WEBINAR: The Patient’s Guide to Tinnitus: 2016

>> NANCY MACKLIN: Okay. We're ready to go. Good night, everybody, good to see everybody
in the room tonight. Before we get started, though, I want to thank
Cindy Thompson for providing CART this evening. Thank you very much. Cindy is always right on time and she's an
excellent CART provider so we really appreciate her being here tonight
(Thank you!). >> NANCY MACKLIN: It's my privilege to introduce
Dr. Douglas Beck.

I know you can read the entire bio on our
web site but I just wanted to mention that he is writing an article for the January-February
issue of Hearing Loss Magazine and I'm excited about that because he's a prolific writer,
he's an excellent writer on topics related to hearing loss and audiology. So we're very excited about that. And I'm happy to report that he has submitted
a paper for HLAA2017 convention in Salt Lake City so keeping my fingers crossed that that
is accepted and he'll be presenting. I know this topic of tinnitus is one we get
questions about all the time. And it's a popular topic, I know so many people
suffer from it. So Dr. Beck, welcome, thank you, again for
presenting tonight. And I'll let you get started. >> DR. DOUGLAS BECK: Thank you, Nancy. It's a pleasure to be here, even though I
can't see any of you. It's just like sitting here and speaking to
my computer. But I guess that's okay. The overriding thought that I want to give
you about tinnitus is that no two people perceive tinnitus the same way.

There are many different types of tinnitus,
many manifestations. And the fact that two people may have tinnitus
and may describe it very similar doesn't mean it's the same. Because our perception of sound is a unique,
individual experience. So let's start with the first slide. And my plan is to go just under an hour, probably
about 50 minutes or so. And then we'll take questions from you guys. And if the questions run into overtime, that's
fine. I've got a plane to catch early in the morning
but I'm good. So we can stay an extra couple of minutes,
if need be. In general, when we talk about tinnitus, there
are two types. And it's very important to understand that
you can't tell the difference unless you're professionally evaluated. Now, the reason I say that is many times people
will present, they will come into an office and they will complain about ringing in the

And indeed, if it has a physical origin, it
could be that their ear is full of wax. It could be a broken eardrum. It could be the three little bones, the malleus
the stapes and incus can be damaged lots of people could have tinnitus that's physical
and that's called objective. Now the good news with objective tinnitus
is that we can fix it. If you see an audiologist or a hearing aid
dispenser and they think your tinnitus is objective, that means it has a physical source. They will probably refer you to an ear, nose
and throat doctor. And he or she will examine you and perhaps
offer medicine or surgery or whatever is appropriate at that moment. Unfortunately, only about 3% of all tinnitus
is objective. So that means 97% is subjective. Now, subjective tinnitus has a couple of good
and bad things about it, as well. The good news is subjective tinnitus is unlikely
to cause any physical damage. And the good news is that up to about 90%
of the time — and you know, I've shown the data on this to many audiences. And I don't have the time to share it with
you but I'll give you the summary.

And the summary is that probably 90% of the
time people who have tinnitus can be effectively managed. And that's what this slide is saying. 90% of the time we can manage it. What I mean by effectively managing it, I'm
talking about managing it so you may perceive it, you may not. But it will bother you considerably less. That's the goal. If the goal were to cure tinnitus, it would
be unlikely we could do that. It's not likely we could cure tinnitus. It's very likely we can help manage tinnitus. So what is tinnitus? Well, this is a definition I put together
in 2012 for the British Academy of Audiology, I was doing a presentation for that group
on tinnitus. And this is a compilation. I didn't create any of these words.

I just assembled them from many of my colleagues
and other authors who write on tinnitus. So two things, it's a phantom sound or noise
perceived in the ears most often described as a buzzing, ringing, crickets, whistling,
humming, static, high pitch tone, any of those things that occur in the absence of a known
external stimulus. So that known external stimulus, that would
be objective tinnitus. If you have tinnitus being caused by a physical
sign or symptom it would be objective. Most of it isn't, it's subjective. And part 2 of the definition is a failure
to habituate. And what I mean by that, most of you who are
listening and reading the closed captioning or CART right now, you're not aware of your
socks until I said “socks” because you're habituated to it. It's a very common human psychological adaptation. We habituate rapidly to different stimuli,
whether it's sound whether it's visual stimuli. Whether it's a smell – if you smell something
that's really foul after a while you smell it less intensely because you start to habituate
so the thing.

With tinnitus it's a phantom sound generally
90% of the time and one cannot easily adapt to it or habituate to it. Now the people who can habituate to it don't
complain about it. It doesn't mean they don't have it. But it doesn't cause them to stress so the
numbers look like this. There's let's say 330 million people in the
United States. There’s perhaps 33 to 35 million who perceive
tinnitus. Of those, about 10% or 3 million, maybe 3.5
million would say that it's bothersome so it's a relatively small amount of people but
perhaps 1% or the population maybe a little bit more, perceive tinnitus so badly they
might seek help or a solution to it so a relatively small amount of people unless you're one of
them, in which case it has tremendous influence on your life.

The three main things that it does when people
perceive tinnitus and can't habituate to it, it causes difficulty in hearing. It causes difficulty in concentration and
causes difficulty in sleep patterns so those are the three areas we look at. As I said earlier two people, they — if they
describe it the same it could be totally different this is a study from Dr. Eggermont published
in 2012 he pointed out if you give series of people with normal hearing and give them
a pure tone like a 4,000 hertz tone about 34% of it will describe it as a tone so they
are correct, about 1 out of 3 people get it correct. 26% of people listening to a tone describe
it as a hissing sound. 18% say it's a roaring sound and 22% might
say it's whistling, squeaking, whatever that's my point the fact somebody says yeah it's
ringing or sounds like static I'm sure that's their perception and that's what it sounds
like to them but to each person those words have different meanings. Good to know it doesn't change very much but
the — it tells us if a person describes it as a roaring sound a hiss or whistling sound
doesn't necessarily mean I would describe it that way.

