Hearing Health Hour Webinar | Measuring Tinnitus and Reactions to Tinnitus

– Well, hello and welcome to our Hearing Health Hour webinar. And thank you for joining us for another research presentation from Hearing Health Foundation. Today, we're going to learn about tinnitus. If you're new to Zoom, please
review the technical guide that has been shared in the chat. Please note this event
has a live captioner. You can enable closed captioning by clicking on the CC in the toolbar at the bottom of your screen. By way of introduction, my
name is Dr. Anil Lalwani. I'm a professor and vice
chairman for research in the department of otolaryngology,
head and neck surgery, as well as associate
dean for student research at Columbia University Vagelos College of Physicians
and Surgeons in New York, which is my background.

I'm also a board member at
Hearing Health Foundation, where I oversee the Emerging
Research Grants program, also affectionately known as ERG. Well ERG provides critical
funds to researchers studying hearing and balance conditions. These grants have made it possible for many leaders in our field to become successful scientists. Today, we're going to hear
from Dr. Richard Tyler who received an ERG grant himself from Hearing Health
Foundation back in 2012. He serves as professor
and director of audiology in the department of otolaryngology, and department of communication
sciences and disorders at the University of Iowa. He's published over 270 articles — that's a lot! — on tinnitus and his work focuses on research studies that help tinnitus patients.

If I personally have a question about tinnitus or tinnitus research, my first step is to do a quick search on Dr. Tyler's publications, as usually I can find my answers there. Tinnitus is a frustrating condition with no documented cures. It is a significant research focus of Hearing Health Foundation. In fact, the next issue
of Hearing Health magazine that's being released this week, is themed Tinnitus and Hyperacusis. I'm excited to read it, and
I hope that you are too. Of course, all our work on tinnitus as well as other related
hearing and balance conditions is only possible through the generosity of supporters like you.

And if you'd like to support
our work on hearing loss, tinnitus, and related conditions, you can do so today at HHF,
Hearing Health Foundation, hhf.org/donate. And without further ado, now we're going to move to the presentation by Dr. Richard Tyler on Measuring Tinnitus and
Reactions to Tinnitus. And we're going to have Q&A at the end. Thank you. Dr. Tyler. – Okay, thank you. I hope that I can be helpful
here and of interest.

Tinnitus is actually quite common and there's opportunities to help people, and part of that often begins with understanding and measuring it. So the first slide here I refer to as our psychological
model of tinnitus, which we developed back in 1992. And in that, it is important
to make the distinction between the tinnitus
characteristics itself. So it has some sound like pitch
and loudness and duration, and the annoyance caused by that tinnitus, and we'll talk quite a bit
about the different reactions that people can have,
different for different people. But the important point
here is the reactions depend not only on what
the tinnitus sounds like, whether it's loud or soft, but also on the
psychological characteristics or makeup of the individual
who gets tinnitus. So we're all different, we have different backgrounds
and different experiences, and that has a role to play
in the overall annoyance that one gets when one
ends up with tinnitus. Next. So it's important to measure
tinnitus for several reasons, for the patient, for the clinician, obviously essential in research, and sometimes I even do legal cases and propose some of the measurements.

Next. So for the patient here, many of the patients come into the clinic and they're concerned. What is this? Why did it happen to me? Is it real? You know, do I have some mental issue? Am I making this up? And so it's very important
to show the patient, to show people that,
in fact, this is real, you have a sound that's
not supposed to be there and we can measure it.

And most of the patients also have a pure tone threshold loss, we usually start off with the audiogram showing them that their hearing loss is probably related in some
ways to their tinnitus, in most cases, at least. And remember the average
normal hearing is zero dB HL. So some people with hearing
thresholds of five dB HL might actually have a
pure tone threshold loss. So it's helpful just to show
the patient as the first step, what their hearing is like, and how that might be a factor in the disorders of their auditory system that is causing tinnitus. Next slide. So for the clinician, that can be very helpful for
us to help with management.

We can use the measurements
in terms of counseling, we can use the measurements
to determine the severity, and in some situations,
we can also help design and focus on the treatment that is needed depending upon the
measurements that we get. So this is particularly important in our Tinnitus Activities Treatment that the counseling
strategies that we've used that focuses on the four different possible components of tinnitus that includes emotions, hearing,
sleep, and concentration. So most people with tinnitus
have some emotional issues, most of them have difficulty hearing sometimes caused by the tinnitus, sometimes caused by their hearing loss, but many also, but not all, have problems with sleep
and with concentration. We wanna be able to monitor the progress with our measurements. And in addition to this,
many of the clever devices that are available these days
to help people with tinnitus, might require measurements, such as the spectra that is effective, the level of the noise needed, whether one can mask the
tinnitus in one ear or both, whether the tinnitus gets worse or better when you take a masker off.

