Tinnituspaloosa 10/24/2008. Paula Schwartz, Au.D. Tinnitus and Hyperacusis Clinic Edina, MN.

10/24/2008 Tinnituspaloosa Paula Schwartz, Au.D. Tinnitus and Hyperacusis Clinic Edina, MN. Tinnitus and Hyperacusis Clinic 6444 Xerxes Ave. South Edina, MN 55423 952-831-4222 www.tinnitusclinicminnesota.com plschwartz@msn.com t 1

10/24/2008 Why Add Tinnitus To Your Practice? Passionate about Tinnitus? Business Decision? Market Niche? Sell More Hearing Aids? Help the Tinnitus it Patient? t? Increased revenues? Haven t a clue, just curious Jump in Feet First!! Jastreboff s course in TRT ATA online course Neuromonics training Reading materials Other audiologists i ATA professional level listserv Business Considerations Why a separate LLC? Do insurances cover tinnitus? Pros and cons to being a participating provider Medicare and ABN forms Pi t P Private Pay Bundle or Unbundle? 2

10/24/2008 Staffing and Timing Considerations Telephone inquiries Associate or office staff support Initial tinnitus assessment Follow up care and programs Reports Financial Considerations To bundle or not to bundle, that is the question pros and cons Initial assessment fees for audiology versus tinnitus Charges for hearing aids, sound generators, sound enrichment equipment, Neuromonics etc. Fee for Service Relationships with Medical Community Otolaryngologists Audiologists Multidisciplinary Teams - sleep specialist - psychologist - otologist Primary Care docs 3

10/24/2008 Marketing Internet!!!!!!!!! Physician journals Primary Care physicians Seminars to ENT practices Local media/television i i Neurologists, psychologists, balance clinics If the tinnitus patient is your passion: Do your homework Set up the business model knowing that tinnitus is not covered by insurers Realize that profits from tinnitus are less than hearing aids. Patients are needy, volatile and time consuming Realize that increased hearing aid sales are NOT part of the tinnitus clinic BUT DO REALIZE: a tinnitus clinic adds credibility if done well; adds additional revenue; and provides a great satisfaction that you have helped individuals who are in desperate need of assistance as the most of the medical community has blown them off. 4

HYPERACUSIS IT HURTS TO TALK IT HURTS TO TALK Collapse of loudness tolerance in other words, sound hurts! 1

How to identify the tinnitus patient That s easy. The patient comes in with earplugs in his pockets always! Often the patient speaks in a very soft voice The case history shows the patient s quality of life is severely affected by hyperacusis SOUNDS OF HYPERACUSIS CASE HISTORY FOR HYPERACUSIS NAME DOB LAST FIRST ADDRESS TEL. STREET CITY ZIP REFERRED BY 1. When were you first aware of having sensitivity to sound? What sounds bother you? 2. vacuum cleaner baby/child crying traffic noise store noise your own voice dishes rattling refrigerator/air conditioner Other Have you made major changes in your life style due to your sensitivity to sound? 3. No Yes Explain 2

Questionnaire cont. Name 4. Do you wear earplugs No Yes, most of the time Yes, sometimes If yes, when do you wear earplugs? If yes, what kind of earplugs do you wear? 5. Do you have ringing in the ears (tinnitus)? No Yes, most of the time Yes, sometimes If yes, which is worse the tinnitus or the sensitivity to sound? 6. Do family members and friends understand how sensitivity to sound affects you? Yes No 7. Have you tried any treatments for your sensitivity to sound? Questionnaire, cont. 8. Do you feel you have a hearing loss? Yes No If yes, would you be willing to wear a specially made hearing aid (s) if you feel it would help your sensitivity and improve your hearing? Yes No If no, would you be willing to wear a special device(s) to help your sensitivity? Yes No Recommendation: Counseling Desensitization using.. Wearable sound generators using pink noise Neuromonics Combination units with hearing aid and sound generator Sound machine Gradual independence from earplugs Testing for hyperacusis Since you have taken the case history and you see that the patient s work, social and spare time are affected by the hyperacusis, testing is secondary to identification LDLs are the usual way we test for hyperacusis but go slowly. Start at 10 db SL and go up in 5 db steps to 75 db and then go up in 2 db steps. Don t reach for it. The patient will not thank you for it. 3

