TINNITUS MANAGEMENT CONSIDERATIONS

TINNITUS MANAGEMENT CONSIDERATIONS JOEL EDWARDS AU.D., CCC-A TINNITUS PRACTITIONERS ASSOCIATION (TPA) CLINICAL AUDIOLOGIST BOYS TOWN NATIONAL RESEARCH HOSPITAL Disclaimer: I am not receiving monetary fees for this presentation I am not recommending purchase of any products or services in this presentation I have no financial interest in any products or services mentioned in this presentation Learner objectives: Increase knowledge about tinnitus Be able to explain tinnitus and demystify tinnitus to your patient Be able to give your tinnitus patient options to help with tinnitus annoyance Be able to create a treatment plan for your tinnitus patient 1

PERSONAL BACKGROUND INTRODUCTION Education: Au.D. 2010 A.T. Still University/Mesa Arizona MS Audiology UNL 1984 Music Education degree K-12 1977 Work Experience Boys Town National Research Hospital 2003 to present Audiologist Methodist Health System 1985-2003 Hearing Science at University of Nebraska Omaha/Adjunct Professor PERSONAL BACKGROUND I have had tinnitus since age 12. PERSONAL BACKGROUND I had right ear stapes surgery. 2

MY INITIAL EXPERIENCE WITH TINNITUS PERSONAL BACKGROUND Surgical procedure was PORP. Total/Partial Ossicular Replacement Prosthesis BACKGROUND- TINNITUS INTEREST PERSONAL BACKGROUND I have had tinnitus in my right ear since that surgical procedure. 3

PERSONAL BACKGROUND I play trumpet and am exposed to some loud noise. I use musician s ear plugs! PERSONAL BACKGROUND Tinnitus interest began when working in a large multi-specialty clinic TINNITUS MANAGEMENT ASHA/AAA 4

MANAGEMENT TINNITUS ASHA 1) Audiologic evaluation by certified Audiologist. 2) Medical evaluation recommended to find any underlying cause for tinnitus symptom. 3) Measure tinnitussubjective responses and through questionnaires. AAA 1) Obtain data and careful listeningmaking strategy changes as neededtrained counselor as needed. 2) Identify reactions to tinnitus and try to learn new responses to reduce negative thought and behavior patterns CBT or sound therapy and directive counseling. Reduce contrast between silence and tinnitus perception (TRT). MANAGEMENT TINNITUS ASHA AAA 4) Tinnitus help: to include hearing aids, maskers, noise machines 5) Knowledge about tinnitus may reduce their anxiety and secondarily reduce tinnitus annoyance in the patient. 6) Help patient understand his or her tinnitus. 3) Hearing aids/tinnitus instruments Maskers and Home masker devices- Mask tinnitus partially or completely. Commercial tinnitus maskers, special noise recordings, fans, table top sound machines. May reduce annoyance and help with relaxation. 4) Self help and support/education groups- Informed with latest information about tinnitus. Groups should be lead by audiologists/psychologists 5) Stress management- Biofeedback-yogamediation-exercise 6) No evidence alternative treatments help TREATMENT FOR CHRONIC TINNITUS Journal of the American Academy of Audiology 25:106-125. Experimental, Controversial, and Futuristic Treatments for Chronic Tinnitus. Folmer RL, Theodoroff SM, Martin WH, Shi Y. (2014) 5

FOLMER RL, THEODOROFF SM, MARTIN WH, SHI Y. (2014) EXPERIMENTAL, CONTROVERSIAL, AND FUTURISTIC TREATMENTS FOR CHRONIC TINNITUS. JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY 25:106-125. 1) Ineffective treatments out number effective treatments for tinnitus. FOLMER RL, THEODOROFF SM, MARTIN WH, SHI Y. (2014) EXPERIMENTAL, CONTROVERSIAL, AND FUTURISTIC TREATMENTS FOR CHRONIC TINNITUS. JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY 25:106-125. 1) Ineffective treatments out number effective treatments for tinnitus. 2) Non invasive effective treatments include hearing aids and sound emitting devices. FOLMER RL, THEODOROFF SM, MARTIN WH, SHI Y. (2014) EXPERIMENTAL, CONTROVERSIAL, AND FUTURISTIC TREATMENTS FOR CHRONIC TINNITUS. JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY 25:106-125. 1) Ineffective treatments out number effective treatments for tinnitus. 2) Non invasive effective treatments include hearing aids and sound emitting devices. 3) CBT is effective tinnitus treatment option, relaxation, counseling, hypnosis, biofeedback. 6