We covered the numbers already. It's about 30 — some of my publications have
written up to 50 million people. You see that. I published that one in 2011. The Journal of the American Academy of Audiology
says 50 million but I'm thinking it's probably closer 30 to 35 million I could go through
the reasons and rationale but it's not that important so about 10% of the population say
they have a ringing sound in their ears and 10 to 20% of them it's clinically significant
that is it bothers them enough they would seek a solution many people think tinnitus
is tied to hearing loss that is if you have hearing loss you're likely to have tinnitus
and that's true that there's a greater likelihood.

But it's only about 80%. Now this is a weird number it's called the
80/80 rule again something I came up with in 2012 if you Google this put it into Google
not now before after the class put in tinnitus comma 80/80 rule put that into Google, you'll
see this comes up 80% of patients with sensorineural hearing loss patients they will say they have
a buzzing and 80% of people with tinnitus have a sensorineural hearing loss But it's
certainly not a one-on-one correlation if we think about 35 million people in the United
States let's say 35 million have tinnitus 80% of that would be 7 million people so 7
million people have tinnitus without hearing loss
And that's important. Because many times you'll hear a physician
or an audiologist or a hearing aid dispenser say well the reason of tinnitus is because
of your hearing loss the problem with that is I have 7 million people in America who
have tinnitus without hearing loss that doesn't ring true to me it might be true a little
bit for some people some of the time but certainly not a universal truth.

Another thing that comes up people say you
have tinnitus because your brain is filling in missing sounds because of your hearing
loss. Again I have 7 million people with no missing
sounds but have tinnitus it may be true a little bit maybe some people some of the time
certainly not a universal truth. To me, and let's see, there's about 40 people
in this room and hopefully you'll get a little bit of time at the end to talk about and share
your perspectives, but most often tinnitus is a manifestation of stress. And then it's interesting because hearing
loss absolutely matters. The auditory system matters. The emotional/psychological status of the
patient matters. The overall health of the patient matters
the drugs they are on matters.

All of these things matter. But there's a study out of either Sweden or
Norway. Let me see if I gave you that study. Yes, this is a study that was kind of clever
it came out in 2012 and it's in the scientific literature. It's a journal it's a very well highly respected
journal in America and it's peer reviewed and they had 20,100 people chosen at random
to receive a questionnaire what you should know in Sweden which is pretty sure where
it's done these people didn't come to — come pay to see the physician or audiologist or
the dispenser, their care is free.

Whoa I should have done that ten minutes ago
that's a better picture so 20,000 people got a questionnaire. Those 12,166 returned their questionnaire
now if you have ever done any surveying at all that's an unbelievably high return rate,
61% of people returning the questionnaire is unbelievable particularly when you have
12,000 of them The typical response rate if you send out
a questionnaire in America is going to be between 1 and 3% if you have done a phenomenal
job and make it easy and people are interested in your topic you might get 5%. So 61% unbelievably high return rate the conclusion
of the study was stress was the difference between significant and mild tinnitus if you
have mild tinnitus just a little bit you notice it now and then but you're under stress that
stress becomes significant — that stress manifests your tinnitus as significant.

So those seem to be the two things. If you have a little bit of tinnitus to begin
with you're one of those 35 million but now you're under stress, now it's significant. And now you start to perceive it a bit more
and worry about it. And it's not just ears. We said the 80/80%, 10% of tinnitus seems
from hearing. But it can from tactile issues or somatosensory
issues it can come from anywhere in your brain, anywhere in your body I know it sounds bizarre
but if you look into research literature there's many people who have made this claim and it's
the idea of something called synesthesia now that's when we perceive one sensory system
like vision or hearing for another that may seem a bit bizarre but if you Google that
you'll find 1 of about 200 people is synesthetic they may get a visual or tactile stimuli and
perceive it auditorily because of time I'll leave it there but I think you get the idea
it's not just coming from ears, it can be a lot of different systems that contribute
to the perception of tinnitus.

Because what we experience is not just a product
of raw sensory input like vision or smell or taste or tactile. But what we experience reflects the combined
influence of all of your sensory systems working together and the internal state of the observer. Now, this is a note I took from Dr. John Serences
at University of California San Diego a clinical psychologist but you get the idea so it's
what you perceive and it's dependent on the internal state of the observer but it's also
how it makes you feel and what you think about it.

These things are very important. This is a dear friend of mine Aaage Moeller,
we met probably 35 years ago and he has one of the first PhDs in the world from Sweden
in auditory neurophysiology back in the '60s and he's a Professor Emeritus I believe at
the University of Texas Dallas. Dr. Moeller's book in 2011 is actually the
scientific reference book on tinnitus and I was interviewing him for the American Academy
of Audiology in 2011.

And that's where this quote comes from. Now, you can find this if you go to the American
Academy of Audiology Web site which is just audiology.org you see that on the bottom of
your screen and put in Moeller it will pull it up he said this it's a very important issue:
Tinnitus is not one thing, it's many things when people say they want to cure tinnitus
it's very much like saying you want to cure cancer or cure pain.

The thing with cancer, tinnitus they are not
one and the same it's a lot more difficult than you may realize tinnitus has many forms
shapes, sizes manifestations and perceptions and it may very well be different in every
person who perceives it so curing it with the same treatment is noble and an honorable
goal but it's unlikely that's usually where I put in this little thought, in hearing loss
and I'm an audiologist, my doctorate is in audiology, in hearing loss, in tinnitus, there
are no go-to solutions. In other words, given this hearing loss, we
do that, that's not the best way to think about things what we say is with these hearing
losses — you have this hearing loss I'll run this test so I can figure out the basis
of the hearing and how it impacts the person then I'll talk to the person and see what
problems are for them and what solutions make sense for them it's not that we can treat
everybody the same way it depends on who the individual is and how much difficulty they
are having as a result of their hearing loss or tinnitus.

