The Medical/Audiologic Approach

1. Goals:

• To establish an accurate tinnitus diagnosis; maintain hearing and communication abilities; control balance.
• To identify presence/absence disease of head and neck.
• To identify clinical types of tinnitus.
• To attempt to provide tinnitus control based on accurate tinnitus diagnosis.
• To establish the medical significance of tinnitus.
• To identify and treat factors known to influence the clinical course of tinnitus.

2. Plan - Completion Medical Audiologic Tinnitus Patient Protocol

A. Initial Visit:

• Self administered tinnitus questionnaires completed by the patient for tinnitus, stress, behavior, mood, communication ability(ies) - Tinnitus Handicap Inventory. Tinnitus Stress Test, Measurement of Depression Scale, Tinnitus Intensity Index, Tinnitus Annoyance Index, and Tinnitus Severity Index.
• Neurotology consultation - physician - interview/history taking; physical examination.
• Hearing Screening Test.

B. Recommendations: Extensive tests of the nerve of the ear and brain for hearing and balance to attempt to clinically identify the type of tinnitus and any underlying condition(s) which may influence the tinnitus.

• Comprehensive Site of Lesion Audiometry
• Ultra High Frequency Audiometry
• Brainstem Auditory Evoked Response Testing
• Otoacoustic Emissions
• Computerized Rotary Chair Testing
• Electronystagmography Testing
• Tinnitus Evaluation - Identification of tinnitus parameters e.g. location, duration, frequency, intensity; masking; rebound; Measurement residual inhibition; Masking curves.
• Hyperacusis assessment
• quantitative Electroencephalography
• Recommended in Selected Cases - Central Auditory Speech Testing; MRI/SPECT of Brain

C. Follow-Up Consultation Plan of Treatment/Control Tinnitus Medical/Audiologic Conference with Patient

• Review test results - including correlation with history, initial exam.
• Identification medical significance of tinnitus.
• Management/treatment/control plan of treatment individual.

Realties 2006:

Both the professional and the patient must face some realities about tinnitus in 2006.

1. There is no cure for tinnitus at this time.
2. There are different clinical types and subtypes of tinnitus. Further, it is necessary to differentiate between patients with severe disabling tinnitus and the general tinnitus population. Tinnitus of the severe disabling type causes a serious interference in activities of daily living - e.g. sleep, work, and social skills.
3. There is no general agreement about a definition of tinnitus, a classification system of tinnitus, or mechanisms of tinnitus production.
4. There is no one treatment appropriate for all tinnitus patients.
5. There are many options for the relief/control and treatment of tinnitus.
6. Instrumentation offers significant tinnitus control to the tinnitus patient.

   Since not all tinnitus is the same, not all tinnitus patients need the same medical/audiologic work-up. However, most patients with the primary complaint of tinnitus want to know the following: What do I have? What is the medical significance? Is this a life-threatening condition? Do I have a brain tumor? does this mean I am going deaf, or losing my mind? Will it get worse? What caused it? What can I do to get rid of it?

Protocols of Diagnosis and Treatment

At our clinic, the patient with tinnitus NOT of the severe disabling type can expect to receive:

1. Neurotologic examination (of the ears, nose and throat, and cranial nerves) to exclude major diseases of the head and neck (e.g. acoustic neuroma).
2. Hearing screening test.
3. Tinnitus questionnaire to identify tinnitus by its parameters: its location, intensity, and other characteristics.
4. For asymmetric (one-sided) sensorineural hearing loss: a magnetic resonance imaging (MRI) test of the internal auditory canals to identify the presence or absence of an acoustic tumor.
5. Follow-up office visits for treatment.

