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Management of the Tinnitus Patient

Jill Meltzer, Au.D. North Shore Audio-Vestibular Lab

ILAAWSHA 2015

Tinnitus Defining Tinnitus

•  A perception of sound originating in the head of its owner

•  A phantom perception of sound •  A symptom arising from a dysfunction in the

auditory system , Wilson & Henry

Definitions

•  “The perception of sound resulting exclusively from activity within the nervous system without mechanical or vibratory activity in the cochlea, and not related to external stimulation of any kind” Jastreboff

•  Tinnitus is the perception of sound in the ears

or head where no external source is present ATA

Incidence of Tinnitus

•  Tinnitus •  Ringing in the ears is an extremely common

phenomenon found at some time or another in up to one-third of the adult population; 12% have it sufficiently severely for them to seek a medical opinion about it.

P. Alberti, Pathophysiology of the Ear, World Health Organization

Incidence of Tinnitus

•  The ATA estimates 50 million people in the US have tinnitus

•  Incidence increases with age •  80% of those who experience tinnitus are not

significantly bothered by it •  12 million are sufficiently concerned that they

seek medical attention •  Up to 40% of those with clinically significant

tinnitus have sound tolerance issues

VA.Gov

•  Tinnitus is the #1 disability among veterans

•  Tinnitus affects at least 1 in 10 American adults

Tinnitus and the Military •  Tinnitus is currently the number-one service-

connected disability of veterans returning from Iraq and Afghanistan.

•  Tinnitus and hearing loss top the list of war-related health costs

•  Since 2005, veterans receiving service-connected disability for tinnitus has increased by at least 15 percent each year.

American Tinnitus Association 9-2010

AAA Website

Tyler, Kochkin & Born 2011 •  Estimate 30 million Americans have

tinnitus •  13 million report no hearing loss •  27% of 65 to 84 year olds have tinnitus

•  Generally correlated to HL •  40% experience it 80% of the time •  1 / 4 rate it loud •  1 / 5 rate it as disabling or near disabling

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Tinnitus Patient / or patient with tinnitus

•  These are not the same –  The patient reporting tinnitus may

not be significantly bothered by it –  For the Tinnitus Patient, the

tinnitus is having a significant (negative) impact on their life

•  Concentration •  Sleep •  Work •  QRA •  General sense of well being

Phantom Perception

•  Severe tinnitus shares some attributes to severe chronic pain – Sleep disturbances, anxiety & depression

commonly reported – Both are subjective – Phantom Limb Pain

•  One can perceive pain from a missing hand, foot, toe, etc….

•  It’s a brain thing!

Types of Tinnitus

•  Objective or Somatosound •  Subjective •  Characteristics

–  Intermittent – Constant – Pulsatile

Types of Tinnitus

•  Objective or somatosound – A perception of sound generated within the

body by vibratory rather than neural activity •  Pulsatile

–  Vascular lesions –  Benign intracranial hypertension – High cardiac output

•  Non-pulsatile –  Palatal myoclonus –  TMJD

Jastreboff and Hazell, (2004) Tinnitus Retraining Therapy , p. 205

Subjective Tinnitus

•  Hearing loss – Presbycusis – Noise exposure – Ototoxic medications or solutions – Trauma (whiplash, airbag) – Metabolic disorders (diabetes)

How is Tinnitus Perceived

•  Ears – Aural fullness – Pressure

•  Head •  Low Pitched

– Meniere’s – Middle ear disease

•  High Pitched – HFHL

Co-morbidities of Tinnitus

•  Anxiety •  Concentration problems •  Depression •  FEAR •  Stress •  Sleep disturbances •  Mood disorders

Medical evaluation is recommended prior to tinnitus evaluation to rule out any medically treatable conditions

The Tinnitus Evaluation

•  Informational letter •  Send tinnitus questionnaires before appt.

