Rethinking Tinnitus Management: Insights from Dr. James Henry

Hello, everyone. This is Jim Henry. I first want to say what a great honor it is for me to be here to speak with you about tinnitus. And I thank the organizers, Michael and everyone else for inviting me and giving me this privilege to talk to you about tinnitus for the next 30 minutes. This is a lot to cover, tinnitus, clinical management, past, present, and future. But we’ll try to hit the highlights, and hopefully this will be a good way to kick off this meeting. Just to give you a little background of who I am. My tinnitus journey started when I played loud music in my teens. And in my 20s I finally gave that up. I was a carpenter for four years after that. So a lot of noise, no hearing protection. Even when I was playing music, I knew I had tinnitus. I caused hearing loss. I have hyperacusis. I’ve got the works. So I’ve experienced all of this. And I really am careful to protect my ears now because I have a deaf daughter. I was interested in audiology. So I went back to school, got my master’s degree in audiology in Portland at Portland State University. Right out of school, I got hired by Dr. Fausti and Dr. McDermott at the VA Hospital in Portland to be a research audiologist. And I discovered how much I loved research. So I went back to school again. I went to Oregon Health and Science University, got a doctorate in behavioral neuroscience. And for the six years I was there, I was in the lab of Dr. Jack Vernon and Mary Meikle. And that’s what really got me interested in tinnitus, was being in that lab, being in their clinic, and just being exposed to what they did every day to help people with tinnitus. So that really kicked off my career. Once I finished my program, I was still at the va, went back to full time at the VA and wrote a grant about tinnitus, got it funded. That was 1995. I’ve been doing tinnitus research ever since. I retired from the VA in 2022. So I’ve been retired for over two years now. And my focus now is writing books about tinnitus and other auditory conditions. So here’s my three tinnitus books that are currently available. They’re all done. The first one, the tinnitus book, is just an overview of tinnitus, just all the details about tinnitus. Second book, Tinnitus Retraining Therapy. Third book, Progressive Tinnitus Management and these books are written not just for consumers but for everybody. I try to write in a way that is scientifically valid. I reference everything and I try to make the language understandable by anyone in any field and even consumers. So hopefully these will be of value to you. I self publish them to keep the cost down. And I’ve got more books in the works. This Hyperacusis and Misophonia book will be available in the winter. I’m working on that now. The Tinnitus Stepped Care book will be the next one Plural Publishing is going to publish that one and then I have more after that. So writing books is my retirement hobby and I’m enjoying that now. So let’s talk about tinnitus. The basics. Different forms of tinnitus. There’s primary tinnitus and there’s secondary tinnitus. So we are going to focus on primary tinnitus, which is basically nerve activity in the brain that is perceived as sound. Its all nerve activity and it’s brain related. A secondary tinnitus actually is sound in the head that is perceived through the normal bone conduction mechanism. Its real sound with real sound waves. And we’re not really going to focus on that during this conference. It’s relatively rare, but quite a few people have secondary tinnitus and, and they’re the ones who need to see ENT and have a complete examination and potentially have their secondary tinnitus corrected. Now secondary tinnitus is often referred to as objective tinnitus. Primary tinnitus can be referred to as subjective tinnitus or sensorineural tinnitus. So kind of take your pick. But I like the the designations primary and secondary because that was what was recommended by the American Academy of Otolaryngology Head and Neck Surgery foundation in their guidelines that they published for tinnitus. And then there’s also somatosensory tinnitus, also known as somatic tinnitus, also known as somatically modulated tinnitus. Now this would be a variation of primary tinnitus. It is not secondary tinnitus. Somatosensory tinnitus means that your tinnitus sound can be altered by certain physical or somatic maneuvers. And there are ways to evaluate a person to see if their tinnitus can be somatically modulated. I’ve undergone that evaluation and mine cannot. But apparently at least 50% of people with primary tinnitus have a form of tinnitus. That can be somatically modulated. So it’s very common. It doesn’t indicate that the person has any particular medical concerns, but is something to be aware of. Often patients ask about it. They want to know why does my tinnitus change when I turn my eyes to the right or when I touch my ear or whatever they say. It’s just, it’s very common, very normal and nothing for them to be concerned about. So like I said, this symposium is going to focus on primary tinnitus. So we’ll start with the 1970s. I would refer to that as the modern tinnitus era. And back in 1972 if you do searches on PubMed and you put tinnitus in the title bar, you will find There were only eight publications with tinnitus in the title back in 1972. Then fast forward to 2023. There were 475 peer reviewed articles with tinnitus in the title. So there’s a lot of renewed interest in tinnitus. There’s a lot of interest around the world. A lot of researchers, clinicians are focusing on tinnitus. We’re learning a lot. But I would have to say there’s really no breakthroughs. And that’s because there is no cure for tinnitus. There’s the sound of tinnitus that can’t be cured. So we have to address the reactions to tinnitus to help people to just live a normal life in spite of having tinnitus. So the first dedicated tinnitus clinic was Dr. Jack Vernon, shown here. And he started the OHSU Oregon Health and Science University tinnitus clinic back in 1976. And he’s known for pioneering the use of sound to do the masking method of treatment. He wrote a lot about that. I mean if you’ve looked at the tinnitus literature, his name pops up all over the place. He co founded the American tinnitus association, the ATA. And he