Quiz #1 Tinnitus Class

Tinnitus CPG Work Group Definition

Tinnitus is the perception of sound that does not have an external source. It can be described as ringing, buzzing, hissing, sizzling, roaring, chirping, or other sounds in the ear or ears or the head.

ASHA’s definition of tinnitus

Tinnitus is a sound (like ringing, buzzing, or hissing) that you hear in one or both ears and/or in your head, even though there is no outside source of the sound. You may have this for a short time, like after attending a music concert, or it may happen all the time. It can be very bothersome in some cases and rarely noticed in others.

brief/transient ear noise (TEN)

a tonal or ringing sound heard suddenly in one ear, sometimes accompanied by a sense of hearing loss and aural fullness. The sound usually goes away within five minutes. This does not generally require clinical management.

• lasts seconds to 2 minutes

• harmless

very common, ~75% of adults report this

How common is transient ear noise (TEN)?

prolonged spontaneous tinnitus (PST)

tinnitus lasting more than 5 minutes at any time

Either a middle ear muscle spasm or a blood vessel spasm in the cochlea

What is transient ear noise (TEN) thought to be caused by?

acute tinnitus

Type of tinnitus that refers to a recent onset (fewer than 6 months) and can last for a few minutes, hours, days, or weeks.

ear infection, medications, head or neck injury, recent hazardous noise exposure, occluding cerumen, changes in blood pressure or metabolism.

What can cause acute tinnitus?

acute tinnitus that occurs immediately after noise exposure to loud sounds

• gunfire

• explosions

• concerts

What is a big risk factor for acute tinnitus?

mechanical damage to stereocilia on the tops of hair cells within the cochlea

Physiologically, how does acute tinnitus result from loud noise exposure?

chronic/persistent tinnitus

Tinnitus that usually is persistent for 6 months or more and can also result from the conditions listed above in the “acute” definition, and is more likely to occur in people who have hearing loss.

• people w/this generally try to self-fix because they have been dealing with it for so long

• There is no “cure”, but we can manage this to improve QoL

objective tinnitus

Tinnitus that can be heard by people in close proximity to the patient’s ear or head. This tinnitus is extremely rare, accounting for fewer than 1% of all cases.

• vascular abnormalities (congenital arteriovenous fistula, acquired arteriovenous shunt, gloms jugular, high-riding carotid artery, carotid stenosis, persistent stapedial artery, dehiscent jugukar bulb, vascular loop such as the anterior or posterior inferior cerebllar artery compressing the auditory nerve)

• mechanical disorders (abnormally patent Eustachian tube, palatal myoclonus, temporomandibular disorder, stapedial muscle myoclonus)

What can cause/be associated with objective tinnitus?

subjective tinnitus

Tinnitus that is heard only by the patient, accounts for most tinnitus cases

primary tinnitus

tinnitus that is idiopathic and may or may not be associated with SNHL

secondary tinnitus

tinnitus that is associated with a specific underlying cause (other than SNHL) or an identifiable organic condition

roaring

What type of tinnitus sound is a big charactersitic of Meniere’s?

bothersome tinnitus

Tinnitus that detracts from a person’s enjoyment and QoL. Interferes with concentration, relaxation, sleep, work, leisure activities, or any combination of these. Likely rated as “severe” or “significant” problems by the patient. People who experience this type of tinnitus are more likely to seek medical care than people who consider it an insignificant or benign perception that can be ignored most of the time.

pulsatile tinnitus

Tinnitus that may sound like a heartbeat and be completely synchronized with one’s pulse, typically described as hearing their heartbeat loud in one or both ears

• vascular

• thinning of bone

• paraganglioma or glomus jugulare tumor

• SSCD

• blood flow to the cochlea

• ear canal occlusion

• can be idiopathic

What are some possible causes of pulsatile tinnitus?

• the 10-15% does not include the VA, the VA has a much higher prevalence due to noise exposure

• Conflicting articles have varying rates

• People might not complian of tinnitus until it becomes chronic

Why is tinnitus prevalence difficult to quantify?

10-15%

What percent of adults experience chronic tinnitus?

males (10.5% vs 8.8%)

Is tinnitus more common in males or females?

excessive earwax (this can cuase some tinnitus which might go away after it’s removed)

What are the tinnitus risk factors of the outer ear?

