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Author: admin | 26.06.2014 | Category: Ringing Of The Ears Treatment

Introducao: A Tinnitus Retraining Therapy (TRT) e o metodo de tratamento baseado no modelo neurofisiologico de Jastreboff que visa eliminar a percepcao do zumbido. Objetivo: Descrever a experiencia preliminar com o tratamento do zumbido atraves do metodo da TRT em hospital publico de Sao Paulo. Material e Metodos: Dez pacientes do Grupo de Zumbido do Hospital das Clinicas da Faculdade de Medicina da USP foram selecionados para tratamento do zumbido atraves de TRT, sendo cinco do sexo feminino e cinco do masculino, com idade variando de 35 a 59 anos (media de 46,8 e mediana de 45,5 anos). Resultados: Pela avaliacao subjetiva do paciente, houve melhora em seis pacientes (60%), sendo que tres permaneceram inalterados e um referiu piora. Conclusoes: A experiencia preliminar com TRT em pacientes de hospital publico revelou resultados satisfatorios e comparaveis a centros internacionais. Introduction: Tinnitus Retraining Therapy (TRT) is based on the neurophysiological model, and aims to decrease the annoyance and the perception of tinnitus. Aim: To describe the preliminary experience with TRT in tinnitus management of patients attended in a public hospital in Sao Paulo. Methods: Ten patients attended in the Tinnitus Service of Clinics Hospital of University of Sao Paulo were selected to perform TRT, five males and five females, whose age varied from 35 to 59 years (mean=46,8 and median=45,5years). Results: According to the patient’s subjective evaluation, there was 60% of the cases improved tinnitus perception, 3 remained unchanged and one worsened. Conclusions: The preliminary experience with TRT in patients of a public hospital showed satisfactory results, comparable to international tinnitus centers. IntroducaoApesar dos recentes avancos cientificos, o zumbido e um sintoma envolto em inumeras incognitas e permanece sendo um dos desafios da otorrinolaringologia.Em cerca de 80% dos casos, o zumbido e de grau leve e intermitente, nao trazendo maiores consequencias a vida do individuo e nem mesmo levando-o a procurar auxilio medico (1). Tinnitus Retraining Therapy (TRT) is a well-defined method for treatment of individuals who suffer from tinnitus [1-4].
Habituation is a concept that has been a part of the learning and conditioning literature for many years and refers to a decrease in responsiveness because of repeated stimulation with an inconsequential stimulus [7]. Treatment with TRT has two components, and each component addresses a different aspect of habituation. Prospective controlled studies have not been reported to document outcomes of treatment with TRT [10,11].
TRT was first offered to patients at the University of Maryland Tinnitus and Hyperacusis Center in 1990. Clinical implementation of TRT requires patients to receive a thorough audiological and medical evaluation before entering treatment [6]. The examiner recommends treatment for TRT based primarily upon patients' audiological test results and their verbal responses from the TRT initial interview [14]. The TRT initial interview is designed to delineate a patient's relative problems with tinnitus, hearing loss, and loudness intolerance.
The original version of the TRT Initial and Follow-up Interview forms appears in a condensed format that is intended to simplify administration of the interviews as well as record keeping [14]. Because TRT is often used for treating tinnitus, practitioners must have access to standardized TRT assessment tools. Category 1 patients require extended treatment for their tinnitus condition but do not require the use of hearing aids. Proper patient categorization requires the clinician to clearly understand the patient's subjective difficulties with each of the conditions of tinnitus, reduced sound tolerance, and hearing loss. Tinnitus of recent onset (up to about 6 months duration) may be more labile than longer-duration tinnitus and thus may resolve spontaneously [27].
From a population of over 1,800 tinnitus patients, 43 percent were reported to have described their tinnitus as consisting of multiple sounds [28].
Most patients responding to the TRT initial interview will have negative emotions associated with their tinnitus, with consequent effects on certain life activities.
This item comprises a series of questions related to the patient's use of hearing protection. Question 10 is straightforward in asking if the patient is receiving any other tinnitus treatment. Question 12 identifies bothersome aspects of tinnitus from a closed set of different activities that can be adversely affected by tinnitus.
These two questions will obtain an estimate of the percentage of waking hours that patients are consciously aware of, and annoyed by, their tinnitus. Patients are given an opportunity to provide any additional information concerning their tinnitus. Decreased sound tolerance can involve different components, including hyperacusis, misophonia, and phonophobia [4].
These questions are the same as questions 7 through 18 for tinnitus, but focus on effects of reduced sound tolerance.
The TRT Follow-up Interview form (Figure 2) duplicates those questions from the TRT initial interview that would be considered necessary to monitor treatment progress and to determine treatment outcomes [14].
In the scripted instructions to the follow-up interview, patients are told to consider their tinnitus and its effects over the previous month when answering the questions.
Question 1 contains a series of questions about whether patients experience some days that are more affected by their tinnitus than others. Question 5 determines the impact of tinnitus on various activities, as does Question 12 from the initial interview.
Questions 6 and 7 are the key questions that assist in determining if patients are habituating to, respectively, tinnitus perception and tinnitus reaction.
Questions 8, 9, and 10 ask patients to estimate, respectively, their tinnitus loudness, annoyance, and life impact. Questions 23, 24, and 25 are particularly important for a clinician to determine the relative effects of tinnitus, reduced sound tolerance, and hearing loss on the patient's life.
