Tinnitus
When sound is a problem…
The way in which we interpret or perceive sound is very personal. The sound of a door creaking open at night can create positive or negative emotion based on our perception of the sound. If we are expecting a loved one to come home, hearing the door open is a positive sound and relieves the stress of waiting for them to arrive. If we are not expecting someone and hear the same creaking door sound, this can evoke a fight or flight response. While our ears perceive external sound, our brains interpret what we hear. When sound is irritating or uncomfortable it decreases our enjoyment of daily living. Three common sound perception conditions below are treatable when diagnosed and treated by professionals with knowledge of these conditions.
Tinnitus
Definition: Tinnitus is the perception of sound when no external sound is present. Tinnitus can be described as a ringing, whistling, rushing, pulsing sound as well as many other auditory sounds. Many people who have tinnitus are able to ignore it, but for about 10% of those with tinnitus, it is extremely bothersome, and intervention is necessary. Finding professionals who are knowledgeable is a key to successful management. There is a lot of misleading information on the internet.
Two good sources of information include:
The American Tinnitus Association (ATA): https://www.ata.org/understanding-facts
The British Tinnitus Association (BTA): https://www.tinnitus.org.uk/
Hyperacusis
Definition: Hyperacusis or Decreased Sound Tolerance - Present when everyday sounds cause a negative reaction. Present when everyday sounds are perceived as being uncomfortably loud or cause physical pain.
An evaluation for sound sensitivity with or without tinnitus is approximately a 1.5 hour appointment and includes a detailed interview regarding your problems and concerns, measurements of outer hair cell function, measurement of loudness discomfort levels, and possibly some other specialized tests. The results of the evaluation will be explained and treatment options discussed. The discussion of treatment options may be scheduled on a different day to provide you with the greatest attention to detail and allow ample time for questions.
Misophonia
Definition: Misophonia - When everyday sounds cause a negative emotional reaction. Examples of emotions that can be triggered from sound include annoyance, rage and fear.
The initial evaluation for Misophonia is approximately 1.5 hour appointment and includes a detailed interview regarding your issues and concerns, a hearing evaluation, and loudness discomfort levels. Following the evaluation, a detailed explanation of the auditory system and the mechanisms thought to be responsible for soft sound sensitivity syndrome will be discussed as well as options and strategies for management of the misophonic symptoms.
Take the First Steps:
Consult with an otolaryngologist through your medical insurance to rule out medical problems that may be causing or are related to your tinnitus. Depending on your insurance plan, you may need to request that the otolaryngologist refer you to Audible Difference for a tinnitus evaluation (CPT code 92625). Check with your insurance plan regarding coverage and benefits for this procedure.
Complete a comprehensive audiologic evaluation in conjunction with the otolaryngology appointment to rule out audiologic factors that may be causing or related to your tinnitus.
Request that your medical and audiological records related to your ears and tinnitus be sent to Audible Difference for a Tinnitus Consultation and Tinnitus Evaluation.
What should I expect at my initial appointment with Audible Difference?
When you arrive at Audible Difference after you have ruled out medical causes of tinnitus, you are ready to explore non-medical causes and treatments for your tinnitus. Your initial consultation is one of learning and exploring. Prior to the initial appointment, you will be asked to complete several detailed forms and questionnaires, all of which help put the pieces of the sound puzzle together. Reviewing the medical reports and the results of the information you return to me are helpful in understanding your tinnitus prior to your visit.
When we first meet, we will review of the questionnaires, discuss your tinnitus and concerns, plan for specialized testing to evaluate your tinnitus, and come up with the best tinnitus treatment plan for you. What we learn together defines what steps we take next: evaluation, intervention, counseling, referral, sound therapy, and cognitive behavioral therapy. There are many paths to a successful outcome, but each person’s journey is different depending on their situation.
The Evaluation of Tinnitus, Decreased Sound Tolerance, and Misophonia
The sound perception evaluation is a comprehensive 1.5 hour appointment. The tests are easy to perform and are not loud or painful. The evaluation adds to the information from the audiologic evaluation you have already completed with an emphasis on understanding more about your perceptions, including outer hair cell function, presence of spontaneous otoacoustic emissions, pitch and intensity matching, loudness discomfort levels, and a check for residual inhibition. The types of tests performed keep evolving as we learn more about tinnitus and which tests are most helpful in determining treatment options.
The results of the evaluation will be analyzed, and a treatment plan formulated in a formal report. Your individualized treatment plan may include one or more of the following:
Hearing Instruments with Sound Generators
Noise generating devices
One-on-one counseling
Referral to dentist
Referral to tinnitus coach for mindfulness training or cognitive behavioral therapy
It is possible to have both tinnitus and hearing loss. Some hearing instruments have tinnitus sound therapy options built into the programming of the instruments. Your options for the type of devices, performance, price, and style will be discussed with you to ensure that you get the best value.
