TINNITUS

TINNITUS

INTRODUCTION:-  Tinnitus and Hyperacusis  are two challenging in audiology as patients can be desperate and t`here are no cures. Tinnitus can been defined as a perception of sound (it must be heard, Involuntary (not produced internationally) and originating in the head (rather it is not an externally produced sound) , whereas Hyperacusis does not  have a widely accepted definition. Hyperacusis can involve loudness, annoyance, fear and pain. We have noted that tinnitus is often accompanied by hyperacusis and many current sound therapy protocol that tinnitus and hyperacusis in parallel.

NEUROPHYSIOLOGICAL CAUSES MECHANISM AND MODELS:-

Hearing loss can also produce tinnitus. The most common causes are noise exposure, aging, head injury, and medication. Sometimes the causes are unknown. The prevalence of tinnitus increase with

Age and hearing loss, but in particular is influenced by noisy situations report that the onset of tinnitus is gradual. Initially tinnitus is heard only occasionally during the day or for brief periods after work. The onset of tinnitus occurs after the onset of hearing loss. Tinnitus is classified as either Sensory/neural or middle ear .Middle ear tinnitus is typically related to middle ear vascular or muscular dysfunction. Sensory neural tinnitus originated in the cochlea and neural auditory pathway.

AUDITORY HALLUCINATION AS TINNITUS:-

When someone reports hearing sounds that are like music or voice, it is important to considered mental illness. Reports of imagined voices or music can occur as part of psychotic illness such as Schizophrenia. If there is no record of such illness, but there is evidence of depression, anxiety, or unrealistic thoughts or actions, then these should be addressed with the client and a referral provided to a mental health professional. In the absence of indications of mental illness, one could treat this as with other type of tinnitus. Certainly tinnitus has a central origin. Patients who present no sign of mental illness and who hear music and voices could benefit from programs described later. It is important not to overact to the patients reports.

MEDICAL EVALUATION:-

Often a focus of the evaluation will be on the cardiovascular system and on metabolic disturbance such as diabetes and hypercholesterolemia. Laboratory examination (e.g. cholesterol levels, glucose, zinc, and screen for ototoxic drugs) and imaging tests (e.g. ultrasound, computed tomography scan magnetic resonance angiography) might be utilized.

Middle ear tinnitus is associated with either abnormal middle ear blood flow or middle ear muscle ear muscle contraction. Some call this “objective” tinnitus” because it can be amplified and heard by the examiner. Some spontaneous otoacoustic emissions, which are produced in the cochlea can also be heard. Therefore we prefer the term middle ear tinnitus. Otologists may determine whether the tinnitus sensation changes with manipulation of blood flow. These manipulations can change the pulsing sensation. A proportion of these can be eardrum and can sometimes be observed . Movement of the eardrum can sometimes be observed visually or with the help of measurement of air pressure in the external canal with tympanometery. Oral cavity examination may demonstrate myoclonic activity.

Tinnitus can sometimes be influenced by movements of the head and neck. Some ototlogists search for sign of temporomandibular dysfunction which can involve jaw or facial pain or tenderness and difficulty or discomfort in chewing. Another focus is a search for treatable sensory neural tinnitus .

Another focus is a search for treatable sensory/neural tinnitus. This includes some forms of sudden hearing loss, Méniére’s disease, or a tumor of the auditory nerve. It could be that some forms of tinnitus might be caused by metabolic diseases and deficiencies (e.g., anemia, diabetes, hypercholesterolemia, zinc and vitamin deficiency). Evaluations for these conditions would involve studies of the blood and urine.

Measuring the Tinnitus

The pitch, loudness, and amount of noise necessary to mask tinnitus can be measured to quantify tinnitus, provide assistance for fitting maskers, and monitor changes in tinnitus perception. Patients can usually compare the pitch produced by a puretone to the “most prominent pitch” of their tinnitus. Pitch matching can be highly variable, and an indication of the variability should be reported in the patient chart. Patients can also adjust the intensity of a tone so that it has the same loudness as their tinnitus. Sensation level is not a measure of loudness.