– Tinnitus Handicap Inventory (THI) – Tinnitus Reaction Questionnaire (TRQ) –  Iowa Tinnitus Handicap Questionnaire (THQ) – Hospital Anxiety and Depression Scale (HADS)

–  Yes definitely, yes sometimes, no not much, no not at all

– Tinnitus Functional Index (TFI)

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The Evaluation

•  Audiometric thresholds – Look at ultra high frequencies

•  Otoacoustic Emissions •  Tinnitus measures

– Pitch matching – Loudness matching – Minimum masking levels – Residual Inhibition

•  Loudness Discomfort Levels (LDL’s)

Listen to the Patient

•  Listen like you care –  Note body language

•  Let the patient tell their story •  Address myths and misconceptions

–  What have they been told

•  Clinician should be patient, empathetic, and knowledgeable

•  Offer hope

•  Victim of Tinnitus becomes Manager of Tinnitus

Tinnitus Evaluation

•  Case History –  Tinnitus description

•  Ringing •  Hissing •  Buzzing •  Unilateral / Bilateral / Head •  Intermittent / Constant •  Pulsatile

General Medical History

•  How is the general health – High blood pressure – Diabetes – Hearing loss – Medications (Rx and OTC) – TMJD

Characteristics of Onset

•  Sudden / Gradual •  Associated with some event

– Medication – Noise exposure – Dental work – Chemical

•  Toxic chemicals + noise exposure have synergistic effect increasing likelihood of tinnitus

Tinnitus

•  What makes it better – Build on this…

•  What makes it worse – Can these circumstances be minimized

•  Associated manifestations – TMJD – HL

Hearing and Aging Ear Anatomy Auditory Pathway

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The Neuronal Network

•  The brain is very plastic

•  New connections constantly forming

•  Brain can “relearn”, be “retrained”

Cochlea External sounds enter

Auditory Nerve

Neuronal Network

Subconscious Pathways

Auditory cortex (Awareness)

Aage Moller

•  Obstacles •  Most severe chronic tinnitus is caused by

maladaptive neuroplasticity causing dysfunctional neural networks

•  Patients often insist the ear is the location of the problem

•  2 Components •  Sound of the tinnitus •  Effect (not sound) of the tinnitus (suffering)

•  Tinnitus Research Initiative (free newsletter)

Tinnitus

•  Research in progress aimed at reversing maladaptive neuroplasticity.

•  Various methods to reverse maladaptive response

•  Share current research studies •  Vagus nerve stimulation •  rTMS •  Other

Case History Revisited

•  Go back to case history •  Lifestyle •  Medications •  Medical history

– Diabetes – High blood pressure – Alcohol use

•  Noise exposure •  Military experience

Use Visuals

conscious

subconscious

Vicious Cycle

R. Folmer

Blaming Tinnitus for Hearing Problems

•  Reactions to tinnitus may be reactions to hearing loss

•  Hearing loss may have caused

the tinnitus

Reviewing Test Findings

•  Audio •  Tinnitus measures •  LDL •  OAE •  Residual Inhibition •  Questionnaires

•  benchmark

Reactions to Tinnitus

•  Most tinnitus therapies address REACTIONS to the tinnitus

•  Various methods attempt to:

– Calm fears about tinnitus – Take attention off of tinnitus – Educate about tinnitus

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Negative Counseling

•  Well meaning professionals can leave patient feeling as bad or worse than when they arrived

•  They come looking for reassurance and information

•  Even if the “TINNITUS” hasn't changed, the effect of negative counseling can impact how it affects them.

Negative Counseling

•  Well meaning comments: – Just live with it – Tinnitus is incurable – You have Tinnitus –  It may get worse – There's nothing to be done –  It can be quite devastating – You probably don’t have a brain tumor

So What do we do?

