Tinnitus

Question 1

Above which level are (LDLs) is classified as normal?

Answer 1

LDLs = loudness discomfort levels
Normal is above 90dB
Borderline is 70-90dB
Abnormal is below 70dB

Question 2

What is hyperacusis and how common is it in those with tinnitus?

Answer 2

Oversensitivity to louder sounds, or sounds that wouldn’t normally bother people - reduced tolerance.
i.e. everyday sounds in a soft-medium level tolerable for normal people - not for hyperacusis.

Question 3

What is the prevalence of hyperacusis related to tinnitus?

Answer 3

40% of people with Tinnitus have Hyperacusis

86% of people with hyperacusis have Tinnitus

Question 4

In what ways could pitch matching help with tinnitus management?

Answer 4

To individualise masking noises, matching to a masker and identify properties of a potential masker

Details of the tinnitus - range, volume, frequency

See if there is a correlation to the audiogram and if there is any AB comparisons of sounds

Question 5

What factors might make it difficult for a client to pitch match their tinnitus?

Answer 5

• If it is not present during the appointment - relying on recall
• If tinnitus fluctuates - intermittent or varies slightly
• If they have tinnitus with two sounds i.e rumbling and a high pitch ringing
• More than one type of tinnitus

Question 6

What is the difference between somatic tinnitus and somatic modulation of tinnitus?

Answer 6

Tinnitus Modulation (is more common) – Exacerbation of tinnitus with head, neck or jaw issues or shoulder movements. Depending on the body movements causes tinnitus. i.e. you turn your neck and tinnitus increases it

Somatic Tinnitus - Related to physicality, caused by the body in terms of a disorder in terms of the neck, jaw (TMJ), shoulders, head - this is the origin (sematomotor/ sematotsensory)

Question 7

What are some situations in which you would refer to a dentist or physiotherapist for further investigation?

Answer 7

If tinnitus is looking somatic in origin, or shown modulation tinnitus in your testing.

Question 8

At what level do you commence pitch matching?

Answer 8

15-20dB Sensation Level (above the threshold)

Question 9

What are the stimulus parameters and process for pitch matching?

What would be your instructions?

Answer 9

• 15-20dB SL
• Avoid octave frequencies (i.e. 500 and 1kHz)
• Use Pure Tones (may use warble if tinnitus is more similar to that)
• Use headphones (aim for tinnitus ear)

“I;m going to play two different beeps one after the other, and I want you to let me know which one sounds more like your tinnitus. There will be tone A and Tone B. It’s a bit like an eye test”

Question 10

What causes tinnitus?

Answer 10

There can be many causes. Some very common ones can be things like hearing loss or noise exposure. There can be other triggers, such as a stressful event in life, health issues, medical causes.
There are also lots of exacerbating factors such as stress and anxiety, depression, and issues with sleep.

Question 11

Will I have the tinnitus forever?

Answer 11

Tricky question, and it varies a lot from person to person. We can’t say if the tinnitus will last forever or not, but we know that with good management it can be reduced significantly. Even if it is there in the long term, it can be reduced to a point that you may not even really notice it. There are lots of management strategies for tinnitus.

Question 12

Is there a cure for tinnitus?

Answer 12

Unfortunately, there is no cure. However there are many management strategies which can have an improvement on the severity or impact of your tinnitus on your life. The reason that there is no cure for tinnitus is: it is not a disease, it is a symptom of something. There can be many different underlying causes for it.

Question 13

My doctor told me there’s nothing I can do about tinnitus – is this true?

Answer 13

No, that’s not true. There are lots of management strategies again that can be implemented that can greatly improve the impact that tinnitus is having on your quality of life.

Question 14

Is tinnitus common?

Answer 14

Yes, very common-in terms of general, intermittent ringing in the ears. Tennis is just a word that we use to describe any sound that you here in your ears or in your brain, that is not related to an external source.
10-15% of people suffer with constant, bothersome tinnitus

Question 15

Is there medicine I can take to cure my tinnitus? Is there surgery I can have to fix my tinnitus?

