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Tinnitus Patient Management. Robert W. Sweetow, Ph.D. University of California San Francisco, California. Some questions you need to consider. How much time does it take? Is this worth my time? How much will it cost me? (time, money, emotions) How do I get reimbursed? My very first case.

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Tinnitus patient management l.jpg
Tinnitus Patient Management

Robert W. Sweetow, Ph.D.

University of California

San Francisco, California


Some questions you need to consider l.jpg
Some questions you need to consider

  • How much time does it take?

  • Is this worth my time?

  • How much will it cost me? (time, money, emotions)

  • How do I get reimbursed?

  • My very first case


Possible mechanisms l.jpg
Possible Mechanisms

  • Abnormal rhythm or rate of spontaneous 8th nerve discharges

  • Increased spontaneous activity in dorsal cochlear nucleus resulting from reduced peripheral input

  • Unlike spontaneous activity, these neural discharges may become phasic and correlated


Proposed mechanisms l.jpg
Proposed Mechanisms

  • Imbalance of afferent and efferent:

    • Deficient afferent neurotransmitter glutamate at the cochlear-8th nerve synapse

    • “disinhibition” from neurotransmitters such as gamma aminobutyric acid (GABA)

  • Toxicity or imbalance of other of neurotransmitters

  • Ion channel regulation for excitability of neurons

  • Calcium induced changes in intra or extracellular processes (noise)

  • Vitamin B , zinc deficiencies?


Proposed mechanisms5 l.jpg

Correlated activity across nerves by phase locking - ephaptic transmission

Extralemniscal neurons, particularly in dorsal cochlear nucleus and AII area, receiving input from somasthetic system

over-representation of edge-frequencies (neural plasticity)

Increased activity in one hemisphere (right OR left, but not both, as occurs during sound stimulation)

Enhanced perception hypothesis

Sensory remodeling in the central auditory system

Association with fear and threat (limbic system)

Proposed mechanisms


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Tinnitus and Hearing Loss ephaptic transmission


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Correlation between tinnitus severity and auditory threshold ephaptic transmission

Tsai, Cheung, and Sweetow, 2007


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Tsai, Cheung, and Sweetow, 2007


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  • Subjective tinnitus idiopathic sensory neural central

  • Objective tinnitus vascular muscular


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Some outer and middle ear pathologies associated with tinnitus

cholesteotoma mastoiditis

otosclerosis otitis media

impacted cerumen allergies

palatal myoclonus head/ear trauma

patulous eustachian tube

glomus jugulare tumor

abnormal middle ear resonance


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Some inner ear tinnituspathologies associated with tinnitus

acoustic trauma presbycusis

noise exposure meniere’s disease

labyrinthitis acoustic neuroma

head/ear trauma ototoxicity

meningitis perilymph fistula

autoimmune inner ear disease

vestibular schwannoma

sudden hearing loss


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Some central auditory nervous system pathologies associated with tinnitus

  • vascular

  • dementia

  • cardiovascular disease/hypertension

  • blood disease /anemia

  • multiple sclerosis


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Other factors associated with tinnituswith tinnitus

  • temporomandibular disorders

  • cervical misalignment

  • menses/menopause

  • renal disease / Alport’s / kidney transplants

  • lyme disease

  • zinc deficiency

  • poor circulation

  • Hypothyroid/ hyperthyroid disorders


Results summary l.jpg
Results Summary with tinnitus

  • Tinnitus Percept Laterality is captured by Model 2 ( maximum difference for two consecutive frequencies) for 63% cases.

  • Tinnitus Percept Severity is uncorrelated to absolute or relative hearing loss.

Tsai, Cheung, and Sweetow, 2007


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Tsai, Cheung, and Sweetow, 2007


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Mechanisms & Etiologies completely percept laterality

  • Para-auditory structures (Tyler,1993)

    • Body continually produces noise that can be transmitted to the base of the skull.

    • Usually these noises are inaudible but the patient becomes aware of these noises for a variety of reasons

  • Vascular neoplasms, arteriovenous malformations, venous hum, TMJ syndrome, and muscle contraction tinnitus.


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Para-auditory generation completely percept laterality

  • Vascular neoplasms

    • Cochlea detects blood flow

    • Potentially serious prognosis--symptom of vascular disease

    • Management--generally surgical


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Para-auditory generation completely percept laterality

  • Arteriovenous malformations

    • Developmental abnormalities--microscopic channels may canalize rapidly and result in rapid enlargement with increasing tinnitus

    • Often characterized by pulsatile tinnitus and may include distortion of the face or neck and discoloration of the skin.

    • Pulsatile rate increases with increased heart rate


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Para-auditory Generation completely percept laterality

  • Venous hum

    • Low pitched hum arising from the neck of many children and some adults, particularly young women.

    • Has been attributed to the transverse process of the second cervical vertebra impinging on the jugular vein.

