residual inhibition - ENT
residual inhibition - ENT
residual inhibition - ENT
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CLINICAL ASSESSM<strong>ENT</strong> OF TINNITUS<br />
AN AUDIOLOGICAL APPROACH<br />
Prof. Dr. B. Vinck<br />
University of Ghent, Belgium<br />
University of Pretoria, South-Africa
Introduction<br />
“I'm going to bring such a disaster<br />
on this place that the ears of<br />
everyone who hears about it will<br />
ring”<br />
Jeremia 19:3
Clinical Measurement of Tinnitus
Clinical measurement of Tinnitus<br />
It is important to measure tinnitus in order to obtain a status before<br />
the start of any treatment.<br />
Without that status it is difficult to show that different treatments really changed<br />
anything<br />
It is important to measure tinnitus in order to gain more insight<br />
about the nature of the problem.<br />
It is important to measure tinnitus in order to provide reassurance<br />
to the patient that today “the doctor believes him/her” and “that<br />
his/her tinnitus is real” (important too for family members)<br />
Medicolegal aspects …..
CIBA Foundation Symposium (‘85)<br />
TINNITUS PITCH<br />
TINNITUS LOUDNESS<br />
MASKABILITY<br />
RESIDUAL INHIBITION<br />
To allow comparison between different clinics
PURE TONE AUDIOMETRY FIRST !!!<br />
(If loudness intolerance mentioned : LDL)<br />
Advanced Clinical Audiometer<br />
HF – 2 SEPARATED CHANNELS<br />
HIGH FREQ RESOLUTION …. e.g. Interacoustics AC 40
125 Hz – 16000 Hz<br />
e.g. SENNHEISER HEADPHONES<br />
HIGH FREQUENCY AUDIOMETRY
TINNITUS and HIGH FREQUENCY<br />
AUDIOMETRY<br />
Shim et al, 2009<br />
12/18 tinnitus patients elevated high<br />
frequency thresholds between 10-16 kHz<br />
compared to control group<br />
ALSO VERY IMPORTANT FOR ASSESSM<strong>ENT</strong> TINNITUS PITCH !!!
HISTORY : TONAL VERSUS NOISE LIKE<br />
TINNITUS<br />
DESCRIPTION OF TYPES OF TINNITUS<br />
RINGING<br />
CRICKETS<br />
HIGH-PITCHED TONE<br />
HISSING<br />
HUMMING<br />
ROARING<br />
BUZZING<br />
CLICKING<br />
PULSING<br />
RUNNING WATER<br />
STATIC NOISE<br />
SIREN<br />
CRACKLING<br />
FIZZING<br />
James Hall (2007)
HISTORY : TONAL VERSUS NOISE LIKE<br />
TINNITUS<br />
REDUCE DESCRIPTION TO TWO CATEGORIES<br />
NOISE TONE
HISTORY : TONAL VERSUS NOISE LIKE<br />
TINNITUS<br />
TINNITUS CLINIC UNIVERSITY HOSPITAL<br />
GH<strong>ENT</strong> (SINCE 1998 : n = 22368 patients)<br />
GH<strong>ENT</strong>
31%<br />
5%<br />
IMPORTANT FOR PITCH MATCHING<br />
TYPE OF TINNITUS<br />
64%<br />
n = 22368<br />
patients<br />
Tone<br />
Noise<br />
?<br />
TINNITUS POPULATION UG<strong>ENT</strong><br />
(1998- 2010)
HISTORY : LOCALISATION OF TINNITUS<br />
UNILATERAL OR BILATERAL ??<br />
20%<br />
10%<br />
34%<br />
LOCALISATION<br />
BE CAREFUL : STENGER EFFECT !!!<br />
36%<br />
UNI LEFT<br />
UNI RIGHT<br />
BILATERAL<br />
HEAD<br />
n = 22368 patients<br />
TINNITUS POPULATION UG<strong>ENT</strong><br />
(1998- 2010)
4 kHz<br />
Unilateral<br />
Tinnitus<br />
RIGHT !!!!<br />
STENGER<br />
PHENOMENON<br />
4 kHz
TINNITUS PITCH<br />
TINNITUS LOUDNESS<br />
MASKABILITY<br />
RESIDUAL INHIBITION
1. ASSESSM<strong>ENT</strong> TINNITUS PITCH<br />
I. Identify “Tinnitus Ear” and<br />
“Stimulus Ear”<br />
II. Ear with most bothersome<br />
tinnitus is “Tinnitus ear” and<br />
contralateral ear is “Stimulus<br />
ear”<br />
Remark (1)<br />
In case of binaural diplacousis : ipsilateral<br />
matching is indicated !<br />
Remark (2)<br />
Be sure the patient understands the<br />
different between pitch and loudness
Procedure<br />
ASSESSM<strong>ENT</strong> TINNITUS PITCH<br />
TWO ALTERNATIVE FORCED CHOICED METHOD<br />
Two tones are presented alternately to the patient (several<br />
times) and patient indicates which tone (noise) is more like the<br />
tinnitus<br />
The order of presenting the pair of tones (noises) must be<br />
varied at random !