Question 26 determines if patients feel that their auditory condition has benefited overall, considering tinnitus, sound tolerance, and hearing loss. This article provides tools to evaluate patients for treatment with TRT and to monitor the efficacy of treatment with TRT. The TRT Initial and Follow-up Interview forms were revised primarily to help determine outcomes of treatment in a standardized manner for a randomized clinical study currently being conducted at the Portland Department of Veterans Affairs (VA) Medical Center (VAMC) in which subjects receive treatment with either Tinnitus Masking or TRT. There are accepted methods for developing and testing scales that measure health or functional status.
Substantial literature exists concerning tinnitus outcomes instruments-some of which have undergone the more traditional method of development and testing. With regard to the preceding comments, a need exists to provide further development and testing for the TRT interview forms to be documented as valid and reliable. Finally, it should be noted that the developers of the original TRT interview forms administer the Tinnitus Handicap Inventory to all of their patients in addition to performing the interviews [41,42]. We wish to acknowledge the significant contributions from Tara Zaugg, MS; and Barbara Tombleson, BS. O tratamento e embasado na plasticidade do sistema nervoso central e apresenta dois principios basicos: aconselhamento terapeutico e enriquecimento sonoro. Nenhum paciente apresentava perda auditiva clinicamente importante (categoria 1 de Jastreboff). Pela nota da escala analogo-visual, houve melhora em oito pacientes (80%), enquanto dois permaneceram inalterados. Adaptacoes podem ser realizadas desde que ambos os principios basicos do protocolo sejam seguidos. It is based on the plasticity of the central nervous system and has two basic principles: counseling plus sound enrichment. All patients belonged to category one and received counseling plus broadband noise generators (Silent Star devices). According to the visual analogue scale, improvement occurred in 80% and two remained unchanged. Adaptations may be performed if the basic principles of TRT protocol are strictly followed. Entretanto, quando se manifesta de maneira importante, pode prejudicar a qualidade de vida, afetando o sono, a concentracao, o equilibrio emocional e ate as atividades sociais, incapacitando a realizacao das atividades diarias. The TRT Initial Interview form was developed to guide clinicians in obtaining essential information from patients that would specify treatment needs. It is estimated that about 80 percent of individuals who experience constant tinnitus naturally habituate to their tinnitus to such a degree that their tinnitus does not constitute a problem requiring clinical intervention [1,8]. The individual with problematic tinnitus first must habituate to any emotional responses to the tinnitus.
Outcomes data have been reported from a number of clinics, however, indicating that treatment with TRT significantly benefited 70 to 85 percent of their patients (reviewed by Henry et al. In addition, patients must demonstrate that their tinnitus condition is sufficiently problematic to warrant implementation of long-term treatment with TRT. The TRT initial interview is a structured set of questions that are designed specifically to determine proper placement of patients into TRT treatment categories (described in TRT Patient Categories section). Using the TRT Initial Interview form, each of these three potential problems is discussed individually, enabling the clinician to differentially assess the subjective impact of each. These categories have been fully described elsewhere [4-6,21] and thus are only briefly described here (see the Table).
They are fitted with wearable ear-level sound generators and counseled repeatedly, usually over a period of 1 to 2 years.
Understanding the patient's natural tinnitus history is considered important for counseling [8].
The potential for spontaneous improvement is important to consider in the assessment of patients for treatment. This question seeks to determine if there are days when these tinnitus effects are noticeably worse than on other days. Patients commonly report that their tinnitus becomes louder as a result of exposure to certain sounds. The questions will stimulate discussion about the need to provide hearing protection in dangerously noisy situations, but the main purpose is to determine if the patient is overprotecting his or her hearing. Often, patients have not analyzed specifically why tinnitus is a problem for them and this list prompts them with the most likely concerns. Patients are asked to rank their tinnitus with respect to loudness, annoyance, and life impact. In most cases, the TRT initial interview will have covered all the issues and patients will have nothing further to add. Patients must clearly understand the intent of Question 19 because their response to it will determine whether or not they are identified as having a problem with sound tolerance. Patients will often confuse functional effects of reduced sound tolerance with tinnitus effects.
There can also be Category 4 placement specific to hyperacusis as shown in the Table, page 159. No clear relationship exists between patients' audiograms and how they feel about their hearing [39]. During the preceding questioning, patients will have learned to distinguish between the conditions of tinnitus, reduced sound tolerance, and hearing loss. Some of these questions have been modified relative to the initial interview as appropriate for follow-up evaluation. Thus, they are not asked to respond in relation to any particular day or circumstance, but to think of how the tinnitus has affected them generally during the previous 30 days.
The clinician should have the patient's responses to the initial interview in hand during administration of the follow-up interview. Similar to Question 1, patients are asked to report if they feel that the amount of time they have been aware of their tinnitus, or annoyed by their tinnitus, has changed during the previous month. For these questions, as well as Questions 23, 24, and 25, clinicians are again advised to have the patient's previous answers available to indicate to the patient whether improvement has been noted.
If improvement is not noted after 1 to 2 years of treatment, the clinician must assess honestly as to whether continued treatment with TRT is in the patient's best interest.
If reduced sound tolerance was not noted as a problem during the initial interview, these questions are bypassed during the follow-up interview.
The question requires only a yes or no response, but its intent is to raise the issue as a discussion point to evaluate whether the patient considers hearing loss a problem [39].
In some cases, only one of these is a problem at the beginning of treatment and treatment will be specific to that condition throughout the program.
Question 27 is somewhat unusual because it asks patients how they would feel about giving back their ear-level devices.