Sound therapy devices and professional services for tinnitus are typically not covered by insurance. Check with your individual insurance plans for coverage and benefit information.
Diagnostic Testing and Consultation Fees
FINANCIAL POLICY: Payment is required at the time of service. We will gladly file the claim with your insurance company. The insurance company will reimburse you for any covered expenses. If you need financial assistance, please talk with us about options to assist you prior to your appointment.
Initial Evaluation Fees (Fees are subject to change without notice)
1/2-hour consultation: $100
Comprehensive evaluation of tinnitus, DST/hyperacusis, and/or Misophonia: $300
Tinnitus in Children
Researchers have documented the prevalence of tinnitus among children and adolescents. Mahboubi et al., 2013 looked at 3,250 adolescents and found that around 8% had experienced tinnitus and about half that number were bothered by it for more than three months. Some associated tinnitus with family history, subjective hearing loss, dizziness, depression, and anxiety (Kim et al. 2018).
Problems associated with tinnitus in children may include:
Sensitivity to noise
Problems with concentration, attention, and listening
Restlessness or irritability
Anxiety or depression
Problems hearing speech in noise
Families are helpful in providing details of the child or adolescent’s history including:
Description of the tinnitus
Factors that trigger the tinnitus
How the tinnitus affects the child and the family
Exposure to loud music, video games, sporting events, use of headphones
Strategies used to manage tinnitus
Management of tinnitus may include:
Strategies to promote relaxation and sleep
Strategies to manage tinnitus in the classroom
Referral to tinnitus coach or therapist
Use of sound therapy
The good news is that 97% of children and adolescents who received a simplified version of TRT showed improvement after 3 months (Bae et al., 2013).
Frequently Asked Questions
How do you treat tinnitus?
Tinnitus Retraining Therapy (TRT), is based on the model of tinnitus first published in the late 1980s by Pawel J. Jastreboff and Jonathan W. P. Hazell. While the use of sound to treat tinnitus has been documented since the Egyptian times, the work of Jastreboff and Hazell was the first to explain tinnitus based on a neurophysiologic model. Their research changed the attitudes and beliefs about tinnitus and helped professionals and patients understand that tinnitus itself was not a symptom of a disease, but the ability to “to hear sounds generated by the auditory (hearing) system, evidence of compensatory mechanisms that are part of its normal function. The problem is the distress created – not the type of sound.”
Audiologists who provide TRT understand that the goal of TRT is to facilitate habituation to the sound of the tinnitus, so it is no longer bothersome or causing an emotional reaction. This treatment has been used internationally and involves a tinnitus evaluation, counseling sessions, the use of external sound, and frequently the use of sound devices. Since that time other variations have evolved including Progressive Tinnitus Management (James Henry, et al.) and the use of Cognitive Behavioral or Mindfulness therapies.
What does tinnitus retraining therapy mean?
Tinnitus is not something you can consciously ignore. In TRT, sound is used to teach the ear-brain connection that the sound of the tinnitus is not important. Once the brain lets go of the emotional response to the tinnitus, the tinnitus can move into the background of normal physiologic noise so you are longer aware of or annoyed by your tinnitus.
Are there any side effects of the treatment?
There are no side effects.
I recently had audiological tests done. Do they have to be repeated?
The tinnitus evaluation is separate from the audiologic evaluation.
Is the counseling a form of psychotherapy or biofeedback?
No, the directive counseling provided by the audiologist provides information about how your tinnitus evolved, how TRT works, and how you can manage your tinnitus. TRT relies on both the professional component of care in addition to any sound generators that are used. Many patients benefit from seeing a “tinnitus coach,” or Cognitive Behavioral Therapist (CBT) to help the brain re-imagine the tinnitus.
What is the role of external sound?
Noise from ambient sounds such as the HVAC, soft ambient sound, music, talking books, television, and other soft low-level sounds keep the brain occupied so it is not focusing on the tinnitus. This reduces the contrast between complete quiet and tinnitus.
What are the devices and what do they look like?
There are many types of devices that are used in TRT. The consultation and results of the testing will help determine which device is best for your situation. Some are small instruments that are worn either behind or inside both ears. Others are combination hearing instruments and sound generators. The sounds that are generated by these devices are not loud and will not interfere with your work.
Why can’t I just buy the devices?
The devices may or may not be recommended for your situation. If they are recommended, you will spend time talking with the audiologist to choose the style and features that are right for you. You need both the right technology for your specific situation AND the professional guidance and care to make them effective for your specific tinnitus or sound perception challenge. Purchasing and wearing inappropriate devices can do more harm than good.
What is the difference between maskers and sound generators?