The results of a tinnitus loudness match can be reported in dB sensation level (SL), but this level can only be interpreted over time for a particular patient if the hearing threshold at that frequency does not change. An alternative approach is to convert the physical intensity of the sound into the subjective loudness scale based on sones. Sones represent an international standard; 1 sone equals the loudness of a 40-dB sound pressure level (SPL) 1,000 Hz tone (about 49 dB HL) in a normal listener. A sound that has a loudness of 4 sones is four times as loud. Another measure of the magnitude of tinnitus is the amount of noise required to mask the tinnitus, sometimes referred to as the minimum masking level. The noise level (specify the frequency characteristics of the noise, e.g., broadband 250 to 8,000 Hz) is increased until it just masks the tinnitus. Several things can contribute to the variability of tinnitus measurements. First, one should be aware that the test stimuli can change the tinnitus. This is probably more likely to happen for intense stimuli and when stimuli are presented ipsilaterally to the tinnitus. The ear receiving the stimuli should be reported. Second, in many patients the perception of tinnitus is not constant but varies throughout the day or from day to day. A reasonable approach to this is to make multiple measurements and report each value. The variability of the measurements can be documented by replicating the measures and recording the results of each trial in the patient’s chart. For example, we often use the average of three loudness matches, three minimum masking levels, and six pitch matches (because pitch tends to be more variable). In patients with highly variable tinnitus, additional measurements can be made, and the measurements can be repeated at subsequent visits. Measuring the Reaction to the Tinnitus People’s reaction to their tinnitus covers a broad range. Some appear not to be particularly bothered by it, whereas for others, the tinnitus can have a dramatic effect on their lifestyle. The primary impairments can result in difficulties with thoughts and emotions, hearing, sleep, and concentration Sleep disturbance is one of the most common of these impairments causing some to have difficulty falling asleep, whereas others have difficulty falling back asleep if they wake up in the night. The impact tinnitus is having on an individual’s life, an easy first step is to ask the person to “list all the problems you have that you associate with your tinnitus, starting with the problem that bothers you the most”. This can be done before the first appointment and can lead to an open discussion of the important problems as perceived by the patient. Several questionnaires designed to quantify the problems caused by tinnitus are available. These differ based on the scale used. Our experience is a 0 to 100 scale is easy for patients (a familiar decimal scale like dollars), in which a patient will respond 0, 5, 10, 15, . . . 100, which enables a 21-point scale. This provides greater resolution than a 0 to 10 scale. Questionnaires also differ on the scope of questions asked. Tinnitus Handicap Questionnaire has been widely used to assess the influence of drugs, cochlear implants, and sound therapy approaches. Others also include general questions on the quality of life. We believe this can make the questionnaire less sensitive to treatment effects, as the quality of life can be influenced by many factors not directly captured by treating tinnitus. The Tinnitus Primary Function Questionnaire which focuses on emotional, hearing, sleep, and concentration difficulties and is sensitive for clinical trials and assists in determining treatment needs. All appendices can be found at the end of the book.

TREATMENTS

There are two basic types of tinnitus treatment strategies: Those designed to reduce or eliminate the physical perception and those designed to change the patient’s reaction. Counseling

There are various counseling approaches: They range from providing information to more engaged collaborative counselling.  Many of these are based on the work known as tinnitus habituation Special Populations therapy. Others include strategies for improved coping, management, and behavioral change. Among these are tinnitus activities treatment, tinnitus retraining therapy, and tinnitus cognitive behavior therapy . The aim of these procedures is to provide ways for the person suffering with tinnitus to adjust his or her reactions to the experience.

The goals of these psychologically based therapies often overlap. For example, patients can

be helped to habituate to their tinnitus by de-emphasizing the fear associated with it. Another approach is to decrease the attention given to the tinnitus, often with the help of background sound. The way a patient thinks about the tinnitus can influence his or her reactions to it. Therefore, some clinicians will help patients consider how they think about their tinnitus. These thoughts can be challenged and revised. Another approach is to assist patients to change their focus away from their tinnitus.  It is our general view that many patients concerned about tinnitus can adapt to it after the explanation of its origin and its nonthreatening nature. A substantial number of patients such reassurance is less effective, and a more elaborate intervention is needed. The descriptions in the following sections provide guidance on the sorts of appropriate counseling within the context of general audiologic practice. When more elaborate counseling is required, reference to the clinical psychologist is appropriate. Important attributes of the clinician include

• Ability to listen

• Patience

• Ability to be encouraging to the patient

• Emotional insightfulness

• Self-awareness

• Ability to laugh at the bittersweet aspects of life

• Positive self-esteem

• Ability to talk candidly about depression, anxiety, and other psychologic stressors At the initial interview, it is helpful to determine if patients are curious, concerned, or distressed about their

tinnitus. Much of the anxiety associated with tinnitus stems from uncertainty regarding its source and consequences. Curious patients typically require only basic information regarding possible causes, mechanisms, prevalence, consequences, and likely outcomes. These patients find that once the mystery of tinnitus is explained to them, their reaction is largely resolved.

Concerned patients require more detail and benefit from information regarding things they can do on their own or other treatment options. Depending on the level of concern, these patients can require a more formal evaluation that includes the questionnaires and psychoacoustical measurements discussed earlier. Distressed patients require specific tinnitus treatment. Patients with severe anxiety and depression should obtain help from psychologists or psychiatrists. Patients who report suicidal thoughts or self-harm need to be further questioned regarding their intentions, and a referral to clinical psychology or psychiatric services should be made immediately if any concern exists.

