Jastreboff, 2014 1

Jastreboff, 2014 1
Ear-level instrumentation in the treatment
of tinnitus
Pawel J. Jastreboff, Ph.D., Sc.D., M.B.A.
Professor
Department of Otolaryngology
Emory University School of Medicine
Atlanta, GA
pjastre@emory.edu
www.tinnitus-pjj.com
Disclosure Statement:
No relevant financial or non-financial relationships to disclose
Jastreboff, 2014 2
Sound is important to our well being and for
correct functioning of our auditory system

Sounds in daily environment

Sounds of nature

Voices

Music
Jastreboff, 2014 3
Music and / or sounds of nature
are recognized to help

Reduce stress

With sleep problems

Promote learning, including helping dyslexia

Induce positive changes in cognitive function

In recovery from traumatic events including health problem
(cardiac operation)
Jastreboff, 2014 4
Is tinnitus a real physical sound?

Are rules governing interaction of tinnitus with external sounds the
same as for two external sounds?
dB SPL
NO!!!
Two external sounds
Tinnitus
Critical band
frequency
Therefore
There is no vibratory activity in the cochlea corresponding to
tinnitus perception and thus
Tinnitus is a phantom auditory perception
Jastreboff, 2014 5
Patients’ comments about perception of
tinnitus

Tinnitus is loud

Tinnitus takes my attention from other sounds and things I should
be doing

Tinnitus causes that I cannot understand people

Tinnitus is getting louder when I am in quiet

Tinnitus is getting louder when I am exposed to loud sound
Jastreboff, 2014 6
Use of sound in tinnitus treatment

Sound is an important part of many tinnitus
treatments; it is used to:
–
Cover-up (masking)
–
Achieve immediate relief
–
Distract attention from monitoring tinnitus
–
Decrease stress
–
Help with sleep
–
Decrease the difference between the tinnitus signal and
background neuronal activity (principle used in Tinnitus
Retraining Therapy - TRT)
Jastreboff, 2014 7
How sound is used

When tinnitus annoying

A few times a day

As an exercise in set times

When convenient

All the time
Jastreboff, 2014 8
Use of ear level instrument for tinnitus
in the past


Ear level instrument started to be used in tinnitus
therapy over 30 years ago
–
Hearing aids
–
Maskers
What have we learned from past experiences?
Jastreboff, 2014 9

Ear level instruments, such as sound generators (SG),
hearing aids (HA), combination instruments (Combi),
can be very helpful and an important part of tinnitus
treatment

However, alone these devices are seldom the solution
for high level tinnitus control and should always be
utilized in conjunction with counseling; proper
counseling is an essential part of any effective tinnitus
treatment protocol
Jastreboff, 2014 10

Practically everybody experience tinnitus when put in
sufficiently quiet environment for some time

Many people report having tinnitus, but only small
proportion of people hearing tinnitus is bothered by it
Why tinnitus is bothersome only to some people?
Jastreboff, 2014 11
Observation

Lack of relationship between
psychoacoustical description of tinnitus, its
severity and treatment outcome
Conclusion

Auditory system plays a secondary role in
clinically-relevant tinnitus;
other systems in the brain are dominant
Complains of tinnitus patients point out
systems which might be involved
Jastreboff, 2014 12
The Neurophysiological Model of Tinnitus
Processing of tinnitus-related signal within various parts
of the central nervous system has to be included in the
analysis of the phenomenon of bothersome (clinicallysignificant) tinnitus
Jastreboff, 2014 13
Perception & Evaluation
Auditory & other Cortical Areas
Detection
Emotional Associations
Subcortical
Limbic System
Source
Annoyance
Cochlea
Autonomic Nervous System
Jastreboff, 2014 14
Perception & Evaluation
Auditory & other Cortical Areas
HE
Detection
Subcortical
HE
Emotional Associations
Limbic System
HR
Source
Annoyance
Cochlea
Autonomic Nervous System
Jastreboff, 2014 15
Perception & Evaluation
Auditory & other Cortical Areas
HP
Detection
Subcortical
HE
HE
Emotional Associations
Limbic System
HR
Source
Annoyance
Cochlea
Autonomic Nervous System
Jastreboff, 2014 16
Techniques to achieve habituation

