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Topics In Audiology > 3) Tinnitus > Flashcards

3) Tinnitus Flashcards

1
Q

Tinnitus is derived from the Latin word tinnire meaning “to ____”

A

ring

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2
Q

Because tinnitus is a real sound we can ____

A

Measure it

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3
Q

Define tinnitus

A
  • 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).
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4
Q

What are different ways tinnitus can be described to sound like?

A

Tinnitus may sound like ringing, buzzing, roaring, whistling, humming, clinking, hissing, etc.

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5
Q

Tinnitus shows a prevalence of ____ in the adult population

A

10-15%

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6
Q

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

A

70, 24-45%

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7
Q

In people with bothersome tinnitus, it may lead to what four things:

A

̶- Distress
̶- Difficulty concentrating
̶- Psychiatric symptoms (anxiety, depression, insomnia)
̶- Interfere with normal life.

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8
Q

Does tinnitus severity or annoyance/intrusiveness change over time?

A

̶- 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.

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9
Q

Explain the tinnitus intrusiveness three-level pyramid analogy

A
  • 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
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10
Q

The prevalence of the following five symptoms was higher in those with bothersome tinnitus:

A
  • Poor self-reported mental health
    ̶- Mood disorder
    ̶- A weak sense of community belonging
    ̶- High daily stress
    ̶- Poor quality sleep
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11
Q

People with hearing loss and tinnitus (%11) were twice as likely as those with hearing loss (5%) alone to use ____.

A

hearing aids

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12
Q

What is the most prevalent to least prevalent risk factor for tinnitus in canada?

A

This is why tinnitus is prevalent in young people

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13
Q

What are the prevalence of mental, emotional, and QoL characteristics for tinnitus in canada?

A
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14
Q

The occurrence of tinnitus is not directly related to ____ in the standard audiometric frequency range (250-8000 Hz)

A

SNHL

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15
Q

____% of people with tinnitus also have HL (but can also be independent)

A

85-95

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16
Q

However, ____ is mostly concomitant with SNHL

A

constant tinnitus

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17
Q

Five Known Risk Factors for both SNHL and Tinnitus:

A
  • Head trauma
    ̶- Noise exposure
    ̶- Sudden hearing loss
    ̶- Ototoxic drugs (e.g.: Aminoglycosides, Platinum-based anticancer drugs (Cisplatin), Salicylates, Macrolide antibiotics)
    ̶- Aging
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18
Q

What are the 2 types of tinnitus?

A

1) subjective tinnitus
2) objective tinnitus

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19
Q

What is subjective tinnitus?

A

Audible only to the patient

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20
Q

What is objective tinnitus?

A

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

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21
Q

Tinnitus can either be ____ or ____

A

Permanent (constant) or Intermittent

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22
Q

What is intermittent tinnitus?

A

Episodes of sound sensation lasting at least 5 minutes, twice a week

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23
Q

Etiology: five Idiopathic vs. Associated with Diseases or Otologic Conditions, e.g.:

A

̶- Meniere’s Disease
̶- Vestibular Schwannoma
̶- Unilateral sudden SNHL
̶- Semicircular canal dehiscence (autophony and/or pulsatile tinnitus)
̶- Benign intracranial hypertension (pulsatile tinnitus)

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24
Q

5 mechanisms are implicated in the pathogenesis of tinnitus including:

A

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

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25
Q

What is oxidative stress?

A
  • 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.
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26
Q

What is genetic disposition?

A
  • 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.
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27
Q

What are somatosensory integrations?

A
  • The auditory system receives information from other sensory systems, especially vision and touch, at different levels: brainstem, midbrain, thalamus, and cortex.
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28
Q

Somatosensory tinnitus is often (4):

A
  • 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
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29
Q

5 Possible reasons for somatosensory tinnitus:

A
  • 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
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30
Q

2 evaluation/physical examinations of somatosensory tinnitus?

A

1) Digitial pressure (trigger points)
2) Maneuvers (jaw, teeth, neck ,shoulders, eyes)

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31
Q

3 Treatments for somatosensory tinnitus?

A
  • Relaxation therapy
  • Manual therapy by physiotherapists
  • Trigger point deactivation
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32
Q

What is Jastreboff’s Neurophysiological Model of Tinnitus?

A
  • 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
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33
Q

What are the 4 steps Jastreboff’s neurophysiologic model of tinnitus?

A

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)

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34
Q

Explain A) Generation of Abnormal Neural Activity

A
  • 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.
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35
Q

Explain B) Interpretation of Abnormal Neural Activity

A
  • 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.
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36
Q

Explain C) Perception and Evaluation in High CNS Regions

A

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.

