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Key words: blast injury, clinical trial, cognitive-behavioral therapy, education, hearing disorders, military Veterans, rehabilitation, telehealth, tinnitus, traumatic brain injury. Traumatic brain injury (TBI), defined generally as a traumatically induced structural injury or physiological disruption of brain function resulting from external forces to the head, is a leading cause of death and disability in the United States, with an estimated incidence of 1.4 million persons per year--excluding war [1-2]. TBI is a major problem among returning Operation Iraqi Freedom (OIF) and Operation Enduring Freedom Veterans, with reports suggesting approximately 20 percent having experienced at least a mild TBI [6]. In both civilians and Veterans, TBI is often associated with concurrent trauma to the auditory system. Our research has focused on developing effective, evidence-based methods of tinnitus management for Veterans. Telehealth (or telemedicine) encompasses a range of clinical services performed when distance separates provider and patient. Home-based telehealth refers to the provision of healthcare services remotely to patients in their home environment. The objective of this pilot study was to develop and test the feasibility and potential efficacy of a telehealth tinnitus-management approach for Veterans and military personnel with TBI. PTM is a hierarchical method of providing clinical services for patients who complain of tinnitus. As originally developed, the level 3 workshops consisted of two group sessions facilitated by an audiologist [24]. Patients who need further help after attending the level 3 workshops are advised to undergo a level 4 Interdisciplinary Evaluation [13]. The study team included (but was not limited to) a neuropsychologist (DMS) with expertise in TBI, an audiologist (PJM) with expertise in TBI and patient health education, and a research psychologist (CJS) with expertise in using CBT for tinnitus management. The study participants underwent a cognitive screen to determine their ability to comprehend the counseling information and to follow through with the management recommendations. CBT and sleep hygiene tips were added to the protocol to help the participants learn coping techniques that were not addressed by the earlier version of the PTM counseling.
Before this pilot study, psychological concerns associated with tinnitus were not specifically addressed by the PTM intervention. CBT is a type of psychotherapy that targets specific thoughts, core beliefs, and negative appraisals of situations that are unconstructive (and may cause distress) while providing tools for implementing more adaptive behavioral and cognitive modifications [28-29]. The addition of CBT to the clinic-based PTM protocol required expansion of the self-help workbook, so we developed a second edition of the workbook that was sent to all participants at the time of their enrollment [34]. All the telephone interventions were conducted by the research audiologist (TLZ) and research psychologist (CJS). Microsoft Outlook (Microsoft Corp; Redmond, Washington) served as a schedule management tool, enabling the research assistant, research coordinator, and intervention counselors to effectively schedule appointments and reminders.
A Microsoft Access (Microsoft Corp) relational database was developed to collect screening and outcome data.
In addition, outcome data were entered from questionnaires that were completed and returned by participants. All procedures for recruitment, informed consent, and conduct of this study adhered to the requirements of the institutional review boards (IRBs) at the PVAMC and VACHS for protection of human research participants.
Communications with candidates and participants were made via telephone (using the PVAMC and VACHS toll-free numbers for inbound calls). Figure 1.Number of callers expressing interest in pilot study with regard to how many were recruited, screened, enrolled, and assigned to three study groups. For initial screening, the research assistant (1) explained the study, (2) administered the THS, and (3) assessed probable symptomatic TBI using a modified version of the VA TBI Screen (Appendix 4, available online only).
Qualified candidates were sent the self-help workbook, ICF, and written baseline questionnaires (Table 1).
Assignment to one of the three TBI categories was based on responses to the VA TBI Screen plus criteria developed in consultation with TBI screening specialists (PJM and DMS). The THI provides an index score, ranging from 0 to 100, with higher scores reflecting greater perceived functional limitations due to tinnitus [39-40]. The four-question PC-PTSD is used by the Department of Defense and the VA to detect probable PTSD and to initiate appropriate referral [42]. During this TBI and mental health history evaluation appointment, the psychologist (1) assessed for any obvious cognitive impairment via a symptom checklist and mental status examination, (2) reviewed the completed screening forms that participants completed at home and assessed for mental health conditions as indicated, (3) asked participants to describe their history of TBI(s) and to report relevant medical data so as to affirm the presence and severity of TBI(s) according to the study protocol, and (4) made appropriate referrals if warranted. The intervention protocol normally involved six telephone appointments--four with the audiologist (TLZ) and two with the psychologist (CJS).
These sessions were individualized; thus, the information was provided at a pace that was comfortable for each participant. INTRODUCTION: Tinnitus is considered as one of the major symptom associated with many pathologies along with its presence in individuals with normal hearing.
OBJECTIVE: Study was undertaken to find the efficacy of Residual Inhibition Therapy as treatment procedure for unilateral tinnitus in individuals with normal hearing by comparing pre and post Residual Inhibition Therapy, Contra-lateral Acoustic Reflexes and Tinnitus Handicap Inventory. MATERIALS AND METHODS: Ten subjects between the age range of 20-45 years were included for the study. RESULTS AND CONCLUSION: Statistical analysis revealed no significant difference, however, elevated contra-lateral acoustics reflexes post Residual Inhibition Therapy were seen. Tinnitus is referred to, a sound generated by brain in the absence of acoustic stimulation due to increased neural activity1. Today, with advancing field of Audiology, treatment strategies are aimed to reduce or eliminate symptoms and distress caused by tinnitus which includes Residual Inhibition Therapy (RIT), Masking Tinnitus Retraining Therapy and Cognitive Behavioral Therapy. In support of the literature, audiological practice encounters an increasing number of tinnitus and thus, one needs to evaluate the efficacy of the treatment. Reflexometry at 500 Hz, 1000 Hz, 2000 Hz and 4000 Hz was repeated to elicit the baseline contra-lateral acoustic reflexes pre Residual Inhibition Therapy.
