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AUDE 6220 > final exam new info > Flashcards

final exam new info Flashcards

1
Q

goals of a tinnitus assessment

A

rule out/confirm disease, document health conditions influencing tinnitus, evaluate auditory function, describe severity of tinnitus, define impact of tinnitus and contribute to decisions regarding management plan

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2
Q

with a new patient, what are the 3 things we need to do

A

screening questionnaires, case history and hearing assessment

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3
Q

importance of a screening questionnaire

A

helps choose appropriate intervention or referral, identify areas that need to be addressed and document changes through intervention
-can help quantify impact on quality of life
-identify psychological distress as well

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4
Q

what aspects do we need to include in the case history

A

any referrals or previous management, medical history, perceptual features of the tinnitus, factors that alter the tinnitus perception and psychosocial/functional impacts

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5
Q

what do we mean by perceptual features of the tinnitus

A

location of tinnitus, the sound of tinnitus, how loud it is, how annoying it is, information on the pitch and if it changes

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6
Q

what are some components that can be included in the hearing assessment

A

otoscopy, tymps, acoustic reflexes, thresholds, SRTs, WRS, LDL, tinnitus evaluation, DPOAEs, HFA, reflex decay and QuickSIN

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7
Q

with the hearing assessment, what is the proper order to conduct testing in

A

begin with threshold testing and the softer signals then go onto the louder signals or the ones at suprathreshold (i.e. WRS and LDL)

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8
Q

what is a potential concern with pure tones and tinnitus patients

A

they may have false positives
-using warble tones and pulsed tones may be helpful

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9
Q

what is the role of the DPOAEs in a tinnitus assessment

A

can confirm a cochlear origin by identifying absent or below normal amplitudes in patients with SNHL OR we can identify cochlear dysfunction in patients with normal hearing sensitivity providing a physiological explanation for their tinnitus

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10
Q

referring with tinnitus patients

A

refer to other professionals as the presenting symptoms would indicate

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11
Q

tinnitus characteristics indicating a referral to an ENT

A

unilateral tinnitus, secondary tinnitus (somatosounds) or pulsatile tinnitus

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12
Q

referrals to an ENT with …

A

symptoms suggesting somatic origin of tinnitus, ear pain/drainage and vestibular symptoms (dizziness or vertigo)

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13
Q

referrals to emergency care or ENT with ….

A

tinnitus plus physical trauma (facial palsy) or sudden unexplained HL

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14
Q

referral to mental health or emergency care with …

A

tinnitus and suicidal ideation or mental health problems

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15
Q

assessment of tinnitus for legal claims

A

some patients may need documentation to support a claim for financial compensation and with these patients we need to be careful
-needing to make qualified judgements to help with the legitimacy of such claims

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16
Q

as a conclusion of assessment, what are 4 things that we should understand about the tinnitus

A

presence of tinnitus (if its present and if it can be classified as pathological), severity of tinnitus (determine the impact and extent of the issue), etiology of tinnitus (identifying potential causes) and permanency of tinnitus (based on duration of symptoms)

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17
Q

what are some common management options for tinnitus patients

A

HAs, sound therapy, education/counseling, lifestyle modifications, mindfulness, rTMS, bimodal neuromodulation, and drug therapies

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18
Q

how do HAs help tinnitus

A

improves hearing related quality of life, reduced attention to tinnitus, reduces the stress/fatigue associated with straining to hear, enables masking by ambient sound and provides stimulation to the auditory system

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19
Q

in order for HAs to work best, what should be present in regards to the patients hearing/tinnitus status

A

good low frequency hearing (allows them to hear the ambient noise), strong reaction to the tinnitus and if the tinnitus pitch is within the fitting range

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20
Q

what fitting formula is recommended for tinnitus patients

A

DSL V5

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21
Q

recommended features of HAs for tinnitus patients

A

binaural fitting, open fit to avoid occlusion, low compression TK, expansion turned off, omnidirectional microphone, noise reduction turned off, therapeutic sound option, wireless communication and frequency lowering

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22
Q

purpose of the low TK and expansion being turned off

A

they can help ensure that audibility of the low frequencies/environmental sounds will be heard
-further allowing it to try and mask the tinnitus

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23
Q

sound therapy

A

uses sound to decrease the loudness of tinnitus with a variety of sounds that can be used
-focusing on other sounds/noises to help take the focus away from the tinnitus