Reclassify tinnitus to category of neutral stimuli
Retraining COUNSELING

Decrease strength of tinnitus-related neuronal activity
SOUND THERAPY
Jastreboff, 2014 17
Principles of using sound in TRT

Sound used as a part of sound therapy in TRT should never induce
annoyance or any kind of negative reaction from the patient, as this
would increase the activation of the autonomic and limbic nervous
systems, and consequently may prevent habituation from occurring

Systematic masking should be avoided

Sound level should be above range of stochastic resonance

Improve hearing abilities with amplification, when needed

Consistent increased stimulation with sounds decreases gain within the
auditory system

Current TRT protocol is geared toward using at least two types of sound

–
Sounds of nature, particularly water
–
Broadband noise
Music is used in majority of patients, mainly as element of protocols for
misophonia
Jastreboff, 2014 18
Effects of silence on tinnitus

It has been shown that practically everyone develops
temporary tinnitus, if put in an extremely quiet environment:
“It is so quiet that ears are ringing”

As a rule, patients with tinnitus find that their tinnitus seems
much louder and more intrusive in a quiet room or when their
ears are blocked

The gain in the auditory system increases resulting in
enhancement of the tinnitus signal

It is crucial to have an enriched sound environment together
with sound provided by ear-level instruments

The sound of the instruments provides “safety net”
Avoid silence!
Jastreboff, 2014 19
Principles of perception of strength of a signal

All of our senses reacts not to the absolute value of a stimulus,
but to the difference between the stimulus and background

The strength of any signal in the nervous system is related to its
difference with background neuronal activity

By increasing background neuronal activity, it is possible to
effectively decrease the strength of tinnitus-related neuronal
activity within the auditory pathways and consequently in all
systems involved
Jastreboff, 2014 20
Strength of tinnitus signal
depends on its difference from a background
TINNITUS
BACKGROUND
TINNITUS
BACKGROUND
Jastreboff, 2014 21
The role of sound therapy in TRT

Decrease contrast between tinnitus and background neuronal activity

Interfere with the brain’s ability to detect the tinnitus signal

Reduce abnormal gain in the auditory system

Increase frequency range of the stimulation of the auditory system

Preserve or restore symmetry of stimulation of the auditory system

Improve communication ability

Decrease the strain-to-hear

Decrease focus on the ear and sound perception

Increase patient’s sense of control

Decrease general stress caused by tinnitus
Jastreboff, 2014 22
Enhanced stimulation by sound
can be provided by

Environmental sounds (e.g., table-top machines, iPod,
MP3 players, CDs, TV)
–
non amplified
–
amplified by hearing aids or combination devices

Recent advances in hearing aids allow for streaming sound
from iPod, MP3 players, CDs and other devices directly to
hearing aids

Sound generators or sound generator part of combination
devices

Ear level devices should be used concurrently with
enhancement of the environmental sounds
Jastreboff, 2014 23
Why to use ear level instruments?

To facilitate the implementation of sound therapy which results in
improvement of the compliance with the protocol

To give a patients a sense of control and of doing something
tangible (psychological aspects)

About 30% of patients have hyperacusis. For these patients use
of well controlled, stable sound source, such as provided by sound
generators, is highly beneficial

Additional positive consequence is decreasing “strain-to-hear”
phenomenon in patients with hearing loss by using hearing aids or
combination instruments
Jastreboff, 2014 24
General rules for choosing instruments (in TRT)

Recent tinnitus or tinnitus is not a significant concern
=> no instruments necessary (but still can be used)

Bothersome tinnitus, no hearing loss => SGs

Bothersome tinnitus and hearing loss => Combi or HAs

Hyperacusis => SGs

Hyperacusis & tinnitus => SGs

Hyperacusis & tinnitus & hearing loss => Combi

Always use binaural fitting to preserve / restore the
symmetry of stimulation of the auditory system
Jastreboff, 2014 25
Stochastic resonance

Stochastic resonance causes that weak, close to threshold signal,
is better detected and it is enhanced by addition of low level noise

Sound therapies with random noise are used in treatment of
tinnitus and hyperacusis

Results of specific study showed that, consistently with stochastic
resonance, tinnitus loudness match was increased (~10%) in
statistically significant manner by adding low level of noise