Statistical analysis using paired sample t test is carried out with Bonferroni's correction applied for multiple comparison between pre and post comparison of four frequency thresholds in contra-lateral reflexometry. The present study investigated the effectiveness of RIT using a questionnaire aiming to betterment of tinnitus and contra-lateral acoustic reflexes in adult individuals. From Table 2, the Tinnitus Handicap Inventory did not show any significant changes in the scores obtained pre and post RIT. Similarly, obtained contra-lateral reflexes pre and post RIT were compared using sample t-test. From Figure 1 we can conclude that, post RIT contra-lateral acoustic reflexes required higher intensity in comparison to pre RIT contra-lateral acoustic reflexes to elicit a reflex. From Table 3 it is evident that there is no significant difference (p > 0.05) between contra-lateral acoustic reflexes pre and post RIT (Boneferroni's correction applied for multiple comparisons). Primary aim of the study was to establish the effectiveness of RIT on subjects experiencing tinnitus. The depth and duration of residual inhibition was found to be varied from individual to individual and the peak measurement of duration of residual inhibition was 70 sec. The current study results are in support with the previous literature where the 57% of tinnitus experiencing subjects relapse in 2 minutes, 23% subjects in 2 to 4 minutes, 11% subjects in 4 to 6 minutes, 4% subjects in 6 to 8 minutes, 2% subjects in 8 to 10 minutes and 3% subjects with more than 10 minutes19.
The current study used duration of 60 seconds for the presentation of target stimulus and the RIT success rate is obtained with increase in number of the target stimulus experienced to suppress tinnitus however, due to the fatigue of masking in subjects some might require longer duration of target stimulus to maintain residual inhibition12. The poor agreement with the earlier literature could be due to differences in noise bandwidths used for the study, tinnitus pitch tuning methods, sound levels used and the various differences in the experimental details. The present study aimed at testing the effectiveness of RIT using pre and post tinnitus questionnaire response and contra-lateral acoustic reflexes. Paper submitted to the ITJ-SGP (Publishing Management System) on May 21, 2015; and accepted on June 23, 2015. This study evaluated the interference of tinnitus on the quality of life for noiseexposed workers enrolled in a hearing conservation program. Most tinnitus research has focused on effective treatments and the mechanisms of the cause, detection, and perception of tinnitus. In addition to its medical and audiological aspects, the psychosocial consequences of tinnitus can be of significance and have also been investigated.
Tinnitus is a common complaint among noise-exposed workers, and in some countries it is even recognized as a work-related condition for compensation purposes. The objective of our study is to evaluate the impact of tinnitus on the quality of life of workers who are exposed to noise and enrolled in a corporate hearing conservation program. We enrolled participants from a meat-packing facility in the state of Rio Grande do Sul, Brazil. We administered a questionnaire to all the employees of the company (N = 372) at the beginning of the training sessions of their hearing conservation program. To assess the workers' hearing status, we performed otoscopy and pure-tone audiometry, according to the requirements of the Brazilian legislation [10]. We administered to the 52 participants the Brazilian version of the Tinnitus Handicap Inventory (THI) questionnaire, elaborated by Newman et al. We calculated Pearson coefficients of linear correlation and tested their significances via the Student's t -test and Fisher's exact test, using a significance level of 5%. Eighty-two workers (22%) of the total population of 372 workers in the studied company reported tinnitus in the first interview of this study.
Company records also indicated that 15% of the participants who were exposed to noise were also exposed to other hazards. The results of the relationship between tinnitus and the three THI scales are presented in Figure 2.
Table 2 displays the correlations between the functional, emotional, and catastrophic scales and medical history. Table 3 presents the correlations of the THI results with the health problems described by the participants (n = 52). We separated the participants into two groups: The first was composed of 37 participants with normal hearing (71%), and the second included 6 participants (12%) with a bilateral high-frequency notch.
Twenty-two percent of the noise-exposed participants complained of tinnitus, a finding comparable to rates of 25% reported by Sahley and Nodar [14] and 15.5% reported by Zimmermann [15].
Seventy-one percent of the participants with tinnitus complaints presented normal audiometric results, which suggests that tinnitus can be an early indicator of auditory risk from exposure to noise. The application of the Brazilian version of the THI was both easy and expedient, as indicated by Newman et al.
In Table 2, we found significant results involving the functional scale results with the use of prescription drugs and the catastrophic scale results with consumption of coffee. Concerning the degree of severity of tinnitus, 44% presented degree 1 or "slight" tinnitus according to the classification by McCombe et al.
We observed a significant correlation between tinnitus severity and exposure to noise and chemical pollutants, predominantly CO. We observed a significant correlation between the duration of noise exposure and the emotional scale for the participants with high-frequency notches, suggesting an extra-auditory effect of noise. The results of this study demonstrated that the prevalence of tinnitus was high (22%) in this population, despite the fact that study participants were young individuals who had a short duration of noise exposure. The Brazilian version of the THI proved to be an easy instrument to use for evaluating the impact of tinnitus on the quality of life of noise-exposed workers. Others the noise is entirely random tinnitus could not be troubled, even deeply appreciated if u can maintain me updated.