The original one-page interview forms, both initial and follow-up [14], can work effectively for the experienced TRT clinician. Since all subjects in both groups were to receive the TRT initial and follow-up interviews, administering the interviews in a consistent fashion was essential. None of these instruments, however, has achieved discipline-wide consensus as a standardized method of evaluating the negative effects of tinnitus.
Jastreboff and Jastreboff state that the choice of supplemental questionnaires is a matter of personal preference of the provider [14].
Todos receberam a orientacao em forma de aula conjunta e a doacao de geradores de som Silent Star bilaterais. The results were evaluated after 18 months of treatment, considering two different parameters: a. Sao esses os pacientes que procuram ajuda medica.Em um estudo previo com 358 pacientes do Grupo de Zumbido do Ambulatorio de Otorrinolaringologia do Hospital das Clinicas da FMUSP, 50% apresentaram disturbios do sono, 43,5% da concentracao, 59% do equilibrio emocional e 14% da atividade social.
The TRT Follow-up Interview form is similar to the initial interview form and is designed to evaluate outcomes of treatment. The model identifies different areas of the brain that can be involved in tinnitus and theorizes as to how those areas interact to create a clinical condition of tinnitus [5,6]. Such natural habituation apparently does not occur for about 20 percent of these individuals.
In 1999, Jastreboff created another center to treat tinnitus and hyperacusis patients at the Emory University School of Medicine in Atlanta, Georgia.
In addition to questions about tinnitus, the TRT interview includes questions about decreased sound tolerance (hyperacusis) and about subjective hearing difficulties [6,15].
In addition, use of the interview educates the patient to understand these problems and how they differ. The abbreviated nature of the questionnaire items requires the clinician to fully understand the intent of each item in order to phrase the questions appropriately and is a reminder to assure that all questions are asked.
This paper provides the expanded forms of the initial and follow-up interviews to clinicians who are practicing, or who intend to practice, TRT with their tinnitus patients. Category 0 identifies patients whose tinnitus condition requires only basic counseling and sound therapy without the need for wearable sound generators or hearing aids.


Category 2 patients also require extended treatment for their tinnitus condition, but in addition, they report significant hearing difficulties. The treatment approach will vary according to category; thus, accurate placement of patients into these categories is critical to provide proper treatment.
The tinnitus description defines the symptom for both patient and clinician, providing a common reference for the remainder of the tinnitus-related questions.
With an increase in tinnitus duration, the likelihood of tinnitus being a permanent condition also increases. Based on these data, tinnitus is likely to consist of multiple sounds for about half of all patients attending tinnitus clinics. Many patients with tinnitus use earplugs or earmuffs to prevent their tinnitus from becoming worse. This information is important for the clinician to help the patient determine the best overall course of treatment.
Since habituation is the primary goal of TRT, these questions are particularly helpful in assessing this outcome of treatment.
Only the end points of each scale have labels; thus, patients must select a number on the continuum in relation to the two extremes.
Hyperacusis is a physiological response to certain sounds; thus, some level of physical discomfort is involved. It is thus important to guide the patient to respond appropriately, keeping in mind the different components of reduced sound tolerance as described for Question 20. In the latter case, certain sounds will exacerbate the hyperacusis for an extended period of time (at least until the next day). Some patients will reveal a significant reduction in hearing sensitivity and yet will not be bothered particularly by their hearing loss. These three questions now allow them to consider how much each condition is a problem in relation to the other. It is thus important to know if patients feel that they are having fewer bad days than before. Indicating the previous responses on the follow-up interview form is helpful when asking about these activities. An awareness that improvement has occurred can be very encouraging to the patient and is an important incentive to maximize compliance with the treatment protocol.
If reduced sound tolerance was initially reported, completing these questions will enable an evaluation of treatment efficacy. This perception often changes from appointment to appointment, which can potentially result in making changes in ear-level devices. In other cases, more than one of these conditions will be a problem at the outset of treatment and their relative effects can change during treatment. Many clinicians, however, especially those who are relatively new to TRT, have expressed the need for scripting of questions and for explaining the various questions in the forms.
The interview forms therefore were revised so that exact wording of each question would be provided on each form. Such an approach has not yet been taken with the TRT interview forms, which were originally developed by the second and third authors of this paper because of their perception that take-home questionnaires were inadequate for assessing tinnitus patients [14]. Meikle and Griest have reviewed the various outcome measures that have been developed and have noted the many discrepancies between them [40].
A working group has been formed that is presently evaluating four tinnitus outcomes instruments, including the TRT interview forms, the Tinnitus Handicap Inventory [41,42], the Tinnitus Handicap Questionnaire [19], and the Tinnitus Severity Index [43]. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. Celebrating a decade of evaluation and treatment: The University of Maryland Tinnitus and Hyperacusis Center.
An experimental study to test the concept of adaptive recalibration of chronic auditory gain: interim findings.
Modification of loudness discomfort level: evidence for adaptive chronic auditory gain and its clinical relevance. Shifts in dynamic range for hyperacusis patients receiving Tinnitus Retraining Therapy (TRT). Changes in loudness discomfort level and sensitivity to environmental sound with habituation based therapy. Psychometric adequacy of the Tinnitus Handicap Inventory (THI) for evaluating treatment outcome.
