Talking Tinnitus: Interview with Gemma Gray, AuD, of HearUSA

Dave Kemp 0:10
All right, everybody, and welcome to another episode of This Week in Hearing. I’m very excited for today’s conversation with Dr. Gemma Gray. So Gemma, tell us a little bit about who you are and what you do.

Gemma Gray 0:23
I, it’s a pleasure to be here. I’m actually director of learning and development for hearing care professionals at HearUSA, I am in sunny San Diego, and basically just had up the professional development for my team of audiologists here in the States. I started as a neuroscientist like 19-20 years ago, at the Mayo Clinic in Florida. And that’s kind of what brought me over from England to America and working on dementia research and everything, it kind of wants to be more of a clinician, and that’s kind of how I fell into audiology, and, and kind of fascinated between the science than your physiology and the link between dementia and hearing loss. So

Dave Kemp 1:07
Well, thanks for being here today. Um, I’m really looking forward to this, chat. And yeah, I think it’s really neat that you have a background in neuroscience, I just continue to think that this link between the ear in the brain and the relationship between the two is just super fascinating. And I feel like it’s just going to become more and more relevant as time goes on. As we learn more about the connection between the two, which sort of segues into what we’re going to talk about today it is tinnitus awareness week or month, whatever you want to call it. But I know that you have a lot of really interesting thoughts and approach to how you think about tinnitus, particularly about how you you know in the clinic itself and how the patient interaction is and how to kind of like best address it. So I figured this would make for a great conversation. So why don’t we start with you setting the stage a little bit with some of the like high level statistics to paint a picture of the pervasiveness of tinnitus right now?

Gemma Gray 2:11
Absolutely. Yeah. So your tinnitus impacts a huge number of patients that we see in our clinics every day. A meta analysis of the global prevalence and incidence of tinnitus. By Sharrock last year estimates that 14% of the world population actually have experienced tinnitus, and more than 2% are actually in that can In more severe categories that are bothersome and need to do something about it. So overall, it’s 120 million people worldwide. I don’t remember the stats, these are just ones that I have looked up, and it just blows my mind every time when I read how many people are affected. So I think it’s our responsible that our responsibility as HCPs hearing care professional to really help these people.

Dave Kemp 2:55
Absolutely. Well, cool. Um, and yes, that’s a large, large number. And obviously, a lot of these people are suffering considerably. And I think that one of the biggest issues for them is where did they turn? Where do they go in? How does audiology brand itself better to be the de facto solution in the mind of the, you know, stereotypical person that’s walking around, suffering from this? And so I wanted to get into this with you, because I feel like it’s one of those things that sort of on the peripheral a little bit within audiology of like, you know, within the industry, you know, it to be something that’s one of the services that you provide, but it seems like there is some apprehension, writ large by some of the audiology community of really treating this. And I don’t know why that might be. So I figured we could kind of discuss this. So why don’t we talk through maybe initially here, when you are having that patient, initial patient visit? What are the kinds of questions that you’re asking? What kinds of red flags? Are you asking, you know, are red flags? Are you looking for that you would then know to refer them on to a different medical professional?

Gemma Gray 4:11
Great questions, lots to unpack that. Yes,

Dave Kemp 4:13
this is very well,

Gemma Gray 4:15
I think first off, kind of going back to your comment there. How do we as audiologists become kind of known as the experts, and anything that is something that we need to advocate for ourselves and get out there in the community get out there in the medical field as well, because we know so often that someone will turn to their primary care physician, or even the ante and go, Oh, my goodness, you know, I’ve got tinnitus, what can I do about it? And often, it’s so heartbreaking, but they get told there’s nothing can do. You know, at least it’s not this medical thing, you know, they’ve had a brain scan, you’re fine. Go on your merry way. So it’s kind of it’s very important for us to establish like we’re the ones to turn to, and I’ll come on to kind of building a network of medical referring physicians, ENT, counselors, psychologists, we need to kind of build that awareness in the medical field, so that we have people to refer on to when we need it. But equally they can refer to us. Because, you know, oftentimes it is, you know, sound therapy, hearing aids, that can be very, very helpful. So, yeah, kind of, what do we need to do is we don’t need to become experts in cognitive behavioral therapy, we don’t have to become experts in tinnitus, retraining therapy when I think it’s just, you know, a general provider that has an hour to assess someone’s hearing needs to also take that time to kind of explore tinnitus as well. So I knew that I in my clinic, we always had separate tinnitus appointments, which were a little bit long bear, but essentially, you could do it within an hour and really address any so I think they become experts just know the experts around you, for sure.

