Tinnitus Today • Spring 2022

TINNITUSTODAY To Promote Relief, Help Prevent, and Find Cures for Tinnitus

Vol. 47, No. 1, Spring 2022

Tinnitus Is More Than Just a Sound Why Do We React to Sounds Differently?

Expanding Tinnitus Awareness With Texas Roadhouse Positive Psychology and Well-Being What’s Masking?

A publication of the

Visit & Learn More About Tinnitus at ATA.org

The ATA thrives through the dedication of a vast number of people who make a difference every day.

Join the Jack Vernon Legacy Society Jack Vernon, PhD and leading tinnitus researcher, was a founding member of the American Tinnitus Association who dedicated his career to helping people with tinnitus. Jack’s goal was to provide meaningful relief from the condition while cultivating a research community that could advance treatments and eventually find cures.

Thanks to his leadership and vision, we have a far better understanding of tinnitus, its causes, and ways to reduce its negative impact on patients. Most importantly, today, we have an active community of researchers carrying on his mission to eliminate tinnitus.

The ATA invites you to continue Jack’s mission to fund innovative research to put an end to tinnitus. How can you contribute?  M onthly or annual financial contributions  Name ATA in your trust or estate  Ask ATA to create a Tribute Page in memory of a loved one  Convert stock and/or real estate into a unitrust

   

Gifts of stock Gifts of real estate Deferred gift annuities Donations to ATA in lieu of flowers in memory of a loved one

For more information about adding the ATA as a beneficiary or ways to reduce your taxes through charitable contributions, please contact Torryn Brazell, ATA’s Chief Executive Officer, via email at tinnitus@ata.org.

Table of Contents SPECIAL FEATURES

Vol. 47, No. 1, Spring 2022

38 |

We Need to Share Our Tinnitus Journey to Build Acceptance

4| If Only We Could See | 57 What Is a Sound the Damage of Noise 24| Tolerance Condition?

Exposure a Sports Head 35| When Injury Triggers How to Achieve a Sense of Well-Being

Unexpected Auditory Issues

PERSONAL STORIES

xtreme Sports 8| EDidn’t Prepare Me for One Competitor: Tinnitus

Music Didn’t Stop 20 | The With Tinnitus

hen Sounds 30| WMake You Angry or Annoyed: Understanding Misophonia

SCIENCE & RESEARCH NEWS

33 | 45 |

How the Brain Responds to Sounds Tied to Misophonia

54 |

Tinnitus Is More Than One Condition: Why Creating Subtypes Helps Patients and Research

Tinnitus Q & A | 22 The Best ATA NEWS

exas Roadhouse 10| TDine-to-Donate

47 |

Reclaiming Life on My Terms

TINNITUS TOOLS & RESOURCES

Exploring Biomarkers for Tinnitus Loudness and Distress

Can Covid-19 Infect the Inner Ear?

the Valley to 50| FtheromMountaintop:

Raises More Than $700,000 for ATA Programs

Earplug Depends on the Situation and Sound

Tinnitus Q & A | 41 What Type of

Masking Works?

ow Do Veterans 42 | HAccess Tinnitus Clinical Services at VA Hospitals?

ould Auditory 52 | CBrainstem Response

Eventually Serve as an Objective Measure of Tinnitus?

innitus Support 60 | TGroup Listings potlight on 62 | SPatient Providers

 FROM THE BOARD CHAIR

Commemorating a Legendary Man and Tinnitus Awareness

David Hadley, MBA Chair, Board of Directors

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I’ve struggled for years to explain what tinnitus is like to friends, family, and colleagues, even though all of them have experienced it for a few hours or a few days.

But when tinnitus fades, the fear, tension, and anxiety that come with it also fade, leaving many people with the thought that it isn’t a big deal. That thought can make it hard to talk about living with chronic tinnitus, to raise funds for research, and to be taken seriously by healthcare providers.

Thus, to have Texas Roadhouse—a major corporation with over 600 restaurants throughout the United States— partner with the ATA to raise awareness about tinnitus was indeed legendary, the adjective that Kent Taylor, the late founder of Texas Roadhouse, used to describe the quintessential ingredient in people, ideas, and products that sets his brand apart.