FOLMER RL, THEODOROFF SM, MARTIN WH, SHI Y. (2014) EXPERIMENTAL, CONTROVERSIAL, AND FUTURISTIC TREATMENTS FOR CHRONIC TINNITUS. JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY 25:106-125. 1) Ineffective treatments out number effective treatments for tinnitus. 2) Non invasive effective treatments include hearing aids and sound emitting devices. 3) CBT is effective tinnitus treatment option, relaxation, counseling, hypnosis, biofeedback. 4) OTC meds and prescriptions may help with sleep, anxiety, depression etc. however, be careful regarding actual claims of tinnitus cure. FOLMER RL, THEODOROFF SM, MARTIN WH, SHI Y. (2014) EXPERIMENTAL, CONTROVERSIAL, AND FUTURISTIC TREATMENTS FOR CHRONIC TINNITUS. JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY 25:106-125. 1) Ineffective treatments out number effective treatments for tinnitus. 2) Non invasive effective treatments include hearing aids and sound emitting devices. 3) CBT is effective tinnitus treatment option, relaxation, counseling, hypnosis, biofeedback. 4) OTC meds and prescriptions may help with sleep, anxiety, depression etc. however, be careful regarding actual claims of tinnitus cure. 5) Tinnitus sound therapies vary in terms of performance and perceived help in reduction of tinnitus annoyance. FOLMER RL, THEODOROFF SM, MARTIN WH, SHI Y. (2014) EXPERIMENTAL, CONTROVERSIAL, AND FUTURISTIC TREATMENTS FOR CHRONIC TINNITUS. JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY 25:106-125. 1) Ineffective treatments out number effective treatments for tinnitus. 2) Non invasive effective treatments include hearing aids and sound emitting devices. 3) CBT is effective tinnitus treatment option, relaxation, counseling, hypnosis, biofeedback. 4) OTC meds and prescriptions may help with sleep, anxiety, depression etc. however, be careful regarding actual claims of tinnitus cure. 5) Tinnitus sound therapies vary in terms of performance and perceived help to reduction of tinnitus annoyance. 6) CBT and ACT (acceptance and commitment therapy) can reduce tinnitus annoyance 7

TINNITUS GUIDELINES American Academy of Otolaryngology Head and Neck Surgery (AAO-HNS) 2014 http://oto.sagepub.com/content/151/2_suppl/s1.full.pdf TINNITUS DEFINITIONS AAO-HNS 2014 Tinnitus is the perception of sound when there is no external source of sound. Primary Tinnitus is idiopathic with or without underlying hearing loss Secondary tinnitus is specific with an underlying cause Recent onset- 6 months or less Bothersome tinnitus is life impacting Persistent tinnitus is present 6 months or greater Non bothersome tinnitus is when tinnitus has no life impacting effect on the patient AAO-HNS 2014 Guideline focuses on people with primary tinnitus that is persistent and bothersome 6 months or longer. 8

TINNITUS PREVALENCE NIH TOPICS COVERED NEXT Tinnitus Patient Non Auditory Effects from Tinnitus Approaches to Tinnitus Management How Can I Prepare for My Tinnitus Patient Audiologist Tinnitus Toolbox Case Studies Examples THE TINNITUS PATIENT 9

TINNITUS PATIENTS COME IN ALL AGES YOUR PATIENT MAY EXPERIENCE A WIDE RANGE OF TINNITUS PERCEPTIONS FROM ACUTE TO CHRONIC TINNITUS TINNITUS COMPLICATIONS Sleep problems 10

TINNITUS COMPLICATIONS Sleep problems rats, I ll never get to sleep or what am I going to do or there must be something seriously wrong with me TINNITUS COMPLICATIONS Sleep problems rats, I ll never get to sleep or what am I going to do or there must be something seriously wrong with me TINNITUS COMPLICATIONS Mood swings happy 11

TINNITUS COMPLICATIONS Mood swings happy to sad LIMBIC SYSTEM EMOTIONAL BRAIN TINNITUS COMPLICATIONS Distress by tinnitus TINNITUS COMPLICATIONS Distress by tinnitus Nucleus accumbens LIMBIC System 12

TINNITUS COMPLICATIONS Concentration is poor DR. JENNIFER GANS ONLINE DISCUSSION REGARDING MINDFULNESS THERAPY ILLUMINATED WORK FROM DR. JASTREBOFF RECENTLY. Not Bothered 33 million Bothered 15-16 Million Debilitating 2-3 million Tinnitus 2-20dBSL measured in all groups SECONDARY EFFECT OF TINNITUS NON AUDITORY 13

SECONDARY EFFECT OF TINNITUS Fatigue SECONDARY EFFECT OF TINNITUS Fatigue Depression SECONDARY EFFECT OF TINNITUS Fatigue Depression Anxiety (serotonin?) 14

SECONDARY EFFECT OF TINNITUS Fatigue Depression Anxiety Memory problems SUMMARY Fatigue Depression Anxiety Memory issues Concentration FATIGUE MEMORY DEPRESSION CONCENTRA TION ANXIETY Tinnitus Management 1) There is no magic pill for tinnitus yet. 2) No magic process or therapy where one size fits all. 15

Treatment Behavioral Therapies ATA Cognitive Behavioral Therapy (CBT) (R. Sweetow) Relaxation, cognitive restructuring to help habituation process. QOL improvements are possible. Mindfulness Based Therapy of Stress Reduction (J. Gans) Accept and embrace the tinnitus Reduce anger and negative moods about tinnitus. Acceptance and Commitment Therapy (ACT) (S. Hayes) Accept negative thoughts control over reactions. Basically give up worrying about tinnitus and getting on with life. Treatment Behavioral Therapies ATA Tinnitus Activities Treatment (TAT) R.Tyler Centers on four areas a) thoughts and emotions about tinnitus, b) sleep c) concentration d) communication. Consists of lower level sound than used in TRT. Tinnitus Retraining Therapy (TRT)P. Jastreboff Demystify tinnitus with counseling, discuss anatomy Directive counseling and masking to habituate tinnitus Reduce emotional response from limbic system Constant low level noise used at mixing point to help with reducing annoyance. Avoid silence. IN QUIET 16

