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Mariko Takahashi is an ENT physician and an associate professor at Nagoya City University in Japan. Learn about an easy step-by-step process that will allow you to successfully manage patients with tinnitus. This course reviews a comprehensive process in working with patients who report severe cases of tinnitus. This course will focus on all the elements required in offering tinnitus management in your facility. When working with tinnitus patients, it is imperative that your referring physicians are educated in tinnitus therapy and proper referrals.
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Its main components are directive counseling to decrease tinnitus-related negative reactions and sound therapy to reduce the strength of the perceived tinnitus signal (Jastreboff, 2011).
The tools and counseling techniques will comfortably guide you through a process of meeting the needs of these patients and recommendations for appropriate referral considerations. This presentation will give you solutions on how to have this conversation with your referring physicians.
This informal discussion will teach you about using Zen for this population and provide an opportunity for you to ask questions to an expert on your patients. Soundasleep is the Original Speaker Pillow, combining medium support that's suitable for those who sleep on their front or their back, with a quality speaker inside. Broadband noise or conventional hearing aid amplification are commonly used in sound therapy in a TRT framework, since they are relatively neutral to listen to and thus unlikely to attract attention and induce strong emotional reactions in the patients. Music, on the other hand, is generally not recommended, since it may induce strong emotions, and may attract attention as well (Jastreboff & Hazell, 2004). However, we have seen a number of clinical cases in which neither of the two conventional TRT sound stimuli produced the desired effect. Fractal music is described as sequences of tones with no lyrics, which sound something like wind chimes. Predictable without being monotonous, the music sounds familiar, but is not associated directly with music that the listener holds in memory (Sweetow & Jeppesen, 2012). The results were positive, so a larger trial with a total of 91 patients in TRT categories 1 and 2 was initiated.
The Tinnitus Handicap Inventory (THI) is a 25-item questionnaire with three subscales: functional, emotional and catastrophic responses. The responses are summed with a total score that ranges from 0 to 100 (higher scores indicating a greater self-perceived handicap).The minimum THI score considered clinically significant is 18.
The average age, gender, hearing level, THI, and HHIA scores at the initiation of the study are shown in Table 1. According to the manufacturer’s specifications, the fractal music produced in the Zen program consists of sequences of tones with no lyrics. The fractal music and broadband options can be used separately or in combination, with the hearing aid microphones switched on or off. Patients were instructed to try all options (fractal music style, broadband noise, conventional amplification) included in their devices at home. The data logging function was activated to record the patients’ daily hearing aid usage and use of different program options.
The following trend was observed:Patients who chose to purchase the conventional simple sound generator (Group 2) were typically the ones with a relatively mild (or no) degree of hearing loss (self-perceived and objectively measured), while their THI score suggested a severe degree of tinnitus (Table 1). For these patients, the tinnitus is expected to have a greater impact on their daily lives than the hearing loss.The reverse client profile was observed in the group who preferred conventional hearing aid amplification as sound therapy (Group 3).

These patients typically had a moderate-moderately severe degree of hearing loss (self-perceived and objectively measured), while their tinnitus was at the moderate end of the scale. Thus, the assumption was that the hearing loss may be the greater problem for the patients who chose a conventional hearing aid.Client profiles for the patients who chose the combination device (Group 1) varied, but they typically had a severe degree of tinnitus combined with a moderate (or more severe) degree of hearing loss (self-perceived and objectively measured), and a severe degree of depression.
20% (6 patients) replied that they already owned a pair of hearing aids, while 17% (5 patients) were unable to perceive an effect from the sound therapy.
The remainder of this paper will report the results for this specific group.Of the 33 patients who purchased a combination device with the Zen feature, 25 participated in the re-evaluation after three and six months of therapy. Notable improvements were observed already after the first three months in the THI (Tinnitus Handicap Inventory) scores of the majority of patients who used fractal music as sound therapy.
Scatter plots of 25 patients’ THI scores at the initial visit and after six months of therapy. Each data point represents a single patient’s THI at the initial visit (horizontal axis) and after six months of therapy (vertical axis). Data points located to the right of the stippled line indicate an improvement of 20 points or more in THI.The patients were also asked to indicate the intensity level and frequency of occurrence of their tinnitus at the initial visit and after 6 months of therapy. Notable improvements were observed both in the VAS scores assigned for intensity level and for frequency of occurrence after 6 months of therapy.
Scatter plots of 22 patients’ VAS scores for perceived intensity level of their tinnitus at the initial visit and after six months of therapy. Each data point represents a single patient’s VAS score at the initial visit (vertical axis) and after six months of therapy (horizontal axis). Scatter plots of 23 patients’ VAS scores for frequency of occurrence of their tinnitus at the initial visit and after six months of therapy. The results are summarized in Figures 4-8.Overall satisfaction scores are shown in Figure 4. 69% of the patients reported being either satisfied or very satisfied with the sound therapy. A small minority (8%) reported being dissatisfied, while 23% replied that they were neither satisfied nor dissatisfied with the therapy.Figure 4. Overall satisfaction with sound therapy in patients who used Zen for 6 months.One of the basic rules for the use of sound generators in successful TRT treatment is that it must not evoke negative feelings in the form of discomfort or annoyance in the patient (Jastreboff, 2011).
The patients were therefore asked to evaluate the fractal music in terms of how pleasant they perceived it to be, and whether they had become tired of it after six months’ use. 65% reported perceiving the fractal music as either comfortable or very comfortable, while 35% were neutral. None of the patients reported perceiving the fractal music as uncomfortable to listen to (Figure 5). According to the manufacturer, under normal circumstances the music should not interfere with speech perception, unless the patient has a very narrow dynamic range resulting from a severe degree of hearing loss (Widex zen therapy, 2012).
This was largely supported by the results in the present study, as 82% of the patients reported being able to hear speech well in the presence of fractal music (see Figure 7).Affordable price was reported to be the main motivation for choosing a simple broadband sound generator by many patients in Group 2. Patients in Group 1 were therefore asked to evaluate the combination device in terms of price. 75% of the patients who had chosen the combination device responded that it was expensive, 8% that it was too expensive, while 13% found it reasonable.Figure 7. Both cases were part of the initial pilot study group of 24 patients.Case 1Case 1 was a 70-year-old female who had had severe hearing loss in her left ear since childhood. She was not concerned about her hearing loss, however, and had not considered hearing aids. Her motivation for seeking help was a strong perception of tinnitus in her right ear which had begun two months previously and had steadily grown worse.

