1. Introduction
1.1 Brief Overview
Tinnitus is the term used to describe the feeling of hearing sounds in the head or ears without the existence of an external cause. About 3% of adults find tinnitus unpleasant and disturbing, and it affects 12–30% of the population (Zenner et al. 2017). Tailored strategies that take into account both psychological and auditory factors are necessary for effective management. A 31-year-old veterinary nurse with severe tinnitus, severe mental distress, and reluctance to wear hearing aids is the subject of this case study, which looks at evidence-based treatments. This case study initially focused on the proper management of a patient with tinnitus, following the information gathered from a scenario-based clinical history and utilising the Tinnitus Functional Index (TFI). The study's main purpose is to explore the case history and key index findings and provide a comprehensive management plan covering two potential options with supporting evidence and outlining how to facilitate patient choice.
1.2 Case Brief
The chosen case scenario reflects a 31-year-old male veterinary nurse who had been experiencing progressive hearing problems for a few years, probably brought on by exposure to noise at work, such as handling animals or equipment, came in for an examination. The tinnitus grew louder over time, and he avoided social events because of it, and he claims that this has caused him to have strained relationships with his coworkers.
2. History Taking and Questionnaire Results
2.1 Detailed History
Clinical History
In the clinical context, exploring the comprehensive history associated with tinnitus symptoms, it can be reported that most of the critical symptoms include critical hearing loss, vertigo, and hyperacusis, which addresses the increased sensitivity to sound and long-term dizziness. As per the opinion of Fuller et al. (2020) and Lewis et al. (2020) from the perspectives of clinicians, at a basic level, medical inquiry includes gathering the patient's opinion concerning sleep disturbances, difficulties faced in concentrating on anything, as well as emotional distress. Moreover, gathered data by the clinician as the case history of the patients includes their facing limitations to take active participants in a variety of occupational as well as social activities. As per the opinion of Hofmann et al. (2012) in case of Tinnitus, patients suffer from a hearing high-pitched sound issue. This problem is more acute in peaceful surroundings, such as the evenings or nights, and he is unable to concentrate at work, which affects his mood and mental health. His tinnitus causes him anxiety and depression.
Associated Symptoms
This section reflects the symptoms faced by the patient and the way it hampers the patient's daily life and activities. Case history reveals He doesn't have any pressure or fullness in his ears. No dizziness or trouble balancing, no discharge or pain in the ears. He has not experienced any pain or discomfort from sounds or suffered from any sensitivity to them. His tinnitus gets worse when he is under stress. Additionally, he can avoid noticing it if he is preoccupied with his work. He had no prior history of neurological disorders, head injuries, jaw issues, or ear infections. He doesn't use any medications that could cause tinnitus. He hasn't been around loud noises lately, and he doesn't wear earplugs when he's around noise. He enjoys taking walks and listening to music in his spare time. He lives alone. For his tinnitus, he has never before seen a specialist.
2.2 TFI Results Analysis
In the chosen case scenario, to address the severity of Tinnitus, a widely used “Tinnitus functional index questionnaire” has been used. The questionnaire and the gathered responses have been presented in the appendix section. When it comes to presenting the result obtained from the conducted test, following is the evident -
Subscale Scores (Out of 100):
Intrusive (70), Sense of Control (63), Emotional (67), Cognitive (57), Sleep (57), Quality of Life (50), relaxation (47), auditory (23)
Overall TFI Score:
54 (big problem with the grading system)
Key Concern:
It was extremely stressful to be unable to manage his tinnitus, weary by psychological overwork, and fearful of his professional failure.
Explanation
The result obtained from “Tinnitus functional index questionnaire” reflects high impacts of tinnitus on the chosen patient’s life. With an average TFI score of 54, indicating a "big problem," the individual in question is experiencing significant distress and limited function. This score suggests that tinnitus is more than just a background noise; it is a chronic problem that affects many facets of his well-being. Analysing these scores is going to offer more minute and insightful data concerning the impacts of tinnitus and severity to enhance facing difficulties. As per the opinion of Landry et al. (2020) and McCormack et al. (2016) the Tinnitus Functional Index (TFI) is a survey that people complete themselves that doctors can use to determine the severity of a person's tinnitus and how it affects their everyday functioning. In the score achieved, it has come into an observation that “Intrusive” subscale reflects a 70 score which denotes bothersome as well as persistent nature of the chosen health issues. It disrupts the daily activities of the patient by minimising their ability to pay long-term attention. Moreover, the "Sense of Control" a subscale score of 63 indicates a strong struggle to regulate and cope with the symptoms of tinnitus, which contributes to feelings of powerlessness and frustration. As stated within the "Key Concern" section, the patient's distress is mostly due to a lack of control. On the other hand, the emotions subscale presented in the chosen questionnaire reflects the way the emotional state of the patient is disrupted by facing issues like Tinnitus. The questionnaire assesses how tinnitus affects hearing, sleep, and emotions, among other factors. The higher one's score on the TFI, the greater the severity and impact of their tinnitus. The psychological effect of tinnitus is highlighted by the "Emotional" subscale score of 67, which shows intense discomfort, anxiety, and terror. 57 on the "Cognitive" and "Sleep" subscales indicate that tinnitus impairs with concentration, clear thinking, and restful sleep. These impairments in cognition and sleep may worsen the patient's emotional distress and hinder their ability to function effectively.
