Tinnitus Final Flashcards
What are the goals of a tinnitus assessment?
- rule out / confirm disease
- document health conditions influencing tinnitus
- evaluate auditory function
- describe the severity of tinnitus
- define impact
What needs to be done with a new patient?
case history, screening questions, hearing assessment
What do you need to ask in a case history?
medical history
referrals or previous treatment
how they perceive their tinnitus?
does anything alter their tinnitus?
how it impacts their life?
What is the importance of a screening questionnaire?
They help us decide the appropriate intervention or referral and identify areas that need to be addressed and documented throughout the intervention. can also inform us of the patient’s mental state
What can be included in a hearing assessment?
otoscopy, tymps, reflexes & decay, DPOAE’s, pure tones, HFA, SRT, WRS, QuickSin LDL,
What is a potential concern when using puretones on tinnitus patients?
they can have false positives because they are also hearing their tinnitus so you might want to see warbled or pulsed tones
Why use DPOAE’s in a tinnitus assessment?
they can tell us confirm our suspicion that the tinnitus is of cochlear origin because the OAE’s will be absent or below normal if they have SNHL
OR
it can tell us there is cochlear dysfunction if they have normal hearing sensitivity meaning there is a physiological explanation
what is a perceptual feature?
how they perceive their tinnitus including - location, the sound, the pitch & if it changes, how much it annoys them
what warrants a referral to an ENT
pulsatile tinnitus, unilateral tinnitus, somatic origin, vestibular symptoms like vertigo, ear drainage/pain
what warrants a referral to a mental health provider or in some cases emergency
suicidal ideation & mental heath concerns
what warrants an emergency referral
sudden unexplained hearing loss (SSHL) or tinnitus plus physical trauma like facial palsy
At the end of an appointment what should we know about the tinnitus?
- do they have it & can it be classified as pathological
- how severe is it
- potential causes of their tinnitus
- how permanent is it based on current duration
what are common tinnitus management options
HA, sound therapy, counseling, lifestyle modifications, rTMS, bimodal neuromodulation, and drug therapies
how to hearing aids help tinnitus
reduces attention on tinnitus, reduces stress associated with trying to hear, allows us to mask tinnitus with ambient sounds to stimulate the auditory system
what kind of hearing works best for treating tinnitus patients with hearing aids
good hearing in the low frequencies so they can hear the masking
what is the fitting formula for tinnitus patients
DSL V5
what HA features should be used
open fit,
compression TK
omnidirectional mics
turn off expansion & noise reduction
wireless communication
frequency lowering
why do we turn off expansion and use a low TK
to ensure the low freq & environmental sounds are audible
what is sound therapy
reduced tinnitus audibility by replacing it with a different sound to shift your focus. this stimulates the auditory system, replacing spontaneous activity, and helping you relax
how to educate tinnitus patients
explain what tinnitus is and the different types, tell them why we conduct assessments, and the different management strategies (no cure)
why is it important to counsel tinnitus patients
to help them understand their perceptions of their tinnitus and their reactions impact their tinnitus. we want to give them coping strategies
what can make the patient’s tinnitus worse
stress, being tired, constant noise exposure, using high doses of asprin, alcohol, caffeine, tobacco, high amounts of sodium
what is mindfulness
a technique that helps people be more present and understanding of their experiences so in this case their tinnitus
what is mindfulness-based cognitve therapy (MBCT)
combines mindfulness techniques with cognitive therapy to help manage psychological conditions
what is receptive transcranial magnetic stimulation (rTMS)
it is a device that delivers short magnetic pulses through a magnetic coil placed near the scalp to modulate brain activity in areas associated with mood
what is bimodal neuromodulation
combines auditory and somatosensory stimulation to target the trigeminal and auditory nerves to alter the tinnitus pathway in the brain
are there drug therapies to treat tinnitus
there are no FDA approved therapies but there are medications to help relieve the perception based on the associated symptoms
what medications can help with tinnitus
antidepressants - reduce loudness
anticonvulsants - stabilize neuronal activity
benzodiazepines - alleviate tinnitus anxiety
glutamate - reduce neuronal hyperactivity
what is cognitive behavioral therapy (CBT)
uses cognitive and behavioral strategies to teach patients to monitor their negative thoughts and recognize the impact between their thoughts, emotions, and behaviors
how is CBT used for tinnitus
talk therapy - we teach them how their negative thoughts affect their tinnitus and teach them to replace them with positive thoughts. the goal is not to eliminate the tinnitus but to reduce the stress around it. for this to work patients need to actively participate and complete their homework between sessions.