So it's important for
our clinicians as well to be able to measure tinnitus. Next. So again, I'm going to focus
on two different areas here. I'm going to focus on the measurement
of the tinnitus itself, the pitch, the loudness, and the masking, and the measurement of
the reactions to tinnitus and the primary functions affected are thoughts and emotions, hearing, sleep, and concentration. Next. So keep in mind that all
measurements have some variability, so measurements are not perfect, some of it is just the
procedure and test retest, but it's more complicated
in tinnitus patients because some tinnitus patients have tinnitus that changes over time.

Also, we have to be aware that sometimes the test
stimuli that we're using can actually change the tinnitus. So for each patient, we try and establish the variability that that
person is experiencing. And if we can, the source
of that variability as well. Next. So, the psychoacoustical
testing of tinnitus involves pitch matching. That is we're going to match
the pitch of my tone to the most prominent
pitch of your tinnitus. And even though the tinnitus
might sound quite complicated and like a hum or a buzz, it can usually have a prominent pitch.

So we'll do that by providing
two options of pitches and I'll go into that in a minute. We also measure the loudness by asking the patient to judge the loudness of their tinnitus to the loudness of my sound. The third approach is
minimal masking level. So we're going to put in
a broadband noise usually and we're going to increase
the level of that noise until it just masks the
tinnitus, if we can do that. And the last one we refer
to as residual inhibition, and that is we can present
a noise for a few seconds for example, 60 seconds,
to cover up the tinnitus, and then we can turn that noise off and see what happens to the tinnitus after our noise is turned off.

So we'll talk about that as well. Next slide. So pitch. Well, the pitch
match of the tinnitus might be related to the audio audiogram, what's causing the hearing loss, and maybe what's causing the tinnitus. And it may be that if we can
change the patient's pitch, which is often related
to spontaneous activity and listening to a pure tone, maybe we can get more focused on what the mechanism is and
how we can approach that. Measuring the pitch might also be helpful for fitting some devices. So for example, we suggested early on that you could use narrow
band noises in some situations to mask the tinnitus. Knowing what the pitch match would be, we can move a noise over
top of that prominent pitch. And there are also strategies where there is a notch in
music or a notch in noise that is a frequency region of the noise or the music missing. And that might be needed to put that notch over
the pitch match frequency of the tinnitus. So that's another reason
why pitch is important. Next. So, we used focus on
the most prominent pitch even though the tinnitus
might sound like a cricket.

There are several methods available, but as I usually say,
try and keep it simple. Important to measure the pitch with a monaural stimulus, going to one ear because some people have diplacusis, a different pitch in each ear. You can do this pitch
matching in the ipsilateral or the contralateral ear for someone with unilateral tinnitus, but that might be dependent
upon why you're doing this. And I'll just mention that pitch matching, even for normal hearing listeners, matching a pure tone to
a pitch in the other ear can also be highly variable. So keep that in mind with
tinnitus patients as well. Next. So we've looked at this with
relationship to the audio gram to see if the pitch
match could be predicted from the hearing loss.

And it looked like, in general, that some people might show a relationship between the audiogram and the hearing loss and the pitch match, but it wasn't very
clear for most patients. Next. We did a follow-up study with several hundred
patients many years later, and the bottom slides show
that we grouped these patients and their pitch match was
low frequency on the left, and then middle frequencies
in the middle two graphs, and then at the bottom, again, people that had really
high pitched tinnitus, they were on the right-hand side.

Now the average audiograms
are shown in the middle panels and the individual audiograms 
are shown at the top. So the point here is that
for the typical person, the audiogram itself does
not really predict at all what the pitch match frequency is, 'cause you can see the 
audiograms can be very similar, but the pitch match can be
very different, high and low and there's no clear
relationship, at least on average between the pitch match
frequency and the audiogram. Next slide. So loudness. So my background
is in psychoacoustics and one of the things
we do is we ask patients to adjust the loudness, to assess the loudness of their tinnitus on a scale from zero to 100. So zero would be a very, very faint sound. You can just barely hear it. And 100 would be very, very loud. So I would like to know
the subjective rating of your tinnitus on the
scale from zero to 100.

