2/6/2019. What Is Tinnitus? Learner Outcomes. Presentation Overview. Theories. What is Tinnitus?

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1 Evaluation and Treatment Options for the Tinnitus Patient Brittany Grayless, Au.D., CCC-A Assistant Professor Learner Outcomes Perform a Describe and explain what tinnitus is and where is derives from List three standardized tinnitus questionnaires Develop a treatment plan for the tinnitus patient Presentation Overview Part I: What is Tinnitus Part II: What Is Tinnitus? Part II: Counseling the Tinnitus Patient Part IV: Tinnitus Treatment Options What is Tinnitus? The perception of sound, typically in the absence of an external acoustic signal Neural signals interpreted by the brain as sound Ringing, hissing, humming, buzzing, roaring, crackling, sizzling, whooshing, howling, grinding, etc. Objective Theories Neural Plasticity Phantom limb pain and reorganization of somatosensory inputs Excitatory and inhibitory inputs (reduction in GABA) Hyperactivity of neurons Hearing loss and the reorganization of tonotopic maps Neurons will tune to the frequencies just outside region corresponding to the cochlear lesion Subjective Heller AJ. (2003). Classification and epidemiology of tinnitus. Otolaryngologic Clinic of North America, 36(2): Salvi, R.J., Lockwood, A. H., Burkard, R. (2000). Neural Plasticity and Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp ). 1

2 The Tinnitus Patient The Tinnitus Patient Psychological factors Irritation, annoyance, concentration, depression, despair Erlandsson, S.I., (2000). Psychological Profiles of Tinnitus Patients. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 26). General anxiety High anxiety increases attention to threat-related stimuli Broadbent, D., & Broadbent, M. (1988). Anxiety and attentional bias: State and trait. Cognition and Emotion, 2, Stress Mazurek B, Haupt H, Olze H and Szczepek AJ (2012) Stress and tinnitus from bedside to bench and back. Front. Syst. Neurosci. 6:47. doi: /fnsys Psychological profiles of tinnitus patients Three different dimensions to focus on during clinic session: 1. Mood and emotional reactions Depression, anger, irritability, anxiety 2. Audiological dimension Hearing problems Distress at an individual level and the demand in social situations 3. Intrusiveness Continuous focus on the tinnitus Concentration issues Patient s sleep (insomnia) Assessment of Psychological Aspect of Tinnitus Case History Reaction to the Tinnitus Factors that may exacerbate the tinnitus Is there something that makes the tinnitus itself, more distressing? Erlandsson, S.I., (2000). Psychological Profiles of Tinnitus Patients. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 33 34). Factors related to the prevalence of tinnitus: Noise: Excessive noise exposure affects the auditory system at various levels, causing hearing loss and tinnitus Pathologically: Leads to hair cell damage Leads to damage to the auditory nerve and central auditory system Factors related to the prevalence of tinnitus: Smoking Experimental work on animals Nicotine can have degenerative effects on cochlear structures Zelman (1973) found an increase in the incidence of hearing loss among smokers than non-smokers, especially in the high frequencies Further studies needed to determine the direct correlation between smoking and tinnitus. Davis, A., Rafaie, E.A., (2000). Epidemiology of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 15). Veile, A., Zimmerman, H., Lorenz, E., Becher, H. (2018) Is smoking a risk factor for tinnitus? A systematic review, meta analysis and estimation of the population attributable risk in Germany. BMJ Open, 8(2) Davis, A., Rafaie, E.A., (2000). Epidemiology of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 15). 2

