Includes the following article: Tinnitus and
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"TINNITUS AND AMPLIFICATION"
Max S. Chartrand, M.A.,
DigiCare Hearing Research & Rehabiliation
RECENT STUDIES by the American Tinnitus Association
(ATA) indicate a much higher incidence of tinnitus
in the U.S. population than previously accepted. In
fact, it is now believed that up to 25% of the U.S.
population experience some degree of tinnitus,
either of an intermittent or constant nature.
Taking into account that these Figures would include
all types of tinnitus involving both normal hearing
and hearing impaired populations, it must be noted
that the array of treatment protocols utilized today
on the general population may not be sufficient in
effectively meeting the needs of the more narrowed
group that is in contact with the services of the
hearing aid dispenser.
For instance, if we were to take a sampling of the
actual causes of tinnitus in the general population,
we will find a wide array of physiological,
neurological, and psychological manifestations: food
and inhalant allergies, hypertension, toxicity,
vascular constrictions, alcoholism, and depression,
to name a few. However, tinnitus sufferers that are
commonly in the care of the private practice hearing
aid dispenser manifest more selective categories of
causes, primarily those resulting from epithelial
atrophy (presbycusis) and noise damage. Hearing
impaired patients exhibiting pulsatile, spasmodic,
or vascular causes generally fall into the medical
realm of conductive cases.
During a seven-year study of tinnitus in cases of
hearing aid users with sensorineural losses and/or
presbycusis, several "common threads" were found to
describe their cochlear-based tinnitus complaints.
They complained of varying degrees of intensity,
from mild to severe, and with descriptions of the
actual sound of the tinnitus such as "ringing", "hissing","frying",
"buzzing", "sirens", etc.
By the traditional definition of tinnitus these
cases would be classified as subjective tinnitus
(i.e. not heard or observed by any but the
sufferer). But since we have noted a number of
observers who have actually heard or could amplify
these sounds by way of a stethoscope or other means,
we are inclined to reclassify these complaints as
objective cochlearvestibular or peripheral tinnitus.
This distinction we feel, is vital when addressing
the beneficial effects of amplification.
Further, it was noted that hearing aid dispensers
may more thoroughly and accurately evaluate a
patient's cochlear-based tinnitus through better use
of the
case history, tinnitus "matching" with simple
audiometric equipment, and certain observations
during testing and fitting of hearing instruments.
Several points of thesis were arrived at during the
course of this study that we feel maybe of
significant interest to the professional dispenser.
COMPARING POPULATIONS
Tinnitus sufferers in general and the hearing
impaired population serviced by the hearing aid
dispenser differ in many respects. The non-hearing
impaired, for instance, have demonstrated relief
from several approaches related to their particular
health and dietary factors. Hoover" reported in 1987
that 76% of those patients in their general
population study were found to have tinnitus caused
by or related to allergies of all types. House and
Johnson and others have reported substantial success
utilizing biofeedback and tinnitus maskers.
Marchiando et al3 report successful surgical
procedures to relieve stapedial spasm conditions
that are activated by the onset of noises or
conversations. And Arenberg4 describes elaborate
medical and surgical procedures for vascular
pulsatile tinnitus. Still others report treatment
for tinnitus that is caused by tension, injury,
tumors, and infection.
The hearing aid user that is seen everyday by the
hearing aid dispenser, however, rarely complains of
these conditions or types of tinnitus. At the least,
it has been found in our study that when any of
these conditions were observed during the normal
course of dispensing activities, the patient was
immediately referred for medical evaluation.
REPORTS ON HEARING AID USE
As far back as 1977 Vernon5 reported the relief of
tinnitus through the use of hearing aids, and again,
in 1979, House and Johnson6 reported, "in patients
with
hearing loss whose chief complaint is tinnitus, the
use of hearing aids can be
dramatic." (Italics added.) Indeed from their
two-year study of those patients who were referred
and subsequently fitted with hearing aids, 78%
reported some degree of relief from their tinnitus.
Numerous other reports have mentioned the
effectiveness of hearing aids, both from a masking
and stimulative effect. However, during a cursory
review of the literature it became quite evident
that there was a lack of information on the effects
of hearing aids on tinnitus, or systematic, yet
practical, methods whereby the dispenser may observe
the affects of amplification, par- ticularly when
the prescription formula of the circuitry was aimed
at correction of hearing impairment. Therefore, our
main focus was upon those tinnitus suffering ferers
with accompanying sensonneural loss or presbycusis-and-the-effects
of fitting hearing aids to the affected ear(s).
Tinnitus and Hearing Aid Users
In taking a sampling of over 2,000 hearing aid users
whose records were used as a resource for our study.
