Management of Balance & Tinnitus

>>INSTRUCTOR: Hello, everybody!

I hope you are doing well and still managing

to keep safe and healthy while we are continuing our online instruction,

online lectures, for Introduction to Audiology for Spring Semester.

So this is the lecture for Monday,

April – no, not Monday; Tuesday,

April 7th. And this is, uh – the topic today is management of balance disorders,

tinnitus, and decreased sound tolerance.

So these are some issues that,

um, have been touched upon in previous lectures as

potential symptoms or components of different disorders,

but now we're gonna talk about them specifically and individually.

So today's outline takes us beyond disorders

that cause hearing loss and treatments for those disorders.

So today, we're talking about disturbances of balance.

So we'll revisit some tests for vestibular abnormality.

We talked about a couple of these in a previous lecture,

but there's actually more tests of vestibular function than we've already covered.

Uh, we'll talk about vestibular rehabilitation – so,

essentially, management of vestibular problems in our patient population.

Tinnitus is its own category.

Tinnitus is not a disorder, but a symptom of some other underlying condition.

But it's something that's highly prevalent in the US population,

and so it does deserve its own category or its own topic in terms of coverage in this course.

We see many more audiologists that engage in tinnitus evaluation and management.

So we'll talk about its classifications,

how it's evaluated and managed.

We'll also talk very briefly towards – at the

end of the lecture about hyperacusis and misophonia,

which are two sort of sub-categories of,

um, of sound disorders that land on the caseload of audiologists.

So it's important for us to know about them.

OK, so let's start off with disturbances of balance.

So disturbances of balance can include complaints of true vertigo,

which we've talked about before.

So vertigo is that sensation of true spinning or motion.

It can be dizziness. Dizziness is sort of that imprecise term that

needs to be further defined but can be sort of

all-encompassing because it can include things like lightheadedness and disequilibrium,

disorientation – Lightheadedness is that woozy sensation;

disorientation, not really knowing where you are in space,

potentially; imbalance or gait disturbance,

making it difficult to walk; and then decreased gaze stability can be a part of this,

and that has to do with vision.

How steady is your gaze? And that helps you maintain your balance as part of the balance system.

So those are the things that can present,

or these are the symptoms that our patients can present with when they have balance disorders.

Now, balance is something that we generally don't

think about in terms of disorders in the pediatric population,

but we are learning more and more about the fact

that balance – there can be balance problems in our pediatric population.

So it's estimated that balance problems or disturbances

of balance can affect as many as 1 in 5 children,

which is 20% of our pediatric population.

And that's – that's a fairly high number,

and it's only been recently, probably within the last 10-15 years,

that we've started to see more attention be paid

to evaluation of vestibular function or balance function in children.

You know, the issues here are that we may see delays in postural control and motor skills development.

We can think that these might be those clumsy

kids that are going through growth spurts – we

see a lot of clumsiness related to growth spurts

– but this could be a child who's routinely clumsy,

who falls a lot, and that could be related to growth,

but it could also be related to disturbances of balance.

And for children, if there's gaze instability or oscillopsia,

that could cause problems with their visual acuity.

And this may, in turn, adversely affect their reading success and their literacy.

If they have gaze instability,

they're not able to focus on a given line on a text,

whether it's a book or a computer screen or whatever the case may be.

And if you're not able to steady your gaze and focus in on that one single line,

it's gonna be hard to read. Disturbances of balance are extremely common in the geriatric population.

Very common complaint of older adults.

We see that 1 out of 4 patients over the age

of 72 years report at least one episode of dizziness.

That's 25% of our geriatric population reporting dizziness.

It's one of the most common reasons an elderly person will visit their primary care physician,

and it could be true vertigo,

it could simply be dizziness or unsteadiness,

lightheadedness, or it could be problems with their gait and their balance.

And so that impacts their ability to walk.

And so this puts them at high risk for falls.

And so you can see in a couple of the images

that I pulled off of the internet – here's an older woman holding on to a wall for support,

and then you see an image of an older man who has fallen on the stairs.

So these are two images that suggest that balance disturbances have significant consequences,

you know, particularly for the elderly or the geriatric population.

Falls are a huge concern, because falls,

um, lead to hospitalization, they have a high co-occurrence of hip fracture,

and hip fracture in the geriatric population

usually is a triggering event for this cascade

of problems or continued health problems post-hip-fracture.

And I think I mentioned really early on in the

semester why we're interested in balance as part of audiology,

which is – We think generally just about hearing;

why are we interested in balance?

Well, it's part of the auditory system,

and for our geriatric population who have balance or vestibular weaknesses,

they're at risk for falls, and there's a high percentage of those older folks that do fall,

break a hip, and then because of that cascade,

die within a year of that fall.

So if we can prevent those falls through treatment

of vestibular weaknesses or disturbances of balance,

we can prevent falls and we can prevent that cascade of more health problems.

And then the other part of this is that disturbances

of balance or vestibular problems often precipitates

early placement in assisted living facilities or nursing homes.

So if you think about – Elderly individuals or geriatric individuals often live alone,

maybe because they – their spouse has passed away,

um, and their children live in another city or another state;

or they may live with another elderly person,

so their spouse is elderly as well.

Now, that means that if they have disturbances of balance or vestibular problems,

they may require care to help them with their daily living or activity of daily living.

And so these issues can trigger movement into an assisted facility,

which is not something that most people want

to do – or they want to put that off for as long as possible.

So this is, again – these last two slides are giving us sort

of the framework for why disturbances of balance

are so important for us to understand and to be able to treat,

and audiologists are on the front line of this assessment and treatment process.

Here are some more statistics pulled from the Vestibular Disorders Association.

So more than 1/3 of adults in the US 40 and older

have experienced some sort of vestibular dysfunction.

That's a huge percentage, and so there is something going on out there,

and this can have – It could be something very innocuous that – you know,

you experience a little bit of vestibular dysfunction,

you compensate for it, and then you're good.

But it could have this cascade effect that I mentioned earlier.

Balance is controlled by the inner ear;

that's why we are so interested in the vestibular system and imbalance.