3 Factors related to the prevalence of tinnitus: Caffeine Central nervous system stimulant May cause tinnitus without affecting the hearing status Still needs to be studied further Alcohol Data relating alcohol and tinnitus are insufficient and contradictory Patients have reported worsening of the perceived tinnitus loudness and pitch of tinnitus temporarily Some patients have reported an improvement of tinnitus via alcohol consumption Psychoacoustic Measures of a Davis, A., Rafaie, E.A., (2000). Epidemiology of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 16). Why Measure Tinnitus? To provide reassurance to the patient that their tinnitus is real To be able to reproduce a similar sound to demonstrate to family and significant others some of the characteristics of the tinnitus experienced by the patient To provide information that might assist in the determination of site in the auditory system where the tinnitus originates To distinguish different subcategories of tinnitus To determine whether the tinnitus has changed To determine if a treatment has had an effect To provide treatment guidelines To determine which patients are likely to benefit from some types of treatment Tyler, R.S. (1992). The psychophysical measurement of tinnitus. In J.M. Aran & R. Dauman (Eds.), Tinnitus 91: Proceedings of the Fourth International Seminar (pp ). Amsterdam, The Netherlands: Kugler Publications Providing Reassurance Producing a Tinnitus Simulation Tyler, R.S., (2000). The Psychoacoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 149). Tyler, R.S., (2000). The Psychoacoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp ). Determination of the Site of Tinnitus Central Involvement Sectioning of the nerve fiber does not reduce tinnitus Masking can reduce the effect of tinnitus in either the ipsilateral or contralateral ear Frequency independent tonal masking of tinnitus There can be the appearance of tinnitus in the contralateral ear with ipsilateral masking of unilateral tinnitus. Tyler, R.S., (2000). The Psychoacoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 172). Determination of the Site of Tinnitus Peripheral involvement Tinnitus sensation in only one ear Etiologies known to effect the peripheral structures Meniere s disease Middle ear disorders Ototoxicity Unilateral sensorineural hearing loss in the ear experiencing the tinnitus Inability to mask unilateral tinnitus from the contralateral ear In a patient with bilateral tinnitus, ipsilateral masking affects only the ipsilateral ear Tyler, R.S., (2000). The Psychoacoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp ). 3

4 Perceptual location Patients perceive their tinnitus One ear Both ears Back, middle (centrally), side or front of their head Outside of their head A distinction between peripheral and central tinnitus cannot be based on the patient s report of tinnitus location Determine which type of patients are likely to benefit from some types of treatment One treatment may benefit one patient and not another Patients can react differently when using an identical acoustic stimulus Ex: one patient may HATE white noise, another may find it relaxing Tyler, R.S., (2000). The Psychoacsoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp ). Tyler, R.S., (2000). The Psychoacoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 150). Determining whether the tinnitus has changed In many patients, the perceptual characteristics of tinnitus changes over time An evaluation could potentially document that the tinnitus itself has not changed, but the patient s view towards it has Measuring TREATMENT EFFECTIVENESS Before treatment During treatment After treatment Measuring EFFECTIVENESS of treatment Re-administer the tinnitus evaluation Re-administer questionnaires Tinnitus Reaction Questionnaire a scale designed to assess the psychological distress associated with tinnitus Tinnitus Handicap Inventory Beck Depression Inventory (PQRS- Medicare Guideline) 21 questions Beck Hopelessness Scale Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology, 42(6), Beck Anxiety Inventory State Trait Anxiety Inventory Tyler, R.S., (2000). The Psychoacoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 150). Tinnitus questionnaires Tinnitus Reaction Questionnaire (TRQ) 26 items rated on a 5 point scale, global measure of degree of distress Score of over 17 is clinically significant Tinnitus Handicap Inventory (THI) 27 items, 3 subcategories: emotional, social, and physical effects of the tinnitus 0-16: Slight or no handicap (Grade 1) 18-36: Mild handicap (Grade 2) 38-56: Moderate handicap (Grade 3) 58-76: Severe handicap (Grade 4) : Catastrophic handicap (Grade 5) Tinnitus Questionnaires Tinnitus Functional Index (TFI) 8 Subscales: intrusiveness of tinnitus sense of control cognitive interference sleep disturbance auditory issues relaxation issues quality of life emotional distress 4