When describing hearing loss we generally look at three attributes: type of hearing loss, degree of hearing loss, and the configuration of the hearing loss.
Conductive hearing loss occurs when sound is not conducted efficiently through the outer ear canal to the eardrum and the tiny bones, or ossicles, of the middle ear. Sensorineural hearing loss occurs when there is damage to the inner ear (cochlea) or to the nerve pathways from the inner ear (retrocochlear) to the brain. Sensorineural hearing loss not only involves a reduction in sound level, or ability to hear faint sounds, but also affects speech understanding, or ability to hear clearly. Sensorineural hearing loss can be caused by diseases, birth injury, drugs that are toxic to the auditory system, and genetic syndromes. Sometimes a conductive hearing loss occurs in combination with a sensorineural hearing loss. Unilateral hearing loss (UHL) means that hearing is normal in one ear but there is hearing loss in the other ear. The configuration or shape of the hearing loss refers to the extent of hearing loss at each frequency and the overall picture of hearing that is created. Combat-related TBI in this new generation of Veterans is most frequently associated with blasts caused by improvised explosive devices (IEDs) or other sources [7]. Clinical and epidemiological studies confirm that TBI is strongly associated with tinnitus [9]. These efforts led to the development of Progressive Tinnitus Management (PTM), a program involving patient educational counseling that assists patients in learning how to self-manage their reactions to tinnitus [13]. Home-based telehealth is an appropriate option for chronic conditions when in-person appointments are unnecessary and the methodology has been demonstrated to be effective [17]. The telephone intervention was based on the educational counseling that is used with PTM, with the addition of components of cognitive-behavioral therapy (CBT). Level 4 services are required by relatively few patients and involve primarily in-depth interviews by an audiologist and psychologist, who attempt to determine why the tinnitus continues to be a problem.
These collaborators assisted in modifying the PTM protocol so that it was appropriate for telephone-based administration to TBI-affected persons.
Some people distressed by their tinnitus report symptoms of depression and anxiety, such as sleep disturbance, difficulty concentrating, fatigue, irritability, and even suicidal ideation [25-27]. Only two coping techniques were introduced with this trial of PTM to enable all the telephone counseling to be covered in a reasonable number of sessions. The workbook was designed so that the information would be comprehensible to people with low health literacy [33]. The workbook was revised with assistance from the psychologist (CJS) to incorporate cognitive and behavioral coping skills for patients. The audiologist was located at the National Center for Rehabilitative Auditory Research (NCRAR), which is hosted by the Portland VA Medical Center (PVAMC) in Portland, Oregon.
Whenever the research assistant, research coordinator, or an intervention counselor talked to a candidate or participant on the telephone, the database was opened to the person’s record. In lieu of a paper chart, the intervention counselors (audiologist and psychologist) had access to the completed outcome questionnaires that were scanned into a database that both could view. Participants included only Veterans and military personnel who were informed of the study via a recruitment flyer that was sent to VA and military audiologists. As of November 2009, 172 potential candidates had contacted research assistant (RA) to express interest in study.
Because the telehealth intervention was designed to help only with tinnitus problems, and not with hearing problems, it was necessary to distinguish these two problems to determine candidacy for the study.
Callers who responded that they already had been diagnosed with TBI or who endorsed all four sections of the TBI Screen were considered to have probable symptomatic TBI. The baseline questionnaires included (1) Tinnitus Questionnaire, (2) Hospital Anxiety and Depression Scale (HADS), (3) THI, (4) Primary Care PTSD screening tool (PC-PTSD), and (5) Epworth Sleepiness Scale (ESS). We highlight that individuals assigned to the mTBI category were those with probable symptomatic mild TBI; individuals with a history of mild TBI but no current symptoms that could be attributable to a TBI were assigned to the noTBI category. It obtains demographic data as well as information about the participant’s tinnitus and its effects, prior clinical services received for tinnitus, hearing difficulties, and prior services received for hearing loss. This self-screening questionnaire consists of 14 questions--7 for anxiety and 7 for depression. The THI has been validated for use with patients, and it is one of the most often used and cited tinnitus instruments. A cutoff score of 3 has been shown to have 76 percent sensitivity and 92 percent specificity for clinical PTSD among OIF soldiers [43].
During this appointment, the research coordinator explained the ICF and assessed the candidate’s capacity-to-consent (assessment of capacity-to-consent was required by the IRB and a set of questions was developed to address this requirement).

Results of the TBI evaluation determined the participant’s assignment to one of the three TBI categories. With varied cause and mechanism of its generation and increase in number of individuals with complaint of tinnitus, rehabilitation becomes crucial for Audiologists. Even though small sample size made it hard to conclude on the effectiveness of Residual Inhibition Therapy as treatment of tinnitus, elevated contralateral acoustic reflexes post Residual Inhibition Therapy pay way for further advanced studies on the same. It is considered to be an auditory phantom sensation experienced by 10-15 persons out of general population2.
RIT is referred to the auditory stimulation that results in temporary suppression of tinnitus6. Thus, the study was designed to know the effectiveness of RIT by comparing pre RIT contra-lateral acoustic reflexes to post RIT contra-lateral acoustic reflexes in normal hearing subjects experiencing continuous tinnitus unilaterally. The study protocol was approved by the Institutional Ethical Committee Board at Nitte Institute of Speech and Hearing, Mangalore.