   We strongly believe that individuals WITH severe disabling tinnitus, who have seen several health care providers and are still suffering and unable to function, require a comprehensive evaluation. In our practice, we perform the Medical Audiologic Tinnitus Patient Protocol (MATPP). This is a team approach that attempts to identify the medical significance of the symptom of tinnitus, the clinical type(s) of tinnitus, and the identification and treatment of factors that are known to influence tinnitus. In this manner the physician and the audiologist establish a basis for tinnitus control. The MATPP includes:

6. A Neurotologic history (a review of the patient's complaints of hearing loss, tinnitus, vertigo and/or ear blockage which might reflect a disorder of the central nervous system).
7. Hearing screening test.
8. Consultation with the patient and physical examination of the head, neck and cranial nerves.
9. Individualized cochleovestibular tests to measure the sensitivity of the nerve of the ear for hearing and balance.
10. A live trial of instrumentation or ultra high frequency therapy with the UltraQuiet device or ultra sonic therapy with the Hisonic TRD.
    
11. Tinnitus evaluation to identify the parameters of tinnitus.
12. Questionnaires - to be completed by the patient including a tinnitus questionnaire, a stress test, a depression scale, and the tinnitus handicap inventory. Our patients are also given an explanation and understanding of their tinnitus, plus counseling without avoidance of loud noise exposure and the use of ear protectors in the presence of loud noise.

TESTS:

Patients who have been to other doctors frequently ask "Why do I need another hearing test? I had all of these tests last year. I'm here for my tinnitus, not my hearing problem. And why do I need balance tests? I only have an occasional feeling of unsteadiness when I get up too fast, but it doesn't bother me". Tinnitus is closely associated with the hearing and balance system. And because the nerve of the ear has two parts - one for hearing and one for balance - both parts of the system need to be evaluated. Many patients with severe disabling tinnitus are anxious and fearful that testing will increase their tinnitus. This is always a possibility! Patients must decide if they are willing to take the chance, no matter how small. This has been an infrequent occurrence in our practice. Generally if tinnitus increases in intensity, it will return to its usual level. However, no one can guarantee it. The following is an explanation of the specific tests we perform for cases of severe disabling tinnitus.

Audiologic Examination:

1. Site-of-lesion testing. This is a series of hearing tests that attempt to establish the location of the tinnitus. The tests consist of pure tone audiometry, speech audiometry (including speech recognition threshold), tone decay testing, and short increment sensitivity index.
2. Central auditory speech testing. These are tests to identify central auditory nervous system disorders in the hearing mechanism from the level of the cochlea nuclei along the auditory pathway up to and including the auditory cortex. Conventional speech tests are made more difficult by altering the acoustic signals; i.e. modifying frequency range, duration or length, rate of speech, addition of competing messages, etc. Central auditory speech testing is not routinely performed. It is performed, however, for individuals who complain of hearing difficulty because of their tinnitus whose hearing tests and Auditory Brainstem Testing are satisfactory, and for individuals whose site-of-lesion test results do not explain the patients' complaint of difficulty in hearing or understanding .
3. Impedance Audiometry: This battery of tests consist of tympanometry, acoustic reflexes, reflex decay, and the Metz test for detecting lesions within the inner ear. These tests help establish the presence or absence of hearing los, the type and degree of hearing loss, and the presence or absence of Recruitment (a sensitivity to sound). They also help the audiologist evaluate the functional condition of the patient's middle ear, tympanic membrane, and Eustachian tube. For the patient complaining of ear blockage, these tests can determine if the source of the blockage is the middle or inner ear.
4. Tinnitus Evaluation: It is important to "quantify", or specifically define, the patient's tinnitus experience to provide a basis for communication about the tinnitus between the examinations and the patient. This is an attempt to objectivize the subjective complaint. Establishing the tinnitus parameters - quality, location, duration, frequency, intensity, maskability, and rebound (an increase in tinnitus intensity following sound presentation - also enables us to follow and monitor any changes that result from treatment. The tinnitus evaluation includes: pitch matching, loudness matching, and the measurement of residual inhibition (temporary, post-masking tinnitus suppression), the Feldmann Masking Curves (Minimal Masking Levels), and loudness discomfort levels. After the results are analyzed, an individualized trial of live instrumentation is offered. We hope that individuals who experience residual inhibition when they are tested will have the same experience following the use of instrumentation for masking. If rebound occurs, the otologist attempts to medically control the conditions influencing this phenomenon. From masking curve test data we can determine if maskability is positive or negative and which ear (or ears) should be fitted with devices Loudness discomfort levels are established for each ear individually at frequencies from 250 - 8000Hz to assess the presence or absence of hyperacusis and their sound sensitivities. The outcome of these tests also influences the choice of instrumentation.