The tinnitus had a pervasive negative affect on her daily life, making it difficult for her to maintain her relationship with her family, and reducing both her performance at work and her ability to do simple housework at home. Her appetite was lost from anxiety and fear that the tinnitus would remain untreatable until her death. Prior to her visit at the Sekiya ENT clinic, she had sought treatment in several other clinics, and had tried a variety of therapies, but had experienced no improvement. Visual Analog Scale (VAS) measures of 100% were assigned by the patient for both loudness and frequency of occurrence of the tinnitus.
Audiogram for Case 1.Due to her reluctance to trial hearing aids and the asymmetry between the hearing loss in the left and right ears, it was decided to let the patient wear a combination device (Widex mind440) on her right ear only during the trial period. At the first follow-up visit after a month, she described fractal music as a comfortable listening experience and said that her anxiety was reduced.
After 3 months, she was coping well with her tinnitus even without the device, and her THI score had dramatically improved from 96 to 12.
After six months, the amplification-only program was used more than the fractal music program, and her THI score remained low at 18. Usage pattern and self-perceived tinnitus and hearing loss for Case 1.Case 2Patient 2 was a 67-year-old female who had been suffering from severe tinnitus in her left ear for more than a year. She had sought treatment at eight different clinics, and had tried a variety of therapies, but had experienced no improvement. The patient rejected the suggestion of wearing hearing aids, but her tinnitus was so distressing that she was willing to try a combination device (Widex mind) as a TRT sound therapy device for her left ear.Figure 10. However, the patient complained that she was annoyed with the broadband noise already after two weeks. The broadband noise combinations were then replaced with a hearing aid + fractal music, and a fractal music-only option.
Her THI score had improved to 50 after the three months, and the patient reported that the tinnitus had not bothered her so severely.
The broadband noise options were replaced with fractal music options after two weeks.ConclusionsAs the sound has to be listened to for prolonged periods of time, the TRT protocol prescribes the use of neutral stimuli that facilitate passive listening and do not evoke a strong emotional response in patients, such as broadband noise or conventional hearing aid amplification. Although not prohibited in TRT, music is not generally recommended, since it may invoke a strong emotional response and attract attention (Jastreboff & Hazell, 2004). However, a good effect was obtained when using the fractal music available in the Widex CLEAR, mind440, and mind220 combination devices within a TRT treatment framework.
Improvements in THI scores were observed after six months in 92% of the patients who used fractal music as sound therapy. Our results indicate that some patients will eventually tire of the music, which suggests that patients should be given several Zen tunes or advised to use their preferred Zen style in combination with other stimuli.The results obtained in the present study suggest that a combination device offering flexible program combinations with conventional amplification, broadband noise and fractal music is an optimal choice for hearing-impaired patients with high THI scores.
The two cases also illustrate how a combination device is sometimes effective, not only in reducing the negative effects of tinnitus, but also as a way of introducing amplification to reluctant hearing aid candidates.ReferencesHenry, J. Tinnitus retraining therapy: An implementation of the neurophysiological model of tinnitus.
Psychometric adequacy of the Tinnitus Handicap Inventory (THI) for evaluating treatment outcome.
The hearing handicap inventory for adults: Psychometric adequacy and audiometric correlates.

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