Stochastic resonance might play a role in worsening tinnitus

Performing REM is recommended

Patients with misophonia are at the highest risk
Jastreboff, 2014 26
Effects of Stochastic Resonance
Signal
strength
Threshold
of a signal
detection
Additional
noise
Additional
noise
Jastreboff, 2014 27
Change of tinnitus loudness [dB]
1.4
1.2
1
0.8
0.6
0.4
0.2
0
-12
-9
-6
-3
-0.2
0
3
6
9
12
-0.4
White noise level [dB SL]
Jastreboff, 2014 28
Therefore, precautions should be taken not to use
too low levels which could be close to the threshold
levels of sound perception, as these could enhance
the tinnitus signal due to the stochastic resonance.
Jastreboff, 2014 29
“Mixing point ” Tinnitus changing
Annoyance
Tinnitus
suppressed
Threshold of
hearing
Effective range
of sound use
Jastreboff, ‘95
“masking”
Intensity of a sound
Jastreboff, 2014 30
-10
Effectiveness of habituation
FACILITATION
“Mixing point”
Annoyance
Effective range
of sound
Suppression
(“masking”)
10
20
30
Sound intensity [dB SL]
INHIBITION
Stochastic resonance
Jastreboff, 2014 31
Sound generators

Should be used only for patients who have normal hearing

Can be used for tinnitus and / or hyperacusis and as a part of
protocols for misophonia

Particularly needed for cases with hyperacusis

Must provide control of the sound level used to patients

Used in past smooth change of sound level has been replaced
by an increase by pre-set value (toggle or remote-controlled
step value)

Shaping of the sound spectrum is needed for improving the
acceptance of a sound by patients
Jastreboff, 2014 32
History of sound generators

Viennatone Silent Star – characteristics like old AM/Ti, but better
cosmetic appeal - still available in Europe

GHI in-the-ear or OTE - smoother and expanded in high
frequency region frequency characteristics

Audifon / Kind, Hansaton, other companies

Currently, due to decrease of prices of combination devices they
can be used as sound generators
Jastreboff, 2014 33
Viennatone AMTi
Jastreboff, 2014 34
Silent Star
Jastreboff, 2014 35
Jastreboff, 2014 36
Jastreboff, 2014 37
Real Ear Measurements
(in Tinnitus Retraining Therapy)

Verbal reports are not sufficient to determine sound levels
used by patients during treatment

Modified Real Ear Measurements (REM) of the sound level in
the ear canal were performed to:
–
To measure sound level used by patients at the beginning of the
treatment
–
To determine potential changes in sound levels during treatment,
–
To determine potential differences in sound setting between
tinnitus only and hyperacusis patients
Jastreboff, 2014 38
Jastreboff, 2014 39

Average sound level used by the patients was ~11 dB SL (Re:
threshold of perception of the sound produced by SG - range
from 0 to 20 dB SL)

This sound level should not interfere with speech perception,
except in cases with significant hearing loss in frequency range of
1 kHz to 3 kHz

There is no difference in setting sound generators between
patients with tinnitus only, and patients with tinnitus and
hyperacusis

The comfort level for noise provided by sound generators
appears to be the factor determining sound level used by patients

REM measurements decrease the risk of the use of sound levels
within the range of stochastic resonance or overstimulation

REM is highly recommended as a part of TRT protocol
Jastreboff, 2014 40
Tinnitus Retraining Therapy
S o u n d P ressu re L ev el (d B a t
3 k H z)
Volume Control Taper
70
60
50
40
30
20
10
0
0
10
20
30
40
50
60
70
80
90
100
Percent CW Rotation (%)
Jastreboff, 2014 41
Jastreboff, 2014 42
Tinnitus Retraining Therapy
Frequency Response
Jastreboff, 2014 43
Instruction for setting SGs in TRT - tinnitus

Sound should not create annoyance or problems because of
any reason!

