1. Tinnitus & Attention Training
Kim Wise,
MNZAS, CCC (New Zealand), Ph.D.
Audiologist; Research Fellow
Mayo Clinic In-service Talk

2. Definition
TINNITUS: the conscious awareness of sound, perceived in the ear/ears or head, lacking an external, driving sound source or mechanical activation of the cochlea.
This is the working-definition I will use when referring to tinnitus for my talk. You may have heard “Phantom Perception”, relating to Jastreboff’s 1990 definition, (when viewing the literature) and there are other definitions, but this is what I will use. I will keep you in suspense for a bit regarding a definition for attention.

3. Objective Tinnitus
Objective tinnitus – sound produced by causal pathology which may be heard by an examiner (usually via amplified stethoscope)
Pulsatile tinnitus – matches pulse
Possible vascular etiology
Either objective or subjective
Increased or turbulent blood flow through paraauditory structures

4. Objective -Pulsatile tinnitus
Arteriovenous malformations
Vascular tumors
Venous hum
Cardiac murmurs
Pregnancy
Paget’s disease (disorganized bone remodeling)
Benign intracranial hypertension

5. Arteriovenous malformations
Pulsatile tinnitus
Headache
Papilledema (Optic Nerve Swelling-a hallmark of elevated intracranial pressure)
Discoloration of skin or mucosa

6. Venous hum-associated causes
Benign intracranial hypertension
Dehiscent jugular bulb
Transverse sinus, partial obstruction
Increased cardiac output from:
Pregnancy
Thyrotoxicosis
Anemia
Thyrotoxicosis is a common disorder, especially in women. The most frequent cause is Graves' disease (autoimmune hyperthyroidism).

7. Benign Intracranial Hypertension (BIH)-presentation
Young, obese, patients
Hearing loss
Aural fullness
Dizziness
Headaches
Visual disturbance
Papilledema

8. Muscular Causes of Tinnitus
Palatal myoclonus
Clicking sound
Rapid ( beats/min), intermittent
Contracture of tensor palantini, levator palatini, levator veli palatini, tensor tympani, salpingopharyngeal, superior constrictors
Muscle spasm seen orally or transnasally
Rhythmic compliance change on tympanogram

9. Myoclonus-associated causes
Palatal myoclonus associations:
Multiple Sclerosis and other degenerative neurological disorders
Small vessel disease
Tumors
treatments: muscle relaxants, botulinum toxin injection

10. Stapedius Muscle Spasm
Idiopathic stapedial muscle spasm
Rough, rumbling, crackling sound
Exacerbated by external sounds
Brief and intermittent
May be able to see tympanic membrane movement
Treatments: avoidance of stimulants, muscle relaxants, sometimes surgical division of tensor tympani and stapedius muscles

11. Patulous Eustachian Tube
Eustachian tube remains open abnormally
Ocean roar sound
Changes with respiration
Lying down or head in dependent/particular position provides relief
Significant weight loss, radiation to the nasopharynx
Can sometimes change tympanometric compliance readings with respiration

12. Subjective Tinnitus Hearing loss, Presbycusis Noise exposure
Meniere’s disease
Otosclerosis
Head trauma
Acoustic neuroma/Schwannoma
Drugs
Middle ear effusion
TMJ problems
Depression, stress, fatigue
Hyperlipidemia
Meningitis
Syphilis
Diabetes
Lyme Disease
Much more common than objective
Usually non-pulsatile
Heard only via the patient
No consensus regarding exact mechanism(s) of tinnitus production
Abnormal conditions in the cochlea, cochlear nerve, auditory pathways, auditory cortex
Hyperlipidemia is a heterogeneous group of disorders characterized by an excess of lipids in the bloodstream

13. Mechanisms: Evidence for Central Site
Auditory nerve section (Darby, 1941; House and Brachmann, 1981)
Near-normal hearing & tinnitus (high-frequency assessments)
Tinnitus still remained after sectioning the auditory nerve
Those with audiometrically near-normal hearing can be chronically affected by tinnitus as well.
This has strengthened the argument for tinnitus as the result of central events or changes, rather than peripheral in nature. Although peripheral hearing loss can contribute to central changes due to neural plasticity.

