3) Tinnitus Flashcards
Tinnitus is derived from the Latin word tinnire meaning “to ____”
ring
Because tinnitus is a real sound we can ____
Measure it
Define tinnitus
- Tinnitus is defined as the sensation of sound without any external acoustic sound source (i.e., phantom
perception of sound) - According to McFadden (1982), Tinnitus can be defined as
- A perception of sound (it must be heard)
- Involuntary (not produced intentionally)
- Originating in the head (not an externally produced sound).
What are different ways tinnitus can be described to sound like?
Tinnitus may sound like ringing, buzzing, roaring, whistling, humming, clinking, hissing, etc.
Tinnitus shows a prevalence of ____ in the adult population
10-15%
The incidence rate and the prevalence of tinnitus increase with age up to approximately ____ years, from 10-15% in the general adult population to ____% in older adults
70, 24-45%
In people with bothersome tinnitus, it may lead to what four things:
̶- Distress
̶- Difficulty concentrating
̶- Psychiatric symptoms (anxiety, depression, insomnia)
̶- Interfere with normal life.
Does tinnitus severity or annoyance/intrusiveness change over time?
̶- In about 75% of individuals, tinnitus remains the same throughout their life.
̶- In about 10% of the individuals, the tinnitus gets worse.
̶- In about 15%, it improves over time.
̶- Most patients learn to adjust to it.
Explain the tinnitus intrusiveness three-level pyramid analogy
- Tinnitus affects people differently
- Based upon Dobie’s (2004) three-level pyramid analogy, the base of the pyramid contains nearly 80% of people with tinnitus who are not annoyed by tinnitus.
- The next higher level contains people whose tinnitus is bothersome, ranging from mild to severe (this is who we provide audiology services for)
- The tip of the pyramid also includes those individuals who are debilitated by their tinnitus
The prevalence of the following five symptoms was higher in those with bothersome tinnitus:
- Poor self-reported mental health
̶- Mood disorder
̶- A weak sense of community belonging
̶- High daily stress
̶- Poor quality sleep
People with hearing loss and tinnitus (%11) were twice as likely as those with hearing loss (5%) alone to use ____.
hearing aids
What is the most prevalent to least prevalent risk factor for tinnitus in canada?
This is why tinnitus is prevalent in young people
What are the prevalence of mental, emotional, and QoL characteristics for tinnitus in canada?
The occurrence of tinnitus is not directly related to ____ in the standard audiometric frequency range (250-8000 Hz)
SNHL
____% of people with tinnitus also have HL (but can also be independent)
85-95
However, ____ is mostly concomitant with SNHL
constant tinnitus
Five Known Risk Factors for both SNHL and Tinnitus:
- Head trauma
̶- Noise exposure
̶- Sudden hearing loss
̶- Ototoxic drugs (e.g.: Aminoglycosides, Platinum-based anticancer drugs (Cisplatin), Salicylates, Macrolide antibiotics)
̶- Aging
What are the 2 types of tinnitus?
1) subjective tinnitus
2) objective tinnitus
What is subjective tinnitus?
Audible only to the patient
What is objective tinnitus?
It is audible to others.
̶- It can be identified during a physical examination.
̶- It is often associated with otologic conditions
̶- It may be somatosound: a noise originating from other body organs such as in pulsatile tinnitus
Tinnitus can either be ____ or ____
Permanent (constant) or Intermittent
What is intermittent tinnitus?
Episodes of sound sensation lasting at least 5 minutes, twice a week
Etiology: five Idiopathic vs. Associated with Diseases or Otologic Conditions, e.g.:
̶- Meniere’s Disease
̶- Vestibular Schwannoma
̶- Unilateral sudden SNHL
̶- Semicircular canal dehiscence (autophony and/or pulsatile tinnitus)
̶- Benign intracranial hypertension (pulsatile tinnitus)
5 mechanisms are implicated in the pathogenesis of tinnitus including:
1) Maladaptive neuroplasticity or Neurophysiological Models of Tinnitus
2) Oxidative stress
3) Genetic disposition
4) Vascular dysfunction or blood vessel diseases (pulsatile tinnitus)
5) Otologic conditions
What is oxidative stress?