Goal for tinnitus patient is “mixing” point

Step method is recommended

Avoid consistent masking of tinnitus; short periods of masking
are not important

Volume of sound generators should be stable – kept at the
same level regardless of behavior of tinnitus or listening
environment during the block of usage

Recommended sound level 6 to 20 dB SL
Jastreboff, 2014 44
-10
Effectiveness of habituation
FACILITATION
“Mixing point”
Annoyance
Effective range
of sound
Suppression
(“masking”)
10
20
30
Sound intensity [dB SL]
INHIBITION
Stochastic resonance
Jastreboff, 2014 45
Use of hearing aids in sound therapy
(present hearing loss)

Commonly they are first type of instrumentation used as 80% of
tinnitus patients have some hearing loss

Hearing aids are implemented to expand stimulation of auditory
system and secondarily to alleviate strain to hear

Aids are implemented primarily for tinnitus treatment,
communication is a secondary benefit

Aids should be worn during all waking hours

Enrichment of environmental sound is crucial

May mask tinnitus

Limited effectiveness, if not used as a part of specific program of
treatment and sound use
Jastreboff, 2014 46
Setting Hearing Aids - “tinnitus fitting”

Patient is gradually eased into amplification

The aim is to provide amplification above 6 kHz (through
gradual process)

More stress on high quality of amplified sound

Recommendation to disable all “noise reduction” features

Automatic adaptive functions are to be used with caution

Some patients may require volume control due to misophonia
or psychological reasons
Jastreboff, 2014 47
Unilateral losses

Approach is based on multisensory integration of auditory
and visual systems

CROS

BiCROS

Stress on impact of hearing loss on the auditory system

–
Plasticity
–
Improved symmetry of stimulation
External sound enrichment is crucial
Jastreboff, 2014 48
Combination instruments (in TRT)

Adding a noise produced by SGs may negatively influence speech
discrimination in patients with hearing loss

Therefore, HA part of the Combi is used mainly to prevent decrease
of speech understanding

Amplification is set primary to compensate for the effect of noise
introduced by SG, thus, frequently initial amplification is set below
recommended “target”

Amplification is gradually increased during subsequent appointments

Patient needs to understand the rationale of implemented protocol

Combination instruments may be recommended for patients whose
mild hearing loss would not indicate the need to use hearing aids
alone
Jastreboff, 2014 49
Open fitting

Recommended for all type of instruments

To prevent attenuation of environmental sounds

Occluding the ear canal makes tinnitus worse
Jastreboff, 2014 50
Jastreboff, 2014 51
Selected list of companies offering
tinnitus-orieted ear-level devices

Amplisound

Audifon

General Hearing Instruments

GN ReSound

Hansaton

Oticon

Phonak

Siemens

Starkey

Unitron

Widex
Jastreboff, 2014 52
Amplisound
Quell
TINNITUS DEVICESFDA 510(k): K132965
Features
dB HL
Interchangable
soundtips available
in 4 lengths.
Locking handle
for a secure and
comfortable fit
Suggested Fitting Range
Available
in beige or taupe
Domes available
in 3 sizes
Easy to use scrolling
volume wheel.
0dB at minimum.
On/Off Switch in VC.
Frequency in Hz
#10 battery (90 hours)
Manufactured by Amplisound
solacefortinnitus.net
Jastreboff, 2014 53
Quell
TINNITUS DEVICESFDA 510(k): K132965
Quell tinnitus devices offer a reliable and
affordable solution for sound therapy by
qualified tinnitus practitioners. The sound
stimulus has been carefully designed for a
smooth, extra broad band response.
Quell tinnitus devices can be fit to the patient
with the standard initial program settings.
As needed, these devices can be adjusted with
Hearing Studio programming software.
Adjustable features include:
 12 band equalizer for frequency shaping and
tone quality adjustment
 Low battery indicator tone which is pre-set at
60 dB and 500 Hz (can be turned off)
Manufactured by Amplisound
solacefortinnitus.net
Jastreboff, 2014 54
Audifon

Company well know in Germany where offers variety
of instruments for tinnitus

Relatively recent in the USA

Promotes devices as tailored to TRT

Only two devices available at the moment

SG: switch TRT

Combination devices: Switch 8 TRT
Jastreboff, 2014 55
Jastreboff, 2014 56
General Hearing Instruments
Jastreboff, 2014 57
Jastreboff, 2014 58
Jastreboff, 2014 59
GN ReSound

Combination devices on the market for several years

Current models: Verso TS, LiNX TS (LTN961-DRW, LTN761DRW, LTN977-DW, LNT777-DW, LNT988-DW, LNT788),

ReSound LiNX TS is compatible with iPhone 5s, iPhone 5c,
iPhone 5, iPad Air, iPad (4th generation), iPad mini with Retina
display, iPad mini, and iPod touch (5th generation), using iOS
7.X or later.
Jastreboff, 2014 60
Hansaton

Private company well know in Germany

Two models of the Hansaton SOUL tinnitus combination
instruments: the Slim BTE and the X-mini RIC BTE in two
technology levels as well: the SOUL Economy class (8 channels/8
bands), and the SOUL Business class (16 channels/ 16 bands).