However, it can be reported that the patient is severely suffered from Tinnitus which adversely impacts emotional cognition of individual and psychological thinking that directs their behavioural approaches.
3. Possible Management Plans
3.1 Management Option 1: Tinnitus Retraining Therapy (TRT)
Moderate to severe tinnitus can be treated with "tinnitus retraining therapy (TRT)." It teaches people to ignore the noise in their ears by combining sound therapy with psychotherapy. Maladaptive cognitive-emotional reactions are suggested by high TFI scores in the areas of intrusiveness (70), emotion (67), and sense of control (63). As per the opinion of Cima et al. (2012) the consultation involved retraining and teaching on the neurophysiological concept of tinnitus. Patients received an introduction to sound therapy and instructions for wearing and monitoring their wearable sound generators. The gadgets were to be worn during all waking hours. If this is not possible, clinicians will try for at least 8 hours, which can be divided into small blocks of time. The sound enrichment intensity was set to the "mixing point," resulting in partial suppression of the tinnitus sound. Participants received a 30-minute follow-up session over the phone using the same concepts. There is limited evidence supporting the tinnitus reconditioning therapy strategy, with most published data based on retrospective and uncontrolled studies. Gathered data information as evident reflects that the 220-person study is one of the largest ever undertaken on real-world patients following tinnitus therapy using a medical device. According to a retrospective examination of real-world patients, 91.5% achieved clinically significant reductions in tinnitus following 1 to 2 weeks of treatment with Lenire (medrxiv.org, 2024). 78.0% experienced a clinically significant reduction in tinnitus following 6-weeks of therapy with Lenire. These favourable results and high levels of patient satisfaction in the real-world patients setting are congruent with clinical trial findings and provide new hope to the chronically neglected tinnitus patient group. In this manner, it has remained justified for the case scenario as one of the recommended management options.
3.2 Management Option 2: Cognitive Behavioural Therapy (CBT)
Tinnitus is frequently treated with “cognitive behavioural therapy (CBT)”, a set of psychological therapies based on cognitive as well as behavioural traditions of psychology, and is commonly used to treat persons suffering from this ailment. A talking therapy called “cognitive behavioural therapy (CBT)” seeks to change the patient's psychological and/or behavioural reactions to their tinnitus problems. The given scorecard of “Tinnitus functional index questionnaire” in the chosen clinical context, concerning substantial emotional distress, where the emotional subscale scored 67, the cognitive interference subscale score reflects 57, along with facing difficulty with sleep, which is evident as a score of 57, Tinnitus can be effectively managed by Cognitive behavioural Therapy (CBT). As per the opinion of Marks et al. (2023) the fundamental of “Cognitive Behavioural Therapy (CBT)” is highly focused on identifying and working on negative behavioural patterns and thought practices of individuals. Beck (1970) and Ellis (1962) proposed that maladaptive cognitions can perpetuate emotional suffering and behavioral issues. Beck's approach identifies maladaptive cognitions as general assumptions or schemas about the world, self, and future that lead to automatic thoughts in specific situations. The basic paradigm suggests that treatment efforts for changing maladaptive cognitions result in reduced emotional distress and problematic behaviors. CBT for tinnitus may benefit those with depression, however, the data is limited and the quality of the studies is questioned. Individuals with co-occurring depression should seek depression-specific treatment alongside tinnitus-specific CBT (Hoare et al. 2015; McKenna et al. 2014). There is insufficient evidence to support cognitive behavioral therapy (CBT) for tinnitus if the primary goal is to enhance anxiety, quality of life, or change negative tinnitus interpretations. This review suggests that cognitive behavioral therapy (CBT) can effectively reduce the impact of tinnitus on quality of life, with minimal adverse effects (though further research is recommended). These findings support two clinical guidelines that promote cognitive behavioral therapy (CBT) for people with chronic tinnitus. Based on this range of available data information, this particular management solution is considered more impactful to minimise the health problem of the chosen patient case.
4. Patient-centred Decision Making
4.1 Helping Patient Choose
In the time of providing required help to the concerned patient, it can be reported that, following the above-presented management option, significant strategy-based action can be taken. Some of those are as follows-
- It is important to consult with those with tinnitus and their family/caregivers about their experience, effect, and concerns.
- It can be beneficial to develop a management strategy based on the individual's needs and preferences. The plan should contain information on tinnitus and an opportunity to discuss various therapy options (Jun et al. 2013; Handscomb et al. 2020).
- It is critical to go over with the individual the outcomes of any recent evaluations and their implications for the management plan.
- It is considered also beneficial for the patient in terms of sharing the management plan with relevant health, education, and social care experts after obtaining approval from the individual or their parent/carer.
- It is also critical to plan a follow-up session to evaluate the patient's condition and to deal with any issues or queries.
5. Conclusion
As a result, it is possible to conclude that cognitive behavioral therapy can be used to cure tinnitus. It has little effect in improving the acoustic features of tinnitus, but it does improve the reaction to tinnitus. Thus, CBT is an effective treatment choice for tinnitus. Tinnitus is a feeling of sound or commotion in the absence of actual acoustic stimulus. Although a solution for tinnitus is still elusive, many management measures have been discovered to assist alleviate the symptom's severity. Tinnitus Retraining Therapy (TRT) emerged in response to the release of a neurophysiological representation of tinnitus.
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Reference List
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