final exam new info Flashcards
(116 cards)
1
Q
goals of a tinnitus assessment
A
rule out/confirm disease, document health conditions influencing tinnitus, evaluate auditory function, describe severity of tinnitus, define impact of tinnitus and contribute to decisions regarding management plan
2
Q
with a new patient, what are the 3 things we need to do
A
screening questionnaires, case history and hearing assessment
3
Q
importance of a screening questionnaire
A
helps choose appropriate intervention or referral, identify areas that need to be addressed and document changes through intervention
-can help quantify impact on quality of life
-identify psychological distress as well
4
Q
what aspects do we need to include in the case history
A
any referrals or previous management, medical history, perceptual features of the tinnitus, factors that alter the tinnitus perception and psychosocial/functional impacts
5
Q
what do we mean by perceptual features of the tinnitus
A
location of tinnitus, the sound of tinnitus, how loud it is, how annoying it is, information on the pitch and if it changes
6
Q
what are some components that can be included in the hearing assessment
A
otoscopy, tymps, acoustic reflexes, thresholds, SRTs, WRS, LDL, tinnitus evaluation, DPOAEs, HFA, reflex decay and QuickSIN
7
Q
with the hearing assessment, what is the proper order to conduct testing in
A
begin with threshold testing and the softer signals then go onto the louder signals or the ones at suprathreshold (i.e. WRS and LDL)
8
Q
what is a potential concern with pure tones and tinnitus patients
A
they may have false positives
-using warble tones and pulsed tones may be helpful
9
Q
what is the role of the DPOAEs in a tinnitus assessment
A
can confirm a cochlear origin by identifying absent or below normal amplitudes in patients with SNHL OR we can identify cochlear dysfunction in patients with normal hearing sensitivity providing a physiological explanation for their tinnitus
10
Q
referring with tinnitus patients
A
refer to other professionals as the presenting symptoms would indicate
11
Q
tinnitus characteristics indicating a referral to an ENT
A
unilateral tinnitus, secondary tinnitus (somatosounds) or pulsatile tinnitus
12
Q
referrals to an ENT with …
A
symptoms suggesting somatic origin of tinnitus, ear pain/drainage and vestibular symptoms (dizziness or vertigo)
13
Q
referrals to emergency care or ENT with ….
A
tinnitus plus physical trauma (facial palsy) or sudden unexplained HL
14
Q
referral to mental health or emergency care with …
A
tinnitus and suicidal ideation or mental health problems
15
Q
assessment of tinnitus for legal claims
A
some patients may need documentation to support a claim for financial compensation and with these patients we need to be careful
-needing to make qualified judgements to help with the legitimacy of such claims
16
Q
as a conclusion of assessment, what are 4 things that we should understand about the tinnitus
A
presence of tinnitus (if its present and if it can be classified as pathological), severity of tinnitus (determine the impact and extent of the issue), etiology of tinnitus (identifying potential causes) and permanency of tinnitus (based on duration of symptoms)
17
Q
what are some common management options for tinnitus patients
A
HAs, sound therapy, education/counseling, lifestyle modifications, mindfulness, rTMS, bimodal neuromodulation, and drug therapies
18
Q
how do HAs help tinnitus
A
improves hearing related quality of life, reduced attention to tinnitus, reduces the stress/fatigue associated with straining to hear, enables masking by ambient sound and provides stimulation to the auditory system
19
Q
in order for HAs to work best, what should be present in regards to the patients hearing/tinnitus status
A
good low frequency hearing (allows them to hear the ambient noise), strong reaction to the tinnitus and if the tinnitus pitch is within the fitting range
20
Q
what fitting formula is recommended for tinnitus patients
A
DSL V5
21
Q
recommended features of HAs for tinnitus patients
A
binaural fitting, open fit to avoid occlusion, low compression TK, expansion turned off, omnidirectional microphone, noise reduction turned off, therapeutic sound option, wireless communication and frequency lowering
22
Q
purpose of the low TK and expansion being turned off
A
they can help ensure that audibility of the low frequencies/environmental sounds will be heard
-further allowing it to try and mask the tinnitus
23
Q
sound therapy
A
uses sound to decrease the loudness of tinnitus with a variety of sounds that can be used
-focusing on other sounds/noises to help take the focus away from the tinnitus
24
Q
reasons for the use of sound therapy
A