But it's also controlled by the eyes,

our vision; and our sense of touch,

or proprioception. So it's this three-pronged system that all interacts to give us our sense of balance,

our ability to maintain our gaze,

our ability to walk and not fall,

etc. Symptoms of vestibular disorders include balance problems,

like what we've been talking about.

It can affect cognition, so there could be problems concentrating.

If your cognitive load is – If you are so heavily

engaged in just trying to maintain your balance,

it doesn't leave much cognitive resources for

attending to communication or to a problem that you're working on.

It can create vision disturbances and hearing

changes because the vestibular system is so – is part of the hearing system.

Diagnosis: Vestibular disorders are not easy to diagnose.

This is true because we have three different systems that interact.

Is it the inner ear? Is it the visual system?

Is it a neural component with proprioception?

Um, so the average patient consults 4-5 doctors before receiving a diagnosis.

We can certainly do better than that.

IT's just educating patients on who they should see.

And then we're gonna do a variety of different types of tests to get at that diagnosis.

Treatment depends on the diagnosis.

It could be physical therapy – so just strengthening those muscles and proprioception.

It could be positioning maneuvers – we'll talk about in a little bit.

Diet and lifestyle changes, that could potentially improve balance.

Anti-vertigo medications, or antivertiginous medications,

can help. Um, surgery is pretty drastic.

It's probably one of the last things on the list that can help,

but certainly is something that could be used to treat vestibular problems.

All right. What are some causes of balance problems?

We see this table here that was pulled from your

textbook separating causes in the pediatric population from the adult population.

And you're gonna see some overlap here.

So the very first one is labyrinthitis or inner-ear disorders.

So labyrinthitis is just a catch-all term for any infection or inflammation of the inner ear.

And that's gonna have multiple symptoms,

including dizziness, vertigo,

or imbalance. For pediatrics,

it could be poor visual convergence.

Visual convergence is just a,

a term that refers to the two eyes working together to give you binocular vision.

So, the two, uh, eyes – the signal that the two eyes receive converge and,

into one individual percept. And for kids,

if they don't have good visual convergence,

that can create some dizziness or vertigo or balance issues.

Low core strength, so just – I guess we all need to strength our core.

Poor midline development, poor tactile awareness – this has to do with proprioception,

so just poor awareness of their proprioception from their feet.

Poorly integrated reflex patterns,

and a big cause, uh, for balance problems for both kids and adults is head injury or traumatic brain injury.

For adults, we see vision problems on that list,

numbness and nerve disorders – that's gonna affect their proprioception.

Uh, joint and muscle problems – that should be "joint,

" not "join. " Joint and muscle problem that – it's just gonna

be strength of being able to stand upright and maintain balance.

Cardiovascular issues, psychological factors,

medication side effects – a lot of older adults are on a lot of medications,

which can have some negative side effects.

Low blood pressure often gives that sensation of lightheadedness.

So low blood pressure could be something that's causing,

um, a balance issue. And again,

there's head injury on our list.

OK, so what are the tests that we use for vestibular abnormalities?

So the – the one that's been around the longest is videonystagmography,

or electronystagmography. So ENG or VNG.

And this is measurement of nystagmus using the caloric test.

And this test has been around for a long time,

and it's something that we've already covered when we talked about the inner ear.

So ENG – ENG is the historic test which used

electrodes to measure eye movement and to measure nystagmus.

Videonystagmography or VNG does the same thing,

but with the use of goggles that you see over

here in this image of this young man wearing these goggles.

They're infrared goggles that record eye movement.

And they're gonna record eye movement while we're doing the caloric test,

so that's part of this whole process where we

present warm and cold water or air into the ear canal.

And what that does is that induces nystagmus in people with normal vestibular systems.

And then if you have a vestibular weakness or some sort of vestibular disorder,

you're gonna see reduced nystagmus or no nystagmus during that caloric testing.

So a lack of nystagmus or reduced nystagmus is an indication of vestibular abnormality.

The other test that we've already talked about: This is a newer test,

computerized dynamic posturography.

So this really measures, um, balance rather than vestibular – specifically vestibular abnormalities.

It's part of the balance. Remember,

vestibular system is part of our balance mechanism.

So CDP assesses the ability to coordinate movements,

and you can see how that works.

Patients are placed in these harnesses,

and then they stand on a pressure plate,

and then, um, the, uh, the equipment simulates these different environments

or different conditions that the patient is either looking at or they're closing their eyes.

And what it's measuring is the vestibulospinal reflex.

So it is the culmination of the vestibular system

with the proprioception spinal system that maintains balance.

And so we can do this in really good simulated

conditions or in sensory-compromised conditions by having them close their eyes.

And that takes away that input,

and you can see what that affect would be on

their balance through that pressure plate that they're standing on.

So those are two tests we've already talked about.

But there are a couple of other tests that have

been more recently developed to get at other aspects of vestibular function.

One is called vHIT, or the video head impulse test.

This is one that has been pretty recently developed,

and the idea here is now we're measuring the vestibulo-ocular reflex.

So now it's the vestibular system and the visual system working together.

So we're measuring that reflex in response to head movement.

And you can see, um, over on the right-hand side this image where you – especially right in the middle.

You have the patient wearing a set of goggles that's recording eye movement,

which you see over, um, to the right-hand side of this screenshot.

And then you see the examiner holding her chin and neck,

and what's gonna happen is: The examiner is going

to very rapidly or abruptly accelerate and decelerate the head.

So there's these really quick movements to turn

the head very quickly and then stop it very quickly.

And you get a very specific response from that.

And the way in which you move the head,

the direction allows you to assess specific semicircular canals.

And that's what's shown in this image.

So you can see, uh, how the head is positioned gives you assessment of a specific canal.

And you see that from the top to the middle to the bottom,

that the examiner is moving this young man's

head in different orientations to get at the different semicircular canals.

So that's just a little extra information to

give you an idea of what is actually happening with this test.

Another test is where we place patients in a rotary chair.

So it's this chair that can be mechanically rotated each direction,

and following that rotation, they're wearing a set of goggles that measures any nystagmus that might have happened.

And so, you can measure this yourself.