Next slide. So we can also do loudness matching. So for example, I'm going to present a tone and I want you to adjust
the level of my tone so it has the same
loudness as your tinnitus. And there are several
psychophysical procedures one can use here, but the most important
thing I would suggest is that the loudness matching be done in the ipsilateral ear of
the tinnitus, the same ear, and using monaural stimuli only. Next slide. So this is a survey done by
Jack Vernon and Mary Meikle who measured the loudness
matches of patients. And as you can see, the
sensational level above threshold at that frequency where
the loudness match was done was often only six dB
or less above threshold.

And of course, a lot of patients complain that their tinnitus is very loud, but it was only six dB above threshold. Why do they perceive it so loud? Next slide. So dB sensation level is
not a measure of loudness, it's a measure of the intensity
of a sound above threshold. And most of the tinnitus
patients have some hearing loss and likely have loudness recruitment. Therefore something only
a few dB above threshold can actually be very loud. Next. So this is an audiogram
of two different patients. Frequency on the bottom axis
and the level on the other axis and zero dB hearing level is shown on the bottom
with the gray areas, that's in dB sound pressure level. And the audiogram of this person is shown in this ear with the circles. Their pitch match frequency
is where the arrow is on the right-hand side
of that left-hand figure.

And the square shows the pitch match, the loudness matching at
the pitch match frequency. So in this case, it's only
a few dB above threshold. The diamond above that is
the loudness discomfort level and we also do work with hyperacusis. But the main point here is
that for that individual, the loudness of their tinnitus was only a few dB above threshold, but that's when we did
that at a high frequency where their pitch match was.

If we go to the other end
of that lower left figure, and we look at the other open box, it's actually 30 dB above threshold, and that's because that
person has normal thresholds at that lower frequency, and therefore did not
have loudness recruitment. So something above threshold, only a few dB would be very, very quiet. Next slide shows our attempts
to measure binaural masking. So this was interesting in
some of our early experiments in trying to focus on different kinds of masking procedures. So we could measure in the right ear. We'd put the exact same
noise in the left ear, so you see the little scribbles
is the noise wave form, the same in the right ear
and the same in the left ear. When we put that noise in
both ears at the same time, which is the fourth one down, then the noise is heard in the middle. But if we put in a different
uncorrelated noise wave form that's heard throughout the head, but if it's a correlated,
if it's the same noise, then for a low frequency
noise in particular, you will hear that in
the middle of your head.

If you use a time delay, so
you keep the same wave form but you delay the wave form of one of those correlated noise sources, you can actually move the perception of the
noise around in your head. So we thought maybe we could actually come
up with a noise level that was more effective
at masking the tinnitus. Next slide. So we were not very successful, I think we tested about 10 patients, but only one patient, the upper right-hand patient subject four, and these are just different conditions where we show the amount of noise required to mask the tinnitus, but we see with the time
delayed one on the far right, it was actually 20 dB less noise required to mask the tinnitus for that one subject out of about 11. So in any event, it was
an interesting approach and certainly has some
potential for setting maskers with that more sophisticated
approach of correlated noise.

Next slide. So frequency dependent masking
is also kind of interesting. That is, that I could ask
you to adjust the level of my pulse tone at a certain frequency until it just masks your tinnitus. So adjust the level of my tone so it just masks your tinnitus. And I could do that out
of variety of frequencies below and above the most
prominent pitch of your tinnitus. Next slide shows the audiogram of four different hypothetical patients. In the upper right hand corner, we see somebody who has, their audiogram is with the straight line, the arrow pointing down is where their pitch match frequency is. And for this person, a
high sound pressure level, that's those squares at the
bottom of the audiogram, those are the levels
required to mask the tinnitus for that patient. So it didn't matter what the frequency of the masker tone was, it required a high level
at all of the frequencies. Below that, you will see another patient who had a similar pitch match but we could not mask the
tinnitus in that patient at all, even at the highest levels available.

If you now go to the
upper left-hand screen, you see, again, the audiogram, the line, and the arrow
where the pitch match is. And for that patient, you
could mask the tinnitus at a very low sensation level, independent of the frequency. Now this was quite a surprise for me because when you do a similar experiment in normal hearing listeners, and now I want you to look
in the lower left hand box, if you put in a pure tone to people and try and mask that pure
tone with another pure tone, when the pure tones
are close in frequency, it's easy to mask the
first one, the pulse tone. And as you move the masker tone
further away in frequencies, it makes it more difficult
to mask that pure tone.