100 users were designated as the focus group,
ranging in ages 22-97. Seven percent of the focus
group were found to have conductive losses while the
remaining 93% exhibited mixed and sensorineural
impairments. This represents a fair sampling of what
we believe is a typical hearing aid dispensing
practice clientele population.
Patient reports regarding tinnitus were obtained by
both written and verbal case histories immediately
before and during the routine hearing evaluation.
Descriptions of the tinnitus were futher
substantiated, where possible, by a matching
procedure for pitch, band-width, and intensity of
the tinnitus as closely as possible using
pure-tones, narrow-band, and wide-band noise on a
two-channel audiometer. Out of the mixed and
sensorinieural cases 55% reported tinnitus in the
following categories:
% Focus Group Description Hz Range
63% “Ringing” 1.5KHz-3KHz
27% “Buzzing” .53Hz-3KHz
11% “Pulsating” Wide-band
7% “Crickets” NB 1KHz-4KHz
7% “Multi-Band” Wide-band
(Note: Totals more than 100% because of multiple
descriptions. Most common frequency description was
from 3KHz-6KHz.)
In most cases where the bandwidth of the tinnitus
was identifiable, we found that the point of
greatest progression in a high-frequency impairment
(usually 2KHz-6KHz) and the description of the
tinnitus often correlated or nearly matched. In
fact, in progressive cases monitored over the
seven-year period it was found that the pitch of the
tinnitus often followed the drop in precipitious
losses while often simultaneously increasing in
intensity.
In almost all bilateral cases the tinnitus was
eventually found to be bilateral. However, many
patients were initially unaware of the tinnitus in
one of the ears because of the differential in
thresholds and/or tinnitus. Therefore, when these
particular cases were fitted monaurally, the client
often made comment that they noticed tinnitus in the
unfitted ear where they had not noted it previously.
RESIDUAL INHIBITION, MASKING & HEARING AIDS
Vernon has published several reports regarding a
phenomenon often called residual inhibiton. which
means a lowering or cancellation of the tinnitus for
a period of time after stimulation of the tinnitus
with pure-tones or masking.
Noted in subsequent reports was the evidence of
masking the tinnitus with the use of hearing aids.
However, residual inhibition from hearing aids was
not evidenced in his and others’ reports.
However, during our study we often noted reports of
residual inhibition by users of hearing aids under
the following conditions:
1. The fitted instruments) response range must be
capable of producing effective gain covering the
frequencies of the accompanying tinnitus. In most
cases the required response range was above 6KHz.
Less than 6KHz rarely produced residual inhibition.
2. Residual inhibition was found to be possible only
after regular wear of the hearing instruments.
Intermittent or short-term users have rarely
reported inhibition.
3. The affected tinnitus correlated with the
peripheral audiogram and was not complicated with
otosclerosis, high blood pressure, ototoxicity, or
vascular conditions. When we found several
simultaneous causes in the same individual, we found
that only the cochlear-based tinnitus seemed
affected by hearing aid use, while the other forms
of tinnitus continued unchecked.
Indeed, a report by House8 in 1984 brought our
attention to the matter of correlating
high-frequency hearing loss accompanied with
tinnitus and the ef-fects of hearing aid use. In
part the reporrstated, “... many of the patients
with unrelenting tinnitus have a high-tone
sensorineural hearing loss. . .when hearing aids
were tried, the tinnitus and hearing ability
improved.” (Emphasis added.)
Using our focus group of hearing aid users, a method
of analysis was developed for matching the tinnitus
and identifying its intensity using standard
audiometric equipment. Once the bandwidth was
identified and approximated to a narrow-band of
noise or pure-tone, ten seconds of narrow-band noise
@ 10-20dB above threshold was presented, preceded by
instruction given to the patient to indicate whether
the tinnitus was softer, louder, or completely
absent after the stimulation was terminated.
Sometimes, because of difficulty in communicating
these instructions, the test would be repeated.
If they indicated that the tinnitus was much softer
or absent after stimulation with narrow-band noise,
they were instructed to notify us if and when the
tinnitus came back to its original intensity.
Further, notations were made on the evaluation form
in regard to inten sity, bandwidth, and possible
residual inhibition as a result of masking
stimulation. At times, wide-band noise was used in
place of the narrow-band stimulus.
Seventy-one percent (71%) of those tested reported a
lessening of intensity as a result of the 10-second
stimulation. Thirty percent of that group reported
that the tinnitus was absent for the remainder of
the evaluation. Additionally, 27% of all those
reporting tinnitus reported "no change" resulting
from the procedure, and 2% reported an actual
increase, a result of complications in their
impairment requiring medical referral and
intervention.
