Grand Rounds: Tinnitus - The Buzz in Audiology Case study Karrie Slominski, Au.D. Senior Staff Audiologist Henry Ford West Bloomfield Hospital

Henry Ford Tinnitus Management Clinic (referral process): Patient comes in for HT & ENT appointments Primary c/o tinnitus and/or hyperacusis Tinnitus Reaction Questionnaire (TRQ ) administered < 16 (considered normal disturbance) > 16 (considered possible candidate for sound therapy treatment) Clinician sends me an e-mail with patient’s name and MRN Medical Record reviewed Tinnitus packet will be sent via email or regular mail. Patient is encouraged to call/e-mail if they have questions and/or if they would like to set up a Tinnitus Evaluation

Intake Process Subjective scale measurement Useful tools for scaling the severity and negative impact of tinnitus Can be used as a guide to track progress of therapy Tinnitus Reaction Questionnaire (TRQ) – quantifies the psychological distress from tinnitus. General distress. 26 items General distress (helplessness, interference with ability to work), severity (sleep disturbance) and avoidance (noisy situations) Tinnitus Handicap Inventory (THI) – Looks at the aspects of hearing loss related to tinnitus disturbance. Most specific ‘clinical classifications’. 25 questions – 3 primary areas Limitations caused by tinnitus (i.e. difficulty concentrating, not enjoying social activities, trouble with sleep) Tinnitus Functional Index (TFI) 25 items – 8 important domains of the negative impact of tinnitus Intrusiveness, reduced sense of control, cognitive interference, sleep disturbance, perceived auditory difficulties, interference with relaxation, reduced QOL & emotional distress.

Psychoacoustic Objective measurements Pitch matching Pairs of tones are presents to the contralateral ear of the perceived tinnitus. Similar to eye exam which pitch is closest to the sound of the tinnitus. Could be a pure tone (PT) or narrowband noise (NBN), as tinnitus can be described in various ways. Loudness matching Once pitch is determined, loudness is measured in the ear with the perceived tinnitus Slowly increasing the signal (2dB steps) until the person reports the signal is equal to the volume in the ear with tinnitus Minimum Masking Levels (MMLs) Determines the lowest level at which NBN or broadband noise cover the tinnitus. Increased in 2dB steps. Performed on the ear with perceived tinnitus. Rarely, tinnitus is reported as louder for a short period (exacerbation of tinnitus)

Psychoacoustic Objective measurements Residual inhibition MML + 10 dB. The person will listen to noise for about 1 minute. When stimuli is turned off, the patient will report on level of tinnitus (louder, softer or no change) LDL Because tinnitus is often associated with loudness discomfort, this level must be determined. 5dB steps. Sound will be gradually be louder and the patient will report the volume that is tolerable. Not if they like the sound or not, but if it is tolerable.

10/03/2006: Hearing test Purpose of today’s appointment hearing test and ENT appointments 2nd opinion Repeat hearing test Looking for conventional and unconventional treatment for his tinnitus.

10/03/2006: History 57 year old male, married, college aged children Profession: Dentist Sudden right SNHL 1 year prior White noise sound (right ear only) Linking tinnitus to onset of the SSNHL No history of loud noise exposure, except the drill. No history of ear surgery or head injuries. No diagnosis of TMJ. Moderate sounds make the tinnitus worse. History of Liver Cirrhosis. Treated medically. Awaiting transplant with University of Michigan.

Tinnitus has caused this patient: Difficulty with general conversation, especially patients Difficulty with sleep Difficulty with concentration Frustration at work and home Anxiety Stress Annoyance Depression Reduced social activities

History/Treatments tried (2006) Already tried CROS hearing aid (Phonak Cassia) Minimal benefit perceived from current CROS. Oral steroids at previous ENT clinic. Did not improve disturbance. Tape of White Noise Helps when he wears the ear buds. Xanax .25mg (3x/day) Minimal improvement. Made him extremely tired. Hypnosis Minimal improvement in relaxation. Acupuncture Did not help.

10/03/2006: Audiogram (Seen within 6 months) Tinnitus Reaction Questionnaire (TRQ): 58

10/03/2006: Audiologist Recommendations Referred to ENT for further evaluation as scheduled Has not been seen in Henry Ford System Further evaluation as clinically indicated for SSD. Discussed options for SSD pending medical clearance and patient interest CROS Baha Communication Strategies Consider Tinnitus Evaluation Refer to 1st slide on referral process for tinnitus evaluation.