Masking uses an external sound such as white or pink noise to cover up the tinnitus. While it can be helpful in providing some relief, as soon as the masker is turned off, the tinnitus returns. Sound generators are used at a level that mixes with the tinnitus, and over time will diminish the perception of the tinnitus as the emotional response is reduced. Using sound generators according to the proper protocol for your situation will allow you to habituate to the tinnitus.
Will I be cured?
TRT is a treatment for tinnitus and is not a cure because it is an internal pattern perceived by your brain. Over time, you will no longer be bothered or annoyed by your tinnitus, but if you concentrate and try to hear your tinnitus, you will.
What is the guarantee that I get better?
Research worldwide shows that over 80% of people treated with TRT reported significant improvement. That is a better outcome than any drug on the market.
How are sound tolerance issues treated?
Sound tolerance issues are also treated using the sound generators with a specific treatment protocol for decreased sound tolerance. In most cases it involves wearing the sound devices between 6-12 months with careful counseling. Sound tolerance problems are addressed prior to tinnitus or hearing loss treatment.
Credentials for Tinnitus Treatment – Dr. Veronica Heide
Veronica H. Heide, AuD received her tinnitus training at Emory University from Drs. Margaret and Pawell Jastreboff in 2001.
She maintains active continuing education in the area of tinnitus and sound tolerance issues and is licensed by the State of Wisconsin as an Audiologist.
She has over 20 years of experience in tinnitus and sound tolerance diagnosis and treatment.
Academy of Board of Audiology (ABA) Certificate Holder-Tinnitus Management (CH-TM) Program - 2019
Member – American Tinnitus Association
Member – Tinnitus Practitioners Association
References:
The American Tinnitus Association (ATA) website: https://www.ata.org/understanding-facts
The British Tinnitus Association (BTA): https://www.tinnitus.org.uk/
Mindfulness-Based Stress Reduction for Tinnitus, an online video course: Dr. Jennifer Gans, Licensed Clinical Psychologist Consultant to UCSF Department of Otolaryngology VA of Northern California Phone: 415.244.7711
Tinnitus Treatment: Clinical Protocols. Tyler, R, S. (Ed). New York: Thieme: 2006. Henry J.H., & Wilson P.H.
The psychological management of chronic tinnitus. Boston: Allyn & Bacon: 2001. Henry J.H., & Wilson P.H.
Tinnitus: A Self-Management Guide for the Ringing in Your Ears. S.D. Dragin (Ed.). Boston, Allyn and Bacon: 2002. Jastreboff, P.J.,
Phantom auditory perception (tinnitus): mechanisms of generation and perception. Neuroscience Research, 1990, 8, 221-254. Jastreboff, P.J. and Hazell, Jonathan W.P.
A neurophysiological approach to tinnitus: clinical implications. British Journal of Audiology, 1993, 27, 7-17. Jastreboff, P.J.
The Origins of Tinnitus Retraining Therapy. Tinnitus Today, March 1998, 11-12. Nagler, M.D., Stephen M.
Tinnitus Retraining Therapy and the Neurophysiological Model of Tinnitus. Tinnitus Today, March 1998. Tabachnick, Barbara
Tinnitus Retraining Thearapy – The Newest of the New. Tinnitus Today, March 1998, 10.
Tinnitus and Hyperacusis Centre, London, UK, Jonathan Hazell F.R.C.S. Director University of Maryland School of Medicine,
Tinnitus and Hyperacusis Center, Baltimore, MD.
References for tinnitus in children:
Bae S, Park S, Park J, Kim M, Yeo S, Park S. Pediatric Otolaryngology: Principles and Practice: Childhood tinnitus: Clinical characteristics and treatment. American Journal Of Otolaryngology--Head And Neck Medicine And Surgery [serial online]. March 1, 2014;35:207-210. Available from: ScienceDirect, Ipswich, MA. Accessed November 18, 2017.
Baguley D, Bartnik G, Kleinjung T, Savastano M, Hough E. (2013). Troublesome tinnitus in childhood and adolescence: Data from expert centres. International Journal of Pediatric Otorhinolaryngology [serial online]. 77, 248-251.
Bartnik G, Stępień A, Raj-Koziak D, Fabijańska A, Niedziałek I, and Skarżyński H (2012). Troublesome Tinnitus in Children: Epidemiology, Audiological Profile, and Preliminary Results of Treatment. International Journal Of Pediatrics, Vol 2012 (2012) [serial online]. 2012;Available from: Directory of Open Access Journals, Ipswich, MA. Accessed November 18, 2017.
S.Y. Kim, Y.J. Jeon, J.-Y.Y. Lee, Y.H. Kim (2017) Characteristics of tinnitus in adolescents and association with psychoemotional factors Laryngoscope, 127, pp. 2113-2119.
Mahboubi H, Oliaei S, Kiumehr S, Dwabe S, Djalilian H. (2013) The prevalence and characteristics of tinnitus in the youth population of the United States. The Laryngoscope. 123(8):2001-2008.