So I'll move on the point I make — I made
early on we can't cure tinnitus but we can successfully manage it because there's two
components, the sound you perceive and how it affects you so two people can perceive
the exact same sound one person it hardly bothers at all and another person it drives
to distraction the same sound so as audiologists, hearing aid we can try to match the pitch
of the loudness of the tinnitus that's important to do sometimes. More importantly is we do something called
a THI, tinnitus handicap inventory and that tells us quite a bit about how you're perceiving
it because what we want to do once we know it's subjective and it's not going to cause
physical damage is we want to help you manage it so we need to get a good quantifiable analysis
which we can do there's two or three tools that are very good but my favorite is the
THI, tinnitus handicap inventory about 25 questions I would ask you, you would answer
and then I would give you a score.

And that tells me how disabling or how severe
or how significant that tinnitus is to you. And that's then what I want to manage I'm
hoping if I manage you successfully, a couple of months later we can do the THI again and
you'll have a much lessor score — lower score. We talked about this earlier. This is from Rich Tyler, he's a professor
at University of Iowa and in Rich's work he said early on — in 2011 he said when you
have tinnitus that's very significant it's going to impact your hearing about 39% of
patients, concentration about 26% of patients with tinnitus they have it so bad they can't
concentrate well and it's going to interfere with sleep in about 1 in 5 patients but in
2014 Dr.

Tyler added to this very, very clever but he said you know what it impacts your
thoughts and emotions 100% of the time so the tinnitus patient really cannot adapt to
it and simply saying something like everybody has tinnitus you have to get used to it, it
doesn't help anybody with tinnitus and it's kind of an inappropriate thing to say because
if they can get used to it they wouldn't have come to see you so how do you know which treatment
for which patient because quite frankly there's hundreds of treatments out there. And we try to approach things scientifically. You know, this is the short list of course. Pardon me. We can talk about all of these different treatments
and perhaps if you want to ask questions about them in particular at the end of the lecture
I'll go into them in detail but the No. 1 treatment of all time for tinnitus is hearing

Hearing aids fit excellent — with excellence
by a professional will control tinnitus the vast majority of the time make it much more
manageable because of the 80/80 rule so think about this 80% of the people with tinnitus
have hearing loss. Well, people with hearing loss are stressed
because they don't communicate easily. They have to ask for repeats. They can't remember what's being said They
get confused easily in background noise because their hearing isn't very good so the tinnitus
that they perceive starts to manifest as a greater and greater and greater problem because
it's interrupting all of these other things so if you fit somebody with excellent hearing
aids, you tend to destress them because now they can communicate much more readily.

I'll give you a sentence on each of these. Biofeedback it helps a couple of people here
and there. Not a big solution. Hypnosis, not really. There are some of you in the audience who
have probably stopped smoking or lost weight with hypnosis it's fantastic I don't say anything
negative about it but I'll tell you what scientific literature says is you really wanted to do
it and it helped get you over the edge so that's useful is it a big cure studies with
hypnosis and tinnitus not really. Counselling, yes, in particular cognitive
behavioral therapy so the two things I almost always recommend people with tinnitus after
we have ruled out anything medical, surgical and medically controllable, then the two things
are hearing aids and counselling. Because there are some people who have horrible
tinnitus that I'm — they are not going to put a hearing aid on for some reason but they
would probably do very well with cognitive behavioral therapy. That type of therapy, retraining the brain
how to perceive sound is very, very effective.

And in fact probably it is the single most
effective therapy for all — of all time for the tinnitus patient. What it does is restructures reconceptualizes
how the patient perceives and reacts to the tinnitus again we're not going to eliminate
the tinnitus but for the patient who is really bothered by it if we can give them control
over it it's a magical thing. Habituation okay, tinnitus retraining therapy
that's a popular one. And that comes from my colleague Powell Jastreboff
he's brilliant I've known him for 30 years I am not a huge fan I think when he created
it about 25, 30 years ago it was the single most clever well thought through helpful model
but now if I have to pick one I would probably pick a different one something called PTM,
progressive tinnitus management.

And that's a series — it's got five levels
from Dr. James Henry out in Oregon. Progressive tinnitus management is what we
use for veterans and the young men who come back from battlefields who have horrible hearing
loss and tinnitus – they get progressive tinnitus management and it's the most proven in the
scientific literature it's the most proven approach to managing tinnitus. So as an audiologist if I saw you, I would
probably — if you had hearing loss I'll certainly go ahead and proceed with the hearing aids
to see if it helps out it and it probably will. If it doesn't I'll pay more attention to something
more formal like progressive tinnitus management and make sure we work through all of those
steps and the final step in that happens to be cognitive behavioral therapy so it's inclusive
of all of these things so those of you looking for protocol and looking for an answer you
want one thing to look up on Google, PTM, progressive tinnitus management, really good.

Electrical stimulation doesn't work. 50,000 bolts in his ears he fell over backwards
and out for about six months not a good therapy not a good way to go. Tinnitus maskers if a patient says to me I'm
only bothered when I'm about to go to sleep my tinnitus keeps me up at night, it's driving
me crazy, if I had a different sound that would be great – well then get a tinnitus
masker go to Amazon go to Google put in tinnitus maskers, bedside tinnitus maskers you can
get these for 20, 30 $40 they are infinitely variable and they are great and so that's

But when you talk about hearing aids we're
talking about walking around with something in your day-to-day existence. Something comfortable. Something flexible. Something that a tinnitus masker is usually
quite large, the size of a CD player or something so you probably don't want to walk around
with that on your shoulder but a set of hearing aids who are well fitted, people don't really
notice them anymore because they have become remarkably small. Sound generators, yes, depending on what the
sound generator is. Different types of sounds. Fractal tones they sound like wind chimes
they help relax some people sometimes Pink noises like: And white noise is more like
. . . it's hard to do those there's no evidence that any one of those brown noise, red noise,
that any one of those is any better than any other they all work on some people some of
the time. And that's terrific .
Support groups are good. If they are led by a professional who is actually
well versed in tinnitus.