O resultado foi avaliado apos 18 meses de tratamento, considerando dois parametros diferentes: a. Assim, fica evidente que o sofrimento da populacao que procura auxilio medico em consultorios e hospitais difere bastante da populacao geral com zumbido.Uma contribuicao muito importante para a compreensao dos mecanismos fisiopatologicos do zumbido surgiu com a publicacao do modelo neurofisiologico de Pawel Jastreboff (1990), que envolve a participacao das vias auditivas e nao auditivas na percepcao do zumbido clinicamente significativo (2). The treatment approach is aimed to induce and facilitate habituation by the patient to his or her tinnitus. Habituation to tinnitus perception can only occur if there has been habituation to the associated emotional responses. In the past 7 years, he has conducted 13 three-day instructional courses in the United States that have been offered to physicians and audiologists to learn the TRT protocol. It is thus critical to accurately assess the patient's condition, need for treatment, and motivation to comply with all treatment requirements. Hyperacusis is a condition that is observed to occur to some degree for approximately 30 to 40 percent of patients who are evaluated for TRT [4,16,17]. The process helps the examiner and patient to mutually determine the optimal course of treatment. To help conduct the interview in a standard manner, the main questions are presented verbatim at the bottom of the forms. Further, to ensure that the TRT practitioner fully understands the intent of each question, detailed explanations are provided. Typically, these patients achieve enrichment of their sound background using tabletop sound generators and other sound-generating devices [22].
They receive the same treatment as for Category 1 patients except that they are fitted with either hearing aids or ear-level combination devices that incorporate both hearing aids and sound generators.
This baseline description might also be useful for the clinician to compare during and following treatment to determine if the patient's tinnitus characteristics have changed as a result of treatment.
For the TRT evaluation, it is important for patients to identify which of the tinnitus sounds is most bothersome. Such action in fact will result in the tinnitus sounding louder, because of the occlusion effect, and is reported to cause reduced loudness tolerance [29-35].
Many of these other types of treatment have no scientific basis and the patient should be educated regarding realistic expectations. Question 13 determines the amount of time patients spend thinking about their tinnitus; thus, it is specific to habituation of tinnitus perception.
The main consideration is to determine whether patients have trouble tolerating everyday sounds that are otherwise tolerated comfortably by most other persons. It is an educational process for some patients who will gradually begin to understand how these different factors have affected their lives differentially. Other patients complain about considerable hearing difficulties that would seem incongruous with their mild hearing loss. The clinician should be aware if the patient is concurrently receiving treatment with anxiolytics or other psychotropic medications and should consider potential effects of such treatment. Patients can be told if they have shown improvement or not, but it is not advised to inform them of their previous responses. Such changes will usually involve the addition of amplification as the patient recognizes the degree to which hearing loss is a problem. For example, if hyperacusis is the primary problem at the beginning of treatment, the treatment protocol will be specific to the hyperacusis. In most instances, patients will indicate adamantly that they would not be comfortable giving up their devices. These revised forms now are being used in the TRT training seminars, and their clinical application will minimize variability in administration of the questionnaires. These authors therefore designed structured interviews to be a guide for acquiring information from patients and to evaluate potential changes during treatment. Meikle and Griest emphasized the need for a single standardized instrument to assess tinnitus-related distress and resulting functional impairment.
A aplicabilidade clinica desse modelo deu origem ao tratamento que se utiliza do fenomeno da habituacao, tambem conhecido por TRT (tinnitus retraining therapy), apresentando atualmente os resultados mais eficazes no controle do zumbido de toda a historia de seu tratamento, possibilitando a melhor reabilitacao do paciente nas suas atividades diarias.O modelo neurofisiologico de JastreboffSegundo Jastreboff, o zumbido clinicamente importante e o resultado da interacao dinamica de alguns centros do sistema nervoso central, incluindo vias auditivas e nao auditivas (Figura 1). The forms have been used in a highly abbreviated format with the potential for inconsistent interview administration between examiners. The inherent variability in administering the TRT interviews can be reduced further by scripting each question. Further details regarding administration of the Initial Interview form have been provided elsewhere [6].
These patients require fewer follow-up visits than do patients in the other TRT categories. Category 3 patients have the primary problem of hyperacusis and are treated for this condition with a specific TRT protocol that involves use of wearable sound generators or combination instruments. The first is that the patient who has recent-onset tinnitus should be started on full treatment as soon as possible. Constraining the psychoacoustic evaluation to the most bothersome tinnitus sound can save a substantial amount of time and, therefore, is subsequently used as a reference during the tinnitus matching procedures.
It is important for the clinician to be sensitive to the patient's potential need for psychological or psychiatric evaluation and treatment and to refer the patient as necessary [6]. Patients in Category 4 are the most difficult to treat effectively, and a specific variation of TRT is implemented for these patients [21,23].
It is thus an important issue, but the examiner must use caution during the questioning so as not to give patients the new concern that sound might make their tinnitus worse. Question 14 evaluates how much of their time they are annoyed by their tinnitus, which helps to determine if they are habituating to their tinnitus reaction. If this occurs, patients can generally recall the types of everyday sounds that cause loudness discomfort.
The objective of these questions is to determine the patients' subjective feelings about their hearing, regardless of their hearing thresholds. Thus, for some patients, it is simply a matter of continuing to encourage them in spite of their lack of progress. At a follow-up visit, the hyperacusis may become less of a problem and the tinnitus might become the primary concern. Question 28 is quite general in asking if patients are glad or not that they started the program. Our hope is that this information will be useful for promoting a higher level of standardization in conducting TRT.