reduces the audibility of tinnitus by replacing it with a different sound, provide stimulation of auditory pathways (replacing spontaneous activity) and aid relaxation
25
when educating patients about tinnitus, what should be included
explain tinnitus and the different types with the reassurance that it is not dangerous, value of audiological assessments, explaining the various management strategies even though there is no cure
26
common counseling strategies for tinnitus patients
helping people recognize how their beliefs impact their reactions and providing coping/management strategies
27
what are some lifestyle factors that may exacerbate tinnitus
stress, fatigue, consistent noise exposure, use of aspirin in high doses, alcohol, high caffeine consumption, tobacco and high sodium intake
28
mindfulness
technique that helps people manage their tinnitus by teaching them to be more present and accepting of their experiences
-mental state by focusing ones attention on the present moment
-teaches to accept and help calm
29
mindfulness based cognitive therapy (MBCT)
therapeutic approach that combines mindfulness practices with elements of cognitive therapy to help manage psychological conditions
30
receptive transcranial magnetic stimulation (rTMS)
device that delivers short magnetic pulses through a magnetic coil placed near the scalp to modulate brain activity in specific areas associated with mood
-uses electromagnetic signals to reduce neural hyperactivity
31
bimodal neuromodulation
combines auditory and somatosensory stimulation
-targets both the trigeminal and auditory nerves to alter tinnitus pathways in the brain
32
tinnitus and drug therapies
there are no FDA approved drugs currently available to treat tinnitus however there are drugs to help relieve the perception based on its associated symptoms
33
examples of medicine used to treat tinnitus
antidepressants to reduce tinnitus loudness, anticonvulsants to stabilize neuronal activity, benzodiazepines to help alleviate tinnitus related anxiety, glutamate receptor antagonists to reduce neuronal hyperactivity
34
cognitive behavioral therapy (CBT)
problem focused and action oriented psychological intervention combining principles from behavioral and cognitive psychology
35
principles of CBT
thoughts, behaviors and emotions
36
goals of CBT
treatment involves specific learning experiences that teaches patients to monitor their negative thoughts and to recognize the relationships between thoughts/emotions/behaviors
37
CBT for tinnitus
a form of structured talk therapy
-structuring how they think about tinnitus as we teach them about the negative thoughts and teach them how to replace it with more positive thoughts
38
goals of CBT for tinnitus
alter maladaptive cognitive, emotional and behavioral responses to tinnitus and no to abolish the sound itself
-addressing the psychological distress associated with tinnitus
39
principles of CBT for tinnitus
involves active participation and homework assignments between sessions
-clients work closely in a collaborative relationship
-strategies used aim to promote habituation
40
two strategies for CBT
cognitive and behavioral strategies
41
CBT : cognitive therapy
focuses on altering how one thinks about tinnitus, aiming to reduce negative ideation
-working on the thoughts aspect
-replacing negative thoughts with positive ones
42
CBT : behavioral strategies
focuses on using techniques like positive imagery, attention control to divert focus from tinnitus, exposure to stressful situations to lessen the impact and relaxation training to ease symptoms
43
examples of what can be done with CBT
relaxation training, cognitive restructuring, attention control techniques, imagery techniques and sleep management
44
what is relaxation training
teaches tension reduction through muscle relaxation exercises
-dealing with the rigid body and side effects of the tinnitus
45
CBT : cognitive restructuring
with cognitive therapy, this involves the identification of dysfunctional beliefs and negative thoughts
-identifying how the patient feels and what they think and working towards replacing those negative reactions with positive reactions
-teaching them how to think about their tinnitus and restructuring it
46
CBT : attention control techniques
patients learn to redirect attention from tinnitus to other environmental details
-encourages engaging other senses (i.e. smelling or tasting)
-teaching the patient to learn different strategies
47
CBT : imagery techniques
modifying negative associations with tinnitus by either masking the noises or integrating them into positive scenes
-masking through imagination (guiding patients to imagine their tinnitus as other sounds)
-incorporating into pleasant scenes (including imaging scenarios)
48
CBT : sleep management