The reason I don't like support groups unless
they have a strong leader who is very knowledgeable is it tends to be people complaining to people
about how bad their life is or how bad their tinnitus or Meniere's disease and I get it,
it is miserable absolutely, but a group of people sitting around talking about how bad
it is, I don't see it being beneficial, unless it's led by somebody who knows a lot about
it and can tell you management strategies and how to benefit from what he or she has
learned. Self-help groups same thing. Drug therapy – this comes up a lot; there
are no drugs that work directly on tinnitus Now, if you have a very wise physician and
a very good relationship with your physician he or she may recommend particular drugs like
perhaps Valium or a derivative of that, because it helps destress the patient. So, it's not acting directly on the tinnitus. But it helps to make your life a little bit
less stressful and then you might sleep better.

And be less distracted and it might be a part
of your cognitive behavioral therapy perhaps because it gives you a bridge between learning
strategies and knowing strategies. So drug therapy doesn't work directly on tinnitus
but does help certain tinnitus patients some of the time. Stress management, well, of course. I believe the No. 1 contributing factor to
tinnitus is going to be stress. Chiropractic there's absolutely no studies
in the peer reviewed literature showing that chiropractic has ever had a direct impact
on hearing loss or tinnitus. However, much like pharmacology, if the chiropractor
destresses you because you feel better, like a massage therapy session might do, well,
if it destresses you and you're better able to cope with your tinnitus, that's a good
thing. I wouldn't argue against it but it's not a
direct cause and effect between that treatment and the problem.

So let's go on to the next one. So which treatment, how do you know which
one? We've got millions of people with tinnitus
how do you know which treatment to pick? Well, I'm going to pick the one that will
work most likely most of the time for most of the patients. That's going to be hearing aids. Now the hearing aids that were — that are
available in 2016 have nothing to do with the hearing aids that were available ten years
ago or even five years ago. Some patients will say they tried hearing
aids it didn't work I would urge them to try it again. The technology has skyrocketed. We have hearing aids my company in particular
and I won't make this a commercial thing but very, very pleasant sounds like you hear the

Now some other companies did that earlier
where they had the ocean going out here and coming in here so the parents would come schizo-
— I didn't say that outloud. Did I? So we have hearing aids talking to each other
in realtime, sounding like the ocean sounds going out and coming in it helps a lot because
it gives a masking sound alternative sound you're listening to but gives you a sound
that's pleasant that might destress you. There's a study out of England I have shared
this with many colleagues you can find this where the National Institute of Health in
the United Kingdom said certainly the go-to solution I hate that term but you get the
idea was hearing aids some patients use hearing aids with cognitive behavioral therapy and
that same Working Group said if those things — if the patient does not have hearing loss,
they will still approach it the same way, they would still go with hearing aids because
it's the most proven treatment for tinnitus and cognitive behavioral therapy.

So I can't say put hearing aids on people
if they don't have hearing loss. But we do know that hearing aids are very
effective in masking tinnitus and they are very effective in destressing patients who
have hearing loss. So it might be worth a try. Again I'm not — that's going to vary by who
you see and what the state licensure laws are and other things but it's an option and
if patients aren't getting relief any other way I might try it I personally try these
things and generally they work out well as long as they have a good scientific foundation
Let me show you some of the hearing aid success stories – this comes from the Hearing Review
in 2008 so it's already about eight years old but this is Dr.

Kochkin and Rich Tyler. Dr. Kochkin did brilliant work for us for
25 years. Rich Tyler is from Iowa beneath work for our
company they say — neither work for us they say 60% of patients report some relief of
their tinnitus when just using hearing aids so 22% actually report major relief of their
tinnitus when just using hearing aids so about 82% find benefit for tinnitus issues by just
wearing hearing aids here is another study more recent 2011 you see Dr. Tyler and Dr.
Kochkin. Here is what they say in November 2011 and
you could Google this by the way look at the top line the prevalence of tinnitus in the
USA and self-reported efficacy of various treatments if you Google that and pull up
2011 you'll pull up this study, 28% of hearing aid users moderate to substantial reduction
in tinnitus with just hearing aids.

66% tinnitus relief most or all of the time
with just hearing aids 29% hearing aids alleviated their tinnitus
all of the time. So pretty impressive numbers. This is a very recent study this was 2012
this is on 70 patients. You see about two-thirds male one-third female
average age 55. 26 patients, tinnitus totally masked with
just hearing aids. 28 patients or 40%, partial masking. But about 16 of the 70 no masking. They didn't find any benefit with their hearing
aids. So these are patients I wouldn't give up on
them at all. I would totally be working with a counselor,
usually a PhD clinical psychologist is my favorite. That's not to say there aren't social workers
who do this very well or other types of counselors who do this very well, PhDs, psychologists
who does cognitive behavioral therapy so those 16 on the bottom line with no masking benefits
from hearing aids that would be the next step and maybe would it be an earlier step had
I chosen to go with progressive tinnitus management.

So you get the idea hearing aids reduce audibility
of tinnitus and sound of tinnitus and improves the patient’s reaction to tinnitus. Let's go on to the next one. So one question that comes up a lot is patients
ask me and other professionals ask me do I need to have a masking device in my hearing
aid? So in addition to making sounds louder, hearing
aids can offer pink noise, white noise, ocean sounds, rain sounds, these sorts of things. I think it's good to have it there not to
get commercial just so you know in our hearing aids the company I work for Oticon when we
have tinnitus device within the hearing aids there's no extra charge for them, they are
included in most of the hearing aids that have those solutions.