And that's because of the masking occurs, or at least for a pure tones, on the basilar membrane
inside the cochlea. And so we thought that people that had a tinnitus masking pattern like in the lower left-hand corner, that would indicate that their tinnitus was actually originated
on the basilar membrane. And that might help us with our understanding of the mechanisms. It turns out most people don't have that, a few do, but most people do not. And you can see the wide variety of different examples we showed in terms of trying to
mask patient's tinnitus with pure tones.

So it's important, not
just in measurements, but also in counseling,
that we're all different and certainly that the tinnitus can be quite different
in different people. Next slide. Okay, so the next thing I want to show you is postmasking effects, sometimes referred to
as residual inhibition. So in this case, we presented a noise that masks the tinnitus for 60 seconds. We presented that noise 10 dB above the level of the tinnitus, and we left it on for 60 seconds and then we turned it off right away. And then we quantified the
loudness of that tinnitus before and after we had our masker on. Next slide. So the top slide shows
the tinnitus loudness in the dash line, and
the masker in that box, and in the first patient
at the top, patient A, we turn the masker on and the person doesn't hear
their tinnitus anymore.

And we turn the masker off, and the tinnitus comes back
to the exact same level. In example B, we turn the masker off and the tinnitus is there right away, but it's at a lower level. In example C, the tinnitus
has gone completely. So the person's listening
to a masking sound, we turn the masking sound off,
and the tinnitus has gone. And I recall doing this
experiment in England where my first job was, and I had a 31-year-old
man in the soundproof booth going through this, these experiments, and he came out of the booth crying. And he came out of the booth crying because this was the
first time, as he told me, this was the first time in 10 years he had not heard his tinnitus. That was quite moving for me. So in D, the tinnitus has gone when the masker is turned off and then comes back on abruptly, and in E, which does
not happen very often, but as important in terms of considering using masking strategies for treatments, you can see in E when the
masker noise was turned off the tinnitus was much worse.

And fortunately, it did return
to its pre-masker level. So different subgroups, different types of tinnitus patients here, and what'd likely be relevant
to treatments as well. Next slide. So we've talked so far about
measuring the tinnitus itself, and now I want to focus on measuring the
reactions to the tinnitus. So, we started off, one of my
first experiments in England was an open-ended questionnaire. So instead of thinking, "I know all the correct questions to ask," we use this: "Please make the list of the difficulties that you have as a result of your tinnitus." So this is good for
patients in the waiting room or at home before they
come into the clinic. We want to know what you think is important. "What difficulties are you
having because of your tinnitus?" So we asked them to list
them in order of importance, and we used these to understand
where the patient is at. So clinically, with their
Tinnitus Activities Treatment, we want to know where the patient is at.

It's not that I'm the clever clinician, I want to sit back and learn
from where the patient is at and what their needs are, and how their tinnitus
is affecting their life. So this open-ended question is often a very good place
to start in our clinic. Next slide. So we then developed
the first questionnaire for clinical trials referred to as the Tinnitus
Handicap Questionnaire.

And that has been translated worldwide. There are 27 items, which
score from zero to 100, and it has been used in
several trials around the world actually in treating tinnitus. So that's one that we sometimes use, the Tinnitus Handicap Questionnaire. Next. A more recent questionnaire is the Tinnitus Functional Index. And I actually do not
like this questionnaire because it has a few
questions that are general, like, "Do you feel in control
in regard to your tinnitus?" Or some quality of life questions like, "How much has your tinnitus interfered with your enjoyment of social activities or your relationships with
family, friends, and people?" And it certainly is true
that tinnitus can do that, but the problem is with this questionnaire that if people are having trouble at work, or having trouble with their
family or their partner, then they might answer
some of these questions in a negative way, not because of their tinnitus but because of other issues
going on in their life. So I think the Tinnitus Functional Index is not a good questionnaire.

Next slide. The one that we use is based
on our model of tinnitus. So the functions affected
are thoughts and emotions, hearing, sleep, and concentration. And this comes out in a World Health
Organization model as well. And then depending upon
how that individual is affected in these four different areas, and again, some people have
no difficulty sleeping; some people have difficulty concentrating. They have difficulty reading
a book or focusing on a hobby because of their tinnitus. And these different
functions that are impaired have impacts on their
activities of daily life, including socialization and what they're doing at work and their economic situation. So tinnitus is really, really important in lots of different ways, and it's really important to appreciate the different ways that
people are affected, particularly these four functions. So next slide. So that led us to develop the Tinnitus Primary
Function Questionnaire. And this has been translated and is used worldwide in clinical trials. So some examples of these are "I have difficulty
focusing my attention on some important tasks
because of my tinnitus." "My emotional peace is one of the worst
effects of my tinnitus." "In addition to my hearing loss, my tinnitus interferes with
my understanding of speech." "I lie awake at night
because of my tinnitus." So those are some examples.