TWO PHASES<br />
ASSESSM<strong>ENT</strong> TINNITUS PITCH<br />
PROVISIONAL PITCH MATCH<br />
OCTAVE CONFUSION TEST
EXAMPLE<br />
PROVISIONAL PITCH MATCH<br />
* PROVISIONAL MATCH = 5000 Hz<br />
1000 Hz 2000 Hz 2000 Hz<br />
2000 Hz 3000 Hz 3000 Hz<br />
4000 Hz 5000 Hz 5000 Hz<br />
5000 Hz 6000 Hz 5000 Hz<br />
*
OCTAVE CONFUSION TEST<br />
* BEST MATCH = 5000 Hz<br />
1000 Hz 2000 Hz 2000 Hz<br />
2000 Hz 3000 Hz 3000 Hz<br />
4000 Hz 5000 Hz 5000 Hz<br />
5000 Hz 6000 Hz 5000 Hz<br />
5000 Hz 10000 Hz 5000 Hz<br />
*
80% > 2000 Hz !!!<br />
Percentage (%) (n= 22368)<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
8<br />
< 1000<br />
Hz<br />
PITCH MATCHING<br />
12<br />
1 kHz - 2<br />
kHz<br />
2 kHz -<br />
4kHz<br />
Prevalence<br />
21<br />
19,8<br />
4 kHz - 6<br />
kHz<br />
TINNITUS POPULATION UG<strong>ENT</strong><br />
(1998- 2010)<br />
18,3<br />
6 kHz - 8<br />
kHz<br />
14,2<br />
8 kHz -<br />
10 kHz<br />
6,7<br />
10 kHz -<br />
16 kHz<br />
ANNOYANCE FOR HIGH PITCHED SOUNDS > LOW PITCHED SOUNDS ! IMPORTANT<br />
FOR TREATM<strong>ENT</strong> (PITCH REDUCTION)
TINNITUS PITCH<br />
TINNITUS LOUDNESS<br />
MASKABILITY<br />
RESIDUAL INHIBITION
2. ASSESSM<strong>ENT</strong> LOUDNESS<br />
I. Often tinnitus loudness is<br />
reported in dB sensation level<br />
I. dB SL represents the intensity,<br />
NOT loudness, of the signal<br />
above threshold<br />
I. Problem :<br />
At frequencies with normal<br />
hearing the match in dB SL can be<br />
much greater than at<br />
frequencies with hearing loss<br />
(Recruitment !!!)
2. ASSESSM<strong>ENT</strong> LOUDNESS<br />
Some prefer to report loudness in<br />
SONES<br />
ADVANTAGE :<br />
• MORE MEANINGFULL<br />
e.g. Loudness of 4 sones =<br />
tone : 60 dB SPL at 1 kHz<br />
• EASIER TO COMPARE PATI<strong>ENT</strong>S
FLETCHER MUNSON CURVE
2. ASSESSM<strong>ENT</strong> LOUDNESS<br />
Figuur Tyler pagina 158 inscannen<br />
L sones = k(P − P 0 ) 6<br />
P = Intensity of matched sound (in Pa)<br />
P 0 = Intensity of auditory threshold
2. ASSESSM<strong>ENT</strong> LOUDNESS<br />
MOST CLINICS STILL MEASURE IN<br />
dB SL
2. ASSESSM<strong>ENT</strong> LOUDNESS<br />
REPORT LOUDNESS IN dB SL<br />
AT PITCH TINNITUS AT FREQ = 1 KHz<br />
Recommended !
