|Year : 2017 | Volume
| Issue : 1 | Page : 1-5
Sound therapy for tinnitus patients
Mohamed I Shabana, Abeir O Dabbous, Ayman M.M. Abdelkarim
Department of Audiology, Faculty of Medicine, Cairo University, Cairo, Egypt
|Date of Submission||04-May-2017|
|Date of Acceptance||11-May-2017|
|Date of Web Publication||31-Aug-2017|
Ayman M.M. Abdelkarim
Department of Audiology, Faculty of Medicine, Cairo University, Cairo, Post Box: 3090, Zip Code: 11471
Source of Support: None, Conflict of Interest: None
Sound therapy, or use of any sound for the purposes of tinnitus management, is widely accepted as a management tool for tinnitus. Sound therapy have varying goals. Reducing the attention drawn to tinnitus, reducing the loudness of tinnitus, substituting a less disruptive noise. Sound therapy can be achieved with many modalities: Environmental Enrichment, tinnitus maskers, hearing aids and combination instruments such as: Danalogic iFIT Tinnitus, ReSound Live TS, Oticon’s Tinnitus “SoundSupport”, Phonak’s Tinnitus Balance and Widex Zen Fractal Tones. There are other sound devices e.g.: Acoustic Co-ordinated Reset, Neuromodulation, Serenade, Neuromonics, Phase-Out, Phase-shift and tinnitus inhibitory pathway activation.
The advantages of sound therapy are: being non-invasive, reduce patient frustration and anxiety, some patients experience residual inhibition and it can facilitate patient’s habituation to tinnitus.
Keywords: hearing aids, music therapy, sound devices, sound therapy, tinnitus, tinnitus maskers
|How to cite this article:|
Shabana MI, Dabbous AO, Abdelkarim AM. Sound therapy for tinnitus patients. Adv Arab Acad Audio-Vestibul J 2017;4:1-5
| Body|| |
Sound therapy, or the use of any sound for the purposes of tinnitus management, is widely accepted as a management tool for tinnitus. The rationale for the use of sound in the management of tinnitus is to minimize the patient’s perception of tinnitus by effectively reducing the signal-to-noise ratio between the tinnitus and ambient or environmental sounds ,.
The American Tinnitus Association states that ‘sound therapy is currently the most effective’ treatment for tinnitus and ‘has shown a consistent success rate of 60–90% in treating tinnitus but few predictors exist as to which patients will benefit and what the magnitude of success will be’ .
Kochkin et al.  assessed nine tinnitus treatment methods (hearing aids, music, medication, relaxation exercises, counseling, nonwearable sound generators, herbs and dietary supplements, wearable sound generators, and psychological counseling). They found that the most substantial tinnitus amelioration was achieved with hearing aids (34%), followed by the use of music (30%). None of the other treatments achieved an efficacy rating of more than 10%.
Tyler  stated that despite this common rationale, approaches to sound therapy have varying goals: reducing the attention drawn to tinnitus, reducing the loudness of the tinnitus, substituting a less disruptive noise (background sound) for an unpleasant one (tinnitus), and giving the patient some control.
Sound therapy uses sounds found in natural settings, including those associated with streams, rain, waterfalls, and wind, to decrease the strength of the tinnitus-related neuronal activity within the auditory system . To this end, the background neuronal activity in the auditory system is increased by exposing the patient to a low-level, continuous, neutral sound that is nonintrusive, not annoying, and easy to ignore. Such a sound should not be meaningful, pleasant, or arousing in a way that attracts attention, making listening to a television, the radio, or music unsuitable . Some patients are distracted by the sounds of bird calls, crickets, or thunderstorms, and hence care is required when applying these sounds .
