2. What is tinnitus?
Any sound that is perceived by the listener that does
not originate from an external sound source
May be perceived in one or both ears (peripheral)
and/or in the head (central)
60% bilateral
30% unilateral
10% central
From latin word, tinniere, which means “to ring”
4. Causes of Tinnitus
Most commonly caused by some sort of change
to the auditory system
80% of patient’s with SNHL have tinnitus
Hearing loss results in changes in the neural
activity of the auditory system, which the
auditory cortex interprets as sound
Much like phantom limb syndrome. Areas of the
cochlea where there is hair cell damage can no
longer amplify sounds where damage has
occurred so a phantom sound is interpreted by the
brain.
5. Other Causes of Tinnitus
Hearing loss, especially in cases of noise-induced
hearing loss (NIHL)
External or middle ear issues (wax, fluid)
Acoustic neuroma (UNILATERAL tinnitus)
Medications
Sinus/allergy issues
Dental issues (TMJ-temporal-mandibular joint
syndrome)
Cardiovascular
Neurological (MS)
Stress/anxiety
7. Some musician’s consider it a badge of
honor…
Peter Frampton
“I wonder how you’re feeling. There’s ringing in my ears.
And no one to relate to, ‘cept the sea.”
Bob Seger
“With the echoes of amplifiers ringing in your head.”
8. Prevalence of Chronic Tinnitus
NIDCD.NIH.GOV
•~22 Million Americans
•10% of adult population
9. Types
Subjective
Can only be perceived by the patient
Most common type (95%)
Objective
Can be heard by others
Rare (<5% of all tinnitus cases)
Usually pulsatile (in sync with heartbeat)
Causes: vascular or muscular
10. Causes of Objective Tinnitus
Vascular
Arteriorvenous aneurysm
Glomus jugulare tumor
Muscular
Patent eustachian tube
Palatal myoclonus: involuntary muscle jerk of the roof of
the mouth
Spasm of stapedius or tensor tympani muscles
11. Bothersome/Uncompensated Tinnitus
Only about 20% of people with tinnitus are bothered
by it
The tinnitus itself isn’t the problem. The person’s
REACTION to it is what is problematic.
Tinnitus may result in irritability, fatigue/sleep disturbance,
depression, suicidal thoughts
These patient’s need to be referred to a mental health
professional
12. A Viscious Cycle
Attentional Factors (patient chooses to attend to
tinnitus)
Emotional reaction
Limbic system: negative emotional labeling of the tinnitus
Autonomic system: activation of the fight-or-flight
mechanism (Can this tinnitus harm me?)
Stress
Amplification of tinnitus signal (louder)
14. Masking
Use of noise to temporarily mask or “cover up” the
tinnitus so it cannot be perceived
This is often successfully accomplished when patients
with hearing loss use traditional hearing aids. The
amplification of environmental noises often reduces or
completely masks tinnitus.
Our newest generation hearing aids have optional tinnitus
maskers built-in for when hearing aids aren’t enough to
mask tinnitus. This may benefit that 20% of patients with
tinnitus that are truly bothered by their tinnitus.
15. Masking
There are companies that manufacture tinnitus
maskers for those with normal hearing. May be in-
the-ear with a very large vent or a
behind-the-ear, open-ear device
www.ata.org www.siemens.com
16. Masking
The use of a sound machine or external noise
source (i.e. ceiling fan) can be very helpful at night
Different types of noise are utilized in masking: white
noise, pink noise, brown noise, grey noise (all have
varying complexity based on frequency components)
17. Tinnitus Handicap Inventory
Patient self-survey
Sample questions
Do you feel you have no control over your tinnitus?
Because of your tinnitus do you feel tired?
Because of your tinnitus do you feel depressed?
Does your tinnitus make you feel anxious?
Quantifies the severity of tinnitus
Rates degree of handicap from slight to catastrophic
18. Tinnitus Retraining Therapy
Jastreboff created TRT
Combines counseling with use of noise generators
Counseling: reclassify tinnitus to a category of neutral
signals
Sound therapy: weaken the tinnitus-related neural activity
Goal: Habituation to the tinnitus (no longer pay
attention to it)
19. Neuromonics
Six to eight month therapy protocol
Uses spectrally modified music that has been
tailored according to each patient’s hearing and
tinnitus characteristics
Combined with an underlying neural stimulus
Retrains the brain to filter out
tinnitus disturbance
Very expensive~$5000 for treatment that lasts less
than a year
20. Other Sound Disorders-Hyperacusis
Everyday sounds seem “too loud” or “uncomfortable”
About ½ of those with tinnitus, also have
hyperacusis
Affects 1 in 50,000
21. Hyperacusis Causes
Hearing loss
Noise Injury
Head injury (i.e air bag deployment)
Ototoxicity
Lyme disease
Viral infections involving the inner ear or facial nerve
(Bell’S palsy)
TMJ
PTSD (post-traumatic stress disorder)
Chronic fatigue syndrome
Epilepsy
Depression
Migraine headaches
22. Hearing Aids in Patients with Hyperacusis
The measurement of LDLs is very important to ensure
that the maximum output of the hearing aids (MPO)
never exceeds the patient’s comfort level
Real-ear-to-coupler difference (RECD) should be performed to
convert the patient’s LDLs in dB HL (audiometer) to dB SPL
Real-ear measurements are VERY important to confirm that the
MPO of the hearing aid in the patient’s ear is below the patient-
specific LDLs (in dB SPL)
23. Hearing Aids in Patients with Hyperacusis
It may be beneficial to perform a closed ear fitting (rather
than a completely open fit)
Using a closed dome, custom earmold, or custom aid will
prevent environmental noise from naturally entering the ear
canal
This will allow you to better control the sounds that are allowed
through the hearing aid to make the patient as comfortable as
possible
On the other hand, patients with hyperacusis AND tinnitus may
find that a closed fitting makes their tinnitus seem louder.
As you can see, we walk a very fine line with hyperacusis and tinnitus
patients
24. Other sound disorders
Misophonia
Dislike of sound
Phonophobia
Fear of sound
Often these patients come in reporting that they use
earplugs in everyday circumstances. This is NOT
recommended. It will actually worsen problem.
25. When in doubt…
If you have a patient with bothersome tinnitus
and/or hyperacusis, it is important to refer them to an
ENT physician for medical evaluation and treatment
A good indicator that a patient needs to be referred
for medical evaluation is when they report that the
tinnitus and/or hyperacusis is worse than their
hearing loss
Use the Tinnitus Handicap Inventory as a guide