5 TFI SCORING Scoring: o Mean score of 14 (range 0-17) not a problem. o Mean score of 21 (range 18-31) small problem. o Mean score of42 (range 32-53) moderate problem. o Mean score of 65 (range 54-72) big problem. o Mean score of 78 (range ) very big problem Overall Score: o 25 or less = relatively mild tinnitus and little or need for intervention o = significant problems with tinnitus and a possible need for intervention o 50 or greater = tinnitus severe enough to qualify for more aggressive intervention meaningful change occurs when TFI scores are reduced by 13 or more Reference: Henry JA, Stewart BJ, Abrams HB, Newman CW, Griest S, Martin WH, Myers PJ, Searchfield G. (2014) Tinnitus Functional Index Development and Clinical Application. Audiology Today 26(6): Beck Depression Inventory 1-10 These ups and downs are considered normal Mild mood disturbance Borderline clinical depression Moderate depression Severe depression over 40 Extreme depression Beck, A.T., Steer, R.A., Carbin, M.G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty five years of evaluation. Clinical Psychology Review 8(1): Variability of Tinnitus Variability of tinnitus measurements Test-retest variability Normal fluctuation of tinnitus is present in some patients Changes in the tinnitus can be seen as a result of the measurement of the tinnitus (reactive tinnitus, residual inhibition) Errors in judgment as to what constitutes an equal pitch or loudness, and what has been masked, is observed in normal hearing individuals and should be expected in tinnitus patients Tyler, R.S., (2000). The Psychoacoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 151). Variability of Tinnitus The interpretation of the patient s description of quality Patient s description of tinnitus is dependent on their vocabulary and listening experience: Therefore, they have limited significance for interpretation Buzzing, pulsing, ringing, roaring, whistling, hissing, etc. Patients may describe hearing two or more sounds This may suggest separate generators for the two sounds middle ear, inner ear, vascular, etc. Tyler, R.S., (2000). The Psychoacoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 151). It is important to identify patients who may have middle ear pathologies Middle-ear tinnitus resulting from blood-flow abnormalities pulsing, swooshing, or beating tinnitus Middle-ear tinnitus resulting from muscle twitching twitching or clicking tinnitus American Academy of Audiology GUIDELINES Scope of Practice Audiologists are qualified to evaluate, diagnose, develop management strategies, and provide treatment and rehabilitation for tinnitus patients. In evaluating and managing tinnitus, it is helpful and worthwhile for audiologists to work with a multidisciplinary team approach. Comprehensive case history Loudness discomfort levels; Tinnitus pitch matching; Tinnitus loudness matching; Minimal masking level; Subjective questionnaires Professionals that specialize in the assessment and treatment of tinnitus also may find additional audiologic procedures useful for diagnosis and counseling. Tyler, R.S., (2000). The Psychoacoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 151). American Academy of Audiology. (2000). Audiologic guidelines for the diagnosis and management of tinnitus patients. Retrieved from resources/document library/audiologic guidelines diagnosis management tinnitus patients 5

6 Tinnitus assessment appointment guide: 1. Questionnaires 2. Otoscopy 3. Tympanometry 4. Comprehensive audiometry (include up to 16kHz if hearing and equipment permits) 5. Assessment of tinnitus 1. Pitch matching 2. Loudness match 3. Minimum masking level 4. Residual inhibition 6. Loudness discomfort levels (LDL s) Each clinician will undoubtedly evolve his or her own refinements or additions to the basic set of measures described in this article Vernon, J.A., Meikle, M.B., (2003). Tinnitus: clinical measurement. Otolaryngol Clin N Am. 36: Initial interview/case history Overall well being can be captured via questionnaires Time of onset, description, location of the tinnitus Extent to which the patient is bothered External circumstances- noise exposure, lack of sleep, stress Medications Support system- personal, social, occupational relationships Expectations Previous therapies Assessment of Tinnitus: Pitch matching A pitch match can be used to show a correlation with damage to the auditory system (Henry, J.A., Meikle, M.B., 2000) Make audible for the patient; ideally, keep loudness consistent to tinnitus loudness across frequencies Ex: Present at 10dB SL Two Alternative forced choice method Present stimulus to ipsi ear if bilateral tinnitus, contra ear if unilateral tinnitus in two paradigm Choose A (1000Hz) or choose B (4000Hz) Want to include ultra high frequency testing is available American Academy of Audiology. (2000). Audiologic guidelines for the diagnosis and management of tinnitus patients. Vernon, J.A., Meikle, M.B., (2003). Tinnitus: clinical measurement. Otolaryngol Clin N Am. 36: Powers, L., & Ramirez, T. (2014, March). Clinical management of tinnitus. AudiologyOnline, Article Retrieved from: Instructing the Patient I m going to present two tones to you, choice A and choice B I want you to tell me which sound is closest to your tinnitus Present each pure tone for about 5 seconds at 10dB SL or as close to the loudness of their tinnitus Pitch Matching Results The tinnitus pitch is typically matched to a highfrequency tone. the high frequency tone of tinnitus is likely related to the notion that most patients with tinnitus often have high frequency hearing loss octave confusions - If a tone that is one octave above or below the suspected frequency is perceived as closest to the tinnitus pitch Henry, J.A., Meikle, M.B., (2000). Psychoacoustic Measures of Tinnitus. J Am Acad Audiol. 11: Tyler, R.S., (2000). The Psychoacsoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp ). 6

