are commonly observedin clinical practice (. Table 9).

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Hearing loss and hearing aidsPatients with tinnitus often attributehearing problems to tinnitus and thuspart of assessment is to determine howmuch of a patient’s complaint is dueto a hearing problem and how muchis due specifically to the tinnitus [192].Hearing loss is often an unnoticeableand gradual process, and many peopleare surprised when they are told thatthey have a hearing loss. For patientswho have even a mild hearing loss andtinnitus, there is consensus that usinghearing aids may be helpful because theyamplify normal environmental soundswhich otherwise may not be heard andmay thus reduce the perception of tinni-tus [124, 209]. Where they are available,clinicians should discuss hearing aids orcombination hearing aid options.

Hyperacusis and tinnitusMany people who experience tinnitusalsoreporthyperacusis, an increasedsen-sitivity to everyday sounds that makesthemuncomfortable tohear[186]. Anat-ural response canbe to block out asmuchsound as possible, for example using earprotection, but avoiding sound canmakehyperacusis, and tinnitus, worse. Oftenusing sound in a very controlled way canimprove hyperacusis [198].

Looking after your hearingExposure to loud noise can cause a tem-porary shift in hearing thresholds as welltemporary tinnitus or make existing tin-nitus worse. Patients should be informedthat these temporary changes will likelyresolve within a few days following thenoise insult but that repeated episodesof noise exposure increase the likelihoodthat the tinnitus will become worse inthe longer term [195].

The clinician should teach the patientwhat is “too loud”. Examples of what istoo loud are:4 If you have to shout to be heard by

somebody around a meter away4 If you find your hearing is dulled after

exposing yourself to noise4 If you find a ringing or buzzing in

your ears (tinnitus) after exposingyourself to noise

4 If a sound is painfully or uncomfort-ably loud, stop exposure immediately

People should take care of their hear-ing by wearing proper ear protectors foractivities that are “too loud”, e. g. usingpower tools or being near noisy motorsfor any amount of time. Ear protectionis also important if the patient attendslive music events or plays in a band ororchestra. Ear protection should not beused if ordinary, everyday sounds are un-comfortable [198].

Patients should also be educated tolimit the amount of time and the volumewhen they are listening tomusic throughearbuds or headphones. A simple 60/60rule can be useful; never turn the volumeabove60%andrestrict listeningtimewithearbud headphones to 60min per day. Athigher volumes, the amount of listeningtime needs to be reduced significantly.Earmuff-style or noise-cancelling head-phones are preferable. For leaflets on safelistening volumes available in many lan-guages, visitwww.who.int/pbd/deafness/activities/MLS/en/.

AdaptationA thorough clinical assessment will de-terminewhere andwhen tinnitus ismoreand less intrusive, and a follow-on dis-cussion should include what can be doneto make the patient’s environment more“tinnitus friendly”, e. g. introducing somelow-levelsound. It is importanttoexplainthat, whilst many people have tinnitus,only some are aware of it all the time orbothered by it. This is because peopleoften get used to the noises just as weget used to other noises around us (e. g.air conditioning, a clock ticking) in theshort term, i. e. they adapt to the pres-ence of those unimportant sounds. If ourattention is focused on something else, itmay be possible to “forget” the tinnitusat times and thus reduce its impact. Itis a new sensation and patients need togive themselves time to adapt to it. Mostpeople find that their tinnitus seems tosettle down over time as they notice itless. There is good evidence from clini-cal trials that in general tinnitus becomesless bothersome over time, even withoutdoing anything [193, 207].

Patients should be encouraged to keepdoing the things they enjoy. If they startliving life differently to accommodate thetinnitus, it is going to seem more of

a problem. They may need to do somethings differently, however. For exam-ple, if they enjoy reading but it becomesa quiet activity where tinnitus is morenoticeable they may need to start usingsome backgroundmusic or environmen-tal noise. The important thing is that theyfind ways to keep doing what they enjoy.

RelaxationPatients should be reassured that it isperfectly normal to feel anxious or afraidbecause of tinnitus, especially when theyfirst experience it [57, 214]. Tinnitusworks a bit like an “emotional barom-eter”—it is often more intrusive whenthere is anxiety or fear around. Tinnitusmight become more bothersome whenunder duress.

