Jastreboff, 2014 1

Pawel J. Jastreboff, Ph.D., Sc.D., M.B.A.
Professor
Department of Otolaryngology
Emory University School of Medicine
Atlanta, GA pjastre@emory.edu
www.tinnitus-pjj.com
Disclosure Statement:
No relevant financial or non-financial relationships to disclose
Jastreboff, 2014 2

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Sounds in daily environment
Sounds of nature
Voices
Music
Jastreboff, 2014 3

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Reduce stress
With sleep problems
Promote learning, including helping dyslexia
Induce positive changes in cognitive function
In recovery from traumatic events including health problem
(cardiac operation)
Jastreboff, 2014 4

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Are rules governing interaction of tinnitus with external sounds the same as for two external sounds? dB SPL
Two external sounds
Tinnitus
Critical band frequency
Therefore
There is no vibratory activity in the cochlea corresponding to tinnitus perception and thus
Jastreboff, 2014 5

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Tinnitus is loud
Tinnitus takes my attention from other sounds and things I should be doing
Tinnitus causes that I cannot understand people
Tinnitus is getting louder when I am in quiet
Tinnitus is getting louder when I am exposed to loud sound
Jastreboff, 2014 6

 Sound is an important part of many tinnitus treatments; it is used to:
– Cover-up (masking)
– Achieve immediate relief
– Distract attention from monitoring tinnitus
– Decrease stress
– Help with sleep
– Decrease the difference between the tinnitus signal and background neuronal activity (principle used in Tinnitus
Retraining Therapy - TRT)
Jastreboff, 2014 7

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When tinnitus annoying
A few times a day
As an exercise in set times
When convenient
All the time
Jastreboff, 2014 8

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Ear level instrument started to be used in tinnitus therapy over 30 years ago
– Hearing aids
– Maskers
What have we learned from past experiences?
Jastreboff, 2014 9

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Ear level instruments, such as sound generators (SG), hearing aids (HA), combination instruments (Combi), can be very helpful and an important part of tinnitus treatment
However, alone these devices are seldom the solution for high level tinnitus control and should always be utilized in conjunction with counseling; proper counseling is an essential part of any effective tinnitus treatment protocol
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Practically everybody experience tinnitus when put in sufficiently quiet environment for some time
Many people report having tinnitus, but only small proportion of people hearing tinnitus is bothered by it
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 Lack of relationship between psychoacoustical description of tinnitus, its severity and treatment outcome
 Auditory system plays a secondary role in clinically-relevant tinnitus; other systems in the brain are dominant
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Processing of tinnitus-related signal within various parts of the central nervous system has to be included in the analysis of the phenomenon of bothersome (clinicallysignificant) tinnitus
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Perception & Evaluation
Auditory & other Cortical Areas
Detection
Subcortical
Emotional Associations
Limbic System
Source
Cochlea
Autonomic Nervous System
Jastreboff, 2014 14

Auditory & other Cortical Areas
H
E
Detection
Subcortical
H
E
Emotional Associations
Limbic System
Source
Cochlea
H
R
Annoyance
Autonomic Nervous System
Jastreboff, 2014 15

Auditory & other Cortical Areas
H
P
H
E
Detection
Subcortical
H
E
Emotional Associations
Limbic System
Source
Cochlea
H
R
Annoyance
Autonomic Nervous System
Jastreboff, 2014 16

 Reclassify tinnitus to category of neutral stimuli
Retraining COUNSELING
 Decrease strength of tinnitus-related neuronal activity
SOUND THERAPY
Jastreboff, 2014 17

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Sound used as a part of sound therapy in TRT should never induce annoyance or any kind of negative reaction from the patient, as this would increase the activation of the autonomic and limbic nervous systems, and consequently may prevent habituation from occurring
Systematic masking should be avoided
Sound level should be above range of stochastic resonance
Improve hearing abilities with amplification, when needed
Consistent increased stimulation with sounds decreases gain within the auditory system
Current TRT protocol is geared toward using at least two types of sound
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Sounds of nature, particularly water
Broadband noise
Music is used in majority of patients, mainly as element of protocols for misophonia
Jastreboff, 2014 18

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It has been shown that practically everyone develops temporary tinnitus, if put in an extremely quiet environment:
“It is so quiet that ears are ringing”
As a rule, patients with tinnitus find that their tinnitus seems much louder and more intrusive in a quiet room or when their ears are blocked
The gain in the auditory system increases resulting in enhancement of the tinnitus signal
It is crucial to have an enriched sound environment together with sound provided by ear-level instruments
The sound of the instruments provides “safety net”
Jastreboff, 2014 19