retired in 1996 and he was taken over. His clinic was taken over by Dr. Billy Martin who I also know well and he’s greatly respected in the tinnitus field. He’s also retired, but sometimes he makes himself available for consultation. The masking method is generally misunderstood. It’s true that Dr. Vernon did try to cover up people’s tinnitus to begin with. That was the original masking method. He soon realized he didn’t have to completely cover up their tinnitus. He just needed to give them enough sound that they felt like they had a sense of relief from their tinnitus so they could still hear their tinnitus but they could also hear the sound and he would turn it up to whatever level was comfortable for them. He typically used ear level maskers he was instrumental in developing combination instruments hearing aids with maskers built in and his method used a lot of counseling. Now he’s never really written up what did they do for counseling but they just did a lot of counseling and they if you ever knew Bob Johnson Bob Johnson was the primary counselor there and he was compassionate and knowledgeable and he just did a good job counseling so so masking was a combination of counseling and sound therapy and then these are all other methods of counseling and sound therapy that have evolved that evolved after Jack Vernon’s masking method. Now CBT cognitive behavioral therapy does not necessarily include sound therapy but the CBT practitioners will advise their patients to use sound in the. Background and they’ll advise them in different ways. So CBT is primarily a method of counseling. But patients are also advised to use sound as therapy. Tinnitus activities treatment was developed by Rich Tyler and his group starting in about 1987. Tinnitus retraining therapy, which most of you are probably aware of, was started by Pavel jastreboff in about 1988. So these are all well established evidence based methods that are structured. Theyre written up. We know exactly what’s involved in conducting these methods. And I would say any of these can work well to help patients with tinnitus overall. So CBT was applied to tinnitus by Robert Sweetow Now that’s interesting. He’s an audiologist and he’s also retired now. But he was the first to write about applying CBT specifically to tinnitus treatment. And CBT has cognitive components changing the way a person thinks about their tinnitus to be more positive and more constructive. Behavioral components are generally distraction activities, relaxation techniques and then a lot of education about how to live life in a way that is more conducive to being less bothered by your tinnitus. And CBT is generally provided by psychological health providers. Anyone trained in CBT can administer it. Very few are actually available to provide CBT for tinnitus. So that is a general issue that CBT has this really the strongest evidence in the research literature for tinnitus treatment. And yet finding a CBT provider is often really difficult. There is now third wave cbt. I don’t know if you know Bruce Hubbard, he is one of the proponents of using third wave CBT. So first wave CBT or first wave therapy was using different behavioral techniques, second wave added the cognitive components, and then the third wave cbt, rather than using some of the techniques and the philosophies of traditional cbt, which would be second wave cbt he and others have moved in the direction of people really focusing more on being aware of their tinnitus and accepting their tinnitus for what it is. Now that’s very different from distracting yourself from tinnitus. We could talk a lot about that and hopefully somebody will in this symposium we’d like to, we’d like to know more about that. But he has incorporated acceptance and commitment therapy and different mindfulness approaches. And that’s basically what third wave CBT is. It’s incorporating ACT and, and mindfulness. Pavel Jastreboff is given credit for developing tinnitus retraining therapy TRT The goal is habituation, habituation to the perception of tinnitus, habituation to the reactions to tinnitus. He’s got five treatment groups basically addressing do they have tinnitus? How bad is their tinnitus? Do they have hearing loss? Does their hearing loss present difficulties to them? Do they have hyperacusis? Do they have misophonia? And do they have a reactive tinnitus? Dont have really more time to talk about trt, but it’s based on the neurophysiological model of tinnitus which he developed. The counseling is very structured and it’s a lot of material to cover with patients. The sound therapy is critical. All patients are advised to avoid silence and enrich their sound environment. And the method is delivered mostly by audiologists. And probably thousands of audiologists have been trained in TRT directly by Pavel and Margaret Jastreboff and others on his team. Tinnitus activities, treatment. There’s Rich Tyler. Its been around a long time. Its also very well defined. It’s been written up. There’s book chapters and articles that describe it in detail. And it’s another combination of sound therapy and counseling. He breaks his patients up into curious patients, concerned patients, and distressed patients. And it’s like almost like Jastreboff’s different patient categories. But mainly he’s looking at how bothersome is the tinnitus for the person and based on how bothersome it is that the level of services is provided accordingly. And mostly audiologists provide tat progressive tinnitus management. That’s the method that I helped develop. We first published about it in 2005. It’s a stepped care method. So patients are only receiving the level of care that they need on an individual basis. Level one is the referral level, making sure they go to the right person to begin with to get the help they need. Level two is the audiology evaluation. Level three is skills education. That’s really the counseling level. And it involves a combination of individualized sound therapy. So we don’t, we don’t subscribe to any one particular form of sound therapy. We just say patients need to be informed about how sound can be used to reduce their effects of tinnitus. And then you help them put together a program so that they use sounds that work well for them. And then they also Receive components of cognitive behavioral therapy some cognitive