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24
Q

reasons for the use of sound therapy

A

reduces the audibility of tinnitus by replacing it with a different sound, provide stimulation of auditory pathways (replacing spontaneous activity) and aid relaxation

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25
Q

when educating patients about tinnitus, what should be included

A

explain tinnitus and the different types with the reassurance that it is not dangerous, value of audiological assessments, explaining the various management strategies even though there is no cure

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26
Q

common counseling strategies for tinnitus patients

A

helping people recognize how their beliefs impact their reactions and providing coping/management strategies

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27
Q

what are some lifestyle factors that may exacerbate tinnitus

A

stress, fatigue, consistent noise exposure, use of aspirin in high doses, alcohol, high caffeine consumption, tobacco and high sodium intake

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28
Q

mindfulness

A

technique that helps people manage their tinnitus by teaching them to be more present and accepting of their experiences
-mental state by focusing ones attention on the present moment
-teaches to accept and help calm

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29
Q

mindfulness based cognitive therapy (MBCT)

A

therapeutic approach that combines mindfulness practices with elements of cognitive therapy to help manage psychological conditions

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30
Q

receptive transcranial magnetic stimulation (rTMS)

A

device that delivers short magnetic pulses through a magnetic coil placed near the scalp to modulate brain activity in specific areas associated with mood
-uses electromagnetic signals to reduce neural hyperactivity

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31
Q

bimodal neuromodulation

A

combines auditory and somatosensory stimulation
-targets both the trigeminal and auditory nerves to alter tinnitus pathways in the brain

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32
Q

tinnitus and drug therapies

A

there are no FDA approved drugs currently available to treat tinnitus however there are drugs to help relieve the perception based on its associated symptoms

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33
Q

examples of medicine used to treat tinnitus

A

antidepressants to reduce tinnitus loudness, anticonvulsants to stabilize neuronal activity, benzodiazepines to help alleviate tinnitus related anxiety, glutamate receptor antagonists to reduce neuronal hyperactivity

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34
Q

cognitive behavioral therapy (CBT)

A

problem focused and action oriented psychological intervention combining principles from behavioral and cognitive psychology

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35
Q

principles of CBT

A

thoughts, behaviors and emotions

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36
Q

goals of CBT

A

treatment involves specific learning experiences that teaches patients to monitor their negative thoughts and to recognize the relationships between thoughts/emotions/behaviors

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37
Q

CBT for tinnitus

A

a form of structured talk therapy
-structuring how they think about tinnitus as we teach them about the negative thoughts and teach them how to replace it with more positive thoughts

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38
Q

goals of CBT for tinnitus

A

alter maladaptive cognitive, emotional and behavioral responses to tinnitus and no to abolish the sound itself
-addressing the psychological distress associated with tinnitus

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39
Q

principles of CBT for tinnitus

A

involves active participation and homework assignments between sessions
-clients work closely in a collaborative relationship
-strategies used aim to promote habituation

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40
Q

two strategies for CBT

A

cognitive and behavioral strategies

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41
Q

CBT : cognitive therapy

A

focuses on altering how one thinks about tinnitus, aiming to reduce negative ideation
-working on the thoughts aspect
-replacing negative thoughts with positive ones

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42
Q

CBT : behavioral strategies

A

focuses on using techniques like positive imagery, attention control to divert focus from tinnitus, exposure to stressful situations to lessen the impact and relaxation training to ease symptoms

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43
Q

examples of what can be done with CBT

A

relaxation training, cognitive restructuring, attention control techniques, imagery techniques and sleep management

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44
Q

what is relaxation training

A

teaches tension reduction through muscle relaxation exercises
-dealing with the rigid body and side effects of the tinnitus

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45
Q

CBT : cognitive restructuring

A

with cognitive therapy, this involves the identification of dysfunctional beliefs and negative thoughts
-identifying how the patient feels and what they think and working towards replacing those negative reactions with positive reactions
-teaching them how to think about their tinnitus and restructuring it

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46
Q

CBT : attention control techniques

A

patients learn to redirect attention from tinnitus to other environmental details
-encourages engaging other senses (i.e. smelling or tasting)
-teaching the patient to learn different strategies

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47
Q

CBT : imagery techniques

A

modifying negative associations with tinnitus by either masking the noises or integrating them into positive scenes
-masking through imagination (guiding patients to imagine their tinnitus as other sounds)
-incorporating into pleasant scenes (including imaging scenarios)