If you have a chair, like a desk chair that spins,

and then you have another person in the room,

you can spin around in that chair,

like, you know, 5 or 6 times,

and then stop abruptly. And if you look in a mirror,

you'll see your eyes jumping back and forth.

And that's nystagmus. And that's – that's a home test you can do.

But that's essentially what rotary chair does,

a little more controlled and a little bit more advanced.

But what happens with most people is they're

able to suppress that nystagmus pretty quickly post-rotation,

but if you have a vestibular or neurological problem,

you're not able to suppress that nystagmus.

Another test that has been around for about 20 years or so now is the VEMP,

or the vestibular-evoked myogenic potential.

And this is where we use sound to evoke a muscle reflex.

So if you remember, we talked about auditory evoked potentials where

we used sound to evoke an electrical potential.

Well, we can also evoke muscle potentials,

and that's what this is. So we,

uh, acoustically stimulate the saccule,

and if you look over on the right,

I've provided you with an image,

an anatomic image of the auditory inner ear.

And you can see where the saccule is.

And we use sound to stimulate the saccule,

and then we can record a response from either

the trapezius or the sternocleidomastoid muscles.

And you see that in the image below the inner ear anatomy.

So this patient is laying down.

She has electrodes on her neck,

and then she has an insert earphone in her right ear.

That earphone is presenting a loud,

acoustic stimulus. Her head is turned in the opposite direction,

and that electrode is – when she turns her head in the opposite direction,

it engages the muscle where the electrode is attached,

either the trapezius or sternocleidomastoid –

I think it's typically the sternocleidomastoid muscle that is,

is measured. And it engages that muscle.

You got the acoustic stimulation,

and you're able to measure saccules function by doing that.

And then – so you measure it on both the right and left sides,

and you should see very similar responses between the two sides,

the right and the left, and if you don't,

then that reflects abnormalities on the one side where you see the poorer response.

And we see abnormal VEMP responses in patients who have Meniere's disease,

where they have a perilymph fistula.

A perilymph fistula is when there's a hole into the inner ear allowing perilymph to escape.

And then the other abnormality or – the other disorder would be semicircular canal dehiscence.

And we covered those in our inner ear lecture,

and we can measure that with a VEMP.

So those are some tests that can be used to measure vestibular problems.

Once we've identified vestibular problems in a patient,

what do we do with them? Or why is it important to treat them?

Well, vestibular problems and symptoms can be very debilitating for our patients.

They can be acute, they can have sudden onset and last for a short amount of time;

or they can be chronic, and when – either way,

whether they're acute or chronic,

they can be very debilitating,

as you can imagine. If your vision is blurry,

if you're having difficulty maintaining your balance,

if you're dizzy, have spatial disorientation,

or you're falling, you're not going to be able to engage in your typical daily routine.

Is it estimated that 50% of the US population

will experience a vestibular problem within their lifetime,

and vestibular assessment and rehabilitation is within the scope of practice for audiologists.

When working with patients who have vestibular

problems when we engage in treatment or vestibular rehabilitation,

audiologists often work in close proximity or close,

um – work closely with physical therapists because

a lot of physical therapists help patients with

vestibular problems to do exercises that help

them compensate for vestibular weaknesses or vestibular problems.

So what is included in vestibular rehabilitation?

A lot of times, it's exercise therapy where we teach them to

habituate or to adapt to the vestibular weakness that they have.

And this is where physical therapists really play a big role.

So if you have a vestibular weakness that's not going to be able to be treated medically,

we have to figure out how to adapt to that,

and one way to do that is through exercise therapy.

Because the brain can retrain itself;

it can adapt, it can compensate,

and we can speed up that compensation through these exercises,

and you see some images of vestibular rehabilitation here on the right.

Another type of treatment is canalith repositioning,

and this is done to treat benign positional vertigo,

or benign paroxysmal positional vertigo,

or BPPV. And I'm going to talk a little bit more about this in the next few slides,

so we'll just put a pin in that for the moment.

And then we can also work on balance retraining,

where we – This is designed to improve the coordination of muscle responses,

and then to improve integration of sensory information from the eyes,

ears, and muscles that govern proprioception.

So, um, you can see, um, exercise therapy and balance retraining,

really, in that lower image on the right-hand side.

So walking on a balance beam that's directly on the floor,

working on not only exercise but retraining the

brain to be able to balance on something like that.

So canalith repositioning. So what are we referring to there?

So canalith, or canaliths, are another word for otoconia.

And you're gonna say, "Well, Dr.

Roup, what are otoconia? " Well,

otoconia are little crystals that live inside the vestibular system of the inner ear.

And if you look at the image,

the top image on the slide, you're gonna see the otoliths and the otolithic membrane that,

um, are part of the macule and saccule – part of the utricle and saccule;

excuse me. And they're these little crystals that live inside this membrane and,

um, trigger vestibular responses.

So you can see when this young man is sitting upright,

so too is this membrane with – otolithic membrane,

and, you know, these little supporting cells and hair cells are standing upright.

But when he leans forward, that changes the orientation,

and there's gravitational force in that otolithic

membrane and those otoliths which cause the stereocilia of the hair cell to bend,

and that triggers the vestibular system to trigger

a neural response that tells the brain that you're leaning forward.

So that's where the otoconia or canaliths live.

But what can happen is they can get displaced,

and then they get displaced, they can travel into the semicircular canals.

And so that's what you see in the bottom image.

And that creates a disorder referred to as BPPV,

or benign paroxysmal positional vertigo.

And so when you get into very specific positions,

all of a sudden it triggers vertigo.

So, like, if you law down and turn your head to the left,

that triggers this rapid or very acute,

uh, episode of vertigo. But it only lasts for maybe a minute or so.

They're very quick, but they can be very debilitating.

And what's happening is those crystals or canalith particles or otoconia have been displaced,

and then with movement, what it's doing is it's going to the wrong place in the vestibular system,

causing a mismatch within sensory input,

which then is a mismatch that creates vertigo.

And so canalith repositioning,

or the Epley maneuver, is these very specific maneuvers to reposition those canalith crystals or otoconia,

and you can see that in the different schematics here on the right-hand side of the screen.