- Mostly observed subsequent to acoustic trauma.
̶- Excessive noise exposure, may cause Reactive Oxygen Species (ROS) accumulation, which can lead to necrosis and apoptosis of the OHCs.
What is genetic disposition?
- Tinnitus heritability ranges from 0.21 to 0.68.
̶- With an estimate of 0.68 for bilateral tinnitus in men and 0.41 for women.
What are somatosensory integrations?
- The auditory system receives information from other sensory systems, especially vision and touch, at different levels: brainstem, midbrain, thalamus, and cortex.
Somatosensory tinnitus is often (4):
- Unilateral
- Intermittent
- Observed in people with normal hearing thresholds
- Some people report changes in their tinnitus loudness or pitch, commonly by head or neck movements
5 Possible reasons for somatosensory tinnitus:
- Trauma to the head or upper extremities
- Head and/or neck pain and myofascial dysfunction
- Fibromyalgia (widespread musculoskeletal pain)
- Temporo-mandibular joint (TMJ) disorders/dysfunction
- Postural effects: long term sitting posture, improper posture
2 evaluation/physical examinations of somatosensory tinnitus?
1) Digitial pressure (trigger points)
2) Maneuvers (jaw, teeth, neck ,shoulders, eyes)
3 Treatments for somatosensory tinnitus?
- Relaxation therapy
- Manual therapy by physiotherapists
- Trigger point deactivation
What is Jastreboff’s Neurophysiological Model of Tinnitus?
- one of the oldest model of tinnitus (the only model explaining psychiatric disorders as it relates to tinnitus)
- tinnitus is triggering stress, anxiety, and/or depression and lead to higher level of severity of tinnitus
What are the 4 steps Jastreboff’s neurophysiologic model of tinnitus?
A) Generation of Abnormal Neural Activity
B) Interpretation of Abnormal Neural Activity
C) Perception and Evaluation in High CNS Regions
D) Sustained Activation of Non-Auditory Brain Systems (for Clinically Significant/bothersome Tinnitus)
Explain A) Generation of Abnormal Neural Activity
- Abnormal neural activity causing tinnitus is typically initiated in the periphery of the auditory system, potentially in the dorsal cochlear nucleus.
- This abnormal activity is treated as background sound, not initially evoking any reaction.
Explain B) Interpretation of Abnormal Neural Activity
- The abnormal neural activity is detected and processed in the subconscious part of the brain (brainstem).
- In ideal conditions, the abnormal activity is perceived in the auditory cortex without activating other brain systems.
Explain C) Perception and Evaluation in High CNS Regions
In the majority of cases, abnormal neural activity is treated as a neutral stimulus, leading to spontaneous habituation, and there is no activation of the limbic and autonomic nervous systems.
Explain D) Sustained Activation of Non-Auditory Brain Systems (for Clinically Significant/bothersome Tinnitus)
- Classification of tinnitus as an important, negative stimulus develops a self- enhanced loop leading to sustained activation of non-auditory systems such as the limbic and autonomic nervous systems.
- In this loop, the negative stimulus continuously triggers the autonomic nervous system, causing reactions to tinnitus.
What are the 5 things that can cause tinnitus?
1) Meniere’s Disease
2) Vestibular Schwannoma/Acoustic Neuroma
3) Unilateral Sudden SNHL
4) Middle Ear Myoclonus (MEM)
5) Other otologic conditions:
̶ - Semicircular canal dehiscence (SCD)
̶ - Benign Intracranial Hypertension (BIH)
What are 3 characteristics of tinnitus?
1) Tinnitus is secondary to the disease
2) Tinnitus may change after treatment.