Dave Kemp 6:03
That’s interesting. Okay. So when you are having this, call it a 60 minute evaluation where you’re, you know, looking at a whole bunch of different things. To your point, you know, maybe this is a good opportunity to, you know, ask a couple probing questions that might signal that there’s some underlying tinnitus here or something like that. Yes. Walk me through that, like how you kind of envision, you know, if you have 60 minutes, like, how do you break off five of that and allocated properly toward this?

Gemma Gray 6:34
Yeah, they say, usually, you kind of unpack that in the history taking. So it’s kind of the first step of doing a hearing evaluation for anyone. And if they bring up tinnitus at that point, you think, Okay, right. I need to explore this further. Don’t kind of shy away from that. Say we want to ask a question very general open, like, do you have noises in your head or ears? And then if they do answer yes, then the follow up questions we need to determine kind of firstly, is there a medical referral? Like you said earlier, kind of the red flags. Is it unilateral tinnitus, that one sided? Is it pulsatile in nature, we want to kind of rule them out, and certainly get them seeing and nose and throat doctor if it is. So you want to be asking more questions? Is one air both ears? What does it sound like? And that’s kind of, you know, such a subjective. You want to make sure that you’re having it in their words, never ask do you get a ringing? Do you get a buzzing in your ears? It’s like, no. Do you have any sounds in your head? Right? Yes. So it’s kind of important to kind of give them that time to explore what it really does sound like when it happens? And what kind of things you know, stress them can make it worse. So it’s unpacking that

Dave Kemp 7:48
issue? Do you feel that most people that are experiencing tinnitus symptoms? Are they aware that they’re experiencing tinnitus symptoms? Like do they know what the ringing in their ears is? Or the buzzing? Almost like do they kind of come into the professionals? You know, like, chair, having some semblance of what’s going on with them, or most people sort of ignorant to tinnitus? Like, broadly speaking?

Gemma Gray 8:19
I think that’s a big question, so some people kind of say, Yeah, I guess some rigging just occasional and it’s not, you can tell it’s not bothersome. So it’s not necessarily impacting on their lives. They you do, you can explore it a little bit. But genuinely, if, if it’s not something that’s hugely significant, you don’t need to worry too much about the management. If it’s something that they’ve come to you directly, they come in going, I know that you’re an audiologist, you can help me, then absolutely, they’re going to be very much aware of it in their lives. So that’s why, you know, when you’re putting your clinic out there on your website, you should be saying tinnitus management, or at least indicated kind of directing traffic to you. And having links to the American Academy of Tinnitus and things like that. It’s really important.

Dave Kemp 9:06
Yeah, I just figured that’s interesting. Because, you know, obviously, that’s how I was thinking about it is, how do people even come to find the audiologist, for something that they might not really be aware of what they’re experiencing? So there seems to be a lot of of an opportunity, I guess you could describe it and then radiology to really interject themselves here. Like we talked about, like kind of being the person in the medical professional that people think of not only patients but the medical community, as well, because I think that’s a really important part of this are the Medical Referrals, like you mentioned, one question would be okay, so you have a patient, let’s say that you’ve kind of gone through you didn’t identify any major red flags, but yeah, they definitely are experiencing tinnitus. How do you approach that? What’s the way that you’re speaking to All those patients that, you know, you know that there’s definitely tinnitus, you’ve uncovered it.

Gemma Gray 10:06
Yeah, I think it’s more about understanding that by see the properties of their tinnitus, what are they hearing? Is there times when they can actually forget that it’s there that they actually do get some relief. And it might be when they’re busy, it might be when they’re at work that they don’t hear it and they come back home, it’s quieter, less busy, they kind of forget it. So I think that’s kind of a key thing to establish. I think honestly, it’s about kind of delving in what’s relevant to them, how is it impacting on their lives? Was there an initial triggering events, a physical or mental trigger? So was it something so obvious, like a head trauma or an ear infection that needs to be addressed by a medical professional? Or is it kind of the onset of a medication because as you know, some medications or can cause tinnitus, like high doses of aspirin, Chloroquine gentamicin, but honestly, any medication for that matter is toxic or not really can trigger tinnitus. Because if you think of tinnitus, it really can be a symptom or a side effects of many medications, a symptom of other diseases and side effects of medication. So anything that kind of disrupts yours, body’s status quo, and some change in your body, changing your mental ability to tune it out and really kind of bring it to light. So.