Answer 15

No, because it’s a symptom not a disease. However if there’s underlying medical cause causing the tinnitus, there is a possibility that this could be managed by possibly medication, this may be part of management - HOWEVER this is out of our scope.

Question 16

What is the difference btw subjective and objective tinnitus? ANd which is more common?

Answer 16

Subjective (95%) meaning there is now external sound source.

Objective (5%) meaning either there is occurring from audible, physical sounds in the body. Vascular is synchronous with the internal sound (heartbeat, pulse) - idiopathic intracranial hypertension, glomus tumours.

Non-Vascular is asynchronous with the internal sounds. ME muscles involuntary contractions, Patulous Eustachian Tube

Question 17

Is tinnitus associated with anything?

Answer 17

Yes, most commonly hearing loss (90%) 
other associations can be 
-Infections (otitis media)
- age
- SSNHL
- Wax
- Otosclerosis
- Meniere's Disease
- Acoustic Neuroma!

Question 18

What is sudden brief Tinnitus?

Answer 18

Often unilateral, tapers off within one minute. Likely due to Synchrony a phase locked neural discharge-sudden burst of noise in the ear. Really common

Question 19

List and describe the 4 Tinnitus models >

Answer 19

Neurophysiological Model: Having a ‘source’ in the auditory periphery. Loop system, source > detection > perception > reaction. Involves the limbic system relating to the emotional response, autonomic nervous system leads to increased perception and heightened emotional response

Central Gain Model: Hearing loss leads to reduction of input-compensation from the auditory system (more spontaneous activity)

Frontostriatal Gating Model: Gatekeeping system pre-frontal cortex function. If functioning correctly it will modulate the imput, if not functioning correctly negative values placed on the stimuli (tinnitus), increased perception.

Neuroplasticity Model: Peripheral damage and increased spontaneous firing of the CNS, tonotopic map reorganisiation - plastciity changes following overuse or deprivation

Question 20

Discuss the impact of auditory nerve fibres and tinnitus

Answer 20

Auditory nerve fibres in IHCs (10-30), high spontaneous rate, low threshold responding fibres
Low spontaneous, high spontaneous responding fibres (most susceptible to noise - increase our dynamic range)\

• Can still have a normal audiogram, with a low spontaneous fibres loss (becuase the audiogram is testing the High Spontaneous Fibres)

Question 21

Outline a Tinnitus Assessment from the very beginning to the end >

Answer 21

Pre-assessment Questionnaires

• TFI
• DASS
• ISI
• Tinnitus History Questionnaire

Tinnitus Assessments

• Otoscopy, Audiogram + EHF, Speech, Tymps, {ABR, Listn-S)
• Pitch Matching
• Minimum Masking Level
• Residual Inhibition
• LDLs
• Somatic Assessment

Management & Counselling:

• MDT (referrals as appropriate)
• Management strategies including sleep hygiene, reducing triggers, maskers, distractions when it becomes difficult,
• Validation
• Follow up

Question 22

Briefly describe the TFI, DASS, ISI, Tinnitus History Questionnaire

Answer 22

TFI: A screener, 8 subscales, good for compare/contrast, about relaxation, QoL, Emotions, Control, Cognition, auditory, sleep

DASS: Hospital grade - 21 items. Scale normal two extremely severe. Guides management and referrals

ISI: Severity of insomnia. Threshold insomnia to clinical insomnia (severe)

Tinnitus History Questionnaire: Onset, type, exacerbating factors, strategies, vertigo?, goal for appointment

Question 23

What is the purpose of assessing the minimum masking level?

Answer 23

Locates the minimum level of mask are required to cover the 10 notice. Gradually increase NBN until 10 notice is covered just.

Do not! Want to drown out tinnitus. Required to be steady-state, for brain habituation to the masker.

Question 24

LDLs?

Answer 24

Hyperacusis screen. Gradual increase of low and high frequency pure tones (500 Hz, 2kHz)