such as sleep hygiene, bedtime and worry time restriction, relaxation and cognitive restructuring are tailored to meet specific needs of patients with tinnitus
49
with CBT, what are some relapse prevention
identifying risk factors, importance of continuous practice, managing temporary fluctuations, generalization of treatment benefits and giving post treatment support
50
who benefits from CBT
adults ages 40-70 years old, no severe comorbid psychological conditions, has tinnitus and/or suffered for at least 3 months and patients that are seeking to alleviate the impact of tinnitus
51
when discussing TRT, what model needs to be discussed
neurophysiological model (jastreboff)
-remember that the main point is that a number of systems in the brain are involved in tinnitus
52
main systems within the neurophysiological model
auditory system provides the source of a signal which causes activation of the limbic and autonomic nervous system
53
why is the limbic system and autonomic nervous system activated with tinnitus
the limbic triggers a strong emotional response and the autonomic system regulates autonomic body functions such as heart rate and breathing
-both of these systems are critical for well being, learning and brain retraining
-but in the presence of tinnitus it can trigger strong reactions
-once the limbic and ANS is activated the stimulus linked will dominate other functions
54
the vicious cycle
once tinnitus gets a negative connotation and starts to induce activation of the ANS, this initiates a cascade of event s
-leading to a stronger activation of the limbic and ANS through a conditioned reflex arc
-if we continue to react negatively to something, we teach ourselves that it is bad and that its negative
55
conditioned reflex
every time we experience a stimulus, it triggers the reinforcement and the difference between perception and reaction continues to get strengthened
-eventually the stimulus will cause a reaction alone
-the brain will then recognize that there is no reinforcement and therefor through passive extinction there will be no reaction
56
how was conditioned emotional responses studied
the little albert experiment
-found that if perception of a signal is associated with high levels of emotional distress, a conditioned reflex is created leading to the tinnitus to evoke high levels of activation
57
habituation and tinnitus
with the repetitive appearance of a sound, the pathways will block it and the individuals will be unaware that the sound is present
-this prevents the signal from reaching higher cortical areas involved with signal awareness
58
tinnitus habituation will not ______________ the tinnitus however there now requires ______________
completely erase ; active attention
59
what are the two types of habituation
reaction : learning not to react to the stimulus in a negative way
perception : blocking the signal from going up
60
tinnitus retraining therapy (TRT)
habituation based treatment that utilized counseling to decrease the strength of tinnitus evoked reactions and sounds to decrease the strength of the tinnitus signal
-contains retraining counseling and sound therapy
61
TRT : retraining counseling
habituation of the reaction to tinnitus
-structured counseling sessions
-working on the rection and teaching the patient that it is not threatening
62
TRT : sound therapy
habituation to the perception of tinnitus
-weakens the strength of the stimulus, so it will not be perceived as loud
-helping the brain not focus on it as much
63
what is the protocol for TRT
introductory contact, initial visit, assessing for the category of treatment, instrument fitting, follow up visits and closing of treatment
64
TRT : initial interview
a structured set of questions that are designed specifically to determine placement into categories and impact of tinnitus
-taking a proper history is essential for the treatment category
-ensuring the patient understands all aspects of the treatment plan
65
what aspects of the treatment plan are critical for the patient to understand during the initial interview
treatment objectives, schedule of treatment sessions, requirements for using ear level devices, costs associated with treatment and any other pertinent details of the planned treatment
66
what are treatment objectives with TRT
reaching habituation of the tinnitus
67
TRT : categories of treatment
category 0 - category 4
68
category 0 : mild or recent symptoms
low level of tinnitus severity with little impact on life
-includes patients with recent experience of tinnitus
69
category 0 treatment
simplified counseling
-aimed to help view tinnitus as a neutral stimulus
-sound enrichment can be advised
-short follow ups to track patient's status
70
category 1 : tinnitus alone
high severity tinnitus without any hyperacusis, HL or worsening of tinnitus with sound exposure
