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Author: admin, 16.04.2014. Category: Severe Tinnitus Symptoms

People with tinnitus often characterize their tinnitus as “ringing in the ears” or a “buzzing sound.” The American Tinnitus Association (ATA) describes it as a subjective noise that only the patient can hear. About 50 million people in the United States experience tinnitus to some degree and, in severe cases, seek medical attention. HR: Why should hearing care professionals who traditionally focus on hearing impairment get involved in tinnitus?
Clint Keifer, AuD: As audiologists, we possess an in-depth understanding of the anatomical, physiological, and psychoacoustical aspects of the auditory system. Wendy Switalski, AuD: In conversations I’ve had as an audiologist and as a consultant to audiologists, it is clear that these conditions coexist for so many of our patients. Clement Sanchez, AuD: Tinnitus can be a problem for those who are hearing impaired and have a hearing loss. Sanchez: Hearing aids can be very effective if they can reduce the symptoms related to the tinnitus.
A clinician can play a vital role in helping the patient deal with the sounds of everyday living, instead of avoiding sounds all together.
Switalski: Professionals interested in expanding their services have so many resources available. Practices may begin by simply offering tinnitus assessment, patient questionnaires, or surveys.
Keifer: Ideally, practices would be “full-service,” but in practical terms, it is difficult for any one practice to offer every possible solution. Sanchez: Assessing tinnitus can be challenging, so clinicians who decide to add a full-service tinnitus treatment plan have a few details to consider. Aside from my traditional practice, I used to schedule consultation with tinnitus patients 1 day a week and this worked well.
HR: I’ve heard that tinnitus patients can consume huge amounts of practice time and many dispensing professionals are not adequately staffed for that.
Sanchez: Yes, tinnitus patients will need time to express their fears, frustrations, and the discomfort they are experiencing because the sounds they hear are unclear and can be difficult to describe.
I would describe the tinnitus consultation as “a mix of charisma and empathy,” where clinicians can focus on gathering the information that can benefit the treatment. The MADSEN Astera2 features a dedicated tinnitus assessment module designed to help clinicians address increased claims for tinnitus and hearing loss disability. The new tinnitus test module we have developed as part of fundamental audiometry in MADSEN Astera2 supports the professional through a series of integrated questionnaires.
Keifer: Tinnitus treatment protocols should not be rigid, but rather they should adapt to the individual.
The treatment may also involve retraining strategies, amplification, masking, sound therapy device application, support group attendance, and so forth. Sanchez: In addition, it will entail an in-depth hearing assessment, such as audiometry with UCL, immittance, otoacoustic emissions (OAE), and auditory brainstem response (ABR). The full tinnitus psychoacoustic test battery is designed to improve patient counseling and test precision.
Visualization of the tinnitus on the audiogram is a great experience for a patient who has looked for help for years and may have felt misunderstood at times. The electronic questionnaires—Tinnitus Functional Index (TFI), Tinnitus Handicap Inventory (THI) and Tinnitus and Hearing Survey (THS)—can be saved in NOAH and are designed to eliminate the need for paper records.
The next step is explaining that, for example, a 7 dB tinnitus is quite a small issue that can be managed. Once again, dialogue with other professionals is important and should be considered from the very beginning. HR: What types of equipment should you consider for your practice when starting up a tinnitus treatment program? Switalski: Having access to the proper audiometer features is important for performing a tinnitus assessment.
Otometrics has developed a dedicated tinnitus management tool for audiologists, which is integrated with our clinical audiometer, the MADSEN Astera2.
Electrical suppression of tinnitus via a cochlear implant is a secondary benefit for many cochlear implant recipients. Since the advent of cochlear implantation as a treatment for profound sensorineural hearing loss, the additional benefit of electrical tinnitus suppression in some patients has been noted by several investigators.1-8 Some profoundly deaf cochlear implant recipients experience significant diminution of their tinnitus percepts when their cochlear implant is activated.
Tracking measurements of tinnitus loudness over time, McKerrow et al.9 reported that five of six subjects who wore cochlear implants had their tinnitus suppressed effectively with their devices on and receiving a noise input. Dauman, Tyler, and Aranlo reported that the effectiveness of tinnitus reduction using electrical stimulation of the cochlear in two patients wearing cochlear implants was dependent on the site of electrical suppression along the cochlear partition. A report by Hazell, McKinney and Aleksy12 surveyed 808 patients with profound hearing loss referred for cochlear implantation. The purpose of the current study is to describe the frequency, magnitude and time course of the tinnitus percepts of a large group of adult cochlear implant users.