Ifpatients can learn torelaxmore, theywill be less anxious and afraid and so no-tice their tinnitus less. There are manyforms of relaxation such as progressivemuscle relaxation or deep-breathing ex-ercises, and these can be guided by a per-son, audio, or written instructions (e. g.www.tinnitus.org.uk/relaxation). A rel-atively easy way your patient might re-lax is to find somewhere peaceful andjust slow their breathing down (theymayhave some sound on in the background).A simple relaxation exercise is to takea fewslowdeepbreathsandpay full atten-tion to the feeling of the breath enteringthe body, filling the lungs, and leavingthe body.

Both adaptation and relaxation taketime. It may be useful for patients tocreate some catchphrases to use whentinnitus is being more bothersome, suchas “Calming tinnitus takes time”.

Monitoring tinnitusIf life is planned around tinnitus it isgiven much importance, and this pre-vents the patient adapting to it. Simplyput, patients should not avoid activitiesthey thinkmaymake their tinnitusworse.Patients shouldnotbeputting their life onhold. Tinnitus does not have to controltheir life. Each time the patient tries to“monitor” their tinnitus they are guidingtheir attention to it; there is, however,no evidence that this would make tin-nitus worse. They should be advised toengage innormal activitieswhentheyno-

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tice themselves trying to monitor theirtinnitus.

Use of soundPatients should be advised on the useof sound to reduce the intrusiveness oftinnitus in quiet situations such as whentrying to sleep, work, or to read in a quietenvironment. Patients should be advisedto experiment with the type and volumeofdifferentsounds tofindwhatsuits thembest in different situations. Examples ofwhat canbeuseful includeopeningawin-dow to let in sounds, leaving a televisionon in the background, static noise froma radio, noise from a fan, or recorded en-vironmental sounds produced by a bed-side generator [199].

Some research suggests that soundvolumes that allow for constant expo-sure to a very low level of tinnitus helpthe patient adapt to their tinnitus [126,153]. Higher sound volumes may maketinnitus inaudible. but for some patientsthis may make the tinnitus more no-ticeable when the sounds are turned off.Awidevarietyofnon-wearable andwear-able sound therapy devices are availablethat can be helpful for some patients.

Addressing sleep problemsMany patients report difficulty in get-ting to sleep or staying asleep because oftinnitus. It can be a vicious cycle whereworrying about tinnitus and/orworryingabout the sleep difficulty makes it evenmore difficult to sleep. Whilst in a patientpopulation most will complain of sleepproblems, in the general populationmostpeople with tinnitus sleep well and theirtinnitus is no different in quality fromthose who do not sleep well. If sleepis a problem then it may be helpful forthe patient to learn about the biology ofsleep, the internal biological clock, andsleeping patterns.

People who have tinnitus and sleeppoorly tend to worry more at night thanpeoplewith tinnituswho sleepwell [183].Patients should be advised that workingthrough problems during waking hoursis better than doing so in the middle ofthe night when they have nothing elseto occupy them. One strategy patientsmight try is to insert a “worry moment”of 10–15min into their daily schedule,

ideally in the early evening. At that time,they can write down (or think about) allthe worries, plans, comments, questionsthat come to their mind. The good thingabout our brain is that “a thought oncethought, can be filed away”. In otherwords, the patient should know they cancontrol their worry. Another strategy tocounter worry involves “thought stop-ping”; patients may use methods suchas simple breathing exercises (e. g. ex-hale three times consciously, or simplyverbalising the word “STOP” out loud).The practice of relaxation and breathingexercises puts the body in a state that al-lows forrest, reducesworry, and increasesthe effectiveness of your biological clock.General advice:4 Plan participation in any sports or

other high-energy activities for theafternoon or early evening (ratherthan later). Ritually “powering-off” in the last 2h before bed, e. g.dimming the lights, only engagingin low-intensity energy activities,avoiding aggravating television showsor late-night discussions.

4 Be aware that caffeinated drinks andalcohol can negatively affect sleep, asdoes smoking, and the consumptionof meals within 2h of going to bed.Warm milk has a sedating effect.