restructuring, some distraction techniques and some relaxation techniques. And if they need more than that we can do an individualized evaluation which would be in depth evaluation by both an audiologist and a psychologist. And if they need ongoing treatment then we call that level five individualized support. And there’s a telehealth version which we’ve done randomized controlled trials on PTM and tele PTM and we’ve gotten very good results. So these are the established methods cbt, trt, tinnitus activities treatment and ptm. They all use a combination of sound therapy and counseling. They’re all well established, they’re all evidence based. So if you use any one of these methods, I’d say you are using a method that is generally going to be helpful to most people provided the you are a competent provider and you’re really looking out for the best interests of your patient. And there are variations of these methods and people often do vary the methods in different ways. There’s a whole lot of methods that would be considered passive treatment and they’re all listed here. I’m not going to mention them all. But basically what do they all have in common? They involve either taking some substance by mouth or receiving some procedure. All of these methods have been studied to some extent and are reported in the literature. So these might be considered promising methods. None of these methods has strong evidence of benefit but they all have been shown to be helpful in some cases. And then that would be contrasted with behavioral or self care methods where basically the provider is teaching the patient what to do about their tinnitus and then they go home and they do it on their own. And here’s a list of these types of methods and these are the methods that we generally use. All of the established methods that I mentioned would be considered behavioral or self care methods. So what do they all have in common? Patients learn what they can do to manage effects of tinnitus, to sleep better, concentrate better and not react emotionally to the tinnitus. Clinicians teach the techniques and provide support as necessary. Some self care techniques can be learned without a clinician’s help from various books, videos and websites. So where are we headed? Where are we going in the future? I’ve got looks like about nine minutes left to try to cover this. Here’s four different possibilities. Bimodal stimulation, migraine based therapy, repetitive transcranial magnetic stimulation and sound therapies targeting the tinnitus sensation. So bimodal stimulation has a lot of buzz these days. The idea is to stimulate the, basically the dorsal cochlear nucleus with both auditory signals and somatosensory signals. And supposedly that induces more long term plastic in the dorsal cochlear nucleus neurons. And that is what supposedly reduces tinnitus. Now there’s no claim that I know of that it’s going to reduce the sensation of tinnitus. It’s another behavioral method. It’s a method intended to help a person sleep better to concentrate better and to have fewer emotional reactions. So here are three different methods of bimodal stimulation. You probably heard of Lenire. That’s this device with a tongue stimulator. Along with sound therapy. The neosensory device is the tinnitus duo wristband. Its a vibrating wristband. Wish I had more time to talk about it, but I don’t. Combine with sound therapy. So that’s the duosensory aspect of this method. And then the Michigan tinnitus device, that’s Susan Shore. Its not yet FDA approved. These others, these first two are commercially available and they’re both FDA approved. Susan Shore is working on getting. This, her device available to the public, but that has not happened yet. Otologic migraine. It’s just interesting. This is Dr. J. Lillian. I don’t know if I pronounced that. Right, but he’s been sort of the leader in this concept of otologic migraine. And basically people can have migraines without headaches. Now that seems counterintuitive, but it’s really true. And so they could have the symptoms of migraine without the headache. Those would be considered atypical symptoms of migraine. And one of those symptoms is tinnitus. Another is hyperacusis. So they have a whole treatment regimen. That they can use for tinnitus and especially if they consider it to be otologic migraine related tinnitus. So this is an up and coming. Technique to be aware of repetitive. Transcranial magnetic stimulation, rtms. This is Bob Fullmer. He knows a lot about this. He’s done clinical trials, he’s written an article that really lays out the issues. This is a promising technique. It’s used to treat depression and anxiety. And other emotional disorders. Is used effectively. It has not really been proven to work well for tinnitus. But that does not mean it doesn’t work. It just means there’s more research to be done. Sound therapy is targeting the tinnitus sensation. So there are different ways to manipulate sound to try to have a. Long term effect on the tinnitus. One of those is to notch the. Sound around the tinnitus frequency with the. Idea of flooding that frequency region with lateral inhibition and reducing the sound of the tinnitus. Now this could be a cure or. A partial cure if they can figure. Out how to do this on a consistent basis, how to evaluate a person. Design a notch noise therapy for that. Person and deliver it effectively. We’re just not there yet. The rationale is good. Theres a rationale for believing this should work. But the research has not yet been done to prove that it works. Same thing with match noise therapy. It’s just a different concept. Instead of trying to notch sound around. The tinnitus signal, you’re matching the tinnitus. With noise around that tinnitus region. And the idea is to counteract the reduction in activity going into. The dorsal cochlear nucleus. And By counteracting it, you are increasing the activity going to the dcn. Which reduces the activity taking place in. The dcn, which basically is trying to. Normalize what the DCN is doing when it has normal auditory input. That probably didn’t make much sense, but. You’Re trying to restore homeostasis in the dorsal cochlear nucleus. And so there’s a good rationale for. Using this but again we just don’t have the proof that it works. Neurodesynchronization therapy this works on the. Assumption