On February 7, the family of Texas Roadhouse employees opened their doors and brought tinnitus to the table as part of National Tinnitus Awareness Day while diners enjoyed amazing food and service, a hallmark of Kent’s commitment to making everyday dining a fine dining experience. The day acknowledged that every Texas Roadhouse employee had been touched by tinnitus through Kent, who struggled with severe tinnitus in the final year of his life.

And at the end of the week, Texas Roadhouse announced a donation of more than $700,000 to the ATA. This amount will fund the Kent Taylor Texas Roadhouse Tinnitus Research Grant and allow the ATA to expand its tinnitus awareness and support programs.

Beyond a shadow of a doubt, our partnership with Texas Roadhouse drove a huge amount of new public awareness about tinnitus and the ATA. The day also showed that sharing our perspectives and experiences with tinnitus begins with us—finding the words to describe what it’s like, why it matters—so that others won’t suffer a lifetime in search of silence and understanding.

Each of us has been lifted up by the spirit of Texas Roadhouse employees, who know what it is like to lose a loved one to tinnitus. Let’s honor them by talking about tinnitus, raising awareness, and funding research for a better future.

TINNITUS TODAY SPRING 2022

MANAGING EDITOR Joy Onozuka American Tinnitus Association PUBLISHER Torryn P. Brazell, CAE, CFRE American Tinnitus Association PODCAST PRODUCER AND WRITER John A. Coverstone, AuD Sentient Healthcare, Inc. EDITOR-AT-LARGE James A. Henry, PhD National Center for Rehabilitative Auditory Research (NCRAR) U.S. Department of Veterans Affairs EDITORIAL ADVISORY PANEL Marc Fagelson, PhD East Tennessee State University Johnson City, TN USA Gail M. Whitelaw, PhD Department of Speech and Hearing Science The Ohio State University DIGITAL DESIGN & PRODUCTION TEAM JML Design, LLC ADVERTISING Tinnitus Today is the official publication of the American Tinnitus Association. It is published three times per year in April, August, and December and mailed to members and donors. The digital version is available online at www.ata.org. To grow your company’s brand reach, contact tinnitus@ata.org ATA HEADQUARTERS American Tinnitus Association 8300 Boone Blvd, Suite 500 Vienna, VA 22182 USA T: 800.634.8978 (Toll Free) www.ata.org TO GIVE TO THE ATA™ American Tinnitus Association c/o Truist Bank PO Box 424049 Washington, DC 20042-4049 The American Tinnitus Association is a nonprofit corporation, tax exempt under 501(c)(3) of the Internal Revenue Code, engaged in educational, charitable, and scientific activities.

Tinnitus Today magazine is © copyrighted by the American Tinnitus Association.

ATA™ is a registered trademark of the American Tinnitus Association.

www.ATA.org

FROM THE PUBLISHER 

ATA BOARD OF DIRECTORS David Hadley, MBA, San Francisco–Chair Gordon Mountford, South Pasadena, CA– Vice Chair Ron Zagel, Grand Rapids, MI–Treasurer Robert Travis Scott, Abingdon, VA– Assistant Treasurer Stelios Dokianakis, AuD, CH-TM, Holland, MI– Secretary Jill Meltzer, AuD, CH-TM, Chicago, IL– Immediate Past Chair Shahrzad Cohen, AuD, CH-TM, Sherman Oaks, CA Sara Downs, AuD, Duluth, MN Phillip Gander, PhD, Iowa City, IA Fatima Husain, PhD, Champaign, IL Brian Lofman, PhD, Salinas, CA John Minnebo, MBA, Philadelphia, PA Julie Prutsman, AuD, Highlands Ranch, CO Robert M. Traynor, EdD, MBA, CH-TM, Fort Collins, CO Joseph Trevisani, New York, NY Melissa Wikoff, AuD, CH-TM, Atlanta, GA Jinsheng Zhang, PhD, Detroit, MI Torryn P. Brazell, Vienna, VA–CEO HONORARY DIRECTOR William Shatner, Los Angeles, CA ATA SCIENTIFIC ADVISORY COMMITTEE Fatima T. Husain, PhD–Chair University of Illinois, Urbana-Champaign Champaign, IL USA Carey D. Balaban, PhD University of Pittsburgh, Pittsburgh, PA USA Shaowen Bao, PhD University of Arizona, Tucson, AZ USA Christopher R. Cederroth, PhD Karolinska Institute, Geneva, Switzerland Marc Fagelson, PhD East Tennessee State University Johnson City, TN USA Mark S. Mennemeier, PhD University of Arkansas, Little Rock, AR USA Maria Rubio, PhD, MD University of Pittsburgh, Pittsburgh, PA USA Tricia Scaglione, AuD University of Miami, Plantation, FL USA Roland Schaette, PhD UCL Ear Institute, London, England Grant D. Searchfield, PhD University of Auckland, Auckland, New Zealand Jeremy G. Turner, PhD Illinois College, Jacksonville, IL USA Richard Tyler, PhD University of Iowa, Iowa City, IA USA