HANSATON SOUL systems can be operated by remote control for
volume and program changing. Systems are Bluetooth enabled and
allow for direct, wireless contact with the TV or stereo system.
Jastreboff, 2014 61
Oticon

Oticon Hearing released this year their version of tinnitus
management called Tinnitus Sound Support in their Alta Pro
and Nera Pro hearing aids

Tinnitus SoundSupport
–
Provides the sounds based on white, pink or red noise which can be limited
in frequency by high pass or low pass filters
–
Provides the option of amplitude modulation, a volume control and
automatic level steering
–
Generates a broadband noise signal with adjustable spectrum
Jastreboff, 2014 62
Phonak

Phonak Audéo V combination device is RIC portfolio for mild to
severe hearing losses

Four designs, three external receivers and four performance levels

Running on the new operating system, AutoSense OS, Audéo V is
promoted as better in automatic adaptation to listening situations
than previous models
Jastreboff, 2014 63
Siemens

Practically all Siemens HA include sound generators and can
be used as combination instruments

Just introduced binax is promoted as allowing to achieve up to
25% better speech intelligibility than people with normal hearing
in the same cocktail-party situation

System emulates natural binaural listening by linking two binax
hearing instruments using e2e wireless 3.0 data transmission
technology without compromising battery life

Android phones can be used as remote control for Siemens
hearing aids
Jastreboff, 2014 64
Jastreboff, 2014 65
Jastreboff, 2014 66
Starkey

Combination device - Xino Tinnitus product - include Multiflex
Tinnitus Technology

Multiflex Tinnitus Technology

–
Generates a broadband noise signal with adjustable spectrum
–
The sound can be frequency and amplitude modulated resulting in
perception similar to ocean waves or a breeze
SoundPoint Tinnitus feature allows to tailor the sound under the
guidance of tinnitus patient
Jastreboff, 2014 67
Unitron

Moxi2 and Quantum2 combination instruments

Sound generators part is available in nearly all technology levels
and styles

Unique aspect of their hearing aids – a possibility to upgrade given
model to better hearing technology levels at any time
Jastreboff, 2014 68
Widex

Widex promotes a technology of fractal tones, called Zen, to help
relax

Broad band noise can be used as well, level of which can be
modified by remote control

Zen is available in all DREAM and Clear technology

Low-end device, Zen2Go, are promoted for tinnitus
Jastreboff, 2014 69
Current changes in instrumentation for tinnitus

Majority of manufacturers are offering combination instruments
with broad band noise spectrum of which can be modified (e.g.,
Siemens, high-end Widex)

Increase ease of streaming sound to devices (e.g., ReSound
LiNX and iPhone)

Improvement in quality of CROS and BICROS wireless systems

Enhanced frequency range up to 10 – 12 kHz

Wireless communication between hearing aids
Jastreboff, 2014 70
Take home points

Vast majority of tinnitus patients could benefit from the use of
ear level instrumentation

Use bilateral fitting

Selection of instruments depends on the specifics of a patient;
combination instruments are optimal for majority of cases

The sound produced by SG (or SG part of Combi) should never
evoke annoyance

Sound range selected by patients varies from 0 dB SL to 20 dB
SL; it is advisable to avoid sound levels below 6 dB SL to avoid
potential negative impact of stochastic resonance
Jastreboff, 2014 71

Fitting of HAs should follow a specific recommendations of
“tinnitus fitting" which typically involves not reaching initially
the target, fitting performed over several appointments and
disabling noise cancelation features for main program;
providing amplification above 6 kHz (through gradual
process) is recommended

Patients with decreased sound tolerance require even more
gradual introduction of amplification

Sound generators worn under ear muffs are recommended
for patients when ear protection is required

Counseling tailored to specifics of a patient and proposed
instruments is crucial to achieve high level of success
Jastreboff, 2014 72
Thank you
Jastreboff, 2014 73