Dave Kemp 11:31
So it’s interesting, like I’m thinking here about the, you know, the, what’s it called the hearing aid, handicap inventory, I’m blanking. I know it’s not called hearing aid, but it’s something handicap inventory. Is there something similar with tinnitus, where you’re basically going through almost a checklist? I’m thinking through the lens of the clinician, so there’s almost some, you know, rep, you can replicate this process.

Gemma Gray 11:58
Yeah, yeah. And I, I absolutely use a validated questionnaire, I use their kind of initial form the Tinnitus Handicap Inventory. Oh, yeah, yeah. So this 25 questions, super quick to fill out. And often, if I know that they’re coming in to address tinnitus concerns, then I had them fill it out beforehand, either at home or in the waiting room, that you can do it upfront in the clinic, you know, it takes a couple of minutes only. So it’s very much worth worth doing. So what it does is basically identifies and quantifies the difficulties that they’re having. So is that affecting them during the day that night, and then you can use that to really create the the way that you can manage their tinnitus? And so I don’t know if you know, some of the questions, but it really explores like their emotions towards the tinnitus. So ask questions like, Are you feeling frustrated? With the tinnitus? Is that irritating? Does it make you angry, confused, depressed, anxious, and certainly it does highlight whether it gets worse with stress. And I think that’s kind of a key thing to bear in mind with their management. And then it helps to really kind of explore when it impacts them is that it work? Is it at home? It’s during your social activities? And does it interfere with you doing those responsibilities? So? Yeah, it’s kind of I really liked the th I,

Dave Kemp 13:28
that’s great. Okay, I’m glad to know that that exists. So because I feel like it could be any number of like, we’ve chatted about, like culprits that are causing this, but the thing about tinnitus that is kind of frustrating is that, I would imagine for people that are going through it is like it’s it’s hard to identify, it’s hard to maybe treat, because a lot of it are these, like real underlying factors like stress. And it’s hard. It’s like, you know, are you stressed out? Well, a lot of people might say, Yeah, of course, I’m stressed out, like, look around, you know, I’m working parents, you know, trying to like juggle all these different things. And so, something that feels an, you know, completely unavoidable in their lives is the culprit for this thing that’s spiraling, you know what I mean? And I feel like that might be some of the challenge. You know, when, when you’re having these kinds of conversations. Do you feel that like people are almost not satisfied with the, the root of the cause potentially, as being something as common as like stress?

Gemma Gray 14:36
Yeah. Yeah, you’ve got to kind of normalize that as well. I think everyone’s be normal. So when it comes to, you know, talk about hearing aids and things, it’s like it’s normal to have need them because of this, and age and things. So I think with tinnitus, it’s about saying, Yes, it’s very normal for stress to heighten your the invasiveness of your tinnitus and you As part of the management, it’s about exploring what you can do to reduce their stress. And as I said before, it’s not that you need to become experts in CBT, or tinnitus, retraining therapy, it’s about just going, Okay. I’m here to help you, I specialize in ears, but I can certainly give you some advice on you know, what you can do to lower your stress. And firstly, a sleeping well. And, you know, you don’t need to give them all the kind of you should wear blue blocker glasses and you shouldn’t have blue like, literally, you know, you need to let your melatonin kind of ramp up, you need to know that you just need to go like, are you sleeping? Well, is there anything that is stopping you from not sleeping, if it’s the tinnitus, that’s when you can explore sound therapy. And I would encourage everybody to, you know, really know what products that are out there that you can use. So you know, sound therapy machines that play out white noise, or more calming sounds like Birdsong, and like waves, the sound of ocean waves, because it kind of regulates your breathing as well, it’s very calm and relaxing. So there’s lots of things you can do. At night, if you’re not sleeping, it’s a really common complaint. You can lay there at night, and it’s super quiet around you and you just start hearing the tinnitus and then you can’t sleep because your focus isn’t on it. And it’s kind of that cyclical, your your the limbic system in your brain is just, like ramped up and the emotional side of your brain is basically honing in on that. So we were