7 Pitch-Matching Results Pitch-matching and the audiogram Tinnitus pitch may occur in the frequency of maximum hearing loss or at the edge of normal hearing and hearing loss. This is variable, but is expected to be in the hearing loss region Tyler, R.S., (2000). The Psychoacoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp ). Example Audiogram Where would you expect the pitch match to be? Several replications are recommended due to the variable nature of pitch matching (at least 7 replications). (Tyler, Conrad-Armes, 1983) Assessment of Tinnitus: Loudness Match Typically matches are very commonly only a few db (usually within 8dB) of threshold Procedure ipsi ear Using the pitch match, present a tone at threshold and instruct the patient to report if it is louder or softer than his tinnitus If a range of values match, indicate there is a range Recommend starting below threshold and increasing in 1dB steps to avoid residual inhibition The Procedure: Loudness Matching Find threshold at the patient s pitch match 1dB steps Instruct the patient I want you to raise your hand when MY sound is as loud as YOUR sound Hit interrupt or continuous on and increase the pure tone in 1dB steps until the patient raises their hand. Repeat for consistency EX: Patient s Threshold 22dB Document the sensation level Loudness Match 31dB = Sensation Level 9dB Henry, J.A., Meikle, M.B., (2000). Psychoacoustic Measures of Tinnitus. J Am Acad Audiol. 11: Benefits of Loudness Matching It allows comparisons across patients. Individuals could be identified who complain of very loud tinnitus, but whose loudness match suggest a soft tinnitus. These patients may require special counseling. Variability for loudness match is typically low, but does vary across patients Tyler, R.S., (2000). The Psychoacoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp ). Assessment of Tinnitus: Minimum Masking Level Measure for both white noise and narrowband noise Can also use pure tones Along with finding MML, finding a point in which the tinnitus is mostly obscured or a point of sufficient relief, has value since many patients find a low level masker blocks the majority of their tinnitus, but to get complete masking requires much louder stimuli Vernon, J.A., Meikle, M.B., (2003). Tinnitus: clinical measurement. Otolaryngol Clin N Am. 36: American Speech Language Hearing Association. (n.d.). Tinnitus and Hyperacusis. (Practice Portal). Retrieved 12/1/2018 from Portal/Clinical Topics/Tinnitus and Hyperacusis/. 7

8 The Procedure: Minimum Masking Level Broadband noise Threshold search (down to 1dB steps), begin at low db to reduce RI Present noise at threshold and ask if he can hear his tinnitus Increase level until tinnitus can no longer be heard 1dB steps Document sensation level Vernon, Meikle (2003) Instruct Patient: Raise your hand when you can no longer hear YOUR sound EX: Threshold 12dB Masking Level 18dB = Sensation Level 6dB Assessment of Tinnitus: Minimum Masking Level Masking theories: One sound can mask (or swamp) another because that masker has rendered the neural channel busy, similar to a busy telephone line One sound suppresses the neural activity of the other sound The presence of another sound can mask tinnitus completely Document Complete vs Partial Masking Tyler, R.S., (2000). The Psychoacoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 161). Assessment of Tinnitus: Residual Inhibition Procedure: Present white noise at MML + 10dB for 60 seconds At the end of the 60 seconds, ask if the patient can hear their tinnitus, and if so, is it reduced Record the time required for the tinnitus to return to normal Complete Partial No Change Reactive Since the phenomenon of RI has little bearing on long term habituation, it s usefulness from a counseling standpoint is limited Subjective Loudness Scale Not required for reimbursement Procedure Ask the patient how loud their tinnitus is on a scale of 1 10 (not severity or annoyance) THIS IS THE SUBJECTIVE RATING Present tones at the pitch match: at threshold, at the loudness match, and at least two levels 5 10dB above the loudness match (4 levels total) For each presentation, ask the patient to rank the loudness on the same 1 10 scale Sounds may be presented multiple times and averaged (do twice for consistency) The ranking at the loudness match is the SEMI OBJECTIVE RATING The difference between the semi objective rating and the subjective rating is the magnitude of hyper monitoring Vernon, J.A., Meikle, M.B., (2003). Tinnitus: clinical measurement. Otolaryngol Clin N Am. 36: Subjective Loudness Scale Loudness Match Threshold 23dB Loudness 30dB SL 7dB Subjective Loudness Rating (1 10) 8 Threshold [25dB] 1 Loudness Match [30dB] 3 10dB SL [40dB] 7 20dB SL [50dB] 8 Reactive tinnitus Reactive tinnitus is an extreme and rare condition Tinnitus is worsened after exposure to mild-moderate levels of sound Increase tends to last for more than a day RED FLAGS FOR REACTIVE TINNITUS After RI testing, the tinnitus is reported as exacerbated Suspected in people who report a history of: Over-use of hearing protection when not indicated Have found nothing that reduces their awareness of tinnitus Have had trials with other acoustic based treatments (ex: amplification) that has not been successful Keaton, C. (2014, July). Your role in treating the tinnitus patient: What s your professional responsibility? Audiology Online, Article Retrieved from: 8