Electrophysiologic Testing of Hearing (Cochlear) and Balance (Vestibular) Function:

1. Auditory Brainstem Response Testing (ABR): The ABR records the brain's electrical firing capability in the central auditory system by measuring its response to sound. This Òevoked potentialÓ is recorded (via an electrode on the scalp) immediately after a brief auditory click or tone is made. It is the most sensitive and objective test for distinguishing between a cochlear lesion and a retrocochlear lesion (one between the cochlea and the brain). The ABR is believed to increase the ability to identify the clinical peripheral or central site of the lesion responsible for the tinnitus complaint and to establish the clinical type of tinnitus.
2. Otoacoustic Emissions (EOAE's): EOAE's are low-level sounds generated by the outer hair cells of the cochlea. The test is a non-invasive objective method of evaluating cochlear and auditory pathway function. OAEs are a sensitive indicator of cochlear status, especially outer hair cells which are sensitive indicators of change in the cochlea. It provides valuable, objective information about peripheral activity in the cochlea. Clinical application for tinnitus patients includes differential diagnosis of central vs peripheral type of tinnitus. For the tinnitus patient, this improved accuracy of a cochlear diagnosi,s and helps in the selection and monitoring of the therapy.
3. Ultra High Frequency Audiometry (UHFA) including electrical and acoustical high frequency audiometry: The UHFA permits an evaluation of the response of the auditory system from 1000 - 20,000 Hz. It is used to identify the tinnitus; establish octave confusions; and monitor hearing in patients undergoing external electrical stimulation for tinnitus suppression. Using UHFA, significant hearing losses in the high frequencies, i.e. above 8000kHz, have been found in tinnitus patients whose previously recorded hearing levels were “normal” when testing with conventional audiometry.
4. Vestibular and Balance Tests: Vertigo and/or balance complaints are not infrequent in patients with tinnitus. When the chief complaint is tinnitus, our clinical experience with respect to vertigo indicates that a significant number of patients (+20%) have an associated complaint of imbalance. Also, approximately 60% of tinnitus patients - with or without symptoms of vertigo - demonstrate a vestibular abnormality when tested. Secondary endolymphatic hydrops, often found during vestibular testing, requires treatment by an otologist. It can adversely influence tinnitus, result in an increased loss of hearing, and cause the patient to be more sensitive to sound. The identification and treatment of secondary endolymphatic hydrops (A syndrome of delayed Meniere-like attacks) positively influences tinnitus control in approximately 35% of our patients . In our experience, use of maskers, hearing aids, or other devices in the presence of this condition tends to aggravate the tinnitus, cause rebound, and reduce or negate the usefulness of the devices. (Patients often reject the instrumentation). Treatment of the hydrops reduces recruitment and increases the efficacy of instrumentation.
• Electronystagmography (ENG): ENG is a recording of involuntary eyeball movement in response to a series of balance tests. The tests included tracking, gaze, optokinetics, calorics, the Hallpike maneuver, and positional testing with eyes opened and closed.
• Computerized Rotary Chair and Pursuit Tracking Tests: These are used to screen for vestibular abnormalities by identifying peripheral and central vestibular function.
• Craniocorpography: an objective test method for evaluation of the vestibular system and motor response of the patient to a change in behavior/mood by recording movements of the head and neck. This technique is particularly valuable for whiplash injury.