They don't charge for that. Now, does it make a big deal of difference? Well this is a study, again peer- reviewed
in 2015 Dr. Henry this is a guy who wrote a fabulous book on progressive tinnitus management
combination device is a hearing aid with a mask on it so the office investigated this. The first thing they found out is there were
no previous investigations out there in other words nobody had ever compared successful
tinnitus management with just plain old excellent hearing aids versus plain old excellent hearing
aids that had maskers. So after they did this with their patients,
they concluded that hearing aids with sound generators and without sound generators both
provided significant benefit to alleviate the effects of tinnitus however it didn't
matter which one. 87% of all participants reported meaningful
reductions in their tinnitus using hearing aids or using hearing aids with maskers. So that's important to know. The most effective hearing aid setting for
tinnitus suppression may not be the one that is used for hearing loss. In other words, when a patient comes in and
has hearing loss, we tend to set the hearing aid for their hearing loss.

And that makes good sense. But this study by Dr. Shekhawat and Stinear
points out you may need a second program that's dedicated just to the tinnitus perception
if you set it for hearing aids you'll help a lot of people a lot of the time but there
will be more people — some people who need entirely different set of parameters in their
hearing aid to really destress them, to really minimize their tinnitus perception. This was the study I was talking about earlier
from the National Institute of Health research, biomedical research unit and the bothersome
tinnitus alone without hearing loss sufficient criteria for fitting hearing aids the reason
I put that in there are patients with tinnitus that don't have hearing loss and they wonder
should they try hearing aids this study indicates yeah that and this came out in 2015 this is
also peer reviewed from an American publication and it gives you some encouragement that there
are options available with or without hearing loss And I haven't seen this come out of anyone
in the USA but coming out of the UK it's a pretty strong endorsement.

I mentioned a couple of times about cognitive
behavioral therapy. And the reason I do that — you can go online
and find out more about it. Audiologists otolaryngologists, hearing aid
dispensers don't really do this kind of work. This is done by counselors and it's basically
a restructuring of how one thinks about their tinnitus. So behavior modification. And cognitive restructuring Again it's very
easy to Google this and find out about it. So I'm just going to leave it there but I
know I've said cognitive behavioral therapy a couple of times. Some of you are probably wondering what's
that about. And it might take — it's going to depend
on how severe the tinnitus is and how much hearing loss is involved and who the counselor

But it wouldn't surprise me if it took 10
to 20 one hour sessions to do this and I don't know of any audiologists who are involved
in this at this time other than to work with the psychologists who does this type of work
and refer to that individual. As far as references for it, Dr. Henry, the
fellow who came up with progressive tinnitus management he says the primary management
tool based on peer-reviewed evidence is cognitive behavioral therapy. Dr. Cima cognitive behavioral therapy is the
most evidence-based treatment option with regard to managing the tinnitus patient. If you want copies of these references it's
quite easy. The paper is in the upper left corner it's
one I wrote with my colleagues Dr. Paxton and Dr. DePlacido it's called issues in tinnitus
2014-2015 a review of contemporary findings the easiest way to do that is go to hearingreview.com
and put in Beck comma tinnitus and I've written a few papers they will be pulled up that way,
you should have no problem at all.

This is — we talked very briefly about tinnitus
retraining therapy I said it's okay I would prefer progressive tinnitus management in
2016 and this is one of the things that made me look a little bit beyond TRT this is the
peer reviewed paper from the International Journal of Audiology and these guys looked
at tinnitus retraining therapy with sound generators, just . . sort of a sound versus
wearing open-ear hearing aids And they measured the patients' tinnitus using
THI tinnitus handicap inventory and the bottom line conclusion it didn't matter if you used
a sound generator or hearing aid this is based on 91 patients So sound generators are good.

Nothing wrong with sound generators some people
do great with them but again this is why I think many of us hearing aid is the go-to
therapy because we have a lot more control over the sound you will perceive through a
hearing aid and they actually work very, very similarly again this is peer reviewed International
Journal of Audiology 2011 91 patients and the bottom line here the specific sound therapy
whether it's a sound generator or a hearing aid didn't really make much of a difference,
they both did pretty well. PTM we have used that term a couple of times. Let me give you a little bit more on that
and you can find this in your documents, so PTM, progressive tinnitus management offers
strong support for therapeutic sound to manage tinnitus. If it doesn't support any particular sound
as superior to any other rather they say the judicious use of sound is helpful the wise
use of sound putting a lot of sound there is not such a wise thing to do the judicious
use of sound because the goal of intervention with progressive tinnitus management is to
help the patient learn to develop and have individualized plans to manage their reactions
to tinnitus these plans involve the use of therapeutic sound a hearing aid or masking
device or a combination and coping techniques such as CBT, cognitive behavioral therapy.

This is — I used to get a lot more questions
on fractal tones, they are fine, I have no issue with them they are pleasant to listen
to they sound like wind chimes this was published by the Journal of the American Academy of
Audiology a peer reviewed journal they basically said at the end for half the subjects there
were 14 subjects half of them using fractal tones did show a decrease with regard to tinnitus
after six months but the authors of the study were unable to determine this is a very important
point how much of the relief came from overall hearing aid amplification versus how much
of it came from fractal tones so it could have been that the tones were very impactful
or the hearing aids but the point is the patients half of them did very, very well after six
months and that's the take-home message but then the authors added that acoustic treatments
for hearing aids — for tinnitus that is a hearing aid or masking device without the
multiple benefits derived from counselling will likely not suffice. Indeed, tinnitus management procedures need
to be supplemented with appropriate counselling.

So it's not like you're just going to put
a hearing aid on somebody and walk away and they will have their problem solved. This is a study from the Cleveland Clinic. This one also is peer reviewed in the Journal
of the American Academy of Audiology and this is based on 56 patients going through one
therapy with sound generators. Comparing it to something called neuromonics
it's a prescribed therapy treatment it works reasonably well and if you look at the THI
scores what the researchers found if you use a sound generator or neuromonics it didn't
make much difference they both did well the difference was the cost those patients who
used the sound generator paid about one-third the amount of dollars for every one percentage
point of increase in their THI scores So remember we said that THI you score between 0 and 100
so 0 is no perception of tinnitus whatsoever 100 is maximum perception so if a patient
went from 35 to 34, that might have cost $600 using a sound generator and using the neuromonics
tech — neuromonics technique it costs almost $1800 I'm not saying there's a problem with
neuromonics I would remember it sometimes because patients sometimes are more in line
with that protocol or procedure so I would go that way.

