To Provide or Not To Provide Tinnitus Services: That is the Question



Author: Richard Reikowski, Au.D.

While attending the 2011 AAA convention in Chicago, I was amazed at the city sounds — both pleasant as well as those I considered annoying and noisy. Specifically, the “L” Train was very cool in how it smoothly winded throughout the city, above the streets, people, and businesses. I also observed it moving rather close to apartment buildings. I recall asking a friend and fellow audiologist what it must be like to live in an apartment within feet of the noisy “L” Train passing by each and every day. I remarked at how difficult it must be for many to live near those noises and sounds. I also thought many people would not be bothered as those sound may be considered a natural part of “city life.” It was during that conversation that I immediately drew comparisons to those that suffer from tinnitus and how living with the unwanted or unpleasant sounds, that are heard within their heads, during most waking hours, are so very troublesome and even disturbing. On the way to the convention center, my colleague and I continued talking and sharing stories of patients that suffer from tinnitus.

Tinnitus is described in many ways and can be considered defined as sounds that are heard, within the head, without external or real stimuli. There are many potential causes of tinnitus from the most common noise exposure, trauma, medications, to unknown causes. Common belief is that tinnitus is generated within the inner ear, cochlear, and central nervous system. I have found a great interest in offering tinnitus assessments and treatment in our clinical practice. We are seeing an abundance of clinical research from various educational institutions and medical facilities. We are also becoming aware of many tinnitus therapy devices from sound generators fitting at ear level and those portable for desk and table use. 

The purpose of this article is to help my fellow audiologists weigh the pros and cons of offering tinnitus services in their practice. Let’s begin by asking the most fundamental question. Should you offer tinnitus management services in your practice? There are many areas to consider when formulating an answer to this question. Since tinnitus management is within an audiologist’s scope of practice it is our responsibility and duty to serve as an advocate for people who may present with this condition. From this standpoint, it makes sense to offer tinnitus management services. My practice has chosen to offer tinnitus management services. We maintain a patient education blog and hold a membership with the American Tinnitus Association. On the other hand, many audiologists choose not to offer tinnitus management services because they are time consuming and treatment options oftentimes result in inconsistent patient outcomes.

Tinnitus Management Considerations
Ultra high frequency audiometry is needed for measuring hearing loss in a tinnitus management center. The cost of a new stand alone or PC based ultra high frequency audiometer can range from $4500 and upward. It is also imperative to gain some additional education about tinnitus management by attending a reputable workshop or course on the subject. In addition, we are challenged to educate insurance carriers to have a greater awareness in maintaining tinnitus assessment billing codes.

We are currently using several devices that are proving successful in helping patients with tinnitus. As a research member of The American Tinnitus Association, our clinical staff places a great emphasis toward gathering post fitting data and clinical outcomes. Successful outcomes can be seen daily with patients having tinnitus.

Let me share a recent case example. A specific patient, male and in his early sixties, having severe tinnitus, felt as though there was no end or hope for his tinnitus. He described the sounds he experienced such as a tire leak, being of a high piercing sound. Once measured, the loudness levels surpassed that of conversational speech. Hearing loss was not causing a significant communication concern. In fact, tinnitus and loudness intolerance, or sensitivity to sounds, were his first and second issue of need and hearing tertiary. There were also concerns of depression and significant anxiety related stress areas. Once we obtained the necessary gathering of data, ordering the appropriate tinnitus management device, he is achieving a slow progression toward “better days”. He feels his anxiety level and the short fuse that he prior had was diminishing. The negative effects in which he described his tinnitus, through subjective responses to a series of questions, he is less troubled or disturbed. In short, we have found a desire to be a part of those that have, quite potentially, no source for a resolution. Often they have nowhere else to go. We are proud to be a part of their successes.

People in general and potential patients alike do recognize when good services are offered. If you have been doing the right thing in your practice with a true desire for best patient practices, would people not allow you to treat not only their hearing issues, but their tinnitus? Your physician base is seeking answers for their patients. Shouldn’t they recognize you as a community leader or advocate for helping a great need amongst this tinnitus patient base? During visits to physician lunches the common issue is brought up for discussion is the lack of treatment options for those they serve with tinnitus. We are asked very pointed questions of the efficacy of tinnitus treatment and are called to support our decisions of the choices we make to resolve tinnitus in patients. Offering tinnitus management services can be a great way to provide personalized and effective care to a largely underserved group of patients.    
Richard Reikowski, Au.D. is the Director of Hearing, Balance, and Tinnitus at the Family Hearing and Balance Center in Ohio. He can be contacted at: rreikowski@familyhearingbalancecenter.com

Tinnitus Management Services as an Alternative Revenue Stream
By Brian Taylor, Au.D., Audiology Practices Editor

We know from Kochkin et al (2011) that about 10% of the entire population suffers from tinnitus and a disproportionate number of these patients also suffer from hearing loss. Additionally, these researchers reported that hearing aids offered substantial benefit for a significant number of patients suffering from tinnitus. Tyler (2012) reports high proportions of tinnitus patients will seek, accept, and pay for treatment, however, they clearly prefer less invasive (i.e., external) devices if they completely eliminate tinnitus. Differences among tinnitus patients are vast and there was only a “…little relationship between tinnitus loudness and annoyance and the amount of money….” tinnitus patients are willing to pay for relief. Furthermore, Tyler (2012) stated that many tinnitus patients would pursue surgical options and many would pay $10,000 for treatments to reduce their tinnitus.

These two recently published articles encapsulate the opportunities and pitfalls associated with offering tinnitus management services in an audiology practice. Indeed there is a relatively large demand for these services, yet the relationship between the magnitude of the tinnitus and patient outcome is murky at best. Once a practitioner makes the careful decision to enter the tinnitus management arena, there are several considerations. One of the most well respected medical institutions in the world, Cleveland Clinic, offers a comprehensive tinnitus management service. If I were opening a tinnitus management center in my clinic, I would seriously consider modeling my program on theirs.

Audiologists interested in opening a tinnitus treatment center are also encouraged to read Tyler et al (2008), which discusses several important considerations. Here is a summary of what Cleveland Clinic offers patients suffering from tinnitus. It should serve as general guide for establishing a comprehensive, patient-centric tinnitus management center.

  1. Medical clearance from an otolaryngologist prior to enrollment in the program
  2. A multidisciplinary approach to assessment and treatment, including evaluations from neurology, dentists, physical therapy and psychology
  3. The use of group education and support sessions
  4. Following the multidisciplinary assessment an individualized tinnitus treatment plan is devised. This plan may include the trial use of hearing aids, sound therapy, behavioral modification therapy and/or physical therapy.
  5. Patients are charged an initial fee of $300 for the initial visit. Subsequent fees for devices and services may be billed to an insurance provider.
References
Kochkin S, Tyler R, Born J. (2011) MarkeTrak VIII: The Prevalence of Tinnitus in the United States and the Self-Reported Efficacy of Various Treatments. Hearing Review18(12):10–26.

Tyler, RS., (2012): Patient Preferences and Willingness to Pay for Tinnitus Treatment. Journal of the American Academy of Audiology 23:115–125.

Tyler RS, Haskell GB, Gogel SA, Gehringer AK. (2008) Establishing a Tinnitus Clinic in Your Practice. American Journal of Audiology 17(1):125–37.