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All of our senses reacts not to the absolute value of a stimulus, but to the difference between the stimulus and background
The strength of any signal in the nervous system is related to its difference with background neuronal activity
By increasing background neuronal activity, it is possible to effectively decrease the strength of tinnitus-related neuronal activity within the auditory pathways and consequently in all systems involved
Jastreboff, 2014 20

TINNITUS
BACKGROUND
TINNITUS
BACKGROUND
Jastreboff, 2014 21

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Decrease contrast between tinnitus and background neuronal activity
Interfere with the brain’s ability to detect the tinnitus signal
Reduce abnormal gain in the auditory system
Increase frequency range of the stimulation of the auditory system
Preserve or restore symmetry of stimulation of the auditory system
Improve communication ability
Decrease the strain-to-hear
Decrease focus on the ear and sound perception
Increase patient’s sense of control
Decrease general stress caused by tinnitus
Jastreboff, 2014 22

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Environmental sounds (e.g., table-top machines, iPod,
MP3 players, CDs, TV)
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– non amplified amplified by hearing aids or combination devices
Recent advances in hearing aids allow for streaming sound from iPod, MP3 players, CDs and other devices directly to hearing aids
Sound generators or sound generator part of combination devices
Ear level devices should be used concurrently with enhancement of the environmental sounds
Jastreboff, 2014 23

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To facilitate the implementation of sound therapy which results in improvement of the compliance with the protocol
To give a patients a sense of control and of doing something tangible (psychological aspects)
About 30% of patients have hyperacusis. For these patients use of well controlled, stable sound source, such as provided by sound generators, is highly beneficial
Additional positive consequence is decreasing “strain-to-hear” phenomenon in patients with hearing loss by using hearing aids or combination instruments
Jastreboff, 2014 24

(in TRT)
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 Recent tinnitus or tinnitus is not a significant concern
=> no instruments necessary (but still can be used)
Bothersome tinnitus, no hearing loss => SGs
Bothersome tinnitus and hearing loss => Combi or HAs
Hyperacusis => SGs
Hyperacusis & tinnitus => SGs
Hyperacusis & tinnitus & hearing loss => Combi
Always use binaural fitting to preserve / restore the symmetry of stimulation of the auditory system
Jastreboff, 2014 25

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Stochastic resonance causes that weak, close to threshold signal, is better detected and it is enhanced by addition of low level noise
Sound therapies with random noise are used in treatment of tinnitus and hyperacusis
Results of specific study showed that, consistently with stochastic resonance, tinnitus loudness match was increased (~10%) in statistically significant manner by adding low level of noise
Stochastic resonance might play a role in worsening tinnitus
Performing REM is recommended
Patients with misophonia are at the highest risk
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Threshold of a signal detection
Signal strength
Additional noise
Additional noise
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1.4
1.2
1
0.8
0.6
0.4
0.2
0
-12 -9 -6 -3
-0.2
0 3 6
-0.4
9 12
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Therefore, precautions should be taken not to use too low levels which could be close to the threshold levels of sound perception, as these could enhance the tinnitus signal due to the stochastic resonance.
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“
” Tinnitus changing
Annoyance
Threshold of hearing
Effective range of sound use
Tinnitus suppressed
“masking”
Jastreboff, ‘95
Intensity of a sound
Jastreboff, 2014 30

Effective range of sound
Annoyance
FACILITATION
Suppression
(“masking”)
INHIBITION
Stochastic resonance
Sound intensity [dB SL]
Jastreboff, 2014 31

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Should be used only for patients who have normal hearing
Can be used for tinnitus and / or hyperacusis and as a part of protocols for misophonia
Particularly needed for cases with hyperacusis
Must provide control of the sound level used to patients
Used in past smooth change of sound level has been replaced by an increase by pre-set value (toggle or remote-controlled step value)
Shaping of the sound spectrum is needed for improving the acceptance of a sound by patients
Jastreboff, 2014 32

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Viennatone Silent Star – characteristics like old AM/Ti, but better cosmetic appeal - still available in Europe
GHI in-the-ear or OTE - smoother and expanded in high frequency region frequency characteristics
Audifon / Kind, Hansaton, other companies
Currently, due to decrease of prices of combination devices they can be used as sound generators
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(in Tinnitus Retraining Therapy)
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Verbal reports are not sufficient to determine sound levels used by patients during treatment
Modified Real Ear Measurements (REM) of the sound level in the ear canal were performed to:
– To measure sound level used by patients at the beginning of the treatment
– To determine potential changes in sound levels during treatment,
– To determine potential differences in sound setting between tinnitus only and hyperacusis patients
Jastreboff, 2014 38

