Final Exam Flashcards

1
Q

what is tinnitus

A

Tinnitus is the perception of sound occurring in the ear or head when no external sound is present
Phantom auditory perception
It is a symptom, not a disease/disorder

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2
Q

what are the theories of peripheral mechanisms

A

cellular mechanisms
edge theory
discordant damage of IHC & OHC
tectorial membrane displacement
NTs & receptors
Synaptopathy

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3
Q

what are the theories of central mechanisms

A

auditory deprivation
inhibitory gating mechanism
hyperactivity & hypersynchrony
neural crosstalk
MOC dysfunction

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4
Q

complex sensory network that allows our brain to perceive and interpret sensations from the body

A

Somatosensory mechanisms

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5
Q

triggers for tinnitus of Somatosensory mechanisms

A

temporomandibular joint syndrome or whiplash
Anything related to the head and neck

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6
Q

what is the limbic system

A

Involved in our behavioral and emotional responses - feeding, reproduction, caring for our young, and fight or flight responses

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7
Q

what is the limbic systems role in tinnitus perception

A

Mediates the emotional response to tinnitus
Those with strong emotional responses often show enhanced sympathetic nervous system activity - fight or flight response

When it is heard there is a reaction and the reaction is controlled by this system and it can make it worse which explains why some cannot ignore it while others can

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8
Q

what can make the tinnitus worse in regards to the limbic system

A

Anatomical or physiological abnormalities in the limbic system - lead to emotional reactions to the tinnitus
if there is any lesion or damage, limbic system will not block the tinnitus signal meaning that all of it reaches the cortex and perceived causing it to be loud and clear

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9
Q

Greater brain connectivity between auditory and limbic areas =

A

more distress levels

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10
Q

subjective tinnitus

A

most common
heard only by the PT
can be bothersome or nonbothersome

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11
Q

common causes of subjective tinnitus

A

Ototoxicity - high-pitched sound
Meniere’s - LF tinnitus with vertigo & HL that fluctuates
OTSC - high-pitched, white noise and can initially be pulsatile

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12
Q

ototoxicity tinnitus

A

high pitched

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13
Q

meniere’s tinnitus

A

LF tinnitus with vertigo & HL that fluctuates

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14
Q

OTSC tinnitus

A

high-pitched
often white noise
can initially begin as pulsatile

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15
Q

how does OTSC cause tinnitus

A

CHL causing deafferentation (reduced auditory information going to the brain)
Reduction of masking effect - ex if you cover your ears you miss hearing the environmental noise
Environmental noise can mask the tinnitus but if you have CHL this is not the case so you hear it more
Rich blood supply causing pulsatile
Arteriovenous malformations
Cochlear tinnitus caused by toxic enzymes produced by otosclerotic bone, bony invasion of the cochlea, and damage to the cochlear blood supply

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16
Q

What is the common description of tinnitus reported by patients with otosclerosis?

A

Usually the first symptom noted is pulsatile in nature.

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17
Q

Tinnitus is a common symptom in otosclerosis patients and sometimes it can appear as the first symptom, explain.

A

If tinnitus is the initial symptom, it suggests that the patient hasn’t yet experienced conductive hearing loss. This means there’s no auditory deprivation triggering the brain to compensate for the reduced auditory input.

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18
Q

objective tinnitus

A

heard by the PT and examiner; sounds generated within the body and can be audible to another person
Rare
Vascular or mechanical in origin - Usually due to vascular disturbances or muscular spasms in the head/neck

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19
Q

causes of objective tinnitus

A

Glomus tumors
ME muscle spasms
Palatal myoclonus
ETD

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20
Q

acute vs chronic tinnitus

A

acute - short duration, <6 mos, associated w/ recent exposure triggers, high chance of spontaneous recovery

chronic - persistent, >6mos, involved in sustained neurobiological changes, less chance of spontaneous recovery

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21
Q

bothersome vs nonbothersome tinnitus

A

bothersome - significantly impacts quality of life

nonbothersome - has minimal impact

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22
Q

primary tinnitus

A

Tinnitus that is idiopathic & may or may not be associated with SNHL (source is unknown)
If we do not know the cause or disorder that caused it

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23
Q

secondary tinnitus

A

Tinnitus that is associated with a specific underlying cause (other than SNHL) or an identifiable organic condition
If we do know the cause of the tinnitus

