Tinnitus: an Introduction, Mechanisms and Theories

Tinnitus: an Introduction, Mechanisms and Theories Richard Tyler The University of Iowa What is it like to have tinnitus? What if you heard a sound that wasn t supposed to be there? Unpleasant No control over it No cure! Nobody understands! Sign of serious illness? There for life? 3 4 DEFINITION OF TINNITUS (AFTER McFadden, 1982) PERCEPTION OF SOUND must be heard INVOLUNTARY not produced intentionally ORIGINATES IN HEAD not super hearing of an external sound Other Considerations FREQUENCY OF PERCEPTION Needs to be often to be a problem MAGNITUDE OF DISTRESS Degree of impact on life Tinnitus is a symptom, like hearing loss 1

Categories of Tinnitus Middle ear Originates in the middle ear Sensorineural Originates in the sensorineural system Parallels how we diagnose and treat hearing loss Other Categories of Tinnitus Objective (really means Middle ear) objective because it can be heard, but some spontaneous otoacoustic emissions from cochlear can be objectively measured Subjective (really means Sensorineural) SENSORINEURAL TINNITUS COCHLEAR VASCULAR MECHANICAL SENSORY NEURAL RETROCOCHLEAR NEURAL BRAINSTEM CENTRAL Physiological Models of Tinnitus Perception, must be in Temporal Lobe Increased spontaneous activity fed by increase, decrease, or edge Cross fiber correlation normal or increased spontaneous activity (Eggermont, Moller) More fibers with similar best frequency following hearing loss (Salvi et al.,) Reaction to Tinnitus Amygdala, autonomic nervous system Theories of Tinnitus increased spontaneous activity Theories of Tinnitus cross fiber correlation Hearing Nerve Spontaneous activity in quiet normal Normal Unrelated Activity Table No external sound - Tinnitus The word table Normal perception of sound Quiet with lots of random activity Activity is heard (tinnitus) Related Activity Across Nerve Fibers 2

Auditory Brain Reorganization After Hearing Loss (AFTER SALVI, LOCKWOOD AND BURKARD) Hair cells destroyed Corresponding silent regions in brain After months, silent neurons respond in normal way, but to same frequencies as adjacent regions Over representation of these frequency regions in brain TINNITUS PERCEIVED STOUFFER AND TYLER, 1990 UNILATERAL 37% BILATERAL 52% HEAD 10% OUTSIDE 0.6% after Salvi, 2000 Davis and Rafaie (2000) Hoffman and Reed (2004) 3

PREVALENCE OF TINNITUS (Medical Research Council, 1987) Figure 1. Tinnitus population (millions, 2008) 15% lasting more than five minutes 8% interferes with getting to sleep 0.5% severe ability to lead normal life Presence of noise exposure doubles likelihood of tinnitus at any age and for both genders Kochkin, Tyler & Born (2011) Patients who adapt to tinnitus Initially concern and distress Short term Questions, coping strategies Long term Attentiveness declines Focus on other aspects of life Occasional awareness Maybe older, gradual onset, known cause 21 Current Medical Treatments At this time, there are no widely accepted cures for tinnitus, There are no studies that have shown a cure that have used appropriate research designs and have been replicated by others Anxiety Depression Sleep Medications OK for 24 4

The Measurement of Tinnitus Tinnitus Pitch, Loudness, Masking Reaction to tinnitus Primary and secondary Dauman, R. and Tyler, R.S. (1992) PITCH Adjust my tone so that it has the same pitch as the most prominent pitch of your tinnitus Method of limits, or adjustment or an adaptive method Test in ipsilateral or contralateral ear Test with monaural stimuli Can be highly variable LOUDNESS Adjust my tone so that is has the same loudness as your tinnitus Methods of limits, adjustment or an adaptive method Test in ipsilateral with monaural stimuli Sensation level is not loudness Sones Vernon and Meikle (2000) Tyler, R.S. and Conrad Armes, D. (1983) Hearing Loss (db HL) 5

MASKING Adjust my noise so that it just covers your tinnitus Methods of limits, adjustment or an adaptive method Can test with monaural or binaural stimuli Can test in ipsilateral or contralateral ear CLINICAL APPLICATIONS OF MEASUREMENTS patient knows you understand quantify change pitch, loudness, minimum masking level 4 possible primary areas involved What are they??? 33 6

4 possible primary areas involved 38 4 possible primary areas involved Emotional 4 possible primary areas involved Emotional Hearing 39 40 4 possible primary areas involved Emotional Hearing Sleep 4 possible primary areas involved Emotional Hearing Sleep Concentration 41 42 7

Tinnitus Questionnaires Open ended questionnaire (Tyler and Baker, 1983) Please list the difficulties you have as a result of your tinnitus List them in order of importance Allows them to list what is important to them Tinnitus Handicap Questionnaire (Kuk, Tyler, Russell, & Jordan, 1990) Validated n= 275 27 items, scored from 0 100 used worldwide, translated in many languages (Google Iowa tinnitus) Validity & reliability independent verified by Newman et al (1996) and Dauman et al. (1998) in French Designed to test treatment effectiveness Tinnitus Functional Index Meikle et al. (2012) Validated on 30 questions Recommended 25 Scored 0 10 8 factors Over past week Includes 4 questions on Quality of Life Tinnitus Functional Index General question Do you feel in control in regard to your tinnitus? Quality of Life How much has your tinnitus interfered with your enjoyment of social activities? Your relationships with family, friends and other people? Problems Resulting from Tinnitus 8

Tinnitus Functions Impaired Thoughts and Hearing Sleep Concentration Emotion Activity Limitations Socialization Physical Health Work Education Economic Tinnitus Primary Activities Questionnaire Four categories (5 questions per area) Thoughts and emotions, hearing, sleep, concentration e.g. I have difficulty focusing my attention on some important tasks because of tinnitus Currently under review Scoring form available Search Iowa Tinnitus) Evaluation Strategy 1. Be a good listener 2. Understand individual patient needs and expectations. 3. Nurturing patient expectations Be a good listener Understand the whole patient Overall well being Where is the patient at External circumstances Support system, lack of understanding? General emotional and physical health 51 52 Understand individual patient needs and expectations. Reasonable to have strong negative reaction Previous therapies tried? Expectations from you? Individuals experience different difficulties Three responses to tinnitus Defeat overwhelmed Control Some habituation Wishing for it s cessation Accept habituate 53 54 9

Expectations Nurturing Expectations to Help Tinnitus Patients Negative Less likely to seek and benefit from treatment Positive More likely to engage in treatment and be helped Patient expectations are influenced by YOU Tyler, R.S., Haskell, G., Preece, J., and Bergan, C. (2001). Nurturing patient expectations to enhance the treatment of tinnitus. Seminars in Hearing, 22(1): 15 21. Being Perceived as a Knowledgeable Professional Demonstrate That You Understand Tinnitus confidence in therapist and self confidence well educated, degree articulate, professional, well educated with respect to tinnitus knowledgeable about tinnitus has previous successful experience with tinnitus patients Provide a Clear Therapy Plan feelings of mastery can influence outcome hope that patient can be helped provide a plan to reduce effects of tinnitus make patient key part of the plan have patient participate in designing plan Be Sympathetic Towards the Individual Understand their tinnitus and the personal problems that have resulted from it 10