Post-fitting evaluations generally affirmed the
initial expectations of the hearing instruments on
the tinnitus condition. Further, we cannot leave
this part of our discussion without affirming what
other investigators have already ascertained:
hearing aid use has been found to be a very
effective "masker" of
tinnitus in most cases of those exhibiting hearing
impairment. However, the masking effect is only
available during actual wearing of the instruments.
TINNITUS & HEARING AID RESPONSE
As noted earlier in this report, response range of
the hearing aids often had a direct bearing on both
the masking and stimulative effects of the offending
tinnitus. While conclusive data is not yet
available, indications point to several factors in
our findings:
1. The masking effect of hearing aids was
particularly pronounced when low- frequency
amplification (100-500Hz) was present in the hearing
aid. When there was a reducation of the low
frequencies, less masking effect was noted.
2. High frequency tinnitus above 6 KHz rarely
exhibited any inhibition from the use of hearing
aids.
3. The stimulative effects of hearing aids could
best be predicted as a result of
the narrow-band test when the tinnitus centered
around 500Hz-2KHz.
4. In cases of tinnitus ranging 2KHz-6KHz, a
wide-band instrument producing usable gain up to
7KHz-8KHz was essential to realize inhibition.
Special notations on the order form to the factory
should include a description of the tinnitus
(frequency band and intensity level) and the
affected ear. If the manufacturer is not presently
aware of the relationship between hearing aid
response and tinnitus, it would be wise for the
dispenser to begin that dialogue to develop such a
dialogue and accomodation in future cases. Generally
speaking, the best frequency configuration for
tinnitus is the one that best accommodates the
actual impairment. However, the frequency range must
extend substantially past the bandwidth of the
tinnitus for stimulative effects over time.
In some cases, more low frequencies than normally
called for will be needed to enhance the masking
effect. Additionally, two very severe cases in the
study required round-the-clock wear of their hearing
aids. In these cases, in-the-ear or custom canal
instruments with hypo-allergenic shells were
required. Since these also required low-frequency
emphasis for effective masking, we further recommend
that the client obtain a separate set of instruments
for "day use" to provide better signal-to-noise
ratio benefits not found in the "masking set" of
instruments. Subsequent adjustments and remakes were
required in these cases to accomodate physiological,
psycho-acoustical, and environmental idiosyncracies.
Keep in mind that several of the cases in the study
were previous masker or masker/ hearing aid users
and had complained of both the inconvenience of
wearing these instruments and lack of desirability
in experiencing another noise to cover the offending
tinnitus in their ears. Al beit, the hearing aid
route put them back into a "masking environment"
while providing amplification for their hearing loss
at the same time.
Another benefit of hearing aid-based tinnitus
treatment was found to be the reduction of stress
when the hearing loss was corrected through
amplification.
Indeed, Surr et al reported in 1985 both some
residual inhibition and the reduction of the
tinnitus through lessening of the stress caused by
uncorrected hearing impairment.
CONCLUSION
While some may argue that legitimate tinnitus
treatment is exclusively the domain of the medical/audiological
practice, we have concluded through observation and
experience that the medical profession has not yet
adequately addressed the prevelance of potential
treatment of tinnitus among hearing aid users. As a
general rule, we have found that hearing aids have
been overlooked, in our opinion, in what appears to
be the most universally effective treatment for
peripheral-based tinnitus in the hearing impaired.
Conversely, many hearing aid dispensers and
audiologists are already treating tinnitus
inadvertantly through their routine services in
hearing aid fittings.
A CHALLENGE FOR THE PROFESSION
How many people in the U.S. suffer from tinnitus? A
good guess: one million with severe tinnitus, nine
million with moderate symptoms, and another twenty
million mild cases.
Hearing aid dispensers, during the course of their
everyday practice, see up to one-third of them. And
the road that brings them to the dispenser's door is
a long, dubious one for many. For, once they muster
the courage to ask for help for their tinnitus, they
are likely to be told: "It's all in your
imagination." Or, "You'll have to get used to it."
Couple the tinnitus with a hearing impairment and
the psychosomatic tendenices of the tinnitus become
added to the psychological effects of their hearing
loss.
Little wonder that so few voluntarily seek help for
their condition. And little wonder, again, that the
dedicated men and women who dispense hearing aids
find themselves spending such inordinate amounts of
money, time, and ingenuity in trying to get the
hearing impaired to "raise their hands". There is a
huge mountain of opposition to overcome in achieving
the needed response.
But there is hope, hope in the hands of those
dedicated and caring profes-
sionals who will expand their reach: providing
practical and professional insight to the medical
community, education for loved ones and concerned
others about hearing impairment and tinnitus, and,
most of all, inspiring confidence and motivation in
the hearing impaired to have the courage to burst
from their "noisy isolation booths".