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24
Q

auditory and non-auditory cauess of secondary tinnitus

A

Auditory causes: impacted cerumen, ME diseases, cochlear abnormalities, auditory nerve pathology
Non-auditory causes: vascular anomalies, myoclonus, intracranial hypertension, tonic tensor tympani syndrome, TMJ disorder

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25
pulsatile tinnitus
characterized by the sound that is rhythmic and resembles the heartbeat
26
somatosensory tinnitus
Tinnitus caused or influenced by sensory input in the body apply pressure or clench jaw etc. and they notice the tinnitus
27
Somatic and pulsatile could be classified as secondary because we know what is causing it
true
28
what are ways to classify tinnitus
temporal characteristics, duration, impact
29
what are temporal characteristics
how often they experience the tinnitus broken down into spontaneous, temporary, occasional, intermittent & constant
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spontaneous
sudden sound, usually unilateral lasting 2-3 min
31
temporary
lasts minutes to days often after noise exposure or medications and can accompany TTS
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occasional
occurs less than weekly (e.g., every few weeks, months or every few months) and lasts at least 5 minutes
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intermittent
occurring regularly (daily or weekly) and lasts at least 5 minutes
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constant
continuous sound
35
what is duration
how long you had it classified: recent/acute: experienced less than 6 months persistent/chronic: experienced for >/= 6 months
36
impact
how does it affect their life or interfere classified: bothersome or nonbothersome
37
pulsatile tinnitus
In synch with the heartbeat Rhythmical noise usually the same beat as the heart Usually caused by blood flow changes near the ear or by a change in awareness of blood flow whooshing sound
38
causes of pulsatile tinnitus
Hypertension Hyperthyroidism Vascular stenosis Unilateral head or neck pain with abrupt tinnitus onset = carotid dissection Tinnitus intensity changes with head movement = venous source
39
how to determine if it is pulsatile tinnitus
Complete audio testing - comprehensive audio, tymps, reflexes DPOAEs Find pulse to determine if pulsing matches tinnitus Tinnitus of venous origin can be suppressed by compressing the jugular vein Use 2 fingers to press firmly on SCM muscle & carotid artery for 10 sec. On the right and left sides of the neck Ask PT if pulsing changes in any way (may stay, go away or change to a different sound) If it does change, refer for medical workout of vascular pathways
40
glomus jugulare symptoms
HL is the main presentation - unilateral CHL or mixed Pulsatile tinnitus (decreases when you push on carotid), vertigo, otorrhea, CN involvement Red ™ - rising sun appearance
41
what is clicking tinnitus
Rare Can be objective; somatosounds Not all are detectable by examiner appears to be due to contractions of the tensor tympani or the nasopharyngeal muscles controlling the patency of the ET Or a symptom of ME myoclonus (jerking of a muscle group) Bilateral clicking = palatal myoclonus
42
bilateral clicking
palatal myoclonus
43
clinical manifestations of clicking tinnitus
May be seen on tymps Detectable using ARTs or decay Reflexes sometimes are too short Have PT tap their leg when they hear it and look for corresponding results to the taps
44
how to find clicking tinnitus
Have PT tap their leg when they hear it and look for corresponding results to the taps on reflex decay
45
should you refer for clicking or pulsatile tinnitus
yes
46
clinical manifestations of somatosensory tinnitus
Normal hearing Symptoms - High-pitched constant ringing No other hearing or vestibular complaints & neurological exams show no abnormalities
47
how to determine if it is SS tinnitus
different maneuvers and holding for 5-10s Temporomandibular joint Have PT clench their jaw for 10 s. Any change in tinnitus? Have PT open jaw wide/protrude jaw for at least 5s. Any change in tinnitus? Maneuvers involving the neck Active neck movements - with and without resistance Passive muscular palpation in order to search for myofascial trigger points (MTP) or tender points
48
Characteristics/Causes of SS tinnitus
Muscle tension, TMJ/jaw issues, dental disorders, head injuries, cervical spine issues, chronic stress, teeth clenching, etc
49
tinnitus red flags to refer for
Pulsatile tinnitus Tinnitus in association with vertigo Unilateral tinnitus or hearing loss Examination showing abnormalities of the ears Tinnitus in association with asymmetric hearing loss Psychological distress Significant associated sleep/concentration problems Anxiety regarding possible underlying pathology Distressing tinnitus not improving, despite initial treatment Patient request for ENT/audiological assessment Tinnitus in association with significant neurological symptoms
50
