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Author: admin, 16.05.2014. 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. Key words: compensation, hearing disorders, loudness matching, loudness perception, malingering, pitch matching, pitch perception, rehabilitation, reliability of results, tinnitus, tinnitus diagnosis. The proliferation of books, Web sites, and organizations focusing on tinnitus has increased its visibility as a legitimate medical condition. Patients reporting tinnitus are generally taken at their word because there would normally be no reason to dispute their complaint. No objective measure currently exists to prove the presence of chronic tinnitus or to verify its reported severity [5,9–10]. We have conducted studies since 1995 to develop computer-automated, self-guided tinnitus assessment procedures that can be used in a standardized fashion [13–18]. Using the TES, we conducted a series of experiments comparing responses between study participants who have tinnitus versus participants who do not have tinnitus. Interested parties contacted the Research Coordinator, who conducted telephone screening using a standardized recruitment guide. Candidates who passed the telephone screening were scheduled for a hearing evaluation to determine whether they were eligible for the study (described in next paragraph) and to obtain informed consent. At their appointment, candidates had their hearing evaluated by an audiologist (conventional hearing threshold evaluation with results in decibels hearing level [dB HL]). To balance groups with respect to degree of hearing loss, we recruited equal numbers of participants for the tinnitus and non-tinnitus groups in the following four categories: (1) younger normal to near-normal hearing, (2) younger hearing impaired, (3) older normal to near-normal hearing, and (4) older hearing impaired. Audiometric testing was conducted in an Acoustic Systems (Austin, Texas) Model RE-245S double-walled sound-attenuated suite. The Pod (Figure 1) served as a user interface, enabling participants to control stimulus parameters and respond to tests. The Pod is a single integrated device with insert earphones ER-4B (Etymotic Research, Inc; Elk Grove Village, Illinois) permanently attached (Figure 1). During TES testing, the audiologist was kept blinded as to whether a participant did or did not report the perception of tinnitus.
Non-tinnitus participants were coached to respond to all testing as if they perceived tinnitus. Tinnitus matching requires individuals to distinguish between a matching tone and the tinnitus. For the non-tinnitus participants, if one ear was reported to have better hearing sensitivity, then that ear was designated the stimulus ear. This sequence of testing (hearing threshold followed by LM) was repeated at the remaining test frequencies in ascending order.
When LM testing was complete, on-screen instructions explained the tinnitus PM task–basically to rotate the encoder dial to find a tone that best matched the pitch of the tinnitus. MML refers to the minimum level of broadband noise required to render a person's tinnitus inaudible. RI is the temporary suppression or elimination of tinnitus following auditory stimulation [25–26].
The first automatic audiometer was developed by B??k??sy in 1947, and his technique is referred to as B??k??sy audiometry [27]. The FCDS procedure is fundamentally different than tinnitus pitch matching in that patients classify a comparison stimulus relative to the tinnitus rather than matching the stimulus to the tinnitus. For phase 2, 43 new participants (23 with tinnitus and 20 without) performed testing in the sound booth.
The goal of the analysis was to find a set of metrics derived from the TES components that best identifies people with tinnitus. The MML in dB SL was computed from the threshold and MML responses using broadband noise; an indicator for whether RI occurred and how much RI occurred were computed from that test component. A prediction model was developed from the phase 1 and phase 2 samples, and the phase 2 model was validated in the phase 3 sample.
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. Veterans can claim tinnitus as a 'service-connected– disability if the tinnitus is thought to be connected to military service. When approved, tinnitus claims nearly always result in a 10 percent disability rating, which qualifies the claimant for monthly compensation. Veterans are more aware of tinnitus and are increasingly submitting disability claims and requesting services at VA medical centers. Some patients, however, seek documentation to support a claim for financial compensation or to become eligible for medical services. The assessment involves several components, with each component requiring the examiner to make a decision based entirely on the claimant's subjective report. Assessing tinnitus is similar to assessing pain, which depends on self-report, scaling of the subjective symptom, and medical history [11]. The automated system has undergone numerous iterations and was eventually redesigned to enable clinical implementation. We have therefore conducted testing of individuals with and without subjectively reported tinnitus using the TES. The study was conducted in three phases, and multiple psychoacoustic tests were conducted during each phase. Study participants were recruited by a combination of local newspaper advertising, recruitment flyers posted at the Portland VA Medical Center (PVAMC), and by contacting individuals who had previously participated in research at the National Center for Rehabilitative Auditory Research. While still on the telephone, they were informed that the study was being conducted to develop a new technique for determining whether a person has tinnitus or not. Exclusion criteria at this stage included visible signs of middle or outer ear problems, air-bone gaps of 15 dB at two or more frequencies in one ear, or air-bone gap of 20 dB or greater at any one frequency.
Normal to near-normal hearing was defined as all hearing thresholds within 35 dB HL in the test ear.
We used the fifth-generation version of the TES, which provides completely automated testing sequences [13–18].