Subjects answered a questionnaire developed by five experienced Audiologists to rule out nature of complaint.
For this, obtained questionnaire score and contra-lateral acoustic reflexes were measured at octave frequencies between 500 Hz and 4000 Hz were compared. Bonferroni's correction was applied for multiple comparison between pre and post comparison of four frequency thresholds.
However there is no significant difference between the pre and post RIT contra- lateral acoustic reflexes. For this, pre and post RIT questionnaire response and contra-lateral acoustic reflexes were compared. This variation may be due to quieter level of stimulus intensity and lesser duration of narrow band noise played to the subjects which were required to influence the tinnitus triggering system.
Explanation on subject's response to RIT after the target sound ends is with the start of silent phase of 20 to 35 seconds, followed by 30 to 35 seconds in which the tinnitus sound gradually recovers back. RIT has approved good effectiveness when the pitch of the tinnitus is matched with the target sound presented to suppress tinnitus15 however; in the present study we used narrowband noise of the nearing experienced tinnitus frequency.
Also, sample size used is small which can significantly influence the effectiveness of RIT.
Contra-lateral acoustics reflex thresholds obtained post therapy state is relatively higher than the pre therapy state, however, Tinnitus Handicap Inventory scores showed not much improvement. Lectutrer, Nitte Institute of Speech and Hearing, Mangalore University, Approved by Rehabilitation Council of India.
Intern (BASLP), Nitte Institute of Speech and Hearing, Mangalore University, Approved by Rehabilitation Council of India. Noise measurements, a questionnaire, a Brazilian version of the Tinnitus Handicap Inventory (THI), and pure-tone audiometry were conducted with 52 participants (mean age, 29 years) who suffered from tinnitus. Among the risk factors for tinnitus, the most prominent are age, gender, various diseases (otological, metabolic, neurological, and vascular alterations and dental factors), hearing loss, and exposure to noise, ototoxic drugs, caffeine, nicotine, and alcohol [1-4]. Tinnitus can alter an individual's ability to function in professional, social, and leisure activities and in family relationships, hence affecting the quality of life [5,6]. In addition to being beneficial for clinical applications, the tinnitus questionnaires are valuable for understanding the relationship between personality and the psychopathology of tinnitus, its impact on the daily life of persons who suffer from tinnitus, the difficulties and the perception of social support in relation to the problem, and the incapacities and the difficulties produced by tinnitus that can seriously affect quality of life [7-9].
Occupational hearing loss prevention initiatives rarely focus on the prevention and management of tinnitus. The company employs 372 workers (120 female, 252 male) working in two fixed 8-hour and 48-minute shifts. The questionnaire gathered information on demographics and occupational and medical histories for each worker. We also used Spearman's rank correlations to examine the results of exposure information versus the outcome. Because of attrition, we were able to study only 52 workers (14% of total population of the plant). Of those, 62% were exposed to carbon monoxide (CO), 13% to CO and vibration, 12% to hydrochloric acid, and 13% to sodium hydroxide. We observed that of the 52 participants, 71% had normal audiometric results, whereas 12% presented a bilateral high-frequency notch and 17% presented audiometric configurations of hearing loss due to causes other than noise, such as unilateral losses and flat audiometric configuration. Median of hearing thresholds for the groups with normal hearing (all thresholds 25 dB hearing level [HL]), hearing loss configurations suggestive of noise-induced hearing loss (NIHL), and hearing loss from various causes. The distribution of poorest scores across scales of the Tinnitus Handicap Inventory, in percent (n = 52). We observed a significant correlation between headaches (p = .0458) and the duration of tinnitus. We did not include the remaining 9 individuals (17%), who displayed other audiometric configurations of hearing loss in the statistical analysis. The prevalence of tinnitus complaints in male subjects was 16% and in female subjects was 9%, similar to what has been reported [16-18]. Schleuning [2] explained that caffeine and nicotine could aggravate tinnitus because they are stimulants and can induce the constriction of blood vessels.
The participants of the study who had such combined exposure had a higher degree of tinnitus severity.
Moreover, a negative impact of tinnitus on the subjects' quality of life could de detected. The 22% tinnitus rate among workers, most of whom nonetheless had normal hearing, suggests a need to address tinnitus in occupational hearing loss prevention initiatives.
Rick Davis and Robert Randolph (National Institute for Occupational Safety and Health, USA) and Alberto Behar (University of Toronto, Canada) provided helpful critiques of the manuscript.
There are three basic types of hearing loss: conductive hearing loss, sensorineural hearing loss and mixed hearing loss. Conductive hearing loss usually involves a reduction in sound level, or the ability to hear faint sounds.
In other words, there may be damage in the outer or middle ear and in the inner ear (cochlea) or auditory nerve. The numbers are representative of the patient's thresholds, or the softest intensity at which sound is perceived. For example, a hearing loss that only affects the high frequencies would be described as a high-frequency loss. Symmetrical hearing loss means that the degree and configuration of hearing loss are the same in each ear. Determine if debris or earwax is in the ear canal and if the eardrum is visible and intact. We developed Progressive Tinnitus Management (PTM), which uses education and counseling to help patients learn how to self-manage their reactions to tinnitus. TBI is often categorized as mild, moderate, or severe according to the duration of loss of consciousness (LOC) and posttraumatic amnesia.