10/03/2006: Recommendations PLAN ENT appointment. MRI ordered. MRI was unremarkable (negative) Referral for Hearing Aid Selection Tinnitus Evaluation PLAN Patient scheduled appointment for Tinnitus Evaluation and Hearing Aid Selection Appointments. Opted for Neuromonics.

01/11/2007: Assessment * For the evaluation, the contralateral ear was used for psychoacoustic objective measurements. Current standard audiogram (within 6 months of the evaluation). Screened for stability. High frequency audiogram (9kHz, 10kHz, 12.5kHz) Loudness discomfort levels (LDL) Psychoacoustic measures Pitch-matching, loudness matching, masking, residual inhibition Counseling and discussion of sound therapy options  

01/11/2007: Assessment Results Dominant tinnitus ear: Right Ear Pitch-match: 12.5kHz for NBN stimuli. Patient was very good at the tasks. TRQ: 57 Awareness: 60%. Disturbance: 30% Tinnitus Loudness Match: (presented to the LE) HTL Threshold: 6dB Loudness Match: 29dB Sensation Level: 23dB BBN Minimum Masking Level: (presented to the LE) BBN Threshold: 0dB Masking Threshold: 35dB Sensation Level: 35dB   NBN Minimum Masking Level: (presented to the LE) NBN Threshold: 8dB Masking Threshold: 63dB Sensation Level: 55dB Loudness Sensitivity: Normal: >90dB at 500Hz, 1kHz and 4kHz, bilaterally Residual Inhibition: No effect, bilaterally.

01/11/2007: Assessment Results: Results & treatment options (including Neuromonics & a longer hearing aid trial) were discussed with patient. Patient seemed to understand the above, but still opted for Neuromonics. Order was submitted via fax. He was scheduled for a Neuromonic orientation.

02/06/2007: Fitting Orientation to the processor, appropriate use within lifestyle. Set Goals and Milestones. Signed the Agreement. Patient’s Goals: Reducing the impact of his tinnitus. Increase sleep to 7-7.5 hours Try to go to more social functions Fitting the Neuromonics: 20-30 minutes (lunch hour), after work (when reading), Friday & Sundays Stress and relaxation: Continue regular exercise Try to manage the stressful events in life Get massages

02/16/2007: Phone Call Patient is still reporting less disturbance. Questions were answered.

02/22/2007: Follow Up Appointment Review proper use of the Neuromonics. Time of day and amount of use. Using it at lunch and after work. Progress towards goals was positive. Better sleeping patterns, better diet and going out more socially in minimally noisy places. Follow-up appointment is scheduled May be transitioned into Phase 2 pending outcome measurements at appointment.

04/06/2007: Transition Appointment Patient was seen today for his 8-week check-up on his progress with the Neuromonics Tinnitus Treatment. SUBJECTIVE: Patient reported that he was still doing well with the treatment meaning minimal disturbance. OBJECTIVE: TRQ indicated his progress was going in the right-direction (TRQ score of 57 on 1/11/07 and a score of 21 at today's appointment). Transitioned patient into Phase 2. A discussion of progress and continued counseling was performed.

04/06/2007: Assessment Results Dominant tinnitus ear: Right Ear TRQ: 21 Tinnitus Loudness Match: (presented to the LE) HTL Threshold: 8dB Loudness Match: 38dB Sensation Level: 30dB BBN Minimum Masking Level: (presented to the LE) BBN Threshold: 0dB Masking Threshold: 44dB Sensation Level: 44dB   NBN Minimum Masking Level: (presented to the LE) NBN Threshold: 8dB Masking Threshold: 58dB Sensation Level: 50dB Loudness Sensitivity: Normal: >90dB at 500Hz, 1kHz and 4kHz, bilaterally Residual Inhibition: No effect, bilaterally.

04/06/2007: Transition Appointment Transitioned patient into Phase 2. A discussion of progress and continued counseling was performed. Phone call will be placed on 4/20/2007. Next out-patient appointment has been scheduled for 6/22/2007. Patient will contact the clinic should he need anything before that date.

04/20/2007: Phone Call Progress check for active stage. Patient reported he was doing much better since using Neuromonics. Milestones were reviewed again. Many goals were met. Considering new goals. Overall happy with treatment and his progress. Slowly returning to everyday activities.

