PHYSICAL DISABILITIES

PHYSICAL DISABILITIES

Persons who are deaf or hard of hearing should have similar motor development and skills as those with normal hearing unless vestibular function is affected. That is, deafness alone does not affect motor abilities or balance function. In fact, 93% of children with deafness have average to above average motor skills. Environmental factors such as emphasis on physical skills in the school curriculum, opportunities for practice and play, and parenting styles are believed to influence physical development of children with hearing loss. Audiologists should be aware of expected gross motor milestones in typically developing children. If a child with hearing loss is not walking by 15 months of age, a referral for further evaluation by a developmental psychologist or pediatrician is warranted.

Vestibular abnormalities that can result in gross motor problems include cochlear malformations such as Mondini’s deformity and cochlear hypoplasia. Other congenital causes of gross motor deficits in children with hearing loss include syndromes such as CHARGE syndrome and Usher syndrome type I (described in a later section) and CP. CP is a disorder of neuromotor function. Approximately 3% of children with hearing loss also have been diagnosed with CP, which is characterized by an inability to control motor function as a result of damage to or an anomaly of the developing brain. This damage interferes with messages from the brain to the body and from the body to the brain. The effects of CP vary widely from individual to individual. There are three primary types of CP:

·    Spastic—characterized by high muscle tone (hypertonia) producing stiff and difficult movement

·    Athetoid—producing involuntary and uncontrolled movement

·   Ataxic—characterized by low muscle tone (hypotonia) producing a disturbed sense of balance, disturbed position in space, and general uncoordinated movement

·    Quadriplegia—all four limbs are involved

·    Diplegia—all four limbs are involved and both legs are more severely affected than the arms

·    Hemiplegia—one side of the body is affected and the arm is usually more involved than the leg

·    Triplegia—three limbs are involved, usually both arms and a leg

·    Monoplegia—only one limb is affected, usually an arm

CP is not a progressive condition. The damage to the brain is a one-time event. However, the effects may change over time. For example, with physical therapy a child’s gross and fine motor skills may improve with time. However, the aging process can be harder on bodies with abnormal posture or that have had little exercise, so the effects may result in a gradual decline in motoric ability. It is important to remember that the degree of physical disability experienced by a person with CP is not an indication of his or her level of intelligence.

The brain damage that caused CP may also lead to other conditions such as learning disabilities or developmental delays. Approximately 20% of children with CP will also experience hearing or language problems. The hearing loss is typically sensory/neural in nature. In addition, between 40% and 75% of individuals with CP will also have some degree of vision deficit.

Special Testing Considerations

Individuals with motor delays may not respond behaviourally to auditory stimuli because their physical disabilities limit their ability to orient to sound. However, when testing children, VRA can still provide reliable information even for those with poor head and neck control. Modifications that might need to be made in the test arrangements for VRA include the use of an infant seat to provide additional head support. However, audiologists should ensure that head supports do not block the ears and impede sound field stimuli. If children with motor difficulties cannot make a head-turn response to sound, response modifications can be made. Modifications include alternative responses such as localizing to the sound stimuli with their eyes as opposed to head turns. CPA might also require modifications. Response modifications might need to include options that do not require the use of fine motor skills. Examples of such modifications could include asking a child to drop a ball into a large bucket rather than having the child insert a peg in a pegboard, partial hand raising, or even just a head nod. Additionally, a variety of gross motor responses can be used to trigger an electronic switch that will, in turn, activate a computer screen programmed for appropriate visual reinforcement.

If the physical disability has a neuromotor component, such as with CP, physiological measures might be affected. That is, abnormality in measures such as the auditory brainstem response (ABR) may be misinterpreted as indicative of hearing loss when, in fact, the abnormality is in neurotransmission. Therefore, interpretation of the ABR must be made cautiously and in concert

with the entire battery of auditory tests, behavioral and physiological. Sedation may be required when conducting ABR with individuals who have CP in an attempt to relax their head and neck or to reduce extraneous muscle movements, thus reducing myogenic artifact.

AUTISM SPECTRUM DISORDER

AUTISM SPECTRUM DISORDER

Autism spectrum disorder (ASD) is a developmental disorder characterized by symptoms appearing in early childhood and impairing day-to-day life function. These symptoms include qualitative impairments in social/communication interaction and repetitive and restricted behaviors, according to the Diagnostic and Statistics Manual of Mental Disorders. Under the umbrella of ASD, a patient’s symptoms will fall on a continuum, with some showing mild symptoms and others, more severe. A diagnosis under the general diagnostic category of ASD is relatively new. Prior to the publication of DSM-5, there were five ASDs, each of which had a unique diagnosis: classic autism, pervasive developmental disorder (PDD), Asperger’s disorder, Rett’s syndrome, and childhood disintegrative disorder. With the exception of Rett’s syndrome, these disorders are now subsumed into the diagnosis of ASD. Rett’s syndrome is now its own entity and is no longer a part of the autism spectrum.