Dave Kemp 16:27
talking about this a little bit before we started recording, I find this absolutely fascinating. So with the limbic system, like the example that you pointed out was your phone, you know, you hear your phone ring in the middle of the day, your brain doesn’t really react to it, because it’s just my phone ringing. You know, you hear your phone ringing in the middle of the night. And it like is jarring it shocks you know, like, What’s the emergency? Exactly? Yeah. So that’s kind of how it is with tinnitus, right? It’s like your brain is it’s, it’s aware of the sounds. But like, what is it like that it makes it hyper aware, in certain situations of sounds that like it’s become habituated to it. That’s fascinating to me how your brain works like that,

Gemma Gray 17:09
definitely. And stress is causing that. So if you’re, you’ve got all these other stresses mental and physical, on your body, your your brain genuinely, genuinely does not have the energy to be tuning out the tinnitus to habituate to it anymore. So suddenly, you’re then aware of it. And usually for tinnitus, it is something that is long term in that you might have years of not hearing it, and then it’s coming back. And it’s just to do with the amount of energy it takes to really kind of ignore it and tune it out. So, I mean, it’s different in every every, every case, you know, there’s a physical reason why there’s tinnitus, whether it’s over stimulus one over or something like that’s obviously a different cause. But if it is stress linked, then you’re more likely to hear it when you’re stressed out.

Dave Kemp 17:54
I like this, though, because, you know, I think that, you know, you’ve pointed out that the role of the audiologist, unless you’re really looking to specialize in this, which all the more power to you to do that. But I think that like, if I’m understanding what you’re kind of saying is the main message here is that every audiologist can be providing that first line of defense, let me just kind of gather information for you. Because A, you’re looking for red flags. And then B when you do like the tinnitus handicap inventory, you’re able to get to at least a couple of the potential culprits for this, that again, you’re you’re really just acting as a resource for people that are desperate. So obviously, the identification of the issue is key. Once you’ve identified that, if you do want to go a step further, what are some of the different kinds of solutions out there to treat tinnitus chronically, like you said there at night? Maybe a white noise machine? I know hearing aids are another often touted solution, but can you maybe walk me through kind of the suite of types of solutions that exist for treating tinnitus today?

Gemma Gray 19:05
Okay, so I would say starting off with, it’s very, very linked to hearing loss. So obviously, the disruption in the auditory system is going to cause you to be more likely to get tinnitus. And often you see kind of the presbycusis kind of rolled off in your high frequencies to age related hearing loss, you tend to get tinnitus in the area where it’s starting to roll off. So let’s say from like 3kHz, you might have that as your sound. And I’m not kind of suggesting that in our one hour evaluations, we should be doing like tinnitus, pitch matching or loudness matching, I would say just kind of having an awareness of what sort of sounds they’re hearing. And that’s really important when you go to fitting the hearing aids and understanding that hearing aids are going to be such a great help if there is a hearing loss. So first So you want to get some hearing aids on them straight out of the booth. So you’ve finished their hearing test, just don’t wait, put them on fit them. And kind of say, as part of the evaluation, does this help your hearing your tinnitus? Does it help alleviate some of that sound. And often it does. And you know, by the time you’ve got the hearing aids on, it’s kind of explain what you’re doing there, then explain the results of the hearing test and the speech testing that you’ve just done. They’ve not been thinking about their tinnitus, and then code, that’s an example of them being able to forget it. And if you’ve got the example of them going, Oh, I didn’t notice it in the last five minutes, then you can say, hey, that’s really great, you know, great progress in that these hearing aids really might help you, you might want to take this away for a trial, you might want to buy them on the spot, but you know, I really do encourage people to take them away and give them a go, because that’s where they’re gonna get their the real benefit, if they’ve got a hearing loss. So and the hearing aids, you probably know, they can be set with tinnitus, sort of sound therapy with a numb, so you’ve got fractal tones. And you can also stream from their phones, whatever the sounds that they like. And we talked a little bit about kind of the calming sounds, they’re so useful to have on just in the background if they need it, but But generally, just hearing the external sounds around them helps to ignore the internal sounds.

Dave Kemp 21:22
That’s interesting. Okay, cool. So, so hearing aids, obviously, a really good solution for some, maybe some people though, they might not want to go down that route. So like, for those types of people, what would you what are kind of the other basic things that are worth considering for clinicians to think about having, again, if you’re, it’s like, there are layers of this, you can you can really go down and you can specialize in this to a large extent, or you can have a more of a surface level. So for the people that are at that more surface level, what are some other good solutions to consider?

