Robert W. Sweetow, Ph.D.

1
Tinnitus Patient Management

• Robert W. Sweetow, Ph.D.
• University of California
• San Francisco, California

2
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

3
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

4
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?

5
Proposed mechanisms

• 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)

6
Tinnitus and Hearing Loss
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Correlation between tinnitus severity and
auditory threshold
Tsai, Cheung, and Sweetow, 2007
8

• Models based on peripheral measures fail to
  predict completely percept laterality
• Role of CNS adaptation (neural plasticity)
• Absolute and relative depth of hearing loss are
  uncorrelated to percept severity
• Role of CNS emotional binding (limbic system)

Tsai, Cheung, and Sweetow, 2007
9

• Subjective tinnitus idiopathic sensory
  neural central
• Objective tinnitus vascular muscular

10
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

11
Some inner ear pathologies associated with
tinnitus

• acoustic trauma presbycusis
• noise exposure menieres disease
• labyrinthitis acoustic neuroma
• head/ear trauma ototoxicity
• meningitis perilymph fistula
• autoimmune inner ear disease
• vestibular schwannoma
• sudden hearing loss

12
Some central auditory nervous system pathologies
associated with tinnitus

• vascular
• dementia
• cardiovascular disease/hypertension
• blood disease /anemia
• multiple sclerosis

13
Other factors associated with tinnitus

• temporomandibular disorders
• cervical misalignment
• menses/menopause
• renal disease / Alports / kidney transplants
• lyme disease
• zinc deficiency
• poor circulation
• Hypothyroid/ hyperthyroid disorders

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Results Summary

• 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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• Models based on peripheral measures fail to
  predict completely percept laterality
• Role of CNS adaptation (neural plasticity)
• Absolute and relative depth of hearing loss are
  uncorrelated to percept severity
• Role of CNS emotional binding (limbic system)

Tsai, Cheung, and Sweetow, 2007
16
Mechanisms Etiologies

• 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.

17
Para-auditory generation

• Vascular neoplasms
• Cochlea detects blood flow
• Potentially serious prognosis--symptom of
  vascular disease
• Management--generally surgical

18
Para-auditory generation

• 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

19
Para-auditory Generation

• 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

20
Para-auditory generation

• Venous Hum
• Benign Intracranial Hypertension
• Obesity
• Menstrual irregularities
• Hypothyroidism
• Hyperthyroidism
• Anemia
• Vitamin A or D Deficiency
• Side Effect of Oral Contraceptives
• Pregnancy and Postpartum

21
Para-auditory Generation

• TMJ syndrome
• The petro-tympanic fissure is traversed by the
  mandibular ligament (Pintos 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

22
Para-auditory Generation

• 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)

23
Diagnostic Issues in Tinnitusa Neuro-otological
Perspective

• Robert Aaron Levine, MD

24
Tinnitus - unilateral

• 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

25
Fluttering

• Stapedius muscle contractions
• If associated with facial movements, then
  stapedial contractions are likely cause
• Commonly seen after recovery from Bells 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 or non-lateralized

• Pulsatile
• Clicking
• Autophony (echoing of the voice), or blowing
  tinnitus
• Hallucinations (non-verbal, stereotyped
  repetitive)

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Pulsatile

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

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Pulsatile - history

• 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)

29
Pulsatile

• 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

• 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 Schwartzes 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

• 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.

32
Pulsatile - Diagnostic studies

• 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.

33
Clicking

• 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

34
Autophony (echoing of the voice), or blowing
tinnitus

• 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.

35
Musical hallucinations

• 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.

36
Auditory hallucinations

• 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

37
Tinnitus quality

• 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.

38
Always unilateral, may be with vestibular
symptoms

• Menieres Syndrome
• Perilymphatic fistula
• Herpes Zoster Oticus (Ramsay-Hunt Syndrome)
• Cerebellopontine angle tumors
• Central nervous system caudal to trapezoid body
• Sudden idiopathic hearing loss

39
Menieres Syndrome

• 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.

40
Perilymphatic fistula

• 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.

41
Herpes Zoster Oticus (Ramsay-Hunt Syndrome)

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

42
Sudden idiopathic hearing loss

• Always unilateral

43
Always with hearing loss,may be unilateral or
non-lateralized

• Acute acoustic trauma
• Chronic progressive hearing loss (presbycusis,
  chronic acoustic trauma, hereditary hearing loss)
• Autoimmune inner ear disease

44
May be no hearing loss, may be unilateral, or
non-lateralized

• Somatic (head or upper cervical)
• Trauma
• Post-infectious
• Medication-related (including withdrawal
  syndromes)

45
Somatic (head or upper cervical)

• 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 patients tinnitus

46
Properties suggesting somatic component

• Intermittency
• Large fluctuations in loudness
• Variability of location
• Diurnal pattern
• No hearing loss but head or neck trauma

47
Somatic Diurnal fluctuations

• 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.