Sound therapy can use various sound sources, such as table-top sound machines and compact disc players. The sound intensity should be at or below the level at which the patient can perceive the tinnitus and the external sound separately . The sound must be applied bilaterally to avoid asymmetrical stimulation of the auditory system as stimulating only one side in unilateral tinnitus frequently results in a shift of the perceived location of the tinnitus to the opposite side because of strong interactions within the auditory pathways. Occlusion with ear plugs should be minimized by using open ear molds to allow normal access of environmental sounds to the ear . Applying sound therapy during the night can be helpful for individuals without sleep problems because the auditory pathways are fully active up to the level of the inferior colliculi during sleep .
The advantages of sound therapy are that it is noninvasive, reduces patient frustration and anxiety, some patients experience residual inhibition (tinnitus suppression or temporary disappearance after exposure to external sounds), and it can facilitate patient’s habituation to tinnitus .
Sound therapy can be achieved with one of the following modalities:
| Environmental enrichment|| |
This is to add pleasant sounds to any environment that is too quiet to provide a distraction from tinnitus. During the day, a variety of sounds can be used such as music, television, or relaxation CDs. At sleep, less distracting sound sources can be used such as table-top sound machines, table-top water fountains, sound pillow, or pillow speakers . Music activates the limbic system and other brain structures (including the frontal lobe and the cerebellum) and has been shown to produce physiologic changes associated with relaxation and stress relief .
| Tinnitus maskers|| |
Masking is another approach to sound therapy. A benefit of total masking is that the patient may experience immediate tinnitus relief; however, patients may find that the sound required for total masking of tinnitus is too loud to tolerate, particularly for extended periods of time .
Partial masking involves the use of a sound that allows the patient to hear both the masking sound and the tinnitus. Use of sound that partially masks the tinnitus may provide a distraction such that the patient does not focus on the tinnitus as much as if no sound was present .
The fact that tinnitus can be masked completely in many patients by the presentation of pure tone or noise suggests that the tinnitus and the response to the acoustic stimulus share the same neural channels somewhere in the nervous system .
Tinnitus maskers are devices that deliver a broad band of sound frequencies (typically between 100 and 8000 Hz). It is preferred to have a user-adjustable frequency emphasis to enable the user select the optimum noise band for achieving masking of tinnitus. A wearable device has been developed that uses high-frequency bone conduction to conduct masking sounds into the head without the need for occluding the ear canal .
A number of studies have found that a tinnitus management program that integrates a noise stimulus delivered by a wearable device may be effective in treating tinnitus ,,.
| Hearing aids|| |
Standard hearing aids have been used in the treatment of tinnitus, especially when the condition is accompanied by hearing loss. It has been suggested that, for certain patients, hearing aids can provide enough sound stimulation to produce some relief from the loudness level of the tinnitus. Proponents of this theory contend that even patients with minimal hearing loss or with normal hearing may gain a masking benefit from hearing aids through the additional auditory stimulation associated with hearing aid use .
Hearing aids can be very effective in decreasing the perception of tinnitus because (a) the increased stimulation sent to the cochlea and ultimately the auditory cortex can minimize the brain’s attempt to ‘overcompensate’ for the lack of stimulation by turning up its sensitivity, (b) they may mask or partially mask tinnitus, and (c) they may reduce contrast between tinnitus and silence . The use of hearing aids in tinnitus patients with a hearing loss makes the patient less aware of the tinnitus and it improves communication by reducing the annoying sensation that sounds and voices are masked by the tinnitus. With hearing aid amplification, external sounds can provide sufficient activation of the auditory nervous system to reduce the tinnitus perception. To obtain the best results, hearing aids should be fitted to both ears and use an open ear aid (hearing aids with large ventilation). In the ear, hearing aids produce too much occlusion effect, which can lead to an increase in the perception of the tinnitus. It is also appropriate to use hearing aids with the widest possible high-frequency amplification for patients with high-frequency hearing loss .
| Combination instruments|| |
These are devices that combine two circuits hearing aids and sound generators into one wearable unit, which are used if the patient tried hearing aids and experienced some benefits, but believe that they might receive additional tinnitus relief from a sound generator .
