TRT categories Flashcards
Name the Category
- Patients show a low level of tinnitus severity, and tinnitus has relatively little impact on life. This category also includes patients with a very recent experience of tinnitus who have not received negative counseling.
- Treatment consists of one session of simplified counseling and to help them view tinnitus as a neutral stimulus. Sound enrichment should be advised. Short follow-ups after the initial visit are mainly focused on checking the patient’s status.
Category 0
Category 0
- mild or recent symptoms
- low level of tinnitus severity
- Little impact on life
- includes patients with recent experinece of tinnitus who have not received negative counseling
Treatment
* One session of simplified counceling
* help to view tinnitus as neutral stimulus
* Sound enrichment advised
* Short follow ups focused on checking the patient’s status
- Tinnitus alone
- Patients have tinnitus of high severity as their predominant complaint and do not have hyperacusis, subjectively significant hearing loss or prolonged exacerbation of tinnitus from sound exposure.
- Treatment includes intensive counseling focused on tinnitus and sound therapy with ear-level devices set to a level close to the mixing point. Follow-ups are initially more frequent and later spaced every six months, typically lasting 9-18 months.
Category 1
Category 1
- Tinnitus alone - high impact
- Tinnitus high severity as prodominant complaint
- do not have: hyperacusis , subjective HL, increased tinnitus severity with soud exposure
Treatment: - intensive counceling & sound therapy
- ear level devices set close to mixing point
- Follow up: more frequent and later spaced every six months
- 9 - 18 months
- Tinnitus and subjectively significant hearing loss without hyperacusis
- Patients have tinnitus coexisting with a hearing loss, which has a significant effect on their lives. These patients do not have significant hyperacusis, and sound exposure has no prolonged effect on tinnitus.
- These patients receive appropriate counseling and sound therapy, involving the fitting or refitting of appropriate hearing aids. Counseling in category 2 focuses on hearing loss and its role in triggering and enhancing tinnitus. These patients are instructed to provide an enriched auditory background while using the hearing aid as an amplifier. Hearing aids should be used during all waking hours and not simply for communication. Follow-up visits focus on sound enrichment strategies.
Category 2
Category 2
- Tinnitus & Subjective HL
- significant impact of Quality of life
- Does not have: Hyperacusis & sound exposure does not effect tinnitus
Treatment
- counseling and sound therapy
- fitting/refitting of hearing aids
- Counceling: focuses on HL & its role in triggering/enchancing tinnitus
- enriched auditory background w/HA as an amplifer
- HA’s should be worn constantly
- Follow up: sound enrichment strategies
- Hyperacusis without prolonged enhancement from sound exposure
- Patients exhibit significant hyperacusis, with or without significant tinnitus and may have misophonia.
- Initial treatment focuses on hyperacusis, using sound therapy for desensitization and addressing other auditory issues. Treatment often resolves hyperacusis within six months, after which other issues are addressed.
Category 3
Category 3
- Hyperacusis
- with out without tinnitus and or misophonia
- no prolonged enhancement from sound exposure
Treatment - focuses on hyperacusis; sound therapy for desenitization & addressing other auditory issues
- treatment resolves around 6 months
- other issues can now be addressed
- Prolonged worsening of symptoms by sound exposure
- Patients are the most difficult to treat. Typically, hyperacusis is the dominant complaint, with tinnitus secondary or absent. The crucial feature is the exacerbation of symptoms for prolonged periods of time as a result of noise exposure.
- Treatment requires extensive counseling focused on hyperacusis and many adjustments in sound therapy to allow for gradual desensitization based on the patient’s individual needs.“ Patient education on physiological mechanisms in TRT is important.
Category 4
Category 4
- Hyperacusis main compalint w/ tinnitus 2nd
- worsening is symptoms with sound exposure
- Most difficult to treat
Treatment - extensive counceling focused on hyperacusis
- many adjustments to sound therapy allow for graudal desensitization
- Education on physiological mechanisms in TRT is important
What is involved in retraining counseling?