4 Ensure an ambient temperature inthe bedroom. Reserve the bedroomfor sleeping (and intimacies). Tryand limit any other activities (evenreading and watching television) toas little as possible in the bedroom.Try to get into a routine of going tobed at a fixed time each night, but, atthe same time, go to bed only whentired.

4 When the preferred sleep patternis disturbed (e. g. when travellingor working in shifts), take as littlesleep (naps) as possible outside yournormal routine.

Addressing psychologicalproblemsThe clinician should emphasise to pa-tients that although there is no cure thereare many things that they can do tomake tinnitus less of a problem. Thereare a wide variety of psychological treat-ment options available, from providing

the basic information described earlier,to treatment elements that focus on cer-tain problems with thoughts, emotions,and behaviours leading to functional dif-ficulties (concentration, sleep, daily ac-tivities). The patient should be providedwith informationabout the treatmentop-tions available locally.

One structured approach to tinnitustreatment is tinnitus retraining therapy(TRT; [130]). The basis of TRT is thattinnitus is prioritised by the brain as animportant signal. This treatment uses bi-lateral sound generators or hearing aidsat a certain sound level to try to reducethe percept of tinnitus so ad to allowpatients to adapt to the tinnitus sound.Sound is used in combination with di-rective (educational) counselling. Mostclinicians who treat tinnitus use some el-ements ofTRT (e.g. Cima et al. [13], whoused the neurophysiologicalmodel to ex-plain tinnitus) but the strict method isnot frequently used because it is resourceintensive and there is limited evidence forits effectiveness [153].

Cognitive behavioural therapy (CBT) isa psychological approach to treating tin-nitus that has substantial high-level evi-dence for its effectiveness [84, 120, 125,139]. The basic premise should be ex-plained to the patient. It works on theprinciple that when the patient becomesawareof tinnitus, theyrespondnegativelyto it. For example, the patient developsa belief that something is seriouslywrongwith them (belief) and this leads to anx-iety and fear (emotion), and unhelpfulbehaviours such as avoiding silence (be-haviour). Cognitive behavioural therapyhelps patients to recognise which beliefsor behaviours are unhelpful. They thenwork with their clinician (usually a psy-chologist, specialist audiologist, or hear-ing therapist) to develop different waysof responding to the tinnitus that ulti-mately make it less bothersome (see Ap-pendix E).

A clinician-guided Internet-deliveredversion of CBT is available in somecountries and there is good evidence forits effectiveness when delivered by thismedium [215].

Mindfulness-based interventions, orsimply mindfulness, have been classifiedas a psychological treatment aimed at

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psychological distress associated witha range of complaints [196] and typicallyconsists of up to ten group sessions.Mindfulness trains the skill of beingmindful, fostering moment-to-momentawareness, and observing emotions, sen-sations, and cognitions non-judgmen-tally. The rationale for usingmindfulnessis that if the patient stops trying to avoidunpleasant sensations (such as tinnitus)they will be able to perceive the tinni-tus without the struggle. The approachoffers individuals a new way to relateto thoughts that allow them to reducetheir tendency to engage in negative andcatastrophic thoughts. Mindfulness fortinnitus has been tested in clinical trialswith evidence that it is feasible as a treat-ment for tinnitus [141, 197] and maybe beneficial in reducing negative emo-tions, rumination, and psychologicaldifficulties [206].

Acceptance and commitment therapy(ACT) has its roots in the behaviouraltradition (see Appendix E). The focus inACT is on functional utility of thoughtsand actions, and not on their “right-or wrongfulness” [190]. One of thekey elements of ACT is to help expe-rience psychological events (thoughts,perceptions, and emotions) in a non-judgmental way, not trying to change ormodify those events. This leads to amorefunctional awareness of how thoughts,emotions, and behaviours create andmaintain distress. Since mindfulnesspromotes present-moment awarenessand observation in a non-judgmentalway, it has become an integrated part ofthe ACT protocol.