The Pod provides for signal generation and signal processing (mixing, attenuation, switching, muting, and headphone buffering). Tests and test parameters are preset into operator-created session templates, which enables the same battery of tests to be run on multiple patients. Responses made with the Pod encoder dial and response buttons were recorded to the same database from which test session parameters were read. The Pod was calibrated in the laboratory (using a Br??el & Kjaer [N??rum, Denmark] type 2231A sound level meter and type 4157 ear simulator) and then delivered to the testing location. Pod connects to computer and is hardwired to ER-4B insert earphones.Click Image to Enlarge.
If hearing sensitivity was symmetrical, then participants could choose which ear would be the stimulus ear. Obtaining an LM at a test frequency requires first determining the hearing threshold at that frequency to enable the LM to be reported in decibels sensation level (dB SL) (decibels above threshold). To ensure that participants understood the concept of loudness, an instruction screen was shown to explain the difference between pitch and loudness [21,23].
To perform B??k??sy audiometry, patients depress a button when a tone is audible and release it when the tone is inaudible.
The laboratory version of the FCDS procedure is time consuming and requires participants to be trained in the test paradigm [28]. A rough initial estimate of the tinnitus pitch was first obtained using a simple up-down staircase procedure with a large step size. The second staircase initiated at one step above the previous response in the first staircase.
The three phases reflect modifications to the procedures to attain more reliable, accurate, and pertinent responses from the study participants.
However, the audiologist sat in the booth along with the participant and was available to answer questions and provide instructions as needed for the different tests. As dictated by the results of the phase 2 analysis, phase 3 participants only completed threshold, LM, and PM testing. Statistical approaches used to achieve this goal are based in methods of diagnostic test development [30] and machine learning [31]. Participants without tinnitus were on average older than participants with tinnitus across study phases. 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 VA adjudicates each claim and determines whether reasonable evidence exists to support it.
The examiner must possess the skills to conduct such an assessment and to make qualified judgments as to the legitimacy of such claims [6]. These components generally include assessing the presence, impact, etiology, and permanency of tinnitus [8]. Assessing tinnitus for litigation purposes typically involves establishing consistency between verbal responses and medical records, reliability of tinnitus psychoacoustic measures, and sufficient duration of the tinnitus to assume permanency [8]. Preliminary data have revealed significant differences in responses between groups [17–18]. Tests conducted during phase 1 included tinnitus LM, tinnitus PM, MML, RI, B??k??sy, and forced-choice double staircase (FCDS).
Those who did not have tinnitus were told that their task was to pretend that they experienced tinnitus and to respond accordingly with respect to all testing, questionnaires, and interview questions. All test parameter options and settings are stored in a Microsoft Access database (Microsoft Corp; Redmond, Washington).
Participants were not instructed to use any particular method to behave as though they were convincing the audiologist they had tinnitus.
Instructions to non-tinnitus participants for performing tinnitus matching were the same as for the participants with tinnitus. Participants rotated the encoder dial to find the point of minimum audibility for the tone, and then selected the threshold level by pressing the response button.
Participants rotated the encoder dial followed by a button press to identify and select the PM. Testing can be done using either continuously variable (sweep) frequencies or discrete (fixed) frequencies.


For our study, the FCDS protocol was simplified to the extent possible to be conducted rapidly and without training. It was assumed that the pitch of the test tone on the first trial was well below that of the tinnitus [29], and accordingly, the participant reported that the pitch of the test tone was below that of the tinnitus. This was an iterative study, with results of each phase determining protocol changes that were indicated for subsequent phases. The training set is used to develop a candidate statistical model that predicts the chances of having tinnitus given the TES test results. High frequency pure tone averages (PTAs) (3, 4, 6, and 8 kHz) were within 10 dB between groups of each study phase. 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.
Currently, determining the presence of tinnitus is based on subjective reporting–objective measures do not exist. There is further the question of functional effects (impact, distress, reactions, etc.) of the tinnitus [12]. Before the present study, measures obtained with the TES included (1) hearing threshold, (2) loudness match (LM), (3) pitch match (PM), (4) bandwidth match, (5) minimum masking level (MML), and (6) residual inhibition (RI). The tests conducted during phases 2 and 3 were chosen based on results of the previous phase.
This maximum hearing loss criterion was imposed to ensure that participants could hear the test stimuli delivered from the TES.
Controls on the Pod include a continuous rotating encoder dial that provides a single-point adjustment of signal parameters. Test sessions are launched by creating a new or selecting an existing patient record and choosing a preconfigured template.
Participants determined on their own how they would respond in spite of their nonexistent tinnitus.
If the tinnitus perception was reported to be symmetrical, then participants were given the choice as to which ear received the stimulus.
Following instructions, a continuous tone was presented at a randomized output level above the hearing threshold just established.