There's, I think, a 16-item questionnaire and a 24-item questionnaire of this Tinnitus Primary
Functions Questionnaire which has been translated
in many different countries and is used worldwide in
clinical trials and in clinics. Next slide. So this is some work that we did with our Tinnitus Activities Treatment where we use the counseling
and these four different areas depending on the area that's affected. And this was just a slide showing that we could help people
with our counseling, and the responses that people
get from their tinnitus. So remember the very first slide: We might not be able to
change the tinnitus itself but we can help patients
change the reactions. And these are the four different reactions that they experience. Next slide. So for the questionnaires,
just as a review, the open-ended questionnaire
is very helpful clinically just to listen to the patient and let them focus on what
is important for them. So that's really helpful. It's important as a clinician
to be a good listener, and this is create some formal way of letting the patient share
what is important for them.

We use the Tinnitus Primary
Function Questionnaire to plan our treatment. So almost all patients
get thoughts and emotions and hearing conservations, including hearing aids and sound therapies, in our Tinnitus Activities Treatment. But if someone doesn't
have problems concentrating or doesn't have problems sleeping, we can ignore those
modules in our counseling. For clinical trials, it's important because this
is a very sensitive tool, each question is scored from zero to 100 and we've published some, I think, really interesting
work, as have others, focusing on different clinical trials using this Tinnitus Primary
Function Questionnaire. Next slide. So, in summary, there are
some very important benefits to measuring tinnitus. And the first one is just improving your
communication with the patient. So, as I said, some
patients are surprised: "You mean you can measure this?" And that connects with them and shows them that you understand tinnitus, and that their problems are
real and we understand that. We can provide reassurance by showing them that they're not alone, that lots of people have problems, and these are the common problems.

So they have real tinnitus, it's a real sound that they hear. We can measure it. We
can do pitch matching. We can do loudness matching. We can quantify it and show
the patient that that's real. They're not making this up. Categorize the tinnitus. So for some patients, as I said, the tinnitus gets worse after noise. For some patients, it gets better. For some patients, you can
mask it with pure tones, for some patients, you
can't mask it at all.

So developing a pill and
developing a surgery for tinnitus is only going work if we
subcategorize tinnitus patients. They're all different. One pill is not going to help everybody. We're going to have to find
different subgroups of tinnitus, different categories of tinnitus, and try and determine if that pill can help that particular subgroup or particular category of tinnitus, likely based on the measurements that I've described here today. Fourthly, the measurements can be used as a baseline for treatment
and subsequent assessments. So we want to know if the
patient is feeling better. We want to know if they're
feeling better or not in what particular area.

If they're having trouble sleeping even after our counseling,
we'd like to know that. Maybe we need to try something else. Maybe a sleep medication
is okay in the short term. So we want to follow our treatments
and their effectiveness and what areas are effective, and what areas are not effective. So that's important. The selection of treatments is helpful. As I said, we can use the Tinnitus Primary
Function Questionnaire to decide whether people
want or need counseling in terms of the sleep, or need counseling in terms
of the concentration or not.

Most people benefit from
thoughts and emotions and from hearing counseling. And being able to show the patient that we can mask their tinnitus is helpful in fitting sound therapy devices. We want to know what their
tinnitus is going to be like when they take the sound
therapy device off at bedtime. And as I also mentioned, there are some sound therapy treatments that depend on the pitch match
frequency of the tinnitus.

So in that case, the
measurements are an essential tool in designing that particular
treatment strategy. And then finally, it's
important to document tinnitus. So as opposed to someone
just saying they have it, it's important to be able to document it, and to show that it's real. And for some people, in both legal cases and in work-related composition, and getting time off
from work or teaching, having some documentation that
it's real and can be measured helps that patient in their
daily life activities. Okay. ANIL: Well, that was terrific. Very clear. I especially
enjoyed that figure about pitch matching, but hearing test looks very
similar all the way across that it was kind of, I've
not seen that before. That's a very interesting finding, sort of unexpected in some ways. There are a lot of questions, Dr. Tyler, about treatment for tinnitus, and I thought maybe you could
broadly take the question, "Do you see any new promising
treatments on the horizon?" What's got your attention at this time? RICHARD: Well, I'm going to say that
there's lots of interest in tinnitus now because
there's so many people have it and because there is no pill and because there is no surgery.

