Exam 1 (Tinnitus Assessment: Psychoacoustics)

Question 1

what are the goals of tinnitus assessments

Answer 1

Rule out or confirm disease or pathology underlying tinnitus
Document health conditions and factors influencing tinnitus perception
Evaluate auditory function to identify peripheral or central auditory dysfunction associated with mechanisms of tinnitus
Describe and quantify the severity of PT tinnitus
Define impact of tinnitus on quality of life
Contribute to decisions regarding an effective management plan

Question 2

what are the benefits to a tinnitus assessment

Answer 2

Improve PT-provider communication
Tinnitus PT reassurance
Establishing reference point
If HL or tinnitus got worse
Repeat original measurements and see if there are any changes
Basis for treatment
Documentation

Question 3

what are the psychoacoustic assessments

Answer 3

Pitch matching
Loudness matching
MML
Residual inhibition

Question 4

why are pa done

Answer 4

Establishes uniformity in quantifying tinnitus symptoms across clinical and research settings
Quantifies and validates tinnitus to reassure patients
Monitors changes in tinnitus perception
Matching pitch helps choose the masking noise, HAs or sound therapies

Question 5

can you do pa if the pT isn’t experiencing tinnitus

Answer 5

no can only be done if they have tinnitus at the time of the appt

Question 6

Rationale for Test Order

Answer 6

Acoustic stimulation can alter tinnitus perception especially with increased intensity
Accounts for potential hyperacusis

done in this order because the acoustic simulation can alter tinnitus perception (especially with increasing intensity) & account for potential hyperacusis

Question 7

what is the testing order recommended

Answer 7

Pure tone thresholds
SRT
Psychoacoustic measures (pitch, loudness, MML, RI)
LDLs
WRS
DPOAEs
immittance - reflexes, decay

Question 8

Routine audiological testing is done with

Answer 8

psychoacoustic assessment, extended HF audiometry & DPOAE testing

Question 9

how to perform pitch masking

Answer 9

Use a two-alternative forced choice (2AFC) method to determine the pitch of a patient’s tinnitus.
Presentation
stimuli at 10 – 20 dB SL at frequencies with normal limits
Stimuli at 5 –10 dB SL at frequencies with hearing loss.
Instruct the patient: example, “I want to get a close estimation of the pitch of your tinnitus. I am going to present two sounds in your — ear, and I want you to tell me which one sounds more like the tinnitus sound in your —- ear”. Try to ignore how loud the sound is and focus on the pitch.”
Start by presenting 1000 & 2000 Hz tone to the “stimulus ear” (contra ear to the ear with tinnitus)
Unilateral tinnitus: present stimulus to the non-tinnitus ear (stimulus ear)
Bilateral tinnitus: present stimulus to the ear with the softest tinnitus. If tinnitus is perceived the same in both ears, test either ear or the ear with the better thresholds.
Ask the patient which tone is closer in pitch to the tinnitus sound in their “tinnitus ear”.
Based on the patient response, either present a lower or higher frequency.
Ex:
Continue presenting different frequency tones at octave intervals to identify octave frequency that is the closest match to patient’s tinnitus pitch.
Once an octave frequency is identified as a ‘‘close match’’ to the tinnitus, continue testing at adjacent interoctave frequencies.
Test for “octave confusion” by alternating the pitch-matched tone with a tone an octave above and an octave below the matched tone to confirm final pitch match. The match using this procedure is the final, octave-confirmed pitch match.

Question 10

what is octave confusiton

Answer 10

ometimes it is 6 and sometimes it is 4 = octave confusion

Question 11

Use a two-alternative forced choice (2AFC) method to determine

Answer 11

the pitch of a patient’s tinnitus.

Question 12

goal of pitch masking

Answer 12

Estimate the general frequency region of the patient’s perceived tinnitus
Goal: to determine the frequency of a tone or noise that is closest to that of the PT’s most bothersome tinnitus

Question 13

goal of loudness matching

Answer 13

Obtain loudness match at the pitch-matched frequency
Goal: to determine the loudness of a tone or noise that is closest to that of the PT’s most bothersome tinnitus

Question 14

loudness matching procedure

Answer 14

For the pitch-matched frequency tone, obtain a hearing threshold to the nearest 1 dB.
Start 5 dB below the AC threshold and then gradually increase the level in 1-dB steps until the patient hears the tone.
Instruct the patient, ‘‘For each tone that I present, please tell me whether the tone should be made louder or softer to be the same loudness as your tinnitus.’’
Gradually increase intensity in 1-dB steps until a loudness match is obtained. Record results in dB HL and dB SL.
Repeat 3x

Question 15

purpose of tinnitus quality matchig

Answer 15

Tinnitus Matching to Bands of Noise
Determine whether tinnitus sounds like a tone or like noise

Question 16

tinnitus quality match procedure

Answer 16

Present a tone at the pitch and loudness from previous steps.
Then present NBN at the same frequency and same loudness.
Ask the PT “Which of these sounds most like your tinnitus”
Tone is selected = testing is complete
NBN is selected = determine if it is NBN or BBN (white or speech noise)
Present the NBN for a few seconds followed by the BBN for a few seconds at levels that approximate the patient’s tinnitus loudness; both speech and white noise should be presented to the patient for the final decision.
Using the final noise-match stimulus (NBN, speech noise, or white noise), obtain a hearing threshold and loudness match to 1 dB resolution, and record the loudness match in dB HL and dB SL.
If the PT selects either noise, match its loudness to the tinnitus

Question 17

purpose of MML

Answer 17

Identify the lowest level of BBN that completely masks the tinnitus
Goal: Determine the lowest level of BBN that completely masks the tinnitus (MML).
Determine whether patient’s tinnitus is bilateral or unilateral.