9 Classification of Hyperacusis Impact on tinnitus treatment Hyperacusis None/Negative Mild Moderate Severe Loudness Discomfort Levels 95 db or greater at all frequencies db at 2 or more frequencies db at 2 or more frequencies 60 db or lower at 2 or more frequencies 8% to 40-50% of patients with disturbing tinnitus report Hyperacusis. If not addressed appropriately, this condition can: Prevent patient from achieving relief from sound therapy Contribute to stress which can exacerbate tinnitus HAVE TO ADDRESS BEFORE TINNITUS CAN BE EFFECTIVELY MANAGED Goldstein, B., Shulman, A., (1996). Tinnitus Hyperacusis and the Loudness Discomfort Level Test A Preliminary Report. International Tinnitus Journal 2: Keaton, C. (2014, July). Your role in treating the tinnitus patient: What s your professional responsibility? Audiology Online, Article Retrieved from: CPT Codes : ICD:10 H93.13: TINNITUS, BILATERAL H93.11: TINNITUS, RE H93.12: TINNITUS, LE H93.19: TINNITUS, UNSPECIFIED Going Over the Results The Audiogram Use the patients audiogram to help your case What did we want to accomplish today? Tinnitus evaluation: going over results Explain what we were testing Discuss the audiogram first Go over hearing test and include discussion about high frequency testing With tinnitus this frequency will often be damaged With loss of hearing, brain will search for sound Nerves over-firing and will create it s own sound Similar to phantom limb pain: sensory receptors over-firing 9

10 : Going over the results What did we want to accomplish today? Could we match the pitch of your tinnitus? Could we measure how loud it is? Could we cover it up? The Questionnaires What was their score on the TRQ? What was their score on the Beck Depression? Use this information to help validate the patient s feelings towards their tinnitus Going over results Phone Apps (i.e.: Resound Tinnitus Relief) Sound clips to download Use sound to take edge off, use minimal level to blend with tinnitus Night time and quiet time Tinnitus triggers Sodium Caffeine Alcohol Nicotine Alternative Treatment options Yoga Acupuncture PROMOTE RELAXATION Treatment Options Take into account: Hearing Loss? How bothered is the patient? When is it most bothersome? Treatment Options Informational/Educational Counseling Self help groups Sound Therapy Wearable Devices Non-wearable Devices Amplification/Combination Devices Counseling Series/Cognitive Behavioral Therapy Stress Management American Speech Language Hearing Association. (n.d.). Tinnitus and Hyperacusis. (Practice Portal). Retrieved 12/1/2018 from Portal/Clinical Topics/Tinnitus and Hyperacusis/ American Academy of Audiology. (2000). Audiologic guidelines for the diagnosis and management of tinnitus patients. Retrieved from 10