• infections in the middle ear

• otosclerosis

• middle ear muscle contractions

  • middle ear myoclonus (not to be confused w/tinnitus)

  • palatal myoclonus

What are the tinnitus risk factors of the middle ear?

middle ear myoclonus

Classified as irregular ear clicking, it shouldn’t be confused with tinnitus. When two ME muscles spontaneously twitch and cause a clicking noise, when one muscle twitches, it pulls on the ossicles, causing a sound.

• noise exposure

• hearing loss

  • SNHL

• ototoxicity

  • aminoglycoside antibiotics

  • cisplatin

  • loop diuretics

• meniere’s disease

• age

• neoplasms

  • vestibular schwannoma

• infections (bacterial, viral, fungal)

• cholesteatoma

What are the tinnitus risk factors of the inner ear?

• auditory cortex of the brain

• head and neck injuries

• genetic predisposition

• cardiovascular conditions

  • hypertension

• metabolic conditions

  • anemia

  • hypo- or hyperthyroidism

  • diabetes mellitus

• musculoskeletal abnormalities

  • temporomandibular disorder (TMD or TMJ)

• hearing loss

  • presbycusis

  • noise induced

  • acoustic trauma

  • autoimmune hearing loss

  • middle ear infections

• genetic predisposition

What are some other tinnitus risk factors, not specific to outer, middle, or inner ear?

• stressful life events/stress

• fatigue

• alcohol consumption

• caffeine consumption

• smoking

• exercise (due to increased vascular system)

What are lifestyle tinnitus risk factors?

• noise exposure

• risk of head injury (concussion, blasts, explosions)

• service connection ratings?

Why is the military considered a tinnitus risk factor?

risk factors for tinnitus

Any condition or exposure that results in hearing loss or damage to the auditory system can contribute to the generation of subjective tinnitus. Tinnitus usually coincides with some type of damage to the auditory system.

Performs complex signal processing in the brainstem. It connects the inner ear to the cortex

What does the CANS do?

hyperacusis

A physical condition of discomfort or pain caused by sound. No emotional responses are involved. Patient will present with distress from the volume of a sound that others find comfortable.

misophonia

“Dislike of sound” implying that emotions are somehow involved in the reaction to sound. When people have an emotional reaction to sounds such as chewing or crunching. This is a learned response. Some people have only one trigger sound while others will have multiple.

phonophobia

This is a subcategory of misophonia, and specifically is a fear response caused by sound. There is usually an anticipation that sound will be uncomfortably loud. It refers to the persons state of mind with response to sounds in the environment. These sounds will NOT cause damage to the auditory system!

hyperacusis

What sound intolerance coincides with tinnitus?

noise exposure

What is the most common cause of hyperacusis?

8-15.2%

What is the prevelance of hyperacusis in adults?

teenage years (but can develop at any age)

When does misophonia usually develop?

• eating/drinking (smacking lips, chewing, loud swallowing)

• breathing noises (snoring, sniffing, nose blowing)

• activity and movement noises (tapping fingers, clicking a pen, loud typing)

• mouth/throat (throat clearing, coughing, kissing)

What are some common sound types that may be considered “triggers” for misophonia?

traffic, kitchen sounds, doors closing, loud speech

What type of environmental sounds usually trigger phonophobia?

loudness recruitment

This is often confused with hyperacusis. Its the abnormally rapid growth in the perception of loudness. Typically a phenomenon of cochlear or SNHL. Associated with reduced auditory thresholds and abnormal loudness discomfort levels. The dynamic range is compressed, but there is an abnormal tolerance to louder sounds.

• migraine

• lymes disease

• PTSD

• depression

• SSCD

• autism

• bell palsy

• Ramsay-hunt syndrome

• ADHD

What are some underlying conditions that should be excluded from differential dx of sound intolerance? AKA what disorders does sound intolerance coincide with?

sound intolerance evaluation and management protocol (STEM)

an adjunct program primarily for patients who have a sound tolerance problem that precludes them from participating in PTM (the sound-based intervention given out in this program might also help their tinnitus)

• sound tolerance interview

• testing of loudness discomfort levels (LDLs)

• use of ear-level instruments

What three parts does STEM include?

