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Published on : Jul 10, 2021 | Views : 1790 | Downloads : 5

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Slide 1-

Tinnitus & Attention Training Kim Wise, MNZAS, CCC (New Zealand), Ph.D. Audiologist; Research Fellow Mayo Clinic In-service Talk
Slide 2-

Definition TINNITUS: the conscious awareness of sound, perceived in the ear/ears or head, lacking an external, driving sound source or mechanical activation of the cochlea.
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Objective Tinnitus Objective tinnitus – sound produced by causal pathology which may be heard by an examiner (usually via amplified stethoscope) Pulsatile tinnitus – matches pulse Possible vascular etiology Either objective or subjective Increased or turbulent blood flow through paraauditory structures
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Objective -Pulsatile tinnitus Arteriovenous malformations Vascular tumors Venous hum Cardiac murmurs Pregnancy Paget’s disease (disorganized bone remodeling) Benign intracranial hypertension
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Arteriovenous malformations Pulsatile tinnitus Headache Papilledema (Optic Nerve Swelling-a hallmark of elevated intracranial pressure) Discoloration of skin or mucosa
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Venous hum-associated causes Benign intracranial hypertension Dehiscent jugular bulb Transverse sinus, partial obstruction Increased cardiac output from: Pregnancy Thyrotoxicosis Anemia
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Benign Intracranial Hypertension (BIH)-presentation Young, obese, patients Hearing loss Aural fullness Dizziness Headaches Visual disturbance Papilledema
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Muscular Causes of Tinnitus Palatal myoclonus Clicking sound Rapid (60-200 beats/min), intermittent Contracture of tensor palantini, levator palatini, levator veli palatini, tensor tympani, salpingopharyngeal, superior constrictors Muscle spasm seen orally or transnasally Rhythmic compliance change on tympanogram
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Myoclonus-associated causes Palatal myoclonus associations: Multiple Sclerosis and other degenerative neurological disorders Small vessel disease Tumors treatments: muscle relaxants, botulinum toxin injection
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Stapedius Muscle Spasm Idiopathic stapedial muscle spasm Rough, rumbling, crackling sound Exacerbated by external sounds Brief and intermittent May be able to see tympanic membrane movement Treatments: avoidance of stimulants, muscle relaxants, sometimes surgical division of tensor tympani and stapedius muscles
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Patulous Eustachian Tube Eustachian tube remains open abnormally Ocean roar sound Changes with respiration Lying down or head in dependent/particular position provides relief Significant weight loss, radiation to the nasopharynx Can sometimes change tympanometric compliance readings with respiration
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Subjective Tinnitus Much more common than objective Usually non-pulsatile Heard only via the patient No consensus regarding exact mechanism(s) of tinnitus production Abnormal conditions in the cochlea, cochlear nerve, auditory pathways, auditory cortex Hearing loss, Presbycusis Noise exposure Meniere’s disease Otosclerosis Head trauma Acoustic neuroma/Schwannoma Drugs Middle ear effusion TMJ problems Depression, stress, fatigue Hyperlipidemia Meningitis Syphilis Diabetes Lyme Disease
Slide 13-

Mechanisms: Evidence for Central Site Auditory nerve section (Darby, 1941; House and Brachmann, 1981) Near-normal hearing & tinnitus (high-frequency assessments)
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Role of Affective State Folmer et al (1999) reported patients with depression rated the severity of their tinnitus higher although loudness scores were the same. Interactions between tinnitus, stress, anxiety and depression can be complex and dual-directional (Andersson & McKenna, 1998; Halford & Anderson, 1991)—principle to, or a consequence of tinnitus
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Drugs that may cause tinnitus Anti-inflammatories Antibiotics (aminoglycosides) Some Antidepressants (Benzodiazepines) Aspirin Quinine Loop diuretics Chemotherapeutic agents (cisplatin, vincristine)
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History (TSCHQ) General Health: Infection, illness, flu, or major life changes Trauma (esp. with resultant change in vision, hearing, balance, memory/cognition, patient’s own voice quality) Noise exposure Hx Medication usage (Ototoxic, associated with tinnitus genesis or potential interaction suspected) Medical history (Cancer treatment, systemic infection or transplant recipient Vertigo Pain (ear, neck, jaw, headache or with certain sound-Hyperacusis) Family Hx Impact on patient (sleeping?, depression?, anxiety?) Tinnitus modulators neck movement (flexion or turning)/light compression, jaw clenching, eye gaze, facial movements Aggravators/alleviating factors Hearing loss & laterality Tinnitus Characterization ONSET OTHER TREATMENTS
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Audiological High-frequency audiometry (if speech-dominant range is normal) & complaint of high-frequency tinnitus. N=192, Pitch-match most often to 9 or 10 kHz— (Shekhawat & Searchfield, 2011) Bone conduction (even if AC is normal) with complaint of autophony + Hx head trauma Otoscopy Acoustic Reflexes—May need to proceed with caution for tinnitus + sound sensitivity Cochlear implants: Ito & Sakakihara (1994) N=26, For those implanted who had tinnitus 77% reported tinnitus either abolished or suppressed; 8% reported worsening CROS Consistent information (flip-books, websites) Outcome & quantifying measures (THI, TFI, TSNS, DASS)
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Assessment & Referral Complete head & neck exam vascular or musculoskeletal ENT/ORL Sleep specialist Counselling support Jaw specialist Review by Prescribing Physician (Pharmacological) Audiology/Vestibular assessment Research
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TINNITUS Cascade Reorganisation Spontaneous Synchronous Resultant “mimicry” Sound template mismatch Perceptually stands out Non-auditory factors Eggermont, J. J. & Roberts, L. E. (2004). The neuroscience of tinnitus. Trends in Neurosciences, 27(11), 676-682.
Slide 20-