TINNITUS Other Therapy Considerations Masking Masking is Louder than tinnitus. Originally described by Jack Vernon in mid 70 s IN QUIET 17

COMPLETE MASKING Treatment Behavioral Therapies Progressive Tinnitus Management (PTM) Focus on reaction to the tinnitus. Design a sound plan Use a tinnitus relief scale 0 5 Sound grid Sounds that are soothing, background, interesting. Change thoughts and emotions about tinnitus. Imagery sight and sound. Create happy thoughts 1) Triage referral to appropriate specialty 2) Audiologic Evaluation 3) Group /Individual education Tinnitus intervention. 4) Tinnitus evaluation 5) Individualized Treatment : Mental health support, ear level devices, updating sound plans Other Therapy Considerations Hearing aids/combination units Available with most manufacturers White noise / Fractal sounds / Environmental sound options Apps Work without hearing aids Imagery and counseling apps Immediate access for patients Lower cost (?) Many choices available Some apps can sync with hearing aids (Bluetooth streaming) 18

Questions? Prep for Tinnitus Patient Tinnitus Practitioner Be a good listener! While we are not psychotherapists, we do impart information to reduce anxiety and stress about tinnitus, a form of CBT. Be honest: there is no cure to date but we can help With information, technology and professionalism, we can help reduce tinnitus annoyance for most patients impacted negatively. Tinnitus support groups may help some patients 19

Tinnitus Tool Box Audiologic Assessment Patient self reporting inventory regarding tinnitus annoyance questionnaires Patient education regarding tinnitus Treatment plan may include noise generators personal listening devices apps hearing aids with noise/masking/environmental sounds/sound pillows Devices, Hearing Aids, Maskers, Apps Implement Plan Monitor patient/support groups Outcomes TINNITUS SCREENING/ASSESSMENT TINNITUS SCREENING Comprehensive Audiologic Evaluation Include inter-octaves; Consider High Frequency OAE; Immittance Psychometric Screening Inventory Tinnitus Handicap Inventory Tinnitus Handicap Inventory (THI) Grade Score Description Slight 0-16 : Only heard in quiet environment, very easily masked. No interference with sleep or daily activities. NCRAR Tinnitus and Hearing Survey (THS) Mild18-36 : Easily masked by environmental sounds and easily forgotten with activities. May occasionally interfere with sleep but not daily activities. Moderate38-56 : May be noticed, even in the presence of background or environmental noise, although daily activities may still be performed. Severe 58-76 : Almost always heard, rarely, if ever, masked. Leads to disturbed sleep pattern and can interfere with ability to carry out normal daily activities. Quiet activities affected adversely. Catastrophic 78-100 : Always heard, disturbed sleep patterns, difficulty with any activity. 20

TINNITUS ASSESSMENT http://www.tinnitusresearch.org/en/consensus/consensusdocuments/en /consensus.pdf BEFORE YOU SEE THE PATIENT 1) Have a plan and your established procedure. 2) Determine how long you want the evaluation to go (2-3 hours) 3) Don t let the tinnitus patient run the appointment. 4) Use case history that details tinnitus. If you don t have a case history there are sample forms on http://www.tinnitusresearch.org/en/consensus/consensusdocuments/ en/tinnitus_sample_case_history_questionnaire.pdf 5) Have a fan or noise machine in your office to help them feel more comfortable. Doesn't have to be loud just audible. BEFORE YOU SEE THE TINNITUS PATIENT 5) Tinnitus Questionnaires- Tinnitus Functional Index (TFI), Tinnitus Handicap Inventory (THI), Tinnitus Reaction Questionnaires (TRQ), Tinnitus and Hearing Survey (THS) 6) Graphic to explain auditory pathway in simple terms with respect to tinnitus. 21

TINNITUS ASSESSMENT Date of Tinnitus Onset: Medical History: ENT/Neuro/Psych Evaluation : ABR, MRI, MRA Tests HISTORY: USE TINNITUS SENSITIVE CASE HISTORY Noise Exposure Caffeine Alcohol Nicotine Sleep Stress Meds/OTC TINNITUS QUESTIONNAIRES Tinnitus Handicap Inventory (THI) score Tinnitus Functional Index (TFI) score Subscales: Intrusive Sense of Control Cognitive Sleep Auditory Relaxation Quality of Life Emotional Distress Tinnitus Reaction Questionnaire (TRQ) score VAS (0-10) http://www.tinnitusresearch.org/en/consensus/consensus_en.php AUDIOLOGIC ASSESSMENT Audiologic Test 250-8000Hz (include 3000 and 6000Hz) Speech Tests Reception and Recognition/Admittance 22

