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Tinnitus & Attention Training
Kim Wise,
MNZAS, CCC (New Zealand), Ph.D.
Audiologist; Research Fellow
Mayo Clinic In-service Talk
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.
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
Objective -Pulsatile tinnitus
• Arteriovenous
malformations
• Vascular tumors
• Venous hum
• Cardiac murmurs
• Pregnancy
• Paget’s disease
(disorganized bone
remodeling)
• Benign intracranial
hypertension
Arteriovenous malformations
• Pulsatile tinnitus
• Headache
• Papilledema (Optic Nerve Swelling-a hallmark
of elevated intracranial pressure)
• Discoloration of skin or mucosa
Venous hum-associated causes
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Benign intracranial hypertension
Dehiscent jugular bulb
Transverse sinus, partial obstruction
Increased cardiac output from:
– Pregnancy
– Thyrotoxicosis
– Anemia
Benign Intracranial Hypertension
(BIH)-presentation
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Young, obese, patients
Hearing loss
Aural fullness
Dizziness
Headaches
Visual disturbance
Papilledema
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
Myoclonus-associated causes
• Palatal myoclonus associations:
– Multiple Sclerosis and other degenerative
neurological disorders
– Small vessel disease
– Tumors
• treatments: muscle relaxants, botulinum toxin
injection
Stapedius Muscle Spasm
• Idiopathic stapedial muscle spasm
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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
Patulous Eustachian Tube
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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
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
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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
Mechanisms: Evidence for Central Site
• Auditory nerve section (Darby, 1941; House
and Brachmann, 1981)
• Near-normal hearing & tinnitus (highfrequency assessments)
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 dualdirectional (Andersson & McKenna, 1998;
Halford & Anderson, 1991)—principle to, or a
consequence of tinnitus
Drugs that may cause tinnitus
• Antiinflammatories
• Antibiotics
(aminoglycosides)
• Some
Antidepressants
(Benzodiazepines)
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Aspirin
Quinine
Loop diuretics
Chemotherapeutic
agents (cisplatin,
vincristine)
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
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)
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
TINNITUS
Eggermont, J. J. & Roberts, L. E. (2004).
The neuroscience of tinnitus. Trends in
Neurosciences, 27(11), 676-682.
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Cascade
Reorganisation
Spontaneous
Synchronous
Resultant “mimicry”
Sound template mismatch
Perceptually stands out
Non-auditory factors
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):105463. Fig 4 p 1057
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.
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.
Internet Programs
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
Medical/Surgical
Tinnitus Treatment Options
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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.
Non-invasive
Neurological
Tinnitus Treatment Options
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Brain Stimulation
rTMS, TMS
TCS
Magnetic or electrical current to portions of
the brain to modify tinnitus or prepare for
tinnitus treatment (encourage neuroplasticity)
Pharmacological
Tinnitus Treatment Options
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Anti-depressants
Anti-convulsants
Anxiolytics
Hypnotics
Tranquilizers
Drug provision to manage identified conditions
contributing to, or exacerbating, tinnitus
percept.
Psychological/
Counselling
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
Self-management
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.
Sound Therapy
Tinnitus Treatment Options
Audiological - Generic
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Cochlear Implants
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Hearing Aids
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Music Therapy
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Sound Therapy
Cricket  tinnitus
Background image  background sounds
• A:
– Hearing loss
BACKGROUND SOUNDS NOT
AUDIBLE ENOUGH TO
INTERFERE WITH TINNTIUS
DETECTION
• B:
– Hearing aid
BACKGROUND SOUNDS ARE NOT AUDIBLE
VIA AMPLIFICAITON & MAKE TINNITUS
STANDOUT LESS
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
Sound Therapy
Tinnitus Treatment Options
Customized Sound
• Coordinate Reset
• Notched Music
• “Phase Out “ or Phase Shift
Sound Therapy
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
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”.