Show that You Sincerely Care Take time to listen Schedule follow up visit Call if questions or difficulties arise Counseling for Tinnitus Rich Tyler, Ph. D. Theoretical approaches to counseling for tinnitus Cognitive inappropriate ways of thinking about tinnitus Sweetow (1984a,b), Andersson and Kaldo (2006), Hallam and McKenna (2006) Attention Failure to shift attention away from tinnitus Hallam et al., (1984, 1989), Hallam & McKenna (2006) Learning Responses to tinnitus are learned Jastreboff and Hazell (1993), Bartnik and Skarzynski (2006), McKenna (2004), Hallam et al., (1984) Fearfulness Afraid it will never go away (continuous anxiety) Loss of locus of control Patient has no control over tinnitus and life Acceptance Copyright R.Tyler Tinnitus is part of me, I own it (Mohr, 2006) Counseling Therapies for Tinnitus Lindberg et al. (1984) coping Hallam (1987) habituation Sweetow (1984) cognitive behavior therapy Henry and Wilson (2000) cognitive behavior therapy Tyler et al. (1999) Patient Expectation Nurturing Tyler & Erlandsson (2002) Refocus Therapy Copyright R.Tyler Changing Thoughts reassurance common problem many known causes (e.g. noise exposure) not a health risk lots of people have enjoyable lives with it follow-up care available Changing behavior Refocus Activities replacement Managing stress Relaxation Copyright R.Tyler Copyright R.Tyler 11

Differences Among Procedures Tyler and Babin (1986, 1993) Counseling and Sound Therapy Consider all difficulties of that patient Information about tinnitus Provide reassurance Include family members sleep counseling Hearing aids, partial and total masking Copyright R.Tyler Copyright R.Tyler Cognitive Behavioral Therapy Henry and Wilson (2000, 2001) Event Belief Result reducing general arousal, tension or discomfort cognitive restructuring attention direction processes stress management coping modification of avoidance behavior Waiting for a friend who is late She doesn t care Can t wait to see her Hope she is OK Depressed Excited anxious Copyright R.Tyler Copyright R.Tyler Counseling for Tinnitus Providing information Patient expectation nurturing Counseling Providing information Changing thoughts about tinnitus Changing behavior Hearing Hearing loss Tinnitus epidemiology Tinnitus mechanisms Central nervous system Habituation Attention Learning Sleep Concentration Auditory training Lifestyles Self image Treatment options for hearing loss Treatment options for tinnitus Copyright R.Tyler Copyright R.Tyler 12

Counseling beyond information Listening to the patient individual patient needs Nurturing expectations Consider emotional problems related to tinnitus Sleep management Change attitude and Self esteem Diversionary tactics (attention) Coping strategies Relaxation Modifying the environment Consideration all problems (e.g. relationships) Reassurance The use of diaries Activities lifestyle changes (being positive and active) stress management Simple Reassurance common problem many known causes (e.g. noise exposure) not a health risk First 6-12 months are worst Distressed reaction is normal/ok lots of people have enjoyable lives with it follow-up care available Copyright R.Tyler Changing behavior Refocus Activities replacement Managing stress Relaxation, Meditation, Yoga, Mindfulness Tinnitus Activities Treatment Collaborative Determine needs and understanding individual patient Uses Tinnitus Masking Therapy Low levels of partial masking Include Activities, Coping / Management Strategies Programmatic counseling in 4 areas Thoughts and emotions, Hearing, Sleep, Concentration Copyright R.Tyler Copyright Tyler Picture-Based Tinnitus Activities Treatment Counseling (provided on our website) A series of pictures that can help with your counseling session Provide orderly fashion Not overlook important concepts Easier for the patient to understand concepts Counseling Sessions Introduction Session 1 Thoughts and Emotions Give Activities (e.g. diary) Session 2 Review of Session 1Activities Hearing and Communication Give Activities Copyright Tyler 13

Counseling Sessions Session 3 (optional) Review of Session 2 Activities Sleep Give Activities (e.g. diary) Session 4 (optional) Review of previous Session Activities Concentration Give Activities Counseling Sessions Summary Session Review of previous Session Activities General overview Questions? Relapse prevention Copyright Tyler Copyright Tyler Overall Plan Emotional Well-Being 1. Your story 2. Information about hearing loss, tinnitus, and attention 3. Ways to make tinnitus less prominent 4. Changing things to manage better 5. Review of action plan Emotional Well-Being 82 Where do you want to start? What do you think caused your tinnitus? Emotional Well-Being 83 Emotional Well-Being 84 14

How has tinnitus influenced your life? How do you think we might be able to help you? Emotional Well-Being 85 Emotional Well-Being 86 Tinnitus is an Increase in Spontaneous Nerve Activity Things That Capture Our Conscious Attention Normal Hearing Hear Silence Unusual Hearing Loss (No Tinnitus) Hear Silence Important Tinnitus Hear Sound Scary Unexpected Emotional Well-Being 87 Emotional Well-Being 88 3. Factors that Affect Communication Hearing and Communication Session 4 Hearing loss Background noise Ability to see the talker Familiarity with talker Familiarity with topic of discussion Stress level Copyright: R.S. Tyler 2006, The University of Iowa Hearing 89 Copyright: R.S. Tyler 2006, The University of Iowa Hearing 90 15

4. How Tinnitus Can Affect Hearing Tinnitus is not damaging your hearing When you focus on your tinnitus, it is harder to attend to your communication partner Tinnitus might make some sounds difficult to hear 5. Strategies to Improve Hearing and Communication 1. Amplification 2. Reducing background noise 3. Watching faces 4. Using repair strategies 5. Positively influencing the communication situation Copyright: R.S. Tyler 2006, The University of Iowa Hearing 91 Copyright: R.S. Tyler 2006, The University of Iowa Hearing 92 Activities Utilize the strategies discussed to improve hearing and communication. List the most difficult listening situations for you 1. 2. 3. What can you do to improve those listening situations? 1. 2. 3. What can you do to reduce the background noise? 1. 2. 3. Sleep Copyright: R.S. Tyler 2006, The University of Iowa Hearing 93 Normal Sleep Patterns Adults need an average of 8 hours a night Amount of sleep varies from one individual to another The best sleep consists of uninterrupted sleep Things That Affect Sleep Stress and emotions (e.g. depression, anxiety) Environmental factors Noise Light Temperature Irregular work schedules Jet lag/time zone changes S-3 95 S-3 96 16

Progressive Muscle Relaxation (PMR) Learn to systematically tense and relax groups of muscles With practice you will recognize a tensed muscle or a relaxed muscle This skill allows you to produce physical muscular relaxation at the first signs of tension Concentration S-3 97 C. Things That Affect Concentration The environment Noise Distractions Lighting Temperature Your physical state Hunger Tiredness Current health status Concentration 99 E. Strategies to Improve Concentration 1. Interpret tinnitus as not important 2. Decrease prominence of tinnitus 3. Eliminate distractions 4. Adjust work habits 5. Stay focused 6. Take control of your attention Concentration 100 6. Take Control of Your Attention The focus of our attention is largely under voluntary control You can learn to control the focus of your attention under various conditions By bringing the focus of attention under control, tinnitus-related distress will be reduced at certain times Attention Control Exercises Learn to switch attention from one stimulus (e.g. object, sensation, thought, activity) to another at will Allows you to refocus your attention from your tinnitus onto other stimuli, external or internal Concentration 101 Concentration 102 17