PROVIDING INFORMATION

Most approaches provide information about hearing, hearing loss, and tinnitus. They usually include the causes, prevalence, and common consequences of tinnitus. For many people, the unknown aspects of tinnitus are the most alarming. They often find this basic information about tinnitus reassuring and may require no further assistance.

THOUGHTS AND EMOTIONS

It is helpful to distinguish the tinnitus itself from the person’s reaction to the tinnitus. The way people think and feel about their tinnitus can have a major influence on their reactions. One focus of cognitive behavior therapy, and other counselling strategies, is on challenging a person’s thoughts about tinnitus and thereby facilitating changes to the reactions to the tinnitus.

MEETING THE PERSON’S NEEDS

Some counseling procedures go beyond providing information and attempt to understand and influence the overall emotional well-being of the patient.  Several approaches are available to help individuals understand and change the emotional consequences of their experience with

their tinnitus.  

COPING/MANAGEMENT STRATEGIES

Some counseling approaches include coping/management strategies to help patients understand and change their perceptions about tinnitus and to modify their reactions and behaviors. Activities are planned to determine situations in which tinnitus might be a problem and then to modify their specific situation to reduce these occurrences. For example, patients might report that their tinnitus is worse when they first get home from work. This might be a result of sitting in a quiet room reflecting on the day’s activities. An alternative activity might be to go for a walk while listening to music, or physical exercise, such as Tai Chi or yoga, to limber up. Just about any activity that reduces stress can be helpful.

RELAXATION AND IMAGERY PROCEDURES

Some patients benefit from learning specific relaxation or imagery procedures. These can be used when people experience stress, and it can be helpful for them to learn relaxation strategies or to focus attention to other thoughts. Exercises to learn how to redirect attention away from the tinnitus are also employed. For example, in a quiet room, patients can imagine the sound of waves on a deserted beach. Then, they can redirect their attention to their tinnitus—then back

to the waves.  

Sound Therapies

Sound therapies include strategies that use background sounds to reduce the prominence of tinnitus or decrease its loudness or level of annoyance.

THE USE OF HEARING AIDS

Most patients with tinnitus also have hearing loss. Properly fitted hearing aids should help with communication and often also help with tinnitus by reducing the stress involved with intensive listening and by amplifying low-level background sounds. Hearing aids are often the first component of sound therapy for patients with tinnitus.

Tinnitus Activities Treatment

Our counseling approach has evolved over the years. We continue to prefer the partial masking strategy we recommended in the 1980s, although some patients benefit from total masking.

THOUGHTS AND EMOTIONS

The way patients understand and think about their tinnitus influences their reactions to it. Providing information in a collaborative fashion to ensure understanding is essential. Key aspects of this area include

•              Listening to the patient and addressing issues that are important to him or her

•              Providing information about hearing, hearing loss, tinnitus, and role of conscious and subconscious attention

•              Understanding the patient’s reactions to unexpected, uncontrollable events

•              Suggesting changes in behavior and lifestyle that can facilitate acceptance and habituation

It is important to help patients recognize the difference between the tinnitus itself and their reaction to it. Cognitive therapy separates the tinnitus from the patients’ reactions to it and may provide a sense of control over the impact tinnitus has on their lives.

HEARING AND COMMUNICATION

Tinnitus and hearing loss often occur together, but the patients cannot “hear” their hearing loss, so they project their communication problems on the tinnitus. Reviewing the patient’s hearing loss and its impact on communication may redirect some of the anxiety to an area where treatment is more obvious. In addition to hearing aid information, a review of assertive communication versus passive or aggressive communication styles is useful.

SLEEP

Understanding normal sleep patterns is the first step in gaining control over the problem. Other strategies include

•              Exploring factors that can affect sleep (e.g., stress, environmental noise, room temperature)

•              Arranging the bedroom to promote sleep (e.g., comfortable bedding, remove distracting items from room)

•              Avoiding alcohol, smoking, and eating before bedtime

•              Using sound to mask tinnitus (e.g., noise generators or soft radio)

•              Learning relaxation exercises (e.g., imagery, progressive relaxation)

CONCENTRATION

In our therapy, we discuss the importance of concentration and things that affect our concentration. We review factors in the environment (e.g., lighting, background noise, distractions, and temperature) and personal factors (e.g., being tired, current health status, and other stressors in our lives) that impact our ability to focus our attention for a sustained period of time. Activities in “attention diversion” give patients practice switching attention from one engaging task or stimulus to another. This type of exercise shows people that they can control what sounds, images, or other stimuli they consciously focus their attention on. Repeated practice with this type of activity can help give patients a sense of control over their attention as well as their tinnitus.