Raising Tinnitus Awareness to Find Meaning in Loss Before 2021, I had never heard of Kent Taylor, the founder of Texas Roadhouse and the creator of a legendary world of roadies, good times, and insanely good food for all.

But in the year since his death, I’ve learned that Kent was a visionary who beat the odds in building an extraordinary restaurant brand, and he was deeply loved by those who knew him.

Humor, grace, creativity, positivity, laughter are all reminders of what Kent brought to the table. He clearly resides in the memories of his family of employees, in every corner of his restaurants, and in every inch of the Texas Roadhouse headquarters in Louisville, Kentucky. He is there in spirit and in practice by those he left behind.

Kent connected with people because he was passionate about people. He lifted others up, believed in their dignity and autonomy, and created a place where everyone would feel welcomed. How do I know this? Because I was embraced by those carrying on his vision when I visited Texas Roadhouse headquarters this February to thank them for partnering with the ATA for Tinnitus Awareness Week.

By honoring Kent through raising awareness of tinnitus in his restaurants, we’ve turned a new page. The Texas Roadhouse gave the ATA the largest corporate donation we’ve ever received. It will fund new innovative seed grant research in Kent’s name, expand our Tinnitus Advisors Program, and increase our educational awareness activities.

For Texas Roadhouse, raising awareness of tinnitus helped honor Kent’s memory, his struggle with severe tinnitus, his anger that there was no cure, and his search for meaningful help. Part of his legacy is that no one should struggle with tinnitus on their own.

Like all of us, the Texas Roadhouse family never expected to be a part of the tinnitus community. And when we find ourselves in this space, the choice often seems to be either hope or despair. But by choosing hope, combined with extraordinary generosity, Texas Roadhouse has empowered us all to live with greater clarity, vision, and courage and the conviction that answers to tinnitus can be found through research and meaningful help. Thank you, Texas Roadhouse for embracing hope!

Torryn P. Brazell, CAE, CFRE Publisher

The opinions expressed by contributors to Tinnitus Today are not necessarily those of the publisher or the American Tinnitus Association. This publication provides a variety of topics related to tinnitus for informational purposes only.

ATA’s publication of any advertisement in any kind of media does not, in any way or manner, constitute or imply ATA’s approval or endorsement of any advertised product or service. ATA does not favor or endorse any commercial product or service.

Fan-Gang Zeng, PhD University of California, Irvine, Irvine, CA USA www.ATA.org

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SPECIAL FEATURE

How to Achieve a Sense of Well-Being The first article in a three-part series on utilizing positive psychology to thrive—not just survive—while living with tinnitus and/or hyperacusis.

By Deborah Hall, PhD

Positive psychology is the scientific study of what makes people thrive, and it is also an applied approach to help people develop optimal ways to achieve or regain a sense of well-being. There is so much in the field of positive psychology that is compelling and powerful— yet not everyone sees it that way.

Positive psychology has been openly criticized for putting an excessive emphasis on positive emotional states while failing to adequately consider negative experiences; for its lofty aims of forging a path toward authentic fulfillment; for its shift away from scientific ideals toward promoting particular values; and for its rampant commercialization.

Many have expressed concern that positive psychology makes light of the negative lived experience of those in distress through creating a (false) narrative about their personal suffering. If you experience distress from tinnitus and/or hyperacusis, and if this describes your perspective on positive psychology, then maybe this

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first of three articles on the topic may change your view.

Here, I introduce positive psychology as a branch of mainstream psychology. I explore the evolution of positive psychology over the past 20 years as it has matured as a field of scientific inquiry, self-reflection, and debate, and I discuss some of the myths and misconceptions.