PSYCHOACOUSTIC MEASURES Tinnitus Pitch Match Tinnitus Loudness Match Minimum Masking Levels Residual Inhibition Tinnitus Assessment is 92625 2016 ICD-10-CM Diagnosis Code H93.19 TEST TONE GENERATOR PITCH MATCH PRACTICE 23

HOW TO DO TINNITUS MEASUREMENT 92625 Pitch Match -Test ear with better hearing. Multiples of 1000 at 5-10dB above threshold. i.e. 1000-2000Hz, 2000-3000Hz etc. 75% of tinnitus sufferers report pitch at 3500Hz or higher. Several matches recommended due to subject variability. Loudness Match- 1 db increments and external stimulus is equal to the tinnitus loudness in dbsl, may be 4-7dB above threshold. Minimum Masking Level-Test ear with tinnitus -record in SL Narrowband or wideband noise that just masks the tinnitus. Describe if tinnitus is louder, softer or masked. Can be 8 dbsl or less. Residual Inhibition-Value from MML plus 10dB SL-Present to the tinnitus ear for 60 seconds and then record the seconds of inhibition. Also, you may report if RI is complete, partial or worse. http://www.tinnitusarchive.org/datasets/1/methods/tinnitusclinictestprotocol/ AUDITORY PATHWAY AND TINNITUS TINNITUS ASSESSMENT EXPLANATION OF BASIC EAR ANATOMY AND TINNITUS May be any process that explains hearing and possible theories of tinnitus. Tympanic membrane- Receives sound collected from the pinna. Middle ear ossicles- transfer information from TM to footplate of cochlea. Cochlea (snail shaped organ) lined throughout with IHC and OHC. Responsible for sending signals to the auditory nerve. Higher brain- Controls information back and forth to the cochlea and mid brain. Lower brain- Helps send information to collaterals within the cochlea and other parts of the brainstem. There are also connections to the high brain as well. 24

TINNITUS ASSESSMENT Limbic system- Talks throughout the system and controls emotional system and can help or hinder habituation of tinnitus and keep tinnitus active in the forefront of awareness. This system helps reject and accept tinnitus for some people. Negative Association- Main component for tinnitus annoyance. This happens when the brain is annoyed with the tinnitus. Depends on interaction of the limbic system. Habituation with Tinnitus Retraining Therapy (TRT): Habituation is the process that occurs when the tinnitus is no longer annoying or perceived by the individual. Tinnitus becomes neutralized. TINNITUS ASSESSMENT Category 0 Tinnitus is a minimal problem. Category 1 Tinnitus is the significant problem but no significant hearing loss. Category 2 Tinnitus and hearing loss are significant problems but no hyperacusis. Category 3 Hyperacusis is significant, may include patients with normal hearing or those with significant hearing loss. Tinnitus is irrelevant. Category 4 Prolonged tinnitus exacerbation caused by sound. Hearing problems irrelevant. Prolonged hyperacusis caused by noise, hearing is irrelevant and tinnitus irrelevant. HAVE A PLAN IF YOUR PATIENT TALKS ABOUT SUICIDE! TINNITUS EVALUATION #1 Goal Find the method that works best for each patient. There are many methods and some are diametrically apposed. Most common elements of a tinnitus assessment include: patient education, sound therapy, stress reduction, relaxation, improve sleep as main components in helping your patient with tinnitus. Use evidence based procedures PTM,TRT,TAT,CBT, Neuromonics, Masking, Hearing aids. 25

TINNITUS TREATMENT PLAN Use sound enrichment at night for sleep *soft broadband noise, not modulated, not interesting noise. Create a sound plan. Noise generators or relief sounds need to be non-annoying with little emotional content. Homework to include seeking out sounds that give them relief. Directive counseling as needed *CBT with regular visits to include homework on thoughts and emotions, change maladaptive thoughts about tinnitus. Reduce all or nothing thinking about tinnitus. Amplification with wide bandwidth as applicable Tinnitus support group *strict TRT method feels support groups are contraindicated. Relaxation therapy (breathing ex. 4 sec in, 4 sec out eyes closed) Refer to Psychology or Family Counselor, Mindfulness Based Therapy for Tinnitus help. CREATE A SOUND PLAN Get patient involved Give patient home work to try to find things around the home that they can use to increase the noise in a quiet environment such as fans, water, radios, TV s, music, environmental noise and reduce tinnitus annoyance. Describe noise, sound, music, environmental emitting devices such as sound machines, smart phone apps/i phone I pad apps and give examples for them. Try out apps before giving to the patient to make sure they work.. Stress that noises, music, sounds, environmental sounds should be neutral and not elicit emotions. Give examples where noise is interesting, relaxing or soothing and as back ground noise. CREATE A SOUND PLAN examples- Back ground noise Help concentration-reduce contrast from tinnitus. A patient that has to study in quiet but hears tinnitus may need a noise that lets them concentrate yet helps reduce tinnitus annoyance. So the noise needs to be more back ground in nature and neutral. Relaxing and soothing sounds-help sleep-helps with relief and stress from tinnitus. A patient has trouble sleeping at night in quiet however a sound app under the pillow or in the room may be just the thing to reduce tinnitus annoyance and allow for improved sleep. Interesting sounds- Reduce tinnitus annoyance with active listening A patient is at work in an open cubicle however tinnitus is driving the patient crazy. Listening to cricket noises seems to reduce the perception of the tinnitus. An app that emits cricket sounds able to connect to the smart phone via Wi Fi at work. Annoyance is reduced and can concentrate at work. 26