3) It may be somatosound.
4 overview points of meniere’s disease:
̶- Its incidence varies widely, according to the ethnic and geographic background in the world, ranging from 3 to 513
per 100, 000 individuals
̶- Affects both biological sexes equally and often presents in the fourth age decade.
̶- Is characterized by recurrent vertigo, tinnitus, hearing loss, aural fullness, and loudness recruitment.
̶- Tinnitus can be bilateral in some cases.
3 Tinnitus Characteristics in Meniere’s Disease:
̶- Predominately low-pitched (125–250 Hz), with roaring, buzzing, or ocean-like sounds.
̶- Tinnitus severity and annoyance tend to be higher in Meniere’s disease compared to other otologic conditions.
̶- Increased tinnitus may be part of the prodrome to vertigo attacks
What are 3 treatment/management strategies for tinnitus in meniere’s disease?
1) Audiologic Management
2) Medical Management
3) Stress Management
Meniere’s disease - what is audiologic management?
- Audiologic Management: Sound therapy (ST) and amplification
̶- Amplification may be complex due to potential hearing fluctuations and loudness recruitment.
Meniere’s disease - what is medical management?
- Intratympanic steroids or gentamicin primarily target vertigo.
̶- They may have variable effects on tinnitus, with reports of improvement or exacerbation.
̶- Some patients, post-successful vertigo control, may shift their focus to tinnitus, emphasizing the need for concurrent interventions for both vestibular and hearing symptoms.
Meniere’s disease - what is stress management?
̶- Psychiatric symptoms (stress, anxiety, and depression) hold a high incidence in Meniere’s disease.
̶- Screening, monitoring, and onward referral, using self-assessment scales e.g.: Hospital Anxiety and Depression Scale (HADS).
̶- Helpful stress management strategies: Progressive muscle relaxation therapy, biofeedback, and sleep hygiene.
What are 3 overview points of vestibular schwannoma/acoustic neuroma (VS/AN)?
̶1) It is a benign neoplasm on the vestibular nerve.
̶2) Incidence is around 1 to 2 per 100,000.
̶3) It can be bilateral in conditions like neurofibromatosis type 2 (NF2).
Tinnitus in Vestibular Schwannoma (3):
̶- Tinnitus is a common symptom reported in 73%
̶- Postoperative tinnitus persists in 83% of cases, even after successful tumor removal.
̶- Changes in tinnitus may cause concern about tumor progress, necessitating more frequent monitoring using MRI
What are 2 treatment/management strategies for tinnitus in VN/AN?
1) Stress Management
2) Audiologic Management
VN/AN - stress management (2)
Stress Management:
̶- Relaxation therapy
̶- Onward referrals for psychiatric symptoms, monitored using questionnaires (e.g., HADS)
VN/AN - audiologic management (4)
Audiologic Management:
̶- Counseling about tinnitus mechanisms can help understand the condition and cope with tinnitus.
̶- Hearing aid prescription
̶- Cochlear implants (CIs) and contralateral routing of signal (CROS) devices may suppress or reduce tinnitus.
̶- ST
Contradiction of ST for those with unilateral, profound SNHL before or after tumor removal, why?
- Exacerbated hearing handicap: Difficulty in hearing and SIN perception.
- Exacerbated tinnitus, in some patients.
What are 3 overview points of unilateral sudden SNHL?
̶- There are reports of:
̶ - Distressing tinnitus
̶ - Hearing handicap: Communication problems, even with a normal contralateral ear.
̶- SSNHL is an otologic emergency, requiring urgent steroid therapy to restore hearing ability
7 Causes of SSNHL:
̶- Barotrauma
̶- Head trauma
̶- Surgical trauma
̶- Blast injury
̶- Ototoxic damage
̶- Vestibular schwannoma
̶- Idiopathic factors
Unilateral sudden SNHL audiological management after ____
Steroid Therapy
4 Audiologic Management Strategies After Steroid Therapy for unilateral sudden SNHL:
̶- Counseling (information about tinnitus mechanisms)
̶- Cochlear implants for suppressing tinnitus in those with severe tinnitus
̶- Hearing aids
̶- Hearing tactics to address hearing handicap.