Visual Attention Example 1. Focus on a nearby object (e.g. pencil, book, etc) 2. Study that object 3. Now switch your attention to looking in the distance (e.g. out the window, down the hall, etc) 4. Switch back and forth between the two several times 5. Notice that you can choose which item you visually pay attention to while ignoring other things around you Sound Example 1. Listen for a prominent sound around you (e.g. talking, heater noise, etc) 2. Now listen to a different sound in the room 3. Continue to try and focus on certain sounds while ignoring others around you Concentration 103 Concentration 104 homework assignments Give at least one example of the link between a situation thought emotion Self Help books for Tinnitus Copyright Tyler Event: Thought: Emotion: Event: Thought: Emotion: waking up in the middle of the night I ll be exhausted tomorrow! worry, frustration waking up in the middle of the night I ve only had 4 hours of sleep, but I used to do this in college/when my children were young, I ll survive less uptight GROUP SESSION Overview Sample slides form our Once a month Partners welcome 6-10 people Leader (you) must be in charge! Introductions Hearing Hearing loss What is tinnitus Treatments for tinnitus Our options counseling and sound therapy, hearing aids, tinnitus devices Self help 18

Introductions Your first name What your tinnitus sounds like (e.g. ringing, humming)? How long have you had tinnitus? Nerve activity carries information to the brain Inner Hair Cell To Brain Nerve Activity Nerve Fiber What is tinnitus Causes Prevalence Mechanisms 19

There are many different causes of tinnitus What do you think caused your tinnitus? Noise Head Injury Medications Age Unknown? Disease Tinnitus is Common 10 in 100 (10%) people have tinnitus 1 in 100 (1%) people are bothered by their tinnitus 20 in 100 (20%) people over 60 years old have tinnitus Nerve activity carries information to the brain Inner Hair Cell Nerve Activity To Brain Nerve Fiber Tinnitus is likely the result of an increase in spontaneous nerve activity Tinnitus Does Not Normal Hearing Hearing Loss (No Tinnitus) Hear Silence Hear Silence Make you deaf Lead to senility Imply a sign of mental illness Tinnitus Hear Sound 20

Reactions to tinnitus What is the biggest problem you have that you believe has resulted from your tinnitus? 21

Reactions to tinnitus Thoughts and emotions Reactions to tinnitus Thoughts and emotions Hearing difficulties Reactions to tinnitus Thoughts and emotions Hearing difficulties Sleep Reactions to tinnitus Thoughts and emotions Hearing difficulties Sleep Concentration Treatments for tinnitus What have you tried? What has been successful? 1

Treatments At this time, there are no widely accepted cures for tinnitus, There are no studies that have shown a cure that have used appropriate research designs and have been replicated by others Excellent options Counseling and Sound Therapy Individualized Tinnitus Activities Treatment Hearing Aids Tinnitus Devices Tinnitus Activities Treatment Individualized Focus in areas of THOUGHTS AND EMOTIONS, HEARING, SLEEP, CONCENTRATION Activities reviewed, homework assigned Doorbell Doorbell Doorbell Our Thoughts and Emotions Neutral Fire Injury Anxiety Angry neighbor Flowers Friend Happiness Prize Do any sounds make your tinnitus less noticeable? Sound Therapy Hearing Aids Improve hearing Improve communication Reduce stress of intensive listening Hearing aids often help tinnitus Less stress, facilitates positive reactions to tinnitus Background noise creates partial masking Our hearing aid center provides excellent service 2

Sound Therapy Options Non-wearable sound demonstration Wearable options Hearing aids Noise generators Tonal sound generators Processed music Low level noise makes tinnitus more difficult to detect Tinnitus Low Level Noise Tinnitus in Low Level Noise After Grant Searchfield Decrease Prominence Level Tinnitus Level Tinnitus 3

Background sound partially masks a barking dog Summary Hearing loss and tinnitus are related Tinnitus is a change in spontaneous activity There is no cure for tinnitus Options include counseling and sound therapy, hearing aids, tinnitus devices How do you want to manage your tinnitus? 1. Focus on other areas of your life and put tinnitus in the background. 2. Use low level sound in your environment (sound machine, CDs, television, etc) 3. Use wearable tinnitus noise generators 4. Undertake tinnitus counseling with an expert 5. use hearing aids (in the case of tinnitus and hearing loss) HEARING AIDS FOR TINNITUS Rich Tyler Hearing Aids for tinnitus First recommended by SALTZMAN & ERSNER (1947) Surr et al. (1985) 124 new hearing-aid users Tinnitus Reduced 25% Eliminated 29% Became Worse 5% 7% Benefit after turning aid off Copyright Tyler 4

Reasons people have not obtained hearing aids Figure 1. Tinnitus population (millions, 2008) Kochkin, 2007 Copyright Tyler Copyright Tyler Kochkin, Tyler & Born (2011) Figure 3. Impact of tinnitus on quality of life (n=3,431) Direct Query on Hearing Aids. Effectiveness in mitigating effects of tinnitus (n=1,314) Copyright Tyler Kochkin, Tyler & Born (2011) Kochkin, Tyler & Born (2011)Copyright Tyler Direct Query How often hearing aids are effective in mitigating effects of tinnitus (n=553) Trotter MI, Donaldson I. (2008) Hearing aids and tinnitus therapy: a 25-year experience. audiologically proven hearing loss presenting to a tinnitus clinic before and after hearing aid provision DESIGN: Prospective data collection for patients attending a tinnitus clinic over a 25-year period (1980-2004). 2153 consecutive patients attending a consultant-delivered specialist tinnitus clinic. MAIN OUTCOMES MEASURES: A visual analogue scale RESULTS: 1440 patients were given hearing aids (826 unilateral and 614 bilateral) little difference in tinnitus perception 554 (67 per cent) of unilaterally aided patients 424 (69 per cent) of bilaterally aided patients reported some improvement in tinnitus Kochkin, Tyler & Born (2011) Copyright Tyler 5

Figure 6. Tinnitus mitigation with hearing aids segmented by best practice hearing aid fitting score in quintiles where Q1=bottom 20% of practices and Q5=top 20% of practices (n=732). Searchfield GD, Kaur M, Martin WH. 2010 Kochkin, Tyler & Born (2011) Hearing Aids could help tinnitus because: Improve Communication Therefore Reduce Stress Amplify Background Sound external low-level sounds (distraction/partial masking) Produce Noise, therefore Partial Masking Copyright Tyler Typical assumption for hearing aid fitting Background noise is undesirable Therefore Noise reduction circuits Focused directionality microphones Do not amplify low level sounds as much as high level sounds (input output function) Copyright Tyler General assumptions Tinnitus Low-level noise desirable Amplify low level everyday sounds Do not attenuate low-level sounds In contrast to hearing loss without tinnitus Low-level noise undesirable General approach for fitting hearings for tinnitus Best fitting possible for communication Reduce stress, enjoy life Low-level noise desirable Amplify low level everyday background sounds Do not attenuate low-level everyday background sounds Cannot Determine Effectiveness In Sound Proof Room Copyright Tyler 6