So I think that one of the good things is that there are lots of people and companies exploring this, and they're exploring it, not just on tinnitus patients at large, but they're using measurements, some of the measurements we described, to focus on a subgroup. So, you know, for example, if
you cannot mask your tinnitus, maybe it shouldn't be and you're unlikely to
do on particular drug. There are some drugs
that are being explored for patients that have only had tinnitus for six months or less. There is different vagal nerve stimulation that has become popular. I don't want to say that, if there's anything on
the horizon in my opinion, that it's clearly going to work, but I think it is very exciting
and potentially valuable that there are so many
groups now interested in this and that there are so many
groups are now paying attention to the measurements
that we discussed today as trying to identify different subgroups because identifying different subgroups is going to be critical, in my opinion, in finding those cures,
and I say that in plural.

ANIL: Rachel asked how counseling of tinnitus patients would differ depending on whether the
patient has residual inhibition. How do you incorporate that into your — How you think about the patient,
the treatments, and so on? RICHARD: Well, the aspect of residual inhibition would come into play mostly when we're talking
about sound therapy devices. I have seen how long you
keep the device on for example and at what level you keep the device, you set the masker at. I've certainly seen more than
one patient who has noticed that their tinnitus goes away after they leave a noise
on for several hours and their tinnitus can be
gone for several hours. So, that doesn't happen very often, but I've certainly heard that
once or twice in some patients that are very clear effects of this. So I think that, you
know, paying attention to what happens after
you take the masker off, whether it gets worse or it gets better, is an important ingredient in
trying to coach the patient before they leave the
clinic with their masker because again, a lot of
patients just want a pill and they're willing to try a masker, but they're not quite
sure what's going to happen and providing some guidance
on what they might experience when they go home and listen to a low-level masker sound all day long.

It's important to discuss what the options might be with them before they leave the clinic. ANIL: There are several questions
related to the sound and the tinnitus itself, whether it's a single
tone, multiple tones, overlapping tones, and so on. Does that in any way —
what does that tell you when somebody describes a complex versus maybe a simple tinnitus in terms of the sound quality, its impact on diagnosis and treatment? RICHARD: Right, so I guess I would say that if it sounds like a pure tone, then the implication for that is that it's likely
affecting only one part of the auditory system. Because of course, when
we play a pure tone we are stimulating only one
part of the basilar membrane and all the nerves up
in the auditory cortex. So it may be that if somebody hears a broadband
sound for their tinnitus, that might imply that
there's a lot more areas of their brain activated by the tinnitus as opposed to a pure tone. I don't know, as far as I'm aware that it necessarily dictates
the strategy for masking or for counseling per se.

Certainly it would be more difficult for somebody listening
to a pure tone in general than it would be a
broadband whooshing noise, but it's difficult to know exactly where that's going at this point, what the different implications would be for the mechanisms involved. ANIL: Gotcha, and somebody had asked earlier about what a pure tone was. It's just a simple, single frequency. RICHARD: Pure tone is a single frequency. Like if broadly speaking, if
you hit a single piano key. ANIL: Gotcha. Now, you discussed the importance of assigning individual
to specific subgroups. And given that tinnitus is heterogeneous, being able to identify
some characteristics.

Do you have any sense of when we'll start to see
an instrument to do this, or do you feel like your instrument currently does that for
you, and in some way? RICHARD: Well, we published an
article on this many years ago using a statistical analysis, but I think the bottom line here is these various measurements
that I shared today. So, you know, if you
could take 500 patients and give them all the measurements
that I showed you today, you would see, you know,
50 patients do this, and 50 patients do that, and 100 patients, their tinnitus
is not affected by noise, and, you know, in 50 patients, they have very long post-masking effects where things disappear to zero.

So it is based on these
measurements themselves that I think would be the
starting point of focusing on, so you could give pills to 1,000 people but instead of analyzing the
data based on group averages, which I've criticized for many years, you could determine how
effective that pill was for people who had atonal tinnitus, or for people who you
could mask their tinnitus at a low level, or how effective was that
pill for tinnitus patients who you couldn't mask at all, or had a frequency tuning curve. You know, you could analyze the data based on the particular
subgroup of patients that falls into. And I think that's the goal, I think, in the finding a cure or
cures, I should say, plural, because it's going to depend, I think, on the different mechanisms involved and a particular insight on
that is how we measure it and we have to start analyzing the data based on these kinds of
subtype measurements.