that the reason we have tinnitus or the primary reason is because of neural synchrony, that hearing loss causes this neural synchrony. It’s the neurosynchrony that produces tinnitus. So they have developed a way of delivering sound in a way that supposedly. Disrupts that neurosynchrony to establish normal activity of auditory, of the auditory central nervous system. Theres a company called Dysyncra that. Has since gone out of business. I’m not aware that they, that they’ve restarted this company. Residual inhibition. I believe that has promise. But again the research hasn’t been done. We know that if we do this for people, we, we give them. Sound at a level above the minimum. Masking level for about a minute. We ask, we shut it off. We ask them what does your tinnitus sound like? And 80 or 90% say it’s softer or it’s gone. And I can do this to myself over and over and over. The problem is the tinnitus returns within a few minutes. Now there are methods that have. Been tried to extend the duration of residual inhibition. Theres some research going on in. My mind, not enough research. I think this method really has potential as a clinical technique. But again we’re just, we’re just not there. There’s all kinds of experimental methods and. Because I’m running out of time, I’m. Not going to list them all or talk about any of them. But a lot of them involve Electrical stimulation in different ways. So in summary, and I think I’m good on time there’s no cure for tinnitus. All methods address effects of tinnitus. Sleep problems, concentration difficulties, emotional reactions. We certainly need a cure. And there’s research going on around the world. One of these days somebody’s going to find it. And there’s probably many different cures. There’S different subtypes of tinnitus. We don’t know what all of them are yet. That’s more research that needs to be done. We are at a point where many. Methods can effectively treat the majority of patients. We have these established methods that I talked about. We have all kinds of forms of counseling. We have unlimited forms of sound therapy. And there’s practitioners, clinics, methods, websites, apps and companies that provide different forms of tinnitus management. So there’s a lot out there not a lot of it is proven. But it can be helpful if conducted properly by competent providers. There’s no proof that any one method is more effective than, than any other. All methods of tinnitus treatment may elicit the placebo effect. Competent providers should use whatever works and is in the best interest of patients, including safety concerns and costs. So we need more research, obviously. We need a credentialing program that verifies that a clinician is competent in providing these services. We need standardization of services. And one way to achieve standardization is to develop a learning health network. And we have a presentation on this coming up later, a tinnitus learning health network. And that would be a network of. Clinics that are all working together and communicating with each other and getting a lot of patient input to determine what is best practice. And what could really benefit from. That type of approach is that we. Could figure out what kind of patient. Does best with what kind of treatment. So we really need to get to that point. I’m also going to talk later about. A method called tinnitus stepped care. And that would be an overall framework for providing tinnitus service services without dictating. Exactly what should be done. And then lastly, this living guideline concept. This is an article that I would strongly recommend everyone take a look at. Language et al. 2023. They came up with this idea. We need guidelines for tinnitus. We need people to systematically evaluate what’s going on in the literature. We can’t wait years and years and. Years and years for our clinical practice. To actually change as a result of the research. With a living guideline concept, we would. Have people continually reviewing the literature in. Real time and adjusting their guidelines based. On this real time evaluation. Its a brilliant concept it. Would just require funding. It would require individuals being hired to do this job. But it’s feasibly it could be done feasibly. And I think it’s a great idea. So, in conclusion, the ultimate goal, and. This is from the Languth article, the. Ultimate goal is to help the tinnitus patient. Clinicians should have the leeway to choose appropriate treatment, even if the quality of evidence is low, which is the case for most treatments. A holistic approach that considers all factors should be used in making clinical decisions. So that is it. I’m going to leave you with Some contact information I can make this. I will make this talk available as a PDF with all the slides on it. So that’s it. Thank you so much for listening. And I look forward to the rest of the symposium. And I thank the organizers once. Again for inviting me and letting me participate and kick off this meeting. Thank you.

Hello again, everybody. It’s Jim Henry. I appreciate the opportunity to talk to you now about tinnitus stepped care, a proposed model to standardize tinnitus clinical services. So in my intro talk I gave a background on different methods of treatment that have been used in the past. Current methods, future methods. And so this is a little bit of a continuation of that, and it’s what I am proposing we can do to address the issue of lack of standardization between different clinics, clinicians, researchers. So the following concerns frame all the contents of this particular lecture. There are no official standards for clinical management of tinnitus. That’s the basic problem. Recommendations have been published as clinical practice guidelines. There have been lots of those published in Europe, United States, Japan. There’s a lot of guidelines. They’ve been reviewed. The guidelines are fairly consistent in what they recommend, but they are inconsistently adhered to. So they’re not really doing a lot of good. Any clinician can claim to be a tinnitus expert. That’s unfortunate because there’s so many clinicians claiming to be a tinnitus expert, and they really are not competent. And I don’t know who you are out there, but hopefully you have a high degree of competency and you’re providing excellent services for your