Self-helpSelf-help resources are shown to be use-ful in reducing tinnitus-related distresswithmixedevidenceforeffectsoncomor-bid symptoms such as depression [188].Self-help books are widely available, andsome provide complete programmes ofself-help for tinnitus. For example, thebookTinnitus: A Self-ManagementGuidefor the Ringing in Your Ears by Henry &Wilson[191]providesaseriesofexercisesfocused on a cognitive behaviourmodifi-cation approach, and there is some froma controlled study [200] that it is ben-eficial. Living with Tinnitus and Hypera-

cusis [201] looks at strategies for livingwith tinnitus andhyperacusis. It includesa complete programme of self-help cov-ering causes and mechanisms of tinnitusand hyperacusis; their impact; effectivetreatments; relaxation and sound ther-apy; relieving stress; and avoiding re-lapse.

Hundreds of mobile applications havebeen developed specifically for use inhearing health care, including for tin-nitus [205]. For tinnitus, most were de-veloped to assess the characteristics ofaperson’s tinnitusover time, or toprovidesound-enrichmentoptions [210]. Unfor-tunately, we are at present unable to val-idate these apps or identify which mightbe useful.

It should be acknowledged that thepatient’s family and others may not un-derstandwhat tinnitus isandhowitmightaffect the patient. If that is the case, it canbe helpful for them to talk to someonewho has experience of tinnitus. One op-tionwouldbe for themtoattenda tinnitusself-help group or support group. Thesegroups facilitate an exchange of informa-tion between its members; patients cankeep informed on the latest informationand share treatment experiences by talk-ing to others with similar problems [181,184]. Groups may be lay- or clinician-led. Where possible these groups shouldbe facilitated or attended by a clinicianto prevent misinformation from beingconveyed. Group activities may includelectures fromdifferent relateddisciplines.Cliniciansshouldbeawareof localgroupsor consider forming one if there is nosupport group locally.

Somepatientsmaybeunwillingorun-able to attend a face-to-face self-help orsupport group. An alternative for thesepatients may be to take part in an on-line support group (OSG; [194]). Thesegroups share many of the supposed ben-efits of face-to-face groups such as beinga means to share experiences and seekor provide emotional support. Equally,they risk patients being exposed to inac-curate or misleading information [185].As such, OSGs need to be appropriatelymoderated, ideally by a clinician.

5.3 Further information andsupport

National registered charities for tinnitusare a reliable source of information andsupport for peoplewith tinnitus. Clinicalprofessional organisations also providepatient information and leaflets.4 The British Tinnitus Association

(www.tinnitus.org.uk/) providesa helpline and information leaflets(in English) that are free to all, anda quarterly magazine for its members.

4 The Ida Institute (http://idainstitute.com/) has worked in collaborationwith the British Tinnitus Associationto produce a web resource (www.tinnituskit.com) providing basicinformation about tinnitus and howto deal with it.

4 The Charité German Tinnitus Foun-dation (www.deutsche-tinnitus-stiftung-charite.de/die_stiftung/)provides online information in Ger-man and English (www.deutsche-tinnitus-stiftung-charite.de/en/tinnitus/).

4 The German Tinnitus League (www.tinnitus-liga.de) provides informa-tion only in German.

4 The American Tinnitus Association(www.ata.org/) provides onlineinformation and podcasts in Englishon tinnitus causes, treatment, and theresearch they support.

4 The Dutch Tinnitus Association(www.stichtinghoormij.nl/) providesonline newsletters, information andpublishes about patient meetings andrecent results from the research theysupport.

4 The Dutch ENT-Guidelinecan be found here: https://richtlijnendatabase.nl/richtlijn/tinnitus/behandeling_van_patienten_met_tinnitus.html(only available in Dutch).

4 TheNational Institute onDeafness andother Communication Disorders pro-vides information and PDF leaflets onhearing health and research, availablein English and Spanish: www.nidcd.nih.gov/health/tinnitus

4 The French Patients’ Tinnitus Asso-ciation (www.france-acouphenes.org/).

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4 The Belgian Patients’ Tinnitus Asso-ciation (www.belgiqueacouphenes.be/).