An 87-year-old woman had a year of intermittent severe hissing tinnitus that could be left ear only or bilateral. It followed a cyclical pattern. Following a day or two of no tinnitus, it would begin softly in the left ear but over the next two days become progressively louder as it spread to both ears. It would then lessen over the next two days or so, until the tinnitus was heard only in the left ear and ultimately would disappear completely. She had a long history of bruxism and muscle contraction headaches (tightness over her temples and jaw). When her tinnitus was severe her headaches were severe. Her audiogram showed symmetric mild sloping to moderately severe SNHL, bilaterally. At a visit when her tinnitus was extremely loud (10/10) and bilateral, somatic testing was performed. Her tinnitus loudness decreased to 4/10 and became unilateral (left ear only). These changes in her tinnitus persisted for the remainder of that visit (20 minutes). By the next day, her tinnitus had disappeared completely, but the usual cycle then returned within a day or two.
Type: somatosensory (changes intensity when things change - she has jaw problems, clenching causes migraine,s and comes and goes with certain things) Maneuver relaxed the muscle which is why it could’ve decreased the intensity
51
A 33-year-old man was seen because of non-lateralized tinnitus. His mother had been diagnosed with terminal lung cancer about three weeks earlier, and he had been closely involved with her care. Two days before her death as he was trying to sleep, his tinnitus began. It was described as a high-pitched ringing similar in pitch but much louder than the transient tinnitus he had previously experienced following loud sound exposure. Clenching or turning his head would aggravate his tinnitus. His exam and audiogram were normal. Despite four years of a variety of treatments, his tinnitus has persisted, and he remains distressed. what is the tinnitus & what referrals should be made if any
Type: dishabituation because he experienced tinnitus before and it was gone (occurred due to some change, he habituates and then he is fine and it comes back and the brain perceives it as a new stimulus) Value of digging into the history of PT He has normal hearing Mental health services to deal with the stress and this might change the vicious cycle
52
Most common sound a patient will report for tinnitus is
ringing
53
pushing/whoosing
pulsatile
54
Count the beats you feel and at the same time ask the PT to count the number of tinnitus beats they hear
technique for pulsatile tinnitus
55
Confirmed with tone decay because it provides a larger time window whereas a reflex is shorter (can se there too) and gives a better chance to see it Every time you hear the clicking sound tap your foot and watch decay and changes confirm the clicking
clicking tinnitus
56
Related to muscle spasms, etc. Do maneuvers to confirm this Changes tinnitus (can be worse, different tone, different volume, etc.) Change the head and jaw and have the PT tell whether there is a change in tinnitus They can protrude the jaw or clench the teeth and ask if there is a change Can do head movements
somatosensory tinnitus
57
Objectives of psychoacoustic assessments
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
58
what is pitch masking and the goal
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
59
what should the presentation be for pitch masking
stimuli at 10 – 20 dB SL at frequencies with normal limits Stimuli at 5 –10 dB SL at frequencies with hearing loss.
60
where do you present for pitch masking
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.
61
what is octave confusion
where a person incorrectly identifies the pitch of their tinnitus by choosing a frequency that is either one octave above or below the actual tinnitus pitch.
62
what is loudness matching & the goal
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
63
where should you start for presentation for loudness matching
Start 5 dB below the AC threshold and then gradually increase the level in 1-dB steps until the patient hears the tone.
64
what is tinnitus quality match
Tinnitus Matching to Bands of Noise Determine whether tinnitus sounds like a tone or like noise
65
what is MML
minimum masking level
66
what is MML & the goal
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.
67
how to present MML
The masking noise should be presented binaurally for patients with bilateral tinnitus, and monaurally for patients with unilateral tinnitus.
68
what is RI
residual inhibition
69
what is the goal of RI
To characterize the patient’s tinnitus as a supplement to MML testing and to demonstrate that BBN can have a positive effect.
70
Negative RI
no change in tinnitus perception
71
Positive - Complete RI
complete absence of tinnitus perception in both ears (0% of the usual tinnitus loudness)
72
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%).
73
Rebound or Exacerbation
If there is an increase in the tinnitus loudness level
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Initial intake appointments are for most PTs to give brief education counseling & HA’s if needed what does this include
Includes basic case hx, audiological assessment, tinnitus screening questionnaires & tinnitus classification
75
Comprehensive assessments are for PTs with severe symptoms & include
