Tinnitus Management: The Utilization of a Hybrid Telehealth and In-Person Delivery Model

Abstract

Telehealth, or the delivery of healthcare services from a distance, has historically been used to provide care to underserved populations and to those unable to visit a healthcare center. During the ongoing global COVID-19 pandemic, some providers of tinnitus healthcare services incorporated telehealth into their clinical protocols to allow for continued care for their patients while adhering to social distancing guidelines and safety measures. Bothersome tinnitus can negatively impact one's quality of life. Telehealth has been instrumental in treating this debilitating problem in a time when in-person care has not been easily available. The case of a patient with tinnitus is examined to demonstrate the use of a hybrid delivery model utilizing telehealth and in-person interactions to assess and manage her bothersome tinnitus. In-person services were used for audiological assessments and fitting of treatment devices, while telehealth was utilized for counseling, education, and remote programming of her treatment devices. This combined approach, which has allowed the patient to continue receiving care safely during the pandemic, can be continued for future care. Telehealth offers several advantages to patients and providers alike. While the COVID-19 pandemic will hopefully come to an end, telehealth services for tinnitus management may be here to stay.

Tinnitus is the perception of noise in the absence of an external source of sound. Commonly described as ringing or buzzing in the ears, this symptom can often be exacerbated by internal and external triggers. ¹ If left unmanaged, tinnitus can have a debilitating impact on a patient's quality of life. This impact may be reported by patients as disrupted sleep, cognitive impairments, mental health difficulties, social withdrawal, and compromised auditory function. ² Tinnitus is most often managed through a variety of treatment modalities, including sound therapy, distraction techniques, cognitive behavioral therapy, stress management, and diet and lifestyle modifications. ³

Although evaluation and management of tinnitus has traditionally involved face-to-face contact between patient and provider, the emergence and popularity of telehealth in response to increased safety measures during the SARS-CoV-2 (COVID-19) pandemic has allowed for continuity of healthcare services while observing social distancing techniques. ⁴ According to Swanepoel and colleagues, telehealth, also referred to as telemedicine, is a service delivery model that allows a patient to access healthcare services remotely, often utilizing technology such as video communication. ⁴ For many years, providers have used telehealth services to reach underserved populations who would otherwise have limited to no access to other in-person services. Telehealth has proven to be an effective way to increase patients' access to care and deliver services in a timely and efficient manner, while reducing associated costs. ⁵ While telehealth is not new in the field of audiology, telehealth services geared specifically to managing tinnitus have been limited, at best, prior to the pandemic. ^{4 6 7 8}

At the University of Miami Tinnitus and Sound Sensitivities Clinic, telehealth for tinnitus care was initiated in response to the COVID-19 pandemic. Prior to the pandemic, patients would partake in in-person group tinnitus education sessions as a prerequisite to identifying an individualized tinnitus management plan. Sessions were held in a small clinical conference space and were comprised of 6 patients, up to 1 accompanying individual per patient, as well as 1 tinnitus audiologist. In response to the pandemic, these sessions were immediately ceased to comply with the Center for Disease Control and Prevention guidelines which, in turn, restricted patients' access to essential tinnitus care and management. ⁹

Online conferencing through a secure video communication platform, Zoom, was approved by hospital leadership as a means of meeting remotely, collaborating on projects, and, soon after, providing telemedicine to patients. During this time, many of the clinical services offered through the Department of Otolaryngology were transitioned to a remote virtual format. One patient's case will be highlighted to explore how telehealth was incorporated into a hybrid management approach for the purpose of assessment, education, counseling, and management of bothersome tinnitus during the COVID-19 pandemic.

Case Presentation

Gabby (pseudonym), a 59-year-old female, presented to the Department of Otolaryngology at the University of Miami Health Care system (UHealth) for the evaluation of bilateral tinnitus, hearing loss, and dizziness.

Tinnitus History

The patient reported that her tinnitus had been present for the past 15 years and was perceived as worse in the left ear than in the right ear. Gabby underwent numerous consultations with healthcare providers outside of UHealth over the course of years to identify possible management strategies for her tinnitus. Gabby indicated she received advice limited to the recommendation of over-the-counter Lipoflavinoids, in addition to being told “there was nothing [she] can do about it.” ^{10 11} The patient denied subjective improvements in tinnitus perception following a 3-month intake of Lipoflavinoids.