Fit hearing aid to enable environmental sound to partially mask Use Open ear molds to allow background sound Widely focused directional microphones Higher gain at low levels No noise reduction Consider Extending Low Or High Frequency Range Of Amplification Perhaps have a tinnitus program in multi-memory hearing aids Hearing aids for those with mild hearing loss Many experience tinnitus reaction benefit when using hearing aids Marginal hearing aids candidate often consider hearing aids for tinnitus Many report benefit Good to get patients experienced using hearing aids Copyright Tyler Occasional Dilemma: hearing aids or hearing aids plus maskers? Copyright Tyler Hearing aids or hearing aid + maskers? Patients needs hearing aids Patient uncertain of whether want to listen to masker noise If purchase hearing aids + maskers, can try maskers and decide to use or not (explain that many do benefit) If purchase hearing aids only, will not (or many can, depending on hearing aid company), have opportunity to later upgrade to add maskers Will need to buy new devices later Copyright Tyler Occasional Dilemma: Maskers or hearing aids plus maskers? Maskers or hearing aid plus maskers? Wants to purchase maskers Not sure whether to spend additional money to purchase hearing aids Copyright Tyler Copyright Tyler 7

Maskers or hearing aid plus maskers? Wants maskers but borderline hearing aids candidate Patient uncertain of whether to spend additional money to purchase hearing aids Hearing loss is progressive for all of us Patient will eventually need hearing aids If purchase hearing aids + maskers now, will likely eventually save them money Can experience benefit of hearing aids now Copyright Tyler Hearing aids can make tinnitus worse!! Does not happen very often 1 in 100? Amplified sound exacerbates tinnitus Turn gain down, reduce maximum output Tactile sensation around ear could make tinnitus worse Try alternative aid/earmold strategies Copyright Tyler 1 or 2 hearing aids for tinnitus? two hearing aids almost always better hearing Increase chance of benefit for tinnitus, even in unilateral tinnitus (Erdman and Sedge, 1981; Coles, 1987) Post Masking Effects of Hearing Aids (and maskers) Acoustic stimulation can reduce the magnitude of the tinnitus after the hearing aids are turned off!!! Can be for minutes or hours in different patients Copyright Tyler Other hearing assistance strategies use assistive listening devices, Frequency Modulation (FM) or loop system to provide background sound to patient but not to others in room Improve hearing ability and might help with tinnitus Summary- Hearing aids for tinnitus All benefits of hearing aids!!!! Improve communication Stress reduction Amplification of background sounds can reduce tinnitus Possible relief after hearing aid use Copyright Tyler Copyright Tyler 8

Suggested Readings Kochkin, S., Tyler, R., & Born, J. (2011). MarkeTrak VIII: The prevalence of tinnitus in the United States and the self-reported efficacy of various treatments. Hear Rev, 18(12), 10-27. Searchfield, G. D., (2006). Hearing aids and tinnitus. Tinnitus treatment: Clinical protocols, 161-175. Tinnitus Sound Therapy Rich Tyler 49 Copyright Richard S. Tyler Neurophysiological Models Tinnitus result of changes in spontaneous activity Can reduce prominence of abnormal spontaneous activity by adding noise Low level noise makes tinnitus more difficult to detect (from Tinnitus Activities Treatment) Tinnitus Low Level Noise Tinnitus in Low Level Noise Psychological Mechanisms Attention Model Distract from tinnitus Compete with tinnitus Decrease prominence Habituation Model Continuous, unimportant Tinnitus Activities Treatment Decease the prominence For thoughts and emotions For sleep For concentration e.g. in office, when reading Broadband noise easier to listen to than narrowband noise, single steady-state tones Copyright Richard S. Tyler 9

Treatment developed Vernon (1984) wearable devices Total masking; but patient must decide on actual level so not disturbing Coles et al., 1987 Tinnitus Masking Therapy relies greatly upon the major element of psychological support Use masker about 6 hours/day whether or not tinnitus audible Start before it becomes the usual most troublesome time Copyright Richard S. Tyler Copyright Richard S. Tyler Masker counseling Always combine with counseling Beneficial long-term effects During masking- less attention on tinnitus After masking less troublesome Helps to break vicious cycle Can move on to life without focus on tinnitus Not just immediate effects, some adapt 2-3 months later Copyright Richard S. Tyler Determine who is appropriate for Tinnitus Sound Therapy Do not use Tinnitus Sound Therapy If noise makes tinnitus worse (try to acclimatize to noise first) If have hyperacusis (treat first) If do not have troublesome tinnitus Copyright Richard S. Tyler Differences among Sound Therapies Level Sound quality Philosophy Tinnitus or reaction to tinnitus Mechanisms Line-busy, brain remapping. Copyright Richard S. Tyler Wearable Devices portable music PLAYER e.g. IPod, mobile phone sound generators for tinnitus Hearing aids Combined sound generators + hearing aids Copyright Richard S. Tyler 10

Tinnitus Activities Treatment Developed in 1990s Combines Cognitive Behavior Therapy, Existentialism, Acceptance, Relaxation 1. Emotions 2. Hearing 3. Sleep 4. Concentration Tyler, R. S., Gehringer, A. K., Noble, W., Dunn, C. C., Witt, S. A., & Bardia, A. (2006). Tinnitus Activities Treatment. Chapter 9. In R.S. Tyler (Ed.), Tinnitus Treatment: Clinical Protocols (116-132). New York: Thieme. Level of the background sound Total masking covers tinnitus completely person hears a masker instead of their tinnitus Effective for some Partial masking tinnitus and the acoustic sound can be heard reduces the prominence and/or loudness Copyright Richard S. Tyler Partial Masking Tyler and Babin (1986) both the noise and tinnitus are heard but the tinnitus is reduced in loudness. Patients should use the lowest level masker that provides adequate relief. Bentler and Tyler (1987) urge the patient to use the lowest level of masker level that provides adequate relief Copyright Richard S. Tyler Tyler and Bentler (1987) sometimes a masker can reduce the tinnitus loudness or annoyance, even though the tinnitus remains audible. partially mask the tinnitus yet produce the lowest SPLs and the least interference with speech. Copyright Richard S. Tyler Mixing Point Coles (1987) the masker can be turned up until its loudness is equal to that of the tinnitus, when the patient will often have to listen hard to hear the tinnitus. Hazell (1987) tinnitus just audible through the masking sound. Jastreboff (1995) where the patient perceives that the tinnitus sound and the external sound start to mix or blend together (Tinnitus Retraining Therapy). Jastreboff and Hazell (2004) Added. below the level creating annoyance or discomfort Tinnitus Activities Treatment Mixing point too loud for most patients Mixing point should not be the goal in Partial Masking Use lowest level that is effective Some prefer total masking Mixing point is not superior to total masking Tyler, R., Noble, W., Coelho, C., & Ji., H. (2012). Tinnitus Retraining Therapy: Mixing Point and Total Masking Are Equally Effective. Ear Hear 33(5):588 594 11

This image cannot currently be displayed. 10/11/2017 Complete/Total Masking Partial Masking Level Tinnitus Level Tinnitus Level Tinnitus Masking Level Tinnitus Partial Masking Copyright Richard S. Tyler Copyright Richard S. Tyler Strength of Perception Depends on Contrast After Grant Searchfield Level Tinnitus Level Tinnitus Copyright Richard S. Tyler Copyright Richard S. Tyler Copyright Richard S. Tyler Copyright Richard S. Tyler 12