-the main reason we are seeing them is for the tinnitus
71
category 1 treatment
intensive counseling focused on the tinnitus and sound therapy
-using ear level devices set to the mixing point
-follow ups more frequently initially then more spaced out later on (lasts 9-18 months)
72
category 2 : tinnitus and subjectivity significant HL without hyperacusis
tinnitus coexisting with HL, both having significant effect on their lives
-no hyperacusis and no sound exposure exacerbation
73
category 2 treatment
HAs with amplification and sound therapy
-with more auditory access the tinnitus won't be perceived as much
-counseling is focused on HL and the role it plays with tinnitus
-follow up visits focused on sound enrichment strategies
74
category 3 : hyperacusis without prolonged enhancement from sound exposure
significant hyperacusis with or without significant tinnitus and may have misophonia
-being exposed to loud sounds does not worsen it
75
category 3 treatment
focuses on hyperacusis, using sound therapy
-aimed to desensitize
-treating the hyperacusis first
76
category 4 : prolonged worsening of symptoms by sound exposure
hyperacusis is typically the dominant complaint with tinnitus as a secondary one or is absent
-symptoms worsen with nose exposure
-most difficult to treat
77
category 4 treatment
extensive counseling focused on hyperacusis and many adjustments in sound therapy
-educating the patient on physiological mechanism is important
78
importance of assigning patients to correct categories
essential for successful therapy because inappropriate treatment could make symptoms worse
-incorrect category is often the underlying reason for TRT not working
79
successful treatment with TRT results in ....
patients reaching category 0 before achieving final, complete habituation
80
retraining counseling involves ...
teaching patients about the mechanism of hearing, the basics of brain function and the specifics of the neurophysiological model of tinnitus
81
retraining counseling approaches
nondirective style and directive style
82
nondirective style (client centered therapy)
emphasis of counseling is on the patient more than the problem
-goal is to experience growth which enables them to be better equipped to deal with future problems
83
directive style
focuses on the problem that is the reason for therapy
-goal is to solve the problem through the provision of new information and attitudes to the patient
84
reasoning for retraining counseling
problems caused by tinnitus or misophonia indicate activation of the ANS, preparing the body for unnecessary action
-this then can trigger neuronal and hormonal changes leading to anxiety stress and annoyance and thus triggering the limbic system
-this connection between the ANS, limbic system and auditory system creates connections creating a conditioned reflex
-these reflexes can be retrained
85
sound therapy
refers to enrichment of the sound environment, staying away from silent environment, having some sort of noise present
86
goal of sound therapy
reduce the perceptual contrast between the tinnitus and external environmental noise
87
approaches to sound therapy
introducing additional sounds, increasing volume of existing sounds, using HAs to amplify environmental sounds, using wearable sound generators
-typically more than one approach is used
88
considerations with the sound for sound therapy
sound should minimize the strength of the tinnitus signal. external sounds should not induce any negative reactions, sound should be stable and neutral and the original tinnitus should be preserved and not suppressed
89
why should the tinnitus not be suppressed
habituation will not occur
90
mixing point
this is the level we want to use for sound therapy
-it is the point below partial suppression where the tinnitus can somewhat still be audible when focused on
91
how can ear level devices benefit more than environmental sound
can help combat disadvantages that occur if the talker moves around or if the student moves around
-giving the sound directly to the patients ear
92
fitting aspects with ear level devices
bilateral to avoid asymmetrical stimulation, open fittings to minimize OE, worn throughout waking hours, proper counseling
93
why is it beneficial to give the patient 2 devices even if they experience tinnitus in one ear
if we only cover the tinnitus in the prominent ear, they may become aware of it in the other ear
-so by giving them two devices we can ensure that both sides are truly being covered
94
relating to failure of treatment, why is it important to discuss temporary worsening of symptoms
this is something that is commonly experienced by patients and sometimes they just stop the treatment