4 The Danish Association of the Hard ofHearing (https://hoereforeningen.dk)provides a helpline (open 8:00–21:00)run by volunteers with tinnitus,who have been trained at The DanishAssociation of theHard of Hearing onguidance, support, and the structureof the Danish Health-Care System.

4 The Italian Au-Tu (Acufene Uni-ti–Tinnitus United; www.au-tu.org)provides information in Italian bothonline and through meetings re-porting the state of basic and clinicalresearch on tinnitus and offers amod-erated forum (for subscribers only)for tinnitus patients.

4 The Foundation for the Research ofTinnitus and Hyperacusis (FINVAC):No online information found.

Corresponding address

Dr. R. F. F. CimaFaculty of Psychology and Neuroscience,Department of clinical Psychological Science,Experimental Health Psychology, MaastrichtUniversityMaastricht, The Netherlandsr.cima@maastrichtuniversity.nl

Acknowledgements. A COST Action grant(BM1306) supported collaboration between theauthors and the formation of the COST ActionBM1306 (2014–2018) TINNET Working Group I.

Special thanks are due to Thanos Bibas, ChristopherCederroth, Thomas Fuller, and Sarah Rabau for theircontribution to the initial developmental stages ofthis guideline.

Compliance with ethicalguidelines

Conflict of interest. R.F.F.Cima,B.Mazurek,H.Haider,D. Kikidis, A. Lapira, A. Noreña, andD.J. Hoare declarethat theyhave no competing interests.

This article does not contain any studieswith humanparticipants or animals performedby anyof the au-thors.

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Table A.1 Clinical examination in patients withpulsatile tinnitus

Examination Rationale

Ask the patient to tick his/her finger in eachpulse, while taking radial pulse

Confirm that tinnitus is pulsatile and followsheartbeat

Otoscopy: Special attention to retrotympanicmass

Possibility of glomus jugulare or tympanicum,high jugular bulb, ectopic carotid artery

Press jugular vein and ask patientwhethertinnitus is alternated

Discriminate between arterial and venouspulsatile tinnitus

Use a stethoscope to listen tomastoid, externalauditory meatus, neck, and chest

Look for murmur, indicative of an arteriove-nous abnormality

Appendix A

Pulsatile tinnitus management

Pulsatile tinnitus follows aperson’s heart-beat and can be either subjective or ob-jective [218]. It occurs in less than 5% oftinnitus patients [216]. It is commonlyassociated with venous and arterial ab-normalities, either because of increasedblood flow or stenosis. Pulsatile tinnituscan also be discriminated as venous orarterial, based on whether it disappearswith pressure in the jugular vein or not.

The overall approach and assessmentof patients with pulsatile tinnitus differsfrom that for patients with subjective tin-nitus, and special clinical investigationsshould be implemented because seriousand potentially reversible causes mightbe found. In this brief section, spe-cial examination aspects which shouldbe implemented in addition to a typicaland radiological evaluationalgorithmarepresented.

Clinical examinationA summary of the clinical examinationof patients with pulsatile tinnitus is pre-sented in Table A.1 [217, 218].

Radiological evaluationThe radiological evaluation of pulsatiletinnitus [216, 218–220] comprises:

Arterial pulsatile tinnitus4 Carotid triplex (stenosis)4 Computed tomography angiography

(glomus, aneurysms, atherosclerosis,arteriovenous malformations)

Venous pulsatile tinnitus4 Magnetic resonance angiography

(arteriovenous malformations, empty

sella syndrome, Arnold–Chiarimalformation, Sylvius aqueductstenosis, sigmoid sinus diverticulosis,etc.).

4 When imaging is normal, considerbenign intracranial hypertension,especially in patients with a highbody mass index.

Appendix B

Method for the development of animplementation plan

Per recommendation, and possibly percountry/region, the following pointsneed to be considered:4 In which time frame is it expected/

recommended that the recommenda-tion is implemented across Europe?