Comprehensive case hx Tinnitus impact inventories Psychoacoustic evals Mental health screening
76
role of the hypothalamus
homeostasis- creates & controls hormones, regulates body temp, thirst, emotions & appetite)
77
role of the thalamus
egulates sleep cycles, every sensory function besides smell, thalamic nucleus that includes vision, hearing, and touch - somatosensory)
78
role of amygdala
emotions - fear, pleasure, anxiety, anger), & hippocampus (memory conversion
79
what are questionnaires used for
Used to assess the impact of tinnitus on a PT including PTs reactions to it, tinnitus-related distress, the severity of tinnitus, the primary functions affected by tinnitus & other domains
80
purpose of questionnaires
Help clinicians Choose appropriate interventions or referrals Identify areas that need to be addressed Document changes when administered before, during, and after intervention Did the recommendations work for the PT and was it appropriate for their tinnitus because now it is less Quantify the impact on quality of life Delineate PT reactions & psychosocial consequences Identify potential psychological distress (depression & anxiety) Provide metrics for referral decisionsGuide selection of appropriate management options
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Why do we do the assessment? (five applied benefit of a tinnitus assessment)
Improved patient -provider communication Tinnitus patient reassurance Establish a reference point Basis for treatment Documentation
82
Score Interpretation of questionnaires
for us to figure out how bothersome the patient's tinnitus is, and how it is impacting their daily life. The higher the score, the worse it is.
83
questionnaire examples
Tinnitus Functional Index (TFI) Tinnitus Handicap Inventory (THI) Tinnitus Reaction Questionnaire (TRQ) Tinnitus & Hearing Survey
84
what does TFI assess
used to assess the severity of tinnitus & its negative effects on daily functioning
85
what does THI assess
assesses the impact of tinnitus on their daily life
86
what does TRQ assess
assesses the psychological distress associated with tinnitus
87
what does the tinnitus and hearing survey assess
assists in determining candidacy for tinnitus-specific interventions
88
importance of mental health questionnaires
This is important because the stress of mental health can cause an impact on the vicious cycle and to help with tinnitus we need to also help their stressors can identify suicidal ideation
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Suicidal ideation step
Do they have a plan to end their life? Yes - suicidal intent, medical emergency No - suicidal ideation, refers to mental health
90
examples of mental health questionnaires
Patient Health Questionnaire (PHQ-9) Generalized Anxiety Screener (GAD-7)
91
what is the importance of case history
Understand the PTs problems related to tinnitus Identify areas to address in counseling sessions distinguish between bothersome and non bothersome Educate PT on probable causes and consequences
92
what elements should be included in case history
referral concerns management history medical/surgical history perceptual features factors that change tinnitus perception psychosocial & fxnal impacts
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referral concerns & management hx
Who referred the patient? Why is the patient seeking care? What previous professional care, if any, has the patient received for his/her tinnitus)? What were the recommendations? Were they followed? Did they help? What treatments/management strategies, if any, has the patient pursued on his/her own? Did they help? Have they seen a specialist for it? What have they tried for it? If anything
94
Medical issues that can cause tinnitus
neurosurgery especially areas of the auditory cortex affected, brain tumors like acoustic neuromas, TBIs, concussions, & head trauma, cardiovascular diseases, strokes, TMJ, otologic diseases including ME disorders, autoimmune diseases, & metabolic diseases including abnormal thyroid function
95
Medical issues that can impact how they experience the tinnitus
mental health disorders (anxiety, depression, PTSD, schizophrenia), brain injuries (affecting learning and memory that can impact tinnitus treatment), cognitive disorders, & chronic pain
96
Medications that can cause temporary tinnitus
NSAIDs like aspirin in high risk, loop diuretics like furosemide, & quinine derivatives
97
Medications that can lead to permanent tinnitus
ototoxic chemotherapy meds like Vincristine or nitrogen mustard, aminoglycoside antibiotics (erythromycin, streptomycin), and some antidepressants (Buproprion)
98
perceptual features
What is the location of the tinnitus (left, right, bilateral, can’t locate)? What does it sound like (e.g., hissing, ringing, pulsing, etc.)? How loud is it (eg, 1-10 scale)? How annoying is it in an average day (eg, 1-10 scale)? Does the pitch, loudness, and/or quality change?
99
Factors that change tinnitus perception
What factors, if any, worsen the patient’s perception of tinnitus? What factors, if any, improve the patient’s tinnitus perception or reactions to their tinnitus?
100