Questionnaires were sent to active adult cochlear implant recipients who have received their cochlear implants at the Indiana University Medical Center. The subjects who currently had a tinnitus percept were asked to complete the Tinnitus Handicap Inven-tory developed by Newman, Jacobson, and Spitzer14 to assess their functional, emotional and catastrophic response reactions to their tinnitus. Of the 64 respondents, 53 reported a history of tinnitus but only 15 of the subjects in the final sample had ever sought medical attention for their tinnitus.
Of the 49 patients who perceive tinnitus after implantation, eight patients only notice their tinnitus when their device is off and no patients reported a tinnitus percept only when their device is on. The ranges, mean scores, and standard deviations of the total scores, functional subscale, emotional subscale, and catastrophic sub scale computed from the patient's self-assessment of their tinnitus using the Tinnitus Handicap Scale is presented in Table 3. The data obtained from the questionnaire used in this study suggest that, as a group, there is a relatively high prevalence of tinnitus in adult cochlear implant users.
When compared to the tinnitus percepts of patients participating in the validation study of' the Tinnitus Handicap Scale,14 the subjects who continued to experience tinnitus in this study appeared to have lower scores across all measurement conditions (total scale, functional, emotional, and catastrophic subscales).
As the current memories are retrospective in nature, it is possible that the patients' memories of their tinnitus percepts prior to implantation may not truly represent the actual percepts at the time of implantation.
The management of tinnitus complaints is a difficult task, particularly for patients with severe and profound hearing loss.
Presented at the American Neurotology Society Meeting, Scientific Program, Tinnitus Panel, September 28, 1996, Washington, DC.
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In some cases of objective tinnitus, physicians can identify the symptom with the use of a stethoscope placed on the neck or directly in the ear canal.
There is currently no known cure for tinnitus; however, there are advanced devices and treatments today that can help alleviate tinnitus symptoms. Drs Sanchez, Switalski, and Keifer share their thoughts on the benefits of tinnitus assessment, and provide advice to audiologists and hearing care professionals who are interested in adding tinnitus assessment to their practice. As hearing care professionals, we are skilled in diagnostic, counseling, and rehabilitative approaches to managing auditory disorders. And for some of them, treating the tinnitus is necessary to address the concerns that led them to seek hearing care in the first place.
They may have difficulty sleeping, be unable to concentrate, and experience irritability and high stress levels. A hearing aid can amplify soft sounds, which can have a “masking” effect and helps to decrease the contrast between the environmental sounds and the tinnitus.
This is an important step to address the patient’s fears and provide supportive tools when the tinnitus is too intense. Today, tinnitus management tools also include sound enrichment devices, sound generation pillows, as well as sound generators like MP3 and relaxing music.
Are there different levels at which practices can participate, or should every hearing care practice seek to have a full-service tinnitus treatment plan? They can also provide informational counseling and supplement their fittings with hearing instruments that include features and options for tinnitus relief. My recommendation would be to offer as many options as possible within the means of the practice and the practitioner. Collaboration with other professionals like ENTs, psychologists, and general practitioners is helpful. Prior to the consultation, patients can fill out questionnaires in the waiting room to avoid external influences during the test.
While proper diagnostic testing and quantification measures should be performed for hearing and tinnitus aspects, the treatment options will vary greatly based on the individual and should focus on addressing identifiable needs. Tinnitus can be viewed as a spectrum disorder where trying a combination of approaches may be necessary.
Highlighted in magnifying glass on lower left is the electronic questionnaires for the TFI, THI, and Tinnitus and Hearing Survey (THS), which saves in NOAH and eliminates the need for paper records.
Clinicians should ensure they are working with a subjective tinnitus and characterization via the existing questionnaires, like the Tinnitus Handicap Inventory (THI), Tinnitus Functional Index (TFI), and Tinnitus Handicap Questionnaire (THQ). Testing efficiency and immediate availability of measurement results allow more time for consultation. Test results will provide the professional with information concerning the effect of an external sound on the tinnitus. A high-resolution audiometer in frequency (1 Hz) and intensity (1 dB) is required to perform a characterization of the tinnitus. Today’s clinicians and audiologists can now more effectively evaluate the tinnitus and its impact on the lives of their patients. In one patient, the tinnitus suppression occurred bilaterally even though the stimulation was delivered to only one ear. A pulse rate of 125 Hz showed the greatest efficiency needed to suppress tinnitus, as measured by the amount of current level delivered to the implant.