* Speech reading
* Auditory discrimination practice
What 4 things are we assessing with questionnaites with unilateral sudden SNHL?
- Tinnitus severity
- Tinnitus distress
- Psychiatric symptoms (stress, anxiety, depression, sleep disturbances)
- Quality of life (QoL)
What do questionnaires regarding unilateral sudden SNHL tell us?
Questionnaires can help show the severity of tinnitus before and after treatment (shows how treatment can be beneficial; anxiety/depression may go down)
What is middle ear myoclonus (MEM)?
It is a rare medical condition characterized by involuntary contractions of the muscles within the middle ear.
With MEM, tinnitus is (4):
̶- Somatosound like clicking or buzzing.
̶- Perceived as a repetitive sound sensation or movement perception within the ear.
̶- Is typically unilateral.
̶- Exacerbated by stress.
Diagnosis of MEM relies on (4):
̶- Case history
̶- In may be identified through tympanometry or otoscopy.
̶- MEM can be triggered by blowing air on closed eyelids, facial stroking, or a tuning fork held up to the ear.
̶- A sense of relief by pressing the external auditory meatus (a likely relief during tympanometry).
MEM differential diagnosis from:
Temporomandibular joint clicking, Eustachian tube sounds, palatal myoclonus, foreign bodies, or insects in the ear.
What are 2 management strategies for MEM?
- Tightly fitting custom silicone earmolds can provide long-term relief.
̶- Sectioning muscles in the middle ear: the tensor tympani and/or stapedius muscle in some cases
What are 2 Other Otologic Conditions Accompanying Tinnitus (Somatosounds)?
1) Semicircular canal dehiscence (SCD)
2) Benign Intracranial Hypertension (BIH)
What is Semicircular canal dehiscence (SCD)?
̶- SCD involves an abnormal opening in the bony structure of the semicircular canals.
̶- Pulsatile tinnitus and/or autophony, requiring medical interventions.
What is Benign Intracranial Hypertension (BIH)?
̶- It is characterized by increased pressure around the brain without a detectable cause.
̶- Exacerbation of symptoms when lying down.
̶- Pulsatile tinnitus, often synchronized with the cardiac cycle.
What is the aim of a full tinnitus assessment?
To outline methods for measuring tinnitus and reactions to it in a clinical setting
What are the 4 components of a complete tinnitus assessment?
What are 4 tinnitus psychoacoustic measures?
1) pitch matching
2) loudness matching
3) minimum masking level (MML)
4) residual inhibition
Why do we use psychoacoustic assessments to measure tinnitus?
A discussion about tinnitus measurement should start with a review of psychoacoustics
Psychoacoustic assessments - Sound possesses four physical characteristics and four perceptual characteristics:
Room/Equipment Required for Psychoacoustic Assessments of Tinnitus:
- An acoustic room, like conventional audiometry
- A clinical audiometer, with extended high-frequency audiometry (EHFA) and headphones for HFA.
In many patients, tinnitus is ____
HF (above 9000Hz)
The aim of the Psychoacoustic Assessments of Tinnitus is too:
̶- Tinnitus pitch and loudness (PM and LM)
̶- If the tinnitus can be masked (MML) if it can be masked, may benefit from ST
̶- If the patient may benefit from ST (RI).
Pitch matching - aim:
To measure the pitch of the individual’s tinnitus sound.
Pitch matching - stimulus:
̶- Uses pure-tone stimuli (e.g., 1000 Hz) presented at a supra-threshold level (e.g., 50 dB HL).
̶- Pulsed tones are preferred for tinnitus measurements.