-we need to counsel our patients that this may occur and that its a sign that the treatment is actually helping
95
factors related to failure of treatment
inadequate initial counseling, lack of sufficient follow up, not teaching the model correctly, severe psychological problems, effects of medications, category 4 patients, suppression of tinnitus evoked by HA and focusing on a cure
96
why are category 4 patients difficulty to treat
they show the slowest response to treatment
-these patients should be examined for any underlying causes to cover the bases
97
important information to know regarding closing treatment
decision to end therapy depends on meeting the patients expectations and goals
-this should be a mutual decision between the clinician and the patient
-treatment can typically be closed when the patient achieves minimal symptoms, typically a 1 to 2, with low tinnitus annoyance
98
decreased sound tolerance (DST)
any condition where a patient exhibits any negative reaction to ordinary sounds, which do not cause these reactions in other average listeners
-including hyperacusis, misophonia and phonophobia
99
hyperacusis
reduced tolerance to sound that do not trouble most
-reaction depends on the physical characteristics of the sound
-medium to loud intensity
100
3 types of hyperacusis
annoyance : having a negative response to sounds, feeling more tense or anxious
fear : anticipating that sounds are uncomfortable, causing the fear
pain : perceiving an actual pain with loudness level
101
common complaints of hyperacusis
discomfort, headache, concentration difficulties, fatigue and anxiety
102
misophonia
dislike of certain sounds that trigger emotional reactions
-the loudness does not dictate the reaction, it can be all levels of loudness but includes specific sounds
103
common triggers with misophonia
oral/eating sounds, breathing sounds, repetitive sounds, speech sounds, household sounds, footsteps, finger tapping, whistling, low frequency sounds, animal sounds or visual triggers
104
phonophobia
an anxiety disorder that is characterized as a persistent, abnormal and unwarranted fear of sound shaped by an emotional meaning
-specific cases of misophonia when fear is involved
-specific sound
105
loudness recruitment
abnormally rapid growth of loudness with increasing sound level, caused by loss of outer hair cells (cochlear damage)
-not a sound tolerance problem
-leads to a reduced dynamic range
106
with DST, what is most likely the mechanism
likely involves multiple however excessive central gain is considered a key mechanisms in loudness hyperacusis
107
explain the likely central gain mechanism for hyperacusis
higher intensity is coded by larger groups of neurons whereas a quiet intensity is coded by a smaller group of neurons
-however with hyperacusis, the central system may be truing to compensate for HL so it will increase the neural activities for the louder sounds
-this increased activity is perceived as the hyperacusis
108
what are some other proposed reasons for hyperacusis
genetic predisposition, stress/anxiety/fear, neural changes, brain hyperactivity and blast exposure
109
misophonia and phonophobia are abnormally strong reaction of the ________ and _________ resulting from ............
limbic ; ANS ; enhanced connections between auditory and limbic system
110
with DST patients, why is it important to wean from earplugs
by using protection it prevents habituation
-we can recommend nonlinear/active plus allowing attenuation based on the sound intensity
-patients should gradually decrease the hours they use ear protection
111
DST : treatment
HAs, sound therapies, CBT and TRT
112
DST : hearing aids
the goal is to provide gain without pain by balancing amplification needs with sound tolerance
-gradual amplification increases may need to occur
113
for patients that have HL, tinnitus and DST what do we treat first?
we want to manage the DST then HL then tinnitus
-without treating the DST, by adding amplification we may amplify those loud sounds and therefore heightening their responses to those sounds
-this leads them to not accepting the HAs
114
DST : sound therapies
using controlled sound exposure to increase their tolerance to noises
-continuous low level broadband noise, showing some increase in LDL
-gradual increase of the level and/or duration of sound treatment
-targeted exposure to specific sounds
-adjusting HA with gradual adjustments to normal levels
115
DST : CBT
involves :
-education on hyperacusis
-applied relaxation to help manage their responses to sound
-graded exposure to sounds to desensitize sounds
-cognitive therapy to help reframe negative thoughts
116
DST : TRT
with hyperacusis key is to desensitize the auditory system to sound and with misophonia the key is to retrain the connections between the auditory, limbic and ANS