QUESTIONS? joel.edwards@boystown.org http://inclinicaltrials.com/tinnitus/ Case History A 58 yr old male early retirement. No money worries retired large. He is in good health other than his tinnitus problem. History of noise exposure. Hearing is normal through 4000Hz and drops precipitously to moderate 6-8Khz. Pitch match is 8000Hz right ear. Speech recognition is good. No other issues. ENT referred for tinnitus help. Woke up and noticed right sided tinnitus 10 months ago. Tinnitus is constant most of the time. No real trouble sleeping but during the day tinnitus is constant and he is becoming irritable. I just retired and now I have to deal with this. I ve been dealing with this for 10 months it never going away. Psychometric Scores on Tinnitus Hearing Survey reveal a very big problem with tinnitus and little problems hearing and no sound tolerance. How would you help this person? What goals would you suggest? Case History A Goals/Plan: Reduce anxiety-patient is stating all or nothing type comments. Use directive counseling. Explain the tinnitus path and a story that illustrates fear and relate to tinnitus. Mask tinnitus. Try to find a noise that helps reduce the perception of his tinnitus during the day. Add noise to his bedroom 24/7 and places where he is in quiet or needs to concentrate. Demo a wearable device. Once a masker is found, such as a RIC with masking noise, adjust so the masker and tinnitus are mixed. I would not completely mask this person. Try to allow for habituation over time. He has had this for relatively long time so habituation may take a little longer. Counsel he needs to wear the masker most of his waking hours. Realistic expectations tinnitus may wax or wane. 27

CASE HISTORY B 44 yr. Computer programmer. History of headaches. Referred by ENT. No medical issues. Woke up a year ago and noticed tinnitus and has worsened. Complaints of tinnitus for a year. Audio shows mild-moderate high frequency loss. Visual analog scale 0-10 for tinnitus is 8. Limited time in clinic. What things would you do or tell this patient? Screening with TFI shows the following. TFI score _31 Intrusive_26 Sense of Control_43 Cognitive_40 Sleep_23 Auditory_70 Relaxation_13 Quality of Life_12 Emotional Distress_33 RED small problem Green moderate problem Blue big problem VAS 0-10 tinnitus is 8. TFI Overall is 31 0-17 no problem 18-31 small problem 32-53 moderate problem 54-72 big problem 73-100 very big problem CASE HISTORY B Avoid silence and Make a sound plan. 1) Sounds that are soothing, interesting and for general back ground noise. Im taking this from Progressive Management style the VA uses. This patient is to create a sound plan and use these sounds to help sleep, help concentrate and for general relief of tinnitus annoyance. Images like water, blue sky, that help reduce anxiety and stress can also be found on www.nonanxiety.com in addition to sound. Apps are also included such as Resound Relief App has stress bubbles, environmental noises etc, Phonak Tinnitus app is sectioned to include soothing, interesting and back ground noises. Mild amplification for hearing loss. I demoed a set of RIC devices and this patient noticed a definite decrease in tinnitus. Next after 2 weeks. CASE HISTORY B Computer programmer. RED small problem Green moderate problem Blue big problem Pre Plan TFI score _31 Intrusive_26 Sense of Control_43 Cognitive_40 Sleep_23 Auditory_70 Relaxation_13 Quality of Life_12 Emotional Distress_33 VAS 0-10 tinnitus is 8. Post Plan TFI score _22 Intrusive_20 Sense of Control_66 Cognitive_43 Sleep_6 Auditory_6 Relaxation_6 Quality of Life_7 Emotional Distress_10 VAS 0-10 tinnitus is 3. TFI 22 small problem-over 2 weeks 0-17 no problem 18-31 small problem 32-53 moderate problem 54-72 big problem 73-100 very big problem 28