    • Turning head away from involved side decreases it


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Para-auditory generation completely percept laterality

  • Venous Hum

    • Benign Intracranial Hypertension

      • Obesity

      • Menstrual irregularities

      • Hypothyroidism

      • Hyperthyroidism

      • Anemia

      • Vitamin A or D Deficiency

      • Side Effect of Oral Contraceptives

      • Pregnancy and Postpartum


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Para-auditory Generation completely percept laterality

  • TMJ syndrome

    • The petro-tympanic fissure is traversed by the mandibular ligament (Pinto’s ligament), the chorda tympani, and the anterior tympanic artery...disruption of these structures with a change or misalignment of the jaw can cause tinnitus and other ear symptoms

    • Diagnosis

    • Management


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Para-auditory Generation completely percept laterality

  • Muscle contraction tinnitus

    • Synchronous contraction of many or most of the fibers of one or more middle ear or palatal muscles (palatal myoclonus), either voluntary or involuntary

    • Pulsatile (clicking) tinnitus that does not change with changes in heart rate during exercise

    • Management (botox injections)


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Diagnostic Issues in Tinnitus: completely percept lateralitya Neuro-otological Perspective

Robert Aaron Levine, MD


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Tinnitus - unilateral completely percept laterality

  • Coarse intermittent sounds coincident with jaw or head movements

    • Typical of a foreign body (i.e. cerumen, water or other liquids, or a hair resting against the tympanic membrane)

  • Fluttering


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Fluttering completely percept laterality

  • Stapedius muscle contractions

  • If associated with facial movements, then stapedial contractions are likely cause

  • Commonly seen after recovery from Bell’s palsy

  • When affected side of face contracts, ipsilateral stapedius muscle also contracts (synkinesis) due to aberrant facial nerve regeneration.


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Tinnitus - unilateral completely percept lateralityor non-lateralized

  • Pulsatile

  • Clicking

  • Autophony (echoing of the voice), or blowing tinnitus

  • Hallucinations (non-verbal, stereotyped repetitive)


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Pulsatile completely percept laterality

  • Determine whether it is related to cardiac cycle by comparing your silent count of patient’s cardiac pulse while patient is silently counting the pulsations of his/her tinnitus


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Pulsatile - history completely percept laterality

  • An association with headaches, blurring of vision, and menstrual irregularities in an obese woman is suspicious for benign intracranial hypertension.

  • Abrupt onset with unilateral neck or head pains suggests a carotid dissection.

  • Changes in tinnitus intensity with head turning suggests a venous source for the tinnitus – from a source ipsilateral to the direction that decreases the tinnitus

  • If the patient can obliterate the tinnitus with localized pressure in the periauricular region then an emissary vein is probably accounting for the tinnitus.

  • An associated fluctuating hearing loss raises the possibility of microvascular compression of the auditory nerve causing the pulsatile tinnitus.

    (Ohashi, Yasumura et al., 1992; Waldvogel, Mattle et al., 1998)


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Pulsatile completely percept laterality

  • MRI studies of patients with unilateral tinnitus can detect vascular compression of the auditory nerve on the asymptomatic side as frequently as on the symptomatic side

    (Makins, Nikolopoulos et al., 1998)


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Pulsatile – physical exam completely percept laterality

  • A crescent purple coloration to the tympanic membrane is diagnostic of a glomus jugulare tumor.

  • Otoscopic observation of a red mass behind the tympanic membrane is suggestive of an aberrant carotid artery, dehiscent jugular bulb, or vascular tumor.

  • A unilateral conductive hearing loss in association with ipsilateral pulsatile tinnitus and an otherwise normal exam may suggest otosclerosis, as does Schwartze’s sign (red hue behind the tympanic membrane on otoscopy).

  • Detection of a bruit ipsilateral to the pulsatile tinnitus suggests that the tinnitus is from the same source as the bruit. The source of the bruit then must be sought.


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Pulsatile – physical exam completely percept laterality

  • Obliteration or reduction in the intensity of the pulsatile tinnitus with ipsilateral jugular compression (light or moderate pressure below the angle of the jaw) implicates a venous source of the tinnitus; whereas a decrease in the tinnitus with ipsilateral carotid compression implicates an arterial source arising from the carotid system.


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Pulsatile - Diagnostic studies completely percept laterality

  • Because high cardiac output states such as anemia or hyperthyroidism can cause pulsatile tinnitus (usually bilateral), all patients should have a thyroid profile and a hematocrit.

  • If a carotid lesion is suspected then either a duplex ultrasound study of the carotid or MRA should be performed.

  • If a retrotympanic mass is suspected, then a high-resolution contrast-enhanced CT scan of the temporal bones should be obtained. Otherwise, a contrast-enhanced MRI scan of the temporal bone and cranium should be obtained.

  • If all non-invasive imaging studies have been unremarkable and raised intracranial pressure has been ruled out, then cerebral angiography should be considered, because a dural arteriovenous malformation can sometimes go undetected by another diagnostic study.

    • Because significant, but rare, morbidity can occur with angiography, careful deliberation must be given to the decision to proceed with angiography.


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Clicking completely percept laterality

  • Relatively rare

  • Appears to be due to contractions of tensor tympani or the nasopharyngeal muscles controlling the patency of the Eustachian tube

  • It can sometimes be bilateral, in which case, it is usually associated with palatal myoclonus.