Pitch matching - reason for using pulsed tones:
̶- Pitch perception is influenced by presentation duration. Longer tones may change the pitch perception.
̶- To differentiate tinnitus sound from the presented tone.
Pitch matching - testing ear:
To avoid differences between ears (e.g., diplacusis), all measurements are preferably conducted in the ear where the patient experiences tinnitus.
Pitch matching - method (4):
- Using ascending or descending half-octave steps, Patients indicate if their tinnitus is higher/lower than or similar to the presented tone.
- For this method, it is recommended to present the sound to the same ear (the two ears may not process information in the same way)
- You want to get as close as you can to their tone of tinnitus
- It is recommended to do this 5-7 times
Loudness matching - aim
To measure the loudness of tinnitus sound.
Loudness matching - method (5):
̶- Present the stimulus in the ear experiencing tinnitus.
̶- Present a 500 Hz pulsed tone at the patient’s hearing threshold.
̶- Increase in 2-dB steps until the patient reports “my tinnitus is louder” or “my tinnitus is softer” than the tone.
̶- The results of loudness balancing are reported in sensation level (SL).
̶- For example: 7 dB SL means that the tinnitus is 7 dB louder than the hearing threshold.
Minimum masking level - aim
To investigate if the tinnitus sound could be masked using a pulsed speech-shaped noise.
Minimum masking level - method (5)
- Determine the patient’s hearing threshold for a pulsed, speech-shaped noise (not a pure tone).
- Use an ascending method with 2-dB steps to determine the level (in dBHL) where tinnitus is masked.
- Patients respond to the stimulus by saying “I can hear my tinnitus” or “I cannot hear my tinnitus.” (stop at this level and record the measure).
- Do not exceed 80 dBHL because, for some patients, tinnitus cannot be masked.
- Report the results of 3 trials and the average per ear.
Residual inhibition - aim:
To measure the magnitude of RI of tinnitus and determine if the patient may benefit from ST.
Residual inhibition - method (4):
- Present a broadband masking signal, such as speech-shaped noise for one minute.
- Set the noise level at MML level + 10 dBHL to ensure adequate masking of the tinnitus with the masker.
- After the presentation, ask the patient if the tinnitus sound is the same or different.
- If different: determine timeline: how long (minutes and seconds) did the tinnitus take to return to its pre-masker loudness
What happens if the patient says the tinnitus sound is different?
1) Determine timeline
2) Determine the masking effect per ear
RI different - How do you determine the timeline?
how long (minutes and seconds) did the tinnitus take to return to its pre-masker loudness?
RI different - How do you determine the masking effect per ear?
C is a good candidate for ST
Psychoacoustic Measurements Using Scales work?
The perceptual qualities of tinnitus pitch, loudness (i.e., the most common), annoyance, etc., can also be assessed by obtaining magnitude estimations using single questions.
What are the two types of psychoacoustic scales?
1) Interval Scales
2) Ordinal Scales
Psychoacoustic Measurements Using Scales - What interval scales?
̶- Rating tinnitus pitch from 0 (very low pitch) to 10 or 100 (very high pitch)
̶- Rating tinnitus loudness from 0 (very soft) to 10 or 100 (very loud)
̶- Rating tinnitus annoyance from 0 (no intrusive) to 10 or 100 (very intrusive)
Psychoacoustic Measurements Using Scales - What ordinal scales?
Ordinal Scales (e.g.: a Likert scale)
̶- Rating tinnitus pitch from very low pitch (1) to very high pitch (5)
̶- Rating tinnitus loudness from very soft (1) to very loud (5)
̶- Rating tinnitus annoyance from no intrusive (0) to very intrusive (5)
What type of scale is preferred?
Interval scales are preferred as they have less linguistic ambiguity and are easier for analysis.
Measuring Reactions to Tinnitus - Aims for using validated questionnaires (5):
̶- To measure patients’ reactions to tinnitus.