Sound Therapy Stimulus Options Broadband noise Noise modifying spectrum Noise modifying envelope Combined tones, modulated tones Music, processed music Spectrally adjusted sounds to account for the audiogram Notch noise or music around pitch match Level (db) Broadband Noise and Speech Shaped Noise Frequency (Hz) Noise to inversely match the audiogram Amplitude Modulation (tones or noise) Frequency Modulation Adding tones spa tones, Zen tones 13

Okamoto H et al. PNAS 2010;107:1207-1210 Stage 1 Processed Music inversely matched to audiogram + noise Stage 2 Processed Music inversely matched to audiogram frequency band 1-octave cantered at tinnitus pitch-match frequency removed 2010 by National Academy of Sciences Background Music Easy to ignore Pleasant to listen to Avoid vocals Avoid loud background beating not captivating / interesting Music at low levels Hann, D., Searchfield, G., Sanders, M., Wise, K. (2008): Strategies for the selection of music in the short-term management of mild tinnitus. The Australian and New Zealand Journal of Audiology 30: 129-140.. Fitting considerations Broadband noise easier to listen to than narrowband noise Noise does not have to overlap the tinnitus pitch Can mask in contralateral ear in some patients Try monaural and binaural fittings use low-level stimuli to reduce speech interference, less likely to enhance tinnitus Copyright Richard S. Tyler Determine who is appropriate for Tinnitus sound Therapy Do not use sound therapy If noise makes tinnitus worse try to acclimatize to noise first with very low levels If have hyperacusis treat first with noise at very low levels If do not have troublesome tinnitus Copyright Richard S. Tyler ONE OR TWO MASKERS? If only 1 device Fit worst tinnitus ear first Consider trying both ears 2 devices Likely if tinnitus in the head or binaural Might need even with unilateral tinnitus try all possible combinations, noting levels that are effective 14

Long-term benefit Masker benefit not just while using the maskers relief provided by the masker helps to break the vicious cycle of tinnitus-stress Able to attend to other rehab strategies more easily even while the tinnitus masker is not worn many can discontinue masker use after few months TINNITUS HEARING-AID MASKER COMBINATIONS fit hearing aid first add in just the amount of noise needed re-adjust hearing aid or start over again if needed inform for patient always to turn on hearing aid first Non-wearable maskers Locations o Office/workspace/home o Bedroom for sleep Device options o Specialty instrument o Plays ocean waves, rain on leaves, etc o Music player o RADIO, compact disc player o Household appliances o E.G. Fan, detuned radio o Music from/under pillow Copyright Richard S. Tyler Noise Generators During Sleep Can help getting to sleep Provides relief if wake up in the night Provides relief when wake up in the morning Better NOT with automatic turn-off Maybe just have sound as part of bedroom Copyright Richard S. Tyler Copyright Richard S. Tyler 15

The Patient s Perspective: Treatments Patients Want How willing would you be to accept a this treatment, if it were to completely eliminate your tinnitus? Respond from 0-100 % 0% - you would never consider it 100% you would absolutely try it. Tyler, R. S. (2012). Patient Preferences and Willingness to Pay for Tinnitus Treatment J Am Acad Audiol 23, 115-125 Copyright Richard S. Tyler Number of Patients 140 120 100 80 60 40 20 0 140 120 100 80 60 40 20 0 140 120 100 80 60 40 20 0 External Device Completely Eliminate 0~10 11~20 11~20 21~30 31~40 41~50 51~60 Pill 61~70 71~80 81~90 91~100 0~10 11~20 11~20 21~30 31~40 41~50 51~60 61~70 71~80 81~90 91~100 Implantable Cochlear 0~10 11~20 21~30 31~40 41~50 51~60 61~70 71~80 81~90 91~100 140 120 100 80 60 40 20 0 140 120 100 80 60 40 20 0 0~10 Rating (0-100) Implantable Brain Surface 11~20 0~10 11~20 21~30 31~40 41~50 51~60 61~70 71~80 81~90 91~100 Implantable Deep Brain 21~30 31~40 41~50 51~60 61~70 71~80 81~90 91~100 Conclusions Wide variety of sound therapies Should always be combined with counseling e.g. Tinnitus Activities Treatment Low levels partial masking best for most patients Preference for quality of sound varies widely across patients (give them options!) whatever the tinnitus sounds like, it is useful to try a variety of sounds, and let the patient decide turn it on and forget it. daily masker usage... again individual differences are important asking them to monitor the level and the duration and the situation, is asking them to monitor there tinnitus all day long, which is not good Hyperacusis Activities Treatment Richard Tyler University of Iowa 16

Terminology Loudness Hyperacousis Some moderately loud sounds are very loud Annoyance Hyperacousis Some sounds are annoying (not always loud) Fear Hyperacousis Patients are afraid of some sounds (not always loud) Pain Hyperacusis Sounds evoke pain sensation Other Terms Hypersensitivity Select sound sensitivity Sensitivity refers to threshold Misophonia Dislike of sounds Less confusion if Choose simple terms with clear distinct definitions Avoid temptation for everyone to make up new terms Terminology Loudness Hyperacousis Some moderately loud sounds are very loud Annoyance Hyperacousis Some sounds are annoying (not always loud) Fear Hyperacousis Patients are afraid of some sounds (not always loud) Pain Hyperacusis Sounds evoke pain sensation Hyperacusis Hyperacusis Adult Child Anatomical Concerns Williams Syndrome Autism? Autophony Eustachian tube open Stapedius Reflex Dysfunction Superior Semicircular Canal Dehiscence 17

Many different causes Most unknown few diseases and syndromes associated with hyperacusis. For example; migraine, depression, post traumatic stress disorder, head injury, Lyme disease, William s syndrome, fibromyalgia, Addison s disease, autism, myasthenia gravis and middle cerebral aneurysm (Katzenel and Segal, 2001) Clinical conditions associated with hyperacusis. Clinical condition Generic or Otologic Neurologic Endocrine Infection Medication Deficiency Other? Congenital Hyperacusis and Hearing Loss About 40% do not think they have a hearing loss Likely most (90%?) do Hyperacusis is bigger problem than hearing loss and usually tinnitus Hyperacusis often occurs with mild hearing loss Similar to tinnitus, many hyperacusis patients seek audiological help for hyperacusis, and many end up with hearing aids (Kochkin and Tyler, 2008) Number of patients 180 160 140 120 100 80 60 40 20 0 Do you have a hearing loss? No Yes Patients perspective Possible causes of Hyperacusis 18

Peripheral mechanism in some? Which ear(s) seems to be affected by the hyperacusis? 180 160 140 Unilateral Hyperacusis Does unilateral hyperacusis imply peripheral source of hyperacusis? Number of patients 120 100 80 60 40 20 Unilateral tinnitus patients, can mask in one ear and tinnitus appears in the other Tyler, R. S. (1984). Does tinnitus originate from hyperactive nerve fibers in the cochlea? J Laryngology and Otology (Suppl. 9): 38-44. 0 Both Left Right Hyperacusis and Other Sensory Systems Hyperacusis and Tinnitus First linked by Tyler and Conrad-Armes (1983) Must have common mechanisms in some But also hyperacusis without tinnitus Tinnitus without hyperacusis 19