The interview forms are a clinical tool to conduct TRT and, while not claimed as a universal tinnitus assessment technique, can potentially be used with other types of tinnitus treatment methods. Most importantly, the four questionnaires are being evaluated with respect to how the patients themselves respond to the questionnaire items. Thus, for the clinician or researcher who is actively involved in conducting TRT, we suggest that the interview forms be used along with one of the self-administered questionnaires that has undergone documentation for validity and reliability. Assim, apesar de muitos casos estarem relacionados a alguma causa inicialmente coclear, esta causa nao e de fundamental importancia na determinacao da gravidade do zumbido, agindo apenas como gatilho de uma avalanche de processos dentro do sistema nervoso. Sound therapy is thought to be effective only when the emotional responses have been neutralized. Misophonia reflects dislike of sound [6,18] and is present in the majority of patients [17]. Furthermore, for outcomes research, standardization of wording is vital to ensure consistent administration of the interviews within and across patients and within and across examiners. The TRT Follow-up Interview form is a shortened version of the Initial Interview form because some items in the initial interview would not be relevant to evaluate treatment outcomes at follow-up visits. Category 4 patients are relatively uncommon and suffer from a condition in which their tinnitus or their hyperacusis is significantly worsened because of exposure to certain types of sounds.
From a group of 784 nonveteran tinnitus patients, however, 47 percent was reported as not being able to identify any precipitating event that could be associated with their tinnitus onset [26]. When treatment is provided with TRT, the psychoacoustic characterization of tinnitus is irrelevant and is mentioned only briefly during counseling. Patients need to know that the use of hearing protection for any reason other than protection from damaging levels of sound constitutes overprotection. Many patients will report that the main problem with tinnitus is that it interferes with their hearing ability.
Habituation to both the perception of and the reaction to tinnitus would indicate that the program has been successful [1,36,37]. The responses will determine whether placement in Category 2 is appropriate, which would indicate the use of amplification. At some point, however, the clinician and patient should mutually decide if another form of treatment is the best option. Otherwise, there is the potential that the patient would be constantly frustrated by hearing difficulties. In such a case, the treatment effort would shift to address primarily the tinnitus condition.
Such an analysis is possible because each of the questionnaires has been used in the tinnitus treatment study that is presently being conducted at the Portland VAMC. Uma analogia propicia pode ser feita com a origem de um rio congelado: a primavera e necessaria para dar inicio ao degelo, porem o rio cresce durante seu proprio curso a medida que muitas outras fontes de agua aumentam seu volume, em combinacao com a primavera. The expanded forms are presented in this article, and the intent of each question is explained.
Subjective hearing difficulty is a problem that patients often assume to be the result of their tinnitus [6,19]. The Follow-up Interview form also contains specific instructions for obtaining outcomes information. This study was an analysis of clinical data from 149 patients, of which 28 of the patients reported a total absence of their tinnitus even when attempting to focus their attention on it. The sooner treatment is started, the sooner this vicious cycle can be broken and the patient's normal life can be restored. These examples represent very different kinds of problems that would indicate different strategies of treatment. If treatment is fully successful, these percentages of time will drop to zero or close to zero.


For patients who were initially fitted with hearing aids, it will be important, of course, to provide appropriate follow-up care to ensure that the amplification is performing adequately. It is thus important at each of the follow-up visits to redefine the extent of each of these auditory problems. An important outcome of this effort will be an assessment of the performance of the expanded TRT interview forms in relation to the three self-administered tinnitus instruments that have been documented for validity and reliability.
Standardized administration of these interview forms will facilitate greater uniformity in the initial evaluation and outcomes analyses of patients treated with TRT. Proper training to perform TRT requires attendance at one of these courses, which have been completed by over 300 health professionals in the United States and over 600 in other countries. In most of these cases, the hearing assessment reveals reduced hearing sensitivity of the sensorineural type. With these forms and the instructions provided herein, TRT clinicians have the tools necessary to administer the TRT interviews in a standardized fashion.
If generalizable, these data would indicate that approximately half of the nonveteran tinnitus patient population do not know the cause of their tinnitus, and this may be a major reason why they seek professional help. The second school of thought is that patients should be informed of the potentially labile nature of tinnitus during its first few months. Patients using amplification therefore should be asked any questions that would be important for assessing any problems. Following this effort, a further revised TRT interview form may be proposed that will require testing for validity and reliability. A geracao frequentemente ocorre nas vias perifericas (mas tambem pode ocorrer nas vias centrais) e, na maioria dos casos, esta associada a doencas da coclea e do nervo coclear. Thus, most likely, the tinnitus is not causing their hearing difficulties but rather the decline in sensory cell population in the cochlea is causing their hearing loss [6,20].
This finding leads to the question, Does tinnitus of unknown onset result in greater tinnitus distress than when the cause is clearly identified?
Whether or not the tinnitus resolves completely, the patient's fears may be sufficiently allayed by the hopeful information. Most likely, a generalized version of a self-administered tinnitus outcomes instrument will be developed and promoted for standardized clinical and research application. A deteccao ocorre nos centros subcorticais e baseia-se num padrao de reconhecimento especifico.
For TRT, however, the interview format will be retained for the purposes just mentioned [14].
Por fim, a percepcao ocorre no cortex auditivo com significativa participacao do sistema limbico, do cortex pre-frontal e de outras areas corticais (2).Atualmente nao ha duvidas de que o cerebro tem um alto grau de neuroplasticidade e que esse processo e continuo ao longo da vida do individuo. Each patient should be treated individually, and treatment decisions should be made solely according to what will provide the greatest benefit to the patient. Sempre que aprendemos algo novo ou recordamos algum fato, pequenas alteracoes ocorrem no cerebro devido a modificacoes nas conexoes neuronais.
The common approach with TRT is that a patient with recent-onset tinnitus mainly needs a full evaluation and counseling.