For some people, they respond very well to
tinnitus therapy some people don'ts a we talked about one thing that's interesting this came
out in 2014 this is Dr. Theodoroff's work he says if a patient complains of tinnitus
within their head versus within their ear if they have a self-reported hearing problems
so tinnitus if they perceive it in the head rather than in the ear they have a 3 times
greater likelihood that we can manage their tinnitus successfully. So that's the good news. The bad news is only happens about 10 or 15%
of the time 85% of the patients will perceive it in their ear. Interesting research This is an online survey
that came out in 2015 by carpenter- Thompson and colleagues so it was peer reviewed 1030
people, 630 people responded that's pretty good. And they were working with the idea if you
had high level of physical activity like you play golf, you play tennis, you swim, you
jog, did that improve your quality of life? And lower tinnitus severity? And it seems it does. Physical activity such as tennis or dancing
or swimming had a small but statistically significant correlation with the quality of
life and reducing tinnitus distress so physical activity is good.

Sitting around the house, not so good. Conclusion, so this is if you go to Google
and you put in hearing journal comma Beck comma June 2011, tinnitus, you'll pull up
this article so the conclusion from my 2011 article, hearing aids in tandem with counselling
are beneficial for the tinnitus management up to 90% of the time. Examples of successful management of the tinnitus
patient facilitated through hearing aid amplification are voluminous. I shared with you all of those papers by Kochkin
and Rich Tyler and those folks that's what we're talking about we have documentation
that hearing aids are very beneficial.

Advanced hearing aids, the newer hearing aids,
offer alternatives previously not available such as, open fittings, so your ear is a little
more comfortable, extended bandwidth, so we go up to maybe 10 or 12,000 hertz in some
hearing aids, connectivity that is you can hook up your hearing aids to a TV, to a telephone,
so it's much easier to hear them because you don't get the background noise as prominently
If the hearing aid fitting doesn't work, good news, 100% reversible. You can take them out. So I've concluded that hearing aid amplification
is the primary treatment for tinnitus. So my personal recommendations if we're going
to use some sort of masker, water, rain, shower, ocean sounds are excellent I would recommend
don't buy a $19.95 device. Because you want something reliable. You want something made by a manufacturer
who has been making products for decades, if not hundreds of years. Easy to fit, reliable product. There are tinnitus management guidelines. The American Academy of Audiology has a set,
which are a little bit old.

They are probably 12 or 15 years old but they
are very, very good you can look them up and learn about them, as well the exact protocol
for how to manage your tinnitus TBD that means to be determined by the professional Because
just telling me you have tinnitus doesn't tell me what I need to do for you. We have to talk. We have to share a little bit of time. I have to get to know how it's bothering you. I have to know what it sounds like I have
to know what problems it's causing what solutions are acceptable to you and then I can recommend
something but I can't just say oh I have tinnitus and you're going to do this. Internal motivation matters a great deal when
somebody has tinnitus and putting in a claim a legal claim for financial benefit probably
not going to help them much because their primary concern is sometimes you know that
financial benefit. And so it's very hard to dismiss that.

It's a very real issue that people deal with. But if somebody is totally distressed by the
tinnitus and they really, really, really are open and they don't have any intervening factors
but they are open to solutions and trying things and working with a professional, pretty
good chance of success. Placebo does matter. And in this case, placebo would be something
that acts to help you internally. Remember we talked about Dr.

Serences and
his work from University of San Diego says it's not just hearing or ears but the internal
state matters and if we can make you feel better and safer and more secure, that's going
to help. And brains are plastic and they change over
time So if you tried a very, very serious tinnitus management approach a year ago and
it didn't work you might be surprised to try it again and see that perhaps it would work
because your brain changes over time. So those are the formal slides that I assembled
and the timing is good I estimated 50 minutes, it took us 47. And I have no idea how to turn on the sound
so I'm going to have to let Nancy tell me what to do here and I'll be happy to take
some questions and observations.

>> NANCY MACKLIN: Okay. And people have posted questions in the chat
box. And so I'll just go ahead and feed you the
questions as I see them. The first question is why do some people have
tinnitus even after cochlear implant while others do not have it? >> DR. DOUGLAS BECK: That's a great question. Thank you for asking. So tell me if I've got this right because
there was a little noise at the beginning the question is why do some people with cochlear
implants have tinnitus and some people don't. >> NANCY MACKLIN: Right after a cochlear implant,
yeah. >> DR. DOUGLAS BECK: Right. Well, nobody knows the answer to this. This is a fascinating question. The vast majority of patients who get cochlear
implants I will tell you that their perception of tinnitus is much less. And they find that when they are wearing a
cochlear implant, tinnitus is much more manageable. Some patients not true at all. We have some speculation which I don't want
to share with you because it's speculation.

What I would say is that the best way to handle
that is you have to speak to your audiologist and say okay the cochlear implant clearly
is working fine. I'm getting auditory perceptions. Is there another program you might offer me
that might work a little bit differently with my tinnitus because Dr. Beck said that sometimes
the best program or the best map for hearing loss may not be the best map for tinnitus. So it's something you can try. I wish I had an answer. I don't know of an answer. And I don't know anybody who has an answer. This is a question we've been looking at now
for about 35 years. Cochlear implants were first FDA approved
I believe in '86.