In the past decade, it has become evident that blast-related TBI may be more strongly associated with tinnitus than non-blast-related TBI. For the present study, we were interested in exploring the feasibility of adapting PTM to address the tinnitus management needs of Veterans and military personnel with TBI by providing the educational counseling via home-based telehealth (telephone counseling). Following passage of the Comprehensive Telehealth Act by Congress in 1997, telehealth services have increasingly been provided in rural or isolated communities [14].
CBT is an evidence-based psychotherapy commonly used for pain, depression, anxiety, and tinnitus that also can be effective in individuals with a history of TBI, particularly mild TBI [19-21]. The structured educational curriculum focused on teaching patients how to develop action plans for using sound in specific ways to address situations when the tinnitus was most bothersome. In general, PTM was condensed to conducting assessments using questionnaires and interviews and performing telephone counseling as the intervention. Psychological techniques had already been developed and used with patients who experience tinnitus.
The components used in this study included training in behavioral modification (stress management via relaxation techniques), as well as cognitive restructuring (step-by-step examination of changing thoughts to change how people feel). The primary purpose of the workbook was to impart useful, actionable information that helps patients make good decisions about their tinnitus healthcare. The CBT information led to development of a worksheet (Changing Thoughts and Feelings Worksheet in Appendix 2, available online only) to develop an action plan for implementing specific tasks relevant to managing reactions to tinnitus. The psychologist was located at the VA Connecticut Healthcare System (VACHS) in West Haven, Connecticut. Information could be entered into the database in real time as the individual provided information and responded to questions. Use of the THS (Appendix 3) enables rapid assessment of the effects of hearing loss separate from the effects of tinnitus [23,32]. However, confirmation of TBI history and symptoms and assignment to TBI categories took place during the assessment appointment with the psychologist. The HADS, PC-PTSD, and ESS were administered to screen for anxiety and depression, PTSD, and sleep deprivation, respectively.
Participants with moderate or severe TBI were combined into a separate category; this method was necessary given our relatively low N for this study but also was justified given that mild TBI has been argued to be distinct from moderate and severe TBI rather than on one continuum of cognitive, emotional, and physical severity [3,5]. Participants who had not previously been diagnosed with TBI (according to self-report) and did not endorse all four sections of the TBI Screen (Appendix 4) were assigned to the noTBI category. A change in the index score of at least 20 points is reported to indicate a clinically significant improvement for individuals at the 95 percent confidence level [41].
Assessment of capacity-to-consent simultaneously evaluated the candidate’s speech comprehension ability.
If time permitted, the psychologist introduced the use of CBT for tinnitus, the rationale behind stress management for tinnitus, and the relaxation techniques. The first four intervention appointments were scheduled approximately weekly and alternated between the audiologist and the psychologist. The Pre Residual Inhibition Therapy, contra-lateral acoustic reflexes and Tinnitus Handicap Inventory scores were compared to post Residual Inhibition Therapy, contra-lateral acoustic reflexes and Tinnitus Handicap Inventory scores.
Use of this treatment has shown 90% of the subjects with tinnitus relief and 10% with modification in tinnitus with minimal reliefs7. Questions in the questionnaire probed to know the onset (sudden or gradual), progression (static or progressive), nature of the tinnitus (intermittent, continuous), ear experiencing tinnitus (right, left or both ears) and duration of tinnitus persistence.
Thresholds of each subject were found out using both air conduction and bone conduction mode.
Four individuals reported of reduction in tinnitus loudness, 3 reported of complete termination of tinnitus and 3 reported of no change in the tinnitus. The influence of masking level that deepens the residual inhibition as it goes above the level required to mask tinnitus17 or due to the impedance offered by the cochlear dead region even in normal hearing individuals with tinnitus18 could have yield poorer results.
Similarly, the literature reports that few subjects experience increase in the tinnitus loudness than the decrement which lasts for a duration less than one minute20. Residual inhibition will be effective with longer exposure to target stimulus and subjects who experience no residual inhibition in the initial stages may experience it after regular exposure to target sound21. Residual inhibition functions overlap tinnitus spectra and the region of auditory threshold shift. Evaluation and Selection of Maskers and Other Devices Used in the Treatment of Tinnitus and Hyperacusis. THI results indicated that tinnitus had the greatest influence in the functional scale (54%). We used the overall result to identify the degree of severity of tinnitus for each individual and for completing an analysis of the total scores by scales. Of all noise-exposed female workers in the plant, 11 (9%) reported having experienced tinnitus, and 41 (16%) of the noise-exposed male workers reported the condition.
Spearman's rank correlation coefficient results indicated a significant correlation between noise levels and how often workers experience tinnitus (p = .01).
We also observed a significant correlation between the duration of noise and the functional scale (p = .039).
It is important to notice that the average age of the population of our study (29.2 years) is younger than in other studies, which reported results from groups whose mean ages varied from 40 to 50 years and who had a short duration of noise exposure (average, 7 years)[18-21] .
According to that author, doctors believe that 50% of patients with complaints of tinnitus improve significantly when they stop smoking or reduce caffeine intake. In recent decades, studies have demonstrated that simultaneous chronic exposure to CO and noise represents a potential risk to hearing, but reports of tinnitus exist only for cases of intense poisoning from CO [24]. This supports the inclusion of tinnitus prevention initiatives alongside workplace hearing loss prevention initiatives because of shared causal factors.