ASD is thought to have an early onset, with symptoms appearing before 24 months of age in most cases. Although a definitive diagnosis of autism is not generally made until the age of 3 years or later (Mandell et al., 2005), there are a growing number of reports of stable diagnoses following identification as young as 2 years (Chawarska et al., 2009). Prevalence estimates of ASD have increased steadily over time from reports of 1 to 5 children per 10,000 in the 1970s. Current numbers from the Centers for Disease Control and Prevention suggest a prevalence of 114 per 10,000 children (Baio, 2012; Rice, 2009). It remains to be seen whether there has been a true increase in prevalence of ASD over time or the reported changes in prevalence can be explained by changes in diagnostic criteria and increased awareness of the disorder by parents and professionals. Boys are more likely to be affected with autism than girls, at a ratio of more than 3:1. About 50% to 70% of children with ASD also have an intellectual disability.

There is no strong evidence to suggest that individuals with ASD have a greater risk of hearing loss than the general population. However, the presence of unusual sensory responses, including abnormal responses to sound, is considered an associated feature of ASD. For example, individuals with ASD might completely ignore sounds that would result in a reaction from typically developing individuals. Other times, they often appear to be overly sensitive to sound by covering their ears with their hands when loud or unexpected sounds occur. In addition to these abnormal responses to sound, young children with ASD are known to lag behind on language milestones. Therefore, those with ASD will likely be referred to audiologists for hearing assessments as part of the developmental evaluation to rule out hearing loss as the cause of language delay. On average, behavioral responses to sound of children with ASD who have normal hearing are elevated and less reliable relative to those of typically developing children. Relatively little is known about higher order auditory abilities of individuals with ASD. However, altered temporal processing has been recorded in both adults and children with ASD.

Special Testing Considerations

Children with ASD who have hearing loss are diagnosed, on average, almost 1 year later than those without hearing loss. Therefore, it is reasonable for audiologists to be alert to the general behavioral characteristics of childhood ASD to facilitate referral for evaluation when indicated. Several screening tools are available that can be used by audiologists. These include, among others, the Modified Checklist for Autism in Toddlers (M-CHAT) and the Pervasive Developmental Disorder Screening Test II (PDDST-II).

Understanding the general behavioral characteristics of those with ASD can also be helpful to audiologists as they consider modifications to the traditional test battery. Because the majority of those with ASD exhibit cognitive deficits, behavioural abnormalities, and hypersensitivity to sensory stimulation, audiologists should be prepared to address those issues during the test session. For instance, transitions are often difficult for individuals with ASD. When possible, audiologists should avoid travel from room to room with the patient, taking care to escort the patient to the testing area immediately rather than keeping him or her in the waiting area.

Regardless of the chronologic age of the individuals, audiologists will need to use behavioral test procedures that are appropriate for their patient’s cognitive level. This may mean that procedures typically used with infants and young children such as visual reinforcement audiometry (VRA) or play audiometric techniques will be used with older children or even adults. If VRA is used, one should consider minimizing the impact of the reinforcement by turning off the animation (if a lighted, animated toy is used) or using a video reinforcement. Other testing options for patients functioning at a developmental level of 2.5 years or greater are conditioned play audiometry (CPA) and tangible-reinforcement operant conditioning audiometry (TROCA). TROCA is often used in pediatric practices that specialize in serving those with multiple disabilities. TROCA requires the patient to press a bar or a button whenever a sound is heard, which is paired with the dispensing of a tangible reinforcement (e.g., small piece of food). TROCA is noted to be particularly effective with children having cognitive or behavioral (e.g., ASD) disorders. A significant number of children with ASD receive other clinical services (e.g., speech therapy).

Patients with ASD are often resistant to earphones or probes used for individual ear testing. Audiologists can ask the parent or caregiver to practice listening activities with headphones with the patient prior to the appointment. If a patient with ASD will not allow the placement of earphones or probes, audiologists might have to resort to sedated procedures. This is certainly true if one plans to fit hearing aids. Individuals with ASD are known to be difficult to sedate with currently available pediatric sedating agents and are at risk for seizures while under sedation. Therefore, consultation with the physician in charge of administering and monitoring the sedation process will need to include notification of the patient’s diagnosis of ASD.

