Tinnitus & Hyperacusis

Ozarks Technical Community College

What is tinnitus? Any sound that is perceived by the listener

that does not originate from an external sound source

May be perceived in one or both ears (peripheral) and/or in the head (central) 60% bilateral 30% unilateral 10% central

From latin word, tinniere, which means “to ring”

Descriptive Labels Ringing Hissing Buzzing Roaring Clicking Ocean sound Cicadas Pulsing Heartbeat

Causes of Tinnitus

Most commonly caused by some sort of change to the auditory system 80% of patient’s with SNHL have tinnitus

Hearing loss results in changes in the neural activity of the auditory system, which the auditory cortex interprets as sound Much like phantom limb syndrome. Areas

of the cochlea where there is hair cell damage can no longer amplify sounds where damage has occurred so a phantom sound is interpreted by the brain.

Other Causes of Tinnitus

Hearing loss, especially in cases of noise-induced hearing loss (NIHL)

External or middle ear issues (wax, fluid) Acoustic neuroma (UNILATERAL tinnitus) Medications Sinus/allergy issues Dental issues (TMJ-temporal-mandibular joint

syndrome) Cardiovascular Neurological (MS) Stress/anxiety

Medications that cause tinnitus Anti-inflammatories Antibiotics Antidepressants Aspirin Quinine Loop diuretics Chemotherapy drugs

Some musician’s consider it a badge of honor… Peter Frampton

“I wonder how you’re feeling. There’s ringing in my ears. And no one to relate to, ‘cept the sea.”

Bob Seger “With the echoes of amplifiers ringing in your

head.”

Prevalence of Chronic Tinnitus

NIDCD.NIH.GOV

• ~22 Million Americans• 10% of adult population

Types Subjective

Can only be perceived by the patient Most common type (95%)

Objective Can be heard by others Rare (<5% of all tinnitus cases) Usually pulsatile (in sync with heartbeat) Causes: vascular or muscular

Causes of Objective Tinnitus Vascular

Arteriorvenous aneurysm Glomus jugulare tumor

Muscular Patent eustachian tube Palatal myoclonus: involuntary muscle jerk of the

roof of the mouth Spasm of stapedius or tensor tympani muscles

Bothersome/Uncompensated Tinnitus Only about 20% of people with tinnitus are

bothered by it The tinnitus itself isn’t the problem. The

person’s REACTION to it is what is problematic. Tinnitus may result in irritability, fatigue/sleep

disturbance, depression, suicidal thoughts These patient’s need to be referred to a mental

health professional

A Viscious Cycle Attentional Factors (patient chooses to attend

to tinnitus)

Emotional reaction Limbic system: negative emotional labeling of the

tinnitus Autonomic system: activation of the fight-or-flight

mechanism (Can this tinnitus harm me?)

Stress Amplification of tinnitus signal (louder)

Tinnitus Treatment Surgery (uncommon option) Medication (usually xanax, valium,

antidepressants) Dietary restrictions (caffeine, alcohol, salt,

MSG) Masking Counseling

Cognitive Behavioral Therapy Tinnitus Retraining Therapy Sound treatment

Neuromonics

Masking

Use of noise to temporarily mask or “cover up” the tinnitus so it cannot be perceived

This is often successfully accomplished when patients with hearing loss use traditional hearing aids. The amplification of environmental noises often reduces or completely masks tinnitus. Our newest generation hearing aids have optional

tinnitus maskers built-in for when hearing aids aren’t enough to mask tinnitus. This may benefit that 20% of patients with tinnitus that are truly bothered by their tinnitus.

Masking There are companies that manufacture

tinnitus maskers for those with normal hearing. May be in-the-ear with a very large vent or a behind-the-ear, open-ear device

www.ata.org www.siemens.com

Masking The use of a sound machine or external noise

source (i.e. ceiling fan) can be very helpful at night

Different types of noise are utilized in masking: white noise, pink noise, brown noise, grey noise (all have varying complexity based on frequency components)

Tinnitus Handicap Inventory Patient self-survey Sample questions

Do you feel you have no control over your tinnitus?

Because of your tinnitus do you feel tired? Because of your tinnitus do you feel depressed? Does your tinnitus make you feel anxious?

Quantifies the severity of tinnitus Rates degree of handicap from slight to

catastrophic

Tinnitus Retraining Therapy Jastreboff created TRT Combines counseling with use of noise

generators Counseling: reclassify tinnitus to a category of

neutral signals Sound therapy: weaken the tinnitus-related neural

activity Goal: Habituation to the tinnitus (no longer

pay attention to it)

Neuromonics

Six to eight month therapy protocol Uses spectrally modified music that has been

tailored according to each patient’s hearing and tinnitus characteristics

Combined with an underlying neural stimulus Retrains the brain to filter out tinnitus disturbanceVery expensive~$5000 for treatment that lasts less than a year

Other Sound Disorders-Hyperacusis

Everyday sounds seem “too loud” or “uncomfortable”

About ½ of those with tinnitus, also have hyperacusis Affects 1 in 50,000

Hyperacusis Causes Hearing loss  Noise Injury Head injury (i.e air bag deployment) Ototoxicity Lyme disease Viral infections involving the inner ear or facial nerve

(Bell’S palsy) TMJ PTSD (post-traumatic stress disorder) Chronic fatigue syndrome Epilepsy Depression Migraine headaches

Hearing Aids in Patients with Hyperacusis

The measurement of LDLs is very important to ensure that the maximum output of the hearing aids (MPO) never exceeds the patient’s comfort level Real-ear-to-coupler difference (RECD) should be

performed to convert the patient’s LDLs in dB HL (audiometer) to dB SPL

Real-ear measurements are VERY important to confirm that the MPO of the hearing aid in the patient’s ear is below the patient-specific LDLs (in dB SPL)

Hearing Aids in Patients with Hyperacusis

It may be beneficial to perform a closed ear fitting (rather than a completely open fit) Using a closed dome, custom earmold, or custom aid

will prevent environmental noise from naturally entering the ear canal

This will allow you to better control the sounds that are allowed through the hearing aid to make the patient as comfortable as possible

On the other hand, patients with hyperacusis AND tinnitus may find that a closed fitting makes their tinnitus seem louder. As you can see, we walk a very fine line with hyperacusis and

tinnitus patients

Other sound disorders Misophonia

Dislike of sound

Phonophobia Fear of sound

Often these patients come in reporting that they use earplugs in everyday circumstances. This is NOT recommended. It will actually worsen problem.

When in doubt… If you have a patient with bothersome

tinnitus and/or hyperacusis, it is important to refer them to an ENT physician for medical evaluation and treatment

A good indicator that a patient needs to be referred for medical evaluation is when they report that the tinnitus and/or hyperacusis is worse than their hearing loss Use the Tinnitus Handicap Inventory as a guide