4 What are the conditions that need tobe met for the recommendation to besuccessfully implemented?

4 What are the possible barriers percountry/region for the recommenda-tion to be successfully implemented?

4 What are the possible facilitators percountry/region for the recommenda-tion to be successfully implemented?

4 What is the impact on health-carecosts for the implementation of therecommendation?

4 Who is the responsible party toundertake the actions needed forsuccessful implementation of therecommendation?

In considering the aforementionedpoints, we propose the following:4 Recommendations might be cate-

gorised according to level of recom-mendation (strong—weak—against).All recommendations in the Euro-pean guideline should be weighed,

according to the “strength” of therecommendation.

4 For the strong recommendations,each point will need extensive inves-tigation and reporting.

4 For the weak recommendations,alternatives might be mentioned orconsidered.

4 The recommendations against willbe absolutely discouraged in favourof treatment/procedures with strongrecommendations.

Appendix C

Somatosensory tinnitus

Tinnitus is considered somatosensorywhen it can be modulated by somaticstimulation or movement. It might alsobe considered a subtype of tinnitus thatis associated with activation of the so-matosensory, somato-motor, and visual-motor systems. Somatic modulation oftinnitus has been reported to be observ-able, when actively looked for, in upto 83% of tinnitus patients [229, 236,239, 241]. Somatosensory tinnitus canbe modulated by jaw clench [239] oreye movements [232, 235]. Temporo-mandibular joint dysfunction may causesomatosensory tinnitus [240]. In somecases, pulsatile tinnitus can be modu-lated by movement of the head or upperlateral neck [231].

Pathophysiology

Somatosensory tinnitus is hypothesisedto be related to abnormal cross-modalplasticity of somatic-auditory interac-tions [222, 226, 227, 230, 234]. Somaticmodulation of tinnitus is assumed toresult from abnormal auditory neuralinteractions within the central nervoussystem [237]. Cross-modal interactionis further supported by the observationof auditory cortical area activation indeafness as a result of somatosensorystimulation [222–224].

Diagnosis

Somatosensory tinnitus should be con-sidered when the patient can modulatethe loudness or intensity of their tinnitus

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by movement or tactile stimulation [221,228, 233], and when they report [238]:4 Head or neck trauma.4 That they can modulate tinnitus

quality by manipulation of teeth, jaw,or cervical spine.

4 Frequent pain in head, neck, orshoulder girdle.

4 Simultaneous onset of pain andtinnitus.

4 Tinnitus is aggravated by incorrectbody postures.

4 Severe bruxism.

Table D.1 Characteristics andpsychometrics of existing tinnitus health-related quality-of-life instruments

Instrumenta Developed to Items Scoring Constructvalidity

Reliability (testre-test)

Subscales

Tinnitus HandicapInventory (THI)

Measure level ofperceived tinnitusseverity

25 (0) never + + Functional, emotional,catastrophic responses(2) sometimes

(4) yes

TinnitusQuestionnaire (TQ)

Measurepsychologicalaspects of tinnituscomplaint anddistress

52 True + + Emotional distress,cognitive distress,intrusiveness, auditoryperceptual difficulties,sleep disturbance, somaticcomplaints

Partly true

Not true

Tinnitus ReactionQuestionnaire (TRQ)

Measurepsychologicaldistress due totinnitus

26 (0) not at all + + General distress,interference, severity,avoidance

(4) almost all the time

Tinnitus SeverityIndex (TSI)

Measure howmuch tinnitusnegativelyimpactsa patient’s life andhow bothersomepatients perceivetheir tinnitus tobe

12 (0) never – + None

(4) always

Tinnitus HandicapQuestionnaire (THQ)

Measure patients’perceived degreeof handicap dueto tinnitus

27 (0) strongly disagree + + Physical health/emotionalstatus/social consequences,hearing and communi-cation, personal viewpoint

(100) strongly agree

Tinnitus SeverityQuestionnaire (TSQ)

Measure tinnitusseverity

10 0 (not affected) – – None

4 (always affected)

Tinnitus FunctionalIndex (TFI)

Measure tinnitusseverity andtreatment-relatedchange

25 0 (not affected) + + Intrusiveness, sense ofcontrol, concentration,sleep, hearing, relaxation,quality of life, emotion

10 (always affected)

aSome of these questionnaires are already available in multiple languages. Hall et al. [258] provide a guide to translation and adaptation of hearing-relatedquestionnaires

Treatment

Treatment for somatosensory tinnitustends to include: oro-myofacial therapy,splinting, physical therapy, relaxationtherapy, somatic modulation therapy,electrical stimulation, and local corti-sone injection [225].