Jastreboff, 2014 39

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Average sound level used by the patients was ~11 dB SL (Re: threshold of perception of the sound produced by SG - range from 0 to 20 dB SL)
This sound level should not interfere with speech perception, except in cases with significant hearing loss in frequency range of
1 kHz to 3 kHz
There is no difference in setting sound generators between patients with tinnitus only, and patients with tinnitus and hyperacusis
The comfort level for noise provided by sound generators appears to be the factor determining sound level used by patients
REM measurements decrease the risk of the use of sound levels within the range of stochastic resonance or overstimulation
REM is highly recommended as a part of TRT protocol
Jastreboff, 2014 40

Volume Control Taper
70
60
50
40
30
20
10
0
0 10 20 30 40 50 60 70 80 90 100
Percent CW Rotation (%)
Jastreboff, 2014 41

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Frequency Response
Jastreboff, 2014 43

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Sound should not create annoyance or problems because of any reason!
Goal for tinnitus patient is “mixing” point
Step method is recommended
Avoid consistent masking of tinnitus; short periods of masking are not important
Volume of sound generators should be stable – kept at the same level regardless of behavior of tinnitus or listening environment during the block of usage
Recommended sound level 6 to 20 dB SL
Jastreboff, 2014 44

Effective range of sound
Annoyance
FACILITATION
Suppression
(“masking”)
INHIBITION
Stochastic resonance
Sound intensity [dB SL]
Jastreboff, 2014 45

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Commonly they are first type of instrumentation used as 80% of tinnitus patients have some hearing loss
Hearing aids are implemented to expand stimulation of auditory system and secondarily to alleviate strain to hear
Aids are implemented primarily for tinnitus treatment, communication is a secondary benefit
Aids should be worn during all waking hours
Enrichment of environmental sound is crucial
May mask tinnitus
Limited effectiveness, if not used as a part of specific program of treatment and sound use
Jastreboff, 2014 46

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Patient is gradually eased into amplification
The aim is to provide amplification above 6 kHz (through gradual process)
More stress on high quality of amplified sound
Recommendation to disable all “noise reduction” features
Automatic adaptive functions are to be used with caution
Some patients may require volume control due to misophonia or psychological reasons
Jastreboff, 2014 47

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Approach is based on multisensory integration of auditory and visual systems
CROS
BiCROS
Stress on impact of hearing loss on the auditory system
– Plasticity
– Improved symmetry of stimulation
External sound enrichment is crucial
Jastreboff, 2014 48

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Adding a noise produced by SGs may negatively influence speech discrimination in patients with hearing loss
Therefore, HA part of the Combi is used mainly to prevent decrease of speech understanding
Amplification is set primary to compensate for the effect of noise introduced by SG, thus, frequently initial amplification is set below recommended “target”
Amplification is gradually increased during subsequent appointments
Patient needs to understand the rationale of implemented protocol
Combination instruments may be recommended for patients whose mild hearing loss would not indicate the need to use hearing aids alone
Jastreboff, 2014 49

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Recommended for all type of instruments
To prevent attenuation of environmental sounds
Occluding the ear canal makes tinnitus worse
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Amplisound
Audifon
General Hearing Instruments
GN ReSound
Hansaton
Oticon
Phonak
Siemens
Starkey
Unitron
Widex
Jastreboff, 2014 52

Features
TINNITUS DEVICES FDA 510(k): K132965
Suggested Fitting Range
Available in beige or taupe
Interchangable soundtips available in 4 lengths.
Locking handle for a secure and comfortable fit
Domes available in 3 sizes
Easy to use scrolling volume wheel.
0dB at minimum.
On/Off Switch in VC.
#10 battery (90 hours)
Manufactured by Amplisound solacefortinnitus.net
Frequency in Hz
Jastreboff, 2014 53

TINNITUS DEVICES FDA 510(k): K132965
Quell tinnitus devices offer a reliable and affordable solution for sound therapy by qualified tinnitus practitioners. The sound stimulus has been carefully designed for a smooth, extra broad band response.
Quell tinnitus devices can be fit to the patient with the standard initial program settings.
As needed, these devices can be adjusted with
Hearing Studio programming software.
Adjustable features include:
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12 band equalizer for frequency shaping and tone quality adjustment
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Low battery indicator tone which is pre-set at
60 dB and 500 Hz (can be turned off)
Manufactured by Amplisound solacefortinnitus.net
Jastreboff, 2014 54