Of the 256 patients who were implanted, 21% had no tinnitus, 27% had tinnitus that was not bothersome, and 52% had bothersome or annoying tinnitus.
As a result, the questionnaires included basic demographic information such as gender, age, type of cochlear implant, and ear implanted.
Figure 1 illustrates the estimated duration of the tinnitus percept prior to the implant surgery for the patients who reported any history of tinnitus before receiving the cochlear implant. Forty-one patients reported a tinnitus percept with and without their devices, with 20 reporting no change in tinnitus severity with or without the device, 15 patients indicating that the severity of the tinnitus is less severe when their device is on, and 5 patients reported that their device appeared to increase the severity of their tinnitus.
The functional sub scale is reported to reflect the role limitations in the areas of mental and physical functioning thought due to the patient's tinnitus.13 The emotional subscale reflects the patient's broad range of affective responses to their tinnitus and the catastrophic subscale reflects the patient's perceptions of desperation, inability to escape from their tinnitus, of having a terrible disease, lack of control, and inability to cope with their tinnitus.
Although only a few subjects reported that their tinnitus percept was eliminated after implantation, most users reported either that their tinnitus condition improved or remained stable with the cochlear implant.
There was no report of an increased tinnitus annoyance with the implantation from their subjects. It appears then that this group of cochlear implant users who report tinnitus are not as affected by their tinnitus as the validation group used by Jacobson and his colleagues.14 However, the differences between the mean scores are small and do not appear to be clinically significant. However, many of the informal descriptions of the.tinnitus difficulties described by the patients suggested that they continue to have rather detailed memories of their tinnitus problems both before and after the implantation.
Although cochlear implantation improved or stabilized the tinnitus percept for most adult cochlear implant users, only rarely did implantation result in total elimination of the tinnitus percept.
This may be due, in part, to a lack of residual inhibition of tinnitus in patients using multichannel implants. Additional basic and clinical research is needed to address whether different management strat-egies are required for patients who use or are candidates for cochlear implants.
Berliner KI, Cunningham JK, House WF, House JW: Effect of the Cochlear Implant on Tinnitus in Profoundly Deaf Patients. Battmer RD, Heermann R, Laszig R: Suppression of Tinnitus by Electrical Stimulation in Cochlear Implant Patients.
Tyler RS, Kelsay D: Advantages and disadvantages reported by some of the better cochlear-implant patients.
Zwolan TA, Kileny PR, Souliere CR Jr, Kemink JL: Tinnitus suppression following cochlear implantation. McKerrow WS, Schreiner CE, Snyder RL, Merzenich MM, Toner JG: Tinnitus suppression by cochlear implants. Kim HN, Shim YJ, Lee HK, Kim YM, Kim ES: Effects of Electrical Stimulation on Tinnitus in the Profoundly Deaf. However, the size of the ear canal must be large enough to accommodate the larger receiver. With this clinical foundation, few other health professionals are as well suited to help those with tinnitus. For example, the US Center for Health Statistics estimates that tinnitus was reported by 25% of those who are hearing impaired and have hearing loss. The hearing care professional needs to consider these issues if they want to succeed in managing the hearing loss on top of the tinnitus. However, it’s important to check the effect of the external sound on the tinnitus before introducing the benefits of wearing a hearing aid to the patient.
Additionally, training from hearing instrument manufacturers and collaborating with colleagues can be valuable.

Then be sure to include information that the patient may benefit from—like additional options or resources not offered at your practice.
It is important to consider that treating patients with tinnitus requires the ability to listen and a high degree of patience. When testing patients with tinnitus, clinicians should consider scheduling a dedicated time just for consultation because it will take longer than usual and the patient is expecting a solution.
For this, I would recommend using an analog visual scale of relief to set the objective from the very beginning. When the patient becomes more comfortable describing their situation, the clinician should then begin to drive the conversation.
Then the follow-up treatment can be done online, where the answers provided previously can help clinicians evaluate the impact of this strategy.
This may include education, information, or recommendations for further medical evaluation or treatment by other professionals. Psychoacoustical tests are also important and can include pitch and loudness matching and minimum masking level (MML). If there is a positive impact, like an attenuation of the perception, a strategy like the TRT (Tinnitus Retraining Therapy) can be considered.
The purpose of this retrospective study was to further explore the frequency, magnitude, and time course of cochlear implant stimulation on tinnitus suppression. The poorest tinnitus suppression performance occurred when their subjects used their speech processors set in the usual conditions to perceive speech as the acoustic input. Fifty-five of the patients used a multichannel cochlear implant (44 used a Nucleus and 11 used a Clarion) and the remaining nine used a single channel implant.