I was at the house Ear Institute. And we were the primary group in the U.S.
a few groups UCSF was involved, Utah was involved and Los Angeles I was at the house Ear Institute
when FDA implants were improved and we noticed that early on some patients had relief of
tinnitus some partial relief and some had no relief the work is still ongoing I wish
I could tell you but I can't. >> NANCY MACKLIN: Somebody asked if you yourself
have tinnitus. >> DR. DOUGLAS BECK: I truly do not. I am a musician I have a very little bit of
high frequency loss but I will tell you that everybody has tinnitus from time to time. When you talk to your friends, your colleagues
your associates and you say do you ever hear a ringing or whistling sensation in your ear
the answer is almost always yes but remember the second part of definition is a failure
to adapt so when most people hear tinnitus it's an annoying sensation it comes and goes,
whether it's really gone away or whether you have adapted to it is the same effect it doesn't
bother you anymore.

So I don't, but I play a doctor who does
>> NANCY MACKLIN: If you have hearing loss in one ear and hear the tinnitus in the same
ear, do you need one hearing aid or two? >> DR. DOUGLAS BECK: Excellent question. All the time when you perceive hearing loss
or tinnitus in one ear the very most important thing I can tell you is you need a proper
workup let's presume you've had that done you've seen your doctor you've seen an audiologist. So any time you have one-ear symptoms that
demands a workup so I'm going to presume you have done that and if you haven't, please
do. The answer to that question is we always start
with two. And here is why. If this ear has hearing loss and tinnitus
and I put a hearing aid in here, now I have an unusual different sound in both ears. So I have caused a relative asymmetry in your
hearing and in your tinnitus perception. I would rather fit you with both. And then I can control it more and you're
going to get more of a balanced sensation.

When we fit one ear hearing there's a lot
of problems that come with that. No. 1, think about this, there are no animals
born with healthy ears that have one ear there are no people born with one ear that have
a healthy auditory system. When we only manage one ear, we are giving
you an asymmetric hearing. And it's very, very discouraging in noise
and in frustrating situations. So if we presume that stress is a high percentage
of people with tinnitus are under stress and then we give them an unusual sensation in
just one ear, when they are in noise, they are not going to be able to understand speech
in noise at all so I always start with two.

And you can read — if you go to hearingreview.com,
in 2016 I published a paper with a colleague of mine from England his name is David Baguley
and he is among the premiere authors in tinnitus actually it was an interview I did with him
and I asked him that question in January 2016 I said, so Dr. Baguley if we have a patient
with tinnitus in just one ear what do you do he said we fit them with two hearing aids. >> NANCY MACKLIN: Okay. Teresita commented she's had sensorineural
hearing loss since she was born. Hearing aids really do not help her tinnitus
very much. She still hears the tinnitus. She does what she can to distract herself
so that it's less. And she notices that if she eats foods that
are too salty, the level of tinnitus is more aggressive. Have you heard that before? >> DR. DOUGLAS BECK: Yeah, there's some literature
on salt. Salt certainly is annoying if you have high
blood pressure and if you have cardiac issues.

There are some people who have said that a
higher salt intake bothers their tinnitus there are some people who have said higher
salt intakes are things that can disrupt Meniere's patients making them more dizzy and more likely
to suffer Meniere's symptoms such as dizziness or vertigo or tinnitus or hearing loss. The scientific literature on that has not
really panned out but we certainly know who there are people who are susceptible to salt
intake so one of the easiest things to do it's not going to cause anymore any harm,
throw away the salt shaker, don't buy any prepared foods that have salt in them and
you would be surprised like anything you eat does much like sugar it's such an easy experiment
if the tinnitus is bothering you and you know you put salt on food all the time I would
say the No. 1 thing to do is stop adding salt it's easy, quick, costs nothing and you have
to give it about 30 days some people will see a difference in three days some people
a week but try it for 30 days and if your tinnitus is much less don't put salt on anything.

It's real simple. Now do I think it will work for everybody
for most people no but I do think some people are susceptible to sodium. And salt levels, some will tell you as soon
as I answer that question people will say I use sea salt to your body that's exactly
the same thing you can look this up in Google it's very important to understand all salt
no matter where it comes from your body takes it the same way just like sugar when you talk
about sugar versus honey versus syrup the molecular formula for that is C6 — C6 H12
O6 so it's a carbohydrate and the amount of hydrogen and oxygen and carbon in that molecule
that your body produces sugar it doesn't matter if it comes from syrup or from a sugarcane
it's still sugar to your body and salt is still salt so you won't get around this by
using any other healthy salts you may like them better and that's fine but your body
is the to your body it's the same thing.

>> NANCY MACKLIN: Is there any evidence or
benefit from acupuncture? >> DR. DOUGLAS BECK: Well, so acupuncture is brilliant
for pain relief it's 3,000 years old maybe older. If you go back to my original premise that
people who perceive tinnitus have a high likelihood of having stress, acupuncture decreases pain
very effectively in some people. Not all but many, many people get benefit
and they are peer reviewed benefit from acupuncture absolutely work many people often not everybody
every time but many people often it depends on who the acupuncturist and all of this stuff
but presuming you have a very good knowledgeable acupuncture person and you're under stress,
it wouldn't surprise me if some of those people also have lower back pain, cervical neck pain
or muscular pain and things are difficult and the acupuncture then much like pharmacology
helps to destress them. So it doesn't work directly on their tinnitus
but if it helps to destress them and make their body more comfortable because they are
in less pain it goes a long ways towards relief. >> NANCY MACKLIN: Who would you go see about
the progressive tinnitus management, the PTM? Would you go see your audiologist or an ENT
doctor? >> DR.

DOUGLAS BECK: It's not as easy as it should
be to find people who do PTM. What I would do — and he'll probably get
upset that I said this but I would send an email to Dr. Henry. And I would say dear Dr. James Henry Dr. Beck
was speaking accolades about progressive tinnitus management and I would like to know if there's
a practitioner in my area. Now the other way you could do it is of course
just put your ZIP code in Google and put in progressive tinnitus management comma tinnitus
and you're pretty likely if you're in a major city to find somebody if you're out in the
middle of nowhere it's going to be tough. >> NANCY MACKLIN: Maybe we can get Dr. Henry
to come present in Salt Lake City >> DR. DOUGLAS BECK: Maybe. I have no idea what his schedule is but perhaps. (Chuckles). >> NANCY MACKLIN: Okay. Let's see. Someone says I'm almost certain I got tinnitus
from salicylates. Has anyone tried to lower their intake to
lower tinnitus.