Now, do you need to know each of these different positions?

Nope. This is just some information for you guys to,

um – a little bit more information for you to

have to give you an idea of what repositioning therapy is about.

Here we see it again. On the previous slide it was a schematic;

here we see actual pictures. So with audiologists who specialize in vestibular problems,

the patient starts in a seated position and then

is moved to a supine position while the head is in a very specific position – in this case,

with her head to the right. And the idea here is we're trying to relocate

or reposition those otoconia or canaliths into the correct position to,

um, to resolve the BPPV, or vertigo symptoms that patients experience.

All right. So what are our goals through all these different rehabilitation or treatment strategies?

Well, we're trying to decrease the frequency,

intensity, and duration of dizziness episodes;

we want to improve our patients' functional balance;

we want to decrease the severity of the related symptoms of nausea,

headache, and lightheadedness.

You can imagine #3, that if you're experiencing all those,

that's gonna be very debilitating and it's gonna keep you from doing your regular activities.

So we want to decrease those.

We want to improve upon the individual's performance of daily activities,

and we want to develop compensation strategies

for coping with disequilibrium and dizziness and the accompanying anxieties.

You can imagine that if you're experiencing all of these symptoms,

it can be emotionally taxing.

It can – it can create anxiety.

"Am I gonna be able to get in my car and drive to the grocery store?

Am I gonna be able to go to work,

or am I gonna be too dizzy? Am I gonna be nauseous?

Am I gonna have headaches? " And so,

um, anything we can do through these different treatment

strategies help to resolve all these different issues.

The other part of vestibular rehabilitation is

about – is geared at preventing falls in our elderly.

So this is something I, um, spoke about earlier in this lecture: that vestibular

problems or weaknesses or disorders of balance

put our geriatric population at greater risk for falls.

And falls, like I mentioned, can be this triggering event,

creating this cascade of health problems that ultimately lead to death.

So how can we prevent falls? And this can be something for you to take home

to your family or to friends to keep them healthy.

So, um, what – what medications are they taking?

What health conditions do they have?

Do those health conditions or medications put them at higher risk for a fall?

Well, let's talk about that with their primary care

physician and potentially manage that health condition a little bit better – you know,

high blood pressure, low blood pressure,

diabetes can all, um, put you at a greater risk for falls.

And so, what are the medications that the patients are or are not taking?

Let's engage in general exercise programs to improve strength,

flexibility, and balance. And there are specific exercise programs for

geriatric patients to help them specifically with this.

Keeping your living space well-lit and make generous use of nightlights.

So recall that the balance system is comprised of three individual systems,

anatomic systems: the visual system,

the vestibular system, and proprioception.

And this is when at night, when you're missing your visual system because it's dark,

this is when a lot of elderly fall.

So keeping a living space well-lit at night,

making use of nightlights so that when you get up to use the restroom,

you have some light in your environment,

and that helps prevent falls.

Clearing clutter in the home and securing loose rugs – Again,

loose rugs are gonna wreak havoc on older adults who have poorer proprioception.

Wear well-fitting, sturdy shoes;

avoid slick soles, high heels,

and floppy slippers. Again, we're trying to have our best proprioception possible.

And install railings and grab bars and use a cane or a walker to ensure stability.

And this is all about just prevention.

The more we can prevent falls,

the healthier we can keep our geriatric population.

So that's balance. So let's move to tinnitus.

So tinnitus is another specialty in audiology

where we can really have a significant impact on our patients by believing our patients,

by validating that what they're experiencing is real,

by, um, evaluating the tinnitus and helping them to manage the tinnitus.

One of the, you know, biggest problems that – when it comes to tinnitus that exists out there is that people,

professionals, tell patients that there's nothing that can be done for their tinnitus.

And that just simply isn't true.

And that can lead to some really significant

mental health issues for our patients who do have bothersome tinnitus.

So tinnitus is an experience where patients hear sounds in their head,

and those sounds can be really almost anything from high-pitched ringing,

roaring, hissing, whistling – you can see this list of different adjectives to describe the patient experience.

But the, the word "tinnitus" comes from the Latin word that means "to jingle.

" So the – this idea that it's high-pitched chirping

or clicking or ringing has been around for a long time.

Tinnitus can be intermittent or constant.

It's when it becomes constant that it tends to become more problematic.

It can fluctuate in loudness or it can be pulsating.

And why are these aspects of tinnitus important?

Well, it helps with the diagnostic process.

So if it's intermittent, comes and goes,

it's often less likely of a problem for the patient.

But when it becomes constant,

that can become more bothersome.

When it's pulsating, that can have an underlying medical component to it,

which may indicate the need for a referral to a medical professional.

Tinnitus is pretty common; 40-50 million Americans experience tinnitus with

or without the – with or without hearing loss.

And that's in adults; we don't really know how common it is in children

because children are much less likely to report

sounds that they hear unless they're specifically asked.

So it's not a vocabulary item for tinnitus to

be thinking – or for children to be thinking about tinnitus.

The other thing to remember about tinnitus is that in general,

it's a normal phenomenon. It typically is something that happens to most

people to have these really brief occurrences

in one or both ears of tinnitus that lasts anywhere from 30 seconds to a minute.

So upwards of 90% of individuals are going to experience this,

you know, fairly routinely throughout their life.

It's when it's more common or more constant that

it becomes problematic and where we need to intervene to help manage – our patients manage it.

And you can see who's most at risk for tinnitus.

This is gonna be our geriatric population,

just because they have a high prevalence of hearing loss;

military personnel; musicians;

and people who work in loud environments are

gonna be at risk for tinnitus primarily because of their exposure to loud noise.

OK. So for most people, tinnitus is not bothersome and is just something

that can be easily ignored or goes away quite quickly.

However, for those who do report tinnitus or experience

it – 20% of that population – the tinnitus becomes bothersome.

And that can have a really negative emotional impact on the patient.

Bothersome tinnitus can negatively affect concentration,

sleep patterns, employment, personal relationships,

and social functioning. You can imagine that if you're not sleeping because of the tinnitus,

then the tinnitus is probably worse because you're not sleeping,

but you're not sleeping because of the tinnitus.