The question asked whether the respondent had ever experienced tinnitus, defined as "any sound or noise that seems to come from within or around the head (tinnitus is commonly known as 'ringing in the ears)."' If the subject did not report any experience with tinnitus, shelhe was asked to simply indicate this and return the questionnaire. Forty-four subjects experienced tinnitus before and after implantation whereas 4 subjects experienced tinnitus only prior to implantation and 5 subjects experienced tinnitus only after implantation. Table 1 presents the distribution of the location of the tinnitus percept for those cochlear implant users who continue to experience some tinnitus after implantation.
Although the ranges were relatively large across all subscales and for the total score, the mean values were relatively low as a group. A small number of users reported that the severity of the tinnitus increased after implantation.
However, the findings from this study indicate that although the majority of the users perceived some improvement in their tinnitus percepts after implantation, the effects of the implantation on tinnitus was not consistent across all subjects. Therefore, cochlear implantation is not recommended when tinnitus control is the sole therapeutic goal. It also seems apparent that tinnitus production is not entirely dependent on cochlear disease processes.
The patient may experience a vibration sensation with this power receiver and feedback may be more difficult to manage.
Good tinnitus resources are needed in every community to bring new exposure and business to your office.
The Tinnitus Clinic at Oregon Health and Science University found that 90% of their patients who have tinnitus also have some degree of hearing loss. If the patient can accept a sound generating strategy, many hearing instrument manufacturers deliver interesting solutions today—with or without an amplifier for the hearing loss. A high prevalence of preoperative tinnitus was documented in profoundly deaf adult cochlear implant users.
Four of their six subjects perceived a reduction in their tinnitus percepts with their devices on but without any acoustic input to the speech processor. This is consistent with the observations by Thedinger et al.11 that patients with tinnitus receive minimal success with electrical stimulation from cochlear implants when they are implanted specifically to treat their tinnitus.
For those subjects who reported any experience with tinnitus, they were asked to complete the remaining questions and then return the questionnaire. Three subjects recalled a severe episode of transient tinnitus during the post-operative device hook-up. Table 2 presents the distributions regarding the users perceptions of the annoyance and loudness of their tinnitus at the time they completed the questionnaire and when they believed that their tinnitus was at its worst.
Although the mean scores for the functional sub scale were only slightly higher than the mean scores for the emotional and catastrophic subscales, when adjusted in relation to the possible maximum scores, the means scores across all three subscales were judged to be equivalent.
There was no report of tinnitus onset corresponding with implant surgery or with the initial programming of the device. In contrast to the Kim et al.13 study, some users' tinnitus actually became worse after implantation. For example, a clinician may have to wait for the patient to fall asleep using a sound generator pillow.
Although only a few subjects reported that their tinnitus was totally eliminated after implantation, many users reported improvement or stabilization.
All subjects were found to have experienced some alterations in their tinnitus percept with the device on.
The age range encompassed all decades from the 3rd to the 8th with the majority of patients above 50 years-of-age at the time of the sampling. Items on the questionnaire included whether the subjects had ever sought medical attention for their tinnitus, their experiences with tinnitus before and after implantation, the nature of any current tinnitus or their recall of the nature of the tinnitus they had experienced, their percepts of the pitch and loudness of any current tinnitus, and its perceived annoyance and severity.
Of the 44 patients who experienced tinnitus before and after implantation, 22 patients reported that the cochlear implant had no effect on the severity of their tinnitus, 18 patients indicated that the severity of the tinnitus decreased after implantation (6 indicated that they received "significant improvement" after implantation), 2 patients stated that the severity of their tinnitus increased after implantation, and 2 patients reported that no change in the severity of their tinnitus but that the tinnitus percept changed in regards to pitch and tonality.
Furthermore, there was no report of the tinnitus percept being present only when the device is on. Consequently, the clinical application of cochlear implants alone as the primary means to suppress tinnitus is not supported by the current data. Duration of tinnitus appeared to be a significant factor as all subjects whoreported a significant improvement had less than a 20-year history of tinnitus. The authors concluded that tinnitus sufferers may benefit from electrical stimulation to suppress the tinnitus percept, particularly if the device could stimulate the cochlear at the site corresponding tonotopically to the tinnitus frequency domain.
All subjects who reported a significant improvement from their implantation had less than a 20-year history of tinnitus.

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