  • Often the clicking can be heard by the examiner

  • Sometimes acoustic impedance measurements have abnormalities that correspond


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Autophony (echoing of the voice), or blowing tinnitus completely percept laterality

  • Patulous ipsilateral Eustachian tube

  • Confirmatory features include disappearance of their complaints when their head is in a dependent position and abnormally large changes in the tympanic membrane acoustic impedance with respirations.


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Musical hallucinations completely percept laterality

  • Occur in elderly patients (more commonly in women) with a longstanding progressive moderate to severe bilateral hearing loss.

  • The tunes can be vocal and/or instrumental.

  • While usually bilateral, can be unilateral even with a bilateral hearing loss.

  • Can be precipitated by new medication, and resolved when medication is stopped.


Auditory hallucinations l.jpg
Auditory hallucinations completely percept laterality

  • Differ from musical hallucinations in several respects

  • Usually abrupt in onset and associated with focal neurological findings due to a brainstem stroke or space occupying lesion

  • Brain imaging is required


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Tinnitus quality completely percept laterality

  • 85% of subjects reported having experienced another type of “normal” tinnitus; namely transient (typically less than a minute).

  • Transient tinnitus follows exposure to loud sound.

  • About 55% of population report such tinnitus lasting minutes to days.


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Always unilateral, completely percept lateralitymay be with vestibular symptoms

  • Meniere’s Syndrome

  • Perilymphatic fistula

  • Herpes Zoster Oticus (Ramsay-Hunt Syndrome)

  • Cerebellopontine angle tumors

  • Central nervous system – caudal to trapezoid body

  • Sudden idiopathic hearing loss


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Meniere’s Syndrome completely percept laterality

  • While the tinnitus is often described as roaring early in the illness, with more advanced stages of the syndrome, the tinnitus tends to become more variable in its description.


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Perilymphatic fistula completely percept laterality

  • Tends to be high frequency (hissing, crickets, etc.) with no recovery.

  • The defect can be caused by barotrauma, head trauma, valsalva, or erosion of the bony labyrinth due to an inflammatory or neoplastic process, or following middle ear surgery, such as stapedectomy.

  • Diagnosis can be suggested by the “fistula test” – the induction of nystagmus by positive or negative pressure applied to the external auditory canal.


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Herpes Zoster Oticus (Ramsay-Hunt Syndrome) completely percept laterality

  • Intense ear pain followed by ipsilateral tinnitus, hearing loss, vertigo and facial paralysis


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Sudden idiopathic hearing loss completely percept laterality

  • Always unilateral


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Always with hearing loss, completely percept lateralitymay be unilateral or non-lateralized

  • Acute acoustic trauma

  • Chronic progressive hearing loss (presbycusis, chronic acoustic trauma, hereditary hearing loss)

  • Autoimmune inner ear disease


May be no hearing loss may be unilateral or non lateralized l.jpg
May be no hearing loss, completely percept laterality may be unilateral, or non-lateralized

  • Somatic (head or upper cervical)

  • Trauma

  • Post-infectious

  • Medication-related (including withdrawal syndromes)


Somatic head or upper cervical l.jpg
Somatic (head or upper cervical) completely percept laterality

  • Higher incidence of tinnitus in normal hearing subjects with temporomandibular joint syndrome than in controls (Chole and Parker, 1992)

  • The same is true regarding whiplash (Tjell, Tenenbaum et al., 1999)

  • Tinnitus temporally associated with unilateral somatic disorders are localized to the ipsilateral ear (Levine, 1999a)

  • The physical examination should include:

    • Inspection of the teeth for evidence of bruxism, such as excessive wear of the bottom incisors

    • Palpation of the head and neck musculature for tender muscles under increased tension

    • Forceful systematic isometric concentration of muscle groups of the head and neck for their effects upon the patient’s tinnitus


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Properties suggesting somatic component completely percept laterality

  • Intermittency

  • Large fluctuations in loudness

  • Variability of location

  • Diurnal pattern

  • No hearing loss but head or neck trauma


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Somatic – Diurnal fluctuations completely percept laterality

  • Suggest somatic modulation is operative

  • Tinnitus louder upon awakening raises the possibility that somatic factors (such as bruxism) are active during sleep and are causing an increase in tinnitus loudness.

  • Tinnitus vanished by awakening and then returning a few hours into the day suggests that during the day they are re-activating their tinnitus through somatic mechanisms, such as the tonic muscle contractions required to support the head in an upright position or clenching related to the stress of daily activities.

  • Tinnitus that is louder after awakening from a nap in a chair may related to somatic factors such as stretching of the neck muscles when their head passively falls forward while dozing in a sitting position.


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Otoacoustic emissions completely percept laterality

  • While spontaneous emissions are common (75% of female and 45% of male normal or near normal ears), tinnitus due to spontaneous otoacoustic emissions is uncommon.

    • said to account for tinnitus of 1-2% of the patients of one British tinnitus clinic

  • The diagnosis is made by measuring an emission and showing that its suppression abolishes the tinnitus.