Building the Tinnitus Tool Box

Give Positive Information

•  Avoid Silence •  Many find low-level background sounds

reduce the perception of tinnitus. •  Treatments that others have found helpful

– TRT – CBT – DBT – Masking – Music therapy – Mindfulness

Dialectical Behavioral Therapy

•  DBT Premise •  Radical acceptance paired with change

•  Dialectics •  How to live a life that is not the life you want

•  Distress tolerance •  Emotions constantly change •  Fear of own emotions.. Avoidance behaviors •  Distraction

Jaelline Jaffe, Ph.D 2013 Lemon Aid Counseling

DBT

•  Mindfulness •  Notice, observe, be aware without labeling

•  Within/ outside

•  Describe without interpreting (judging) •  Identify own judgments, not others behavior

* Therapist and patient work on ‘accepting’ uncomfortable thoughts, feelings and behaviors rather than struggling with them

* National Alliance on Mental Illness

Acoustic Therapies

•  Tinnitus Retraining Therapy (TRT) – Education (Directive Counseling) – Hearing Aids – Sound Generators – Combination devices – Environmental Sound Enrichment

Books

Just to name a few

Devices

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Acoustic Therapies •  Music

–  iPod / MP3 • Use any signal that provides relief • Sound machines / nature sounds

– Neuromonics • Music customized to compensate for

hearing asymmetries (Oasis, Haven, Sanctuary,)

• Subject gets full stereo signal • Added ‘neural stimulus’ for tinnitus relief • Music mimics resting heart rate

Rationale for Music Therapy

•  Music used in pain and anxiety management

•  Music can connect the limbic system with pleasant memories/associations

•  Music is pleasant to listen to

Neuromonics

Sanctuary Oasis Haven

Refuge

Feature Sanctuary Haven Oasis Multiple headphone options X X X Sleep timer X X X Single and continuous X X X External speaker X X X Sub charging and synching X X X Adjustable startup volume level X X X Data log viewing X X X Traditional 4 tracks X X X Phase 1 Stimulus X X X Adjustable Phase 1 Stimulus level X X Balance adjustment X X Prog. Muscle Relaxation X X Programmable through NOAH X X Add. Music tracks to choose X Phase 2 scheduling X

Neuromonics: Phased Treatment

Relief while listening •  Provides repeated brief

exposure to tinnitus, in context of relaxation stimuli

•  Masking in music peaks & exposure in troughs

•  Added ‘shower sound’ –  Reduced anxiety, sense of

control

Stage 1 (~ 2 months)

Active Treatment (~ 4 Months)

•  Stage 2 – Lower level of

interaction •  Shower noise removed

–  Intention: Gradual reduction in awareness & disturbance between periods of listening

Other Therapies

•  Inhibitor –  “A hand-held device that emits a 60-second

ultrasonic signal providing temporary relief from tinnitus. 70-75% of patients noticed a total or partial reduction in the loudness of their tinnitus. The benefit of relief ranges from minutes to hours to days.”

From: www.tinnitustreatment.com website

Other Treatments

•  Repetitive Transcranial Magnetic Stimulation (rTMS)

•  Noninvasive procedure that applies magnetic fields to the brain

•  Electrical currents can excite or inhibit neuronal activity depending on stimulus frequency

– http://www.ncbi.nlm.nih.gov/pubmed – De Ridder, D

•  Langguth, B •  Kleinjung. T

Acoustic Coordinated Reset Neuromodulation

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Acoustic Coordinated Reset Neuromodulation (CR)

•  Assumes tinnitus is associated with pathologic enhanced neurosynchronization

•  CR model based on desynchronization technique to counteract tinnitus-related neuronal synchrony inducing an unlearning of pathological synaptic connectivity and neural synchrony

Tass P, Adamchic I, Freund H, Stackelberg T : Counteracting tinnitus by acoustic coordinated reset neuromodulation. Restorative Neurology and Neuroscience 30 (2012) 137-159

Sound Cure

Serenade

Sound Cure

•  Developed at Univ. Calif. Irvine •  Uses ‘S’ tones centered around tinnitus

frequency •  4 tracks

•  ‘S’ tone 1 (slow) •  ‘S’ tone 2 (faster) •  Narrow band noise •  White noise

Sound Cure

•  Temporally Patterned Sounds and the Auditory Cortex •  S-Tones can produce synchronized, robust

neural activity in the auditory cortex. •  Sounds that are too slow produce bursts of activity

and those that are too fast show no synchronization, but within a specific range the neurons fire synchronously to the sound stimulus.

