Tinnitus Defining Tinnitus Management of the Tinnitus Patient Jill Meltzer, Au.D. North Shore Audio-Vestibular Lab 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 ILAAWSHA 2015 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 serviceconnected disability of veterans returning from Iraq and Afghanistan. Tinnitus and hearing loss top the list of warrelated health costs Since 25, veterans receiving serviceconnected 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 1
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, (24) 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 (HA) Yes definitely, yes sometimes, no not much, no not at all Tinnitus Functional Index (TFI) 2
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 3
The Neuronal Network Aage Moller Tinnitus Subconscious Pathways Neuronal Network Auditory Nerve Cochlea External sounds enter Auditory cortex (Awareness) The brain is very plastic New connections constantly forming Brain can relearn, be retrained 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) 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 Use Visuals Vicious Cycle Go back to case history Lifestyle Medications Medical history Diabetes High blood pressure Alcohol use Noise exposure Military experience conscious subconscious 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 4
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 Devices Just to name a few 5
1/25/15 Acoustic Therapies Rationale for Music Therapy 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 Feature 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 Sanctuary Haven Oasis Multiple headphone options Sleep timer Single and continuous External speaker Sub charging and synching Adjustable startup volume level Data log viewing Traditional 4 tracks Phase 1 Stimulus Adjustable Phase 1 Stimulus level Balance adjustment Prog. Muscle Relaxation Programmable through NOAH Add. Music tracks to choose Phase 2 scheduling 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 Neuromonics: Phased Treatment Stage 1 (~ 2 months) 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 Other Treatments Active Treatment (~ 4 Months) Stage 2 Lower level of interaction Shower noise removed Intention: Gradual reduction in awareness & disturbance between periods of listening Acoustic Coordinated Reset Neuromodulation 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 6
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/freetinnitus-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 7
1/25/15 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 Beyond Tinnitus Table Top Devices 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. Application Search Search at Apple app store and Google play Over 60 items Some free Some a few dollars Most expensive $99.99 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. Ear Level Devices Sound Soother 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 BeyondTinnitus.com ipod sharperimage.com iphone Tranquil Moments: Sleep sound therapy brookstone.com Travel Tranquil Moments Travel Sound Soother sharperimage.com Marsona Marsona.com 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 8
Amazon Amazon Rich Tyler - Univ. of Iowa Nature sounds Over 31,0 Relaxation Over 63,0 White noise Over 66 Brown noise Over 2 Pink noise Over 650 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 (25) 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 Category TRT Categories 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 9
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? Perceptions Influence Reactions Not So Soothing Image Same input, different interpretations 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 28;29, 288-290 10
1/25/15 LM Timeline LM QRA Concerts General sense of well being Light sensitivity Tinnitus Insomnia Hypersensitive Anxious LM Audio 12 80 60 40 0 10 20 30 40 50 60 70 80 90 1 110 Other Right Left RE LDL LE LDL 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 Depressed after the concussion Had difficulties LM Audiogram July 2013 Unsure No 30 Yes 0 Unsure 20 Sports events No 0 Church/ Temple Yes 10 Falling Sleep Restaurants Unsure Hearing Concentration Staying Asleep No Hyperacusis Yes 50 Tinnitus Activity 25 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 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,0 Onset 12-2012 LM LM Data Left Ear LDL s 120 80 70 1 70 1 84 80 49 44 42 July 2013 40 30 84 76 80 50 88 84 60 26 60 56 52 Series1 50 44 Oct. 2013 28 26 25.6 20 44 42 42 LE 6K LE 8K Series2 40 20 11 10 6 5 4 0 LE.5K 0 TRQ THI % HA A HA D Khalfa LE 1K LE 2K LE 3K LE 4K TFI Series 1- July Series 2 - October 11
RE LDL s LM Lake Thoreau 120 1 80 60 40 20 0 1 92 92 92 92 94 86 66 58 60 56 58 58 54 RE.5K RE 1K RE 2K RE 3K RE 4K RE 6K RE 8K Series1 Series2 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 Series 1 July Series 2 - October Patient reports he had intermittent tinnitus 5 or 6 years ago, but for last 12 days it s unbearable Tinnitus onset following a 4 th 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 Tinnitus described as ringing, roaring whooshing sound Not pulsatile Audible over loud noise Aggravated by stress and being in quiet environment Concentration severely impaired Audio 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 1% of the time Disturbed 90% to 1% of the time Having trouble functioning at work Tinnitus Hyperacusis Hearing Activity Yes No Unsure Yes No Unsure Yes No Unsure Concentration Falling Sleep Staying Asleep Restaurants Church/ Temple Sports events QRA Concerts General sense of well being Other Tinnitus pitch matched closest to 12,0 Hz. (6dB SL) MML 40dB - 42dB Performed in each ear and binaurally Hyperacusis not indicated 12
Had issues with anxiety and depression in 23 and 25 Medications Just started on Zoloft Lorazepam (Ativan) for anxiety and tinnitus relief Mirtazapine (Remeron) for sleep Offered to try ALL tinnitus treatments 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 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 Data Data 13