Gabby described her tinnitus as a constant, nonpulsatile tonal ringing which impacted her sleep, concentration, and exacerbated her preexisting anxiety. She described nightly use of the television to aid in falling asleep. Due to Gabbys chronic health conditions, she had been approved by her employer to work remotely during the COVID-19 pandemic. Gabby noted that due to this workplace accommodation, she was experiencing hostility and animosity from colleagues who had been required to work in the office. These negative reactions contributed to her heightened stress and anxiety levels, and, in turn, increased the perceived loudness and disturbance of her tinnitus. Gabby was purposely visiting her office after normal business hours to complete work-related tasks to both avoid the stress and for social distancing purposes. Her stress management routine included regular exercise, listening to audiobooks, and practicing guided breathing techniques. History was notable for occasional sensitivity to sound.

Hearing and Vestibular History

Regarding her hearing loss, Gabby noted difficulty hearing the television, talking on the phone, and conversing with coworkers. Gabby confirmed her family history was significant for presbycusis. Gabby indicated she experienced the onset of positional vertigo following spinal surgery 1 month prior. Dizziness was described as a transient spinning lasting seconds, provoked by lying down or getting out of bed. Gabby denied any correlation of her vestibular disturbance with hearing or tinnitus changes or other otologic symptoms.

Medical History

Significant medical history included coronary artery disease, arteriosclerotic heart disease, hypertension, type I diabetes mellitus, panic attacks, general anxiety disorder, fibromyalgia, and nontoxic multinodular goiter. Per patient, her various medical conditions were managed by their respective healthcare specialists. Treatment included the regular intake of various medications, including antianxiety drugs.

Otologic Evaluation

Gabbys initial visit with UHealth included an otologic assessment with a neurotologist within the Department of Otolaryngology; findings were unremarkable. To assess for underlying pathologies within the auditory system, Gabby was accommodated for a same-day comprehensive audiologic assessment. Otoscopic inspection revealed clear ear canals and intact tympanic membranes bilaterally. Audiometric testing demonstrated a bilateral high-frequency hearing loss with excellent word recognition scores (see Fig. 1 ). Tympanometric results indicated normal ear canal volume, static compliance, and middle ear pressure. Acoustic reflex thresholds (ARTs) were present ipsilaterally 1,000 to 2,000 Hz, while contralateral responses were present 500 to 2,000 Hz and absent at 4,000 Hz bilaterally. The patient did not report discomfort to presented ART test stimulus. Distortion product otoacoustic emissions (DPOAEs) were assessed from 750 to 9,000 Hz bilaterally. ART and DPOAE results were essentially consistent with audiometric thresholds bilaterally; absent low-frequency DPOAEs were observed in the right ear (750–900 Hz) and were considered to be a subclinical finding given normal audiometric thresholds, but abnormal outer hair cell function could not be ruled out.

Figure 1.

Comprehensive audiometric results for Gabby A speech recognition threshold (SRT) was obtained at 15 dB HL for both the left and right ears. The adult spondee word list (Auditec of St. Louis) was utilized to obtain SRTs. Word recognition scores (WRS) were 100% for each ear. Testing was conducted using a recorded version of the Northwestern University Auditory Test No. 6 (NU-6) ordered by difficulty word list and presented at 55 dB HL monaurally.

Neurotology Recommendations

Based on audiometric and otologic assessment findings, the neurotologist referred Gabby to the UHealth Tinnitus and Sound Sensitivities Clinic for further education, evaluation, and treatment. Additionally, a referral was made for vestibular rehabilitation therapy (VRT) for the management of suspected benign paroxysmal positional vertigo.

Tinnitus Education

Gabby enrolled in a group tinnitus education session with the Tinnitus Clinic. Upon scheduling an appointment for this session, Gabby enabled her UHealth MyChart patient portal account, which allowed her to sign into her virtual appointments, review test findings, and communicate with her providers. Subjective tinnitus questionnaires, including the Tinnitus Reaction Questionnaire (TRQ), Tinnitus Functional Index (TFI), and Hospital Anxiety and Depression Scale (HADS), in addition to a brief intake questionnaire, were delivered electronically to the patient via her online MyChart account 1 week prior to the scheduled telehealth visit. ^{12 13 14} It should be noted that Gabby did not complete the questionnaires as requested.