Sound Cure •  According to a UCI researcher,

•  “The mechanisms underlying tinnitus suppression are different from those in tinnitus masking. Masking attempts to divert a patient’s attention away from the tinnitus.

is a physiologic process where sounds—in this case, patterned sounds—may likely be modulating the activity of the auditory cortex and interrupting tinnitus generation.”

www.soundcure.com website

•  Listens to sound therapy while sleeping to help brain learn to ignore tinnitus sounds

•  Uses analogy of ‘defragging’ computer for brain reorganization

•  Includes iPod touch with pre-installed Levo software

Web Based Treatment

•  www.audionotch.com •  ‘Online software that creates custom software

to treat tinnitus’ •  Find freq. of tinnitus, then upload music

•  http://lets-beat-tinnitus.co.uk/blog/free-tinnitus-pulse-therapy/ •  Works on the principle of ‘residual inhibition’ •  Free, Has 9 choices of ‘pulsed’ noise sounds

Web- Tinnitus Self Help

•  http://www.tinnitool.com/en/tinnitus_analyse/hoertest.php •  Patient tests themselves for pitch match •  Website reports they tailor treatment for

patient •  Treatment options

•  Soft laser self treatment •  Sound plus neurostimulation •  Sound therapy •  Masking •  Hearing protection

Web

•  Tinnitus Miracle e-book- Thomas Coleman •  http://tinnitusmiraclethomascoleman.org

•  5 step holistic approach •  Dietary changes •  Herbs •  Lifestyle •  Foods / exercise •  Breathing exercises

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Tinnitus Tamer (vavsoft.com) Web Tinnitus Tamer •  The Tinnitus Tamer uses repeating signals that are

similar to the Tinnitus, interspersed with silent periods. The repeating signals are not associated with anything of significance, and will modify the neural networks that they will attenuate the Tinnitus sounds as representing a neutral, nonsignificant signal. The silent periods help the brain to perceive silence when there are no external sounds.

•  Thus, the Tinnitus Tamer uses the resources of your own body to take care of the Tinnitus in a natural way.

•  Versions for iPad, Mac, Windows

BeyondTinnitus.com •  How Does BeyondTinnitus™ Work? •  “BeyondTinnitus is an extremely simple system and one

of the most enjoyable and effective tinnitus therapy programs you will find anywhere. All it takes is 3 easy steps.”

•  Tinnitus Matching •  Our Tinnitus Matching Program allows you to use our

patent pending interface to define the specific frequency and loudness of your tinnitus as well as which ear hears it louder.

Beyond Tinnitus Sound Therapy Using your tinnitus sound frequency and loudness, we

generate customized sound therapy files that will target the specific areas of your brain that cause the perception of tinnitus.

Music Therapy Our program generates customized and patent pending

music therapy files that combine your favorite music with the sound therapy file. This allows you to listen to your favorite music while the sound therapy file is working in the background to reduce the activity of the brain cells that produce tinnitus.

Tranquil Moments: Sleep sound therapy brookstone.com

Sound Soother sharperimage.com

Marsona Marsona.com

Travel Sound Soother sharperimage.com

Table Top Devices

iPod

Travel Tranquil Moments

iPhone

Ear Level Devices

Application Search

•  Search at Apple app store and Google play •  Over 60 items

• Some free • Some a few dollars • Most expensive $99.99

Over the Counter Other Sources

•  Purewhitenoise.com – Variety of environmental sounds mixed with

white noise •  Vectormediasoftware.com

– Tinnitus masker pro •  Rhythmicmedicine.com

– Website of Janaleah Hoffman (music therapist)

•  Soundpillow.com •  Sleepphones.com

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Amazon

•  Nature sounds •  Over 31,000

•  Relaxation •  Over 63,000

•  White noise •  Over 6600

•  Brown noise •  Over 200

•  Pink noise •  Over 650

Amazon Rich Tyler - Univ. of Iowa

•  Univ. of Iowa Tinnitus Clinic •  Counseling •  Sound therapy •  Hearing aids •  Psychological therapies •  Medications •  Things you can do –  You can download presentation and counseling info

from website. –  Just google Univ. of Iowa, tinnitus

Progressive Tinnitus Mgmt. (PTM)

