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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 • • • • Benign intracranial hypertension Dehiscent jugular bulb Transverse sinus, partial obstruction Increased cardiac output from: – Pregnancy – Thyrotoxicosis – Anemia Benign Intracranial Hypertension (BIH)-presentation • • • • • • • 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 – – – – – 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 • • • • 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 • • • • • • • • • • • • • • • 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) • • • • 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. • • • • • • • • 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 • • • • • • • 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 • • • • 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 • • • • • • 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 • Cochlear Implants • Hearing Aids • Music Therapy • 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”.