48
Q

CBT : sleep management

A

such as sleep hygiene, bedtime and worry time restriction, relaxation and cognitive restructuring are tailored to meet specific needs of patients with tinnitus

49
Q

with CBT, what are some relapse prevention

A

identifying risk factors, importance of continuous practice, managing temporary fluctuations, generalization of treatment benefits and giving post treatment support

50
Q

who benefits from CBT

A

adults ages 40-70 years old, no severe comorbid psychological conditions, has tinnitus and/or suffered for at least 3 months and patients that are seeking to alleviate the impact of tinnitus

51
Q

when discussing TRT, what model needs to be discussed

A

neurophysiological model (jastreboff)
-remember that the main point is that a number of systems in the brain are involved in tinnitus

52
Q

main systems within the neurophysiological model

A

auditory system provides the source of a signal which causes activation of the limbic and autonomic nervous system

53
Q

why is the limbic system and autonomic nervous system activated with tinnitus

A

the limbic triggers a strong emotional response and the autonomic system regulates autonomic body functions such as heart rate and breathing
-both of these systems are critical for well being, learning and brain retraining
-but in the presence of tinnitus it can trigger strong reactions
-once the limbic and ANS is activated the stimulus linked will dominate other functions

54
Q

the vicious cycle

A

once tinnitus gets a negative connotation and starts to induce activation of the ANS, this initiates a cascade of event s
-leading to a stronger activation of the limbic and ANS through a conditioned reflex arc
-if we continue to react negatively to something, we teach ourselves that it is bad and that its negative

55
Q

conditioned reflex

A

every time we experience a stimulus, it triggers the reinforcement and the difference between perception and reaction continues to get strengthened
-eventually the stimulus will cause a reaction alone
-the brain will then recognize that there is no reinforcement and therefor through passive extinction there will be no reaction

56
Q

how was conditioned emotional responses studied

A

the little albert experiment
-found that if perception of a signal is associated with high levels of emotional distress, a conditioned reflex is created leading to the tinnitus to evoke high levels of activation

57
Q

habituation and tinnitus

A

with the repetitive appearance of a sound, the pathways will block it and the individuals will be unaware that the sound is present
-this prevents the signal from reaching higher cortical areas involved with signal awareness

58
Q

tinnitus habituation will not ______________ the tinnitus however there now requires ______________

A

completely erase ; active attention

59
Q

what are the two types of habituation

A

reaction : learning not to react to the stimulus in a negative way
perception : blocking the signal from going up

60
Q

tinnitus retraining therapy (TRT)

A

habituation based treatment that utilized counseling to decrease the strength of tinnitus evoked reactions and sounds to decrease the strength of the tinnitus signal
-contains retraining counseling and sound therapy

61
Q

TRT : retraining counseling

A

habituation of the reaction to tinnitus
-structured counseling sessions
-working on the rection and teaching the patient that it is not threatening

62
Q

TRT : sound therapy

A

habituation to the perception of tinnitus
-weakens the strength of the stimulus, so it will not be perceived as loud
-helping the brain not focus on it as much

63
Q

what is the protocol for TRT

A

introductory contact, initial visit, assessing for the category of treatment, instrument fitting, follow up visits and closing of treatment

64
Q

TRT : initial interview

A

a structured set of questions that are designed specifically to determine placement into categories and impact of tinnitus
-taking a proper history is essential for the treatment category
-ensuring the patient understands all aspects of the treatment plan

65
Q

what aspects of the treatment plan are critical for the patient to understand during the initial interview

A

treatment objectives, schedule of treatment sessions, requirements for using ear level devices, costs associated with treatment and any other pertinent details of the planned treatment

66
Q

what are treatment objectives with TRT

A

reaching habituation of the tinnitus

67
Q

TRT : categories of treatment

A

category 0 - category 4

68
Q

category 0 : mild or recent symptoms

A

low level of tinnitus severity with little impact on life
-includes patients with recent experience of tinnitus

69
Q

category 0 treatment

A

simplified counseling
-aimed to help view tinnitus as a neutral stimulus
-sound enrichment can be advised
-short follow ups to track patient’s status

70
Q

category 1 : tinnitus alone

A

high severity tinnitus without any hyperacusis, HL or worsening of tinnitus with sound exposure
-the main reason we are seeing them is for the tinnitus