what is the cognitive therapy aspect of CBT
it focuses on altering how the person thinks about their tinnitus - replacing negative with positive
what is the behavioral strategies aspect of CBT
it focuses on using techniques like positive imagery to remove focus from the tinnitus, relaxation training to ease symptoms
CBT examples
imagery techniques, cognitive restructuring, attention control techniques, relaxation training, and sleep management techniques
what is relaxation training (CBT)
muscle relatation excersises to reduct tension
what is cognitive restructuring (CBT)
identify how the patient feels and thinks then work toward replacing with positive reactions. teach them how to think about their tinnitus to restructure it
what are attention control techniques (CBT)
the patient learns to redirect attention from tinnitus to other things, one way to do this is to engage other senses like smell or taste
what are imagery techniques (CBT)
change negative associations with tinnitus by either masking the noise or integrating it into positive scenes. have the patients imagine their tinnitus as other sounds.
what is sleep management (CBT)
sleep hygiene, bedtime and worry time restriction, relaxation and cognitive restructuring are tailored to meet specific needs of patients with tinnitus
how can we prevent relapse with CBT
identify risk factors, demonstrate the importance of continuous practice, manage temporary fluctuations, give post-treatment support
who is eligible for CBT
40-70 year olds
no severe comorbid psychological conditions
have tinnitus for at least 3 months
ppl seeking to alleviate tinnitus impact
what model has to do with TRT
neurophysiological model (jastreboff/tiger) - a number of systems in the brain are involved in tinnitus - the auditory system provides the source of a signal which causes activation of the limbic and autonomic nervous system
what is the vicious cycle
when you attach negative emotion it activates the limbic system and the ANS through a conditioned reflex. if you continue to act negatively your body thinks its bad and it will increase your perception
what is a conditioned reflex
when we experience a stimulus it triggers reinforcement, meaning eventually the stimulus alone will cause a reaction. this means that eventually there will be no reinforcement and no reaction
how did they study conditioned emotional responses
they used the Little Albert experiment and found that if perception of a signal is associated with high levels of emotional distress a conditioned reflexes are created causing the tinnitus to eoke high levels of activation in the limbic system & ANS. leads to a constant state of alertness because they cant focus attention on anything else, will impact sleep and quality of life
how does habituation affect tinnitus
aka reduces signal awareness
pathways block the repetitive sound and the individual becomes unaware the sound is present
tinnitus habituation will not ______________ the tinnitus however there now requires ______________
completely erase ; active attention
what are the two types of habituation
reaction : learning not to react to the stimulus in a negative way
perception : blocking the signal from going up
what is tinnitus retraining therapy (TRT)
habituation based - (counseling & sound therapy) utilizes counseling to decrease the strength of tinnitus reactions and sound therapy to decrease the strength of the signal
what is TRT protocol
introductory contact, initial visit, assessing for the category of treatment, instrument fitting, follow up visits and closing of treatment
what does TRT intital interview consist of
structured questions used to determine the category and impact of tinnitus. also make sure patients understands the treatment plan
what aspects of the treatment plan are critical for the patient to understand during the initial interview
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
what are treatment objectives with TRT
reaching habituation of the tinnitus
TRT : categories of treatment
category 0 - category 4
category 0 : mild or recent symptoms
low level of tinnitus severity with little impact on life
category 0 treatment
simplified counseling
aimed to help view tinnitus as a neutral stimulus.
sound enrichment can be advised.