- teaching patients about the mechanisms of hearing, basics of brain function and the specifics of neurophysiological model
- Interaction: one on one with aim to demystification of tinnitus and or decreased sound tolerance
Concepts in retarining counceling
Tinnitus & hyperacusis are side effects of what
tinnitus & hyperacusis are side effects of compensatory actions within the auditory pathways, not medical problems
Concepts in retarining counceling
Misophonia results from
misophonia results from enchanched functional connections between the auditory & limbic system
Concepts in retarining counceling
Problems caused by tinnitus or misophonia indicate activation of the autonomic nervous system which
Problems caused by tinnitus or misophonia indicate activation of the autonomic nervous system.
unnecessary preparation triggers neuronal and hormonal changes = anxiety stress and annoyance
Concepts in retarining counceling
Auditoy, limbic and autonomic nervous system typically work normal. The problem results from
Auditoy, limbic and autonomic nervous system typically work normal. The problem results from incorrect functional connections between these systems = a proper response to an improper stimulus
Concepts in retarining counceling
These connections are created and work following
These connections are created and work following the principles of conditioned reflexes
Concepts in retarining counceling
it is possible to retrain conditioned reflexes once …
it is possible to retrain conditioned reflexes once tinnitus is reclassified to a category of neural/slightly negative stimuli, to achieve habituation of the reaction induced by tinnitus and to achieve habituation of it perception
Concepts in retarining counceling
The process of habitiation is facilitated by
The process of habitiation is facilitated by enrichment of the auditory background, which by increasing background neuronal activity weakens the tinnitus signal
TRT
What is the purpose of Sound therapy?
Sound Therapy refers to enrichment of the sound enviorment
* reduce the perceptual contrast between the tinnitus and the external enviormental noise
* reduce stress or to distract attention from the tinnitus
Approaches to sound therapy
- introduction of additonal sounds
- incresing the volume of existing sounds
- Using hearing aids to amplify enviormental sounds by hearing aids
- Using wearable sound generators
Typicallu more than one approach is used
Sound therapy principles
*sound therapy is based on the principle that the strength of neuronal signal within the brain depends on the differenec between the signal and the background neuronal activity
* We react not to the absolute but to **the relative strength of the stimulus compared with the background **
* Candle
Sound therapy
Mixing point Selection Considersations
- Sound should minimize strength of tinnitus signal
- External sound should not induce any negative reaction
- Sound should be stable, neutral, not to attact attention, or interfere with communcaion or affect everyday activities
- Original tinnitus will still be there is tinnitus is fully masked - habituation will never occur
sound therapy
Issues of the mixing point
- intensity of teh sound affects the process of habituation
- When sound is close to threshold, low level signal can enhance the tinnitus though stochastic resonance
- If sound is too intense and tinnitus is inaudible, habituation will not occur
- Sould level used should be close to but below the level of partial suppression/mixing point
What is stochastic resonance?
When sound levels are close to hearing threshold, the low-level signal can enhance the tinnitus through stochastic resonance.
General recommendations for wearable sound generators
- provides controlled sound delivery
- full control over adjustment of sound level in each ear level device
- Instrument fititng must be bilateral to avoid asymmertical stimulation of auditory system
- Open fitting to minimize occlusion effect and reduce access to enviormental noise
- essential iin hyperacusis
- worn whenever low level background noise
- proper coucneling is vital for effectiveness of sound therapy
TRT
Potential factors contributing to treatment failure
- Temporary worsesning of symptoms
- inadequate intial counceling or lack of follow up visits
- Lack of follow ups & not teaching the model properly (MC)
- presence of litigation make habituationn difficult
- Severe Psychological problems
- Effects of medications
- Category 4 patients
- Suppression of tinnitus by HA’s
- Focusing on a cure
TRT
Recommendations for closing treatments
- no precise way to identify the end point of treatment
- end depends on meeting patients expectations & goals
- End should be a mutal decision betweeen clinician and patient. (communcation open for follow ups)
- end when patient reaches minimal symptoms score 1 or 2 with tinnitus awareness at 10% or less and annoyance near zero
- rapid changes should be avoided