Porem, apesar de toda a potencia e complexidade do sistema nervoso, o cerebro nao processa diferentes tarefas conscientes ao mesmo tempo.
Para que um som seja percebido, seu significado tambem e levado em consideracao, e nao apenas a sua intensidade. Assim, sem que tenhamos consciencia, essas informacoes sao avaliadas nas areas subcorticais do sistema nervoso e, se forem valorizadas como suficientemente importantes, atingirao o cortex para serem percebidas conscientemente.
Se essas mesmas informacoes forem classificadas como nao importantes, sao imediatamente descartadas sem que tomemos conhecimento delas.
Por exemplo, se estamos em um restaurante com muito ruido de fundo, podemos concentrar nossa atencao na conversa de nosso acompanhante (informacao importante) e inconscientemente ignorar os sons menos importantes que nos rodeiam, mesmo que sejam mais altos. Por outro lado, alguns sons muito fracos, porem com significado importante (como o chamado de nosso nome ou um sinal de perigo) podem ser percebidos mesmo que estejam envoltos por outros sons, sendo realcados em relacao ao ruido de fundo. Portanto, nossas vias auditivas tem a capacidade de selecionar subconscientemente os sons importantes, enquanto os demais sao ignorados (2-4).Assim, fica evidente que o significado que o som adquire e um fator preponderante na determinacao da reacao do individuo, e nao apenas suas caracteristicas psicoacusticas.
Em neurofisiologia, o fenomeno do desaparecimento da reacao a um determinado sinal e conhecido como habituacao (5).
O processo de habituacao a um determinado som so pode ser alcancado quando o mesmo nao provoca nenhuma reacao emocional, ou seja, quando esse som e neutro ao individuo.
Na verdade, para cerca de 80% dos pacientes, o som do zumbido e neutro e, portanto, pode ser habituado de maneira espontanea e natural. Assim, esses individuos so percebem seus zumbidos esporadicamente (mesmo que estejam sendo gerados constantemente). Por outro lado, se a percepcao do zumbido for relacionada a algo desagradavel ou perigoso (possibilidade de doenca grave, de surdez, de piora com o decorrer do tempo, ou ainda, incapacidade de ter uma vida normal), essas preocupacoes relativamente naturais frente a um sintoma pouco conhecido, impedem que o processo da habituacao ocorra, fazendo com que o individuo passe a perceber seu zumbido continuamente e, portanto, a "sofrer" com ele (2-4).
Por exemplo: se o paciente acha que o zumbido e um problema grave, o sinal que chega ao cerebro e que esse importante problema precisa ser observado e monitorizado. Desse modo, o sinal do zumbido e realcado e o paciente o escuta constantemente, aumentando sua tensao, diminuindo sua concentracao e interferindo em seu sono, uma vez que no silencio sua percepcao e realcada. Assim, o individuo nao percebe o sinal do zumbido e consequentemente nao se incomoda, mesmo que essa atividade neuronal continue presente nas vias auditivas.Esse metodo de tratamento que e baseado no modelo neurofisiologico chama-se habituacao ou retreinamento do zumbido (TRT).
Neste caso, ao inves de dirigir o tratamento a origem do zumbido, que geralmente esta relacionada a orelha interna, utiliza-se os fundamentos da neurofisiologia e da transmissao de sinais pelo sistema nervoso central. Portanto, fica evidente que a indicacao desse tratamento pressupoe a investigacao previa do paciente pelo otorrinolaringologista e a exclusao de possiveis causas trataveis de zumbido.A TRT tem sido usada em inumeras clinicas de zumbido distribuidas pelo mundo. Essa etapa e fundamental para o sucesso do tratamento e, para alcanca-la, e necessario remover os temores do paciente em relacao ao seu sintoma (aconselhamento terapeutico).2. O tempo de zumbido foi superior a dois anos em todos os casos, sendo que sete pacientes apresentavam tempo de historia superior a 10 anos (Tabela 1). Todos pertenciam a categoria 1 de Jastreboff, ou seja, zumbido com alto impacto na qualidade de vida, sem perda auditiva clinicamente importante.Tabela 1.
O incomodo causado pelo zumbido foi avaliado atraves da escala analogico-visual contendo numeros de 0 a 10, onde 0 foi considerado ausencia de incomodo e 10, incomodo no grau maximo referido pelo paciente.
Notas de 0 a 3 sao consideradas como zumbido leve, de 4 a 7 como zumbido moderado e de 8 a 10 como zumbido severo.
Entre os 10 pacientes, 8 classificaram seu zumbido como severo e 2 como moderado.Todos os pacientes receberam informacoes em grupo, dadas em forma de aula pela pesquisadora principal com duracao de 120 minutos.
Todos os pacientes usaram geradores de som bilaterais e retroauriculares da marca Silent Star, acoplados a moldes abertos padronizados. Em cada acompanhamento, o zumbido era reavaliado e o aconselhamento terapeutico enfocava apenas as duvidas de cada paciente. Pela subjetividade do sintoma, o acompanhamento foi feito sempre com base em dois parametros distintos: 1. Seu objetivo e reduzir o incomodo associado ao zumbido e a sua percepcao propriamente dita.A pratica otorrinolaringologica e centrada no controle clinico ou cirurgico de doencas objetivas e o zumbido e certamente uma excecao a essa regra, requerendo abordagens diferentes.
Muitos otorrinolaringologistas e fonoaudiologos atendem frequentemente pacientes com zumbido sem ter familiaridade com a TRT.