11 Tinnitus Specific Management Programs Tinnitus Masking Tinnitus Retraining Therapy (TRT) Pawel J. Jastreboff, Ph.D. Progressive Tinnitus Management (PTM) James A. Henry, Ph.D. Tinnitus Activities Treatment (TAT) Richard Tyler, Ph.D. Category Hyperacusis Prolonged Sound Induced Exacerbation Hearing Loss Impact on Life Treatment 0 Low Counseling Only 1 High Sound generators set at mixing point 2 Present High Hearing aid with stress on enrichment of auditory background 3 Present Not relevant 4 present present Not relevant High High Sound generators set above threshold of hearing Sound generators set at threshold; very slow increase of sound level TRT Jastreboff, P., Jastreboff, M., (2000) Progressive Tinnitus Management 5 Individualized Support 4 Interdisciplinary Evaluation 3 Group Education 2 Audiological Evaluation 1 Triage Bothersome Tinnitus (10 15% of the tinnitus population) Non Bothersome Tinnitus (80% of the tinnitus population) Tinnitus Activities Treatment Is provided for free on the University of Iowa website A counseling and sound therapy treatment Picture based Focused on individual needs Directed at primary areas affected by tinnitus Thoughts and emotions Hearing and communication Sleep Concentration National Center for Rehabilitative Auditory Research. Progressive Tinnitus Management: Clinical Handbook for Audiologists. Retrieved from Case Study #1 Case Studies Case History: Patient describes their ringing as high pitched and constant. They specifically notice it at night, however, it does not interfere with sleep. No concerns with hearing, no noise exposure. 11

12 Case Study #1 TRQ: 14 12kHz threshold: R/L: 70dB Pitch Match: 8kHz Loudness Match: 55dB, 10dBSL right ear 43dB, 11dBSL Left Ear Minimum Masking Level: BBN: 7dBSL Right 7dBSL Left MML: NBN: 11dBSL Right 13dBSL Left Subjective Loudness Scale: 2 Residual Inhibitions: Complete Beck s Depression Screening: 2 Case Study #2 Case History: Patient was involved in a car accident that resulted in a traumatic brain injury. Ever since the car accident, she has experienced tinnitus in her right ear that is constant and extremely bothersome. She reports that doesn t feel like she is in control of her life anymore, as the ringing has made her avoid social situations. Case Study #2 TRQ score: 82 Pitch Match: 4kHz Loudness Match: 75dB, 15dB SL RE Minimum Masking Level: BBN: 22dBSL RE MML: NBN: could not achieve Subjective Loudness Scale: 9 Residual Inhibitions: Partial ~2 minutes Beck s Depression Screening: 30 Case Study #3 Case History: Patient reports difficulty hearing in background noise. Ringing in the ears began about a year ago. For the most part, they are able to put it in the background and not focus on it, but sometimes, it becomes very annoying, specifically at night. Case Study #3 TRQ: 25 12kHz threshold: R/L: 80dB Pitch Match: 4kHz Loudness Match: 51dB, 10dB SL RE 50dB, 13dB SL LE Minimum Masking Level: BBN: 8dB SL RE 12 db SL LE MML: NBN: 10dB SL RE 14dB SL LE Subjective Loudness Scale: 3 Residual Inhibitions: No change Beck s Depression Screening: 0 Case Study #4 Case History: Patient reports ringing in the ears that began after a severe episode of vertigo. During the episode, the patient experienced roaring tinnitus and vomiting, however the tinnitus is now a constant low pitched ringing sound in the right ear. Their primary care physician referred them to you as the first specialist for the patient to see. 12