What causes hyperacusis? (Demystification) Theories only caused by noise trauma, medication, Mennieres, Lyme disease The efferent portion of the auditory nerve is damaged and does not do its job of damping loud sounds The facial nerve is not activating the stapedius muscle The dorsal cochlear nucleus does not inhibit aberrant nerve firing Additional influences Phonofobia sensitivity to sound may lead to fear of sound which leads to avoidance of sound. The Limbic system (emotions) goes into high gear in the presence of sound The reaction of significant others can help or hinder the reaction to sound. What else is going on in the patient s life (loss of job, divorce, change in health status) And the wearing of earplugs Interesting study at the University of Marland (Craig Formby, PHD) Volunteers wore earplugs 23 hours a day After two weeks, sounds were very loud! Those who wore sound generators found sounds less loud 4

EAR PLUGS Treatment for hyperacusis Demystification does this sound familiar? Sound therapy desensitization Hearing aids with compression limiting Hope Relaxation A sound level meter Sound levels (Demystification) Approx. Decibel Level 0 Faintest sound heard by human ear. 30 Whisper, quiet library. 60 Normal conversation, sewing machine, typewriter. 90 Lawnmower, shop tools, truck traffic; 8 hours per day is the maximum exposure to protect 90% of people. 100 Chainsaw, pneumatic drill, snowmobile; 2 hours per day is the maximum exposure without protection. 115 Sandblasting, loud rock concert, auto horn; 15 minutes per day is the maximum exposure without protection. 140 Gun muzzle blast, jet engine; noise causes pain and even brief exposure injures unprotected ears. Maximum allowed noise with hearing protectors. 5

OSHA STANDARDS (Demystification) Duration per Day Sound Level dba slow response 8 90 6 92 4 95 3 97 2 100 1 ½ 102 1 105 ½ 110 ¼ or less 115 DESENSITIZATION USING SOUND TO TREAT SOUND SENSITIVITY SOUND GENERATORS SET AT A VERY LOW LEVEL MAY BE TURNED OFF FOR THE FIRST WEEK GRADUALLY INCREASE THE SOUND PINK NOISE PINK NOISE The amplitude decreases with frequency at a constant rate per octave (3db). The lower frequencies are louder than the high frequencies. Pink noise closely matches the spectrum of sound that we hear in our everyday world. That is why it is most important to increase our tolerance to these frequencies. White noise has equal energy to all frequencies. Since hyperacusis patients are more sensitive to high frequencies, white noise is not the sound of choice for therapy. It tends to slow our progress on re-establishing our tolerances because of the high frequency content in white noise. Hyperacusis network 6

INSTRUMENTS WEARABLE SOUND INSTRUMENTS GENERAL HEARING INSTRUMENTS HANSATONE UNITED HEARING NEUROMONICS MUSIC CD BEDSIDE SOUND MACHINE HOW EFFECTIVE IS TREATMENT? Very! In three or four months, patient can usually tolerate the vacuum cleaner, dishes clattering.. may not be able to take the ambulance sirens In a year, life is fairly normal. What happened in the auditory system? It re-set to normal function GOOD WEBSITE All of your patients have seen the hyperacusis network website http://www.hyperacusis.net/ Dan Malcore, editor, has saved lives with this network. It is good! Compare it to the following: 7