The intention here is to provide enough information so that you have a balanced view of what positive psychology is about.

In the second article (to be published in the Summer 2022 issue of Tinnitus Today), I will delve into applications of positive psychology to tinnitus and hyperacusis, speculate on some future research directions, and share tips that hopefully can help you live well with your condition.

The First Wave of Positive Psychology Positive psychology was born just over 20 years ago, in 1998, when Martin Seligman gave his inaugural presidential address at the American Psychological Association.1 His address set out two calls for radical change in the science and practice of psychology: one to focus on the study of ethnopolitical conflict, and the other to reorient the field away from its “almost exclusive attention to pathology” and healing toward making

the lives of all people more fulfilling and productive.

Since Seligman steered positive psychology into the public consciousness, it has grown at an explosive rate. Seligman himself remains one of the most public advocates of the science of well-being, and his 2011 model of well-being still dominates the field. In essence, the model proposes that global well-being is made up of five components, or building blocks: positive emotion, engagement, relationships, meaning, and accomplishment. These spell the acronym PERMA, which gives rise to the popular name for the model.2 Research has shown that the five components are not necessarily independent of one another because people who are high on one tend to be high on the others. While associations are interesting, establishing the scientific value of this model would require identifying which PERMA components are more (or less) predictive of global well-being or www.ATA.org

SPECIAL FEATURE

determining whether therapeutic interventions targeting individual PERMA components bring benefits specific to that component alone or exert a generic impact on well-being.

To my knowledge, few empirical advances have yet been made to answer these questions.

Other criticisms of the PERMA model have been debated in the academic world. For example, Goodman et al. argue that the PERMA model offers nothing unique beyond an already established model of subjective well-being proposed

by Ed Diener in 1984.3 To explain this claim using an everyday analogy, Goodman and colleagues suggest that Diener and Seligman simply cut the “well-being pizza” into different slices, but at the end of the day it’s actually the same pizza (see next page). Diener’s

model comprises three components: high life satisfaction, frequent positive feelings, and infrequent negative feelings.4 The text box describes the Diener model and the PERMA model and their components in more detail.

The Second Wave of Positive Psychology As a conscious counterpoint to other branches of psychology, the first wave placed an almost exclusive emphasis on the positive. However, this inevitably prompted some psychologists to highlight the subtle dynamic interplay between positive and negative. Thus, while the second wave still focuses on flourishing and well-being, it is characterized by a more nuanced consideration of the positive and the negative, and a recognition that simply removing the disabling conditions is not the same as building the enabling conditions that make life most worth living.5

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The second wave therefore seeks to unify well-being and positivity with the kinds of suffering, doubt, and adversity that are part and parcel of the human condition. One of the main proponents of this view is the psychologist Barbara Held. In 2004, she published a perspective entitled “The Negative Side of Positive Psychology” in which she offers a critique of positive psychology from a humanist perspective.6 Many others have followed and there is now a large body of knowledge about how personal development often involves suffering that, although challenging or emotionally painful, can lead to growth, insight, healing, and transformation.

In summary, the skills that build flourishing are different from the skills that alleviate suffering, and both are needed to achieve true well-being. This is the focus of the second wave of positive psychology.

The Three Components of Well-Being Proposed by Ed Diener in 1984 Life satisfaction is not simply an overall appraisal of your quality of life, but it can also include how you judge satisfaction in specific life domains such as marriage, financial status, and physical health.

Frequent positive emotions are about more than just being happy. It’s about the wide breadth of positive emotions you can experience, such as feeling optimistic, grateful, or proud.

Infrequent negative feelings are those short-term emotional reactions to life events such as feeling sad, angry, or frustrated.

The Five Components of Well-Being Proposed by Martin Seligman in 2011 Positive emotions are about more than just being happy. It’s about the wide breadth of positive emotions you can experience, such as feeling optimistic, grateful, or proud.

When you are engaged in an activity that you love and that uses your strengths, you can lose all

www.ATA.org

sense of time because you feel energized focus and enjoyment.

Meaningful relationships are key to feeling supported. People thrive on interactions built on mutual trust and respect as these promote positive reactions such as love and friendship.

Living with meaning and purpose means that you feel part of something larger than yourself.

Positive psychology promotes hunting for meaning in the routine, in the absurd, and in the dull, not just in the awesome.

