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Author: admin | 01.05.2014 | Category: Tinnitus Causes And Treatments

PurposeWhile tinnitus is very common among the hearing impaired population, specific treatment for tinnitus is not provided in most clinics. You will receive an email whenever this article is corrected, updated, or cited in the literature. For full access to this article, log in to an existing user account, purchase an annual subscription, or purchase a short-term subscription. Mild precipitously sloping to profound means that hearing loss is mild for the lower frequencies. This kind of hearing loss is also called "Ski Slope Loss." Children with this kind of hearing loss can work just fine in quiet rooms. A child with this amount of hearing loss will need to use hearing aids as well as other assistive listening devices to hear what people are saying. A This 5-day international course is designed for those who are keen to specialise in tinnitus and hyperacusis therapy and includes many practical sessions.
In addition, this course provides a range of lectures on the most recent research evidence on tinnitus and hyperacusis. Apart from emotional disturbances such as anxiety, depression, sleep impairments or irritation1, the main complaints of the persons concerned with ringing in the ear are difficulties in concentrating their attention2 and in auditory perception3. Data from human neuroimaging support the hypothesis of a final common pathway for tinnitus6 and propose a compromised "noise cancellation mechanism"7 to be liable for the enduring tinnitus percept.
It is known that pleasant music verifiably reduces activities in the amygdala and enhances activity in nucleus accumbens and thalamus8,9.
Disadvantages are the rather lengthy application and the passive "sounding" of the tinnitus instead of an active exposition to the tinnitus sound. Therefore a short-term Neuro-Music Therapy based on active treatment modules seems to be fruitful in treating chronic tinnitus. The novel treatment according to the "Heidelberg Model of Neuro-Music Therapy" is based on the notion that tinnitus is experienced as an auditory percept - just as musical stimuli are experienced as auditory percepts.
Two standardized protocols for tinnitus music therapy were defined: a "standard therapy" (ST) and a "compact therapy" (CT) (see patient flow-chart). All patients receive a comprehensive psycho-educative counseling in order to establish a cognitive model of tinnitus20. As the specific modules used in therapy are based on the individual tinnitus sound, a tinnitus-equivalent has to be set up by means of a commercially available sinus generator. In the Resonance Training the patient learns a vocal exercise stimulating the cranio-cervical resonating cavities. The Neuroauditive Cortex Training uses tone sequences performed live by the therapist on a piano which have to be vocally imitated by the patient. The Tinnitus Reconditioning offers coping mechanisms related to stress control along with a sound based habituation procedure. During the relaxation exercise, the tinnitus sound will be integrated intermittently into the background music. Patients were eligible if they suffered from chronic tinnitus (duration > six months) which could be musically compiled (distinct frequency) and had no psychiatric co-morbidity. Since patients were recruited nationwide it was not possible to randomize the patients to the groups in the true sense of the word. Based on data from a pilot study23 we calculated the a priori power and thus estimated the minimum control group size with the power analysis program "GPOWER"24 to n = 15. As part of the medical history, psychosomatic and audiologic co-morbidities as well as socio-demographic data and tinnitus characteristics were assessed.
On the whole 69% of the patients presented with high frequency hearing loss (> 20 dB hearing impairment present in at least three test frequencies > 3000 Hz) and about 42% presented with low frequency hearing loss (> 30 dB hearing impairment present in at least one test frequency 0-2000 Hz).
Due to the stratified group allocation, no group differences in socio-demographic data were obtained.
Patients in the music therapy groups ST and CT received a treatment according to the "Heidelberg Model of Neuro-Music Therapy" as described above. Patients in the control group PT received a psychosocial intervention based on psychological tinnitus treatment strategies25 combined with placebo music therapy elements. Assessment of tinnitus symptoms was performed three times, at admission ("pre"), at discharge ("post") and six months after therapy ("follow-up FU"). Apart from statistical significance, individual changes were assessed according to the concept of clinical significance27. At discharge all patients of the music therapy groups had the opportunity to rate their subjective therapy satisfaction.
Statistical analysis of the data was performed using parametrical and non-parametrical tests in SPSS 16 (SPSS Inc. In order to predict parameters possibly influencing therapy outcome, a logistic regression model (CATREG, SPSS 16.0) was calculated using TQ-score immediately after therapy as an indicator for therapy success as a dependent variable.