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 Company well know in Germany where offers variety of instruments for tinnitus
Relatively recent in the USA
Promotes devices as tailored to TRT
Only two devices available at the moment
SG: switch TRT
Combination devices: Switch 8 TRT
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Combination devices on the market for several years
Current models: Verso TS, LiNX TS (LTN961-DRW, LTN761-
DRW, LTN977-DW, LNT777-DW, LNT988-DW, LNT788),
ReSound LiNX TS is compatible with iPhone 5s, iPhone 5c, iPhone 5, iPad Air, iPad (4th generation), iPad mini with Retina display, iPad mini, and iPod touch (5th generation), using iOS
7.X or later.
Jastreboff, 2014 60

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Private company well know in Germany
Two models of the Hansaton SOUL tinnitus combination instruments: the Slim BTE and the X-mini RIC BTE in two technology levels as well: the SOUL Economy class (8 channels/8 bands), and the SOUL Business class (16 channels/ 16 bands).
HANSATON SOUL systems can be operated by remote control for volume and program changing. Systems are Bluetooth enabled and allow for direct, wireless contact with the TV or stereo system.
Jastreboff, 2014 61

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Oticon Hearing released this year their version of tinnitus management called Tinnitus Sound Support in their Alta Pro and Nera Pro hearing aids
Tinnitus SoundSupport
– Provides the sounds based on white, pink or red noise which can be limited in frequency by high pass or low pass filters
– Provides the option of amplitude modulation, a volume control and automatic level steering
– Generates a broadband noise signal with adjustable spectrum
Jastreboff, 2014 62

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Phonak Audéo V combination device is RIC portfolio for mild to severe hearing losses
Four designs, three external receivers and four performance levels
Running on the new operating system, AutoSense OS, Audéo V is promoted as better in automatic adaptation to listening situations than previous models
Jastreboff, 2014 63

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Practically all Siemens HA include sound generators and can be used as combination instruments
Just introduced binax is promoted as allowing to achieve up to
25% better speech intelligibility than people with normal hearing in the same cocktail-party situation
System emulates natural binaural listening by linking two binax hearing instruments using e2e wireless 3.0 data transmission technology without compromising battery life
Android phones can be used as remote control for Siemens hearing aids
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Combination device - Xino Tinnitus product - include Multiflex
Tinnitus Technology
Multiflex Tinnitus Technology
– Generates a broadband noise signal with adjustable spectrum
– The sound can be frequency and amplitude modulated resulting in perception similar to ocean waves or a breeze
SoundPoint Tinnitus feature allows to tailor the sound under the guidance of tinnitus patient
Jastreboff, 2014 67

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Moxi 2 and Quantum 2 combination instruments
Sound generators part is available in nearly all technology levels and styles
Unique aspect of their hearing aids – a possibility to upgrade given model to better hearing technology levels at any time
Jastreboff, 2014 68

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Widex promotes a technology of fractal tones, called Zen, to help relax
Broad band noise can be used as well, level of which can be modified by remote control
Zen is available in all DREAM and Clear technology
Low-end device, Zen2Go, are promoted for tinnitus
Jastreboff, 2014 69

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Majority of manufacturers are offering combination instruments with broad band noise spectrum of which can be modified (e.g.,
Siemens, high-end Widex)
Increase ease of streaming sound to devices (e.g., ReSound
LiNX and iPhone)
Improvement in quality of CROS and BICROS wireless systems
Enhanced frequency range up to 10 – 12 kHz
Wireless communication between hearing aids
Jastreboff, 2014 70

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Vast majority of tinnitus patients could benefit from the use of ear level instrumentation
Use bilateral fitting
Selection of instruments depends on the specifics of a patient; combination instruments are optimal for majority of cases
The sound produced by SG (or SG part of Combi) should never evoke annoyance
Sound range selected by patients varies from 0 dB SL to 20 dB
SL; it is advisable to avoid sound levels below 6 dB SL to avoid potential negative impact of stochastic resonance
Jastreboff, 2014 71

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Fitting of HAs should follow a specific recommendations of
“tinnitus fitting" which typically involves not reaching initially the target, fitting performed over several appointments and disabling noise cancelation features for main program; providing amplification above 6 kHz (through gradual process) is recommended
Patients with decreased sound tolerance require even more gradual introduction of amplification
Sound generators worn under ear muffs are recommended for patients when ear protection is required
Counseling tailored to specifics of a patient and proposed instruments is crucial to achieve high level of success
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