Psychosocial and functional impacts
Sleep disturbance, difficulty concentrating, speech understanding difficulties, avoiding social situations, increased mental/emotional stress, effect on family/friends/coworkers, & depression/suicidal ideation
101
case history picture
History of tinnitus Tinnitus severity Factors related to its onset Behavioral, social and interpersonal and emotional consequences of tinnitus Descriptive characteristics of it Factors that make it worse or better Worse - caffeine, no sleep, alcohol etc. Risk factors for it co-morbidities
102
order of testing for hearing assessment and why
avoid suprathreshold testing first to avoid exacerbating the tinnitus otoscopy pure tones srt tinnitus eval HF audio LDL WRS dpoaes tymps ARTs reflex decay quicksin
103
screening questionnaires
Describes & quantifies the severity of PTs tinnitus Defines the impact of tinnitus on quality of life Contributes to decisions regarding an effective treatment plan
104
case hx
Document health conditions & factors influencing tinnitus perception Rule out or confirm disease pathology underlying tinnitus Contribute to decisions regarding an effective management plan
105
hearing assessment
Rule out or confirm disease or pathology underlying tinnitus Evaluate auditory function to identify peripheral or central auditory dysfunction associated with the mechanism of tinnitus Describes and quantifies the severity of the PT’s tinnitus Contributes to decisions regarding an effective management plan
106
Unilateral tinnitus Secondary tinnitus (somatosounds) Pulsatile tinnitus Whether it is in beat or not with the heartbeat Mental health professionals when warranted
refer
107
when should you refer to ENT
Vestibular symptoms (vertigo/dizziness) Otalgia & otorrhea Tinnitus of somatic origin (pulsing w/ heart)
108
when should you refer for ENT or emergency care
Tinnitus plus any of the following Physical trauma - facial palsy Sudden idiopathic HL
109
when should you refer for mental health or emergency care
Tinnitus plus any of the following Suicidal ideation Obvious mental health concerns
110
should you refer for SNHL & tinnitus findings
advised you do further diagnostic testing is not needed but otology should rule out physical causes of tinnitus
111
Tinnitus of sensorineural origin Hx of noise exposure w/ concurrent or subsequent onset of tinnitus Symmetrical, stable, and non-pulsatile tinnitus Long duration tinnitus Audio consistent w/ symmetrical SNHL
should refer
112
decrease HL sensitivity, no red flags (it is symmetrical), suggests SNHL, what is the recommendation?
HAs Needs medical clearance
113
what can otoscopy reveal
can check for pulsatile tinnitus, might see tumors, cerumen impaction (can cause tinnitus)
114
how can you verify thresholds with pure tones
present one after another to confirm, after establishing all of the thresholds for AC go down 5dB and present and there shouldn’t be a response but when you go back to the threshold there will be a response (threshold is 35 dB go to 30 and present and no response then go back to 35 and there should be a response
115
why is SRT done
to cross check PTA & make sure pure otnes are reliable
116
why include HF audiometry
Especially for those with hearing Shows HF HL before pure tones will Early indication there is damage in the IE
117
why do we include LDL
Decides whether they have hyperacusis Helps with HA’s to make sure we don’t exceed this level
118
why is WRS included
Used for HA assessment Shows if there is retro pathology (unilateral tinnitus, HL & poor wrs)
119
why are OAEs included
Confirm cochlear origin by identifying absent or below-normal amplitudes in PTs with SNHL correlatioin between perceived tinnitus and the low or abs amplitudes in OAEs Identify cochlear dysfunction in PTs with normal hearing sensitivity, providing a physiological explanation for their tinnitus symptoms if they have unilateral tinnitus this can show abnormal OAEs with normal OAEs in the other ear Validates auditory basis, especially with normal audios
120
why are tymps included
rules out conductive component
121
why include ARTsx
Helps to rule out conductive components or if there is a lesion in the reflex arc (tumors) If PT is sensitive here, you can try using BBN to give an idea of a reflex
122
why do we include reflex decay
Would want to include if retro cochlear pathology is suspected (acoustic neuroma, vestibular schwannoma, other lesions in CANS) Would also want to include if clicking tinnitus is suspected
123
why would yo include quick-sin
If suspecting HHL Individual has normal hearing sensitivity but they share issues with hearing speech in background noise Shows SNR loss
124
vernon's 2dB rule
Loudness match - repeat 5-6x with other tests intertwined between the repeated tests Each loudness match is obtained to the nearest 1dB Presence of tinnitus is indicated if the repeated results within a session agree to be within 2 dB Different trial runs have to be witin 2dB of each other Recent studies challenge validity of 2dB rule demonstrating that test-retest reliability is similar for individuals with and without tinnitus
125
what is the goal in those with legal claims