CASE HISTORY C 68 yr old female still working and runs a small printing company. Employee is her husband and one other office helper. She is in good health other than her tinnitus problem. She takes no medicine other than recently taking Anacin. She complains of aches and pains since she started doing more heavy lifting at work. The equipment in her office is quite old but works and she does not use any digital technology. She lost her husband within the last year. Her husband was also her main employee and actually ran the printing presses and maintained the machines. She has started doing all the work and trying to train a helper. Complaints of tinnitus and hearing loss for about 1 year and getting worse. Psychometric Scores on Tinnitus Handicap Inventory was severe. Audiologic testing shows normal hearing 250-8000Hz. Speech recognition is fair. Tinnitus is making it difficult for her to sleep and reported stress level is very high and problems concentrating. She recently started chewing gum to help with stress and now she has an ache in her jaw and happened at the same time her tinnitus worsened. Drinking more coffee. How would you help this person? Tinnitus Handicap Inventory SEVERI TY SCA LE Grade Score Description 1 0-16 Slight: Only heard in quiet environment, very easily masked. No interference with sleep or daily activities. 2 18-36 Mild: Easily masked by environmental sounds and easily forgotten with activities. May occasionally interfere with sleep but not daily activities. 3 38-56 Moderate: May be noticed, even in the presence of background or environmental noise, although daily activities may still be performed. 4 58-76 Severe: Almost always heard, rarely, if ever, masked. Leads to disturbed sleep pattern and can interfere with ability to carry out normal daily activities. Quiet activities affected adversely. 5 78-100 Catastrophic: Always heard, disturbed sleep patterns, difficulty with any activity. CASE HISTORY C Goals: She is under stress because of the obvious loss of her husband and business partner. Ask if she has had counseling. Recommend counseling for loss of husband, see counselor/psychology and maybe take relaxation ex with local yoga instructor. No significant hearing loss Help reduce stress from tinnitus and job Avoid silence. She uses ear protection in her shop now when the press runs Demystify tinnitus through directive counseling Measure Tinnitus-formally or informally to further demystify tinnitus CANSS -Change lifestyle. She is taking huge amount of Anacin- for jaw pain-since shewing gum. Not drinking alcohol, sleep is terrible because of tinnitus. Stress is off the charts. add soothing noise 24/7. Use sound therapy to reduce contrast with background noise as needed to help with concentration i.e. setting type in quiet, it s a print shop but quiet when press is not working. Put on comfortable background noise, music, talk radio in the quiet shop and at home Stop chewing gum, reduce caffeine CASE HISTORY C This patient did come back and wanted to try maskers. I used a wideband masker at the time from General Hearing Instruments TRT Method Tinnitus side first at mixing point -then contralateral match Matched tinnitus masking noise both sides-so she could still hear her tinnitus slightly wear 8-10 hrs a day. For 12-18 months No support groups Avoid silence The vc was screw set style potentiometer so not adjustable by the patient 29

CASE HISTORY D Case History- 35 yr old. Job stress, works in accounting new boss new baby A fellow worker dropped a cup on a hard surface and after that she noticed right ear tinnitus Tinnitus is described as shrill high pitch and pingy Sleep is poor and only getting 4hrs at night if lucky difficulty with concentration feels she can t hear and tinnitus has bothered her over 6 months She works in a relatively quiet environment CASE HISTORY D EXAM Pt Complaints- Persistent Bothersome Tinnitus over 6 months Decreased concentration from tinnitus Family doesn t understand my tinnitus problem I can t sleep I m fatigued and irritable This tinnitus is never going away CASE HISTORY D EXPLAIN RESULTS Explain test results, demystify tinnitus and go over pathway of sound and what areas are thought to cause tinnitus. Even if you don t do all four measures, try to get a measurement of the tinnitus. 30

TINNITUS MEASUREMENT ADVANTAGES Pitch Match Loudness Match Minimum Masking Residual Inhibition Tinnitus Assessment 92625. A type of masker may be discovered Ability to mask tinnitus become apparent RI may give some info regarding effectiveness of the masker, not crucial Shows your patient you are willing to help through measurement and evaluation secondarily help reduce anxiety, anger, frustration from tinnitus annoyance http://www.tinnitusarchive.org/datasets/1/methods/tinnitusclinictestprotocol/ CASE HISTORY D MEASURE TINNITUS WBN8dBSL 6dbSL PM RI 43dBHL Complete Masking 2 minutes Change audiometer to reflect 1 db increments when possible. Tinnitus PM was 6000Hz right ear. Threshold is 25dBHL. The tinnitus is measured at 31dB or 6dBSL re: Threshold, MML for WBN is 33dBHL or 8dBSL, RI is MML plus 10dBSL or 43dBHL WBN. Present for 60 seconds to obtain masking information partial, complete, tinnitus is worse or none. CASE HISTORY D PATIENT INTERACTION 31

CASE HISTORY D QUESTIONNAIRES TRQ 78 THI 65 TFI 80 CASE HISTORY D QUESTIONNAIRES TFI SUBSCALES 73-100 very big problem THI Severe TRQ-Significant problem TRQ 78 THI 65 TFI 80 Subscales SC-90% SL-100% Relax-95% CASE HISTORY D So far- Normal hearing-case history includes high stress, new boss, new baby, no help from husband, acoustic trauma and info from questionnaires, measured tinnitus right ear, positive note patient relief noted after tinnitus measurement. Next steps MEDS CANSS Visual Analog Scale 32

CASE HISTORY D MEDS- NONE CANSS: Caffeine- High power drinks Alcohol - None Nicotine- None Sleep- Poor-New baby-no help Stress- High VAS-8 GOLDEN OPPORTUNITY TO DISCUSS LIFESTYLE CHANGE CASE HISTORY D PLAN Counseling, counsel family members regarding tinnitus and what impact it has on their loved one. add soothing non-interesting noise to bedroom 24/7 to help sleep, increase physical exercise (recent studies reveal ex. Is good for tinnitus pt) per PCP direction, avoid silence, Discuss ways to help improve sleep with a new baby, husband needs to step up and help with the baby. Stop drinking high caffeine energy drinks. Use noise machines or app set on her desk at work amid quiet work environment. Everyone is different.. Sound plan includes environmental, music or Speech. ex. reading a book and tinnitus is bothering, turn on a noise in the room that is in the background that won t interfere with reading and reduce active listening. Sound plan to include soothing, background and interesting sounds as needed per her investigation around her home and at work. her sound plan. CASE HISTORY D OUTCOME Initial TRQ 78 THI 65 TFI 80 Subscales SC-90% SL-100% Relax-95% VAS 8 6 months post plan TRQ 17 THI 20 TFI 35 Subscales SC-10% SL-50% Relax 30% VAS 2 33