5. Quantitative Electroencephalography (qEEG): Quantitative EEG analysis is a computerized digital measure of brain wave activity at the scalp. It measures brain function. Statistical analysis of brain wave patterns are compared to a normative database. Quantitative Electroencephalography (qEEG) has been introduced into the Medical Audiologic Tinnitus Patient Protocol: 1. in an attempt to improve the accuracy of the tinnitus diagnosis by the identification of an electrophysiologic correlate(s); 2. to provide a basis for a biofeedback treatment method influencing brain rhythms called neurofeedback therapy; and 3. as a method to monitor the efficacy of modalities of therapy attempting tinnitus relief.

6. Additional Procedures: Other tests are advised on an individual basis and may include laboratory examinations (like blood work), X-rays, CAT Scan, MRI of the Brain and Temporal Bones, and Single Photon Emission Tomography (SPECT). SPECT scanning of the brain is a functional imaging technique which our Center introduced for the identification of abnormalities of regional blood flow in patients with severe and disabling central tinnitus. SPECT has also shown us an area of hyperexcitability in the brain identical to that identified for epilepsy. This has a practical application for selected tinnitus patients. For example, we can narrow down the selection of drugs to a specific group of drugs, i.e. anti-seizure drugs, to increase the effectiveness of treatment. SPECT has also provided objective support for the speculation that in some patients tinnitus is a sign of central nervous system disease with associated complaints of anxiety, depression, and fear.

7. Management Plan - Tinnitus Targeted Therapy: After completing the MATPP, our patients have a follow-up visit with the neurotologist and the audiologist during which an individualized plan of treatment, or Tinnitus Targeted Therapy, is recommended. Current tinnitus treatments include instrumentation (amplification with hearing aids, masking, habituation with Tinnitus Retraining Therapy, and electrical stimulation, Ultra Quit device), surgery (e.g. intratympanic drug infusion), drug therapy including Receptor Targeted Therapy, neurofeedback therapy, counseling, and cognitive therapy. Individualized patient plans usually combine medication and instrumentation. During follow up visits, patients and their significant others have the opportunity to ask questions about the test results and the plan of therapy.

Instrumentation:

Medical Criteria

In our experience, the following medical criteria usually suggests a patient's suitability for instrumentation.

1. Absence of active ear disease (fluid in the ears, mastoiditis, etc).
2. Satisfactory aeration of the middle ear (proper functioning of the Eustachian tube).
3. Peripheral site of lesion.
4. Absence of or control of vestibular disorder.
5. Patient is emotionally stable.

When an identified medical condition is treated, the chance of success with instrumentation is improved.

Audiologic criteria for selection of instrumentation:

1. Hearing status. Presence/absence of hearing loss.
2. Maskability: as determined using Feldmann masking curves.
3. Hyperacusis presence/absence as determined by the loudness discomfort level test.

Medications:

The introduction and application of new drug therapies have increased the success of our Tinnitus Targeted Therapy since 1997. These medications include calcium channel blockers, free radical scavengers, corticosteroids, glutamate antagonists, and anti-seizure drugs. Surgical insertion of a new microcatheter can deliver drugs through the eardrum to the round window of the inner ear. This procedure increases the possibility of tinnitus relief for cochlear-type tinnitus.

This audiologic/medical approach lets us individualize and target the therapy for tinnitus. Approximately 80-85% of our tinnitus patient population (more than 8,000 patients) has achieved some degree of tinnitus control: 30-35% with medication and 60-65% with instrumentation. Approximately 10-15% have persistent problems. The percentage of problems that persist reflects the complexity of the tinnitus in the patients who visit our practice.

Our goal and the goal of the Martha Entenmann Tinnitus Research Center is to improve the accuracy of tinnitus diagnosis and the modalities of tinnitus control therapy. We also support educational programs both for the professional and the patient. The ultimate goal of our Center is to achieve a cure for all clinical types of tinnitus