Loudness Hyperacusis magnitude estimation Loudness hyperacusis > Hypersensitivity > < normal < Recruitment Related problems Unable to enjoy music Annoyance, Fear and/or pain in places where loud sounds are likely to occur Avoidance of being in these places Withdraw from socialization and communication if desire tinnitus maskers noise might make hyperacusis worse If require hearing aids Amplification can make hyperacusis worse Open-ended questionnaire (Tyler and Baker, 1983) Open ended questionnaire Please list the difficulties you have as a result of your Hyperacusis List them in order of importance Allows patient to describe what is important to them Which of the following sounds or events are often too loud for you? Hyperacusis Questionnaire a. Baby crying/children squealing b. Crowds/large gatherings c. Dishes being stacked d. Dog barking e. High pitch voices/screaming f. Lawnmower g. Music (loud rock concerts) h. Music (religious service) i. Music (symphony, quartet, etc.) a. Power tools b. Restaurants c. Sporting events d. Telephone ringing e. TV/radio f. Vacuum cleaner g. Whistle/horn/siren h. Other 20

Dull Ache / Wound Pain Hyperacusis "The sound of putting on clothing feels like lightly blowing on an open wound." "My ear feels raw and vulnerable to sound as if it were an open wound' "Setting a coffee mug on a wooden table feels like a thumb pressing hard on broken bone, deep in the ear." "Walking on gravel feels as if I am pressing the gravel into my wounded ears." Sharp pain descriptions Tingle / Itch Descriptions " Clinking dishes feel like an icepick stabbing deep into my ears." "High frequency noises feel like needles stabbing my eardrum" "A painful itch I cannot scratch" Lingering pain "The sound feels like acid being poured into my ears." "It feels as if cool air is passing over my burning ears." Burning descriptions "My ear is always burning. It feels like it is sizzling." pain hyperacusis often associated with tinnitus 55% prevalence of pain hyperacusis in tinnitus patients Schecklmann M, Landgrebe M, Langguth B: Phenotypic characteristics of hyperacusis in tinnitus. PLoS One 2014, 9(1) 63%prevalence of pain hyperacusis in tinnitus patients Schecklmann, et al., 2015 Validation of Screening Questions for Hyperacusis in Chronic Tinnitus BioMed Research International 21

Hyperacusis; different symptoms Only specific sounds All loud sounds unexpected sounds frequency and ear dependent specific circumstances Treatments Sound Therapy 1. Hazell & Sheldrake (1989, 1992) Reduce central gain 2. Vernon & Press (1998) Desensitization 3. Tyler et al. (2000, 20099) Tinnitus Hyperacusis Treatment 4. Hearing Aid Adjustments 5. Use of hearing protection Hazell & Sheldrake (1989, 1992) based on their theory of need to reduce central gain (Hazell, 1987) Bilateral noise generators devices Continuous exposure low-level noise See also Formby and Gold (2002) Vernon & Press (1998) Desensitization Pink noise, 2 hrs/day earphones Increase level gradually to Loudness Discomfort Level Requires 3 months to 2 years Tyler et al., (2000; 2009) Hyperacusis Activities Treatment picture based Desensitization Record specific sounds that are too loud play back at low levels in peaceful environment gradually increase levels and duration Gradually work into realistic situations Data on Treatment of Hyperacusis Vernon & Press (1998) Effective in 54-69% Formby & Gold (2002) Can reduce LDLs in some patients Continuous low-levels of noise Case studies 10/11/2017 Hyperacusis 132 22

Formby and Gold, 2002 10/11/2017 Hyperacusis 133 Formby and Gold, 2002 10/11/2017 Hyperacusis 134 Conclusions Formby et al. 80% of subjects benefitted from the full intervention implemented with bilateral noise generators and counseling Full-intervention benefit occurred usually within 2-4 months of treatment onset, with stable effects by 6 months 23

Hyperacusis Treatments Medications? Ear plugs? Hearing aids Sound therapy Counseling Pharmacological approaches patient reports Risperdal Keppra Retigabine Anticonvulsants Lyrica, gabapentin (especially for burning pain) Benzodiazepines Clonazepam and Diazepam Subjective reports, some might benefit, but not all Distinguish reducing hyperacusis or reducing reactions to hyperacusis (Psychological Model of Dauman & Tyler, 1992) Ear plugs? Many patients use earplugs throughout the day in everyday listening situations (not necessarily with high-intensity sounds) The use of earplugs becomes part of their everyday life It is not improving their condition Limiting exposure to sound could make hyperacusis worse Therefore, recommend not to use unless intense noise present Must be gradual reduction in use for some Use of hearing protection wise when there is the potential to create hearing loss, tinnitus and hyperacusis people with noise induced hearing loss, tinnitus and hyperacousis are likely to be more susceptible than the average However, hearing protection prevents people from being exposed to everyday sounds of moderate loudness. When the hearing protection is removed, people can be unaccustomed to the intense sounds, and this might exacerbate hyperacousis Hearing Aid Adjustments Hearing aids can amplify sound to high levels Maximum output of hearing aid can be too high Reaction time of automatic gain control might be too slow Start with low maximum output and progressively increase Lowering maximum output will reduce speech perception Hearing Aids Hearing aids (with closed canal earmolds) can reduce sound by (at most) ~ 30 db Reduce maximum output of hearing aids so that high level sounds are peak-clipped or compressed Adjust input/output (gain) so that low-level sounds are amplified, but not high-level sounds Followed by gradual transition (over months) to normal Sammeth, C. A., Preeve, D. A., and Brandy, W. T. (2000). Hyperacusis: Case studies and evaluation of electronic loudness suppression devices as a treatment Copyright R approach. Tyler Scandinavian Audiology. 29, 28-36. 1

Where do you want to start? HYPERACUSIS ACTIVITIES TREATMENT SAMPLE SLIDES 8 Overview 1. What is hyperacusis 2. How hyperacusis affects you 3. Treatments Noise Level 10 8 Hyperacusis Loud for Normal Loud for Hyperacusis 4 9 10 Your reaction to sound? Loud Annoying Fearful of sounds Painful Loud sounds make tinnitus worse Loud sounds cause pain Can you provide examples of sounds that bother you or are too loud? Are there times during the day when you are particularly bothered? Are there times during the day when you are not bothered? 11 12 2

Causes of Hyperacusis What have you tried for your hyperacusis? Noise Head Injury Medications Ear Problems Unknown? Disease 13 14 Normal Loudness Perception Normal Loudness As level of sound is increased more nerve fibers become active increase in activity in nerve fibers Soft sound Moderately loud Soft Moderately loud Loud sound Loud 15 16 Normal Nerve Activity Theory of Hyperacusis Soft sound Moderately loud Less activity Moderate activity Normally loud sounds result in more nerve fibers active increases in activity of nerve fibers Loud High levels of activity 17 18 3