Examples of combination instruments include:
- Danalogic (GN ReSound, Kirtlington, Oxfordshire, United Kingdom) iFIT Tinnitus: A combination instrument that offers sound generator options of broadband signals, a narrow band signal focused on the frequency of the tinnitus, and the option of using amplitude modulation (fluctuation in the level of noise signal while all other spectral components remain uniform) (http://www.danalogic-ifit.com/danalogic-ifit-tinnitus.php).
- ReSound Live TS: A combination device providing options for the use of broadband or narrow-band noise, with further options for amplitude modulation and environmental steering. Its suggested mechanism of action is the diversion of attention away from tinnitus, thereby promoting habituation .
- The Oticon’s (Oticon Inc., Smorum, Copenhagen, Denmark) Tinnitus ‘SoundSupport’: Sound generator is implemented in Oticon’s receiver-in-the-ear and behind-the ear hearing instrument models because the use of an open-fit hearing instrument configuration is preferable for ear-level sound generators (https://www.oticon.com/solutions/other-devices/tinnitus/).
- The Phonak’s (Phonak, Stäfa, Switzerland) Tinnitus Balance: Noise generator is available in all four performance levels of Phonak Audéo V hearing aids. The noise provides a means of sound enrichment that can be used as part of a tinnitus management program. The type and spectral characteristics of the noise can be adjusted to meet each client’s specific needs using the ‘Phonak Target software’ (https://www.phonakpro.com/us/en/ resources/apps-for-your-clients/tinnitus-balance-app.html).
- Widex (Widex A/S, Lynge, Copenhagen, Denmark) Zen Fractal Tones (Zen): It combines a hearing aid and sound generator using an alternative to conventionally composed and performed music in the form of fractal ‘music’ or tones . Widex A/S is a complete program addressing the tinnitus components based on the use of the fractal tones (Zen tones) included in their Menu hearing aids. This program is introduced under the name of Widex Zen Therapy (https://www.widex.pro/en/products/tinnitus-solutions/zen-tinnitus-relief).
A Fractal is a mathematical algorithm that generates a series of sounds and, like music, fractal tones have been proposed to promote relaxation, which might in turn have lead to benefits for individuals with tinnitus ,. The fractal is ‘a rough or fragmented geometric shape that can be split into parts, each of which is (at least approximately) a reduced-size copy of the whole’. Properties include self-similarity and a simple and recursive definition. Examples include clouds, rivers, fault lines, mountain ranges, snow flakes, crystals, lightning, cauliflower, broccoli, blood vessels, and ocean waves. Fractal tones create a melodic chain of tones that repeat enough to sound familiar and follow appropriate rules, but vary enough to not be predictable. Fractal technology ensures that no sudden changes appear in tonality or tempo. It is an optional listening program in certain hearing aids that plays adjustable, continuous, chime-like tone complexes using fractal algorithms .
Robb et al.  reported that the chimes are generated on the basis of an understanding of the properties of music that would be most relaxing: Ability to self-select music, tempo near or below resting heart rate (60–72 bpm), fluid melodic movement, variety of pitches, no rapid amplitude changes, and element of uncertainty. In passive listening, each program can be individually adjusted to loudness, pitch, and tempo preferences, the fractal tones (or the noise) should be audible, but relatively soft, it should never interfere with conversational speech, and the annoyance level of the tinnitus should just begin to decrease (i.e. tinnitus can still be audible).
Music therapy is a desensitization method that utilizes music that has been spectrally modified according to the hearing characteristics of each patient to allow the masking of tinnitus and to facilitate relaxation at a comfortable listening level. Music directly affects the limbic system, bypassing the slower linguistically based processing in the auditory cortex. Hearing thresholds decrease markedly above 3 kHz among many tinnitus patients, and hence the spectral modification should involve reducing the energy of lower frequency components of the music .