Analysis of TQ scores revealed a highly statistically significant reduction pre-post (p p =.913). The overall reduction in the music therapy groups can be explained by significant changes in distinct sub-scales of the TQ, especially of "E = emotional problems" (p p p p p >.05). According to the concept of "clinical significance", more than 80% of the patients the music therapy groups (ST and CT) achieved a reliable reduction in their tinnitus scores from admission to discharge and could thus be categorized as "responder". On a subjective level, 67% of the patients treated with music therapy regarded their symptoms as "better", 22% observed no change and 11% stated to be worse off.
Apart from immediate therapy-related effects, there could be other factors influencing therapy outcome ("moderator variables"). In order to set the results in the context of existing therapies, a psychologically based treatment group was used as control group. Animal models 29 as well as results from research on tinnitus treatments30 suggest the use of very specific stimuli, i.e. The "Heidelberg Model of Neuro-Music Therapy" on the other hand integrates some well known psychological techniques and strategies in order to reduce the tinnitus sensitivity by means of an immediate exploration of the tinnitus sounds by the patient. The rather low positive feedback rate of the Neuroauditive Cortex Training (only about a quarter of the patients rated this module as helpful) might have been due to the wording during the therapy.
The Resonance Training is a purely vocal exercise that stimulates the auditory pathway by means of somatosensory innervations and enables the patients to control their tinnitus perception. It is known that there are manifold cross-modalities in processing somatosensory and auditory stimuli 35.
The Neuroauditive Cortex Training contains a detailed "intonation-training" with purpose-built musical stimuli, based on the individual tinnitus frequency in order to increase the patients" discriminative abilities and enhance their attentive skills.
In chronic tinnitus characteristic auditory cortical reorganizations are traceable, which seem to be frequency specific 40,41.
Tinnitus Reconditioninghas distinct features in that it combines musical distractors with psychophysiological relaxation and imagination of mental well-being.
Since the application of the "well-being image" is linked to acoustic stimuli (relaxation music, tinnitus equivalent sound), the connection "well-being image - relaxation - tinnitus reduction" can be explained in terms of classical conditioning 46.


The neurological basis seems to be in an endogenous system located in the medial temporal lobe system (MTLS) 6 and the reticular formation (RF) 47.
On the whole, music therapy is a method with short duration, fast onset and long lasting effect for patients with "tonal" tinnitus and light to moderate tinnitus severity (Figure 1 and 2). Paper submitted to the RBCMS-SGP (Publishing Management System) on April 1, 2012; and accepted on August,16, 2012. Tyler, University of Iowa, Department of Otolaryngology, 200 Hawkins Drive, 21167 PFP, Iowa City, IA 52242.
This article provides a plan for establishing a tinnitus treatment program that can be implemented in stages at most audiology clinics.MethodPreparation for establishing a tinnitus clinic includes having an overall plan regarding the type and degree of tinnitus management. If you do not have an ASHA login, you may register with us for free by creating a new account.
He may also need special ear mold add-ons or changes, like the Libby Horn or the Continuous Flow Adapter (CFA) to make these sounds accessible to the child. The main reason seems to be the permanent awareness of the tinnitus and the diminished ability to habituate to the sounds4. According to these assumptions, the tinnitus sounds originate from lesions in the auditory pathways.
Therefore the patients shall be enabled to actively control the sounds in order to reorganize the underlying neuronal mechanisms maintaining the tinnitus17. The overall therapeutic dose rate (500 minutes of therapy) was equal just as were the intervention modules (including the counseling). The aim is not to reproduce a psychometrical pitch-matched tone but rather a sound that is subjectively equivalent to the patients" "ear sounds".
A systematic and targeted training of inaccurately intonated musical sounds enables the patients to exert influence on their auditory processes since they learn to actively filter out irrelevant information and to concentrate on relevant acoustic stimuli. By means of music as calming background stimulus, the balance between the activity of the sympathetic and the parasympathetic branches of the autonomic nervous system shall be restored. The volume is adapted to the individual hearing level compensating for a potential hearing deficit.
The therapy concept was announced by press releases (newspapers and magazines, radio and TV) and offered to patients at the outpatient department of the local ENT-clinic of the university hospital. The therapy was designed as group intervention with five weekly sessions a 90 minutes and an additional individual counselling (50 minutes) leading to therapy duration of 500 minutes equal to the music therapy intervention. The main outcome criteria were the absolute scores of the German version of the tinnitus questionnaire ("Tinnitus-Fragebogen", abbreviated "TQ") by Goebel and Hiller26 as well as the relative decrease in TQ scores. They had to answer three specific questions a) "Was your tinnitus percept changed by the music therapy?" (Answers: worsened - unaffected - improved) and b) "Which elements from therapy did you consider helpful?" (open question). In the logistic regression demographic, therapy and tinnitus related factors were entered in the model to define those factors that are associated with tinnitus and may therefore contribute to therapy success. Therefore there is an urge for a short term therapy with preferably minimal effort but long lasting effect. In terms of treatment outcome this group was target underperforming since just less than half of the patients achieved the desired symptom reduction.