Hyperacusis Loudness Hyperacusis Nerve Activity Soft sound Moderately Loud or Loud Soft sound High levels of activity Moderately loud Loud Moderately loud High levels of activity Loud sound Loud 19 Loud sound High levels of activity 20 Random Nerve Activity Neural Activity Normal Hearing Hearing Loss 10/11/2017 Hyperacusis 21 Quiet Low Level Noise Low Level Noise Too much activity No need to magnify 10/11/2017 Hyperacusis 22 Hyperacusis and Tinnitus About 40% of people with tinnitus also have hyperacusis 2. Your Concerns How has hyperacusis influenced your life? 23 24 4

3. Treatments for Hyperacusis Using gradual exposure to overcome strong reaction Low-level sounds in background Listening periods, with greater and longer durations and levels Record examples of troublesome sounds, and play back with listening intervals under your control 25 26 Increasing the Loudness Begin listening at a comfortable level Gradually increase the loudness over the next several weeks Noise Level 10 4 3 2 1 10 4 3 2 1 10 4 3 2 1 10 Start with very low level Increase gradually Increase gradually 27 4 3 2 1 Frequency Increase gradually 28 Avoid using earplugs unless exposed to loud sounds When you try to avoid sounds you may become more sensitive to them Treatment Plans Changing your hearing aid maximum output Low-level sound exposure Activities 29 10/11/2017 Hyperacusis 30 5

Activities Diary List sounds that are too loud List your reactions What situation/sounds are not too loud Listen to mildly loud sounds Resources for patients Handout on hyperacusis and management options Self-help books Instructional materials relaxation techniques sleep hygiene Information on local and/or national support groups, Information on local stress management or relaxation classes / groups 10/11/2017 Hyperacusis 31 Self Help books for Tinnitus Summary Chapter on Hyperacusis Auricle Inc Publisher, 2008,. ISB-13 9780966182675 10/11/2017 Hyperacusis Loudness, annoyance, fear, pain Hyperacusis involves abnormal neural activity Distinguish loudness of sounds and your reactions to loud sounds Hyperacusis Activities Treatment Thoughts and reactions Hearing aid output reduced Exposure to sound Hyperacusis 34 Tinnitus/Hyperacusis Treatment To download pictures go to: http://www.medicine.uiowa.edu/oto/research/tinni tus/ Search Iowa tinnitus clinic References Dauman, R., & Bouscau-Faure, F. (2005). Assessment and amelioration of hyperacusis in tinnitus patients. Acta Otolaryngol, 125(5), 503-509. Hazell JWP, Sheldrake JB. (1992). Hyperacusis and tinnitus. In: Aran J-M, Dauman R, eds. Tinnitus 91. Proceedings of the Fourth International Tinnitus Seminar, Amsterdam: Kugler Publications. 6

Nelting, M. (Ed.), Hyperakusis (2003). Stuttgart: Georg Thieme Verlag Nelting M, Rienhoff NK, Hesse G, Lamparter U. (2002). The assessment of subjective distress related to hyperacusis with a self-rating questionnaire on hypersensitivity to sound. Laryngorhinootologie;81: 32-4. Tyler RS, Bergan C, Preece J, Nagase S. (2003). Audiologische Messmethoden de Hyperakusis. In: Nelting M, ed. Hyperakusis. Stuttgart: Georg Thieme Verlag. Tyler RS, Noble W, Coelho C, Haskell G, Bardia A. (2009) Tinnitus and Hyperacusis In Katz J, Burkard R, Medwetsky L, Hood L (Eds.) Handbook of Clinical Audiology, Sixth Edition. Baltimore: Lippincott Williams and Wilkins. Pienkowski, M., Tyler, R. S., Roncancio, E. R., Jun, H. J., Brozoski, T., Dauman, N., Coelho, C. B., Andersson, G., Keiner, A. J., Cacace, A., Martin, N., & Moore, B. C. J. (2014, in press). A comprehensive review of hyperacusis and future directions: Part II. Measurement, mechanisms and treatment. American Journal of Audiology Tyler, R. S., Pienkowski, M., Roncancio, E. R., Jun, H. J., Brozoski, T., Dauman, N., Coelho, C. B., Andersson, G., Keiner, A. J., Cacace, A., Martin, N., & Moore, B. C. J. (2014, in press). A Review of hyperacusis and future directions: Part I. Definitions and manifestations. American Journal of Audiology Establishing a Tinnitus Clinic Richard S. Tyler The University of Iowa Advantages of Tinnitus Clinic Help patients More complete overall service Increase referrals Many will require and benefit from hearing aids Disadvantages of Tinnitus Clinic Need a plan for treatment Time commitment Some patients require extensive counseling Services often not covered by insurance Some patients require great emotional support 7

Background Information on Tinnitus Workshops e.g, Management of the Tinnitus Patient (U of Iowa) Books Henry and Wilson Psychological Management of Tinnitus, Tyler (Ed). Tinnitus Handbook (2000) Tinnitus Treatments; Clinical Protocols (2007) Consumer Handbook of Tinnitus (2016) Journal articles Tyler, R.S., Haskell, G, Gogle, S, Gehringer, A. (2008) Establishing a Tinnitus Clinic in Your Practice. American Journal of Audiology; 17: 25-37. Tyler, R. S. & Erlandsson, S. (2003). Management of the tinnitus patient. In: L.M. Luxon, J.M. Furman, A. Martini, and D. Stephens. (Eds.), Textbook of Audiological Medicine (pp. 571-578). London, England: Taylor & Francis Group. Evaluation What are the individual patient s needs? Hearing aids Counseling What level of help needed What problems exist What are patient expectations What has the patient tried already Hyperacusis present? Treatment Options Currently no medication has been shown to reduce tinnitus in well-controlled replicated studies with adequate measurement tools Different severities requiring different approaches Curious basic information (10 minutes) Concerned require time to discuss their specific situation and problems more detailed information on the physiologic and psychologic components Provide some self-directed management strategies (1 hour or more) Distressed detailed analysis of individual needs Individualized treatment based on Thoughts and Emotions, Hearing and Communication, Sleep, and Concentration (several visits) Group Sessions Good introduction to treatment options Cost effectiveness Possible to include spouses, parents and children of the patient Appreciation that related problems are shared by many with tinnitus See Newman and Sandridge (2006) Highly Distressed Patients recognize patients in crisis suicidal risk referral of patients, Psychiatry, psychology, Crisis Services 8

handouts and resources for patients American Tinnitus Association brochures Self-help books Instructional materials on relaxation techniques, stress reduction, sleep hygiene Information on local support group, stress management courses, psychological counseling, yoga, etc. Tinnitus handouts and diaries Part of Tinnitus Activities Treatment Demonstration devices Hearing aids: open-fit programmed to mild high frequency loss Ear level sound generators for tinnitus therapies you are using Sound machine Sound pillow Music therapy CDs Apps for tinnitus Treatments Patients Want How willing would you be to accept a this treatment, if it were to completely eliminate your tinnitus? Respond from 0-100 % 0% - you would never consider it 100% you would absolutely try it. Tyler, R. S. (2012). Patient Preferences and Willingness to Pay for Tinnitus Treatment J Am Acad Audiol 23, 115-125 Number of Patients 140 120 100 80 60 40 20 0 140 120 100 80 60 40 20 0 140 120 100 80 60 40 20 0 External Device Completely Eliminate 0~10 11~20 11~20 21~30 21~30 31~40 31~40 41~50 51~60 Pill 61~70 71~80 81~90 91~100 0~10 11~20 11~20 21~30 31~40 31~40 41~50 41~50 51~60 51~60 61~70 71~80 71~80 81~90 81~90 91~100 91~100 Implantable Cochlear 0~10 11~20 21~30 31~40 41~50 51~60 61~70 71~80 81~90 91~100 140 120 100 80 60 40 20 0 140 120 100 80 60 40 20 0 0~10 Rating (0-100) Implantable Brain Surface 11~20 0~10 11~20 21~30 31~40 41~50 51~60 61~70 71~80 81~90 91~100 Implantable Deep Brain 21~30 31~40 41~50 51~60 61~70 71~80 81~90 91~100 9

