Week 1, Spring 2008

Clinic started off this semester for me with an interesting client. The client was an older man who had suffered from tinnitus for about 25 years. He stated that his tinnitus had been "cured" nearly 20 years ago following 6 years of treatment with various tinnitus masker devices.

Recently, the client reported a return of symptoms. Since the return of bothersome tinnitus, the client first sought assistance from a certified audiologist at our clinic. She completed initial testing including otoscopy, tympanometry, pure tone AC and BC testing, tinnitus pitch matching, and a tinnitus questionnaire. She found normal outer and middle ear appearance and function. Her results for pure tone testing were described as inconsistent and not reliable because the client repeatedly coughed and moved while she was presenting stimuli. Therefore, she recommended repeating pure tone testing in order to determine reliable thresholds.

Findings regarding tinnitus revealed bilateral, generally tonal, high-frequency tinnitus that fluctuated in intensity. The client noted that the tinnitus was sometimes equal in both ears and sometimes perceived as more intense in the left ear. Although persistent, he reported that tinnitus was sometimes pulsating. Relaxation, sleep, and tinnitus maskers decreased his perception of tinnitus while silence made tinnitus worse. A history of noise exposure and current noisy activities, previously regular use of aspirin, and occasional feelings of aural pressure were noted.

Results from the tinnitus questionnaire revealed that the client believed his tinnitus had re-emerged due to exposure to a moderately-loud sound. The questionnaire also uncovered the client's feelings of sadness and moodiness since the return of his bothersome tinnitus. The client was aware of his tinnitus during 50% of his waking hours and was disturbed by it 50% of that time. Patient counseling regarding hearing loss as the likely origin of his tinnitus and discussion about treatment options occurred at the time of his initial visit. However, the audiologist reported that conversations about hearing loss were not particularly well-received, but that the client was willing to try amplification in order to treat his tinnitus.

When I saw the client, he was scheduled for a HE and HAE. In order to help combat some of the patient's obvious apprehension, we talked through some of the case history information again, and he told me more about his tinnitus. He discussed his recent use of a prescribed anti-anxiety medication, and he suggested that he was finding some relief. He denied having any trouble hearing, although he was not able to understand me without use of visual cues. Since the audiologist's report suggested that the client may not be cooperative, my supervisor recommended that I move directly to pure tone and speech audiometry. Results of pure tone audiometry revealed a bilateral sensorineural hearing loss. At low and mid-frequencies, the client's hearing loss was mild to moderately-severe and generally flat. Beyond 3000 Hz in the right ear and 2000 Hz in the left ear, a sloping moderate to severe sensorineural loss was discovered.

A modified speech recognition threshold (SRT) procedure was used to find the lowest level at which the client could accurately repeat low and mid-frequency phonemes in the CID W-1 spondees. The modified SRT was 50 dB HL bilaterally. Word recognition testing was performed at a loud conversation level of 60 dB HL. WR scores were 88% for the right ear and 70% for the left ear. WR scores were good, but below normal, when stimuli were presented at a loud conversational level in an optimal, sound-treated environment. However, in normal reverberant environments at home and in social situations, the client would likely have significant difficulty understanding even loud conversational speech.

Most comfortable loudness levels were obtained at 65 dB HL in the right ear and 55 dB HL in the left ear. During QuickSIN administration, 3 word lists were given, and a mean score of 15.5 revealed a severe signal-to-noise loss.

Bilateral amplification with directional microphones, feedback control, and automatic gain control was recommended. The client was a good candidate for CICs; however, he preferred the look and available features of miniBTEs with RITE technology. Preliminary discussion about amplification occurred, but additional patient counseling was needed. Therefore, the patient was encouraged to return for additional hearing aid consultation following medical clearance.

The following article: Clinical Guide for Audiologic Tinnitus Management I: Assessment by James A. Henry, Tara L. Zaugg, Martin A. Schechter was written about current practices for assessing and treating clients with tinnitus.

This article describes a minimal test battery for those who have tinnitus. This minimal test battery includes the following:

-1. Written questionnaires
-2. Tinnitus Intake Interview
-3. Audiologic assessment
a. Pure-tone thresholds
b. Spondee thresholds
c. Tinnitus loudness and pitch matching
d. MMLs and RI
e. LDLs (only if a sound tolerance problem is reported)
f. Word recognition scores
g. Tympanometry (reflex testing is generally not advised for tinnitus
patients who often have reduced tolerance to sound)
-5. Hearing aid assessment (if needed).

The authors suggested the test battery in this order so that sound stimulation would be minimized prior to obtaining thresholds for pure tones and speech. They stated that sound stimulation can trigger tinnitus, so saving suprathreshold testing for after threshold testing could be of great benefit.

I wanted to talk briefly about some of the tests that I did not perform, including MML and RI testing. MML stands for minimum masking level. The procedure suggested includes instructing the patient to raise their finger (for unilateral tinnitus) or corresponding fingers (right for RE and left for LE for bilateral tinnitus) when they can no longer hear their tinnitus.

For unilateral MMLs, you would present BBN in the ear with tinnitus and ascend in 1 dB steps until the tinnitus is not heard. Then, you would ask the client if they could hear the tinnitus in the contralateral ear.

-If so, you would keep the noise constant in the ipsilateral ear and begin
presenting noise in 1 dB ascents in the contra ear until the tinnitus is not
heard.

-If not, record that level as the MML.

For bilateral MMLs, lock the stimuli ascents so that they are raised in equal increments in both ears. Continue ascending in 1 dB steps until a patient raises at least one finger. When one finger is raised, keep that level constant and continue raising the level in the other ear until the patient signals that they cannot hear their tinnitus. Record both MMLs.

RI testing can also be performed following MML testing. "RI refers to the phenomenon whereby the tinnitus perception is reduced in intensity, or eliminated altogether, following auditory stimulation." "A clinical procedure was developed
that demonstrates the effect in 80%–90% of patients." Reportedly, RI lasts less
than 2 min in 60% of patients, and less than 4 min in 80% or patients. Thus, clients must be made aware of the limitations of this phenomenon, but it can be used as a counseling tool when discussing the benefits of noise generators or amplified environmental noise from hearing aids. RI IS NOT PART OF TRT though!

An abbreviated explanation of RI is as follows: 1. present BBN at 10 dB SL above the MML for 1 minute, 2. following the cessation of the noise, clients should rate their perception of their tinnitus, 3. rate the level of their tinnitus ~ every 10 seconds for 2-4 minutes or until their tinnitus returns to its orginal level. 4. varioius averages can be computed.

All and all, treatment of clients with tinnitus is something very new for me. Sorry if I bored anyone, but I got into all of this! If you'd like more info., this article was a good reference. Enjoy!

http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=17870819&site=ehost-live

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=3&hid=106&sid=55fb21cd-5a39-4c5b-b0a2-4842d09d2093%40sessionmgr108