establish if the responses are consistent, plausible, & credible across all assessment components
126
Legally, assessments focus on
reliability of psycnoacoustic measures , the consistencies of responses, & tinnitus duration determine its permanency
127
what must you keep in mind with those loking for legal claims
Must stay alert to exaggerations in self-reports, aiming to confirm consistency, plausibility and credibility of responses
128
case 1 Case hx High pitched tinnitus in both ears Began 8 mos ago Hears it all the time Believes it is causing hearing problems Anxious and depressed Med hx is unremarkable Audio Mild to moderate SNHL Tinnitus & hearing survey Tinnitus score - 14/16 Hearing score - 13/16 Sound tolerance score - 0/4 what is etiology, temp characteristics, impact, duration, and HL
Etiology Primary Temporal characteristics constant Impact Bothersome - high tinnitus score with anxiety & depression Duration Chronic HL yes
129
case 2 Case hx Referral & Management History: Previous exposure to loud blasts; Initial management with combination instruments, informational counseling & relaxation ineffective. Medical/Pharmacological History: No significant findings Perceptual Features: Bilateral, symmetric high-pitched hissing tinnitus; loudness and annoyance rating 7/10 Factors that change tinnitus perception : No significant dietary or lifestyle factors; workplace noise reduces tinnitus perception. Attitudes & Beliefs: Low self-efficacy for self-management Psychosocial & Functional Impacts: Anxiety; suicidal ideations; denies suicidal intent. Social support: Limited. Tinnitus impact inventory - significant tinnitus Mental health screening - severe anxiety Audio Normal hearing & normal OAEs What factors in Janis’s history might be related to the etiology of her tinnitus? What factors in Janis’s history might be exacerbating her tinnitus? Does Janis require additional tinnitus intervention? What referrals may be appropriate for Janis?
Noise exposure Her stress & anxiety or poor sleep quality causing additional stress yes referral for counseling or mental health support for the PT
130
Case 3 Case history Referral: referred by his primary care physician. The patient was employed in a post office where his duties included unloading and sorting mail. History was remarkable for chronic exposure to recreational noise (loud engines and sports events). Perceptual Features: Bilateral, high-pitched ringing tinnitus. Tinnitus is noticed three weeks earlier after waking up one morning. Patient had a history of bruxism. He reported trying two different over-the-counter mouth guards to minimize the condition. Despite wearing these mouth guards, the patient’s tinnitus became more noticeable. It was unclear if his bruxism intensified or the over-the-counter mouth guards caused the tinnitus to become more noticeable. He reported an increase in anxiety in the past month with several panic attacks, for which he took Alprazolam, that was prescribed to him by another clinician on several occasions. Management history: None Tinnitus impact questionnaire Severe Audio results Normal otoscopy, mild HF SNHL, mild ultra HF loss What factors in Chris’s history might be related to the etiology of her tinnitus? What factors in Chris’s history might be exacerbating her tinnitus? Does Chris require additional tinnitus intervention? What referrals may be appropriate for Chris?
noise exposure, history of TMJ, and stress (possibly the medication could have made it worse but he had the tinnitus before the medication) stress, jaw, possibly the medication yes referral to TMJ specialist because it is affecting his neck and everything and could be increasing his tinnitus
131
what are fxnal effects of tinnitus
Sleep disturbances, difficulties concentrating and varying emotional impacts There is no solution to fit everyone because the causes are all different from patient to patient and we do not know the exact mechanism that causes the tinnitus
132
Multidisciplinary collab/referrals
Do the assessment to help them and as you identify certain issues you want to refer them to specialties to help manage what could be the cause Otolaryngology Psychology Cardiologist TMJ specialist Massage therapist: Get a massage to relieve stress and tension Neurologist Sleep specialist - for those that are unable to fall asleep
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what are managment options
HAs Sound therapy Masking devices Music therapy Sound apps Lifestyle modifications Education & counseling TRT CBT Mindfulness Physiotherapy Transcranial magnetic stimulation Bimodal neuromodulation Drug therapies Supplements Low-level laser therapy (LLLT) - a light therapy that has been used to treat tinnitus, with some studies showing positive results
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If they have bothersome tinnitus with mild HL would you recommend HA’s?
yes
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how do HA's help
Improves hearing-related quality of life Reduces attention to innitus Reduces stress & fatigue related to straining to hear Stimulates the auditory system Might prevent maladaptive neuroplastic changes in the auditory system