At the core of the "Heidelberg Model of Neuro-Music Therapy", the patients are actively "confronted" with their individual tinnitus sounds and are told to deal with their tinnitus explicitly instead of trying to take no notice of the tinnitus. These modules enhance the self-determination and the control beliefs of the patients since they learn techniques in order to actively influence their tinnitus. The patients possibly did not know the scientific label of the intervention thus the answers in the feedback-sheet were blurred because the patients could not label this intervention. One specific of the "Heidelberg Model of Neuro-Music Therapy" is the establishment of a tinnitus-equivalent sound. Many patients can voluntarily change the percept of their tinnitus by for example teeth clenching, pressure on the occiput, forehead, vertex and temples, head turning and shoulder abductions 36. Frequency discrimination training may interrupt the cortical representations that are generating tinnitus 42,43.
This module increases the auditory filtering and supports a modified emotional processing of the tinnitus sound. The MTLS is suspected to be responsible for the establishment of a "tinnitus memory" similar to the pain memory. Further studies are needed in order to evaluate which elements of the music therapy contribute most to the overall effect and to scrutinize the proposed working factors of the modules. The treatment of tinnitus related psychological distress is part of the music therapy concept, though the duration is very short and music therapy presents a focal therapy and no in-depth psychotherapy will be possible. University Hospital for Ear, Nose, and Throat - University of Heidelberg - Heidelberg - Germany. Tinnitus outpatient department - German Center for Music Therapy Research - Heidelberg - Germany. Assessment involves a measurement of tinnitus and of the reaction a patient has to the tinnitus, including the use of handicap questionnaires. So you may want to get your child tested for how his hearing loss will affect him in school. For that reason the predominant wish of the patients is to get rid of the "annoying" and "intrusive" sounds5 and to regain confidence in their sense of hearing. Usually these sounds should be blocked off by feedback connections from limbic regions before reaching the auditory cortex. Musically based interventions11,12,13 also have proven to be highly effective in treating chronic tinnitus - possibly by correcting tinnitus evoking neuronal mechanisms14.
If they could actively influence their tinnitus, their control beliefs will rise and thus let down the strains15. Purpose-built music therapeutic interventions were merged to modules and integrated into a standardized manual.
During the interval between the sessions, the patients have to exercise themselves in Resonance Training for three minutes every hour.
For this purpose, before the training session starts, the patients have to set the background music to a convenient level such that they can easily listen to the music while still being able to follow verbal instructions from the therapist. Only patients coming from the proximity of Heidelberg were allocated in a randomized way (computer generated) either to the ST group or the PT group.
The regression analysis reveals a highly significant relationship between the tinnitus score and the independent variables (p 2= 0.43). The proposed therapy concept "Heidelberg Model of Neuro-Music Therapy" seems to be a potential completion of the therapy spectrum. Given that this group received also placebo music therapeutic elements (active listening to preselected musical pieces) and an individual counseling, it seems reasonable to argue that the positive and long lasting effect of the music therapy according to the "Heidelberg Model of Neuro-Music Therapy" is due to the far more specific and active musical training aiming directly at the individual tinnitus sound. There exists a variety of procedures using a combination of counseling and acoustic stimulation.
In doing so, the duration of the therapy does not exceed ten weeks (standard therapy) and can even be compacted to five days (compact therapy).


Many patients stated though that they would enjoy singing or listening to music subsequent to the therapy.
Levine 37 proposed interactions between auditory perception and somatosensory input at the dorsal cochlear nucleus. Experimental data indicate that it is more efficient to train at normal hearing frequencies rather than in the region of hearing loss or tinnitus frequency 44,45. Biocybernetics of attention in the tinnitus decompensation: An integrative multiscale modeling approach. Development and psychometric adequacy of the screening version of the tinnitus handicap inventory. Final common pathway for tinnitus: theoretical and clinical implications of neuroanatomical substrates. Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion.
