Tinnitus retraining therapy


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Tinnitus retraining therapy

  1. 1. TINNITUS RETRAINING THERAPY Tarek Ghannoum , M.D. Audiology Unit , ENT DepartmentKasr Alainy Hospitals- Cairo University
  2. 2. TINNITUS
  3. 3. ANSI:- Sensation of sounds without external stimulus.Ciba symposium on tinnitus:Sensation of sound not brought aboutby simultaneously applied mechano-acoustical or electrical signals.
  4. 4. Jastreboff and Hazel:The perception of sound that resultsexclusively from activity within thenervous system without anycorresponding mechanical, vibratoryactivity within the cochlea and is notrelated to external stimulation of anykind.
  5. 5. Jastreboff, 1990: 50 million American. 12 million ask for help.Axellson et al.(1989): 5% of Brazilian attending ENT clinics.Pilgramm et al.(1999): 18.7 million German citizen.
  6. 6. *Different lines of treatment have been proposed.*Non is satisfactory.
  7. 7. For improper cure: *Lack of accurate and different mechanisms for tinnitus generation. *Proper classification of tinnitus patients.
  8. 8. Neuro-physiological model. Auditory & Other Cortical areas Perception & Evaluation (Consciousness, Memory, Attention) Auditory Limbic System Reactions subconscious EmotionsDetection / Processing Auditory Autonomic Nervous System Periphery Source
  9. 9. TRT* Retrain the reflexes involving theconnections between the auditory, thelimbic and autonomic nervous systems.* Retrain the subconscious part of theauditory pathway to block the tinnitussignal which is causing annoyance.
  10. 10. Advantages of TRT:*Is based upon a specific model, tested and refined.*Does not have side effects.*Does not required frequent visits.*Does not interfere with hearing aid use.*Can be used in all patients.
  11. 11. TRT is not a cure.
  12. 12. Categorizing factors of tinnitus patients:1- The strength and stability of the connectionsbetween auditory cortex and limbic andautonomic nervous system.2-Hearing loss.3-Hyperacusis and phonophobia.4-Worsening of tinnitus as a resultsof exposure to sounds.
  13. 13. Categories of tinnitus subjects: Prolonged Subjective Hyper- sound ImpactCategory hearing Treatment acusis induced on life loss exacerbation 0 Low Counseling only 1 High Sound generators set at mixing point 2 Present High Hearing aid with enrichment of the auditory background 3 Present Not High Sound relevant generators set above threshold of hearing. 4 Present Present Not High Sound relevant generators set at the threshold
  14. 14. TRT:1-Counseling.2-Sound therapy.
  15. 15. Instruments:- Noise generators.- Hearing aids.- Combination instruments.- Table top, bed-side noise generators.- Environmental sound sources.
  16. 16. Requirements: * Never annoying. * Neutral, not attracting attention. * Not masking. * Sufficiently above threshold. * Used for extended periods of time. * Easy to use and adjust, not occluding.
  17. 17. Rational for sound therapy:- Reduce contrast of tinnitus V. Silence. Interfere with detection of TRA.- Reduce central auditory gain.- Increase plasticity: allow habitation.
  18. 18. B.T.E. Sound Generator Open ear mould
  19. 19. Custom Helix MM4MM5
  20. 20. Directive counseling: 1- Teaching. *Auditory processing. *Tinnitus mechanisms. *Conditional response. *Use stories. 2- Reclassification of meanings. 3- Reducing / abolishing reactions.
  21. 21. Beliefs about tinnitus:* Tinnitus will get worse.* Tinnitus will go on forever.* Tinnitus is a physical disease or injury.* There is no treatment.* I will be deprived of sleep because of tinnitus.* Tinnitus will make me go deaf.* Tinnitus may be caused by a tumour.* Tinnitus means I will have a stroke.* Tinnitus means I can never have silence.* My family and social life will suffer greatly.
  22. 22. How long does TRT take?• Strong held beliefs take time.• Repetition of training information is needed.• Process of habituation is gradual, needs to be followed.• Desensitization techniques take time.
  23. 23. * Average time: 8- 18 Months.* Average number of visits ?
  24. 24. Evaluation of treatment outcome:- Tinnitus Handicap Inventory (THI)
  25. 25. T H I (Cont.)* Yes response : 4 points* Sometimes response: 2 points* No response: 0 point
  26. 26. T H I (Cont.)Total scale range: 0- 100 points.
  27. 27. THI Subscales:1- Functional subscale: The impact on every day function.2- Emotional subscale: a broad range of affective response to tinnitus.3-Catastrophic subscale: Patient desperation.
  28. 28. Handicap Severity Categories: * No Handicap: 0-16. * Mild Handicap: 18 -36. * Moderate Handicap: 38-56. * Severe Handicap: 58-100.
  29. 29. Improvement:* Change from Category to a less severe category.* Pre and post intervention scores > 20 points.
  30. 30. Results:* Sheldrake et al.(2002): 96%.* Hazel (2003): 78%.* Jastreboff (2003): 81%.* Baguely(2005): 79%.
  31. 31. * TRT is not the only way to treat tinnitus.* Single element of TRT may help some patients.* The term TRT should be reserved for the full treatment according to the definition.