ANIL: There's lots of questions about cochlear implants and tinnitus. Do you want to address in any way you can? Whether they can help tinnitus, maybe? Or what are your thoughts about
those two things together? RICHARD: Right, well, I'm glad
to get that question 'cause actually I've been
working with a group in Europe to try and promote this, because for a lot of patients, they get a cochlear implant and they say, "Oh, thanks,
I can hear better now. But even better than that,
my tinnitus is gone." Now, this doesn't happen for everybody. For a very small number,
the tinnitus gets worse, but for most patients, they actually help with their tinnitus when they get a cochlear implant. Then we can use sound therapy, just like we use with hearing aids, process through the cochlear implant.

And it's pretty encouraging. Even in many countries in Europe, when you have a unilateral
deafness — deafness in one ear — many patients actually get a
cochlear implant for that ear, even though they still
have pretty good hearing in the other ear. And they're getting a cochlear implant not because of their
hearing loss in that ear, but they're getting a cochlear implant because it helps them with their tinnitus. And so fortunately, a lot of
the cochlear implant companies are realizing this, and getting more involved
in trying to document it and hopefully more involved in changing the rules and
regulations in the United States for who qualifies for a
cochlear implant or not.

So I'm really excited about the potential for cochlear implants to
help tinnitus patients. ANIL: And I think some people
have actually shown that for unilateral deafness, those patients that have tinnitus as well are actually happier
with the cochlear implant than those without, with normal
hearing on the other side. RICHARD: Absolutely, yep. ANIL: I know this is gonna be a hot topic. I wonder if you have any thoughts
about COVID and tinnitus. COVID vaccination and tinnitus? There's some people out
there who believe that, you know, they're getting their tinnitus
after COVID vaccination.

Any thoughts, any data you have? RICHARD: Right, so I know that I
think the main factor here is the very first slide I showed separating the tinnitus from
the reactions to the tinnitus. And the reactions that you
have from your tinnitus depend upon your psychological makeup, and what status you're in, what kind of challenges you
have in your life right now. So if you had tinnitus for
five years or for five months, and you don't like it, you're
doing the best you can, but you wish it wasn't there, and then all of a sudden you get COVID, the COVID doesn't have
to affect your tinnitus, and I'm not sure that there's any evidence that it does affect the tinnitus, but in that psychological
model I proposed, if you're stressed out
about life because of COVID, that's gonna put you in
a much worse condition to deal with your tinnitus, and you're not gonna be as
able to deal with that tinnitus that you had before the COVID.

So I don't see any — I have not seen any data at all showing that the COVID
treatments cause tinnitus but I do know that people that have COVID and already have tinnitus, their tinnitus can be more problematic 'cause now their life
is even more complicated than it was beforehand. So that's my take on it. ANIL: Gotcha. There are some
questions about hearing aids and their effectiveness in
people that have tinnitus as well as how does masking work for people who otherwise
need hearing aids as well? RICHARD: Right, so hearing aids are
actually wonderful things and I've just published a
new Meaning of Life article.

I developed a questionnaire. I don't like any of the
Quality of Life articles. I don't think they're valid. So we developed a new
Quality of Life questionnaire we called the Meaning of Life, and we administered that to
cochlear implant patients and tinnitus patients. And it emphasizes, it's not about hearing; it's about communicating with people and socializing and having friends and looking forward to the future.

That's what hearing's about. So independent of our tinnitus, we should all take care of our hearing. And I often say to the patients, I hear as well as I did five years ago and five years ago I think
I heard as well as I did five years before that, but we're all getting a hearing loss as part of the natural aging process, and so hearing aids are
really, really important. And when we're hearing better
and communicating better and enjoying life better, we're gonna be in a better position to deal with our tinnitus, whether it's been there before,
or whether it just starts. And the same can be said about the sound therapy
devices, the maskers. They have to be fit appropriately and they don't work for everybody, but they can help for a lot
of patients with tinnitus. Having some background
sound can be very helpful in reducing the magnitude of the tinnitus, or reducing the loudness of it. And it works for a lot of people. There's usually a trial period and the sound therapy for the
maskers and the hearing aids are another great way that we can help our tinnitus patients.