Feeling a sense of achievement can be hugely motivating and help you recognize the effort you’re making as well as how you might have grown and developed from a failure.

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SPECIAL FEATURE

Positive Psychology Pizza 3 Components of Well-Being (Diener, 1984)

5 Components of Well-Being (Seligman, 2011)

The Third Wave of Positive Psychology As it reaches maturity, the discipline is increasingly moving in the direction of embracing human life as a whole from a positive, constructive perspective. In 2021, Lomas and colleagues presented several themes that may be forming into a third wave of positive psychology.7 One set of themes comprises expansions in scope and complexity. These are concerned with going beyond the individual and considering factors that influence wellbeing from the perspective of groups and organizations within a society, or even whole societies and cultures.

Dispelling Five Myths and Misconceptions About Positive Psychology

1

Positive psychology is not Happy-ology!

Well-being is much more than thinking the right thoughts and feeling happy. Well-being is multidimensional and includes factors such as competence, emotional stability, engagement, meaning, optimism, positive relationships, resilience, selfesteem, vitality, and positive emotions.

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“Positive” is not simply the absence of the “negative.”

Positive psychology is not about ignoring negative emotions and always wearing a smiling face.

It does not make good sense to separate these two types of emotions because sometimes “positive” can be negative, and other times “negative” can be positive. In truth, thriving is achieved through a complex

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interplay of positive and negative experiences and emotions.

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Positive psychology does not ignore negativity in our life.

“Toxic positivity,” a common misconception of positive psychology, is when you deny, invalidate, or minimize a negative or distressing situation by overgeneralizing the positives.

Positive psychology recognizes that negative human experiences can be beneficial to personal growth and development and even can help you find a meaningful life.

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There is more to positive psychology than Seligman’s ideology, and there are many positive psychologists based outside the United States.

Although Seligman is credited as the father of positive psychology, and his Positive Psychology Center at the University of Pennsylvania

is considered one of the leading centers, this is a very diverse field. Other leaders in positive psychology include Paul Wong (Canada), Aaron Jarden and Margaret Kern (Australia), Tim Lomas, Ilona Boniwell, and Stephen Palmer (U.K.).

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Positive psychology is not all about the individual.

The first wave reflected the cultural tradition of individualism in North America and other Western countries where positive psychology initially developed. The global spread of the field is now challenging the emphasis on an individual’s power to control his or her own goals, actions, and destiny.

There is an interest in thriving from the perspective of collectivist societies in which the “group” takes priority over the individuals within it.

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SPECIAL FEATURE

Another set of themes comprises expansions in methodologies. These are the consequence of a growing appreciation of the value of narrative responses and storytelling (qualitative data) that add insight to numerical measurements (quantitative data).

boundaries of psychology itself. The diversity of conceptual thought that we are starting to see in this third wave is already incorporating knowledge and research methodologies from a range of disciplines, such as anthropology, sociology, and sociolinguistics. The future looks positive!

Concluding Remarks From the outset, positive psychology created a wave that attracted significant interest and enthusiasm, as well as criticism about the notions of positive and negative. Despite strong views held by outspoken thought leaders, positive psychology is a maturing field that is evolving through self-reflection and academic dialogue. One may even speculate on whether the move toward embracing greater complexity may eventually take positive psychology beyond the

Deborah Hall, PhD, is currently Professor of Positive Psychology and head of the Department of Psychology at Heriot-Watt University Malaysia.

Over the past 25 years, her research has spanned a range of topics on individual and societal well-being.

She is recognized as a world leading expert on tinnitus, but past research projects also include exploring the relevance of positive soundscapes, developing a manualized psychological treatment to increase the

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knowledge base of audiologists in the U.K.’s National Health Service, and advocating, and advocating to bring the public voice into clinical research. She can be reached at deborah.hall@hw.ac.uk 1 M. Seligman. (1999). The president’s address [Annual report]. American Psychologist, 54, 559–562.

2 M. Seligman. (2018). PERMA and the building blocks of well-being. Journal of Positive Psychology, 13(4), 333–335.

3 F. R. Goodman, D. J. Disabato, T. B. Kashdan, & S. B. Kauffman. (2018). Measuring well-being: A comparison of subjective well-being and PERMA. Journal of Positive Psychology, 13(4), 321–332.