Appendix D

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Table E.1 The “third-wave” CBT treatments

MBSR

Mindfulness is a type of psychological treatment aimed at psychological distress, depressivesymptoms, and anxiety, initially devised for individuals suffering from chronic disease. Mind-fulness-based stress reduction (MBSR) was developed by Kabat-Zinn [196, 251]. MBSR proto-cols typically consist of up to ten group sessions. The focus lies on training of the skill of beingmindful, which is a moment-to-moment awareness, and observing emotions, sensations, andcognitions non-judgmentally. Sessions are built around meditational skills, bodily exercises,and psycho-education. MBSR was developed for chronic pain sufferers and was later adaptedfor chronic diseases, such as heart disease, and recently adapted for tinnitus [206, 243, 250]. Asa stand-alone treatment approach, mindfulness has been applied to many psychological disor-ders [245, 253]. Mindfulness is also an important component of other psychological treatmentssuch as acceptanceand commitment therapy (ACT), some forms of behavioural treatment, andcognitive therapy [190, 247, 255]

ACT

According to its founder [190], ACT has its roots in the behavioural tradition. ACT does not em-phasise the accuracy or the content validity of cognitions and behaviours, as is the case in morecognitive approaches. ACT focuses on functional usefulness of thoughts and actions, and not onthe “right- or wrong-fullness” [190, 249]. A key element of ACT is to decrease “experiential avoid-ance” [248]. ACT advocates experiencing psychological events (thoughts, perceptions, emotions)in a non-judgmental way, rather than trying to change or modify those events, leading to a morefunctional awareness of how thoughts, emotions, and behaviours create and maintain distress.SinceMBSR approaches advocate present moment awareness and observation in a non-judg-mental way, which results in decreased rumination and worry, it has been integratedwithin ACTprotocols

Appendix E

Cognitive therapy and cognitivebehavioural therapy

Confusion often exists about the differ-encesbetweencognitive therapyandcog-nitivebehavioural therapy (CBT), asbothterms are used interchangeably. SinceCBT stems from the convergence of twodistinct theoretical schools, the radicalbehavioural school (first wave) and thecognitive school (second wave), CBT en-tails both cognitive andbehavioural prin-ciples and methods, and usually a com-bination of these are used in therapeuticsessions. Cognitive behavioural theoryand treatment have been applied in tin-nitus research for decades [246, 252, 254]and CBT approaches for tinnitus havebeen repeatedly shown to be effective indecreasing tinnitus distress, anxiety, andtinnitus annoyance, and improving dailylife functioning. Although there are com-mon elements across CBT-based treat-ments for tinnitus, the CBT approachesinvestigated vary in number of treatmentsessions, hours spent in therapy, groupversus individual formats, face-to-faceversus Internet-based self-help therapies,combinations of different treatment ele-

ments, and tinnitus diagnostics and out-come assessments.

The cognitive approachThe main premise of the cognitive ap-proach is that cognitive factors maintainpsychological distress. Typical cognitivetherapeutic interventions (or so-calledtalking therapy) are aimed at: (1) cor-recting/changing “erroneous” beliefs orthought processes (cognitions), (2) cur-rentproblemsandthoughtprocesses, andnot so much the past, and (3) advisingpatients to perform behavioural experi-ments in order to test the validity of mal-adaptive thoughts and beliefs [242, 244].The cognitivemodel [57], in line with thecognitive tradition, posits that therapeu-tic strategies to change thesemaladaptivecognitions automatically lead to changesin emotional distress and problematicbehaviours. These cognitive techniquesseem to be helpful in the short term.In addition to educational counselling,techniques include but are not limited to“Socratic dialog”, thought control, ratio-nal thought formulation, exploring auto-matic thoughts, and testing of thoughtsand beliefs through behavioural experi-ments.