Nao e raro que pensem que TRT e semelhante ao mascaramento (quando, na realidade, sao metodos opostos) ou que se restringe ao uso de um aparelho no ouvido (quando e uma associacao obrigatoria entre orientacao e alguma das formas de enriquecimento sonoro). Felizmente, nos ultimos anos tem havido um crescente interesse dos profissionais para a pratica do tratamento do zumbido em geral e da TRT em particular.Avaliacao do pacienteAntes de se indicar TRT, e fundamental que o paciente seja avaliado por um otorrinolaringologista para um exame completo.
Com certa frequencia, o zumbido e um sintoma de alguma afeccao otologica, metabolica, neurologica, cardiovascular, odontologica ou psicologica que pode ser tratada clinica ou cirurgicamente, mesmo que muitos casos ainda sejam diagnosticados como idiopaticos (12-16).Tambem e importante investigar a presenca concomitante de hipersensibilidade a sons nos individuos com zumbido, principalmente a hiperacusia e a fonofobia, pois esses casos podem requerer uma abordagem diferente. A hiperacusia manifesta-se por intolerancia a varios sons do meio ambiente (ex: agua corrente, ventilador, refrigerador, lava-loucas, carro, telefone, campainha, portas fechando), de baixa ou moderada intensidade, independente das frequencias que os compoem (6, 17-22). Na fonofobia (atualmente chamada de misofonia), apenas determinados sons produzem esse desconforto, dependendo do seu significado ou associacao, enquanto outros sons agradaveis (musica, por exemplo) podem ser tolerados em intensidades muito mais altas (6,22,23). Alguns pacientes podem apresentar associacao de hiperacusia e fonofobia em diferentes graus.Apos anamnese e exame fisico otorrinolaringologico, solicitamos a investigacao audiologica basica, composta pela audiometria tonal e vocal, imitanciometria, pesquisa de reflexo estapediano e limiar de desconforto (este ultimo torna-se mais importante nos casos de hipersensibilidade a sons). As provas de caracterizacao do zumbido (frequencia, intensidade e limiar minimo de mascaramento) podem ser interessantes em termos de pesquisa, mas nao sao fundamentais para o diagnostico etiologico e nem para o tratamento.Indicacao da TRTExistem varias formas de tratamento do zumbido. Embora seja largamente utilizada, a TRT deve ser indicada nos casos idiopaticos (apos exaustiva investigacao diagnostica) ou quando a etiologia identificada nao e passivel de tratamento clinico ou cirurgico. E necessario cuidado com a indicacao excessiva da TRT, uma vez que essa abordagem e longa e pode ser substituida por um tratamento mais dirigido quando uma etiologia passivel de tratamento especifico e diagnosticada pelo otorrinolaringologista.Em nossa pratica, atualmente contra-indicamos a TRT em pacientes com alteracoes psiquiatricas, uma vez que a orientacao e mais dificil de ser compreendida ou aceita.
Assim, sugerimos avaliacao psiquiatrica com controle da doenca de base e iniciamos o tratamento do zumbido somente apos o controle do paciente. Hesse et al (2001) sugerem a internacao de tais pacientes, associando-se TRT com psicoterapia intensiva, porem nao temos essa experiencia (24).O aconselhamento terapeuticoO aconselhamento terapeutico e fundamental para alcancar a fase de habituacao da reacao ao zumbido, que e o objetivo inicial do tratamento, onde o zumbido ainda esta presente, porem nao mais incomoda o paciente. Nem sempre e facil alterar as ideias negativas do paciente, sobretudo aquelas referentes a falta de recursos para tratamento. Porem, e fundamental tentarmos a eliminacao das associacoes negativas, ja que o processo da habituacao nao ocorre para sons que possam significar algum perigo. Isso e feito com uma explicacao simples, em linguagem leiga, do modelo neurofisiologico e dos mecanismos do zumbido, mostrando-lhe que suas preocupacoes sao desnecessarias por estarem baseadas em informacoes erroneas, alem de serem as principais causas de impedimento da habituacao como um processo natural.Em geral, o paciente demora alguns meses para notar os efeitos que o tratamento provoca atraves da plasticidade neuronal. Portanto, precisa entender que perseveranca e a palavra-chave nesse tipo de tratamento, devendo sentir-se apoiado e incentivado a prosseguir, reconhecendo cada passo dado em direcao ao seu objetivo final.O enriquecimento sonoroO segundo objetivo do tratamento e alcancar a habituacao da sua percepcao. Apesar do aconselhamento terapeutico ser uma parte importante e insubstituivel do tratamento, na pratica a habituacao da percepcao do zumbido nao acontece automaticamente, mesmo quando o paciente compreende e aceita que nao apresenta nenhum problema grave de saude. Por isso, e necessario lancar mao do enriquecimento sonoro continuo e por longo prazo, como veremos a seguir. Mesmo que o zumbido seja unilateral, os geradores devem ser adaptados bilateralmente para estimular as vias auditivas em conjunto.
A intensidade do som deve ser sempre menor do que a do zumbido, evitando-se ao maximo mascara-lo, ja que o mascaramento desse sinal impede o processo da habituacao. Alem disso, o molde tambem deve ser sempre bem aberto para permitir a entrada dos sons ambientais, que sao muito importantes no processo (desaconselhamos os geradores intracanais pelo efeito de bloqueio do CAE).