Question 18

what needs to be done first for MML

Answer 18

Determine whether patient’s tinnitus is bilateral or unilateral.
The masking noise should be presented binaurally for patients with bilateral tinnitus, and monaurally for patients with unilateral tinnitus.
FIRST, determine white noise threshold in the tinnitus ear(s). (BBN Threshold) - looking for the detection of white noise
Begin testing threshold using the usual down-10-dB, up-5-dB approach. When a threshold has been determined to the closest 5 dB, use a down 5/ up1 to obtain threshold to the closest 1 dB.
Test one ear at a time

Question 19

bilateral MML procedure

Answer 19

Instruct the patient “We’re going to find the softest level of noise that will completely cover your tinnitus. Please raise your right hand (or finger) when you can no longer hear your tinnitus in your right ear, and raise your left hand when you can’t hear your tinnitus in your left ear.”
Adjust the noise level to present white noise to each ear at the hearing threshold levels.
Lock the right and left ear outputs from the audiometer so that the levels are increased equally in both ears at the same time.
Gradually increase the BBN levels in 1-dB steps until the patient signals that tinnitus is completely masked in one or both ears.
If the tinnitus is masked in both ears at the same SL, testing is complete and MMLs are recorded.
If tinnitus is masked in one ear only, keep the level in the masked ear fixed by unlocking the audiometerchannels, and continue to increase the noise level in the unmasked ear until the tinnitus is completely masked.
Document the MMLs in dB SL and dB HL - they will be different in each ear

Question 20

procedure for unilateral mml

Answer 20

Present the BBN at the hearing threshold only to the ear with the tinnitus.
Instruct the patient, then start increasing the level of the noise in 1-dB steps until the patient cannot hear the tinnitus in the test ear.
When tinnitus is masked in the test ear, ask the patient if tinnitus can be heard in the contralateral ear.
If tinnitus is not heard contralaterally, MML testing is complete.
If the patient hears tinnitus in the contralateral ear, maintain the noise at MML in the tinnitus ear while gradually increasing the noise in the contralateral ear in 1-dB steps until the tinnitus is completely masked in that ear.

Question 21

what is the goal of residual inhibition

Answer 21

o characterize the patient’s tinnitus as a supplement to MML testing and to demonstrate that BBN can have a positive effect.

Question 22

should youinform PT that loudness of their tinnitus may be reduced by the RI test

Answer 22

no

Question 23

RI procedure

Answer 23

Begin testing RI immediately after establishing the MML by presenting the same BBN at a level 10 dB above the measured MML (MML + 10 dB).
Instruct the patient “There will be noise presented for exactly 1 minute. You do not need to respond in any way. The noise will then be turned off, and you will be asked if there is any kind of change in your tinnitus”.
Present the white noise for one minute binaurally. Wait a few seconds and then ask the patient ‘‘Does your tinnitus sound the same as before, or has it changed?’’
Report the results as follows:
Negative RI: If there is no change in the tinnitus perception.
Positive - Complete RI: If there is a complete absence of tinnitus perception in both ears (0% of the usual tinnitus loudness).
Positive - Partial RI: If there is a perceptible reduction in tinnitus loudness in one or both ears.
Ask the patient to estimate the current loudness as a percentage of their usual loudness (10%, 25%, 50%, 75%, or 90%).
Rebound or Exacerbation: If there is an increase in the tinnitus loudness level.
Time the duration of complete or partial RI; full RI = 2 minutes, Partial RI = 45 seconds.
Instructions: ‘‘Tell me when your tinnitus begins to return (in one or both ears).’’
The total duration of residual inhibition is recorded i.e. Full RI = 2 minutes or Partial RI = 45 seconds.

Question 24

negative RI

Answer 24

If there is no change in the tinnitus perception

Question 25

positive-complete RI

Answer 25

If there is a complete absence of tinnitus perception in both ears (0% of the usual tinnitus loudness)

Question 26

positive-partial RI

Answer 26

If there is a perceptible reduction in tinnitus loudness in one or both ears.
Ask the patient to estimate the current loudness as a percentage of their usual loudness (10%, 25%, 50%, 75%, or 90%).

Question 27

rebound or exacerbation

Answer 27

If there is an increase in the tinnitus loudness level.

Question 28

cpt code for tinnitus assessment

Answer 28

92625
pitch, loudness, & masking