Percentage (%) (n= 22368)<br />
40<br />
35<br />
30<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
38,4<br />
LOUDNESS MATCHING<br />
21<br />
15,2<br />
12<br />
0 - 2 2 - 4 4 - 6 6 - 8 8 - 10 10 - 15 15 - 20 > 20<br />
6,4<br />
dB (Sensation Level)<br />
IMPORTANT TO USE THIS FACT IN COUNSELING THE PATI<strong>ENT</strong><br />
TINNITUS POPULATION UG<strong>ENT</strong><br />
(1998- 2010)<br />
70 % < 6 dB SL) !!!!<br />
5<br />
2 1
TINNITUS PITCH<br />
TINNITUS LOUDNESS<br />
MASKABILITY<br />
RESIDUAL INHIBITION
3. EVALUATION MASKABILITY<br />
I. DETERMINE THE LOWEST<br />
LEVEL OF NBN OR BBN or<br />
TONE TO MAKE A PATI<strong>ENT</strong>’S<br />
TINNITUS INAUDIBLE (i.e.<br />
Masking the tinnitus)<br />
II. This level is called the<br />
Minimum Masking Level<br />
(MML)
3. EVALUATION MASKABILITY<br />
Examples :<br />
FELDMANN MASKING<br />
CURVES<br />
TYLER CLASSIFICATION<br />
SYSTEM
Feldmann Masking Curves<br />
TECHNIQUE<br />
Continuous tone or<br />
noise band (1-2 sec)<br />
250, 500, 1 K, 2K, 3K,<br />
4K, 6K en 8 kHz<br />
Classification (Type I-V)<br />
1 st NBN, if not maskable then<br />
pure tone stimulation<br />
Unilateral : ipsilateral &<br />
contralateral masking curve<br />
Bilateral tinnitus : ipsilateral<br />
Masking curve of each ear<br />
separately<br />
Conclusions
High pitched tonal tinnitus<br />
Type I. Convergence<br />
Type III. Congruence<br />
White noise tinnitus<br />
Low pitched humming sound<br />
Type II. Divergence<br />
AC threshold<br />
Masking level
≥ 20 dB<br />
White noise<br />
Type IVa. Distance<br />
Type V. Persistent<br />
Tones > Noise<br />
Pulsatile hissing sound<br />
Type IVb. Dispersion<br />
No maskability
Feldmann Masking Curves<br />
12%<br />
20%<br />
33%<br />
35%<br />
Convergence<br />
Congruence<br />
Distance<br />
Other
Feldmann Masking Curves<br />
INTERPRETATION<br />
Types I-III : Good candidate acoustical masking<br />
Types II-IV : Bad candidate acoustical<br />
masking/good candidate electrostimulation<br />
Type V : Bad candidate acoustical masking
Feldmann Masking Curves<br />
Interpretation<br />
Relationship to pathology<br />
Type I Noise induced hearing loss<br />
Type II Unknown etiology – normal hearing<br />
Type III Meniere’s disease<br />
Type Iva Presbycusis<br />
Type Iv Secretory otitis media<br />
Type V Cochlear degeneration
3. EVALUATION MASKABILITY<br />
Examples :<br />
FELDMANN MASKING<br />
CURVES<br />
TYLER CLASSIFICATION<br />
SYSTEM
Tyler classification system<br />
Figuur Tyler pagina 163 inscannen
TINNITUS PITCH<br />
TINNITUS LOUDNESS<br />
MASKABILITY<br />
RESIDUAL INHIBITION
Concept<br />
Residual <strong>inhibition</strong><br />
Feldmann (1971) observed that a substantial<br />
proportion of tinnitus patients experienced a brief<br />
reduction of their tinnitus after cessation of the masker<br />
This phenomenon is known as “RESIDUAL INHIBITION”<br />
(also referred to as “<strong>residual</strong> suppression”
Residual <strong>inhibition</strong> : mechanism
Residual <strong>inhibition</strong> : mechanism<br />
TEMPORAL MASKING
Residual <strong>inhibition</strong> : procedure<br />
DETERMINE MINIMUM MASKING LEVEL (<br />
MML)<br />
APPLY MASKING NOISE AT MML + 10 dB FOR<br />
60 SECONDS<br />
OBSERVE DEGREE OF RESIDUAL INHIBITION<br />
IMPORTANT : WARN THE PATI<strong>ENT</strong> IT IS A TEST – NOT A<br />
TREATM<strong>ENT</strong> !!!!!