Information on tinnitus prevention and treatment could have a measurable, positive impact on a person's quality of life. The authors thank all those who participated in the study for their time, interest, and cooperation. Guidelines for the grading of tinnitus severity: The results of a working group commissioned by the British Association of Otolaryngologists. Its configuration would show good hearing in the low frequencies and poor hearing in the high frequencies. A sudden hearing loss is one that has an acute or rapid onset and therefore occurs quickly, requiring immediate medical attention to determine its cause and treatment.
Fluctuating hearing loss is typically a symptom of conductive hearing loss caused by ear infection and middle ear fluid, but also presents in other conditions such as Meniere's disease. We adapted PTM by delivering the intervention via telephone and by adding cognitive-behavioral therapy.
Mild TBI, synonymous with concussion, is the most frequently occurring category, comprising approximately 85 percent of all TBI episodes [3].
However, reports have suggested that symptoms associated with mild TBI may be occurring in a larger proportion of Veterans than what has previously been observed in the civilian population [8].
For example, in a subset of blast-injured patients seen at Walter Reed Army Medical Center (2003-2005), 49 percent reported tinnitus [10].
In addition to overcoming geographic barriers, telehealth generally increases accessibility and efficiency of clinical services [15].
The education was designed to be patient-centered and to lead to self-efficacy in managing reactions to tinnitus. Multiple trials support CBT as an effective psychological method for managing tinnitus [20]. They found significant improvement in quality of life (decrease of global tinnitus severity) for those receiving CBT compared with those who did not receive CBT. These particular components were selected because they have been identified in studies to be beneficial for patients who have tinnitus [30-31].
This new workbook also contains videos that supplement the written material: (1) an interactive video that guides patients through material in the workbook about therapeutic use of sound (material that normally is presented in PTM group education workshops) (Video 1), and (2) demonstrations of relaxation training exercises including deep breathing and imagery (Video 2). The audiologist participated in the development of the patient education that originally was developed for PTM and had experience using it. Of qualified candidates, 36 were enrolled in study (rest were placed on waiting list or lost contact). The statements in section A address tinnitus-specific problems not related to hearing difficulties.
Each of these conditions can compromise efforts to manage tinnitus, so evaluating the participants for these potential comorbidities was essential. For example, outcomes of moderate and severe TBI tend to follow a gradient of severity predicted by acute injury characteristics, while outcomes of mild TBI can be varied and unpredictable [3].
Those who had previously been diagnosed with TBI or who endorsed all four sections of the TBI Screen were assigned to either the mTBI or the m-sTBI category based on the established criteria. Responses were used by the psychologist and audiologist to assist in determining the potential need to address sleep disorders as part of the intervention or to refer the participant to a sleep disorders clinic.

Failure to pass the capacity-to-consent assessment would exclude the candidate from study participation (no candidates were excluded on this basis).
Participants were invited to begin reading introductory selections from the self-help workbook.
The last two intervention appointments were conducted with the audiologist at about 12 and 24 wk after enrollment. If participants were unable to demonstrate having understood the concepts from previous sessions, then those concepts were reviewed. However, few postulated etiologies can be attributed to age, exposure to loud noise, earwax blockage, air bone changes, Meniere's disease, tempro-mandibular joint disorders, head or neck injuries, acoustic neuroma, etc. Literature has also reported the experience of residual inhibition in more than 8 out of 10 persons with tinnitus8 and reduction in tinnitus loudness by 39%9. Total ten subjects with a complaint of tinnitus persisting for more than two weeks were recruited. The insignificant result to the success of RIT can be attributed to the influence of identification level of tinnitus expertise, the inability to match the tinnitus exactly due to overlapping of tinnitus frequency in some subjects and the effect of RIT lasting for few seconds or minutes8. However, only 54% subjects experienced complete silence in total 46 subjects with tinnitus and who underwent. Proceedings of the Vth International Tinnitus Seminar; 1995 July 12-15, Portland, Oregon, USA. Oregon: Oregon Hearing Research Center, Department of Otolaryngology, Oregon Health & Science. Eighty-two individuals (22% of the total population) had experienced tinnitus and were invited to participate in the study. The equipment used was an Interacoustics audiometer, model AD 229, with TDH-39 earphones, calibrated according to ISO 8253.
The average age of the sample was 29.2 years, and the average duration of noise exposure was 7 years.
Moreover, significant results were found for the degree of tinnitus and exposure to chemical pollutants (p = .02). The THI indicated that even the degree 1 "slight" tinnitus experienced by most of the participants who reported tinnitus nevertheless had an impact on their quality of life.
For instance, lesions in the neck and the middle ear and sinusitis and headaches increase the risk of tinnitus from 28% to 35%. The findings underscore the need for noise control and other effective strategies to mitigate causal factors.
The use of an instrument designed to evaluate the impact of tinnitus on a person's life, such as the THI, can contribute to a greater understanding of the needs of a specific person or group (or both).
Experiencia do hospital das clinicas da faculdade de medicina da Universidade de Sao Paulo. On the other hand, if only the low frequencies are affected, the configuration would show poorer hearing for low tones and better hearing for high tones.
A pilot study was conducted to evaluate the feasibility and potential efficacy of this approach for individuals with and without TBI. Also, 38 percent of inpatients with blast injury at the Palo Alto Department of Veterans Affairs (VA) Polytrauma Rehabilitation Center complained of tinnitus [11].