4 E. Diener. (1984). Subjective well-being.

Psychological Bulletin, 95, 542–575.

5 L. Ruggeri, E. Garcia-Garzon, Á. Maguire, S. Matz, & F. A. Huppert. (2020). Well-being is more than happiness and life satisfaction: A multidimensional analysis of 21 countries. Health & Quality of Life Outcomes, 18, 192.

6 B. S. Held. (2004). The negative side of positive psychology. Journal of Humanistic Psychology, 44(1), 9–46.

7 T. Lomas, L. Waters, P. Williams, L. G. Oades, & M. L. Kern. (2021). Third wave positive psychology: Broadening towards complexity. Journal of Positive Psychology, 16(5), 660–674.

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 PERSONAL STORY

Extreme Sports Didn’t Prepare Me for One Competitor: Tinnitus Can’t Beat It? Befriend It

By Tom Merrill

My journey with tinnitus and hyperacusis literally began as a wakeup call of horrible sounds in my head and dizziness so terrible that I could hardly walk the morning after a very hot day kitesurfing in Panama.

The eardrum of my left ear had popped; it was like something crashed inside my head. I couldn’t hear in that ear, couldn’t balance. I had over-the-top tinnitus and extreme noise sensitivity.

Added to the mix, my life was further enriched by 24/7 dizziness and later frequent bouts of vertigo, lasting for days.

Many years of extreme sports ended abruptly as I became an invalid hiding from sound. Constant tinnitus drove me to the brink, and my sound sensitivity was so acute I had to wear earplugs in the shower. Brain fog was sometimes so heavy I couldn’t even sign my name on a check. Each issue was daunting and—taken together— they made life seem hopeless.

I still had some grit refined by a lifetime of sports, which meant I was familiar with and accustomed to injuries, setbacks, recovery, and physical therapy. But when everything 8

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is focused in your head and you can’t think clearly, it all becomes unreal and quite difficult to deal with. I had never encountered something this daunting.

Frustration and loss of purpose in life took over. I was a mess but fortunate to have an incredibly patient wife.

Desperate for solutions, I reached out to multiple doctors, but it wasn’t until two years had passed, when I traveled with my wife to Oregon Health & Science University (OHSU) in Portland, that things began to turn around. I met with a highly regarded research otolaryngologist for testing.

Another physician put me on extreme bed rest in an inclined position to heal the inner ear. This lasted five months.

Later, surgery alleviated head pressure.

The vertigo attacks ceased, but I still had a list of issues. And the damage to my ear was done, so the tinnitus and noise sensitivity continued.

During this time, I slowly learned about tinnitus and hyperacusis.

Portland, at that time, harbored some of the best in the business for treating and researching tinnitus at OHSU. Jack Vernon had started the first tinnitus clinic there, in addition to cofounding the ATA. I was able to converse with Jack and later with his successor,

Billy Martin. Jim Henry, who headed the VA tinnitus research in Portland, conducted research among some of us who volunteered.

Through these extraordinary people, including other patients I met along the way, I became determined to get my life back. One thing was clear: The brain was involved in all of these issues. So, retraining my brain was my next challenge, but how?

Piecing together what I learned about tinnitus and hyperacusis, while borrowing a page from my days recovering from injuries with physical therapy and a brief stint with vestibular therapy, it seemed logical to use some of the same concepts of slow forward progress using repetition.

I analyzed each problem and addressed it individually, while recognizing the overall approach as similar. I needed to build a toolbox and fill it with tools to try to fix each issue.

• For tinnitus, my tools were masking and diversion.

• For hyperacusis, I needed to desensitize by exposing my ears slowly to sound.

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PERSONAL STORY

• For balance, I needed to train my brain to use the right side more than the compromised left.

But the real turning point was when I made a conscious decision to acknowledge tinnitus as a lifetime companion. I would make it my friend, as unpleasant as that might sound.

Think of it this way: You and one other person are shipwrecked on an island, with no hope of being found.

The other survivor is really horrible, but you can’t run away and are stuck with this person for life. You have a choice: Continue to feel tormented by this person or make peace.

This is tinnitus for many of us.

I decided to make peace with tinnitus. And now “my friend” and I walk through life together. No matter where I am, we are together. And, just like any relationship, there are good days and others when we fight or don’t get along, but we are always together for the long haul.