Residual <strong>inhibition</strong> : results
Rebound<br />
Negative<br />
Partial<br />
Complete<br />
Residual <strong>inhibition</strong> : clinic<br />
9<br />
11,8<br />
37,8<br />
41,4<br />
0 10 20 30 40 50
Residual <strong>inhibition</strong> : procedure<br />
DETERMINE MINIMUM MASKING LEVEL (<br />
MML)<br />
APPLY MASKING NOISE AT MML + 10 dB FOR<br />
60 SECONDS<br />
OBSERVE DEGREE OF RESIDUAL INHIBITION<br />
REGISTER DURATION OF RESIDUAL INHIBITION
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Residual <strong>inhibition</strong> : procedure<br />
63,4<br />
21,2<br />
7,4<br />
5,2<br />
2,8<br />
0-2 Min 2-5 Min 5-7 Min 7-10 Min > 10 Min
Other tests …<br />
Otoacoustic Emissions ABR
Otoacoustic Emissions in the<br />
assessment of tinnitus
Literature<br />
Otoacoustic Emissions in the<br />
assessment of tinnitus<br />
Granjeiro et al. Transient and distortion product evoked oto- acoustic emissions<br />
in normal hearing patients with and without tinnitus. Arch Otorhinolaryngol<br />
Head Neck Surg 134: 2008.<br />
Tinnitus group versus control group<br />
Results :<br />
TEOAES<br />
70% abnormal in Tinnitus group<br />
16% abnormal in Control group<br />
DPOAES<br />
68% abnormal in Tinnitus group<br />
50% abnormal in Control group
Literature<br />
ABR and Tinnitus<br />
Kehrle et al. Comparison of auditory brainstem response results<br />
in normal hearing patients with and without tinnitus. Arch<br />
Otorhinolaryngol Head Neck Surg 134: 2008<br />
Tinnitus group versus control group<br />
Results :<br />
ABNORMAL ABR IN 43 % OF TINNITUS GROUP<br />
SIGNIFICANT INCREASE IN WAVE I-III INTERVAL
EXTRA IN CASE OF HYPERACUSIS
HYPERACUSIS
SCHULTZ et al (1987)<br />
TOLERANCE
TOLERANCE<br />
Decrease in tolerance<br />
Loudness discomfort levels < 90 dB HL in two<br />
or more frequencies (Goldstein, 1996)<br />
Loudness discomfort levels < 100 dB HL in two<br />
or more frequencies (Jastreboff, 2000)<br />
Reduced dynamic range (55-60 dB HL)
TERMINOLOGY<br />
USE OF TERMS FOR SENSITIVITY<br />
ALLODYNIA<br />
Abnormal auditory aversions to normal daily sounds<br />
HYPERACUSIS<br />
Hyperacute hearing thresholds<br />
ODYNACUSIS<br />
Lower ULL (typically 86-98 dB HL)<br />
PHONOPHOBIA<br />
Fear potentiated aversion
HYPERACUSIS MECHANISM<br />
Herraiz, 2008
HYPERACUSIS MECHANISM
HYPERACUSIS DIAGNOSIS<br />
AUDIOLOGICAL TESTING<br />
LOUDNESS DISCOMFORT LEVELS (LDL)<br />
Pure tones<br />
Ascending technique<br />
Continuous, not pulsed<br />
Perform it twice !!!<br />
Patients can stop the<br />
test
Results<br />
HYPERACUSIS DIAGNOSIS
Johnson Hyperacousic Dynamic Range<br />
Quotient<br />
HYPERACUSIS DIAGNOSIS<br />
TOOL TO POT<strong>ENT</strong>IALLY QUANTIFY HYPERACUSIS<br />
QUANTIFY PROGRESS WITH HYPERACUSIS TREATM<strong>ENT</strong>
Johnson Hyperacousic Dynamic Range<br />
Quotient<br />
HYPERACUSIS DIAGNOSIS<br />
Johnson, 1999
HYPERACUSIS and OAE/ABR<br />
ABNORMAL DP GROWTH<br />
FUNCTIONS<br />
Efferent suppression<br />
(Collet effect)<br />
ABR : UNCLEAR ????
HYPERACUSIS DIAGNOSIS<br />
Other audiological parameters<br />
Acoustic reflex testing (ART) & Tymp<br />
Tensor tympani syndrome<br />
94% OF HYPERACUSIS PATI<strong>ENT</strong>S<br />
Often misdiagnosed as Meniere
Other audiological parameters<br />
CERA<br />
LOUDNESS SCALING<br />
…<br />
HYPERACUSIS DIAGNOSIS
SUMMARY AND CONCLUSIONS<br />
CLINICAL MEASUREM<strong>ENT</strong> IS IMPORTANT TO BOTH PATI<strong>ENT</strong><br />
AND AUDIOLOGIST<br />
PSYCHOLOGICAL IMPACT<br />
TRY NOT TO REDUCE YOUR CONSULTATION TO A<br />
TECHNICAL SESSION : TALKING IS IMPORTANT<br />
DO NOT SKIP THE HISTORY !!! MOST IMPORTANT ASPECT<br />
OF ANY TINNITUS APPROACH
Baie dankie<br />
Ngiyabonga<br />
Enkosi<br />
Ndi a livhuha<br />
Asante sana<br />
…..
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