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37
Q

Explain D) Sustained Activation of Non-Auditory Brain Systems (for Clinically Significant/bothersome Tinnitus)

A
  • 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.
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38
Q

What are the 5 things that can cause tinnitus?

A

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)

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39
Q

What are 3 characteristics of tinnitus?

A

1) Tinnitus is secondary to the disease
2) Tinnitus may change after treatment.
3) It may be somatosound.

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40
Q

4 overview points of meniere’s disease:

A

̶- 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.

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41
Q

3 Tinnitus Characteristics in Meniere’s Disease:

A

̶- 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

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42
Q

What are 3 treatment/management strategies for tinnitus in meniere’s disease?

A

1) Audiologic Management
2) Medical Management
3) Stress Management

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43
Q

Meniere’s disease - what is audiologic management?

A
  • Audiologic Management: Sound therapy (ST) and amplification
    ̶- Amplification may be complex due to potential hearing fluctuations and loudness recruitment.
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44
Q

Meniere’s disease - what is medical management?

A
  • 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.
45
Q

Meniere’s disease - what is stress management?

A

̶- 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.

46
Q

What are 3 overview points of vestibular schwannoma/acoustic neuroma (VS/AN)?

A

̶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).

47
Q

Tinnitus in Vestibular Schwannoma (3):

A

̶- 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

48
Q

What are 2 treatment/management strategies for tinnitus in VN/AN?

A

1) Stress Management
2) Audiologic Management

49
Q

VN/AN - stress management (2)

A

Stress Management:
̶- Relaxation therapy
̶- Onward referrals for psychiatric symptoms, monitored using questionnaires (e.g., HADS)

50
Q

VN/AN - audiologic management (4)

A

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

51
Q

Contradiction of ST for those with unilateral, profound SNHL before or after tumor removal, why?

A
  • Exacerbated hearing handicap: Difficulty in hearing and SIN perception.
  • Exacerbated tinnitus, in some patients.
52
Q

What are 3 overview points of unilateral sudden SNHL?

A

̶- 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

53
Q

7 Causes of SSNHL:

A

̶- Barotrauma
̶- Head trauma
̶- Surgical trauma
̶- Blast injury
̶- Ototoxic damage
̶- Vestibular schwannoma
̶- Idiopathic factors

54
Q

Unilateral sudden SNHL audiological management after ____

A

Steroid Therapy

55
Q

4 Audiologic Management Strategies After Steroid Therapy for unilateral sudden SNHL:

A

̶- 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

56
Q

What 4 things are we assessing with questionnaites with unilateral sudden SNHL?

A
  • Tinnitus severity
  • Tinnitus distress
  • Psychiatric symptoms (stress, anxiety, depression, sleep disturbances)
  • Quality of life (QoL)
57
Q

What do questionnaires regarding unilateral sudden SNHL tell us?

A

Questionnaires can help show the severity of tinnitus before and after treatment (shows how treatment can be beneficial; anxiety/depression may go down)

58
Q

What is middle ear myoclonus (MEM)?

A

It is a rare medical condition characterized by involuntary contractions of the muscles within the middle ear.

59
Q

With MEM, tinnitus is (4):

A

̶- Somatosound like clicking or buzzing.
̶- Perceived as a repetitive sound sensation or movement perception within the ear.
̶- Is typically unilateral.
̶- Exacerbated by stress.

60
Q

Diagnosis of MEM relies on (4):

A

̶- 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).

61
Q

MEM differential diagnosis from:

A

Temporomandibular joint clicking, Eustachian tube sounds, palatal myoclonus, foreign bodies, or insects in the ear.

62
Q

What are 2 management strategies for MEM?

A
  • 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
63
Q

What are 2 Other Otologic Conditions Accompanying Tinnitus (Somatosounds)?

A

1) Semicircular canal dehiscence (SCD)
2) Benign Intracranial Hypertension (BIH)

64
Q

What is Semicircular canal dehiscence (SCD)?

A

̶- SCD involves an abnormal opening in the bony structure of the semicircular canals.
̶- Pulsatile tinnitus and/or autophony, requiring medical interventions.

65
Q

What is Benign Intracranial Hypertension (BIH)?

A

̶- 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.

66
Q

What is the aim of a full tinnitus assessment?

A

To outline methods for measuring tinnitus and reactions to it in a clinical setting

67
Q

What are the 4 components of a complete tinnitus assessment?

A
68
Q

What are 4 tinnitus psychoacoustic measures?