  • The emission can be suppressed in either of two ways:

    • Presentation of a low-level tone near the emission frequency

    • The use of aspirin (Penner and Coles, 1992)


Soae associated tinnitus l.jpg
SOAE-Associated Tinnitus completely percept laterality

  • Accounts for 1-9 % of cases

  • May be hum or tonal

  • Generally in younger patients and localized in better ear

  • Responds to drug induced suppression

  • Case


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Sensorineural Generation completely percept laterality

  • Auditory deprivation and conductive hearing loss

  • SOAE-associated tinnitus

  • Cochlear disorders (SNHL)

  • Central processing effects


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Sensorineural Hearing Loss completely percept laterality

  • 70-90% of tinnitus sufferers have hearing loss

  • NIHL is a major factor in approximately 38% of all tinnitus patients

  • Meniere’s is the next most prevalent etiology at 12%

  • The prevalence (not loudness) of the tinnitus is related to the severity of the hearing loss but it accompanies SNHL more frequently when the onset of the hearing loss is sudden


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Central Processing Effects completely percept laterality

  • The organization of the auditory system is dynamic--events causes changes within the system

    • Injury

    • Overstimulation

  • Moller (1995) and Cacace et al. (1995): Severe tinnitus & hyperacusis is caused by hyperactivity of the nuclei in the ascending auditory pathway, particularly within the inferior colliculus


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Auditory Deprivation completely percept laterality

Coles (1995) suggests that the central nervous system reacts to the lack of neural stimulation from the ear (phantom signal) by increasing its “attentiveness” to the auditory signals that do reach it, with consequent awareness of sounds arising from previously subliminal abnormal neural activity in the system.


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Tinnitus triggers completely percept laterality

  • Physical (viral, medication, hearing loss (imbalance between excitatory and inhibitory neurons), neurotoxicity from noise, somatic influences)

  • psychological

  • retirement syndrome

  • stress related


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Tinnitus exacerbating factors completely percept laterality

  • caffeine

  • alcohol

  • nicotine

  • sodium

  • stress

  • noise exposure

  • high cholesterol, hyperlipidemia, hyper and hypothryroidism


Some drugs reported to be associated with tinnitus l.jpg

salicylates completely percept laterality

non-narcotic analgesics

ototoxic diuretics

ototoxic antibiotics

ototoxic cisplatin

caffeine

alcohol

cocaine

marijuana

oral contraceptives

Some drugs reported to be associated with tinnitus


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Essential attributes for inducing tinnitus sensitization (opposite of habituation)

  • Tinnitus is considered noxious

  • Tinnitus may induce fear

  • Tinnitus progression is unpredictable

  • Patient is helpless (loss of control) and can’t cope

  • Patient is anxious

  • If present, engagement; if not present, disengagement


Most common difficulties attributed to tinnitus l.jpg

Sleep (opposite of habituation)

Persistence

Speech understanding

Despair, frustration, depression

Annoyance, irritation, stress

Concentration, confusion

Drug dependence

Pain/headaches

Most common difficulties attributed to tinnitus

Tyler and Baker, 1983


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Tinnitus Management Team (opposite of habituation)

  • Audiologist

  • Psychologist

  • Psychiatrist

  • Otolaryngologist

  • Neurologist

  • Pharmacologist

  • Nutritionist

  • TMJ Specialist

  • Physical Therapist

  • Biofeedback Specialist


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Tinnitus Questionnaire (opposite of habituation)

  • Otologic

  • Medical

  • Audiologic

  • Diet

  • Exercise

  • Emotional Pattern

  • Sleep

  • Previous Treatments


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Defining the tinnitus problem (opposite of habituation)

  • time

  • behaviors affected

  • attitudes and thoughts

  • what affects the tinnitus?

  • how would your life be affected if you didn’t have tinnitus?


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Give the patient a chance to vent (opposite of habituation)

But only for a while!!!!!!!

….And less time each visit


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Assessment inventories and audiological diagnostic tests (opposite of habituation)

  • All testing is done for both diagnostic and therapeutic purposes


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Potentially useful diagnostic procedures (opposite of habituation)

  • audiogram

  • assessment (severity) scales

  • psychological profiles

  • tinnitus matching (do loudness match first)

  • loudness discomfort levels

  • minimum masking levels

  • OAEs

  • ultra high frequency testing

  • immittance/reflexes/decay


Tinnitus matching l.jpg

usually less than 6 dB SL (opposite of habituation)

may be more appropriate to convert to sones

82% match above 3KHz

14% match above 9KHz

Tinnitus matching

Loudness

Pitch

Maskability (MML)

  • 0-3 dB = easy to mask

  • 4-10 dB = masking may be intrusive

  • > 10 dB = difficult to mask


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Assessment Inventories (opposite of habituation)

  • Tinnitus Severity Scale - Sweetow and Levy

  • Tinnitus Handicap Inventory - Newman et al

  • Tinnitus Handicap Questionnaire - Kuk, et al

  • Tinnitus Effects Questionnaire - Hallam, et al

  • Tinnitus Reaction Questionnaire - Wilson, et al

  • Tinnitus Cognitive Questionnaire (TCQ) - Wilson and Henry


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Tinnitus Handicap Inventory (THI) - (opposite of habituation)Newman, et al, 1998

  • 25 items (yes - 4; sometimes - 2; no - 0)

    • functional

    • emotional

    • catastrophic

  • THI = 0-16; No handicap

  • THI = 18-36; Mild handicap

  • THI = 38-56; Moderate handicap

  • THI = 58-100; Severe handicap

  • 20 point difference = significant change


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Minimally screen for (opposite of habituation)depression and anxiety