You can see how this can become a very vicious cycle.

More recently, researchers have,

uh, demonstrated this relationship between tinnitus and post-traumatic stress disorder,

which is something that's fairly common in our veteran military population.

So there's this synergistic relationship or interaction between tinnitus and PTSD,

which can have some pretty devastating consequences.

So what do we mean by a synergistic interaction?

Well, both PTSD and bothersome tinnitus can have a negative emotional impact on our patient,

but synergistic means that the negative impact

is actually greater than the sum of the two parts;

right? So bothersome tinnitus alone is bad;

PTSD alone is bad. But you put them – put them together,

and they're – it's a much greater effect.

And what do we mean by devastating consequences?

These are folks that have very,

um, affected mental health and potentially could be suicidal.

And so, intervention for both of these issues is incredibly important.

Hearing loss and tinnitus – so there's definitely

a relationship between hearing loss and tinnitus.

Tinnitus is associated or is a symptom of both conductive and sensorineural pathologies.

And your textbook kind of talks about this idea that tinnitus might be there,

but because we have – we have ambient noise in our environment,

generally that ambient noise is loud enough to mask any tinnitus we might have.

But because of the development of a hearing loss,

either conductive or sensorineural,

that hearing loss reduces the ambient noise in our environment,

and then the patient becomes more aware of the tinnitus.

It's kind of a theoretical way to think about

why tinnitus becomes louder when you have a hearing loss.

So where does tinnitus come from?

What's the problem? What causes it?

Well, there's a lot of different theories.

It's difficult to figure out exactly where it's coming from.

The reality is that it's probably an interaction

between the – all different aspects of the auditory system,

from the peripheral auditory system,

the cochlea, loss of outer hair cells,

and how the loss of outer hair cells then,

um, impacts function of the auditory cortical areas.

And then, um, we think it might be an interaction between all of those things,

but the reality is, is that where tinnitus comes from is essentially unknown.

We know that it's associated or a symptom of particular disorders,

but what's its true source? We don't know.

And the other thing to recognize is that it's not a disease entity,

but rather is a symptom of some underlying problem.

Some more facts regarding tinnitus.

Twenty million people are dealing with burdensome or bothersome tinnitus on a regular basis.

That's a lot of – lot of people.

2.5 million people are struggling with severe or even – even debilitating tinnitus,

and these are the people that we really want

to help and get into treatment because these are the people that are potentially suicidal.

Tinnitus and hearing loss are the #1 and #2 disabilities among veterans.

So individuals who serve in our armed forces,

in our military – so many of them end up with tinnitus and hearing loss.

And that's a – that's a big thing that the Department of Defense,

the Department of Veterans Affairs are trying to figure out how they can minimize,

um, these numbers. Twenty-six percent of those reporting tinnitus have a constant or near-constant tinnitus.

So that's when it's constant;

that's when it can become bothersome.

Thirty percent of those reporting tinnitus classified the condition as moderate to very big.

Of those reporting tinnitus, nearly 40% experience it 80% of the day.

Think about how distracting that could be and how that could affect your mental health.

As many as 44% of survey respondents report tinnitus with no concomitant hearing loss.

So we know that this could – this can occur with or without hearing loss.

Seniors are particularly prone to developing

tinnitus as they age because they are also developing hearing loss.

Here are some more facts. Uh,

tinnitus associated with hearing loss – this may not always be the case,

and we saw that on the previous slide.

Thirteen million Americans report tinnitus without hearing loss.

Of those with the condition, 40% experience it 80% of their day.

That's a repeat. At least 30 million Americans suffer from it.

These numbers kind of vary depending on what fact sheet you're looking at.

Um, 1 in 5 report them as disabling.

Twenty-seven percent of our older adults experience symptoms of tinnitus.

The point between these two slides on tinnitus

facts is the fact that it's really a common thing that people experience.

What are some potential contributors to tinnitus?

Well, you can see – um, this is a figure from your textbook,

and the, uh, the list of kind of long.

So there's a lot of different disorders that

can potentially contribute to the perception of tinnitus,

and really too many for us to,

to list here. But this is just – The point here is that a lot

of different pathologies can trigger tinnitus in our patients.

So tinnitus can be classified as either subjective or objective.

Subjective is by far the most common type of tinnitus.

It's subjective in that it's a personal perception

or personal sensation that is experienced by the individual.

It's like pain; there's no objective measurement of pain or no

objective indicator of how much pain a person is in.

Tinnitus is essentially the same thing,

where you experience it internally and there's

no way for someone else to tell what you're experiencing.

So it's very much an internal self-perception.

In contrast, there is a category of tinnitus where it actually can be heard by others.

This is called objective tinnitus.

Or, your textbook talks about this idea of a body sound or somato – "somatosound.

" That's a new one; I've never heard it described this way,

and we'll see if that term takes off.

Objective tinnitus just means others can hear what's happening in your ear.

This can happen when blood vessels or muscles

near the ear generate a sound that is then transmitted

to the ear canal that not only can be heard by the patient,

but can be heard by other individuals.

Far less frequent. This is pretty,

pretty rare but can represent an underlying medical condition.

So these are people that should be – that need to be seen by medical personnel.

Your textbook also talks about the idea that tinnitus could be classified based on the ICF,

or the International Classification of Functioning.

And what the ICF does is it addresses the individual's impairment,

which is the tinnitus itself;

its limitations on activities,

or activity limitations – So,

does the tinnitus keep the person from doing their normal activities?

And then, restrictions on participation.

So does the tinnitus restrict the patient from participating in their,

um, daily life activities? So does it create social withdrawal?

And so this is a way of sort of classifying the impact of the tinnitus on the patient.

So the ICF classification scheme would allow

professionals to differentiate their patients

from those who are not bothered by the impairment

or the tinnitus from those whose tinnitus affects

their activities and from those whose tinnitus creates restrictions on life events.

We talk about this ICF classification in terms of hearing impairment as well.