Para o melhor resultado em pacientes da categoria 1, o volume dos geradores de som deve ser colocado no chamado "ponto de mistura", ou seja, aquele que interfere com o som do zumbido, porem sem nunca mascara-lo. Na vigencia de hipersensibilidade auditiva, o volume do gerador de som deve ser ainda menor, de acordo com cada caso.TRT versus mascaramentoE importante frisar aqui que mascaramento e habituacao sao processos completamente diferentes e nao devem ser confundidos. O primeiro, apesar de promover um alivio rapido em alguns pacientes, nao promove nenhuma mudanca em termos de neuroplasticidade, por isso o zumbido geralmente retorna logo apos a retirada do som mascarador, fazendo com que esse tratamento precise ser usado por longo periodo. A habituacao e um processo que, embora lento para iniciar, tem a proposta de alcancar resultados definitivos apos um periodo de tempo determinado, que pode variar de 12 a 18 meses, pela vantagem de alterar as conexoes das vias auditivas com o sistema limbico e o sistema nervoso autonomo.
Uma vez que o processo da habituacao ja esteja estabelecido apos alguns meses, o uso dos geradores de som ja nao e mais necessario. Como medida de protecao, os pacientes devem continuar evitando o silencio, mas de resto, devem levar uma vida normal, ja que o zumbido aos poucos deixa de ser um problema.O mascaramento e contra-produtivo quando se pretende alcancar a habituacao. Dentre os pacientes que completaram o tratamento ate o final, 84% observaram uma melhora importante. Muitos deles continuavam ouvindo algum zumbido por menos de 10% do tempo em que o notavam anteriormente, sendo que quando aparecia, nao mais incomodava.
A esta altura, o zumbido ja havia deixado de ser um problema para eles e ja nao usavam mais os geradores.Os resultados foram semelhantes no Centro de Zumbido e Hiperacusia de Londres (8), com mais de 1500 pacientes. Em Madrid, os resultados de 56 pacientes mostram que em 61% dos casos o zumbido deixou de ser um problema para o paciente, enquanto outros 23% notaram melhora importante, embora sem desaparecimento do zumbido (9).
Embora a casuistica de pacientes submetidos a TRT em nosso Grupo de Zumbido ainda seja pequena quando comparada a dos centros de Baltimore e Londres, nossos resultados iniciais apontam melhora do zumbido em 60 a 80% dos casos, dependendo do criterio adotado.Infelizmente, cerca de 15% dos pacientes demoram muito para beneficiar-se do tratamento e, inclusive, alguns chegam a dizer que estao piores. Frequentemente sao pessoas em tratamento de outras doencas concomitantes ou com problemas emocionais importantes.
As vezes, o processo de habituacao nao se inicia devido ao excesso de tensao e angustia e, nesses casos, a ajuda de um psicologo bem versado em TRT pode ser inestimavel. Em nosso estudo, a unica paciente que referiu piora do zumbido (embora mantivesse a mesma nota na escala analogo-visual) passou por uma fase de doenca terminal de seu marido que culminou com sua morte, entrando em quadro depressivo na vigencia da TRT. Por outro lado, uma outra paciente que referiu melhora no final do tratamento, passou por uma fase de piora importante do zumbido, a qual justificou por um importante desentendimento com a filha.O tratamento de sintomas subjetivos nunca e uma tarefa facil.
Infelizmente, ainda sao comuns algumas ideias erradas a respeito do zumbido, como por exemplo, a da impossibilidade de ajudar o paciente e a da necessidade de se aprender a conviver com o problema. Embora o zumbido ainda seja considerado um sintoma sem cura definitiva, existem opcoes de tratamento para alivia-lo e que devem ser oferecidas ao paciente.A TRT e certamente uma boa opcao, desde que corretamente indicada.
Embora alguns casos melhorem apenas com o aconselhamento terapeutico, nao sendo necessario mais nenhuma abordagem com enriquecimento sonoro, o inverso nao e verdadeiro. Isto quer dizer que o enriquecimento sonoro sozinho, sem o aconselhamento terapeutico, provou ser absolutamente inutil, inclusive prejudicial, uma vez que a expectativa do paciente nao e adequada as exigencias da TRT.
Assim, vale a pena reforcar a necessidade de submeter o paciente ao tratamento integral, como preconizado por Jastreboff, para alcancar uma taxa de sucesso semelhante.Para o futuro, seria extremamente benefico o desenvolvimento de mecanismos para acelerar o processo de habituacao ao zumbido requerido no tratamento da TRT.
Enquanto este futuro nao chega, e muito importante que os profissionais se motivem a ajudar os pacientes que sofrem com o zumbido com os metodos disponiveis no presente.Quadro 1.
Werner Schwendener, Antonius Fleming Krieger e Eliana Coutinho) pela doacao dos aparelhos, permitindo a realizacao deste estudo em hospital publico.Referencias Bibliograficas1. Celebrating a decade of evaluation and treatment: the University of Maryland Tinnitus & Hyperacusis Center. Effects of tinnitus retraining therapy (TRT) for patients with tinnitus and subjective hearing loss versus tinnitus only. Zumbido: estudo da relacao entre limiar tonal e eletrofisiologico e das respostas eletricas do tronco cerebral. Experiencia do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo.
Lidocaine test in patients with tinnitus: Rationale of accomplishment and relation to the treatment with carbamazepine. The management of persistent tinnitus after the treatment of sudden deafness: the effect of intravenous lidocaine and oral carbamazepine. Shifts in dynamic range for hyperacusis patients receiving tinnitus retraining therapy (TRT). Contralateral suppression of transient evoked otoacoustic emission: intra-individual variability in tinnitus and normal subjects.
Chronic complex tinnitus: therapeutic results of in-patient treatment in a tinnitus clinic.



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