  • Used for referral purposes

  • High scores do not determine that patient has a depressive or anxiety disorder


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Red Flags for Behavioral Health (opposite of habituation)Co-Treatment

  • High level of anxiety or depression

  • Obsessional focus on tinnitus

  • Significant work impairment

  • Marginal coping & lack of adequate support system

  • Refuses tinnitus tools but requests excessive or inappropriate treatment


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Tinnitus patient management procedures we won’t discuss (opposite of habituation)

  • Medication

  • Perfusions

  • Surgery

  • Stress Management

  • Biofeedback

  • Nutritional Counseling


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Medications (opposite of habituation)

  • xanax, prozac, neurontin, lexepro

  • muscle relaxants

  • if clinically significant anxiety or panic, med eval for SSRI or appropriate meds

  • if on SSRI, may need to increase dosage

  • can blunt perception of obnoxious physical symptoms & bolster coping skills


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Effects of neurotransmitters (opposite of habituation)

  • Acetylcholine - voluntary movement of the muscles

  • Norepinephrine - wakefulness or arousal

  • Dopamine - voluntary movement and motivation, "wanting", pleasure, associated with addiction and love

  • Serotonin - memory, emotions, wakefulness, sleep and temperature regulation

  • GABA - inhibition of motor neurons

  • Glycine - spinal reflexes and motor behaviour

  • Neuromodulators - sensory transmission - especially pain


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  • Neurons expressing certain types of neurotransmitters sometimes form distinct systems, where activation of the system causes effects in large volumes of the brain, called volume transmission.

  • The major neurotransmitter systems are the noradrenaline (norepinephrine) system, the dopamine system, the serotonin system and the cholinergic system.

  • Drugs targeting the neurotransmitter of such systems affects the whole system, and explains the mode of action of many drugs;

    • Cocaine, for example, blocks the reuptake of dopamine, leaving these neurotransmitters in the synaptic gap longer.

    • Prozac is a selective serotonin reuptake inhibitor (SSRI), hence potentiating the effect of naturally released serotonin.

    • AMPT prevents the conversion of tyrosine to L-DOPA, the precursor to dopamine;

    • reserpine prevents dopamine storage within vesicles;

    • deprenyl inhibits monoamine oxidase (MAO)-B and thus increases dopamine levels.


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Salicylates sometimes form distinct systems, where activation of the system causes effects in large volumes of the brain, called

  • Aspirin, ibuprofen, advil NSAIDs, naproxen, motrin

  • Dristan, anacin, excedrin, bufferin

  • Alka seltzer, pepto bisomol, pamprin, certain breath savers, lozenges, wintergreen


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Alternative Approaches sometimes form distinct systems, where activation of the system causes effects in large volumes of the brain, called

  • ginkgo biloba

  • fish oil omega fatty acids

  • acupuncture

  • hyperbaric treatment

  • magnetotherapy

  • lasertherapy

  • homeopathy

  • naturopathy (like cures like)

  • osteopathy

  • DMSO

  • anticholinergic drugs (glutamic acid)

  • vaso-active drugs and carbogen inhalation

  • baclofen injections

  • electrostimulation


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Newer, unproven approaches sometimes form distinct systems, where activation of the system causes effects in large volumes of the brain, called

  • Tinnimed Laser (20 minutes daily for 10 weeks) designed to “alter cell metabolism”

  • Phase shift tinnitus reduction for mono-frequency tinnitus

  • Melmedtronics ultrasonic “The Inhibitor” (www.tinnitustreatment.com) “hand-held device that emits a 60 econd ultrasonic signal providing temporary relief for 70-75% of patients….lasting from minutes to weeks!”

  • Sequential sound therapy (phase 1 - mask, phase 2 – interact, phase 3 noise < T)

  • Repetitive Trans-cranial Magnetic Stimulation (rTMS) [for unilateral, in opposite cortex]


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“Reasonable” tinnitus patient management procedures (in no special order)

  • Masking

  • Amplification

  • Reassurance (including placebo)

  • Education

  • Desensitization / Habituation (TRT)

  • Cognitive-Behavioral Therapy

  • Neuromonics acoustic desensitization protocol


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Tinnitus maskers no special order)

  • Used at lowest levels possible to mask tinnitus


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Tinnitus and hearing loss no special order)

  • Only 5% of the patients had normal hearing at all frequencies. Twenty-two percent were suitable as hearing aid candidates, but only half of these actually used them. Thus, the remaining 73% possessed a hearing loss, but this was too localized for the high frequencies for hearing aids to be beneficial.