•  Audiologic and tinnitus evaluation •  Administer tinnitus questionnaires •  Conduct tinnitus specific interview •  Provide

–  Hearing aids, sound generators, comb. units –  Rec. individualized sound enhancement program –  Informational counseling re: hearing, HL, tinnitus and

rec. strategies to reduce focus on tinnitus

James Henry, Tara Zaugg, Martin Schechter (2005) AJA, Vol. 14 21-48

ATA.ORG

•  Tinnitus Today Digital Edition •  Tinnitus Today Archives •  Progressive Tinnitus Management

•  Workbook •  Video •  Sound samples

•  ATA’s Masking Sound Library •  ATA Support Network

Jastreboff’s Neurophysiological Model of Tinnitus

•  The unpleasantness of tinnitus is solely the result of limbic and autonomic nervous system stimulation outside of the auditory system

•  The auditory system plays a secondary role in problematic tinnitus

TRT

•  This is SUBCONSCIOUS - the tinnitus related neuronal activity (TRNA) activates the limbic and autonomic nervous system (ANS) on its own

•  In persistent tinnitus, limbic and autonomic

activity continues until the aversive conditioned response is retrained, or relearned

TRT Category Assignment

•  Patients are assigned to categories based

on: – Case history – Diagnostic test findings

•  Counseling will depend on category assignment

TRT Categories Category Severe

Tinnitus Sound

Tolerance Hearing

Loss Kindling Effect

0 No No Yes or No No

1 Yes No Yes of No No

2 Yes No Yes No

3 Yes or No Yes Yes or No No

4 Yes or No Yes or No Yes or No Yes

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Habituation •  One can attend to different body

sensations •  We generally attend to one conscious

sensation at a time •  Some information gets attention, others

get ignored •  Unimportant information is filtered out

[Habituated]

Habituation

•  The Cure for Tinnitus – Turn It Off •  The Next Best Thing – Don’t Listen to It

–  If you don’t listen to the tinnitus, it’s not a problem

– HABITUATION •  the sound may be perceived, but you are not

aware / bothered by it

Perception

What Do You See?

Same input, different interpretations

Perceptions Influence Reactions Not So Soothing Image

Limbic and Autonomic System Involvement

•  Fight or flight response •  Lack of control •  Sleep disturbance •  Anxiety •  Concentration difficulties •  Changes in central gain patterns

Can You See Tinnitus?

•  Yes... – Auditory cortex images of tinnitus patient

differs from controls – Gaze Tinnitus

•  Melcher and Levine

– Muhlnickel et. al •  Used magnetoencephalography (MEG) with

tinnitus patients and control group •  Results show organization of auditory cortex differs

in the tinnitus group than control group

Imaging Tinnitus

•  PET scans have shown asymmetries in aud. cortex of tinnitus pts. w/ increased neuronal activity on the left side, regardless of tinnitus laterality (Langguth et.al)

•  Increased gamma band activity in tinnitus pts. •  Others have shown via EEG and MEG gamma

band activity in aud. cortex correlates with perceptions of auditory signals

Tinnitus and Transcranial Magnetic Stimulation; Seminars in Hearing 2008;29, 288-290

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LM Timeline

Onset 12-2012 •  Female, age 46 fell from a flight of stairs in a

log cabin. •  Hit back of her head and whiplash injury to

the neck. •  Diagnosed with concussion and post

concussion syndrome •  Tinnitus onset immediately after accident •  The head trauma also caused some jaw

problems

LM

•  Tinnitus perceived in both ears and in the head

•  She was dizzy for the first few months, but not at the time of our first meeting She also had some visual sensitivities such as to fluorescent lights