The Future???? A medication?? Zinc for tinnitus Copyright Tyler Selection Process Randomization Zinc to treat tinnitus Zinc n=80 Wash Out Zinc n=80 Placebo n=80 Wash Out Placebo n=80 A priori Single subject design Selected older patients more likely to have zinc deficiency Measured zinc in blood before and after Published Coelho et al., (2013) 3 Difference between final and first (first - final) (placebo) 60 40 20 0-20 -40-60 Zinc takes no effect Placebo takes effect Zinc takes no effect Placebo takes no effect THQ Difference Zinc takes effect Placebo takes effect -60-40 -20 0 20 40 60 Difference between final and first (first - final) (zinc) 104 93 102 58 110 118 21 86 8 78 77 83 35 109 Zinc takes effect Placebo takes no effect 4 16 Difference between final and first (zinc) minus difference between final and first (placebo) 60 40 20 0-20 -40 Zinc better than placebo Placebo better than zinc THQ Difference vs. Starting Zinc Level 8 83 4 109 77 21 35 52 106 102 16 93 31 94 85-60 0 20 40 60 80 100 120 Starting Zinc Blood Level 78 110 58 118 86 104 1

Difference between final and first (zinc) minus difference between final and first (placebo) THQ Difference vs. Zinc Difference Level 60 78 8 40 4 58 20 21 35 52 75 63 16 0-20 -40-60 -30-20 -10 0 10 20 30 40 50 60 Difference between final and starting zinc levels Hannover // 09. 12. März 2016 Richard Tyler, PhD Professor of Otolaryngology NIH Funding (5U44DC010084-05) Richard Tyler is a consultant for MicroTransponder Inc. 3. First Pilot Study Belgium VNS paired with tones while the patient relaxes, reduction of tinnitus magnitude in 6/10 patients 5 of 10 respond on Tinnitus Handicap Index (THI). De Ridder D., Vanneste S., Engineer N.S., Kilgard M.P. 2013. Safety and Efficacy of Vagus Nerve Stimulation Paired With Tones for the Treatment of Tinnitus: A Case Series. Neuromodulation 2013; Double Blind Active Control Study 30 patients, random assignment 1. VNS group paired with tones 2. Control Group unpaired tones 6 weeks of treatment 2.5 hours per day Stimulation every 30 seconds 0 Paired VNS group (n=16) Control Group (n=14) 100 90 Paired VNS (n=16) 100 90 Control (n=14) -5 80 80 Percent change in THI -10-15 -20 Tinnitus Handicap Inventory 70 60 50 40 30 Tinnitus Handicap Inventory 70 60 50 40 30-25 20 20 10 10-30 Baseline 6 weeks 0 Baseline 6 weeks 0 Baseline 6 weeks 2

Somatosensory Tinnitus Trigger Point Some individuals modulate their tinnitus characteristics with movements. Levine, 1999; Levine et al., 2003; Lockwood et al., 1998, Sanchez et al., 2002 Changes in intensity and pitch 3

Pain and Myofascial Dysfunction Somatosensory Tinnitus: Characteristics Unilateral Intermittent Hearing thresholds normal or symmetric Tinnitus onset not associated with an auditory event Clinical History Preliminary studies Previous event of trauma or facial / neck manipulation Wiplash, dental treatment Complains of chronic pain : Neck pain, muscle contracture, trigger points, Fybromialgia Postural features: Computer, phone, overload Tinnitus modulation during pain or movements Acupuncture Hansen et al., 1982; Axelssonet al., 1994 Electrical stimulation Engelberg and Bauer, 1985; Dobie et al.,1986; Lyttkens et al., 1986; Vaneste et al., 2010 Cervical manipulation Alcantara et al., 2002; Hulse and Holzl, 2004; Whedon, 2006 TMJ treatment Wright and Bifano, 1997 Medications Trigger point treatment Eriksson et al., 1995; Wyant, 1979; Estola Partanen, 2000; Rocha et al., 2006; Rocha & Sanchez, 2007T There will be a Cochlear Implant for Tinnitus Richard S. Tyler, Bruce Gantz, Marlan Hansen, Shelley Witt, AJ Keiner Otolaryngology, University of Iowa 5 1

Normalized Ratings of Perceived Loudness (0= inaudible; 100= loudest) 100 90 80 70 60 50 40 30 20 10 0 Effect of Duration of Stimulation on the Perceived Loudness of Tinnitus (DR) Electrode Location: Mid (#3) Stimulus Level: Most comfortable Rate of Stimulation: 2400 pps Duration of Stimulation: 2*, 8 & 20 minutes Nucleus Hybrid Device (Rt ear) *=Data for 2 minutes have been replicated from that obtained for effect of duration. There wasn't enough time to obtain data for 2 and 4 minutes of duration. 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Time (minutes) Perceived loudness of stimulus (2 minutes) Perceived loudness of stimulus (8 minutes) Perceived loudness of tinnitus (2 minutes) Arrows indicate the point in time when the stimulus was switched off. Perceived loudness of tinnitus (8 minutes) Perceived loudness of stimulus (20 minutes) Perceived loudness of tinnitus (20 minutes) 7 Tinnitus Rating (0-100) (The higher, the worse) 100 80 60 40 20 0 Tinnitus Performance Tinnitus Loudness Ratings CCIS CIS HA Hearing aid Cochlear Implant #1 Cochlear Implant #2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Day 8 Future Issues What stimuli should be used (comfortable, easy to ignore) How should stimulus be selected for individual How long electrode (short good for high-frequency loss only) (everyone a candidate) How should tinnitus suppression stimulus be combined with CI to improve hearing Mixed on all electrodes? Only some? Which patients are most likely to benefit 9 Transcranial Magnetic Stimulation Folmer et al., 2015 2,000 pulses per session over 10 consecutive workdays. Post-treatment 26 weeks responders 18/32 people active group 7/32 people placebo group Folmer R, Theodoroff S, Casiana L, Shi Y, Griest S, Vachhani J. (2015) Repetitive Transcranial Magnetic Stimulation Treatment for Chronic Tinnitus: A Randomized Clinical. JAMA Otolaryngol Head Neck Surg July 16. Transcranial Magnetic Stimulation It is possible to influence tinnitus Decrease (or increase?) It is also possible to reduce hearing Studies are not well controlled Placebo effect Studies not able to be replicated At present no good evidence 2

Summary Prepare yourself Evaluate tinnitus and reaction to tinnitus Develop a counseling and sound therapy strategy Consider individual needs of patient Group and individual sessions 3

Recent review of a variety of clinical protocols Copyright R.Tyler 1