    • (Davis, Wilde & Steed, 1999)


Slide80 l.jpg

kHz no special order)

dB HL

The mean hearing threshold levels of ninety consecutive patients in a university tinnitus clinic are displayed in Figure 1 (Davis, Wilde & Steed, 1999)


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Why hearing aids help tinnitus patients no special order)

  • Mask tinnitus

  • Reduce contrast

  • Alter production peripherally and/or centrally

  • Greater neural activity allows brain to correct for abnormal reduced inhibition

  • Structured pattern is created

  • Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight

  • Facilitate habituation


Why hearing aids might not help l.jpg
Why hearing aids might NOT help no special order)

  • Reactive tinnitus (fairly rare)

  • Increased distortion

  • Discomfort

  • Somatic awareness

  • Fear

  • Stigma

  • Cost / benefit ratio


Special considerations for fitting hearing aids l.jpg
Special considerations for fitting hearing aids no special order)

  • Expansion

  • Noise reduction

  • Open fit

  • Feedback

  • Multiple programs

  • Compression and maximum output

  • Trial period may not be adequate


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Use of tinnitus instruments no special order)as maskers

  • Combination hearing aid/masker

  • Improves audibility

  • Reduces contrast of tinnitus to silence


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Tinnitus Retraining Therapy no special order)

  • directive counseling

  • auditory (low level noise) therapy


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“TRT” Model ( no special order)Jastreboff. 1995)

Perception & Evaluation

Auditory and Other Cortical Centers

Detection

(Behavioral)

Emotional Associations

Limbic System

TRIGGER

(Cochlear)

Annoyance


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Research supporting central location no special order)

  • Heller and Bergman, 1951

  • Andersson, et al 1997; Baguley et al, 1992 (translabyrinthine surgery)…

  • Lockwood and Salvi, 1998; Burkard, 2001(PET)

  • Kaltenbach, 2000 (cochlear nucleus hyperactivity despite cochlear destruction)

  • Zacharek, 2002 (sustained DCN acitivity following noise damaged cochlear ablation)


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Objectives no special order)

  • initiate and facilitate tinnitus habituation

  • remove perception from patient’s consciousness


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Perception & evaluation no special order)

  • negative counseling enhances initial aversive association of the tinnitus with an emotional state

  • attitudes and behaviors are subject to modification

  • cortical associations can be altered


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Counseling no special order)

  • Educational

  • Guided

  • Directive


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Basic assumptions no special order)

  • The brain can sort out meaningful stimuli from those which are not

  • Attention is directed toward "salient" or information-bearing stimuli


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Summary - Why brain focuses on tinnitus no special order)

  • brain is “programmed” to respond to sound

  • tinnitus is not a sound

  • brain becomes confused

  • neural plasticity

  • lateral inhibition is diminished

  • Brain is “conditioned” to react


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Mock counseling session no special order)






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Factors influencing patient's ability to habituate no special order)

  • stress levels of patient

  • support system of patient

  • coping abilities of patient

  • patient's insight into disease/disorder

  • patient's educational level

  • interactions among above


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Definition of Cognitive-Behavior Therapy no special order)

The therapeutic effort to modify maladaptive thoughts and behaviors by applying systematic, measurable implementation of strategies designed to alter unproductive actions


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Similarities of tinnitus with pain no special order)

  • subjective

  • invisible

  • affected by extraneous events


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Process no special order)

  • changing the way one interprets thinks and feels

  • modifying one’s actions for a specific purpose

  • removing inappropriate beliefs, anxieties and fears

  • removing tinnitus’ status as an entity of its own

  • standard procedures; in-office and “homework”

  • severity scaling; inventories


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CBT gives patients hypotheses that can be self-tested no special order)Most effective when combined with attention control, imagery training and relaxation


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Learned process no special order)

  • Subject to behavioral and cognitive modifications


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Common cognitive distortions no special order)

  • All or nothing thinking = no shades of gray; my life used to be perfect, now it is horrible

  • Mental filter = one aspect of a complex situation is the focus of attention, while others are ignored; I was having a good time at the party, but my tinnitus ruined everything

  • Mind reading = assuming other’s thoughts without evidence, people think I’m dumb when I ask them to repeat

  • Jumping to conclusions = assuming negative expectations about future events as established facts I will have a lousy day when my tinnitus is the first thing I hear in the morning

  • Emotional reasoning = assuming emotional reactions reflect the true situation; my tinnitus makes me feel hopeless, there is no hope

  • Labeling = attaching a global label to oneself rather than to specific events or actions; having tinnitus makes me a disabled person

    (continued)


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Common cognitive distortions no special order)

  • Overgeneralization = an event is characteristic of life in general, as opposed to specific; because of my tinnitus I was awake sall night. Every night is the same.

  • Disqualifying the positive = positive experiences that would conflict with negative views are discounted; I did better today, but that was a fluke

  • Catastrophizing = negative events are treated as intolerable rather than in perspective; my tinnitus is louder, I must be going deaf

  • Should statements = using should and have to statements to provide motivation or control; I should never have listened to rock music

  • Personalization = assuming one is the cause of a particular event when in fact other factors are responsible; I ruined everyone’s evening because I was miserable


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Examples of Operational Statements no special order)

Inadequate ResponseAcceptable Response

Tinnitus keeps me awakeI fall asleep relatively easily but then I awaken twice each night and it takes about an hour to fall back asleep

Tinnitus drives me crazy I am finding it difficult to concentrate when I can't find any quiet time. This makes me angry and I'm losing my temper around my family.


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Situation no special order)

Cognitive Distortion

Rational Thought

I wake up and

hear my tinnitus,

so I know it’s

going to be a bad

day

What I do will

determine

how my day goes

Jumping to conclusions

All or nothing thinking

BehaviorCurrent StatusMod. Improvement Goal

falling asleep 2 hours

  • 60 minutes 30 minutes


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CBT no special order)

  • “what things do you like to do”

  • Give me some excuses for not doing them”

  • “what would your best friend say to you about these excuses?”