13 Case Study #4 TRQ: 60 12kHz threshold: R/L: 25dB Pitch Match: 500Hz Loudness Match: 73dB, 24dB SL RE Minimum Masking Level: BBN: 21 db SL RE MML: NBN: 18 db SL right ear Subjective Loudness Scale: 8 Residual Inhibitions: Partial ~1 minute Beck s Depression Screening: 25 Case Study #5 Case History: Patient reports hearing loss. Ringing began over the last few years. It is causing him anxiety and emotional stress. He no longer socializes. Primary concern is sleep. Current hearing aid user, uses inconsistently because he reports they are too loud. Case Study #5 TRQ: 70 12kHz thresholds: R/L: No Response Pitch Match: 2kHz Loudness Match: 60dB, 19dB SL LE Minimum Masking Level: BBN: 29dB SL LE MML: NBN: could not achieve Subjective Loudness Scale: 9 Residual Inhibitions: Partial ~ 2min Beck s Depression Screening: 40 Loudness Sensitivity (assume similar results to RE) Case Study #6 Case History: Case History: Patient reports difficulty hearing in her left ear. She noted that her ear feels plugged and can remember the exact day that it happened. Since that time, she has had loud constant tinnitus in the left ear. It makes her feel uneasy and unable to concentrate on daily activities, and it wakes her up at night. She was referred to you by her PCP. Case Study #6 TRQ: 75 Pitch Match: 3kHz Loudness Match: 50dB, 15dB SL RE 40dB, 10dB SL LE Minimum Masking Level: BBN: 34dB SL RE 15dB SL LE MML: NBN: 30dB SL RE, 24dB SL LE Subjective Loudness Scale: 8 Residual Inhibitions: no RI achieved Beck s depression screening: 40 UT Current Research on Tinnitus Effect of hearing aid noise floor on tinnitus loudness Patrick Plyler, Ph.D., Brittany Grayless, Au.D. Marisa Fazzari, Graduate Student Correlations between Tinnitus Reaction Questionnaire and Quality of Life Measures Brittany Grayless, Au.D., Mark Hedrick, Ph.D., Jennifer Hausladen, Au.D. 13

14 References: American Academy of Audiology. (2000). Audiologic guidelines for the diagnosis and management of tinnitus patients. Retrieved from Beck, A.T., Steer, R.A., Carbin, M.G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty five years of evaluation. Clinical Psychology Review 8(1): Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology, 42(6), Broadbent, D., & Broadbent, M. (1988). Anxiety and attentional bias: State and trait. Cognition and Emotion, 2, Davis, A., Rafaie, E.A., (2000). Epidemiology of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 15). Erlandsson, S.I., (2000). Psychological Profiles of Tinnitus Patients. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 33 34). Goldstein, B., Shulman, A., (1996). Tinnitus Hyperacusis and the Loudness Discomfort Level Test A Preliminary Report. International Tinnitus Journal 2: Heller AJ. (2003). Classification and epidemiology of tinnitus. Otolaryngologic Clinic of North America, 36(2): Henry, J.A., Meikle, M.B., (2000). Psychoacoustic Measures of Tinnitus. J Am Acad Audiol. 11: Henry J.A., Stewart B.J., Abrams H.B., Newman C.W., Griest S., Martin W.H., Myers P.J., Searchfield G. (2014). Tinnitus Functional Index Development and Clinical Application. Audiology Today 26(6): Keaton, C. (2014, July). Your role in treating the tinnitus patient: What s your professional responsibility? Audiology Online, Article Retrieved from: Questions? Mazurek B, Haupt H, Olze H and Szczepek AJ (2012) Stress and tinnitus from bedside to bench and back. Front. Syst. Neurosci. 6:47. doi: /fnsys National Research Council (US) Committee on Hearing, Bioacoustics, and Biomechanics. Tinnitus: Facts, Theories, and Treatments. Washington (DC): National Academies Press (US); Powers, L., & Ramirez, T. (2014, March). Clinical management of tinnitus. AudiologyOnline, Article Retrieved from: Salvi, R.J., Lockwood, A. H., Burkard, R. (2000). Neural Plasticity and Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp ). Tyler, R.S. (1992). The psychophysical measurement of tinnitus. In J.M. Aran & R. Dauman (Eds.), Tinnitus 91: Proceedings of the Fourth International Seminar (pp ). Amsterdam, The Netherlands: Kugler Publications Tyler, R.S., (2000). The Psychoacoustical Measurement of Tinnitus. In: Tyler, R. S. (Ed.). Tinnitus Handbook. Clifton Park, NY: Thompson Delmar Learning. (pp 149). Tyler, R.S., Conrad Armes, D., (1983). Tinnitus Pitch: A Comparison of Three Measurement Methods. Br J Audiol 17(2): Veile, A., Zimmerman, H., Lorenz, E., Becher, H. (2018) Is smoking a risk factor for tinnitus? A systematic review, meta analysis and estimation of the population attributable risk in Germany. BMJ Open, 8(2) Vernon, J.A., Meikle, M.B., (2003). Tinnitus: clinical measurement. Otolaryngol Clin N Am. 36: Zelman, S. (1973). Correlation of smoking history with hearing loss. Journal of the American Medical Association, 233, 920. brinehar@uthsc.edu 14