For this study, the Pod was programmed to enable B??k??sy audiometry through incorporation of a sweep-frequency oscillator. The frequency of the test tone was then increased in octave steps until the participant reported that the pitch of the test tone was higher than that of the tinnitus. The two staircase procedures ran concurrently until 12 reversals were obtained for each procedure, disregarding the first 3 reversals obtained before the double staircase procedure was initiated. Measures of central tendency and spread were computed from the B??k??sy continuous and pulse tone responses at both 1 kHz and at the PM frequency.
The model is then applied to the training set to determine whether the prediction model can be refined.
For example, a clinician may have to wait for the patient to fall asleep using a sound generator pillow. It was recently reported that Veterans have twice the prevalence of tinnitus as non-Veterans [3]. By the end of fiscal year 2011, a total of 840,865 Veterans were service connected for tinnitus.
With the VA, however, functional effects are not considered when assessing a tinnitus claim.
Repeated testing with research participants has documented response reliability for all these tests [16,19–22]. To accomplish this objective, we developed and evaluated an automated test battery to be administered in a single session. Those responding 'sometimes– were excluded because of the intermittent nature of their tinnitus. For most of the tests, a sound was presented and participants turned a dial on the Pod to control output level or frequency of the sound. The template can be adjusted for an individual test subject's hearing profile in the session configuration menus. Participants read the on-screen instructions and then proceeded to provide hearing thresholds (as for pure-tone threshold testing as just described). This change in response corresponded to a reversal in that the frequency of the test tone on the next trial was decreased rather than increased.
Finally, additional metrics were computed by contrasting continuous and pulse tone responses on the B??k??sy test component and between staircases of the FCDS response set. This is repeated until an optimal model is developed from which the accuracy of the model is computed.
Using our computer-automated, self-guided tinnitus evaluation system, we conducted three phases of testing to compare psychoacoustic measures of tinnitus between participants with versus without tinnitus.
The greater prevalence of tinnitus for Veterans compared with non-Veterans has also been reported by Adams et al. Tinnitus is clearly a significant and escalating problem for Veterans and for the Department of Veterans Affairs (VA) healthcare system. Participants then completed basic questionnaires providing demographic data and characteristics of tinnitus (duration, tonality, location, etc.).
Following completion of a test session, the operator can open a report summarizing test results.
If newer calibration data became available, they were downloaded from the Pod, saved in the database, and used during testing to provide calibrated stimulus levels.
Following thresholds, the noise was presented bilaterally at levels 5 dB above the respective thresholds. For B??k??sy LM, participants depressed the button when the loudness of the tone was perceived to exceed the loudness of their tinnitus. These estimates were combined to provide a single, more precise estimate of tinnitus pitch after checking the reliability of the participant's judgments. This collection of TES metrics comprised the predictors used in this analysis to identify tinnitus in each sample of participants. More specifically, linear regression was used to estimate regression coefficients for each of the predictor metrics. Phase 1 measures included loudness match, pitch match, minimum masking level, residual inhibition, B??k??sy, and forced-choice double staircase. Both of these factors involve the interpretation of highly subjective information derived largely, if not solely, from verbal report. They released the button when the loudness was perceived as below the loudness of their tinnitus.
The average of the test frequencies at the two reversals provided a rough first estimate of the frequency corresponding to the tinnitus pitch.
Crossvalidated prediction accuracy, defined here as the Schwartz Bayes Criterion (SBC), was computed using random fivefold partitioning of each sample. Across study phases, men were more highly represented than women, and this discrepancy was greater for participants with tinnitus than for those without tinnitus. It would seem likely that noise exposure in the military (weapons fire, aircraft, explosions, etc.) increases the prevalence of tinnitus in Veterans [5]. VA examiners must opine as to the cause of the tinnitus and its potential connection to military service. A custom test template was developed to check the calibration of the Pod at regular intervals, using an Extech Instrument (Nashua, New Hampshire) Model 407768 sound level meter.
The tone decreased in intensity when the button was depressed and increased when the button was released. Predictors were added or removed using stepwise regression so as to optimize the SBC statistic.
The greatest difference was in phase 3, where the percentage of men in the tinnitus group was 15.8 percent higher than for men in the no tinnitus group. Three LM tests were performed–two discrete-frequency tests and a sweep-frequency test. This procedure was repeated until an optimal set of TES predictors was identified that best predicted tinnitus status.
Differences were seen between groups; most notably, higher low-frequency loudness matches and higher median pitch matches were observed for participants with tinnitus. Discrete-frequency testing was done using a 1 kHz tone and a tone at the PM frequency (determined as the average of 10 PMs recorded during the PM task). These predictors were then fed into a logistic regression model, which was used to compute the crossvalidated Receiver Operating Characteristic (ROC) curve and the area under the ROC curve (AUC). A technical discussion of approaches to machine learning and predictive algorithm development are given in Hastie et al. Testing order (sweep vs discrete frequency and continuous vs pulsed tones) was randomized and counterbalanced.



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