patients. Patients. That’s all that really matters. So there’s no credentialing program, and we need a credentialing program to ensure competency of tinnitus clinicians. And then finally, there’s lots of progress. But in my estimation, there are no breakthroughs since the 1970s. So what Vernon and his group were doing with their masking methods, sound therapy and counseling, I cannot say that I’ve seen anything work any better than what they did. Now, they were extremely competent in what they did. They were very compassionate. They really worked hard with their patients. They spent lots of time with them. And they developed this combination of sound therapy and counseling that has been a model, kind of, for a lot of additional methods. Sound therapy and counseling. Sound therapy and counseling. They seem to work well, as long as you’re providing the patient with good information, accurate information, helpful information, and using some form of sound therapy. And there are many different forms of sound therapy. We don’t know that one method works better than any other. So we don’t have a cure. All we can do is treat the behavioral effects of tinnitus. Sleep problems, concentration problems, emotional difficulties, reactions to tinnitus. And we have lots of methods to do that. We can do it well but we cannot say that any one method is proven to work any better than any other method. So here’s what I’m proposing. I developed this recently. I have a publication in the works to publish this whole concept. And I’m also going to be writing a book. And Plural Publishing has already agreed to publish it. And it will go into all the details, but for now, I just, I’m just going to give an overview of tinnitus stepped care. Now, I will say this looks very daunting. At first stepped care means we’re stepping patients through higher and higher levels of services, depending on their need. Some patients only need step one, some patients need all the way to step six, just depending on how bothered they are by their tinnitus and how stubborn their tinnitus is to being treated effectively. And so, and when I say treat their tinnitus, I’m talking about treating their reactions to their tinnitus, the effects of their tinnitus on their life. We’re not treating the tinnitus itself, we’re not treating the sound of tinnitus, we’re treating the effects of tinnitus. So this is a framework. It’s based on progressive tinnitus management, which is a five level step care method of treatment. But it includes specific procedures, especially at levels 2 and 3. Those are the really critical levels for PTM, the evaluation level, the treatment level, basic evaluation, basic treatment that takes care of most people. And there’s. And with PTM, we have very specific ways of doing that. Tinnitus stepped care is based on the model, but instead of suggesting or recommending or even dictating specific procedures, tinnitus stepped care deals with concepts and principles of treatment. So if you’re doing TRT, TAT, CBT, any of these other methods, you can do it within this framework. That’s the concept is to just know what the principles are at these different steps to work within a stepped care model. But to do whatever you’re doing in your clinic, you’re a competent clinician, you’re providing good services. This is proposing a standardized model for how to fit those procedures into a framework, a stepped care framework. So we’ll go through it step by step. Step one, triage, getting patients to the right provider to begin with, what kind of symptoms do they have, who should they see? So there are different options, usually ent, otolaryngology, mental health, emergency care, audiology, if nothing else clinicians, any clinician, any hospital, any provider, any physician should know that if a person complains of tinnitus and they really have tinnitus, and it’s not just some temporary ear noise or spontaneous transient ear noise. And they really have tinnitus. They most likely have hearing loss, and they should have their hearing evaluated by an audiologist. And the audiologist can also assess them for tinnitus, and do they have a problem with tinnitus and also do they need to be referred? So we can look at specific guidelines, which we’ve created a tinnitus referral guide. This could be handed to any clinician, any provider, anywhere. And if they have a patient complaining of tinnitus, they can just look at the symptoms. Based on the symptoms, they’ll know who to refer to. The default referral is always an audiologist, because once they get into an audiologist office, the audiologist will know what needs to be done with that person. So that’s triage level or step one. Step two is audiology services. So I just said the default level would be audiology services. That’s what we’re talking about right here. There are four questions that should be answered at step two. Does the person have symptoms indicating the need for referral to another medical discipline? The audiologist will know if that’s. If a referral is necessary. Does the person have hearing difficulties that would benefit from hearing aids? Audiology have expertise in assessing and fitting hearing aids. Does the person appear to have a sound hypersensitivity disorder? This gets a little more complex and there are many different. Not many, but I have identified five different sound hypersensitivity disorders. And the patient needs to be at least screened to see if they might have a significant sound hypersensitivity disorder. Mention what those are in a moment, and does the patient desire treatment for bothersome tinnitus? Those are the four questions that have to be answered at step two. So to answer these questions, the evaluation should minimally include a medical history, a hearing evaluation, screening for a sound hypersensitivity disorder, and assessing the patient for tinnitus specific complaints. So the medical history and I can’t go into detail on anything, but I can kind of give you an overview. The medical history determines if there are any symptoms or conditions indicating the need for special services or referral to another specialty. Clinicians usually develop their own questions to interview patients to obtain this information. So there is no standard medical history. You can develop your own. And if you don’t have one, a good resource