HYPERACUSIS

HYPERACUSIS

Introduction

Hyperacusis can involve loudness, annoyance, fear, and pain. We have noted that tinnitus is often accompanied by hyperacusis, and many current sound therapy protocols treat tinnitus and hyperacusis in parallel. One can readily imagine that sounds perceived as being very loud could easily become annoying. The anticipation of loud and/or annoying sounds could reasonably lead to the fear of these sounds. However, it is possible for sounds to be annoying or feared without being too loud. Patients also report that some sounds are physically painful, usually those perceived as loud. Occasionally, patients with tinnitus report that some sounds make their tinnitus worse. It is important to separate each of these symptoms, both for the patient and the clinician, to understand the problems carefully, and to offer treatment suggestions.

Neurophysiological Causes, Mechanisms, and Models of Hyperacusis

Anything that which causes a sensory/neural hearing loss can likely also cause hyperacusis. Hyperacusis can also occur without identifiable hearing loss. As a stimulus is increased, the activity of individual nerve fibers increases, and the number of nerve fibers activated increases (and usually its perceived loudness also increases). Moderately intense sounds might result in loudness hyperacusis if

1. greater than normal activity was produced on individual nerve fibers,

2. more nerve fibers were activated than normal, and/or

3. there was greater than normal synchrony across fibers

We suggest that hyperacusis might also be a function of such brain plasticity. Following a peripheral hearing loss, say at 4,000 Hz, nerve fibers in the brain that normally respond to 4,000 Hz begin to respond to other, nearby frequencies, for example, 3,000 Hz. This results in more nerve fibers in the brain responding to 3,000 Hz than would be present normally. If hyperacusis is related to the number of fibers activated, this could account for it as a phenomenon. Hazell (1987) suggested that hyperacusis might be the result of an “abnormal gain control.” It is as if the brain receives a lack of information after hearing loss and therefore turns up some hypothetical gain control.

EVALUATION OF HYPERACUSIS

Medical

The medical evaluation for hyperacusis parallels that for tinnitus. Some conditions have been associated with hyperacusis, including facial paralysis, head trauma, and metabolic disorders, infections (Lyme disease), and genetic (Williams’ syndrome) abnormalities.

Measuring Hyperacusis

LOUDNESS HYPERACUSIS

Loudness Discomfort Levels

Loudness discomfort levels (LDLs) can be performed with puretones at 500 and 4,000 Hz in each ear. We use the following instructions: “This is a test in which you will be hearing sounds in your right/left ear. We want you to decide when the sound first becomes uncomfortably loud.”

Magnitude Estimation of Loudness

It is possible to present tones and ask for a rating of loudness on a scale from 0 to 100, with 100 being the loudest sound a person can imagine. Hyperacusis scales have been developed to attempt

to differentiate loudness and annoyance and to ascertain a general idea of the impact of hyperacusis on a patient’s daily activities. The questionnaire asks individuals to consider several typical events they might encounter in their daily lives. They then separately rate the loudness and the annoyance for the same situations. For example, a patient may rate “telephone ringing in the same room” as 40 out of 100 on the loudness scale (with 100 being unbearably loud), whereas rating it as 85 out of 100 on the annoyance scale (with 100 being unbearably annoying).

ANNOYANCE HYPERACUSIS

In terms of hearing loss tinnitus, and hyperacusis the statement include items such as ‘you avoid shopping’ ‘you feel depressed’ and allow clinician to separate the impact on function that patient perceive from where hearing loss, tinnitus and hyperacusis. Another approach we have tried is to have patients rate recorded sounds. For example, we have patients rate recorded sounds of dishes hitting together, a lawn mower, and crowd noise. A multiple activity scale for annoyance hyperacusis, providing 15 situations (e.g., concert, shopping center, work, church, children). Subjects rated from 1 to 10 each of the “relevant” activities, which were averaged for a total score. They also had patients rate annoyance hyperacusis on a scale from1 to 10.

FEAR HYPERACUSIS

Patients can develop a fear of very specific sounds or categories of sounds (e.g., those containing high frequencies) or of any intense sound. The simplest approach may be to ask the patients to make a list of sounds they fear to determine if a specific pattern exists.

PAIN HYPERACUSIS

Some patients report that listening to some sounds create pain. Often, they are perceived as loud, and these patients typically have fear of these sounds.

TREATMENT FOR HYPERACUSIS

Counseling

In hyperacusis activities treatment, we include four sections.

1.         The first section is emotional well-being. Patients with hyperacusis are often anxious and distressed about being exposed to intense noise.