A fear-avoidance approachRecently, exposure therapy, a cognitive-behavioural treatment strategy, enteredCBT treatment protocols for tinnitus[13]. Exposure therapy, also applied inCBT treatments for chronic pain [256],is a clinical application of what is called“extinction” of the association betweentwo stimuli in classic learning theoryterms. In the case of tinnitus patients, itis assumed they learn to be fearful of thetinnitus signal. That is, in the distressedtinnitus patient the initially neutral tin-nitus signal became associated withsympathetic arousal (alarm detection;[37, 257]). According to fear-avoidancereasoning, the neutral tinnitus signalbecame a predictor of unwanted aversivestates, hereby receiving a very negativevalue (danger). Patients interpret thesignal as a sign of harm or injury, whichis why they are so fearful, and selectivelysingle out the tinnitus signal. They areeventually constantly interrupted andengaging in safety-seeking behaviour,because of these threat expectancies.These mechanisms are likewise at workin arachnophobes, for example. Thespider, which is harmless, has becomea sign of great danger, leading to extremefear.

For arachnophobia, exposure proce-dures consist of repeated confrontationswith spider-related images, objects, andeventually real-life spiders, which evokethe greatest fear of the patient. As a resultof repeated exposure to the most fearedstimuli, the patient learns that confronta-tion with spiders is not life-threatening,and therefore they are not in danger, andthe fear of spiders dissipates (extinction).By analogy, the tinnitus patient is ex-tremely fearful of perceiving the tinnitus.Even though the tinnitus is continuouslypresent, the involuntary response is try-ing not to hear it, and trying to be mini-mally confrontedwith the tinnitus sound(avoidance). Patients do this by try-ing to control their sound environment,not thinking about it, directing their at-tention elsewhere, and consequently in-creasing their monitoring and awarenessof their tinnitus. Consequently, cognitiveresources are depleted, leading to taskinterruptions, more avoidance (safety-seeking), and eventually disruptions in

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functional activities. In the long term, se-vere disability ensues, disrupting all lifedomains and leading to severe dysphoria.

This “new” forms of CBT for tinnitustypically includes the third-wave formsof therapy (see Table E.1) to enhanceinternal observations, increase moment-to-moment consciousness of the tinni-tus, and to provide the ability of ob-serving tinnitus-related emotions, sensa-tions and cognitions non-judgmentally.Exposure therapy for tinnitus patientsentails exposing them to their tinnitussound, the interceptive sensations asso-ciated with the tinnitus, as well as theirmoment-to-moment narrative. To pro-vide an appropriate context, exposure isperformed in quiet circumstances. Thiswaythepatientexperiences that the tinni-tus sound isharmless, notdangerous, andlistening to it in silent environments willnot lead to catastrophe. They also learnthat the aversive consequences are notalways triggered. These experiences leadto a “neutralisation” of tinnitus by adap-tation of fear expectancies; consequently,the tinnitus becomes less intrusive andbothersome, the more they engage in ex-posure.

Comparing the treatments

The theoretical frameworks have strongconceptual overlap, and are based on thepremise that the initially neutral tinnitussignal receives an “alarm” value, throughclassic conditioning. In turn, this neg-ative tinnitus valence exacerbates neg-ative responses in cognitions, emotionsand behaviours, hindering the “normal”process of habituation. Tinnitus distressensues; which is the very negative andaversive state when processes of adapta-tion and the efforts thereto have failedto return the organism to equilibrium orhomeostasis.

Treatment avenues sometimes seemto be contradictory. The neurophysio-logical model-based tinnitus retrainingtherapy includes extensive education and(partial)maskingof the signal (avoidanceof the signal, by avoiding silence at allcosts), hypothesising that both are re-quired for habituation. The habituationtheory and cognitive approaches purportthat thought control and attention-diver-

sion techniques (alter thoughts/beliefsabout the tinnitus and actively direct-ing attention away from the tinnitus)will be beneficial for habituation. Forshort-term habituation, these strategiesmay work. On the other hand, the fear-avoidance approach leads to an oppo-site treatment strategy, promoting expo-sure to tinnitus and eliminating avoid-ance tendencies (such as avoiding silenceor directing attention away from tinni-tus), to adjust threat expectancies anddecrease fear.

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