to develop medical history questions is the American Academy of Otolaryngology Head and Neck Surgeries foundation guideline, Tunkel et al, 2014. I refer to them as the AAOHNSF and they have recommendations for performing a targeted history and I’m going to summarize what they recommend on the next slide. And I go into detail on these two books on medical history for TRT and for PTM. So I’m just going to list these out. If you have a patient and you’re doing a medical history, you need to ask about sudden onset of hearing loss. Do they have unilateral tinnitus, pulsatile tinnitus? Recent onset tinnitus, meaning has it been within the last six months or is it very recent within the last few weeks? Have they had significant noise exposure? Have they taken medications or had potential ototoxic exposures that could be the cause of the tinnitus? Do they have dizziness or vertigo? Do they have symptoms of depression or anxiety? Do they have apparent cognitive deficits? Do they have insights. Insomnia. Do they have migraine headaches or do they have migraine symptoms? Have they experienced a traumatic brain injury? So that’s the medical history. Hearing evaluation is straightforward. Most of you who are in this symposium are audiologists. And so I don’t need to talk about a hearing evaluation except to just mention that many patients with tinnitus have sound tolerance problems. They might not do well with loudness discomfort level testing. And we generally don’t recommend LDL testing. And also reflex testing may be uncomfortable for them. So if a person has tinnitus, you always want to check to make sure that when you’re presenting any louder sounds that they’re going to be comfortable with them. And otherwise let them know and get their permission to do that testing and then screening for a sound hypersensitivity disorder. This could be referred to globally as hyperacusis. People talk about sound tolerance complaints disorders. It can be referred to as many different things. I choose to call them sound hypersensitivity disorders. So what are they? Here’s five possible sound hypersensitivity disorders. Two of these are hyperacusis. And I learned fairly recently that hyperacusis isn’t just hyperacusis. There’s loudness hyperacusis and there’s pain hyperacusis. Loudness hyperacusis is physical discomfort due to fairly low levels of sound that most other people find to be completely comfortable. Pain hyperacusis is distinguished because it’s sharp, stabbing pain. There’s actually pain receptors in and around the ear that can be causing that. There’s other reasons, but it’s a different animal than loudness hyperacusis. Loudness hyperacusis can usually be treated with a sound desensitization technique, whereas pain hyperacusis cannot. So pain hyperacusis needs a different treatment approach. Then there’s misophonia. Misophonia is not physical discomfort. It’s emotional reactions to sound. This is a usually reactions to nose and mouth sounds, Chewing, sniffing coughing, sneezing but it can be other things too. Misophonia is it’s like a psychological problem. It’s not a problem of the auditory pathways. Same with noise sensitivity. Noise sensitivity is an emotional problem where people are just annoyed by sound in general. They have a general problem with sound. They don’t like sound, they avoid sound, they stay away from sound. Thats very different from misophonia. Phonophobia is an irrational fear of Sound. They’re not reacting to sound. But they may have one of these other disorders. They are afraid the sound is going to be too loud and they overcompensate by protecting their ears, wearing earplugs, wearing earmuffs, avoiding sound. They avoid sound all one way or another. And that would pretty much define phonophobia. So that’s more of a psychological problem also. So these are the five possible sound hypersensitivity disorders. I’m writing about that now. I’ll have a whole book available on it sometime this winter. And then assessment of tinnitus specific complaints. What do I mean by that? How do you evaluate for a tinnitus specific complaint? Well, in general, you need to ask questions to your patient about effects of tinnitus that cannot possibly be confused with hearing problems. We discovered that early on in our research that when we thought a patient had a problem with tinnitus, they were often blaming their hearing difficulties for or blaming. Sorry, they were blaming their tinnitus for their hearing difficulties. So they had a hearing problem. They didn’t know they had hearing loss, but they did know they had tinnitus. So they naturally blamed their tinnitus for their hearing difficulties. So that’s generally not the case. And they need to be evaluated separately for their tinnitus specific problems and their hearing specific problems. Now, you can come up with your own questions, but we’ve already done that. I don’t know that anyone else has done it, but I’m not recommending specific procedures. But I can say that the tinnitus and hearing survey can accomplish this issue. The tinnitus section addresses tinnitus specifically. Reactions to tinnitus that would not be confused with a hearing problem. We get a score for that section. And then we evaluate their hearing issues, which would not be conflated with any tinnitus issues, and we get a score for that section. This information is critical at the initial evaluation to know are they really bothered by their tinnitus, and if so, how much? Are they really bothered by hearing problems, and if so, how much? And you compare one to the other. We also screen for a sound hypersensitivity or sound tolerance problem. And if you’re really familiar with those five different methods, you have them fill out these two items or respond to these two items and you will have a good idea whether you think they have a significant sound hypersensitive sensitivity problem or not. And then that would require further services to address those problems. Okay. And then a hearing aid assessment and fitting. That’s something all audiologists know how to do. And then additional measures if needed for a step four method of counseling. So we haven’t gotten to step four yet. We’re in. We’re in step two. But what if you are a TRT clinician? You want to do specific additional measures for TRT, like for example, TRT recommends doing LDL testing. So