2.         The second section is hearing and communication. Some patients avoid communication situations where they expect there to be intense sounds. Sound therapy to reduce loudness hyperacusis should be able to provide some assistance with this. Others will avoid using hearing aids or use gain settings that are insufficient. Patients can set the maximum output of their hearing aids temporarily to a lower level (Search field, 2006) and gradually increase this over time.

3.         The third section is in the area of sleep. Occasionally, patients with fear hyperacusis will report that they do not sleep as well because of the anticipation of an intense sound. Partial masking sound therapy (e.g., playing music throughout the night) can be helpful for some.

4.         The fourth section is that some patients report that they have difficulty concentrating in anticipation of an intensesound. Again, partial masking sound therapy can be helpful.

Sound Therapies

One fundamental issue is whether to protect the ears from moderately intense sounds, for example, with earplugs. Some patients with severe hyperacusis do this on their own. Of course, everyone (including hyperacusis patients) should protect their ears from potentially damaging high-intensity sounds. However, protecting a hyperacusis patient’s ears from moderately intense sounds will not cure the patient’s hyperacusis. In fact, restricting one’s exposure to moderately intense sounds might have a further negative impact. One can imagine that if it is uncommon to hear a sound at 85 dB SPL, then whenever a sound of this level is perceived, it might result in an overreaction. There are currently five general sound therapy strategies that we are aware of for hyperacusis.

PARTIAL MASKING

Partial masking with a continuous background sound can be used to reduce the loudness and prominence of intermittent sounds that might otherwise be annoying. For example, low levels of music can partially mask background annoying traffic noise. Additionally, the low-level music can create a background whereby the patient is less likely to anticipate being disturbed while getting to sleep, sleeping, or concentrating.

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.

CLASSROOM AMPLIFICATION DEVICES FOR CHILDREN

CLASSROOM ACCOMMODATIONS AND HEARING ASSISTANCE

The classroom environment

Classrooms are a critical auditory environment for children yet many do not provide favorable conditions for hearing. The classroom environment is one that must be controlled to provide favorable conditions for hearing. There are three important variables to be noted: Noise, reverberation, and distance from the teacher. Sources of classroom noise may include the children themselves, furniture noise, ventilation systems, and external ambient noise. Ambient noise levels often exceed an optimum 35 dBA (unoccupied), and hard surfaces can reduce hearing effectiveness by increasing reverberation time beyond an optimum maximum of 0.3 to 0.6 seconds (American Academy of Audiology; AAA, 2011a). Signal level and SNR decrease with distance from the signal source.  

Children require a greater SNR than adults for speech recognition. Young children require speech levels that are at least 20 dB above those of interfering noise and reverberation (AAA, 2011b). In practice, this is difficult to achieve without amplification. Consequently, even children with normal hearing may experience difficulty hearing in class. Many children with CAPD particularly have difficulty hearing in background noise. The noise level does not need to be loud to disrupt auditory input. Adults with CAPD describe how noise from a fan or  refrigerator can interfere in properly decoding speech. Some children with CAPD are overwhelmed by all classroom noise levels, becoming distressed and unable to function. Such children are sometimes withdrawn from school.

Sometimes, minor modifications to a classroom, for example, sealing obvious entry points of external noise and introduction of absorbent materials, may improve the acoustic classroom environment, but are unlikely to sufficiently improve the audibility for a child with CAPD. This

is because some children with CAPD may need amplification of the primary signal, not just an improved SNR, to hear well (see Section “Amplification”). Hearing assistive technologies (HATs) and in particular remote microphone systems can alleviate or overcome all three sources of signal degradation in the classroom: Noise, reverberation, and distance from the talker.

Other Environments

Children with CAPD have difficulty when speech is rapid or degraded by distance, acoustic conditions, or accent, when information streams are complex or lengthy, and when competing sounds are present. It follows that HAT can be helpful to them in many aspects of their lives besides the school environment. Moreover, given the positive neuroplastic changes that occur over time from wearing amplification (Friederichs and Friederichs, 2005; Hornickel et al.,

2012), children with CAPD should be encouraged to use their HAT as much as possible.

Amplification

Terminology

The majority of recent studies of amplification for children with CAPD have used remote microphone hearing aids, with body- or head-worn receivers, which receive a signal from a microphone worn by the speaker. The transmission medium has typically been frequency modulation (FM). Hearing systems of this type are usually referred to as “personal FM systems.” This term is ambiguous, because it refers to accessory FM systems used by wearers of conventional hearing aids or cochlear implants. Furthermore, FM is increasingly being replaced by digital modulation (DM) technology. From the point of view of advocacy as well as accuracy, use of the term “remote microphone hearing aids” reinforces the point that children with “central deafness” require amplifying hearing aids in much the same way as do children with peripheral hearing loss. Until remote microphone hearing aids become recognized as simply another type of hearing aid they remain classified as assistive listening devices (ALDs) or, in more current terminology, a type of hearing assistive technology (HAT).