Gabby participated in a group tinnitus education session which was offered virtually via the Zoom platform. A PowerPoint presentation was utilized as a visual aid during this appointment. Gabby and the other patients in attendance were counseled on information and strategies pertaining to the demystification of tinnitus as recommended by the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) and other tinnitus education-based resources. ^{15 16} Information presented included general anatomy and physiology of the auditory pathways, current theories on the pathophysiology of tinnitus, interpretation of an audiogram, and realistic expectations for tinnitus management. Common tinnitus coping techniques were reviewed, including the use of sound enrichment to reduce tinnitus awareness, the practice of changing negative thoughts and emotions pertaining to the tinnitus, and application of therapeutic exercises and devices that could aid in tinnitus management. ¹⁷ The collaborative approach of interdisciplinary care in cases where concomitant healthcare conditions or personal habits could be contributing to tinnitus awareness and disturbance was discussed.

During the session, Gabby and the other attendees were invited to participate in voluntary interactive activities. These activities included asking questions or sharing personal experiences with the audiologist and/or other patients in attendance, engaging in polling questions, and participating in a provider-lead guided breathing exercise. Gabby was an active and engaged participant throughout the educational session, sharing both personal experiences with her tinnitus and useful coping tools she was already utilizing (i.e., audiobooks).

Immediately following the visit, all attendees were provided with an electronic tinnitus education packet and follow-up questionnaire via their MyChart portal. The education packet included contact information for interdisciplinary care in the area, sleep hygiene advice, an informational brochure titled What You Should Know About Tinnitus by the American Tinnitus Association, and tinnitus management tip sheets. ¹⁸ The electronic follow-up questionnaire was issued to aid in identifying a patient-specific tinnitus management plan.

Individual Consultation

Gabby was seen again later the same day for a telehealth hearing aid consultation at her request. As individual patient needs are not addressed in the group education session, an extensive case history was taken, and specific patient-centered tinnitus management recommendations were provided during this one-on-one telehealth appointment.

Natural circadian light cycle and melatonin rhythms can be disrupted by the presence of blue light emitted from electronic devices; therefore, Gabby was strongly recommended to refrain from using her television as a sleep aid. ¹⁹ She was encouraged to replace television use with a sleep aid discussed in the education session, such as a sound pillow or tabletop white noise machine. Due to the presence of ongoing stressors, Gabby was recommended to continue utilizing stress management techniques, including guided breathing. A mental health consultation was encouraged in addition to speaking with her employer for support with conflict resolution. Based on patient's symptoms, lifestyle, listening needs, and patient motivation, bilateral combination units (hearing aids with a tinnitus sound generator) were ordered for the patient. Gabby was also recommended to undergo a psychoacoustic tinnitus evaluation to quantify her perception of tinnitus, assess for the presence of decreased sound tolerance or hyperacusis, aid in counseling and recommendations, and to be utilized as baseline data for comparison purposes during tinnitus treatment. ^{20 21}

Tinnitus Evaluation

Gabby was seen 7 weeks later for an in-person appointment, at which time she reported she was consistently employing various tinnitus coping techniques she learned through the tinnitus education session, such as environmental sound enrichment to reduce the contrast between her tinnitus and a quiet room. A psychoacoustic tinnitus evaluation was performed at this visit, results of which may be viewed in Table 1 .

Table 1. Tinnitus Evaluation Results.

Ear	Pitch match	Loudness match	MML	RI (4,000 Hz NBN at 50 dB HL bilaterally, 1-min presentation)	LDL (500, 1,000, 2,000, and 4,000 Hz)
Left	4,000 Hz, pure tone	38 dB HL	4 dB SL	No change	71–90 dB HL bilaterally

Abbreviations: HL, hearing level; LDL, loudness discomfort level; MML, Minimum Masking Level; NBN, Narrow Band Noise; RI, Residual Inhibition.

Overall results demonstrated that Gabbys perception of her tinnitus coincided with the frequency range of hearing loss demonstrated on her audiogram. Her tinnitus was readily masked with low levels of acoustic stimuli supporting the recommendation of combination devices. Phonophobia to loud sounds and decreased sound tolerance were suspected based on recorded loudness discomfort levels (LDLs) and patient's apprehension to increased stimulus growth despite actual physical discomfort. Hyperacusis, quantified by LDLs of 70 dB HL (hearing level) or less, was ruled out. ²²

Device Fitting

Immediately following the tinnitus evaluation, Gabby was fit with ReSound Quattro 561-DWC combination units bilaterally. Gabby was counseled that with regular use of these devices, it was anticipated that her sound tolerance levels could improve, and tinnitus disturbance levels could decrease over time. ²³ Devices were programmed with two settings: (1) amplification only and (2) amplification with tinnitus sound generator. She was extensively counseled on manipulation of device programs and associated volume controls of both the amplification and tinnitus sound generator features. On-ear verification was conducted using the Audioscan Verifit-I system to verify device programming. Additionally, the verification of the tinnitus sound generator output at patient's identified level of mixing point was performed to serve as a comparison point for monitoring purposes. ²⁴ It was anticipated that as the patient's perception of tinnitus decreases, the mixing point would also decrease. ²⁵ Given decreased LDLs, gain was set to 80% of recommended level, which patient reported was comfortable.