•  Loudness sensitivity •  Loud sounds make tinnitus worse

LM

•  Depressed after the concussion •  Had difficulties

•  Light sensitivity •  Tinnitus •  Insomnia •  Hypersensitive •  Anxious

LM Tinnitus Hyperacusis Hearing

Activity Yes No Unsure Yes No Unsure Yes No Unsure

Concentration X X Falling Sleep X X Staying Asleep X X Restaurants X X X Church/ Temple X X X Sports events X X X QRA X X Concerts X X X General sense of well being

X X X Other

LM Audiogram July 2013

0102030405060708090

100110

250

500

1000

2000

3000

4000

6000

8000

12,00

0

RightLeftRE LDLLE LDL

LM Audio

LM

•  0 to 10 visual analog scale •  From Jan. to May rated problems a 9 •  July- things have gotten better. Today

rated as 7 •  Had to take a leave from teaching due to

decreased sound tolerance and tinnitus

LM Data

49

42

11

5

70

44

26 28

6 4

26 25.6

0

10

20

30

40

50

60

70

80

TRQ THI % HADS A HADS D Khalfa TFI

July 2013 Oct. 2013

Left Ear LDL’s

Series 1- July Series 2 - October

56 52 50

44 44 42 42

76

84 88

84 80

84

100

0

20

40

60

80

100

120

LE .5K LE 1K LE 2K LE 3K LE 4K LE 6K LE 8K

Series1 Series2

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RE LDL’s

66

58 60 56 54

58 58

86 92 92 92 92 94

100

0

20

40

60

80

100

120

RE .5K RE 1K RE 2K RE 3K RE 4K RE 6K RE 8K

Series1 Series2

Series 1 – July Series 2 - October

LM

•  Patient doing much better •  She is back to teaching and does not

usually think about the tinnitus much during the school day

•  Hypersensitivity is also better •  She wears earplugs for fire drills or in other

loud environments •  No longer feels tormented by tinnitus

Lake Thoreau

DS

•  Patient reports he had intermittent tinnitus 5 or 6 years ago, but for last 12 days it’s unbearable

•  Tinnitus onset following a 4th of July concert with his family •  Other family members had no tinnitus or

other sound disturbances •  VAS rating tinnitus as 9 •  VAS rating of ‘effect on your life’ 8-9

DS

•  Tinnitus described as ringing, roaring whooshing sound

•  Not pulsatile •  Audible over loud noise •  Aggravated by stress and being in quiet

environment •  Concentration severely impaired

DS Audio

DS

•  Tinnitus is perceived in both ears but left is usually worse

•  Getting in anxiety loop •  Has had previous issues with anxiety and

panic disorder •  Aware of tinnitus 100% of the time •  Disturbed 90% to 100% of the time •  Having trouble functioning at work

DS Tinnitus Hyperacusis Hearing

Activity Yes No Unsure Yes No Unsure Yes No Unsure

Concentration X X X Falling Sleep X X X Staying Asleep X X X Restaurants X X X Church/ Temple X X X Sports events X X QRA X X X Concerts X General sense of well being

X X X Other

DS

•  Tinnitus pitch matched closest to 12,000 Hz. (6dB SL)

•  MML 40dB - 42dB •  Performed in each ear and binaurally

•  Hyperacusis not indicated

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DS

•  Had issues with anxiety and depression in 2003 and 2005

•  Medications •  Just started on Zoloft •  Lorazepam (Ativan) for anxiety and tinnitus

relief •  Mirtazapine (Remeron) for sleep

•  Offered to try ALL tinnitus treatments

DS

•  First visit July 2-13 •  Let him borrow Sound Cure (not customized)

•  August 2013 •  Pt. spent some time as inpatient for anxiety •  At this time he was in the outpatient program

•  Returned hearing aids and accessories •  Very happy with Neuromonics treatment

•  Enjoys the treatment and finds it very relaxing

DS

•  November •  Ordered and dispensed Musicians earplugs

with 15dB filters and 25dB filters •  Continues to enjoy the Neuromonics

treatment •  Feels like, “I have my life back”

DS Data DS Data