Previous research has indicated that a dynamic sound, or a sound that varies over time, may be more effective than bands of noise in reducing tinnitus annoyance . It is difficult to ascertain from existing studies whether the fractal tones were beneficial because of their relaxation effect, masking, or the extent of benefit from concurrent background amplification relative to the fractal sounds .
| Other sound devices|| |
Acoustic co-ordinated reset neuromodulation
CR neurotechnology is aimed at unlearning the pathological synchronization of nerve cells that is the underlying cause of symptoms associated with neurological disorders such as tinnitus .
It targets pathological neural synchrony that may be responsible for tinnitus generation. Sound stimuli are individualized to span a frequency range centered on the dominant tinnitus pitch. Patients are required to listen to sequences of tones presented at a low volume over an open-fit headphone for up to 8 h daily. The pattern of sound stimuli is predicted to force asynchronous firing of neurons from within a pathologically firing population through a reduction of the mean synaptic weight .
Tass et al.  reported clinically significant improvements in tinnitus handicap [reduction on the Goebel Hiller Tinnitus Questionnaire, (GHTQ) score] after treatment. The GHTQ differentiates between emotional and cognitive distress, auditory perceptual difficulties, and self-experienced intrusiveness produced by the tinnitus. The GHTQ can be used for comparative studies in different tinnitus-related institutions and for the evaluation of the relative effects of different treatment approaches .
It delivers programs of sounds described as ‘cortically interesting’ that are designed to affect highly synchronous cortical responses . Zeng et al.  found that whereas high-rate (2–5 kHz) electrical stimulation had no effect on tinnitus, a 100 Hz electrical stimulation pulse delivered to an apical electrode in a cochlear implant patient provided total tinnitus suppression. A 40 Hz amplitude modulated tone with carrier frequencies near the tinnitus pitch generated the best tinnitus suppression (up to total suppression during stimulation, with residual inhibition lasting ≤90 s after stimulation ended). The Serenade device delivers two tracks of temporally patterned sounds ‘S tones’ that are determined according to the span of hearing loss and the dominant tinnitus pitch. It also delivers a customized narrow band sound and a broad band sound. The manufacturers recommend that it be used on an ‘as needed’ basis to gain relief, for example, before going to bed.
The unique aspect of the Neuromonics approach is that it uses recorded music specifically chosen for its amplitude and tempo characteristics and then filtered in accordance with the individual’s hearing thresholds and delivered through a wearable system consisting of an MP3-like sound processor and high-fidelity headphones. The sound processor provides a background of music mixed with white noise and filtered out to a high frequency (12 500 Hz). The recorded music is presented to the individual with tinnitus at a relatively soft intensity level (designed to just interfere with the tinnitus perception) and to be listened to for 2–4 h/day to induce relaxation and desensitization for a period of 6 months. The background white noise, which is used to mask the tinnitus during the quiet intervals of the music, is utilized during the first couple of months of treatment and then phased out .
On the basis of the principle of noise cancellation, Choy et al.  hypothesized that if a sound was pitch and volume matched to tinnitus and the phase shifted sequentially by 6° at intervals of 30 s (so 360° over a 30 min intervention), the neuronal complex in the auditory cortex responsible for that tinnitus tone would be cancelled at least temporarily.
On the basis of the same principle of noise cancellation, it is produced by TinnitusCare and delivers a stimulus that is of the same amplitude and frequency as the tinnitus sound, but with an inverted phase. The stimulus is delivered over a 30-min session .
Tinnitus inhibitory pathway activation tinnitus device
The tinnitus inhibitory pathway activation
The device works through increasing the periods of residual inhibition ‘probably through inhibitory pathways using digital nonsinusoidal low frequency sounds’. The system uses three different complex tones, each presented for 3 min and played in the order 1, 2, 1, 3 (12 min stimulus in total/day). Case studies suggested that the signal can induce residual inhibition lasting many hours .
Hoare et al.  reviewed practicable options of sound therapy for tinnitus, the evidence base for each option, and the implications of each option for the patient and for clinical practice. [Table 1] shows a summary of the options that they reviewed and the highest level of research evidence identified for each option.
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Conflicts of interest
There are no conflicts of interest.
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