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Therapy
for auditory disorders is largely the province of the otolaryngologist
and the audiologist. The neurologist interested in neuro-otology
however, should have some knowledge of therapy to promote appropriate
referrals. The nature of the treatment program depends, of course, on
the exact diagnosis, that is the type of hearing loss and the age of the
patient. Both medical and surgical therapies are appropriate depending
upon the nature of the disorder. Medical or surgical therapy is used in conductive
losses due to otitis media. Surgery is the primary therapy for
hearing loss caused by otosclerosis, usually manifest as a conductive
type of hearing loss, as described earlier. A discussion of surgical
therapy of otosclerosis is beyond the scope of this chapter. The
interested reader is referred to textbooks of Otology. However, almost
every type of non-conductive hearing loss may be helped by a variety of
amplification devices and/or counseling.
Amplification
Contrary to a commonly held misconception, sensorineural hearing loss
may be helped by the use of a hearing aid. It should be recognized,
however, that hearing aids only compensate for loss of sensitivity, but
the matter in which increased loudness is achieved may reduce distortion
and significantly increase discrimination in certain situations. Modern
hearing aids use the latest microcircuitry and signal-processing
techniques, such as digital filtering, to improve significantly the
effectiveness of amplification.
In addition to hearing aids, devices such as telephone amplifiers,
television/radio access systems, personal listening systems, and
alerting devices are designed to improve communication in difficult
listening situations. There are many assistive devices on the market and
new systems and modifications are appearing at an accelerating rate.
We note that the hearing aid is the most important rehabilitative
tool available for the management of sensorineural hearing loss,
however, counseling should represent a central focus of any management
strategy for the hearing-impaired adult. In addition, the
hearing-impaired should receive counseling both before and after the
provision of amplification. Lastly, cochlear implants have proven to be
extremely beneficial for those individuals with severe to profound
hearing loss who receive minimal benefit from amplification. (Waller and
Roland, 1996)
Management of Tinnitus
The complete evaluation of the tinnitus patient should be approached
from a dual perspective. The patient with tinnitus, regardless of
location, type, or severity, must first have a thorough otologic and
audiologic examination. If there are accompanying symptoms, a complete
neurological examination may be appropriate. The patient with an
isolated symptom of a persistent, yet unexplained, tinnitus should
receive follow-up examinations at definite intervals when initial
medical, otologic, and neurological studies reveal no evidence of
disease. Tinnitus may be the first symptom of disorder, appearing long
before any other symptom, including hearing loss. When medical and
otologic examination fail to disclose a remediable cause for the
tinnitus, or when a diagnosis is ascertained for which no known medical
therapy is presently available at present, the tinnitus patient should
undergo further evaluation to determine the most appropriate nonmedical
avenue for rehabilitation.
When a specific otologic cause for the tinnitus is identified,
otologic management is indicated. When a lesion or disease process is
not identifiable, however, then tinnitus management is more difficult.
Given no underlying otologic disease, there is at present no effective
surgery or medical therapy for the treatment of tinnitus.
Research on the effectiveness of pharmacological therapy for tinnitus,
although certainly encouraging, involve medications, such as
carbamazepine, lidocaine, and intravenous barbiturates, whose
potentially serious side effects limit their usefulness. There is some
suggestion that relatively low doses may prove effective in tinnitus
management.
Masking
The use of masking as a management tool in the treatment of the
tinnitus patient has met with mixed success over the years. The
audiologist should remain cognizant of factors such as the patient's
perception of the pitch and loudness and the overall spectral intensity
of the masking signal. The referring neurologist should be aware of
these issues as well.
Tinnitus maskers are designed to provide relief to the tinnitus
sufferer by introducing an external masking sound into the effected ear
or ears, thereby minimizing or eliminating the perception of the
tinnitus. Although the use of tinnitus maskers has not proved
universally successful, masking is still a feasible technique that
cannot be ignored. The actual efficacy of tinnitus maskers in the
average tinnitus patient is probably less than 30%. The use of a hearing
aid may be more beneficial by addressing the primary hearing problem.
Biofeedback
Experience
with tinnitus patients reveals that many have relatively high levels of
anxiety, tension, or other symptoms of chronic stress. There is a
significant correlation between tinnitus and tension. Biofeedback as a
treatment in the management of tinnitus was first reported in the
literature in the mid-1970s. These early studies reported the use of
biofeedback as effective in the relief of tinnitus or the associated
annoyance produced by it. Biofeedback is quite effective for enhancing
relaxation, as are traditional relaxation procedures. When used
together, muscle tension and general life stresses are reported to be
reduced.
Counseling
The need for effective counseling is one important aspect of tinnitus
management regardless of the management approaches taken with a given
patient. Many patients are frightened by the presence of tinnitus and
need a careful and clear explanation of the disorder, coupled with firm
reassurance from both the neurologist and the audiologist. In light of
the various effects tinnitus may have on a given patient counseling must
be directed toward all of the patient's difficulties, not this specific
problem in isolation.
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