̶- To understand the impact of tinnitus on various aspects of life.
̶- To distinguish between bothersome and non-bothersome tinnitus.
̶- To inform decision-making.
̶- To monitor changes over time or post- treatment.
What are 2 most common questionnaires used in clinics?
1) tinnitus handicap inventory (THI)
2) tinnitus functional index (TFI)
What are the 6 tinnitus questionnaires we will focus on?
1) Tinnitus Handicap Inventory (THI)
2) Tinnitus Functional Index (TFI)
3) Tinnitus Questionnaire (TQ)
4) Tinnitus Reaction Questionnaire (TRQ)
5) Tinnitus Handicap Questionnaire (THQ)
6) Tinnitus Primary Functions Questionnaire (TPFQ)
Tinnitus questionnaires differ in:
- Content (e.g., emotional, cognitive, and health effects are assessed by TQ and THQ vs. tinnitus severity is assessed by THI)
- Scaling methods (ordinal vs. interval).
What are 2 other questionnaires that arent as common?
1) Client-Oriented Scale of Improvement for Tinnitus (COSIT)
2) Tinnitus Diary
What is the Client-Oriented Scale of Improvement for Tinnitus (COSIT)
̶- COSIT identifies problems associated with tinnitus, sets therapy goals, and assesses treatment effectiveness.
̶- The patient is asked to identify 3 to 5 problem areas associated with tinnitus that serve as goals for the therapy.
̶- Moderate convergent validity with established questionnaires indicates its reliability.
What is the Tinnitus Diary
- Patients may benefit from maintaining a tinnitus diary, helping them cope with tinnitus.
̶- However, it is recommended that patients stop journaling after two weeks to avoid constant focus on tinnitus.
What are 2 measures for Measuring Quality of Life (QoL)?
1) WHO Model and Quality-of-Life Scales
2) Meaning of Life Questionnaire
What is goal of Measuring Related Problems/ Tinnitus Comorbid Symptoms
- Tinnitus often coexists with psychiatric disorders or other related problems, e.g.: depression, anxiety, and sleep disturbances.
̶- They are not used for differential diagnosis of psychotic disorders in the audiology practice (out of scope of practice).
̶- To collaborate with psychologists and mental health professionals for more comprehensive patient care.
What are 2 assessments for Measuring Related Problems/ Tinnitus Comorbid Symptoms
1) Beck Depression Inventory (BDI)
2) Hospital Depression and Anxiety Severity (HDAS)
What is the Beck Depression Inventory (BDI)
- Widely used for assessing depression severity.
- Contains 21 multiple-choice items rated between 0 to 3, evaluating the patient’s feelings.
- The total score spans from 0 to 59.
- A higher score indicates a higher level of depression.
What is the Hospital Depression and Anxiety Severity (HDAS)
- HADS is a 14-item self-assessment tool designed for detecting anxiety and depression in clinical settings.
- Each item is rated from 0 to 3 based on the severity of difficulty.
- The HADS total score is the sum of anxiety (HADS-A, 7 questions) and depression (HADS-D, 7 questions) subscale scores.
- Each subscale has a total score range of 0 to 21 and could be reported individually.
- Scores are categorized as normal (0-7), borderline (8-10), and abnormal (11-21).
The neurophysiology of tinnitus is ____
uncertain
The models are predominantly based on ____
animal interventions.
Management options for patients with otologic conditions:
Counseling, hearing aid prescription, relaxation therapy, and onward referral for anxiety and depression.
What are the 4 steps of a complete tinnitus assessment?
1) Psychoacoustic Measurements:
̶- Pitch matching (PM)
̶- Loudness matching (LM)
̶- Minimum masking level (MML)
̶- Residual inhibition (RI)
2) Measuring Reactions to Tinnitus
3) Measuring Quality of Life (QoL)
4) Measuring Related Problems/ Tinnitus Comorbid Symptoms