14. Role of Affective State
Folmer et al (1999) reported patients with depression rated the severity of their tinnitus higher although loudness scores were the same.
Interactions between tinnitus, stress, anxiety and depression can be complex and dual-directional (Andersson & McKenna, 1998; Halford & Anderson, 1991)—principle to, or a consequence of tinnitus

15. Drugs that may cause tinnitus
Anti-inflammatories
Antibiotics (aminoglycosides)
Some Antidepressants (Benzodiazepines)
Aspirin
Quinine
Loop diuretics
Chemotherapeutic agents (cisplatin, vincristine)

16. History (TSCHQ)
Pain (ear, neck, jaw, headache or with certain sound-Hyperacusis)
Family Hx
Impact on patient (sleeping?, depression?, anxiety?)
Tinnitus modulators neck movement (flexion or turning)/light compression, jaw clenching, eye gaze, facial movements
Aggravators/alleviating factors
Hearing loss & laterality
Tinnitus Characterization
ONSET
OTHER TREATMENTS
General Health: Infection, illness, flu, or major life changes
Trauma (esp. with resultant change in vision, hearing, balance, memory/cognition, patient’s own voice quality)
Noise exposure Hx
Medication usage (Ototoxic, associated with tinnitus genesis or potential interaction suspected)
Medical history (Cancer treatment, systemic infection or transplant recipient
Vertigo
Modulation of tinnitus by oral facial movements is considered to be a form of somatic tinnitus. Wherein, tinnitus can be altered by jaw clenching, skin stimulation. Levine in 1999 discovered that over 2/3 of patients presenting to his tinnitus clinic could change their tinnitus by performing head and neck contractions. Loudness, pitch and laterality could all be changed. It is hypothesized that the dorsal cochlear nucleus plays a role in this occurrence.

17. Audiological
High-frequency audiometry (if speech-dominant range is normal) & complaint of high-frequency tinnitus. N=192, Pitch-match most often to 9 or 10 kHz— (Shekhawat & Searchfield, 2011)
Bone conduction (even if AC is normal) with complaint of autophony + Hx head trauma
Otoscopy
Acoustic Reflexes—May need to proceed with caution for tinnitus + sound sensitivity
Cochlear implants: Ito & Sakakihara (1994) N=26, For those implanted who had tinnitus 77% reported tinnitus either abolished or suppressed; 8% reported worsening
CROS
Consistent information (flip-books, websites)
Outcome & quantifying measures (THI, TFI, TSNS, DASS)

18. Assessment & Referral
Complete head & neck exam vascular or musculoskeletal
ENT/ORL
Sleep specialist
Counselling support
Jaw specialist
Review by Prescribing Physician (Pharmacological)
Audiology/Vestibular assessment
Research

19. TINNITUS Cascade Reorganisation Spontaneous Synchronous
Resultant “mimicry”
Sound template mismatch
Perceptually stands out
Non-auditory factors
Eggermont, J. J. & Roberts, L. E. (2004). The neuroscience of tinnitus. Trends in Neurosciences, 27(11),
Tinnitus is apparently not just caused by one thing. It is thought to be due to a cascade of changes, usually brought on by changes in the hearing system. One change is cortical reorganisation. There is evidence of change in the way the nerves behave in response to reduced sound input. Work from animal studies implicate changes in neural behaviour indicating more spontaneous firing. But…They there is also more synchronous firing. Synchronous firing is associated with encoding sound features....only there is no sound coming in for a region of loss....this causes the brain to interpret this change in nerve activity as a result of hearing changes as “sound” ...the pitch of this sound is usually similar to the region of loss...a form of phantom mimicry...similar to phantom pain sensation for a severed limb.
Because this “sound” does not have all the normal features and patterns of externally-generated sounds, the brain cannot match it to a template. It perceptually stands out. It does not follow normal auditory scene analysis rules.
So...this is tinnitus. Some research has linked more distressing tinnitus with non-auditory factors such as fatigue, stress and anxiety. There is currently no cure.

20. Links between tinnitus & a attention
Links between tinnitus & a attention? Can one be trained to not attend to tinnitus?
I did a quick lit. search and found this 2004 model for psychophysiological aspects of tinnitus from Zenner and colleagues. It clearly incorporated attention as a potential, contributing factor (or at least a consideration) in the development more chronic forms of tinnitus.
Zenner HP, Pfister M, Birbaumer N.(2006) Tinnitus sensitization: Sensory and psychophysiological aspects of a new pathway of acquired centralization of chronic tinnitus. Otol Neurotol. 27(8): Fig 4 p 1057

21. What is common?
So, research appears to support that the brain does not work in silos. Sound does not only activate the hearing systems in the brain but some of the ascending auditory pathways make connections with attentional, memory and emotional centres in the brain as well. The brain is highly networked. This may help explain why some of the more auditory-cortex centric approaches for tinnitus have not been as reliably successful as we would like. Some theorise tinnitus is a failure of selective attention. The ability to attend to other target sounds (like environmental sounds) and ignore distracter sounds (like tinnitus). This theory was supported for 4 out of the 6 tinnitus & attention studies I just presented. You will find “selective attention” & “focused attention” used interchangeably.
De Ridder, D., A. B. Elgoyhen, et al. (2011). Phantom percepts: Tinnitus and pain as persisting aversive memory networks. Proceedings of the National Academy of Science of the United States of America [Early Edition]: 1-6.