>> DR. DOUGLAS BECK: Well salicylates means aspirin
it's been linked without any doubt when you take high levels of aspirin you're likely
to get tinnitus and the No. 1 cure for that is discontinue or reduce those. Now don't do that on your own I presume if
you take enough aspirin that it's causing tinnitus that your doctor put you on it and
you need to mention it to your doctor because he or she might say we have many other things
we can do we can put you on Ibuprofen or acetaminophen or some other non-steroidal anti-inflammatory
pain relieving drug but that's not — if you're on that drug because a doctor put you on it
do not get off that drug unless you talk to your doctor because he or she may have put
you on it for other reasons and there may be substitutes available but I would never
tell you to discontinue it without speaking to your physician.

>> NANCY MACKLIN: Carol said what about people
who are totally deaf? I'm assuming she's asking about the incidence
of tinnitus in people that are deaf. >> DR. DOUGLAS BECK: Yeah, and it is a sensation
that deaf people report. So if you are totally deaf meaning absolutely
no perception of sound, because there are deaf patients of course who wear hearing aids
there are deaf patients who wear cochlear implants but if this is a deaf person who
doesn't do either, probably the single most important thing is going to be cognitive behavioral

And the question comes up how do you find
somebody who does that so let me give you hints on that. Many pain relief clinics across America, if
you put in pain relief doctor pain relief clinic it's oftentimes an anesthesiologist
who runs those clinics and he or she probably has psychologists and/or psychiatrists they
work with. And if you say I have tinnitus, I'm looking
for a practitioner who does cognitive behavioral therapy, can you recommend anybody they probably
can. Because oftentimes if your pain is severe
enough to go to a pain clinic there's more to managing it than pharmaceuticals sometimes
it's physical therapy.

Sometimes it's massage therapy. Sometimes it's chiropractic. Sometimes it's cognitive behavioral therapy
sometimes it's other types of counselling. >> NANCY MACKLIN: Several people have asked
about the role of TMJ with tinnitus. >> DR. DOUGLAS BECK: Yeah, this was — TMJ was a
big deal about 20 and 30 years ago. I think there's a likelihood that people who
suffer from temporomandibular joint syndrome probably perceive tinnitus TMJ hurts sometimes
it makes noise it adds to your stress I think with TMJ certainly I would try hearing aids
but I think the likelihood is work with a good dentist, see if we can relieve the signs
and symptoms of TMJ and I presume whoever asked that question has taken at that route
after that there's — if there's hearing loss I would try hearing aids even if there wasn't
hearing loss I might try hearing aids depending on how the tinnitus handicap inventory looks
if the score is high I would be likely to do so and again failing that I would go with
cognitive behavioral therapy because if you have a patient who has TMJ and is very distressing
very annoying very distracting in their life, no hearing loss, and they don't want to be
bothered going into hearing aids, okay, so let's move on to cognitive behavioral therapy
and see if we can offer some relief there.

>> NANCY MACKLIN: Okay. One last quick question since we're right
at 9:00 o'clock, have you had any experience with the Desyncra coordinated reset neuromodulation
device, if so, what's your opinion. >> DR. DOUGLAS BECK: Well, in the tinnitus literature
there are many, many devices that come out all the time I can't say anything about this
one. I'm not familiar with it. Whoever develops a new tinnitus device or
protocol has usually pilot studied it on somebody And they are going to publish that it did
well on that pilot study or they are not going to push the device forward. So I don't know who these authors are and
I don't know the device.

But here is what I would tell you, if there
was a cure that worked on everybody all the time, your audiologist and your doctor would
know about it. If there was a miraculous new device, your
audiologist and your doctor would know about it. If there were an easy way to manage this,
your doctor and your audiologist would know about this. I don't doubt that whoever has put forward
this device has some good, interesting data and I'm certainly not going to say anything
negative about it because I haven't read it and I'm not going to say anything positive
about it because I've never seen one that did better than the others but I would say
this, if you see that the device has been peer reviewed in the scientific journal and
has done well, then you should investigate it I would be very cautious about seeking
too much information based on what could be marketing claims and that doesn't mean that
the marketing claims are false but it means until scientific process has been undertaken
meaning you have people who are experimental group and a control group that's the scientific
method and without that you really don't know what's going on.

We have to have those trials that tell us
we treated these people this way, these people this way, this changed it. This didn't. So when we have that kind of data from an
independent source then we can believe it scientifically again I'm not going to say
they are bad or good or anything else because I'm not familiar with it but I can tell you
at least two or three times a year a new device comes out they always have fantastic claims
when they are looked at scientifically through the peer reviewed literature they tend to
fall away. So I think it's good for you to be aware of
them and it's good to investigate it but I wouldn't spend a lot of money until I have
some peer reviewed data showing that the stuff works. >> NANCY MACKLIN: Good advice. Just wanted to mention that for HLAA 2017
Convention in Salt Lake City we have a whole track on tinnitus and noise. So I know it's just one of those things besides
how to afford hearing aids, a the question I get most often, what do I do about the ringing
in my ears? So I know it's a problem, and any workshops
that we have I know will be very popular with a lot of our attendees.

Thank you, Dr. Beck, very much. I hope that you'll consider presenting again. And for you in the audience, if you enjoyed
this webinar, please consider joining HLAA. If you're not a member already. And you'll be sure to get Dr. Beck's article
in January-February of Hearing Loss magazine thank you again to Cindy Thompson for providing
excellent CART this evening and thank you for attending tonight thanks Dr. Beck. >> DR. DOUGLAS BECK: My pleasure thanks for inviting
me have a good night >> NANCY MACKLIN: You too. Bye bye..

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