HYPERACUSIS REMEDY Hyperacusis Remedy (SinusWars18) Ingredients: All of the ingredients used in the SinusWars18 remedy are prepared homeopathically making them completely safe. The unique combination of these exceptional ingredients makes SinusWars18 an extremely effective and fast working remedy for the treatment of hypersensitive hearing. Borax This ingredient was formed at the bottom of past ancient lakes as white mineral salts. It has no odour and dissolves quickly in liquid solutions. Borax treats the following symptoms: Feeling of falling Nausea and vomiting Anxiety and nervousness Sensitivity to sudden noises Ringing in the ears and ear noises Phonophobia (fear of sound) Hypersensitive hearing Theridion This ingredient is obtained from the venom of a small spider that is found on the island Uacao in the West Indies Through the homeopathic preparation of this ingredient, TinnitusWars renders this product completely safe without any side effects. Remedy (continued) Theridion is used to treat the following symptoms: Hypersensitive hearing Headaches induced by noise Dizziness caused by loud noise Anxiety and panic attacks Belladonna This ingredient has been used for centuries and is often referred to as the "deadly nightshade". The ingredient is obtained from a herb that is highly toxic in its original form. Homeopathic preparation of this ingredient not only makes it safe to consume but also makes it a useful treatment for dizziness. Belladonna treats the following symptoms: Dizziness from sudden movements Vertigo Hypersensitivity in all the sense, especially hearing. Head congestion and pain Ear pain Nux Vomica This ingredient is commonly known as the poison nut and once homeopathically prepared is completely safe to use. This ingredient comes from the nut tree that grows naturally in the Far East. Nux Vomica is used to treat: Hypersensitive hearing (hyperacusis) Relax the nervous system Phonophobia Outcome Measures Can you use the vacuum cleaner? Can you go for a drive in the car? Can you go to shopping mall? Can you enjoy eating in a restaurant? (If you want, you can measure the LDLs again, but that is not really the point. ) 8

HOW TO BILL You will bill insurance/medicare for the hearing test For the consultation, you will have to bill out of pocket I charge $150 beyond hearing testing If wearable sound generators are ordered, I charge $2600 for binaural. Neuromonics is out of pocket around $5500 Rewards A new service in your office Seeing your patient enjoy life again A small monetary reward 9

Tinnitus research: Why most of it is bunk and the challenges of exploring the brain William Hal Martin, Ph.D. Oregon Health Sciences University Oregon Hearing Research Center OHSU Tinnitus Clinic ADA 2008

Oregon Health & Science University Tinnitus Programs Research Oregon Hearing Research Center Patient Care OHSU Tinnitus Clinic Prevention Dangerous Decibels

OHSU Tinnitus Programs Patient Care Research Prevention Tinnitus Clinic is in the Oregon Hearing Research Center 98% of our patients participate in research 30% of all hearing loss is related to sound exposure and could be prevented >75% have history of sound exposure 22% of our patients report noise as key factor in onset Dangerous Decibels = tinnitus prevention & research

OHSU Tinnitus Clinic Patient Care Over 32 years of continual tinnitus care Multi-disciplinary audiology, medicine, neuroscience, pharmacology, psychology, psychiatry Team-approach All clinicians work together Individualized Individualized - Care structured according to each patient s condition, life situation and needs. Whatever it takes

What is tinnitus? The perception of sound, typically in the absence of an external acoustic signal. Objective - mechanical source Subjective - physiological but nonmechanical source Neural signals interpreted by the brain as sound

Mechanisms of Tinnitus INDUCTION Peripheral damage Excitatory / inhibitory imbalance Abnormal spontaneous neural activity MAINTENANCE Reverberant firing patterns Non-auditory systems

Neurophysiological Model of Tinnitus Jastreboff, 1990 SOUND PERCEPTION & EVALUATION Auditory and other cortical areas DETECTION Sub-cortical areas SOURCE Cochlea & auditory nerve

Neurophysiological Model of Tinnitus Jastreboff, 1990 SOUND PERCEPTION & EVALUATION Auditory and other cortical areas DETECTION Sub-cortical areas SOURCE Cochlea & auditory nerve EMOTIONAL ASSOCIATIONS Limbic system REACTIONS

How does tinnitus affect patients?

HSU Tinnitus Clinic Difficult to concentrate 85 % Difficult to relax 85 % Irritable or nervous 83 % Uncomfortable in quiet 83 % Tired or stressed 81 % Interfere with social activities 74 % Hard to interact pleasantly 73 % Problems with sleep 73 % Cause you to feel depressed 70 % Interfere with work activities 66 % Martin et al., 2002

Why does tinnitus become a problem?