Three weeks later, the patient was again seen in office to exchange her Quattro devices for a set of ReSound ONE 561-DRWC combination units, which had become available to her shortly after her initial device fitting. Gabby also was enrolled in the ReSound Live Assist program, to allow for virtual consultations and real-time remote programming adjustments by an audiologist via the provider's hearing aid programming software and Gabbys linked smartphone application. ^{26 27} Virtual remote appointments were offered for future appointments as needed.

Audiology Follow-up Appointment

Two weeks later, the patient was seen in office for a follow-up appointment. Since her last visit, Gabby had begun VRT to manage her dizziness. Hearing aid gain was increased to 100% given the patient's increased comfort level with devices; the patient reported she was satisfied with this adjustment in gain. She indicated she was starting to notice improvements in tinnitus awareness and disturbance levels while wearing her devices.

Three months later, Gabby completed a telehealth follow-up appointment via ReSound Live Assist. At the time of the visit, the patient indicated that she was doing well with her combination units, though she continued to experience fluctuations in her tinnitus secondary to stress and was most bothered when experiencing these “spikes.” She was encouraged to discuss cognitive behavioral therapy, which effectively reduces anxiety in tinnitus patients, with her managing mental health provider. ²⁸ At the conclusion of the visit, Gabby expressed that she was “so grateful” for the option of telehealth tinnitus services, as she most likely would have postponed her tinnitus care until post-pandemic had the virtual group education sessions not been available following her UHealth neurotology consultation. She stated that she attributed the improvements in both her tinnitus and mental state to the information provided at the education sessions, and she voiced appreciation for the option of a hybrid healthcare approach.

Discussion

A disruption of healthcare services has been experienced by practitioners and patients around the globe during the ongoing pandemic. Healthcare facilities faced closures and reduced services, and patients' safety concerns reduced their willingness to seek necessary care and management of both acute and chronic conditions. ²⁹ Providers had to reimagine their service delivery models to ensure patient safety and continuity of care during these unprecedented times.

The application of a hybrid delivery model incorporating both telehealth and in-person services facilitated the continued care of Gabby By providing tinnitus educational counseling remotely and ahead of diagnostic services, Gabby was provided with information which allowed her to start coping with her tinnitus immediately and understand what she could expect from tinnitus management services to inform her decision to receive in-person care. Moreover, the availability of telehealth allowed the provider to remotely triage the patient's needs for specific in-person services, such as diagnostic testing and device fitting.

The COVID-19 pandemic has heightened stress and anxiety for many. ¹ As stress can cause an increase in tinnitus intensity and disturbance, it is critical that during this time, tinnitus patients continue to have access to tinnitus care and education. ³⁰ Telehealth has proven to be a successful delivery model with which to provide tinnitus management services. ^{31 32 33} In cases where in-person services, such as audiological assessment or device fitting, are necessary, a hybrid approach may be utilized to limit both the patient and the provider's exposure and promote social distancing by performing only necessary tasks in person and reserving lengthy counseling to a virtual visit.

Barriers to telehealth include lack of reimbursement, professional licensing limitations, patient acceptance rate, and patient access to technology. When incorporating telehealth into delivery of clinical services, challenges specific to the clinic and the population being served should be identified and addressed to improve the telehealth experience for the patient and provider. Support staff, if available, can assist patients with registration for virtual services. Providers should understand their HIPAA-compliant telehealth software and how to connect with their patient virtually. Additionally, patients should have access to resources with instructions on how to connect to their appointments.

Conclusion

Telehealth services are currently utilized in the management of tinnitus patients to promote social distancing and increase access to healthcare. Although the ongoing pandemic may be the first time many providers used virtual healthcare services, telehealth has likely earned itself a lasting place in the audiologist's toolkit when providing services to patients with tinnitus.