Implementing and researching telehealth services is a major initiative for the Veterans Health Administration (VHA) [16]. Scheduled telephone counseling and education resulted in improved overall outcome, particularly for functional status and quality of well-being, when compared with usual outpatient care.
The purpose was to determine whether telehealth intervention for tinnitus was feasible and efficacious for each of the three groups. Level 1 consists of guidelines for referring patients who complain of tinnitus to the appropriate clinical services. Thus, CBT was incorporated into the PTM method and was expected to be useful for patients both with and without TBI.
CBT is an evidence-based and appropriate addition to PTM to address the psychological components of tinnitus distress that are so common with Veterans.
Specifically, instructions were provided for how to use sound to manage tinnitus in situations when tinnitus is bothersome. Note that those placed on waiting list were informed that we would attempt to renew study, but that renewal required approval for continued funding. The HADS, PC-PTSD, and ESS were selected because of their validated effectiveness for screening purposes. For example, one of the key criteria for assigning participants to a TBI severity category is length of time they experienced LOC at the time of the TBI. If the candidate was qualified, motivated (as determined by expressed interest), and capable of participation, then the research coordinator instructed the candidate about how to sign the ICF, complete the written questionnaires, and return these items in the prepaid and preaddressed envelope that was provided. In addition to the specific procedures outlined subsequently, at each of these appointments the intervention counselor started by explaining the format of the appointment, allowed time to answer questions, made referrals to other relevant healthcare providers if warranted, and ensured that the next intervention appointment was scheduled as appropriate.
Providers also periodically asked participants to summarize the information immediately after it was provided during a session. In contrast to the reasons behind tinnitus3 quoted normal hearing individuals with presence of tinnitus.
In air conduction testing, frequencies 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, 4000 Hz and 8000 Hz were checked. On obtaining baseline, frequency specific narrowband noise was delivered to the ear experiencing tinnitus for duration of 60 sec.
Studies have reported that presence of any phobia related to tinnitus or any negative thought about tinnitus will lead to slow desensitization of tinnitus.
Follow-up report of three subjects in the literature study has shown no change in tinnitus even after exposure to target stimulus for a run of 2 to 3 weeks RIT15. Twenty (24%) of the 82 were not able to participate because they lost their jobs before collection of data, 5 (6%) declined to participate saying that they no longer had symptoms of tinnitus, and 5 (6%) were on vacation at the time of data collection. We performed puretone audiometry for all subjects at frequencies of 0.5, 1, 2, 3, 4, 6, and 8 kHz. The functional subscale, composed of 11 questions, evaluates the limitations that tinnitus induces in the mental, social, occupational, and physical areas. Table 1 displays the findings pertaining to the health problems and auditory and medical histories described by the participants. In the THI, tinnitus was shown to have the greatest relationship to the functional scale (54%), indicating that its impact is more noticeable in social, daily, and reading activities involving concentration, auditory acuity, attention, and rest.
The analysis of the THI results along with the audiometric results indicated that a considerably greater number of significant correlations were verified in the group with altered hearing, which was expected because the two conditions-compromised hearing and tinnitus-are often associated. Information dissemination on the risks and prevention alternatives is of great importance, as is the management of tinnitus. Finally, it could be used in the design of appropriate strategies to manage tinnitus in the workplace. Some hearing loss configurations are flat, indicating the same amount of hearing loss for low and high tones. Participants with clinically significant tinnitus were recruited into three groups: probable symptomatic mild TBI (n = 15), moderate to severe TBI (n = 9), and no symptomatic TBI (n = 12). TBI of all severity levels can cause substantial long-term functional disability among survivors [1]. Tinnitus can occur not only as a symptom of TBI and side effect of medications commonly used to treat cognitive, emotional, and pain problems associated with TBI, but can also be a direct consequence of the event causing TBI, as in the case of blasts. Telephone counseling was described as showing promise as a low-cost, widely available rehabilitation intervention for TBI.
Military and VA medical centers were contacted to recruit individuals with clinically significant tinnitus--both with and without a history of TBI. Unless the patient has urgent medical or mental health concerns, the initial services should involve a hearing assessment and brief assessment of tinnitus impact. Both the audiologist and psychologist completed online VA-endorsed training courses that provide information about people with TBI and PTSD. All the problems in section A are problems that can be addressed with intervention specific to tinnitus that would be available through the telehealth program. Completed forms for all three of these scales were scanned in the scanned-questionnaires database on receipt so as to be available for the psychologist to review and discuss with the participant during telephone appointments.
Those who had LOC for 30 min or less were assigned to the mTBI category and those who had LOC for more than 30 min were assigned to the m-sTBI category. Upon receipt of the signed ICF and completed questionnaires, the candidate was enrolled into the study and the research coordinator scheduled the assessment appointment with the psychologist. If a therapist determined that a participant had not understood a concept, then the concept was reviewed. As opposed to the traditional paradigm-tinnitus as an ear disease, today, tinnitus is accepted as a brain disorder4. This suppression of tinnitus provides brief relief which lets victims to exert some control over the trouble. Subjects with mild to moderate severity (score ranging from 18 to 56) were considered for the study.