Links between tinnitus & a attention? Can one be trained to not attend to tinnitus? Zenner HP, Pfister M, Birbaumer N.(2006) Tinnitus sensitization: Sensory and psychophysiological aspects of a new pathway of acquired centralization of chronic tinnitus. Otol Neurotol. 27(8):1054-63. Fig 4 p 1057
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What is common? De Ridder, D., A. B. Elgoyhen, et al. (2011). Phantom percepts: Tinnitus and pain as persisting aversive memory networks. Proceedings of the National Academy of Science of the United States of America [Early Edition]: 1-6.
Slide 22-

Plasticity Norena, A. J., & Eggermont, J. J. (2005). Enriched acoustic environment after noise trauma reduces hearing loss and prevents cortical map reorganization. The Journal of Neuroscience, 25(3), 699-705.
Slide 23-

Tinnitus Treatment Options Upsalla, Sweden Based on CBT Principles: applied relaxation & cognitive restructuring. Information on rationale, sound use, tinnitus, sleep, hearing, concentration, hyperacusis, exercise & progress maintenance. Pervasive Healthcare Model Internet Programs
Slide 24-

Tinnitus Treatment Options Glomus Tumour Ménière’s SSCDS Sudden Unilateral SNHL Vascular Compression Vestibular Schwannoma Medical management or surgical treatment of pathological condition likely responsible for, or contributing to, tinnitus. Medical/Surgical
Slide 25-

Tinnitus Treatment Options Brain Stimulation rTMS, TMS TCS Magnetic or electrical current to portions of the brain to modify tinnitus or prepare for tinnitus treatment (encourage neuroplasticity) Non-invasive Neurological
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Tinnitus Treatment Options Anti-depressants Anti-convulsants Anxiolytics Hypnotics Tranquilizers Drug provision to manage identified conditions contributing to, or exacerbating, tinnitus percept. Pharmacological
Slide 27-

Tinnitus Treatment Options Hearing aids, tinnitus & counselling CBT Group Therapy Guided Therapy Masking Therapy Neurofeedback Person-Centered Therapy Refocus Therapy Tinnitus Behavior Therapy Informational Counselling Tinnitus Activities Treatment Psychological/ Counselling
Slide 28-

Tinnitus Treatment Options Promotes lifestyle changes. Aims to modify viewpoint & expectations, to stop tinnitus cycle, Address potentially contributing: stress, anxiety, fatigue & depression. Brochures, information packages, sound therapy device(s) & associated equipment. Self-management
Slide 29-

Tinnitus Treatment Options Audiological - Generic Cochlear Implants Hearing Aids Music Therapy Sound Therapy Sound Therapy
Slide 30-

A: Hearing loss BACKGROUND SOUNDS NOT AUDIBLE ENOUGH TO INTERFERE WITH TINNTIUS DETECTION Cricket  tinnitus Background image  background sounds B: Hearing aid BACKGROUND SOUNDS ARE NOT AUDIBLE VIA AMPLIFICAITON & MAKE TINNITUS STANDOUT LESS
Slide 31-

Hearing aids A wide frequency response Noise reduction switched off Microphone noise reduction switched off A low compression kneepoint (at or below 50 dBSPL) A high compression ratio Soft squelch or expansion turned off Fast compression attack and release times An omnidirectional microphone setting An open fitting
Slide 32-

Tinnitus Treatment Options Customized Sound Coordinate Reset Notched Music “Phase Out “ or Phase Shift Sound Therapy
Slide 33-

Tinnitus Treatment Options Customized Sound ● Neuromonics ● Desensitization via passive listening with tinnitus embedded in spectrally-modified music (or music + BBN noise in Phase 1 of treatment). Uses extended bandwidth = 12.5 kHz. Sound Therapy
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Tinnitus Treatment Options Methodological Sound Incorporation TRT Uses a directive counselling style. Case & category-dependent regarding device(s). Provides anatomy & physiology, neural activity discussion, test results & sound therapy information. Habituation Therapy Sound therapy & directive counselling with the aim of promoting habituation to tinnitus reaction. Sound provision at a theoretical “mixing point”. Sound Therapy