Sound intolerance interview

A 6-question interview that takes about an hour. Fits within the framework of PTM. More important than just testing LDLs. It gives insight to specfific situations that cause the patient sound intolerance.

It’s not generally recommended. It can cause discomfort and anxiety in patients. The results don’t help guide intervention procedures. However it is acceptable as long as the patient is okay with it.

Should we be testing LDLs with people with sound intolerance?

Yes! You can turn on the program that cuts loud impulse sounds. You can use the acclimatization feature to get them used to sounds they can’t stand.

Can you use hearing aids for sound intolerance?

Cognitive behavioral therapy (CBT)

Which tinnitus management/intervention approach has the strongest evidence?

Not audiologists! clinical social workers, psychiatrists, professional counselors, advanced NPs

Who can do CBT?

cognitive behavioral therapy (CBT)

Utilizes cognitive and behavioral components of therapy to reduce impact tinnitus has on persons QoL

cognitive

CBT component that attempts to replace negative thoughts and beliefs with thorughts and beliefs that promote a more positive outlook on tinnitus

behavioral

CBT component that involves teaching different coping skills for managing the effects of tinnitus.

• cognitive restructuring

• distraction techniques

• relaxation techniques

• education about the auditory system

• improving sleep

• general health

What are some examples of CBT strategies?

tinnitus activities training (TAT)

A type of tinnitus management that emphasizes counseling, coping strategies, and sound therapy with partial masking. The main goal is to provide patients with a positive outlook on their tinnitus. “Patient expectation nurturing”. Patient-centered care.

1- Audiologic evaluation

2- tinnitus primary function questionnaire

3- based on the results from above, patients are assigned into 3 categories (distressed, concerned, curious)

What is the treatment protocol/steps for tinnitus activities training (TAT)?

tinnitus primary function questionaire

What is the questionnaire specifically made for tinnitus activities retraining (TAT)?

sleep, concentration, thoughts and emotions, hearing and communication

what are the four areas of the tinnitus primary function questionaire

tinnitus retraining therapy (TRT)

A type of tinnitus management that trains the brain to habituate to the awareness of tinnitus. When habituation takes place, the related nerve connections to the brain are “rewired”. This approach attempts to retrain the brain so it’s unaware of the tinnitus and classifies it as background noise, rather than focusing on it.

For the patient to stop paying attention to the tinnitus by adding in another sound.

What is the goal of tinnitus retraining therapy?

mixing point

A sound that best mixes with the patient’s tinnitus to provide distraction for the brain.

1 - Play a sound and raise the level until the patient tells you it changes the perception of their tinnitus.

How do you acheive a mixing point?

Play a sound and raise the level until the patient can just barely hear the sound. Then turn it up just a little more and use that level of sound for the tinnitus retraining.

Some patients don’t have a mixing point, how do you set up the sound therapy for TRT in this case?

1 - Background sound should not cover up your tinnitus

2 - Sound levels should be safe!

What are the two most important tips for habituation?

1 - medical evaluation

2 - one-on-one interview using a structured interview form

3 - audiologic evaluation

4 - loudness discomfort (LDL) testing

What is the treatment protocol/steps for tinnitus retraining therapy (TRT)?

The tinnitus management that uses a stepped-care (progressive approach), meaning patients progress through increasingly higher levels of care depending on their individual need.

1 - triage

2 - audiologic evaluation

3 - group education

4 - interdisciplinary care

5 - individualized support

What are the 5 steps of PTM?

Level 1 - Triage

Level of PTM?: Referral includes a description of referral guidelines for any healthcare provider who encounters patients complaining of tinnitus.

Level 2 - audiologic evaluation

Level of PTM?: Medical Hx and tinnitus questionaire

Level 3 -group education

Level of PTM?: Skills & education consist entirely of the treatment of bothersome tinnitus

Level 4 - Interdisciplinary care

Level of PTM?: Evaluation provided by an audiologist and/or psychologist

Level 5 - Individualized support

Level of PTM?: For those with the most severe tinnitus and can include treatment such as CBT, TRT, or TAT

tinnitus functional index (TFI)

Questionaire that measures the severity of tinnitus and to what degree it is affecting a persons QoL.