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Tyler, et al, 2004 no special order)


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Differences between CBT and TRT no special order)

  • Cog therapy is intensive, collaborative with 8-12 weekly sessions and testing of hypotheses;

  • TRT directive counseling is directive with 4-6 sessions over 18 months.

  • Tinnitus remains, but coping skills improve


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Contrasting anxiety from depression no special order)(Wilson, et al, 1998)

  • TRT assumes an anxiety focus

  • Cognitive therapy assumes a depressive focus


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3 levels of complexity no special order)

1. basic education and support2. small number of general counseling sessions3. extended therapy 2-3 months, with follow up as needed


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CBT / tinnitus books no special order)

  • “Mind Over Matter”; Greenberger and Padesky

  • “Feeling Good” David Burns (Signet)

  • “Tinnitus: A self management guide for the ringing in your ears” Jane Henry and Peter Wilson (Allyn and Bacon) *

  • “Tinnitus Rehabilitation by Retraining” Bernahard Kellerhals and Regula Zogg (Karger)

  • “Living with Tinnitus” Paul Davis (Health Books)


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Turf Wars no special order)

  • Psychologists say… TRT is nothing new

    • Jakes and Hallam basically described it years before it became popular

    • TRT suffers from lack of methodological confirmation (i.e. no treatment waiting control groups)

    • Does not consider depression and anxiety

    • As many as 40% of tinnitus patients may suffer from depression and anxiety

    • Consider interaction/collaboration more important than directive counseling

    • TRT does not teach coping strategies

    • CBT takes 8-12 weeks, not 18 – 24 months


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Turf Wars, (continued) no special order)

  • Herwig, et al suggests TRT is “old wine in new bottles” and is based on Hallam’s 1987 model)

    • Cognitive restructuring (dissociation of negative emotional association)

    • Attention directing

    • Stress management

    • Coping strategies

    • Modification of avoidance behavior

Wilson et al, British Journal of Audiology, 1998; Herwig, et al, Scandinavian Audiology, 2000


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Differences between TRT and Cognitive Therapies no special order)

  • CT is intensive and collaborative designed for 8-12 weekly sessions and direct testing of hypotheses

  • TRT uses directive counseling with 4-6 sessions over 18 month period

  • TRT assumes an anxiety model

  • CT assumes a depression model


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Sound Therapies no special order)

  • Masking

  • Partial Masking

  • Mixing

  • Ultrasonic therapy (hi sonic, quiet sonic) - unproven

  • Music


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DTM no special order)

  • DTM sounds use proprietary “dynamic” (changing) sound formats that are intended to enhance masking and distract attention away from tinnitus.

  • “Dynamic” acoustic technology refers to proprietary semi-random, short-term amplitude and frequency domain modulation signal processing

  • E-Nature and E-Water, have been “dynamically” processed to provide expanded amplitude peaks on the order of 5 to 15 dB, over corresponding time durations on the order of 10 to 500 msec.


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Ultrasonic sound generators no special order)

  • Ultra Quiet (6-20KHz BC)

  • Hi-Sonic TRD (19-27KHz BC)

  • Melmedtronics Inhibitor

    • 60 sec ultrasonic signal with hand held bone vibrator to mastoid (19-25KHz or 42-48 KHz). Claims it works on 75% of patients (by being out of phase of tinnitus!!!!)

    • non-returnable


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Sound enhancement for desensitization / habituation no special order)

  • low level noise interferes with pattern recognition by increasing neuronal activity

  • this makes tinnitus more difficult to detect / reduces contrast

  • gradually increasing input could decrease gain over an extended time


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Acceptable noise level no special order)

  • Nabalek’s ANL measures patient’s willingness to accept background noise when listening to speech


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Current sound treatments no special order)

  • Noise generators

  • Maskers

  • Music

  • Hearing aids

  • Combination instruments

  • Home based

  • CDs (e.g. Personal Growth Tinnitus Relief, Petroff DTM)


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Goals no special order)

  • Active listening (distraction)

  • Masking (covering up)

  • Passive listening (habituation, desensitization))


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Sound (noise) Generators no special order)

  • GHI Tranquil, Harmony, Simply Tranquil

  • Hansaton

  • United Hearing Systems

  • Viennatone Silent Star

  • Starkey masker and combination

  • Ultra Quiet (6-20KHz BC)

  • Hi-Sonic TRD (19-27KHz BC)

  • MelMedtronics Inhibitor

  • Sharper Image Portable Sound Soother

  • Brookstone environmental devices

  • Pillow speakers

  • iPod / Treo


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Neuromonics no special order)

  • a bit of cognitive therapy

  • a bit of TRT

  • music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones

  • rhythm, melody

  • hearing instrument algorithm (equal sensation level) for hearing loss compensation

  • 2 stage program

  • rather expensive


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Davis, et al comparison, 2002 no special order)

Note change between baseline and pre Tx (16 weeks later)


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Mean no special order)Tinnitus Awareness (Percentage of the Time) at Follow-up. Means are the percentage of time which participants were generally aware of their tinnitus over the preceding week.

