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Richard S. Tyler
BSc (CD), MSc, PhD
Professor
The University of Iowa
[Photo of
Presenter]
Hearing Aids could help tinnitus because:
•Improve Communication
•Reduce Stress
•Amplify Background Sound
•Focused on hearing external sounds
(Distraction)
•Produce Noise,
•therefore Partial Masking
General assumptions
• Tinnitus
– Low-level noise desirable
• Amplify low level everyday sounds
• Do not attenuate low-level sounds
• In contrast to hearing loss without tinnitus
– Low-level noise undesirable
Amplify/allow low level noise
• Open ear molds
• Widely focused directional microphones pick up noise
• Higher gain at low levels
• No noise reduction
• Consider Extending Low Or High Frequency Range Of Amplification
• Perhaps have a “tinnitus program” in multi-memory hearing aid
Dilemma: hearing aid or hearing
aid plus sound generator ?
• Marginal hearing aid candidate but wants
masker
• hearing aid candidate but uncertain of
masker
• Consider
– Can turn off one device, so get both
– Costs,
– progressive hearing loss?
Hearing aids can make tinnitus
worse !!
• Amplified sound exacerbates tinnitus
– Turn gain down, reduce maximum output
• Tactile sensation around ear could make
tinnitus worse
– Try alternative aid/earmold strategies
Hearing Aids with Hyperacusis
• initially reduce output maximum
• Increase maximum output gradually over
weeks and months
• Caution
– Limiting dynamic range can reduce hearing
abilities
Figure 1. Tinnitus population (millions, 2008)
Kochkin, Tyler & Born (2011)
Figure 3. Impact of tinnitus on quality of life (n=3,431)
Kochkin, Tyler & Born (2011)
Figure 4. Effectiveness of hearing aids in mitigating effects of tinnitus (n=1,314)
Kochkin, Tyler & Born (2011)
Figure 5. How often hearing aids are effective in mitigating
effects of tinnitus (n=553)
Kochkin, Tyler & Born (2011)
Figure 6. Tinnitus mitigation with hearing aids segmented by best practice hearing
aid fitting score in quintiles where Q1=bottom 20% of practices and Q5=top 20%
of practices (n=732).
Kochkin, Tyler & Born (2011)
Surr et al. (1985)
• 124 new hearing-aid users
• Tinnitus
– Reduced 25%
– Eliminated 29%
– Became Worse 5%
• 7% Benefit after turning aid off
Rehabilitation Strategies
• Brief counseling
• Self-help
• Advanced counseling
– Tinnitus Activities Treatment
• Sound Therapies
Tinnitus Patient
Curious Concerned Distressed
Provide basic
information
Basic information
Review treatment
options
Counseling and
sound therapy
Referral when
appropriate
Theoretical approaches to counseling for
tinnitus
• Cognitive
– inappropriate ways of thinking about tinnitus
• Sweetow (1984), Andersson and Kaldo (2006), Hallam and McKenna (2006)
• Attention
– Failure to shift attention away from tinnitus
• Hallam et al., (1984, 1989), Hallam & McKenna (2006)
• Learning
– Responses to tinnitus are learned
• Jastreboff and Hazell (1993), Bartnik and Skarzynski (2006),
• Fearfulness
– Afraid it will never go away (continuous anxiety)
• Loss of locus of control
– Patient has no control over tinnitus and life
• Acceptance
– Tinnitus is part of me, I own it
• (Mohr, 2006)
Brief Counseling
• Hearing loss linked to tinnitus
• Common
– about 30% prevalence after age 60 yrs.
• Common causes
– Noise, aging, medications, head injury, unknown
• Mechanism likely related to increased spontaneous neural activity
– Brain interprets appropriately as sound
….Brief Counseling
• Likely not to go away
• No medications at present
• Tinnitus different from reactions to tinnitus
– You can change your reactions
• “The more you think about your tinnitus, the more you are going to think about your tinnitus”
– (Tinnitus Activities Treatment)
• How can you make your tinnitus less important in your life?
Self Help books for Tinnitus
Tinnitus Activities Treatment
• Collaborative
– Determine needs and understanding individual patient
• Partial masking sound therapy
• Include Activities, Coping / Management
Strategies
• Programmatic counseling in 4 areas
– Thoughts and emotions, Hearing, Sleep, Concentration
Reactions
to
Tinnitus
Thoughts
and
Emotions
Hearing Sleep Concentration
Use of pictures to standardize
counseling
– Similar protocol across clinicians
– Similar or control differences across treatments
– Replications by others
Nerve Activity Carries Information
to the Brain
Inner
Hair Cell
Nerve
Activity
Nerve
Fiber
To
Brain
What does your tinnitus sound like?
Whistle
Cricket
Your tinnitus?