22. Plasticity
This is a past animal study showing the effect of an enriched acoustic environment on animals exposed to an acoustic trauma shown in a previous work to result in at least a 40 dB hearing loss. The left panel shows animals in the control group, demonstrating normal frequency maps with the warmer colors indicating high-frequencies and cool colors low. The center panel shows noise-exposed animals maintained in a quiet environment for 35 days, post exposure. The right panel shows animals exposed to an enriched acoustic environment for 35 days, consisting of 80 dB SPL—resulting in a more normal-appearing frequency map.
Norena, A. J., & Eggermont, J. J. (2005). Enriched acoustic environment after noise trauma reduces hearing loss and prevents cortical map reorganization. The Journal of Neuroscience, 25(3),

23. Tinnitus Treatment Options
Internet Programs
Tinnitus Treatment Options
Upsalla, Sweden
Based on CBT Principles: applied relaxation & cognitive restructuring.
Information on rationale, sound use, tinnitus, sleep, hearing, concentration, hyperacusis, exercise & progress maintenance.
Pervasive Healthcare Model

24. Tinnitus Treatment Options
Medical/Surgical
Tinnitus Treatment Options
Glomus Tumour
Ménière’s
SSCDS
Sudden Unilateral SNHL
Vascular Compression
Vestibular Schwannoma
Medical management or surgical treatment of pathological condition likely responsible for, or contributing to, tinnitus.

25. Tinnitus Treatment Options
Non-invasive Neurological
Tinnitus Treatment Options
Brain Stimulation
rTMS, TMS
TCS
Magnetic or electrical current to portions of the brain to modify tinnitus or prepare for tinnitus treatment (encourage neuroplasticity)

26. Tinnitus Treatment Options
Pharmacological
Tinnitus Treatment Options
Anti-depressants
Anti-convulsants
Anxiolytics
Hypnotics
Tranquilizers
Drug provision to manage identified conditions contributing to, or exacerbating, tinnitus percept.

27. Tinnitus Treatment Options
Psychological/ Counselling
Tinnitus Treatment Options
Hearing aids, tinnitus & counselling
CBT
Group Therapy
Guided Therapy
Masking Therapy
Neurofeedback
Person-Centered Therapy
Refocus Therapy
Tinnitus Behavior Therapy
Informational Counselling
Tinnitus Activities Treatment
Different approaches for different needs. Appropriate referral, preferably to a professional who has experience in dealing with individuals with tinnitus may help determine which approach is best. The importance of counselling adjunct to tinnitus management cannot be understated.

28. Tinnitus Treatment Options
Self-management
Tinnitus Treatment Options
Promotes lifestyle changes.
Aims to modify viewpoint & expectations, to stop tinnitus cycle,
Address potentially contributing: stress, anxiety, fatigue & depression.
Brochures, information packages, sound therapy device(s) & associated equipment.

29. Tinnitus Treatment Options
Sound Therapy
Tinnitus Treatment Options
Audiological - Generic
Cochlear Implants
Hearing Aids
Music Therapy
Sound Therapy

30. A: B: Cricket  tinnitus Background image  background sounds
Hearing loss
BACKGROUND SOUNDS NOT AUDIBLE ENOUGH TO INTERFERE WITH TINNTIUS DETECTION B:
Hearing aid
BACKGROUND SOUNDS ARE NOT AUDIBLE VIA AMPLIFICAITON & MAKE TINNITUS STANDOUT LESS

31. Hearing aids A wide frequency response Noise reduction switched off
Microphone noise reduction switched off
A low compression kneepoint (at or below 50 dBSPL)
A high compression ratio
Soft squelch or expansion turned off
Fast compression attack and release times
An omnidirectional microphone setting
An open fitting

32. Tinnitus Treatment Options
Sound Therapy
Tinnitus Treatment Options
Customized Sound
Coordinate Reset
Notched Music
“Phase Out “ or Phase Shift

33. Tinnitus Treatment Options
Sound Therapy
Tinnitus Treatment Options
Customized Sound
● Neuromonics
● Desensitization via passive listening with tinnitus embedded in spectrally-modified music (or music + BBN noise in Phase 1 of treatment). Uses extended bandwidth = 12.5 kHz.

34. Tinnitus Treatment Options
Sound Therapy
Tinnitus Treatment Options
Methodological Sound Incorporation TRT
Uses a directive counselling style. Case & category-dependent regarding device(s). Provides anatomy & physiology, neural activity discussion, test results & sound therapy information.
Habituation Therapy
Sound therapy & directive counselling with the aim of promoting habituation to tinnitus reaction. Sound provision at a theoretical “mixing point”.
Directive Counselling…Under this process the counselor plans the counseling process, his work is to analyze the problem, identify the triggers identify the exact nature of the problem and provide various options.