The challenge is there. Now, is the time to
introduce better and more effectivee means to
measure, treat, and counsel to help relieve the
suffering of these conditions. Will we do it?
Moreover, we feel that dispensers and audiologists
are the best poised disciplines to provide a greater
level of relief for a greater number of tinnitus
sufferers who are also hearing aid users because of
their established delivery system of services and
instruments to the private market. To further
accommodate and harness this advantage, however, we
feel it is the time for all those involved in
dispensing hearing aids to begin to add tinnitus
evaluation and prediction to their routine test
protocol for those patients that report the presence
of tinnitus.
The tests are simple and reproducible, and should
become a vital focus of the
dispenser or audiologist. In so doing, the dispenser
will be providing a greatly
needed service, the manufacturers and researchers of
the industry will focus more effective attention in
this area, and, most of all, more hearing impaired
persons will have greater incentive to seek
amplification correction and, as a bonus, enjoy more
consistent relief of their tinnitus.
REFERENCES
1. Hoover, Soraya( 1987). ''innitus and
Allergy",Proceedings III International T:nnitus
Seminar,Mucnstcr.
2. House, J.W. and Johnson, E.W. (1979), "Tinnitus:
Tinnitus Masker and Biofeedback Training",
Transactions of the Pacific Coast
Oto-Opthalmological Society, Vol. 60.
3. Marchiando, A., Pcr-Lcc, J.H., and Jackson, R.T.
(1983), "Tinnitus Due to Idiopathic Stapcdial Muscle
Spasm", Ear, Nose and Throat Journal. Vol. 62.
4. Arenbcrg, L. K. and Balkany, T.J. (1979),
"Objective Pulsatile Tinnitus: Vascular Basis",
Journal of Otolaryngology' Supplement #9.
5. Vemon.J., Schleoning, A.(1978), "Tinnitus: A New
Management", Laryngoscope 88:413-419.
6. ibid ff2, pg. 119.
7. Vernon, J., (1988), "Current Use of Masking for
the Relief of Tinnitus", Tinnitus. Pathophysiology
and Management. Kitahara, cd., pp. 96-106.
8. House, J.W.,(1984), "Tinnitus: Evaluation and
Treatment", American Journal of Otology. Vol. 5,
Number 6, pp. 472-476.
9. Surr, R.K., Montgomery, A.A., and MucUer,
H.G. (1985). Effect of amplification on tinnitus
among hearing aid users. Ear and Hearing.
6:71-75.
Dear Dr. Chartrand: I am 69 years old and have a
loud ringing in my ears. I’ve had so many medical
tests, including CAT scans and the doctors can find
nothing wrong. Why is it that something so
disturbing and disruptive to one’s life remains a
mystery to the medical profession?--- Mr. R. A.
Dear Mr. R.A.: The short answer to your question is
that tinnitus (noises in the ear) is not a singular
condition, but varies significantly from individual
to individual.
However, your doctor should have referred you for a
complete hearing test to determine if there could be
a correlation between the tinnitus and an
uncorrected hearing loss. In most cases, the proper
fitting and programming of a hearing aid is the most
effective remedy of all.
Our practice is currently in the midst of the
Tinnitus & Amplification 2002 Study, from which we
are developing “best practice models” for both the
medical and audiology professions. Since our study
design may be of benefit in “mystery cases” such as
yours, I will outline the program here:
1. General medical and health history, including
available clinical tests, are profiled. In cases
where ototoxic medications or pharmacological
contraindications appear, we will refer you to your
primary care physician for a follow-up review.
2. Video otoscopy and hearing health history are
administered. In this, certain physiological
landmarks are observed in light of FDA Red Flag
conditions. Again, referral may be warranted.
3. Nutrition, stress and hydration issues are
reviewed as well. Certain foods and substances have
been identified in past research as contributive to
tinnitus, balance, and deafness.
4. A complete analysis of your tinnitus (frequency
band, intensity, and correlative factors) is made,
along with a battery of tests to determine effects
of masking, residual inhibition, and auditory
reattention.
5. A complete battery of audiometric tests are then
given to determine degree and nature of any existing
hearing loss, along with an assessment for
amplification.
6. Follow-up of each of the above is conducted over
a 6-8 month period, including hearing aid
programming, auditory rehabilitation counseling, and
reassessment of tinnitus.
There is a great deal of detail in the study not
covered here. But early reports of the effort look
very promising with some dramatic results being
reported from most participants.
But the overriding benefit that has appeared so far
is the increasing awareness among health
professionals and patients alike that tinnitus does
not have to remain a mystery, that there are indeed
viable solutions, if applied individually and
thoughtfully that can make a difference.
The study is open, of course, to all who desire to
be a part of it. So you may consider this an
invitation to participate.
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