  • Noise = 41.9%

  • Counseling = 39.2%

  • Music masking = 30.4%

  • ADP = 12.3%

Davis et al, 2002



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Why can’t we just use an iPod? no special order)

  • Frequency shaping

  • Loudness balance

  • Compression


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Music can be soothing or irritating no special order)

  • The physical body and chakra centers respond specifically to certain tones and frequencies.

  • Meditation and Relaxation recordings may actually produce adverse EEG patterns, as much as Hard Rock and Heavy Metal.

    • With “perceived” soothing sounds, a right/left brain hemisphere synchronization occurs; voltage spike pattern smoothes and voltage differential equalized.

  • Selecting what will work for any individual is difficult.

  • We all have different tastes


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Categorical Expectations no special order)

  • We don’t like the unexpected

  • But certain rules have to be followed

  • Active listening arouses, passive listening soothes

  • Active listening distracts, passive listening may allow for increased cognitive function

  • For tinnitus patients, active listening draws attention to the tinnitus, passive listening may facilitate habituation


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Sounds affect people in different ways, due to inherent and learned preferences (Iversen et al, 2000).

It is thus important to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and avoid exposure to negative or annoying sounds (that activate the sympathetic division)

Bolero example

Selecting the right sound


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Does sound therapy help? learned preferences (Iversen et al, 2000).

  • McKinney, et al; 1999

    • Counseling only; 72% showed “improvement” (N=54)

    • Counseling with sound generators at just audible level; 75% showed “improvement” (N=72)

    • Counseling with hearing aids; 61% showed “improvement” (N=56)

    • Counseling with sound generators at mixing level; 83% showed “improvement” (N = only 36)


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Does sound therapy help? learned preferences (Iversen et al, 2000).

  • Herraiz, et al, 1999

    • Counseling only; 94% showed “improvement” (N ~ 30)

    • Counseling with hearing aids; 85% showed “improvement” (N ~ 35)

    • Counseling with sound generators; 83% showed “improvement” (N ~ 30)

      My conclusion….not definitive proof….yet 70% of TRT users get them!


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Improvement learned preferences (Iversen et al, 2000).

  • Reduction in the number of episodes of awareness

  • Increase in the intervals between episodes of awareness

  • Increase in quality of life

  • Not necessarily a reduction in perceived loudness


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Psychological Treatment Objective learned preferences (Iversen et al, 2000).

  • Tinnitus remains, but coping skills improve

  • “I have tinnitus, it doesn’t have me.”


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So what works? learned preferences (Iversen et al, 2000).

Any of the “reasonable” approaches, depending on the “skills” of the audiologist


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Some suggestions…. learned preferences (Iversen et al, 2000).

  • Ask “what will make this encounter or therapy successful in your mind?”

  • Remember that tinnitus patient management is a journey, remind patients of the ups and downs to be expected

  • Tell patient that 1st thought upon recognizing tinnitus should be…..


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Counsel about the following: learned preferences (Iversen et al, 2000).

  • Tinnitus is not unique to that one patient.

  • Tinnitus is not a sign of insanity or grave illness.

  • Tinnitus may be a “normal” consequence of hearing loss

  • Tinnitus probably is not a sign of impending deafness.

  • There is no evidence to suggest the tinnitus will get worse.

  • Tinnitus does not have to result in a lack of control.

  • Patients who can sleep can best manage their tinnitus.


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Counsel about the following: learned preferences (Iversen et al, 2000).

  • Tinnitus is real, and not imagined.

  • Tinnitus may be permanent.

  • Reaction to the tinnitus is the source of the problem.

  • Reaction to the symptom is manageable and subject to modification.

  • If significance and threat is removed, habituation or "gating" of attention can be achieved.

  • Stay off the internet!


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Factors Affecting Outcome learned preferences (Iversen et al, 2000).

  • mood

  • general health

  • motivation

  • concentration

  • time interval between pre and post tests

  • “Skill” of the professional


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Follow-up considerations learned preferences (Iversen et al, 2000).

  • When

  • How

  • For how long


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Attitude of the Professional learned preferences (Iversen et al, 2000).

  • Patients will not regard therapeutic programs to be viable unless the clinician appears to believe it is

  • “Passion” is the key


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New CPT codes learned preferences (Iversen et al, 2000).

  • 92626 Eval of aud rehab 1st hr (Medicare & other 3rd party payers ok because it's an eval

  • 92627 Each add'l 15 min (Medicare & other 3rd part payers ok as it's an eval

  • 92630 Aud rehab pre-lingual (No Medicare as considered treatment; may bill some 3rd party payers)

  • 92633 Aud rehab post-lingual (No Medicare as considered treatment; may bill some 3rd party payers)

  • 92625 Tinnitus matching

  • 92700 Tinnitus devices


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Tinnitus research issues learned preferences (Iversen et al, 2000).

  • selection and number of subjects

  • group mean data

  • research design

  • measurement scales

  • interpreting the findings

  • follow-up data


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American Tinnitus Association learned preferences (Iversen et al, 2000).

P.O. Box 5

Portland, Oregon 97207

800-634-8978



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