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what do HA work best with for tinnitus
LF hearing is good Tinnitus pitch below 8kHz (within HA fitting range) Strong reactions to tinnitus
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which Rx method is best for tinnitus
DSL has more gain for the LFs Most of the ambient noise is LF so this helps to cover the tinnitus by giving the PT access to the LF soft sounds (ambient sound)
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what features are good for HA's
Bilateral HL = bilateral amp Open dome = less LF occlusion - allows more natural sound in to mask the tinnitus Low compression TK = more audibility of soft sounds (adds more gain to low intesnsity sounds) Turn off expansion = expansion reduces amplification of soft sounds to prevent them from distracting the wearer But in tinnitus we want this Omnidirectional mics = allows sounds from different directions to allow stimulation and ignore the tinnitus Noise reduction off Sound therapy program BT connection to access therapy sounds Frequency lowering - depends
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what is sound therapy
Uses sound to decrease the loudness or annoyance of tinnitus
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what are types of sound therapies used
music noise - white, pink, brown, BB, NB Relaxation or environmental sounds Waves, rain, breezes, etc.
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Lit Candle in a Dark Room Analogy
In a dark space the candle is bright because the room is so dark and you focus more on the light if you hear nothing and then there is tinnitus then they are paying more attention to it – gets louder in quiet – because they pay attention to it more in the presence of nothing If you take that same candle and turn the lights on or put it in a lit room the candle is still there but it is less noticeable because you can focus on other things if there are external sounds, the tinnitus is still there but you are not paing attention to it as much as before because there are other sounds that keep the PT busy
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Rationale for sound therapy
To reduce the audibility of tinnitus by replacing it with a pleasant sound Provide stipulation of the auditory pathways to facilitate adaptation and replace the spontaneous activities Help with relaxation to reduce stress
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education aspects to include
Simple way to share information to the PT so they understand what tinnitus is and the types Reassure it is not dangerous or life threatening Information between tinnitus and HL Explaining that even though there is no cure there are management strategies to reduce the impact on the quality of life Referral for resources
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counseling strategies
Helping them recognize how their beliefs impact their reactions Providing coping/managment strategies *those needing extensive counseling need to be referred to mental health professionals
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lifestyle modifications
Helping them recognize how their beliefs impact their reactions Providing coping/managment strategies *those needing extensive counseling need to be referred to mental health professionals
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mental state achieved by focusing one’s attention on the present moment while acknowledging and accepting one’s feelings, thoughts and bodily sensation
mindfulness
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how does mindfulness help with tinnitus
Technique to help manage tinnigus by teaching them to be more present and accepting of their experiences
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Originally for depression Therapeutic approach combining mindfulness practices with elements of cognitive therapy to help manage psyhnological conditions
Mindfulness-Based Cognitive Therapy
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Magnetic coil placed near the scalp used to modulate brain activity and stimulate the areas of the brain where we regulate mood Uses strong electromagnetic signals to reduce neural hyperactivity
Repetitive Transcranial Magnetic Stimulation (rTMS)
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are there drugs that help with tinnitus
No FDA approved drugs are available to treat tinnitus
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give ex of some off. label use that can help
Antidepressants - reduce loudness & improve quality of life Anticonvulsants - stabalize neuronal activity; mixed results Benzodiazepines - alleviates tinnitus related anxiety & insomnia Glutamate receptor antagonists - reduce neuronal hyperactivity Otoprotectants - explored for preventing NIHL & tinnitus; promising results
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what are the challenges to pharmacological treatment in tinnitus
Tinnitus is heterogenous so there is no one size fits all Brain networks are complex making it hard to study and target effectively Animal studies don’t fully mimic human tinnitus, which limits their usefulness in finding new treatments.
