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