CLASSROOM AMPLIFICATION SYSTEMS

Classroom amplification systems, also referred to as sound distribution or sound field systems, provide amplification of the teacher’s voice through loudspeakers. Their efficacy is variable, depending in particular on the room acoustics. Classroom amplification systems typically improve SNR by 3 to 5 dB, but may worsen SNR in classrooms with very poor acoustics. Adaptive systems which increase the amplification as the noise level increases can achieve better than 5 dB. Portable desktop systems in which a small loudspeaker is placed on the desk of an individual child provide a slightly better SNR, perhaps 10 dB, for that child. Remote microphone hearing aids can provide at least 20 dB improvement in SNR. A meta-analysis by Schafer and Kleineck (2009) comparing speech discrimination in noise with various FM systems in trials involving cochlear implant users showed no significant improvement with sound field systems but 17% improvement with desktop systems and 38% improvement with personal direct auditory input FM systems.

CANDIDACY FOR AMPLIFICATION

It is sometimes mistakenly assumed that only children with CAPD who complain of difficulty hearing in noise, or who score poorly on a speech-in-noise test, will benefit from remote microphone hearing aids. In fact, research results and clinical experience indicate that nearly all children with CAPD show classroom benefit from personal amplification as long as the classroom teacher is cooperative. Results range from children whose hearing ability in class is instantly transformed through to those in whom benefits are more subtle and slower to manifest. There is no known predictive test of degree of benefit to be derived from amplification

(though the Hornickel et al. study reported above shows an interesting correlation between initial inconsistency of the brainstem response and subsequent benefit). However, recommendation of amplification only for children with abnormal scores on tests of hearing in noise undoubtedly denies potential benefit to many children.

Electroacoustic verification of remote microphone hearing aid. Upper curve(vertical hatches) represents audibility of the amplified pathway. Lower curve (horizontal hatches) represents audibility of the unamplified pathway through the open ear canal.

EUSTACHIAN TUBE DYSFUNCTION

EUSTACHIAN TUBE DYSFUNCTION

Normal Eustachian tube function is essential for the well being of the middle ear cleft as it maintains the equilibrium between middle era pressure and the atmosphere. Any obstruction of air from the middle ear with consequent retraction of the drum as a result of a higher atmosphere pressure. Eustachian tube function is characterized by a middle ear pressure of less than 100 m HZ0. Patient with mild hearing loss and feeling of pressure in the ear. If the process continue and the tube does not reopen then a serous exudates occurs which is associated with a more severe hearing loss, discomfort in the ear, occasionally tinnitus and in some patient dizziness. Throat infection may be transmitted by the tube to the middle ear causing otitis media. This is more common in children because their tube is shorter and straighter and has an exuberance of lymphoid tissues in throat. 

TYPES OF HEARING LOSS

TYPES OF HEARING LOSS

Slight hearing loss (16 to 25dB): Difficulty in understanding very soft speech from a distance. E.g. falling or rustling leaves and whisper. Children can experience difficulty in classroom when more than 3 feet away from a teacher.

Mild hearing loss (26 to 40dB): People having mild hearing loss may struggle with having conversation especially if the environment is loud and noisy. E.g. birds chirping, the sound of stream. Children can experience in difficulty in classroom and comprehending some vocabulary.

Moderate hearing loss (41 to 55dB): One a person has moderate hearing loss they will find keeping up with conversation difficulty when they are not in using of hearing aid. Difficulty understanding normal speech especially in a noisy environment. E.g. conversation at home, light traffic and distant large transformers. Children have trouble with normal speech and difficulties with learning.

Moderately severe loss (56 to 70dB): Individuals with moderately severe loss need speech to be loud and difficulty hearing with background noise and in groups. E.g. vacuum cleaner and conversation in restaurant and offices. Children experience difficulties with language and skill development.

Severe hearing loss (71 to 90dB): Persons with severe hearing loss will benefit from hearing aids. They may also need to reply on lip reading and the use of sign language. They cannot hear normal speech and sometimes difficulty with loud speech. E.g. train at 50 feet, food processor, alarm clock, passing trucks. Children require hearing loss habilitation and assistance of a speech therapist.

Profound hearing loss (above 90dB): People who have profound hearing loss will find listening incredibly difficult and are most likely to reply on lip reading or sign language. Difficulty with very loud speech and sometimes cannot hear loud speech. E.g. air craft landing, noise in a train, rock music live, running wipes. Children require hearing habilitation and speech therapy.