06/19/2007: Mid-Treatment Appointment Progress was reviewed. Audiogram was stable per 10/03/2006.

06/19/2007: Assessment Results Dominant tinnitus ear: Right Ear TRQ: 16 (Previously 57->21) Awareness: 25%. Disturbance: 10% (previously 60% and 30%, respectively) Tinnitus Loudness Match: (presented to the LE) HTL Threshold: 8dB Loudness Match: 38dB Sensation Level: 30dB BBN Minimum Masking Level: (presented to the LE) BBN Threshold: 0dB Masking Threshold: 34dB Sensation Level: 34dB   NBN Minimum Masking Level: (presented to the LE) NBN Threshold: 8dB Masking Threshold: 62dB Sensation Level: 54dB Loudness Sensitivity: Normal: >90dB at 500Hz, 1kHz and 4kHz, bilaterally Residual Inhibition: No effect, bilaterally.

06/19/2007: Mid-Treatment Appointment Treatment management Continued use of the processor at appropriate times Continue getting back into daily activities. Appointment was scheduled for 8/28/2007.

08/28/2007: End of Treatment Appointment Reported that the Neuromonics tinnitus treatment has helped him by a large amount in helping him cope with his tinnitus. His overall goals of getting back to "normal" activities and reducing his need of Xanax were accomplished. TRQ went from 57 -> 9 when the treatment was started on 1/11/07.

08/28/2007: Assessment Results Dominant tinnitus ear: Right Ear TRQ: 9 (Previously 57->21->16) Awareness: 20%. Disturbance: 10% (previously 25% and 10%, respectively) Tinnitus Loudness Match: (presented to the LE) HTL Threshold: 48dB Loudness Match: 30dB Sensation Level: 18dB BBN Minimum Masking Level: (presented to the LE) BBN Threshold: 0dB Masking Threshold: 40dB Sensation Level: 40dB   NBN Minimum Masking Level: (presented to the LE) NBN Threshold: 12dB Masking Threshold: 50dB Sensation Level: 46dB Loudness Sensitivity: Normal: >90dB at 500Hz, 1kHz and 4kHz, bilaterally Residual Inhibition: No effect, bilaterally.

08/28/2007: End of Treatment He reported that recently he has been wrapped up in summer activities preventing him from getting the recommended 2-4 hours of usage in, but that he feels that most of the time he does not notice that the tinnitus is present. Patient was overall extremely happy with today's appointment. Counseled patient on still using the Neuromonics device to provide relief and relaxation, as well as to feel free to contact writer should he have any concerns that arise. Patient will be getting a new version of the processor. Appointment was coordinated for 11/9/2007 to exchange for the new processor.

08/29/2017: Patient Update Per recent notes, History of liver transplant at University of Michigan on 10/14/2015 for primary biliary cirrhosis. Feels he is doing well coping with the tinnitus (no disturbance). Says he still attributes his success with his tinnitus management to Dr. Seidman and myself at Henry Ford West Bloomfield Hospital. Now retired, he has returned to social outings and travel. He mentioned is going to Europe in mid-September 2017. He does not use CROS hearing aids for his unilateral hearing loss.

Specific Criteria for Evaluation of Treatment Outcome While this patient had great outcome with his perception from his tinnitus, the psychoacoustic measurements did not necessarily reflect that. Measurements for patient success depends on each patient. A follow-up evaluation performed after at least 6 months of treatment: At least one activity previously prevented/interfered with no longer affected Tinnitus awareness is decreased by at least 20% The impact of tinnitus on the life is decreased by at least 20% Tinnitus annoyance is decreased by at least 20%

Additional Support As defined by ATA: The perception of sound within the human ear in the absence of corresponding external sound.  American Tinnitus Association www.ata.org Dedicated to helping tinnitus patients through information, tinnitus materials, research, support groups, and a hot line Quarterly magazine “Tinnitus Today” whose goal is to “promote relief, prevention and the eventual cure of tinnitus for the benefit of present and future generations. ATA National Headquarters Karrie Slominski, Au.D. P.0. Box 5 kslomin2@hfhs.org Portland, OR 97207-0005 1-800-634-8978

Tinnitus Loudness Match

Tinnitus Pitch Match