QUESTIONS? joel.edwards@boystown.org http://inclinicaltrials.com/tinnitus/ CASE HISTORY E Case History- 15 yr old. Accompanied by his parents. Cursory otoscopy was clear canals bilaterally. Male, does well in school. Plays hockey. No reported hearing loss. Takes no meds, does not drink caffeinated drinks, no stress other than normal adolescence. During a hockey game, while wearing his helmet, he was struck along side the top left part of his helmet and cracked the plastic. Since that time he has noticed tinnitus and thumping when he walks. This patient hears his eyes move in his head and autophony. He was referred by PCP. CASE HISTORY E AUDIOLOGIC EXAM Pt Complaints- Hears thumping when walking, hears own voice much different than prior his hit on the head. Ears feel full. Vision is OK but get dizzy when I hear anything loud. Some problems skating and playing hockey now. 34

CASE HISTORY E EXPLAIN RESULTS CASE HISTORY E FOLLOW UP AUDIO AFTER SURGERY Pre surgical Post surgical TINNITUS MEASUREMENT Pitch Match Loudness Match Minimum Masking. Residual Inhibition 35

CASE HISTORY E MEASURE TINNITUS NBN4 dbsl RI 44dBHL 2dbSL PM Change audiometer to reflect 1 db increments when possible. Tinnitus PM was 4000Hz left ear. Threshold is 30dBHL. The tinnitus is measured at 32dB or 2dBSL re: Threshold, MML for NBN is 34dBHL or 4dBSL re threshold, RI is MML plus 10dBSL or 44dBHL NBN. Present for 60 seconds to obtain masking information partial, complete, tinnitus is worse or none. Partial 15 sec CASE HISTORY E QUESTIONNAIRES TFI Scale 0-17 no problem 18-31 small problem 32-53 moderate problem 54-72 big problem 73-100 very big problem TRQ 13 THI 14 TFI 35 CASE HISTORY E QUESTIONNAIRES-SUBSCALES TFI Scale 0-17 no problem 18-31 small problem 32-53 moderate problem 54-72 big problem 73-100 very big problem TRQ 13 THI 14 TFI 35 Subscales SC-50, Aud-65 36

CASE HISTORY E PATIENT INTERACTION CASE HISTORY E So far- Normal hearing right ear. Mild hearing loss left ear. questionnaires- SC, hearing loss main concerns. MEDS- NONE CANSS: Caffeine None Alcohol None Nicotine Chews tobacco Sleep Good Stress Low-but mentions hearing concerns VAS-2 CASE HISTORY E Plan This patient is mostly concerned about hearing so fitting a RIC device left ear is the plan optional tinnitus masker with ocean type noise preferred earlier. 37

CASE HISTORY E OUTCOME INITIAL RESPONSES TRQ 13 THI 14 TFI 35 Subscales SC-50, Aud-65 MEDS- NONE CANSS: Caffeine- None Alcohol - None Nicotine- Chews tobacco Sleep- Good Stress- Low-but mentions hearing concerns VAS-2 6 month recheck show improvement from outcome measures TRQ 12 THI 10 TFI 15 Subscales SC-16, Aud-14 QUESTIONS? joel.edwards@boystown.org http://inclinicaltrials.com/tinnitus/ CASE HISTORY F 65 year old male with no history of noise exposure and sudden sensorineural hearing loss. He reports hearing to be the same in both ears prior this incident. He is retired and woke up in the middle of the night with left ear roaring tinnitus. He has been seen by ENT. Steroid treatments with diuretics were tried and no improvement in any of the audiologic tests, however this patient did not go to the ENT for 3 weeks since the initial problem. He spent most of his time researching the problem on the internet and trying all sorts of concoctions to stop tinnitus. He reports trouble hearing and sleeping as well as concentration problems. He has huge family issues causing even more stress in his life. 38

CASE HISTORY F AUDIOLOGIC EXAM CASE HISTORY F EXPLAIN RESULTS 1) Demystify Tinnitus. 2) Review anatomy and pathway of sound. CASE HISTORY F MEASURE TINNITUS BIG PROBLEM 39

TINNITUS MEASUREMENT Pitch Match (could not match) Loudness Match (Tolerance Problems) Minimum Masking Level WBN was 75dBHL Residual Inhibition 85dBHL http://www.tinnitusarchive.org/datasets/1/methods/tinnitusclinictestprotocol/ CASE HISTORY F PATIENT INTERACTION Loudness tolerance left ear 75-80dBHL CASE HISTORY F Questionnaires TRQ Reaction to tinnitus is significant. THI Moderate handicap TFI Severe TFI Subscale Intrusive 75 Senses of control 90 Concentration 65 Sleep 75 Auditory 85 Relaxation 65 QOL 50 Emotional 40 TRQ 65 THI 55 TFI 68 40

