Psychoacoustics Flashcards
What are the different providers that a patient could have seen prior to seeing an audiologist for tinnitus?
Primary care physicians
Otolaryngologists
Physical therapists
Holistic health providers (naturopathic providers)
Hearing aid dispensers
Other physician and non-physician providers
*These providers may or may not have tinnitus expertise
What are the benefits to tinnitus assessment?
Improved patient-provider communication
Tinnitus patient reassurance
Establishing a reference point
Basis for treatment
Documentation
What are the goals of the initial tinnitus assessment?
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 the mechanisms of tinnitus
Describe and quantify the severity of the patient’s tinnitus
Define the impact of tinnitus on quality of life
Contribute to decisions regarding an effective management plan
What is the progression of assessment for a new tinnitus patient?
Screening questionnaire
Case history
Audiologic assessment
What are the components for audiological assessment?
Routine audiologic testing
Additional tests (psychoacoustic assessment, EHF audiometry, DPOAE testing)
*These can be included
What is the test sequence for tinnitus patients?
Pure-tone thresholds
Speech recognition thresholds
Psychoacoustic measures
Loudness discomfort levels (LDLs) to speech and pure tones
Word recognition scores
DPOAEs
Immittance (reflex and reflex decay only if tolerated comfortably by patient)
What is the rationale for the test order for tinnitus patients?
Acoustic stimulation can alter tinnitus perception, especially with increasing intensity
Account for potential hyperacusis
What are the components for the tinnitus psychoacoustic assessment?
Pitch matching
Loudness matching
Minimum masking level (MML)
Residual inhibition
*These can only be completed if the patient is experiencing tinnitus at the time of the visit
Why should psychoacoustic assessments be conducted?
To establish uniformity in quantifying tinnitus symptoms across clinical and research settings
Quantifying and validating tinnitus to reassure patients
Monitor changes in tinnitus perception
Matching pitch to choose masking noise, hearing aid amplification or sound therapies
What is the goal of tinnitus loudness and pitch matching?
To determine the loudness and frequency of a tone or noise that is closest in pitch to the patient’s most bothersome tinnitus
What is the pitch matching procedure?
Pairs of tones are presented and the patient is asked to select the tone that most closely matches their tinnitus
Present tones 10 to 20 dB SL at frequencies at which hearing sensitivity is essentially normal
Present tones 5 to 10 dB SL at frequencies at which there is hearing loss
Present to the non-tinnitus ear if unilateral tinnitus
Present stimulus to the ear with the softest tinnitus if bilateral tinnitus
Start presenting tones at a frequency that is well below the tinnitus pitch so they can easily distinguish between them(most patients will match their tinnitus at 2000 Hz or higher)
Example: Present 1000 for 2-3 sec, and then 2000 for 2-3 sec
Patient has to choose which is most similar to the tinnitus
Next pairs are chosen (2 and 3 kHz, 3 and 4 kHz, 4 and 6 kHz)
How should you instruct a patient for the pitch matching procedure?
I want to get a close estimation of the pitch of your tinnitus. I am going to present two sounds for you, and I want you to tell me which one sounds more like your tinnitus. Try to ignore how loud the sound is and focus on the pitch.
Should you repeat the pitch matching procedure after it is performed?
Yes
To ensure reliability of the measure
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
What is the loudness matching procedure?
Find threshold (down 10, up 5)
Start 5 dB below the threshold, increase the level in 1 dB steps until the patient hears the tone
Instruct them on the task
Search for the loudness of the tinnitus
Obtain loudness match to the closest 1 dB
What is the tinnitus matching to bands of noise procedure?
Determine whether tinnitus sounds more like a tone or more like noise
Compare tinnitus-matched tone to NBN at same frequency and same loudness
If patient chooses tone, then the tone remains the final match
If patient chooses NBN, the next step is to determine whether tinnitus sounds more like NBN or BBN
Present each stimulus for a few seconds (at approximate tinnitus loudness)
Ask: ‘‘Which of these sounds most like your tinnitus?’’
Present both white and speech noise to obtain the patient’s final decision
Should the patient choose either noise, match its loudness to the tinnitus
What is the sequence of tinnitus matching?
Frequency matching
Loudness matching
Matching to bands of noise
What is the goes of determining the minimum masking level?
To determine the lowest level of BBN that completely masks the tinnitus
How do you determine the minimum masking level?
Determine BBN thresholds (one ear at a time)
After determining the closest 5 dB to threshold, use a down 5 dB, up 1 dB procedure to determine threshold
Adjust the noise level of the BBN presented to each ear (lock the channels; adjust both ears at the same time)
Raise BBN in 1 dB steps until the patient indicates that the tinnitus is completely masked in one or both ears
Once an ear is masked, unlock the channels and raise the level of BBN in the unmasked ear until masked completely
*only do in the ear with tinnitus if unilateral and verify that it cannot be heard contralaterally
What is the goal of residual inhibition?
To characterize the patient’s tinnitus as a supplement to MML testing and to demonstrate that BBN can have a positive effect
Begin RI testing immediately after the MML for the ears is established, at a level 10 dB above measured MML
What are the instructions for residual inhibition?
‘‘I am going to present a noise to both of your ears 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.’’
How do you conduct residual inhibition?
Present BBN at MML +10 dB for one minute binaurally and then terminate the noise Immediately
Ask the patient if the tinnitus sound is the same as before or has changed
If the patient reports that it sounds the same, the test is over, and the patient has not experienced RI
If the patient reports that the tinnitus is softer, ask the patient to report the current loudness of the tinnitus in relation to the “usual loudness” of the tinnitus (0%, 10%, 25%, 50%, 75%, 90%, or 100%)
What is a complete RI?
Absence of tinnitus perception in both ears
What is a partial RI?
Reduction in perceived loudness of tinnitus in one or both ears
Should you time when the tinnitus returns after RI?
Yes
The total duration of residual inhibition is recorded i.e. Full RI = 2 minutes or Partial RI = 45 seconds
How should you bill and code for tinnitus assessment?
Use CPT code 92625: assessment of tinnitus (includes pitch, loudness matching, and masking)
Other audiometric procedures that may be included as part of a tinnitus assessment (e.g., otoacoustic emissions, pure tone audiometry, tympanometry, etc.)