71
Q

category 1 treatment

A

intensive counseling focused on the tinnitus and sound therapy
-using ear level devices set to the mixing point
-follow ups more frequently initially then more spaced out later on (lasts 9-18 months)

72
Q

category 2 : tinnitus and subjectivity significant HL without hyperacusis

A

tinnitus coexisting with HL, both having significant effect on their lives
-no hyperacusis and no sound exposure exacerbation

73
Q

category 2 treatment

A

HAs with amplification and sound therapy
-with more auditory access the tinnitus won’t be perceived as much
-counseling is focused on HL and the role it plays with tinnitus
-follow up visits focused on sound enrichment strategies

74
Q

category 3 : hyperacusis without prolonged enhancement from sound exposure

A

significant hyperacusis with or without significant tinnitus and may have misophonia
-being exposed to loud sounds does not worsen it

75
Q

category 3 treatment

A

focuses on hyperacusis, using sound therapy
-aimed to desensitize
-treating the hyperacusis first

76
Q

category 4 : prolonged worsening of symptoms by sound exposure

A

hyperacusis is typically the dominant complaint with tinnitus as a secondary one or is absent
-symptoms worsen with nose exposure
-most difficult to treat

77
Q

category 4 treatment

A

extensive counseling focused on hyperacusis and many adjustments in sound therapy
-educating the patient on physiological mechanism is important

78
Q

importance of assigning patients to correct categories

A

essential for successful therapy because inappropriate treatment could make symptoms worse
-incorrect category is often the underlying reason for TRT not working

79
Q

successful treatment with TRT results in ….

A

patients reaching category 0 before achieving final, complete habituation

80
Q

retraining counseling involves …

A

teaching patients about the mechanism of hearing, the basics of brain function and the specifics of the neurophysiological model of tinnitus

81
Q

retraining counseling approaches

A

nondirective style and directive style

82
Q

nondirective style (client centered therapy)

A

emphasis of counseling is on the patient more than the problem
-goal is to experience growth which enables them to be better equipped to deal with future problems

83
Q

directive style

A

focuses on the problem that is the reason for therapy
-goal is to solve the problem through the provision of new information and attitudes to the patient

84
Q

reasoning for retraining counseling

A

problems caused by tinnitus or misophonia indicate activation of the ANS, preparing the body for unnecessary action
-this then can trigger neuronal and hormonal changes leading to anxiety stress and annoyance and thus triggering the limbic system
-this connection between the ANS, limbic system and auditory system creates connections creating a conditioned reflex
-these reflexes can be retrained

85
Q

sound therapy

A

refers to enrichment of the sound environment, staying away from silent environment, having some sort of noise present

86
Q

goal of sound therapy

A

reduce the perceptual contrast between the tinnitus and external environmental noise

87
Q

approaches to sound therapy

A

introducing additional sounds, increasing volume of existing sounds, using HAs to amplify environmental sounds, using wearable sound generators
-typically more than one approach is used

88
Q

considerations with the sound for sound therapy

A

sound should minimize the strength of the tinnitus signal. external sounds should not induce any negative reactions, sound should be stable and neutral and the original tinnitus should be preserved and not suppressed

89
Q

why should the tinnitus not be suppressed

A

habituation will not occur

90
Q

mixing point

A

this is the level we want to use for sound therapy
-it is the point below partial suppression where the tinnitus can somewhat still be audible when focused on

91
Q

how can ear level devices benefit more than environmental sound

A

can help combat disadvantages that occur if the talker moves around or if the student moves around
-giving the sound directly to the patients ear

92
Q

fitting aspects with ear level devices

A

bilateral to avoid asymmetrical stimulation, open fittings to minimize OE, worn throughout waking hours, proper counseling

93
Q

why is it beneficial to give the patient 2 devices even if they experience tinnitus in one ear

A

if we only cover the tinnitus in the prominent ear, they may become aware of it in the other ear
-so by giving them two devices we can ensure that both sides are truly being covered

94
Q

relating to failure of treatment, why is it important to discuss temporary worsening of symptoms

A

this is something that is commonly experienced by patients and sometimes they just stop the treatment
-we need to counsel our patients that this may occur and that its a sign that the treatment is actually helping