I talk about this extensively with my graduate students,

um, but it's something that we can – we can use this

scheme to talk about our tinnitus patients as well,

and you can see that there's some,

there's some, um, benefits to doing that because it really takes

into account the whole person and not just the tinnitus.

So another section of your textbook talks about,

again, about what causes tinnitus,

and I'm not gonna really review this again here

other than there's really no consensus on the origin,

and it really can originate anywhere in the auditory system.

And we know this because it's not necessarily

the cochlea or the auditory nerve because we

know of patients who've had their auditory nerves

severed because of surgery to remove an acoustic neuroma,

and yet they still experience tinnitus.

So that patient who doesn't have any connection

between the inner ear auditory nerve and then the brain still experiences the tinnitus.

So that tells us that it's not as simple as damage to the inner ear or the auditory nerve.

But more importantly, why does it bother some but not others?

That's an excellent question,

and auditory researchers are really delving into

this because we know that tinnitus can become bothersome for our patients,

and then it becomes burdensome when it becomes associated with negative emotions.

So you can see a couple of schematics here where you have – So this first one,

where you have tinnitus and you're listening

to it and you notice it and then that increases your stress levels.

Then that affects your sleep because you're trying to sleep,

but all you hear is the tinnitus.

So you're not sleeping. And then the tinnitus is worse because you're not rested.

And so you can see this can become a really vicious cycle.

And we see that here in this,

um, more detailed schematic on the right,

where, um, you get into this vicious cycle that we can intervene with.

So you get this tinnitus – um,

you might hear a media report on tinnitus and what could potentially cause tinnitus,

so that creates some fear. Listening within yourself,

tension, nervousness, sleep disturbances,

confirmation of fear, feeling helpless – that worsens the tinnitus – and then you're again in this cycle.

So the idea is that we really need to break that cycle.

From that initial appearance of the tinnitus,

then we become increasingly aware of it,

we have a negative emotional reaction,

we pay even more attention to it,

this becomes a chronic problem.

But if we can get these patients into an audiologist to manage it,

we can break this cycle and, really,

improve our patients' quality of life.

So what happens with the tinnitus evaluation?

Well, we want this to be a multidisciplinary approach

where the audiologist is not the only professional involved with the patient.

The patient may need to be seen by a medical

professional to address any potential underlying

medical condition that's causing the tinnitus.

But the audiologic evaluation or audiology evaluation serves two purposes,

and this is really to provide validation for the patient.

I had mentioned this earlier;

a lot of times, patients are just simply told,

"Nothing can be done for the tinnitus,

" and, "You just have to learn to live with it.

" Well, that's not a great thing to tell somebody,

and I'm sure if you were experiencing a problem,

that is not what you want to be told,

either. So just listening to the patient is sometimes the best medicine.

So if you spend a half an hour – 30 or 45 minutes

just talking to the patient about their experience,

then they feel heard, and then you can talk to them about potential treatment approaches.

And this can form a basis for a treatment approach.

So the evaluation includes not only our standard audiologic evaluation,

but we really want a detailed case history on these individuals.

When did the tinnitus start? What were – What are the consequences of that tinnitus?

Does it impact their sleep? Does it impact their relationships?

Does it impact their concentration,

their work? What are factors that might have contributed to the tinnitus?

Do they have a history of noise exposure?

What medications are they taking?

Etc. Then we would have them complete a tinnitus self-assessment.

There's a couple of different questionnaires like the Tinnitus Handicap Inventory,

where they answer questions about the severity of their tinnitus.

This is really important to get a baseline indication

during this initial evaluation of where the patient is in terms of their tinnitus.

And this could help us determine whether or not treatment is necessary,

or, "Do I need to get this patient to a psychiatrist

or psychologist immediately to deal with their negative emotional response?

" So this self-assessment is not only important for moving forward,

but it's also valuable for us to be able to compare post-treatment.

And then, again, we do a standard audiologic evaluation,

including pure-tone audiometry and speech audiometry.

But then we're gonna make actual measurements of the pitch and loudness of the tinnitus.

So we're gonna figure out how loud it is for the patient through loudness matching,

and we're also going to figure out if it's a high-pitched or low-pitched tinnitus.

And then we're gonna figure out if we can actually mask the tinnitus.

So, can I present noise, some masking noise,

to the patient, and can I actually mask the tinnitus?

Is it – Do we have the ability to mask it?

And that – all this information really helps us with treatment approaches.

So what are some different treatment approaches for managing tinnitus?

One of the most common methodologies – and it

is a good place to start – is wearable masking units,

or even just talking to patients about not being

in environments where it's completely quiet or silent,

because then the tinnitus becomes extremely noticeable.

So it could be a bed-level tinnitus masker or noise generator.

But we also have ear-level devices that produce noise to mask the tinnitus.

And you see that in the image of this pinna,

where there's a little device in the – right

above the concha bowl where you can see a battery door,

a volume control, and then there's a little tube that is fed into the ear canal.

And what this is doing is keeping the ear canal open for the patient to hear naturally,

but it's also feeding masking noise into the ear canal to mask the tinnitus,

and the patient has control over the volume.

So this is a great place to start,

but the reality is that these ear-level maskers,

um, don't help the majority of our patients.

But there are some patients that do report immediate

relief and benefit from these ear-level maskers.

So it is a place to start, but the reality is that most likely,

patients will be moving on to a different treatment approach.

Um, neuromonics is another type of masking approach

where the patient has what looks like a little iPod with earbuds.

And the idea behind neuromonics is that the,

um, perception of tinnitus is matched with a pleasant and relaxing acoustic stimulus.

So this neuromonics device plays this acoustic stimulus that is pleasant to the patient,

and so what we do is pair that with the perception of the tinnitus.

And the idea is we're desensitizing the patient to the negative reaction to the tinnitus.

And this has been shown to provide some really rapid relief from patients.

Another methodology that's been used with some success is biofeedback.

Biofeedback is the idea where we observe and

then control our own physiologic activity – for example,

heart rate or blood pressure – and so some patients

have had some success with training to suppress their tinnitus through biofeedback therapy.

So that's one option as well.

These last two that we're gonna talk about for

treatment approaches for tinnitus require a bit more time.