What questionnaire should be used to identify the minimal level of change that would reflect actual benefit perceived by the patient?

a reduction of 13 points

What is the minimum reduction score of the TFI that would prove actual perceived benefit of tinnitus management by the patient?

1 - tinnitus activities training (TAT)

2 - tinnitus retraining therapy (TRT)

3 - cognitive behavioral therapy (CBT)

4 - progressive tinnitus management (PTM)

What are the four tinnitus management resources out there?

counseling and sound therapy

What are the two general categories of treatment for tinnitus?

tinnitus sound matching

The presentation of common tinnitus sounds back to patients, to help them identify their specific perception of tinnitus. This provides an important baseline for subsequent tinnitus management therapies, which are often customized to each patient.

minimum masking level

The volume at which an external narrowband noise masks/covers the perception of tinnitus. Determining this provides an approximate measure of how loud a patient perceives his/her tinnitus and can be used in subsequent tinnitus sound therapies.

loudness discomfort level (LDL)

The volume at which an external sound becomes uncomfortable or painful for a tinnitus patient. This measurement informs the feasibility of sound therapy, masking, and hearing aids as potential tinnitus treatments. This is particularly important for patients with an extreme sensitivity to sound.

loudness ratings

Which is more clinically useful, loudness ratings or loudness matching?

“weak” evidence (educational counseling does work, and it’s important to include it in sessions, even if it’s just a little bit. People have to understand tinnitus before they can decide if they want help)

Evidence of educational counseling as a clinical practice recommendation?

Insufficient evidence

Evidence of Web-based or App-based Self-Management as a clinical practice recommendation?

Insufficient evidence

Evidence of computer-based games and training programs as a clinical practice recommendation?

“weak” evidence (patient working groups emphasized hearing aids as one of the most effective devices for tinnitus treatment)

Evidence of amplification devices as a clinical practice recommendation?

insufficient evidence

Evidence of CROS devices as a clinical practice recommendation?

“weak” evidence (the confidence in the quality of evidence was low, some cases reported worsened tinnitus, but the benefits outweighed the harms)

Evidence of cochlear implants as a clinical practice recommendation?

insufficient evidence

Evidence of bone conduction devices as a clinical practice recommendation?

insufficient evidence

Evidence of sound-based intervention/auditory training alone as a clinical practice recommendation?

“weak” evidence (most effective when used with professional guidance, reduces self-perceived tinnitus handicap)

Evidence of therapeutic use of sound as a clinical practice recommendation?

“Weak” evidence (targets current problems and symptoms and improves functionality by emphasizing changes in unhelpful ways of thinking, improves clinical outcomes in adults with bothersome tinnitus, reduces tinnitus distress, and is effective across all modalities including Telehealth) (insufficient evidence for CBT without a therapist)

Evidence of behavioral intervention alone (CBT) as a clinical practice recommendation?

insufficient evidence (there is less evidence for breathing techniques, mindfulness therapy, and relaxation training than compared to CBT)

Evidence of psychological interventions as a clinical practice recommendation?

“weak” evidence (no studies report adverse affects)

Evidence of combined sound-based and behavioral intervention (CBT) as a clinical practice recommendation?

insufficient evidence

Evidence of neuromodulation/neurostimulation as a clinical practice recommendation?

• evidence against the use of herbal, nutraceuticals, and supplements

• However, acupuncture showed insufficient evidence; there were a couple of studies that showed it led to improvement in tinnitus, but not enough evidence

Evidence of holistic approaches as a clinical practice recommendation?

evidence against the use of anticonvulsants, antidepressants, antiemetics, anthrombotics, betahistine, etc…

Evidence of pharmacotherapy as a clinical practice recommendation?

transcranial magnetic stimulation (rTMS)

Non-invasive, delivers electromagnetic pulses through a coil to the patient’s scalp and affects the underlying neural tissue.

transcutaneous electric nerve stimulation (TENS)

The application of electric current produced by a device to stimulate nerves or other tissues for therapeutic uses.

increased spontaneous activity in the auditory cortex

What is the proposed mechanism of tinnitus?