A

1) pitch matching
2) loudness matching
3) minimum masking level (MML)
4) residual inhibition

69
Q

Why do we use psychoacoustic assessments to measure tinnitus?

A

A discussion about tinnitus measurement should start with a review of psychoacoustics

70
Q

Psychoacoustic assessments - Sound possesses four physical characteristics and four perceptual characteristics:

A
71
Q

Room/Equipment Required for Psychoacoustic Assessments of Tinnitus:

A
  • An acoustic room, like conventional audiometry
  • A clinical audiometer, with extended high-frequency audiometry (EHFA) and headphones for HFA.
72
Q

In many patients, tinnitus is ____

A

HF (above 9000Hz)

73
Q

The aim of the Psychoacoustic Assessments of Tinnitus is too:

A

̶- 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).

74
Q

Pitch matching - aim:

A

To measure the pitch of the individual’s tinnitus sound.

75
Q

Pitch matching - stimulus:

A

̶- 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.

76
Q

Pitch matching - reason for using pulsed tones:

A

̶- Pitch perception is influenced by presentation duration. Longer tones may change the pitch perception.
̶- To differentiate tinnitus sound from the presented tone.

77
Q

Pitch matching - testing ear:

A

To avoid differences between ears (e.g., diplacusis), all measurements are preferably conducted in the ear where the patient experiences tinnitus.

78
Q

Pitch matching - method (4):

A
  • 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
79
Q

Loudness matching - aim

A

To measure the loudness of tinnitus sound.

80
Q

Loudness matching - method (5):

A

̶- 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.

81
Q

Minimum masking level - aim

A

To investigate if the tinnitus sound could be masked using a pulsed speech-shaped noise.

82
Q

Minimum masking level - method (5)

A
  • 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.
83
Q

Residual inhibition - aim:

A

To measure the magnitude of RI of tinnitus and determine if the patient may benefit from ST.

84
Q

Residual inhibition - method (4):

A
  • 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
85
Q

What happens if the patient says the tinnitus sound is different?

A

1) Determine timeline
2) Determine the masking effect per ear

86
Q

RI different - How do you determine the timeline?

A

how long (minutes and seconds) did the tinnitus take to return to its pre-masker loudness?

87
Q

RI different - How do you determine the masking effect per ear?

A

C is a good candidate for ST

88
Q

Psychoacoustic Measurements Using Scales work?

A

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.

89
Q

What are the two types of psychoacoustic scales?

A

1) Interval Scales
2) Ordinal Scales

90
Q

Psychoacoustic Measurements Using Scales - What interval scales?

A

̶- 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)

91
Q

Psychoacoustic Measurements Using Scales - What ordinal scales?

A

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)

92
Q

What type of scale is preferred?

A

Interval scales are preferred as they have less linguistic ambiguity and are easier for analysis.

93
Q

Measuring Reactions to Tinnitus - Aims for using validated questionnaires (5):

A

̶- 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.

94
Q

What are 2 most common questionnaires used in clinics?

A

1) tinnitus handicap inventory (THI)
2) tinnitus functional index (TFI)

95
Q

What are the 6 tinnitus questionnaires we will focus on?

A

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)

96
Q

Tinnitus questionnaires differ in:

A
  • 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).
97
Q

What are 2 other questionnaires that arent as common?

A

1) Client-Oriented Scale of Improvement for Tinnitus (COSIT)
2) Tinnitus Diary

97
Q

What is the Client-Oriented Scale of Improvement for Tinnitus (COSIT)

A

̶- 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.

98
Q

What is the Tinnitus Diary

A
  • 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.
99
Q

What are 2 measures for Measuring Quality of Life (QoL)?

A

1) WHO Model and Quality-of-Life Scales
2) Meaning of Life Questionnaire

100
Q

What is goal of Measuring Related Problems/ Tinnitus Comorbid Symptoms

A
  • 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.
101
Q

What are 2 assessments for Measuring Related Problems/ Tinnitus Comorbid Symptoms

A

1) Beck Depression Inventory (BDI)
2) Hospital Depression and Anxiety Severity (HDAS)

102
Q

What is the Beck Depression Inventory (BDI)

A
  • 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.
103
Q

What is the Hospital Depression and Anxiety Severity (HDAS)

A
  • 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).
104
Q

The neurophysiology of tinnitus is ____

A

uncertain

105
Q

The models are predominantly based on ____

A

animal interventions.

106
Q

Management options for patients with otologic conditions:

A

Counseling, hearing aid prescription, relaxation therapy, and onward referral for anxiety and depression.

107
Q

What are the 4 steps of a complete tinnitus assessment?

A

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

Topics In Audiology (6 decks)

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