So these are – Audiologists who've created these

programs have specific tinnitus clinics for their patients.

The first one that's been around for a little

bit longer is referred to as tinnitus retraining therapy.

So the idea here is that it's educational counseling

therapy aimed at teaching patients to habituate the presence of their tinnitus.

And what do we mean by habituate?

We mean to, essentially – it really is teaching them and

counseling them to learn to ignore the tinnitus

so that they're not paying attention to it anymore.

And so it's actually working with them to teach them how to do that,

rather than just saying, "Learn to live with it,

" and sending them off the door.

But this is actually retraining therapy that uses education,

and it also uses those ear-level tinnitus maskers.

This has shown to have a really high success rate in helping patients with tinnitus,

but it is an investment in time.

These are individuals – This training takes a

good 18 months of continuous therapy to get them through to the end.

But, what it is: It is a successful treatment approach for patients with tinnitus,

and I think that's what we have to concentrate on.

But the one downside is that it does take a lot of time.

But the really big upside is that it really works.

A more recent approach has been developed by Jim Henry,

who's an audiologist at the Portland VA,

where they have a National Center of Excellence for Auditory Research.

And he's, um, done a lot of work in tinnitus management.

And he's, um, presented this program called progressive audiologic tinnitus management.

And what it does is it classifies patients into five different levels of tinnitus management.

Um, so it allows you to categorize or classify where the patient is,

um, in this hierarchy which you see to the right-hand side.

It allows the audiologist to determine whether

the patient needs to be referred for audiologic management or evaluation;

otologic, which would be going to an ear physician;

to mental health, to a psychologist;

to a sleep clinic for a sleep disorder – So,

um, it's taking the whole patient into account and not just their tinnitus.

Like, if we went back a slide,

um, wearable masking units, neuromonics,

and biofeedback – this is all – these are – all

three of these are solely targeting the tinnitus,

whereas if we come back to the slide we were just on,

TRT and progressive audiologic tinnitus management are more about the entire patient.

Um, so PATM is a comprehensive evaluation.

Um, and what it's – what they've found is that most

patients that are referred for this management

approach are helped benefit simply through education.

And then what happens is the remaining patients

are helped with these individualized management approaches.

So if we look at this pyramid to the side,

the vast majority of people that experience tinnitus experience non-bothersome tinnitus.

"Yep, it's happens, it's there,

I forget about it. " It goes away.

Then, as we move up the pyramid,

we get into this category where a percentage

of patients who have bothersome tinnitus – where it's there more chronically or constantly.

So the first thing to do is just to triage them and see what's going on.

Triage often has to do with just doing some education,

talking to them about what causes tinnitus,

um, what it's associated with – you know,

a lot of times when patients develop bothersome tinnitus,

there's a lot of fear associated with what's causing it,

and the fear's associated with potential life-threatening conditions.

"Do I have a tumor in my brain that's causing this tinnitus?

" Well, the triage level, what that does is,

um, explain to them about hearing and hearing loss,

what tinnitus is, and the fact that,

you know, the vast majority of the time,

tinnitus is caused by something that is not life-threatening.

And most of the time, what you're gonna have is that most people are

going to exit out of this management program at this level.

But then, as we keep moving up,

um, we keep moving up into these different levels,

and we see in this box – it's telling us that

progressively more severe problems caused by

tinnitus means that the more severe problems you have,

the more likely you are to get to Level 2,

Level 3, Level 4, and then Level 5.

Um, but the really cool thing about this PATM program is that,

um, by the time we get to Level 5,

this individualized management,

it's only a handful of patients that need that.

Um, we are helping the majority of our patients earlier on through this staged program.

So, I really like this program and its approach and its,

its – The research has shown that it's very,

um, beneficial to patients who experience tinnitus.

Finally, what are some known tinnitus aggravators?

So, what are things that are gonna exacerbate or make tinnitus worse?

And this is something, I think,

that's helpful for you as students,

for anybody that you might know that has tinnitus.

Noise is certainly something that's gonna aggravate tinnitus,

and if any of you have been to a concert,

you're gonna have experienced this.

So concerts are incredibly loud,

and so that triggers tinnitus.

I know it does for me. Usually,

a couple of days following the concert,

I have ringing in my ears, and then it subsides.

Because I forget to bring my earplugs because I'm not a very good self-audiologist.

[chuckles] Why is silence a known aggravator?

Well, I referred to this earlier.

Silence means that there's no ambient noise to mask the tinnitus,

or you're in a completely silent environment – all of a sudden,

the tinnitus becomes incredibly noticeable,

and this can happen in our test booth,

in the audiometric booth. Um,

you put a patient into a test booth who has tinnitus,

and then all of a sudden, all they can hear is the tinnitus.

Stress and fatigue can exacerbate tinnitus,

and that's, I think, probably self-explanatory.

Nicotine, or the product that is in cigarettes and in the

vaping products that we hear about all the time now – Nicotine is a stimulant,

and so stimulants are known to aggravate tinnitus.

Some medications – This list comes from your textbook,

and I have to say, "some medications" is kind of an inaccurate categorization or characterization.

There are a LOT of medications that are going to aggravate tinnitus,

from anti-inflammatories or NSAID,

um, medications – so, pain relievers like ibuprofen,

acetaminophen, they – they are known to aggravate tinnitus.

Antibiotics like our aminoglycosides that we

talked about in the ototoxicity component of the inner ear lecture;

antidepressants, which are pretty common these days;

aspirin, which is a pain reliever;

quinine, which is a drug that's used to treat malaria;

loop diuretics; chemotherapy drugs – you know,

the aspirin, quinine, loop diuretics,

and chemotherapy drugs, you should recall,

are all from our list of ototoxic medications.

So not only are they ototoxic,

which can cause hearing loss,

they're going to induce or aggravate tinnitus.

The big one on this list at the very end is monitoring or dwelling on the tinnitus.

This is when we get into that cycle where,

if I go back a few slides – here,

where we experience tinnitus and then we,

um, we're much more aware of it,

and then we have this negative reaction which increases our attention to the tinnitus.

That's what we're referring to here,

if I go back forward to this #8.