The rewards of music listening: response and physiological connectivity of the mesolimbic system. Auditive stimulation therapy as an intervention in subacute and chronic tinnitus: a prospective observational study. A multi-centre study on the long-term benefits of tinnitus management using Neuromonics Tinnitus Treatment. Listening to tailor-made notched music reduces tinnitus loudness and tinnitus-related auditory cortex activity. A cognitive model of tinnitus and hyperacusis; a clinical tool for patient information, appeasement and assessment. Musiktherapie bei Tinnitus: Interdisziplinare Pilotstudie zur Uberprufung des Heidelberger Modells. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Enriched acoustic environment after noise trauma reduces hearing loss and prevents cortical map reorganization. Treatment of tinnitus with a customized, dynamic acoustic neural stimulus: underlying principles and clinical efficacy.
Cross-modal interactions of auditory and somatic inputs in the brainstem and midbrain and their imbalance in tinnitus and deafness. The effect of a new treatment based on somatosensory stimulation in a group of patients with somatically related tinnitus.
Auditory discrimination training for tinnitus treatment: the effect of different paradigms. Auditory perceptual learning at normal hearing frequencies affects changes in tinnitus intrusiveness and percept. Tinnitus suppression by low-rate electric stimulation and its electrophysiological mechanisms.
Classical conditioning as the basis for the effective treatment of tinnitus-related distress.
The dorsal cochlear nucleus as a participant in the auditory, attentional and emotional components of tinnitus. The western heptatonic musical tonality forms the basis of the active music therapy procedures.
The most common side effects are headache and laryngitis if the exercise is not executed properly, either too often, too long or with too much pressure. Group differences of sociodemographic data and audiometric tinnitus characteristics were analyzed with the c2-test or univariate analysis of variance (ANOVA).
About 80% of the patients accomplished a reliable decrease of tinnitus pathology in the course of music therapy and about two thirds of the patients describe their tinnitus symptoms as "improved" after therapy.
Often the musical stimuli are spectrally modulated in order to account for hearing impairments31,32 and are incorporated as a passive means patients have to listen to for rather lengthy intervals (months up to years). The main parts of the therapy consist of active music therapy modules; hence there is no need and no purpose for spectrally changing the music used. We therefore propose that it is possible to alter the internal tinnitus spectrum by means of the Neuroauditive Cortex Training, which represents a specific perceptual training within the normal hearing frequencies.
RF neurons coordinate sensory and motor functions and influence cortical activity via the thalamus. Four problematic areas in tinnitus management are thoughts and emotions, hearing and communication, sleep, and concentration.ConclusionsLicensed audiologists generally have the essential training necessary to provide counseling and sound therapy to treat tinnitus patients. Mutual stimulation via both the thalamic and paralimbic pathways ultimately lead to tonotopic changes in the auditory cortex7 while reciprocal innervations of the medial temporal lobe system give rise to memory consolidation leading to a paradoxical "tinnitus memory"6. Therefore the Neuro-Music Therapy is indicated only if the patients indentify their tinnitus as "tonal" (sinus tones). Any psychiatric disorder or ongoing medication with antidepressants or antipsychotic drugs yields to exclusion of the patients. Selection of the musical pieces was based on the individual musical taste and preferences as well as on the emotion evoking impact of the musical pieces. Therapy outcome as assessed by the TQ and the CPT were evaluated using univariate analysis of variance (ANOVA) for repeated measure procedures.
This effect was independent of the patient"s treatment allocation to standard therapy or compact therapy.
Additionally, a tinnitus-equivalent sound provides the possibility to deal with the symptoms in an immediate and direct way. Therefore an activation of cranio-cervical and cranio-facial muscles and nerves by means of the Resonance Training might correct the auditory pathway by means of indirect stimulation of the joint "relay-station" cochlear nucleus 36.
Furthermore it is very important to ensure the training regime is intrinsically motivating.
Stress is considered to potentiate the severity of tinnitus due to the proposed accompanying reduction and alteration in auditory masking 6. We introduce 3 levels of treatment implementation, depending on whether the patient is curious, concerned, or distressed. According to the results from the regression analysis, there was - apart from tinnitus masking level - no influence of tinnitus characteristics or otological co-symptoms on therapy success.
A deliberate regulation of emotional responses towards the tinnitus sounds might enhance gate control mechanisms and restore misdirected "filter functions" of thalamic and limbic areas. Finally, the development of a tinnitus clinic centers around establishing a need for individual treatment, creating a treatment plan, estimating the need for additional staff and resources, reimbursement options, and assessing the effectiveness of the program. Nevertheless, the relative reduction and the individual improvement (reliable change index) were independent from the basic TQ-value - therefore also patients with comparatively lower strains still benefit from the therapy in equal measure.



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