To be sure, I need to get away from my constant companion at times, so I’ve developed ways to avoid it. But, when I need space, I don’t fight for it. I have found ways to be alone.

There are many tools to get away from “my friend” tinnitus when needed. Many articles are available to help; but this is such an individual situation, each of us needs to experiment on our own to see what works. Simplifying the information into one basic concept has helped me to develop tools that work.

The most important basic concept is that there are two primary ways to deal with tinnitus: masking and diversion. Masking focuses on alleviating the sound in your head using alternative sounds like white www.ATA.org

noise. Masking with the right sounds is very useful for alleviating stress, and there may be other benefits to explore, such as using sound for visual imagery or falling asleep.

Diversion is exactly as it appears: Divert your brain to focus on something other than the sounds in your head. Over time, I have been able to use masking less and now focus 95 percent of my energy on diversion.

Here are some thoughts you may consider: • Probably the best way to get away from tinnitus is to simply get involved in what interests you most. When focused on things of interest, you don’t notice anything else.

• Another important point is to remember your tinnitus really isn’t so great when irritated, so it’s best not to irritate it with loud noise, sleepless nights, too much partying, or consuming foods or drinks that can cause problems.

The more you get to know your tinnitus, the easier it is to figure out what sets it off.

• Don’t sit around with tinnitus in a quiet room; always make sure others are there, or other sounds can be heard, to keep your brain engaged.

• Running away for brief escapes is great, too. I have five MP3 players that I programmed with music and sounds to help me get away, including quiet music for diversion, white noise for masking, chimes, and nature sounds. I keep a MP3 player at my bedside, in a briefcase, in each car so that one is always available if I need to run away or put it

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on when I go to the market, a restaurant, a home improvement store, or a myriad of other noisy places. Cell phones can be programmed to do the same thing. The idea is to continually have a useful library of sound to divert your attention from tinnitus or other unpleasant sounds. Over time, this has been a great way to make tinnitus less conspicuous, less in my face, less in my head.

• Find quiet time and focus on meditation-type tools to disengage from the world around you. When I cultivate meditative quiet, my tinnnitus recedes for a while.

• I have found that when my head is under water while I swim, my friend quiets down, so I swim a lot.

We all have our own situation, but each of us can find ways to live with this constant companion.

The singular most important change in my life with tinnitus was accepting the challenges and finding positive ways to overcome negatives. Not easy at first, but with time it gets better.

Perhaps you too—drawing on grit, support, your passions, your unique tools—can befriend tinnitus?

Tom testing his core muscles.

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ATA NEWS

Texas Roadhouse Dine-to-Donate Raises More Than $700,000 for ATA Programs Remembering Kent Taylor, Founder of Texas Roadhouse,

by Raising Awareness of Tinnitus and the ATA

For Tinnitus Awareness Week, February 7–13, Texas Roadhouse partnered with the American Tinnitus Association to raise awareness of tinnitus at its restaurant locations across the country. Thanks to all those who participated in the dine-to-donate fundraiser, Texas Roadhouse raised more than $700,000 for the ATA. “We’ve never seen such an outpouring of support, which reflects the love felt by thousands of people for Kent Taylor and his passion to

uplift others through community, commitment, and extraordinary food,” said Torryn Brazell, ATA CEO. “The opportunity to partner with Texas Roadhouse, which understands tinnitus through Kent’s struggle, has given comfort to people who feel alone with the condition and now know that the ATA is here to support them,” said David Hadley, chair of the ATA Board of Directors, adding that the donation is the largest corporate gift that the ATA has received and will

Kent Taylor, Texas Roadhouse founder, at Marco Island, Fla.

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go toward expanding the ATA’s patient support programs and research.

Throughout the week, members of the tinnitus community, including people with tinnitus and their friends and family, researchers, and healthcare providers, dined in or ordered takeout at Texas Roadhouse restaurants to enjoy a meal together and mark • the importance of recognizing the struggles of people bothered by tinnitus, • the need for greater compassion for those living with unwanted sound, • the necessity of tinnitus patients and healthcare providers talking about the condition with family and friends to build awareness and empathy, and • the role of the ATA’s patient advocacy and funding of innovative research to advance treatments and potential cures, disseminate credible research-based information, and operate meaningful patient support services. www.ATA.org

ATA NEWS 

Torryn Brazell, ATA CEO, accepts check from Jerry Morgan, Texas Roadhouse CEO, at the company’s headquarters in Louisville, Ky.