95
Q

factors related to failure of treatment

A

inadequate initial counseling, lack of sufficient follow up, not teaching the model correctly, severe psychological problems, effects of medications, category 4 patients, suppression of tinnitus evoked by HA and focusing on a cure

96
Q

why are category 4 patients difficulty to treat

A

they show the slowest response to treatment
-these patients should be examined for any underlying causes to cover the bases

97
Q

important information to know regarding closing treatment

A

decision to end therapy depends on meeting the patients expectations and goals
-this should be a mutual decision between the clinician and the patient
-treatment can typically be closed when the patient achieves minimal symptoms, typically a 1 to 2, with low tinnitus annoyance

98
Q

decreased sound tolerance (DST)

A

any condition where a patient exhibits any negative reaction to ordinary sounds, which do not cause these reactions in other average listeners
-including hyperacusis, misophonia and phonophobia

99
Q

hyperacusis

A

reduced tolerance to sound that do not trouble most
-reaction depends on the physical characteristics of the sound
-medium to loud intensity

100
Q

3 types of hyperacusis

A

annoyance : having a negative response to sounds, feeling more tense or anxious
fear : anticipating that sounds are uncomfortable, causing the fear
pain : perceiving an actual pain with loudness level

101
Q

common complaints of hyperacusis

A

discomfort, headache, concentration difficulties, fatigue and anxiety

102
Q

misophonia

A

dislike of certain sounds that trigger emotional reactions
-the loudness does not dictate the reaction, it can be all levels of loudness but includes specific sounds

103
Q

common triggers with misophonia

A

oral/eating sounds, breathing sounds, repetitive sounds, speech sounds, household sounds, footsteps, finger tapping, whistling, low frequency sounds, animal sounds or visual triggers

104
Q

phonophobia

A

an anxiety disorder that is characterized as a persistent, abnormal and unwarranted fear of sound shaped by an emotional meaning
-specific cases of misophonia when fear is involved
-specific sound

105
Q

loudness recruitment

A

abnormally rapid growth of loudness with increasing sound level, caused by loss of outer hair cells (cochlear damage)
-not a sound tolerance problem
-leads to a reduced dynamic range

106
Q

with DST, what is most likely the mechanism

A

likely involves multiple however excessive central gain is considered a key mechanisms in loudness hyperacusis

107
Q

explain the likely central gain mechanism for hyperacusis

A

higher intensity is coded by larger groups of neurons whereas a quiet intensity is coded by a smaller group of neurons
-however with hyperacusis, the central system may be truing to compensate for HL so it will increase the neural activities for the louder sounds
-this increased activity is perceived as the hyperacusis

108
Q

what are some other proposed reasons for hyperacusis

A

genetic predisposition, stress/anxiety/fear, neural changes, brain hyperactivity and blast exposure

109
Q

misophonia and phonophobia are abnormally strong reaction of the ________ and _________ resulting from …………

A

limbic ; ANS ; enhanced connections between auditory and limbic system

110
Q

with DST patients, why is it important to wean from earplugs

A

by using protection it prevents habituation
-we can recommend nonlinear/active plus allowing attenuation based on the sound intensity
-patients should gradually decrease the hours they use ear protection

111
Q

DST : treatment

A

HAs, sound therapies, CBT and TRT

112
Q

DST : hearing aids

A

the goal is to provide gain without pain by balancing amplification needs with sound tolerance
-gradual amplification increases may need to occur

113
Q

for patients that have HL, tinnitus and DST what do we treat first?

A

we want to manage the DST then HL then tinnitus
-without treating the DST, by adding amplification we may amplify those loud sounds and therefore heightening their responses to those sounds
-this leads them to not accepting the HAs

114
Q

DST : sound therapies

A

using controlled sound exposure to increase their tolerance to noises
-continuous low level broadband noise, showing some increase in LDL
-gradual increase of the level and/or duration of sound treatment
-targeted exposure to specific sounds
-adjusting HA with gradual adjustments to normal levels

115
Q

DST : CBT

A

involves :
-education on hyperacusis
-applied relaxation to help manage their responses to sound
-graded exposure to sounds to desensitize sounds
-cognitive therapy to help reframe negative thoughts

116
Q

DST : TRT

A

with hyperacusis key is to desensitize the auditory system to sound and with misophonia the key is to retrain the connections between the auditory, limbic and ANS

AUDE 6220 (2 decks)

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