you would do that at level at step two. Now we do not recommend it for, say, for PTM. So each of these methods has specific measures that they require. And those would need to be done at level two if you think the patient may need to move on to receive one of these counseling methods or in particular the one that you do in your clinic. So summarizing step two procedures, I put together this decision tree. And this can be helpful in the clinic. It’s just straightforward. It’s just if this, then this these are the four things that need to be done. For any patient who complains of tinnitus, do a medical history, evaluate their hearing, screen them for a sound hypersensitivity disorder, and assess them for tinnitus specific complaints. We haven’t talked about a tinnitus questionnaire such as the Tinnitus Handicap Inventory, the Tinnitus Functional Index. We don’t recommend that, or I don’t recommend that at this step because you may not need to spend that much time with them. They may be blaming their tinnitus for their hearing difficulties, for example. So these four things need to be done. And based on these four measures or evaluations, you will know if a referral is needed and you will know if treatment for the tinnitus seems warranted. Now, the additional testing I already mentioned for example, they may need a hearing aid assessment, they may have significant hearing difficulties, and you and audiologists will naturally do a hearing aid assessment. Or you may need to evaluate them for the TRT or whatever you might be doing as your tinnitus program. And if they have a sound hypersensitivity disorder or they seem to based on the screening, then there are evaluation methods for these patients for these different methods of treatment. So depending on what you do you may have your own way of evaluating patients for a significant sound hypersensitivity disorder. Otherwise these methods have specific procedures and there are other methods also. So basically they need to be followed up. If they screen positive for a significant sound hypersensitivity disorder and you think they really may have one, they need to be followed up appropriately. All right? And then if hearing aids are not recommended, then basically you want to know, is the tinnitus bothersome? If no tinnitus services are complete? If yes, you want to know, are they going to need the next step in the stepped care program? And the next step would be tinnitus education. Step three. And if they are going to do tinnitus education, you need to do a tinnitus questionnaire. And the reason is because we consider tinnitus education to be treatment for tinnitus. So if you’re treating them for tinnitus, you always need to do an outcome measure before and after the treatment, and that includes education. Now, if you’re fitting hearing aids, same thing. You want to know if the tinnitus is bothersome, but really you want to follow up with them. A month or two later, the hearing aids alone may have been sufficient resolving the tinnitus problems. And so it may be the tinnitus is not bothersome at that point and tinnitus services are complete. Otherwise if the tinnitus still bothers them, they’ve been wearing the hearing aids, they’ve done the follow up, they’re still bothered by their tinnitus, then the next step would be tinnitus education. And here’s tinnitus education. Step three. Basically, patients need to be informed about what tinnitus is. That’s what I wrote about in this book. This is, that’s the intent of this book. It’s just an overview. What is tinnitus? Why is it a problem? How is it a problem? What can be done about it? Patients need that information. You can, you can. Do one on one with your clinician. Spend an hour with them, explain everything. To them, answer all their questions. It can be done in a group setting. Some clinics like to do these Educational sessions once a month, and they invite everyone to them. Sometimes they charge a fee, sometimes they. Just make it free or by providing appropriate learning materials. Send them home with a book like. This, Send them home with a handout. Materials that you’ve put together. Whatever it takes to inform them about these basics of tinnitus so that they can make informed decisions in the future. And so the AAO HNSF has. Made some recommendations for what kind of education patients needed. They said patients need to know what. Are the available management strategies for tinnitus. They want to, they should know what’s. The natural history and prognosis of tinnitus? What do most people do? What is, what is the experience for most people? What’s the association between hearing loss and tinnitus that’s critical for patients to understand? What are the effects of lifestyle factors on tinnitus management? What is their life like? You know, is it more conducive to. Being bothered by tinnitus where they don’t have much to do, they’re bored they are in quiet environments or are they busy? Are they in more noisy environments? You know, what’s, what’s going on in their life? And then hearing protection from noise, that’s really critical. They need to know to protect their ears from loud noise. So following the education, patient completes outcome measures. Okay, remember I said education is treatment. So they need to be assessed. For outcomes before and after the education. So we recommend the tinnitus functional. Index, but you can use any tinnitus questionnaire you like because most of them. Pretty much work well. And you’re looking for a reduction. In the score from pre treatment to post treatment. You want to know that the score. Say, decreased from 60 to 40 or 60 to 30 or whatever. And sometimes the education is all they need. They just need to be educated. However we also recommend a global. Impression of change questions. So ultimately, a change in the tinnitus questionnaire score between pre and post treatment is less important than the person’s impression if there has been improvement. So how do you evaluate that impression? Here’s a question. Compared to before I started the treatment. My tinnitus now bothers me. How much does it bother them more? Does it bother them less? How do they feel about the treatment and how it worked for them? And this is the most important way to assess Outcomes, you still need that score and the change in the score between pre and