Gemma Gray 21:59
Yeah, I think it’s narrowing there. So we’ve got sound therapy and the hearing aids, then we’re kind of addressing the stress side of things. You can also consider, you know, is there something that’s triggering it in their diet, they got kind of an eating healthfully, too much salt, have they, you know, also got some of them migraine triggers that can trigger tinnitus. Some of the finest things in life like red wine, and chocolate and cheeses and things, they can also have all the good stuff in it, because stuff Yeah, unfortunately, has made money should keep a little bit of a diary. You know, I encourage people to, like I would with a vestibular patient, with dizziness, you want to kind of have a tinnitus patient also maybe write down some of the things that might be triggering it. Also, you know, exercise that helps relieve the stress also helps you have a bad night’s sleep, you know, it releases endorphins, it’s kind of trying to counteract some of the more negative sides of tinnitus.

Dave Kemp 22:57
That’s awesome,

Gemma Gray 22:58
kind of just general, you don’t have to be the expert. And it’s just knowing that these things can really help. And as you’re going through the history, you’re really understanding what the problem is, you’re doing tinnitus, handicap, and inventory, you’re kind of really honing in on how to specialize that and management plan for them.

Dave Kemp 23:16
So that’s fantastic. So final thoughts on, you know, setting expectations. I know you work with a lot of, you know, with your role, you’re you’re working with a lot of clinicians, and helping to train them on this. But, you know, it just seems like there is a little bit of apprehension about some audiologists wanting to go and incorporate this. You know, maybe it’s because they feel like they aren’t as specialized as they need to be. But just closing thoughts here, whether it’s about the patient interaction, or a message to the clinicians out there that are that are hearing this?

Gemma Gray 23:58
Yeah, I think it’s kind of two things. It could be that they don’t feel like they should be the experts or no, it’s just just a little me, what do I know about you know, staff management, you don’t have to know a lot, you just need to know how to create that network around you and signpost, people to the right places, but equally, it could be that you know, and I had seen a lot of less experienced hearing care providers, they’ve kind of freeze up at the point that, you know, what solutions do they give? How do I tailor a management plan to that individual in front of me? And so we need to really stop that from happening because that can have an impact on tinnitus patient because if you go, Oh, I’m not sure maybe I should refer me vision or I don’t know. That kind of obviously doesn’t instill confidence in the patient. So I think you just need to kind of really understand you are the experts in as a hearing care provider. You know the basics. You understand what tinnitus is and how it can be managed, and know that you are that first line of defense And you can make those Medical Referrals when needed. So I think it’s just kind of setting the expectations to the patient that it’s great. Thank you so much for being here today, you’re taking that good step towards doing something about your tinnitus. We’re here to help, we can signpost you, I can give you this advice and making sure that you’re having those follow up sessions. When I was working in the UK, in the National Health Service, we had kind of a six week program. And you see so much improvement happened in just that first week, let alone week two. And usually you didn’t have to get all the way to the end of the six week program. But I think it’s just you don’t necessarily have to have kind of the that sort of whole setup, but just understand that every patient is going to be slightly different. And as an audiologist really trying to encourage them to try hearing aids, give them an extra week trial have a two week trial if you have to, just for them to really see that benefit and kind of get that brain stimulated and active and, you know, not going to suffer from the consequences of untreated hearing loss as well as untreated. tinnitus.

Dave Kemp 26:08
Yeah, that’s, that’s excellent. I mean, I’m just thinking in my head right now about the fact that you don’t have to be, you know, the end all solution. I think just even being a sounding board for patients and being something that they can lean on. Because you know more about yours than anybody, and then this relationship between the ears and the brain. And so I think a lot of it really is just like, you know, Lifestyle coaching, if you will, to a certain extent. But I mean, again, I think that just giving people the ability to voice What’s going on is probably beneficial in and of itself. And I think that’s a really important role that audiologists can play.

Gemma Gray 26:51
Oh, no, I agree. I agree. And it is carving out time for that. And I think just, you know, I think one of the biggest kind of hurdles to providing that care is actually having enough time. And also saying, Well, you know, I’ll do what I can in the hours. So you’re saying to yourself, almost, I’ll do what I can in the hour, but know that I can book a follow up next week. If there’s if we want to do the THI next week. That’s perfectly okay. The fact is that they come to you, you need to give them that help and be that sounding board and a listening ear. So

Dave Kemp 27:23
awesome. Well, Gemma, thank you so much. This has been super informative. I’ve really enjoyed this conversation. So thank you and thanks for everybody who tuned in here to the end. We’ll chat with you next time.