When we monitor, we dwell on it or we just pay attention to it,

that can make it worse because,

again, we're gonna have those negative,

um, emotions associated with it.

So that's tinnitus. But I – what I want you guys to go away from

this class with is the knowledge that tinnitus is real;

that most of the time, it is non-bothersome,

but for those folks out there who – where it

is bothersome and does get into this cycle of negative reactions and negative emotions,

it's really important that those people are seen and treated.

Because the devastating consequences are – These

are individuals who are at high risk for suicide,

and we can prevent that in just getting these patients to the right people.

And so when these patients are told that they can't be helped,

it's – it's a tragedy, and we can prevent that.

So if you guys can go forward and you're ever

talking to anybody and tinnitus happens to come up,

you can be knowledgeable to be able to tell them that yes,

you can see an audiologist and you can get help for your tinnitus.

All right. The last few slides on these specialized topics.

Hyperacusis is something that often co-occurs

with tinnitus but can also occur solely on its own.

It refers to a decreased tolerance of loud sounds.

So it doesn't mean that you have really extra-special hearing,

but it means that your loudness tolerance just collapses.

Even a 30- or 40-dB-HL sound is incredibly loud to you.

Because remember, loudness is the psychological perception of intensity,

and for most of us, um, something that's considered loud doesn't – where

we psychologically perceive it to be loud has to be a pretty high intensity – say,

80 to 90 dB and above. But for patients with hyperacusis,

you can see that the threshold for loudness discomfort

can be as low as 20 to 25 dB above their threshold.

That is incredibly low. And this can obviously be really problematic

for these individuals because then it can be

associated with negative emotional reactions

– very similar to what we talked about with tinnitus,

but these are folks that tend to sort of self-

"medicate. " And if you can see,

I use some air quotes around "medicate" – "medicate"

because what – they're not using medications,

but what they're doing is they're "medicating" by using hearing protection.

They're putting in earplugs, they're wearing big headphones to try and keep the sound around them as quiet as possible.

And then these are individuals who tend to withdraw socially because it's too loud for them.

And so, this is where we have issues with hearing and psychology,

and the psychological state of the patient is

wrapped up in this collapse of loudness tolerance.

So this is where we need to get these patients

seen by a psychologist who can help them with desensitization.

So the idea is just, over time,

desensitize them to what they think is too loud;

right? So it's like what we see in this little schematic over on the right,

where someone might be afraid of water,

especially deep water, and you start – you don't start that person off in the deep end.

You start them off in the shallow end of the pool and then you,

step by step, work toward the,

"Woo hoo! I'm swimming in the deep end!

" So desensitization: The first thing to do is

to get these patients to stop using the hearing

protection and headphones and then work towards,

um, going out into situations that they would've avoided or withdrawn from previously.

And then finally, the last thing we're gonna talk about is something called misophonia.

You may or may not have heard of this.

Otherwise referred to as soft-sound sensitivity syndrome,

or S to the fourth power – [chuckles] something.

That's – That is a tongue twister.

I've actually never heard it referred to as that;

I've only heard of misophonia.

But that's what your textbook says,

so we'll believe them. But what we're talking about here is – This isn't

anything that's related in any way to loudness of a sound,

but it is a negative reaction,

and a negative emotional reaction,

to a specific sound, often to a sound that has a specific pattern or meaning.

And it can be something that's very loud;

it can be something that's very soft.

So it's unrelated to loudness,

which is what you see here with this italicized bullet.

Trigger sounds are generally from another person – a lot of times,

a person that you live with, or it could be an animal.

And they're often related to eating – so it's chewing sounds – or repetitive sounds like,

um, typing on a keyboard or finger-tapping.

Um, and you can see that over on the schematic,

that this poor girl has knives in her ears.

I was trying to figure out what those were,

and I'm like, "Oh, those are knives!

That's awful! " But this can be debilitating,

as you can imagine if you have these negative reactions to other people's sounds.

So common triggers are gonna be snacking foods or chewing,

furious pen-clicking, fingernail-tapping – whoo,

look at those fingernails! Um,

a few more: crinkling, plastic wrappers,

silverware on ceramics, intense typing,

that rumbling ice in giant soda cups in a quiet movie theatre – [chuckles] Well,

that's uber-specific. Wow. Um,

but it's – it's referred to here as a neurologic condition in which negative emotions,

thoughts, and physical feelings are triggered by specific sounds.

I'd probably call that a psychological condition rather than a neurologic condition.

I'm not – I don't know a ton about misophonia,

so I'm not sure how accurate that statement is.

Nonetheless, these are actually people that can end up in an audiologist's case load,

especially an audiologist who deals with tinnitus and hyperacusis,

because – because it has to do with sound and hearing.

I know Dr. Whitelaw, who's one of our audiologists in the Speech and

Hearing Clinic – she's the director of our Clinic

– she does deal with these patients on a fairly routine basis,

and once you're known for working with a specific population,

you tend to see more of them.

So a couple of treatment options that were discussed

in your textbook include avoidance of the sounds – triggering sounds.

And the key here, the caveat,

is that when you're not rested – so if you experience misophonia and if you're not rested,

you're tired, you're stressed,

you're fatigued, avoid the individuals or situations that trigger this response.

Um, but again, probably desensitization is probably another treatment option as well.

Um, and then your textbook talked about the fact

that a modified tinnitus retraining therapy approach

can be useful for these individuals or beneficial for these individuals.

So this is a fairly uncommon,

um, issue, but it can end up in an audiologist's case load,

which is, again, why it's important that we have some understanding of what it is and,

um, how potentially we can help.

All right. That brings us to our summary – that,

um, when we think about treating audiologic disorders,

it's not just hearing loss; that balance disorders and tinnitus are common issues that affect many people,

with or without hearing loss;

and audiologists are the natural professionals to evaluate and treat those disorders.

Hyperacusis and misophonia are less prevalent in our case load,

but because they have to do with hearing and sound,

they can often end up in our waiting room,

waiting to be seen. So having a good understanding of what these

are and what they're related to will help us with those patients.

And that is all we have for today.

Again, I hope you guys are doing well! Stay safe, and stay healthy!