48
Otoacoustic emissions

• 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)

49
SOAE-Associated Tinnitus

• SOAEs are estimated to be responsible for at
  least part of the tinnitus in 1 to 9 of tinnitus
  patients.
• Penner (1990) 4
• Baskin Coles (1992) 2
• In most patients, the SOAEs are somewhat variable
  in frequency and amplitude--causing them to be
  audible, counteracting tendency for adaptation.

50
SOAE-Associated Tinnitus

• 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

51
Sensorineural Generation

• Auditory deprivation and conductive hearing loss
• SOAE-associated tinnitus
• Cochlear disorders (SNHL)
• Central processing effects

52
Sensorineural Hearing Loss

• 70-90 of tinnitus sufferers have hearing loss
• NIHL is a major factor in approximately 38 of
  all tinnitus patients
• Menieres 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

53
Central Processing Effects

• 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

54
Auditory Deprivation

• 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.

55
Tinnitus triggers

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

56
Tinnitus exacerbating factors

• caffeine
• alcohol
• nicotine
• sodium
• stress
• noise exposure
• high cholesterol, hyperlipidemia, hyper and
  hypothryroidism

57
Some drugs reported to be associated with
tinnitus

• salicylates
• non-narcotic analgesics
• ototoxic diuretics
• ototoxic antibiotics
• ototoxic cisplatin

• caffeine
• alcohol
• cocaine
• marijuana
• oral contraceptives

58
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 cant
  cope
• Patient is anxious
• If present, engagement if not present,
  disengagement

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Most common difficulties attributed to tinnitus

• Annoyance, irritation, stress
• Concentration, confusion
• Drug dependence
• Pain/headaches

• Sleep
• Persistence
• Speech understanding
• Despair, frustration, depression

Tyler and Baker, 1983
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Tinnitus Management Team

• Audiologist
• Psychologist
• Psychiatrist
• Otolaryngologist
• Neurologist
• Pharmacologist
• Nutritionist
• TMJ Specialist
• Physical Therapist
• Biofeedback Specialist

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Tinnitus Questionnaire

• Otologic
• Medical
• Audiologic
• Diet
• Exercise
• Emotional Pattern
• Sleep
• Previous Treatments

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Defining the tinnitus problem

• time
• behaviors affected
• attitudes and thoughts
• what affects the tinnitus?
• how would your life be affected if you didnt
  have tinnitus?

63
Give the patient a chance to vent

• But only for a while!!!!!!!
• .And less time each visit

64
Assessment inventories and audiological
diagnostic tests

• All testing is done for both diagnostic and
  therapeutic purposes

65
Potentially useful diagnostic procedures

• 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

66
Tinnitus matching
Loudness
Pitch

• usually less than 6 dB SL
• may be more appropriate to convert to sones

• 82 match above 3KHz
• 14 match above 9KHz

Maskability (MML)

• 0-3 dB easy to mask
• 4-10 dB masking may be intrusive
• 10 dB difficult to mask

67
Assessment Inventories

• 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

68
Tinnitus Handicap Inventory (THI) - 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

69
Minimally screen for depression and anxiety

• Used for referral purposes
• High scores do not determine that patient has a
  depressive or anxiety disorder

70
Red Flags for Behavioral Health 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

71
Tinnitus patient management procedures we wont
discuss

• Medication
• Perfusions
• Surgery
• Stress Management
• Biofeedback
• Nutritional Counseling

72
Medications

• 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

73
Effects of neurotransmitters

• 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

74

• 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.

75
Salicylates

• Aspirin, ibuprofen, advil NSAIDs, naproxen,
  motrin
• Dristan, anacin, excedrin, bufferin
• Alka seltzer, pepto bisomol, pamprin, certain
  breath savers, lozenges, wintergreen

76
Alternative Approaches

• 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

77
Newer, unproven approaches

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

78
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

79
Tinnitus maskers

• Used at lowest levels possible to mask tinnitus

80
Tinnitus and hearing loss

• 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)

81
The mean hearing threshold levels of ninety
consecutive patients in a university tinnitus
clinic are displayed in Figure 1 (Davis, Wilde
Steed, 1999)
82
Why hearing aids help tinnitus patients

• 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

83
Why hearing aids might NOT help

• Reactive tinnitus (fairly rare)
• Increased distortion
• Discomfort
• Somatic awareness
• Fear
• Stigma
• Cost / benefit ratio

84
Special considerations for fitting hearing aids

• Expansion
• Noise reduction
• Open fit
• Feedback
• Multiple programs
• Compression and maximum output
• Trial period may not be adequate

85
Use of tinnitus instruments as maskers

• Combination hearing aid/masker
• Improves audibility
• Reduces contrast of tinnitus to silence

86
Tinnitus Retraining Therapy

• directive counseling
• auditory (low level noise) therapy

87
TRT Model (Jastreboff. 1995)
Perception Evaluation
Auditory and Other Cortical Centers
Detection (Behavioral)
Emotional Associations Limbic System
TRIGGER (Cochlear)
Annoyance
88
Research supporting central location