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supplements & tinnitus
clinicians should not recommend Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating patients with persistent, bothersome tinnitus
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purpose of CBT
reduces negative responses to tinnitus by transforming negative thoughts into positive, realistic ones Aims to decrease anxiety and depression enhancing overall quality of life Doesn’t make the tinnitus go away but trains the brain to not treat it as a bad or threatening thing but to learn to ignore it
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Uses a variety of cognitive and behavioral techniques to help people identify and modify the relationships between their thoughts, behaviors, and emotions
CBT
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principle of CBT
based on the basic principle that what we think, how we feel, and how we behave are all closely connected, and each of these factors has a decisive influence on well-being. Thoughts, emotions, behaviors
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goal of CBT
to alter maladaptive cognitive, emotional, and behavioral responses to tinnitus and not to abolish the sound itself.
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CBT aims to
Address psychological stress Change negative thoughts about it with behavior modifications Address emotions and problems to having it and not to tinnitus itself Improve quality of life
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ABC model for tinnitus A
A - activating/triggering event Tinnitus starts
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ABC model for tinnitus B
belief Thoughts when they hear the tinnitus blaming situations or themselves, blaming tinnitus keeping them up at night or etc. overinterpreting all of these things - negative automatic thoughts
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ABC model for tinnitus C
emotional consequences Mad, stressed, depressed, hopeless, desperate
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what are the prinicples to CBT
Structured, set specific goals with time frame to complete Active participation, homework between sessions, strategies for relapse prevention Collaborative relationship to facilitate therapeutic process Motivation for change and to modify behaviors Strategies used aim to promote habituation to help them manage their perception & reaction to tinnitus
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components to CBT
cognitive & behavioral therapy
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cognitive therapy component
focuses on changing how they think about tinnitus Teaches to replace negative thoughts with positive or neutral ones with counseling and cognitive restructuring
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behavioral therapy component
focuses on techniques like positive imagery, attention control to diver focus away, relaxation training to ease symptoms & exposure to stressful situations to lessen the impact
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Elements of cognitive-behavioral therapy
Relaxation Muscle relaxation exercises to reduce tension Cognitive restructuring Identifying negative thoughts in response to life events or sources of distress Attention control techniques Learning to redirect attention from tinnitus to other environmental details Smelling coffee, tasking honey etc. Imagery techniques PTs are guided to imagine what their tinnitus sounds like and being masked by waterfall or ocean waves without real sounds Imagining scenarios walking in nature with different sounds or enjoying snow by a fire etc. Sleep management Bedtime, worry-time restriction, relaxation etc.
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Techniques to prevent relapses
Discussing risk factors for tinnitus getting worse and HL and creating a proactive plan to manage these symptoms
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Candidate selection for cbt
Ages 40-70yrs With or without hearing loss No other severe comorbid psychological conditions Had tinnitus and/or suffered from it for at least 3 months Wants to alleviate impact of tinnitus on their quality of life and daily activities
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Systems stimulated and advantages with bimodal neuromodulation
Auditory system & somatosensory system Combines auditory stimulation via headphones with somatosensory stimulation through a tongue device, targeting both the trigeminal and auditory nerves to potentially alter tinnitus pathways in the brain.
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Combines auditory stimulation via headphones with somatosensory stimulation through a tongue device, targeting both the trigeminal and auditory nerves to potentially alter tinnitus pathways in the brain.
bimodal neuromodulation
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Indications for Lenire
18+yrs Suffer from at least moderate chronic subjective tinnitus (indicated by THI)
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