Fred Jane
Blah, blah,
blah, Fred,
blah, blah
Sounds Interpreted As Significant Are Not Ignored
Subconscious Conscious
Our Thoughts and Emotions
Doorbell
Doorbell
Doorbell
Neutral
Anxiety
Happiness
Fire
Injury
Angry neighbor
Flowers
Friend
Prize
Recent review of a variety of clinical protocols
Copyright Richard S. Tyler
Tinnitus Sound Therapies
Copyright Richard S. Tyler
Psychological Mechanisms
• Attention Model
– Distract from tinnitus
– Compete with tinnitus
– Decrease prominence
• Habituation Model
– Continuous, unimportant
Copyright Richard S. Tyler
Tinnitus
Low Level
Noise
Tinnitus in
Low Level
Noise
Low level noise makes tinnitus more difficult to detect
Copyright Richard S. Tyler
Tinnitus Activities Treatment
pictures can be downloaded
http://www.medicine.uiowa.edu/oto/research/tinnitus/
Copyright Richard S. Tyler
After Grant Searchfield
Copyright Richard S. Tyler
Copyright Richard S. Tyler
Searchfield, 2005
Level of the background sound
• varies with different sound therapies
• Total masking
– covers tinnitus completely
– person hears a ‘masker’ instead of their tinnitus.
• Partial masking
– tinnitus and the acoustic sound can be heard
– reduces the prominence and/or loudness
– Combined sound less obtrusive than tinnitus
Examples of descriptions of Partial
Masking in the literature
• Tyler and Babin (1986)
– use the lowest level masker that provides adequate
relief
• Coles (1987)
– provide only a low level of background sound against
which the loudness of the tinnitus is reduced
• Jastreboff and Hazell (2004)
– Focus on mixing point but below the level creating
annoyance or discomfort
Sound Therapy Options
1. Broadband noise (can filter, shape and modulate)
2. Music (processed, amplified to audiogram)
3. Modulated tones (e.g. fractal ‘spa’ music)
4. Notched noise or music (no stimulus in tinnitus region)
Future Directions
Need to focus research trials on
individuals, not groups
• identify different subgroups of tinnitus
patients
• One treatment will not help everyone
• Need to determine which patients will
benefit from which treatments
Cluster Analysis
Input data on distances between pairs of cities
Output – map defining relationship of variables (cities)
that are close together
Cluster Analysis
results from large group of tinnitus patients
• Cluster 1
– Loud, persistent, distressing
– Loudness hyperacusis
• Cluster 2
– Varies in pitch and loudness
– Worse in noise
• Cluster 3
– Not distressed
– No loudness hyperacusis
– Not influenced by touch
• Cluster 4
– Worse in quiet & better in noise
– Soft loudness, not distressed
Rating (0-100)
Nu
mb
er
of
Pa
tie
nts
Completely Eliminate
External Device
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
Pill
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
Implantable Brain Surface
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
Implantable Deep Brain
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
Implantable Cochlea
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
(N=197)
Rating (0-100)
Nu
mb
er
of
Pa
tie
nts
Completely Eliminate
External Device
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
Pill
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
Implantable Brain Surface
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
Implantable Deep Brain
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
Implantable Cochlea
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
Rating (0-100)
Nu
mb
er
of
Pa
tie
nts
Completely Eliminate
External Device
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
Pill
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
Implantable Brain Surface
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
Implantable Deep Brain
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
Implantable Cochlea
0
20
40
60
80
100
120
140
0~10
11~2
0
21~3
0
31~4
0
41~5
0
51~6
0
61~7
0
71~8
0
81~9
0
91~1
00
(N=197)
What patients want!
43
Tinnitus Performance
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Day
Tin
nit
us
Ra
tin
g (
0-1
00
)
(Th
e h
igh
er,
th
e w
ors
e)
CCIS
CIS
HA
Tinnitus Loudness
Hearing aid
Cochlear Implant #1
Cochlear Implant #2
A cochlear implant for tinnitus
Vagal Nerve Stimulation The vagus nerve is a cranial nerve easily
accessible in the neck region
The vagus nerve projects to nucleus basalis and
other brain structures
Stimulation of the vagus nerve also releases
neurotransmitters including acetylcholine and
norepinephrine
VNS is FDA-approved for epilepsy and
depression
Side effects are well-known and established
Transcranial Magnetic Stimulation External to skull
Changing magnetic polarity creates electrical field
FDA approved for depression and epilepsy
Talk to your patients about future
treatments
• Provide hope
• Be sincere and honest
• Show that people (researchers) care
Summary
• Hearing aids help many
• Be able to provide brief counseling
• Excellent self help books available
• Consider advanced counseling
• Sound therapies are helpful to many
• Discuss possible future treatments
22nd Annual Conference on
Management of the Tinnitus Patient June 13-14, 2014
The University of Iowa, Iowa City, Iowa, U.S.A.
Guest of Honor
Anne-Mette Mohr (Denmark)
Patient-centered Tinnitus Treatment
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