• 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)

89
Objectives

• initiate and facilitate tinnitus habituation
• remove perception from patients consciousness

90
Perception evaluation

• 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

91
Counseling

• Educational
• Guided
• Directive

92
Basic assumptions

• The brain can sort out meaningful stimuli from
  those which are not
• Attention is directed toward "salient" or
  information-bearing stimuli

93
Summary - Why brain focuses on tinnitus

• 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

94
Mock counseling session
95
(No Transcript)
96
TRT - Mean Scores from Tinnitus Severity Index
(Henry)
97
TRT - Mean Scores from Tinnitus Handicap Inventory
98
Mean Percentages TRT Tinnitus Awareness
99
Mean Percentages TRT Tinnitus Annoyance
100
Factors influencing patient's ability to habituate

• 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

101
Definition of Cognitive-Behavior Therapy

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

102
Similarities of tinnitus with pain

• subjective
• invisible
• affected by extraneous events

103
Process

• changing the way one interprets thinks and feels
• modifying ones 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

104
CBT gives patients hypotheses that can be
self-testedMost effective when combined with
attention control, imagery training and relaxation
105
Learned process

• Subject to behavioral and cognitive modifications

106
Common cognitive distortions

• 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 others thoughts without
  evidence, people think Im 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)

107
Common cognitive distortions

• 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 everyones evening because
  I was miserable

108
Examples of Operational Statements

• Inadequate Response Acceptable Response
• Tinnitus keeps me awake I 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.

109
Situation
Cognitive Distortion
Rational Thought
I wake up and hear my tinnitus, so I know its
going to be a bad day
What I do will determine how my day goes
Jumping to conclusions
All or nothing thinking
Behavior Current Status Mod.
Improvement Goal
falling asleep 2 hours
60 minutes 30 minutes
110
CBT

• 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?

111
Tyler, et al, 2004
112
Differences between CBT and TRT

• 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

113
Contrasting anxiety from depression(Wilson, et
al, 1998)

• TRT assumes an anxiety focus
• Cognitive therapy assumes a depressive focus

114
3 levels of complexity

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

115
CBT / tinnitus books

• 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)

116
Turf Wars

• 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

117
Turf Wars, (continued)

• Herwig, et al suggests TRT is old wine in new
  bottles and is based on Hallams 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
118
Differences between TRT and Cognitive Therapies

• 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

119
Sound Therapies

• Masking
• Partial Masking
• Mixing
• Ultrasonic therapy (hi sonic, quiet sonic) -
  unproven
• Music

120
DTM

• 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.

121
Ultrasonic sound generators

• 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

122
Sound enhancement for desensitization /
habituation

• 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

123
Acceptable noise level

• Nabaleks ANL measures patients willingness to
  accept background noise when listening to speech

124
Current sound treatments

• Noise generators
• Maskers
• Music
• Hearing aids
• Combination instruments
• Home based
• CDs (e.g. Personal Growth Tinnitus Relief,
  Petroff DTM)

125
Goals

• Active listening (distraction)
• Masking (covering up)
• Passive listening (habituation, desensitization))

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Sound (noise) Generators

• 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

128
Neuromonics

• 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

129
Davis, et al comparison, 2002
Note change between baseline and pre Tx (16 weeks
later)
130
Mean 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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135
This trial was reportedly done with no
counseling
136
Why cant we just use an iPod?

• Frequency shaping
• Loudness balance
• Compression

137
Music can be soothing or irritating

• 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

138
Categorical Expectations

• We dont 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

139
Selecting the right sound

• 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

140
Does sound therapy help?

• McKinney, et al 1999
• Counseling only 72 showed improvement (N54)
• Counseling with sound generators at just audible
  level 75 showed improvement (N72)
• Counseling with hearing aids 61 showed
  improvement (N56)
• Counseling with sound generators at mixing level
  83 showed improvement (N only 36)

141
Does sound therapy help?

• 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!

142
Improvement

• 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

143
Psychological Treatment Objective

• Tinnitus remains, but coping skills improve
• I have tinnitus, it doesnt have me.

144
So what works?

• Any of the reasonable approaches, depending on
  the skills of the audiologist

145
Some suggestions.

• 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..

146
Counsel about the following

• 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.

147
Counsel about the following

• 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!

148
Factors Affecting Outcome

• mood
• general health
• motivation
• concentration
• time interval between pre and post tests
• Skill of the professional

149
Follow-up considerations

• When
• How
• For how long

150
Attitude of the Professional

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

151
New CPT codes

• 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

152
Tinnitus research issues

• selection and number of subjects
• group mean data
• research design
• measurement scales
• interpreting the findings
• follow-up data

153
American Tinnitus Association

• P.O. Box 5
• Portland, Oregon 97207
• 800-634-8978

154
robert.sweetow_at_ucsfmedctr.org