ANIL: I'm curious: When you see
a patient with tinnitus, does the fact they have hearing loss or don't have hearing loss make a difference to
what your first steps are in their therapy? I mean, you know, would you
go to hearing aids first for the hearing loss, or antidepressants to people who don't, or what are your general thoughts about your approach to the patient? And by the way, a related question, because you're so clear
in your description, how do you describe the physiology of tinnitus to your patients? Maybe if you can combine
those two things together, it'll be good. RICHARD: Right, so I describe the physiology of tinnitus to the patients
is by saying that, you know, there's lots of random activities, we have some slides we show our patients in our tinnitus activities treatment. And so, we show the nerve fiber activity even without sound in a normal year has spontaneous activity on that. And your brain, our brain, is
used to that and ignores it. And so, whatever your cause of tinnitus, whether it's noise exposure,
or medication, or aging, somewhere in the auditory system that spontaneous activity is increased, and your brain does what
it's supposed to do, it interprets that spontaneous
activity as a sound.

Your brain is doing what
it's supposed to do. It's interpreting that extra spontaneous
activity as a sound. I'm sorry, can you remind me
the first part of the question? ANIL: When you start thinking about treatment, what are some of the divergent pathways? Is one of them hearing
loss, or no hearing loss, or as you're picking it up
from a patient and treat? RICHARD: Okay, so when the patient comes in, we almost always just
start with their audiogram, we want them to show us their audiogram and what they think about it, and I go over how important hearing is.

And again, they almost
all have a hearing loss and again, some people's
hearing thresholds were minus 10 dB at age 19, and if their thresholds are now five dB they have a hearing loss. So it helps the patient to confirm that they might have a hearing loss, and we can show that on the audiogram so we're not making this up. And so it's pretty clear, again, emphasizing
how important it is to hear that providing hearing
aids amplifies sound and that helps us deal with
life and interact and socialize. And that's gonna put
us in a better position when we're hearing and communicating, going to put us in a better position to deal with life's challenges. And one of life's
challenges is the tinnitus. But if we can hear and
communicate with hearing aids they're going to improve that, then we're going to be in a better position to deal with tinnitus. And the same thing with maskers. As I said, we often tell
the patients right away that while you've got a
bit of a hearing loss here and the hearing aids are
going to help you hear better, they need to be fit properly.

And also there are a lot of patients that try background sound, and for a lot of patients, they listen to the background sound and it reduces the loudness, and reduces the prominence
of their tinnitus. I tell them it doesn't work for everybody, but there's a trial period, and it works for a lot of people. And so we try and get them started on not just the Tinnitus
Activities Treatment counseling, but also based on hearing
aids and sound therapy at least being aware that are options. ANIL: Well, I should have told
everybody in the audience that was probably gonna
be our last question but maybe one last quick question. Any foods I should avoid
or people should avoid that have ringing? Is there any advice about that? RICHARD: Right, so I get asked this all the time.

There's actually surveys showing that there's a higher incidence of tinnitus, if
you drink a lot of coffee, but there are also some surveys showing that if you drink a lot of coffee, there's less likelihood  that you'll get tinnitus.
ANIL: [Laughs] RICHARD: So what I tell patients is
that whether it's coffee, or whether it's a pill, or even a medication that's
prescribed by your physician, do an experiment on yourself. And I use the coffee as the example. If you think coffee is a factor, then stop drinking coffee for three weeks, and don't change anything
else in your life. Stop drinking coffee for three weeks, don't change anything else in your life, and see what happens.

And that could be a pill. You could do an experiment on yourself even if it's a dietary supplement. I've even told patients that have your partner buy
two different kinds of pills, One that's supposed to help
with tinnitus, one that's not, and do a double blind crossover
experiment on yourself where your partner is
controlling what pill you get. But you can certainly
talk with your physician if you're thinking that a prescription is
causing your tinnitus, which it might be, including
something like, you know an antibiotic or whatever it is, but you can talk to
your physician and say, "Can we change the dosage? Can we decrease that for three weeks? or "Can we try a different
pill for three weeks?" Don't change anything else in your life and see how that affects your tinnitus.

ANIL: Well, Dr. Tyler, thank you so much for your informative
research presentation. I especially want to thank our
audience for joining us today and participating in our seminar. Look out for the next issue
of Hearing Health magazine premiering this week. Themed Tinnitus and
Hyperacusis to learn even more..

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