CASE HISTORY F Hearing loss Waited quite a while for medical intervention MEDS- Multiple meds with tinnitus side effects CANSS: Caffeine Ten cups a day (YIKES) Alcohol Couple beers a night Nicotine None Sleep Poor however no problems sleeping prior the SSNHL Stress High even before this happened VAS-9 GOLDEN OPPORTUNITY TO DISCUSS LIFESTYLE CHANGE CASE HISTORY F PLAN Counseling,counsel family members regarding tinnitus and what impact it has on their loved one. Contact family counselor regarding problems with family dynamic because that is a very stressful piece to this puzzle add soothing non-interesting noise to bedroom 24/7 to help sleep Add amplification to right ear with mild pink noise in both ears avoid silence Stop drinking high caffeine and beer Use hearing aids most of his waking hours Sound plan to include soothing, background and interesting sounds CASE HISTORY F INITIAL TFI Subscale Intrusive 75 Senses of control 90 Concentration 65 Sleep 75 Auditory 85 Relaxation 65 QOL 50 Emotional 40 VAS 9 OUTCOME TFI Subscale Intrusive 25 Senses of control 40 Concentration 35 Sleep 40 Auditory 25 Relaxation 30 QOL 25 Emotional 20 VAS 5 Pre Post TRQ 65 TRQ 35 THI 55 THI 40 TFI 68 TFI 30 41

SUMMARY Maskers and Hearing Aids can not fix everything Be a good listener While we are not psychotherapists, we do impart information to reduce anxiety and stress about tinnitus a form of CBT. Be honest and tell them there is no cure to date but we can help Many ailments have no cure. However with information, technology and professionalism we can help reduce tinnitus annoyance for most patients impacted negatively. Follow up appointments 2 weeks, 6 weeks, 2 months, 6 months. Some people drop off the map because no longer bothered. Difficult to research this group. Tinnitus support groups may help. Internet searches not recommended. References Jastreboff, P. J. (2004). Tinnitus Retraining Therapy: Implementing the Neurophysiologic Model: Cambridge University Press 2004 Gans, J. (2016) Mindfulness Made Accessible to Audiologists and Their Tinnitus and Hyperacusis Patients [Power Point Slides] Retrieved from: ReSound elearning Team <els@audiologyonline.com> Henry J. A., Zaugg, T.L., Meyers P.J., Kendall, C.J., (2010). Progressive Tinnitus Management: Clinical Handbook for Audiologists: Plural Publishing Inc 2010. Henry J. A., Zaugg, T.L., Meyers P.J., Kendall, C.J., (2010). Progressive Tinnitus Management: Counseling Guide: Plural Publishing Inc 2010. Henry J. A., Zaugg, T.L., Meyers P.J., Kendall, C.J., (2010). How to Manage Your Tinnitus: A Step by Step Workbook: Plural Publishing Inc 2010. American Tinnitus Association. http://www.ata.org/ Tinnitus Practitioners Association. http://www.tinnituspractitioners.com/home.aspx AAA. Audiologic Guidelines for Diagnosis and Management of Tinnitus Patients. Retrieved from Online Web site: http://www.audiology.org/publicationsresources/document library/audiologic guidelines diagnosis managementtinnitus patients Handout Creating a sound plan Creating a sound plan Get patient involved Give patient home work to try to find things around the house that they can use to increase the noise in a quiet environment such as fans, water, radios, TV s, music, environmental noise and reduce tinnitus annoyance. Describe noise, sound, music, environmental emitting devices such as sound machines, smart phone apps/i phone I pad apps and give examples for them. Try them out before giving to the patient to make sure they work.. Stress that noises, music, sounds, environmental sounds should be neutral and not elicit emotions. Give examples where noise is interesting, relaxing or soothing and as back ground noise. examples Back ground noise Help concentration reduces contrast from tinnitus. A patient that has to study in quiet but hears tinnitus may need a noise that lets then concentrate yet helps reduce the tinnitus annoyance. So the noise needs to be more back ground in nature. Relaxation soothing Help sleep helps with relief and stress from tinnitus. A patient has trouble sleeping at night in quiet however a sound app under the pillow or in the room maybe just the thing to reduce tinnitus annoyance and allow for sleep. Interesting Reduce tinnitus annoyance active listening A patient is at work in an open cubicle however tinnitus is driving the patient crazy. Listening to cricket noises seems to reduce the perception of the tinnitus. An app that emits cricket sounds able to connect to his smart phone via Wi Fi at work. Annoyance is reduce and can concentrate at work. 42

Handout ANATOMY ASCENDING AUDITORY PATHWAY Handout LIMBIC SYSTEM Handout APPS for Tinnitus Android 43

Handout APPS for Tinnitus Android Handout APPS for Tinnitus I PHONE/IPad Handout APPS for Tinnitus I PHONE/IPad 44

Handout APPS for Sleep 45