post treatment. But you also need to ask this question or a question similar to this. And then we also like to ask. About quality of life. Is there quality of life improved from. Compared to before? Treatment may not have anything to do with the treatment, but it also very well may. So these are the two questions we recommend. Just ask these two questions in addition to your tinnitus questionnaire. So then they’ve completed the education. You’ve done, the outcome measures. Do they need step four, tinnitus counseling? That would be the basic treatment level. Even though education is considered treatment, this. Is very directed treatment. And so the patient decides if tinnitus counseling is desired. And we’ve already talked about all of these different methods. There’s established methods. There’s mindfulness, there’s act and then again, you after you’ve gone through. This treatment, it can be one on one, it can be group, it can. Be video, it can be telehealth, it. Can be any way you provide the. Treatment or any provider provides the treatment may not be you. You may refer them but they need to be evaluated pre and post to see how well the treatment worked. And of course, there’s other, many other methods of treatment. So there’s apps. Apps can be the primary source of therapy, or they may complement another method of treatment. There’s hearing aids. Hearing aids can have sound generators and streaming capabilities. A hearing aid is a very powerful sound therapy device. Psychologists and other psychological health providers are less commonly available to provide the tinnitus counseling. I mentioned that in my first talk. CBT has strong, the strongest evidence for tinnitus treatment. But there’s the fewest providers available to implement CBT. So there’s also the possibility of receiving services remotely. And there are psychologists who provide CBT and third wave CBT virtually. And then the outcome assessment. So following the counseling, your patient repeats the outcome measures. So it should be a basic tinnitus questionnaire pre and post treatment, and then. The global perception of change question or questions that can be anything you put together. This is our suggestion. So was the counseling enough? And it usually is. I mean, if a patient has gone. Through steps 1, 2, 3 and 4, they’ve had all these evaluations done, they’ve. Had their questions answered, they’ve had the. Basic education and they’ve had the counseling. So was that enough or not? And if not, then they need to. Be evaluated very comprehensively by both an audiologist and a psychologist or possibly another specialist. And a psychologist is particularly important because they may have a psychological disorder. That is the reason they can’t seem. To get over their tinnitus. Their tinnitus continues to bother them, but. It may be because they have anxiety that is untreated. And so they need to be treated for the anxiety or they have. Insomnia that’s untreated and the tinnitus may exacerbate the insomnia, but the tinnitus is really not the primary issue. The insomnia is issue is. So anyway, a lot of possibilities of why all the services they’ve received. Have not been sufficient. They may have been non compliant with the treatment recommendations. They may not have attended all of the counseling sessions. They may want their tinnitus cured and nothing else will do. So we have people like that. They come in wanting a cure and. No matter what you say to them. You tell them you can improve their life. You tell them you can help them. To sleep better, concentrate better, not react. So much to their tinnitus. They don’t care. They want their tinnitus gone and nothing else will work for them. So they may go through all these different levels and they still want their tinnitus cured. And that’s all. That’s all they want. So anyway, these are some reasons why patients may need further services. Now if they do need further services, they can move on to step six, expanded treatment. This just opens up all the possibilities for treatment. All the things we’ve been talking about in my intro session, all these experimental methods bimodal therapy bimodal stimulation different apps, different devices. There’s so many different treatments out there. I would say this opens it up. To all of them. Provided you think the treatment might. Help them, it’s appropriate for them. They can afford it and it’s safe to use. They can try just about anything at this point. And they may have their mind set on something. They saw an ad for a particular treatment and that’s what they want. And nothing else is going to work for them unless they get that, that treatment. So anyway, that’s step six, expanded treatment. Okay, well, so that’s basically it. I’ve run out of time. This is, we’ve just talked through all. These six different steps. 1, 2, 3, 4, 5, 6. It’s a framework, it’s not specific procedures. Now we can, we can suggest specific. Procedures within each one of these steps. But the idea is, is for you to do whatever you do within this framework. That’s what I’m suggesting. And if you do it within that framework, it makes it easier to compare between different clinics. So you’re doing TRT, somebody else is. Doing ptm, somebody else is doing cbt. But if you’re all doing it within. This framework, you can compare outcomes, especially. If everyone would agree on a common. Outcome measure or set of outcome measures. If nothing else, the global perception of change question is one good question to. Find out how, how well your treatment worked. So I will end it once again. As I did for my first talk. With this quote from Languth et al. 2023. The ultimate goal is to help the tinnitus patient. Clinicians should have the leeway to choose appropriate treatment, even if the quality of. Evidence is low, which is the case for most treatments. A holistic approach that considers all factors should be used in making clinical decisions. So I’m going to stop there. I thank you once again for Participating and hopefully you are getting a lot out of this symposium and feel free to contact me if. You have any questions or if there’s anything I can do to assist you. In your being a provider Of tinnitus and potentially different sound hypersensitivity disorders. So thank you very much and Look forward to seeing you and talking to you in the future.