However, in bone conduction testing, frequencies 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz were checked. This explains the part of neuro-physiological model, where annoyance or displeasure although not strongly evoked stimulate limbic and autonomic systems producing intrusive and aversive emotions and reducing the quality of life. Therefore, the final sample of the study consisted of 52 participants: 11 females (9% of the total of 120 noiseexposed female workers in the studied plant) and 41 males (16% of the total of 252 noise-exposed male workers in the studied plant). The emotional subscale, composed of 9 questions, includes affective answers for tinnitus (anger, frustration, irritability, and depression).
All participants exposed to noise levels greater than 85 dB are required to use ear muffs, and information on their use and maintenance are given when workers are hired. The emotional scale was the second most affected and is related to manifestations of nervousness, frustration, irritation, depression, anxiety, insecurity, and difficulty in relationships with family and friends. Estabelece diretrizes e parametros minimos para avaliacao e acompanhamento da audicao dos trabalhadores expostos a niveis de pressao sonora elevados.
Participants received telephone counseling (six sessions over 6 months) by an audiologist and a psychologist. While symptoms of mild TBI will often resolve given time and no subsequent insults to the head [3,5], a minority of individuals (~15%) may experience long-term cognitive, emotional, and physical symptoms after the injury event [3]. Chandler and Edmond note that tinnitus is a common but often underreported auditory dysfunction with blast-related injury [12]. Addressing the problems in section B would need to begin with an audiologic evaluation and could not be managed through the telehealth program. Participants who screened positive for any of these disorders were encouraged to contact their primary care physicians for referral to appropriate providers.
Participants who were struggling to learn concepts or who appeared to be learning the information at a slower pace were offered additional appointments.
Tinnitus can be rated as mild to catastrophic level thereby having severe effects on social and emotional status, poor job performances, relationships and social functioning5. Possible reasons for tinnitus suppression are stated as temporary desensitization by brain on exposure to tinnitus matched frequency noise11 and influence of overlapping central mechanism12.
This inventory helped to rate the severity of tinnitus and to know its severity on day today life. Recruitment of the subject for further testing asked for threshold ranging from -10 to 25dBHL. Post first sitting with a time gap of 1-2 minutes, contra-lateral acoustic reflexes were retested. The created negative feelings to a person cannot be treated purely by only audiological help. We also performed daily biological calibration checks on the audiometer immediately before testing subjects.
Last, the catastrophic subscale is composed of 5 questions and examines the most severe reactions from tinnitus (desperation, loss of control, inability to face problems, inability to escape tinnitus, and fear of having a serious ailment)[12]. Walkthrough observations suggest that use of the hearing protection is high, but no information exists on the consistency of hearing protection use.
The catastrophic scale demonstrated alterations related to desperation, intolerance to tinnitus, and loss of control in situations when experiencing tinnitus (see Fig. The research assistant conducted initial screening for tinnitus and TBI and mailed materials to eligible candidates.
During the level 2 evaluation, the brief assessment of tinnitus impact determines whether tinnitus-specific services are appropriate.
If participants were interested in additional appointments, then they were scheduled for these appointments as needed until the final study appointment approximately 24 wk after initiation of intervention.
Thus, the purpose of this study was to gain information on the effectiveness of Residual Inhibition Therapy as a treatment of tinnitus in normal hearing subjects experiencing tinnitus unilaterally and hence the study was undertaken.
Subjects experiencing continuous tinnitus with static nature for two weeks unilaterally were shortlisted. Secondly, Immittance Audiometry (Tympanometry and Reflexometry) using calibrated Interacoustic AT (235) Immittance Audiometer with probe tone of 226 Hz was used to know the integrity of tympanic membrane and middle ear status.
The obtained pre contra-lateral acoustic reflexes and post contra-lateral acoustic reflexes were compared to each other to get the effect of RIT on contra-lateral acoustic reflexes.
In our study, factors such as gender, age, tobacco, and exposure to firearms were not significantly associated with tinnitus.
All groups showed trends reflecting improvement in self-perceived functional limitations due to tinnitus.
The research coordinator assessed capacity to provide informed consent, obtained informed consent as appropriate, and set up the initial telephone counseling appointments.
The THS was used as an eligibility screening tool and as part of a secondary outcomes assessment (data not reported in this article). Nine participants accepted additional appointments with the study audiologist when offered, and three accepted additional appointments with the study psychologist when offered.
Type 'A' tympanogram with present ipsi-lateral and contra-lateral acoustic reflexes were considered. Coles [26], among several authors, reported that the worse the hearing is, the more probable is the occurrence of tinnitus.
An audiologist and a psychologist conducted these appointments at (approximately) 5, 6, 7, 8, 12, and 24 wk.
It also could be used as a clinical tool by the research audiologist during the intervention appointments. These requests generally resulted in 1-2 additional appointments, but one participant required 5 additional appointments with both the psychologist and audiologist. Thirdly, Distortion Product Oto-acoustic Emission (DPOAE) was carried out using GSI Audera to rule out normal outer hair cell functioning. The intervention consisted primarily of efforts to facilitate the therapeutic use of sound and CBT techniques to effectively manage reactions to tinnitus. Note that only one participant dropped out of the study, which occurred during the intervention period. Approximately 20% of the patients with hearing loss present complaints of tinnitus, whereas 90% of those with severe tinnitus had hearing loss.
Outcomes assessment was conducted using the Tinnitus Handicap Inventory (THI) at baseline and at 12 and 24 wk following baseline.

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