Problematic Tinnitus Novelty Fear Selective attention Reinforcement Negative counseling There s nothing that can be done about it You may have a brain tumor

Treatment vs. Management

Problematic Tinnitus MD visit 94% of normal hearing adults hear tinnitus in extreme quiet 4% of the population seek medical help for tinnitus

Problematic Tinnitus MD visit Active disease No active disease

Problematic Tinnitus MD visit Active disease No active disease Objective tinnitus

Active disease Objective tinnitus Vascular abnormalities Congential arteriovenous fistula Acquired arteriovenous shunt Glomus juglare High-riding carotid artery Carotid stenosis Persistent stapedial artery Dehiscent juglar bulb Vascular loop (e.g. AICA or PICA)

Active disease Objective tinnitus Mechanical disorders Patent Eustachian tube Palatal myoclonus Temporomandibular joint disorder Stapedial muscle spasticity

Problematic Tinnitus MD visit Active disease No active disease Subjective tinnitus

Active disease Subjective tinnitus Otosclerosis Infections bacterial, viral, fungal Autoimmune hearing loss Endolymphatic hydrops / Meniere s Neoplasms Otitis media Benign intracranial hypertension

Active disease Subjective tinnitus Genetic predisposition Ototoxicity Vascular hypertension, CVA, cerebral aneurysm, arteriosclerosis Metabolic anemia, hypothyroidisim, diabetes mellitus Head or neck injury

Problematic Tinnitus MD visit Active disease No active disease Treatment Resolved

Problematic Tinnitus MD visit Active disease No active disease

No active disease Subjective tinnitus Presbycusis Noise induced hearing loss - chronic Noise induced hearing loss acute Genetic predisposition Ototoxicity Otosclerosis Post-operative hearing loss Endolymphatic hydrops / Meniere s Idiopathic tinnitus

Problematic Tinnitus MD visit Active disease No active disease Treatment Resolved Tinnitus Management

As with chronic pain, the treatment of chronic tinnitus is more accurately described in terms of management rather than cure. Duckro et al. Biofeedback and Self-Regulation 1984;9(4):459-469

Goal of Treatment Program To medically or surgically resolve active disease processes causing tinnitus To eliminate the presence of tinnitus Whenever possible, active disease processes should be identified and treated prior to tinnitus management

Goal of Management Program Reduce tinnitus perception until it is no longer a controlling factor in the person s life Provide long-term relief

Tinnitus Management

Components of Management Program Acoustical therapy to reduce perception of tinnitus Counseling and education to reduce reaction to tinnitus Address parallel confounding problems

Acoustical therapy Using sound to reduce tinnitus perception Facilitate: Habituation Relief Cortical reorganization

Acoustical therapy: First recorded case Titus returns to Rome after conquering Judea and destroying the Temple Babylonian Talmud - Gittin, 56b Died September 13, 81 A.D.

Counseling and education

Address confounding parallel problems

48 44 40 TINNITUS SEVERITY INDEX SCORE 36 32 28 24 20 16 12 NON- DEPRESSED PATIENTS DEPRESSED PATIENTS Folmer RL, Griest SE, Meikle MB, Martin WH. Tinnitus severity, loudness and depression. Otolaryngology - Head and Neck Surgery 1999; 121:48-51

Key concept Tinnitus management takes time

What s on the horizon? News at 11

OHSU Tinnitus Clinic Research Epidemiology of Tinnitus Oregon Tinnitus Data Registry database of 700+ items from over 5,000 tinnitus patients Tinnitus severity measures Tinnitus Functional Index establishing the gold standard for tinnitus evaluation Neurobiology of tinnitus determining the brain s role Clinical trials for tinnitus treatment - Acamprosate

Tinnitus research is a nightmare Different and complex: Triggers Time courses Manifestations Severity / impact Outcome measures? Experimental controls? Subject selection?

Participant selection: Why not everyone? Subjective vs. objective tinnitus Tinnitus duration Other medical conditions Current or recent medications Other tinnitus treatments Tinnitus stability Psychiatric stability Age Gender Hearing function Tinnitus etiology Tinnitus location Tinnitus characteristics Baseline severity

Study design How many participants do you need? Eliminate non-responders - Enriched enrollment Does it really work? Double-blind with placebo Who does it work for? Identify predictive factors multiple regression analysis

How do you design a clinical trail for a tinnitus treatment? Participant selection Study design Outcomes measures

Outcome measures What constitutes improvement? Psychoperceptual improvement Global severity improvement

Consequences of poor design Results can not be interpreted Results may over or underestimate effectiveness This research is a waste of time and money

Clinical Trial of Acamprosate Developed to prevent alcoholism relapse Possibly rebalances excitatory and inhibitory neurotransmitters in brain Pilot study in Brazil showed significant decrease in how disturbing tinnitus was