short follow-ups to track patient’s status
category 1 : tinnitus alone
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
category 1 treatment
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)
category 2 : tinnitus and subjectivity significant HL without hyperacusis
tinnitus coexisting with HL, both having significant effect on their lives
-no hyperacusis and no sound exposure exacerbation
category 2 treatment
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
category 3 : hyperacusis without prolonged enhancement from sound exposure
significant hyperacusis with or without significant tinnitus and may have misophonia
-being exposed to loud sounds does not trigger it
category 3 treatment
focuses on hyperacusis, using sound therapy
-aimed to desensitize
-treating the hyperacusis first
category 4 : prolonged worsening of symptoms by sound exposure
hyperacusis is typically the dominant complaint with tinnitus as a secondary one or is absent
-symptoms worsen with nose exposure
-most difficult to treat
category 4 treatment
extensive counseling focused on hyperacusis and many adjustments in sound therapy
-educating the patient on physiological mechanisms is important
successful treatment with TRT results in ….
patients reaching category 0 before achieving final, complete habituation
why is it important to assign the correct category
essential for the therapy to be successful because inappropriate treatment can make tinnitus worse. if TRT is not working, an incorrect category is often the reason
retraining counseling
involving teaching patients about the mechanism of hearing, the basics of brain function, and the specifics of the neurophysiological model of tinnitus. there are 2 types nondirective & directive
nondirective style (client-centered therapy)
the emphasis of counseling is on the patient more than the problem
-the goal is to experience growth which enables them to be better equipped to deal with future problems
directive style
focuses on the problem that is the reason for therapy
- the goal is to solve the problem through the provision of new information and attitudes to the patient
reasoning for retraining counseling
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
what is sound therapy
staying away from a silent environment, having some sort of noise present. this reduces the perceptual constant between the tinnitus and external environmental noise.
sound therapy approaches
typically more than one approach is used - introduce additional sounds, increase volume of the existing sounds, use hearing aids to amplify environmental sounds, use wearable sound generations
considerations with the sound for sound therapy
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
why should the tinnitus not be suppressed
habituation will not occur
mixing point
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
how can ear level devices benefit more than environmental sound
helps combat disadvantages that occur if the talker moves around or if the student moves around, giving the sound directly to the patient’s ear
fitting aspects with ear-level devices
bilateral to avoid asymmetrical stimulation, open fittings to minimize OE, worn throughout waking hours, proper counseling
why is it beneficial to give the patient 2 devices even if they experience tinnitus in one ear
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
relating to failure of treatment, why is it important to discuss temporary worsening of symptoms
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
factors related to failure of treatment
inadequate initial counseling, lack of sufficient follow up, not teaching the model correctly, severe psychological problems, effects of medications and category 4 patients, suppression of tinnitus evoked by HA and focusing on a cure
why are category 4 patients difficulty to treat
they show the slowest response to treatment
-these patients should be examined for any underlying causes to cover the bases
important information to know regarding closing treatment
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
decreased sound tolerance (DST)
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
what is hyperacusis
reduced tolerance to sound that do not trouble most
-reaction depends on the physical characteristics of the sound
-medium to loud intensity
what are the 3 types of hyperacusis
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
common complaints of hyperacusis
discomfort, headache, concentration difficulties, fatigue and anxiety
what is misophonia
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
common misphonia triggers
oral/eating sounds, breathing sounds, repetitive sounds, speech sounds, household sounds, footsteps, finger tapping, whistling, low frequency sounds, animal sounds or visual triggers
what is phonophobia
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
loudness recruitment
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
with DST, what is the most likely the mechanism
likely involves multiple however excessive central gain is considered a key mechanisms in loudness hyperacusis
explain the likely central gain mechanism for hyperacusis
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
what are some other proposed reasons for hyperacusis
genetic predisposition, stress/anxiety/fear, neural changes, brain hyperactivity and blast exposure
with DST patients, why is it important to wean from earplugs
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
misophonia and phonophobia are abnormally strong reaction of the ________ and _________ resulting from ____
limbic
ANS
enhanced connections between auditory and limbic system
DST : treatment
HAs, sound therapies, CBT and TRT
DST : hearing aids
the goal is to provide gain without pain by balancing amplification needs with sound tolerance
-gradual amplification increases may need to occur
for patients that have HL, tinnitus and DST what do we treat first?
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
DST : sound therapies
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
DST : CBT
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
DST : TRT
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