Tinnitus is experienced by 10 to 15 percent of the population.

Although about 80 percent of people are able to adjust to living with it, about 20 percent find that the intrusion of constant or intermittent sound interferes with their ability to concentrate, sleep, relax, work, and enjoy relationships with friends and loved ones who don’t suffer from the condition. The negative effects of tinnitus can trigger anxiety, depression, insomnia, a sense of social isolation, suicidal ideation, and, at its worst, suicide.

The ATA is the nation’s only nonprofit dedicated exclusively to serving the tinnitus community through a myriad of activities. The ATA operates the country’s only tinnitus guidance hotline

(1-800-634-8978, ext. 3), funds seed grant research to advance potential breakthroughs in treatment and cures, and provides educational services that improve understanding of patient needs among healthcare providers.

It also raises public awareness of the condition and how it can be managed and prevented.

Bannon at Texas Roadhouse in Chantilly, Va.

Chagall enjoys Texas Roadhouse baked potato.

From left to right, Donna Migliorese, Mauricio Alvarez, Kelly Rice with Jeff and Jill Meltzer, AuD and ATA immediate past board chair, at Texas Roadhouse in Mt. Prospect, Ill.

“The donation is the largest corporate gift that the ATA has received and will go toward expanding the ATA’s patient support programs and research.“ —David Hadley, chair of the ATA Board of Directors

www.ATA.org

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ATA NEWS

ATA member Rob Lee with Chris Sell, at Texas Roadhouse in Glen Mills, Pa.

Kevin Willmann, ATA staff, with son Spencer, at Texas Roadhouse in Woodbridge, Va.

Melissa Wikoff, AuD and ATA board member, at Texas Roadhouse in Marietta, Ga.

Carolyn dressed to enjoy her lunch at Texas Roadhouse in Union City, Calif.

Awareness and Support Can Be Your Guide During Tinnitus Awareness Week 2022—from February 7 to 13—the American Tinnitus Association partnered with Texas Roadhouse restaurants nationwide to raise awareness of the condition and to honor the life of Texas Roadhouse founder Kent Taylor, who struggled with tinnitus in the last year of his life. The ATA wishes to thank the family of Texas Roadhouse employees for the largest corporate donation—more than $700,000—we’ve ever received, and the many people who participated, making it a joyful and memorable event. The event underscored the importance of raising awareness of tinnitus so people know where to get help or how to avoid developing tinnitus, which is often preventable.

Leif, 6, with his brother Kai, 9, with Texas Roadhouse takeout from Iowa City, Iowa.

LaGuinn Sherlock, AuD and past chair of ATA Board of Directors, with Shawn Burns and Mike Burns at Texas Roadhouse in Chantilly, Va. Tinnitus patient and U.S. Army veteran David Nottingham at Texas Roadhouse in Chantilly, Va.

Bryce Onozuka, ATA intern, with Texas Roadhouse staff in El Cajon, Calif.

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Robert Travis Scott, ATA Board of Director’s assistant treasurer, with Marie Scott at Texas Roadhouse in Bristol, Va. www.ATA.org

ATA NEWS 

Increased Financial Support of the Tinnitus Advisors Program (TinnAP™) Tinnitus can feel like a superpower capable of holding a person’s life captive through unwanted and unrelenting sound. Our best armor in such moments is often the voice of someone who understands the challenge and need for emotional reinforcement and effective guidance on tinnitus management. The ATA’s Tinnitus Advisors Program (TinnAP) does that.

For individuals struggling with tinnitus, the ATA provides free 15-minute guidance with tinnitus specialists who have years of experience helping patients. The research-based information is not intended as medical advice or to serve as a substitute for working with local healthcare professionals. The guidance is educational and includes information on research-based guidelines, treatment options, self-management tools, and other topics of concern to the caller.

For help, call 1-800-634-8978, ext. 3.

Lisa Goldsmith at Texas Roadhouse on Wilmot Rd. in Tucson, Ariz.

Robert Traynor, ATA board member, at Texas Roadhouse in Ft. Collins, Colo.

Avital Wikoff enjoying a burger at Texas Roadhouse in Marietta, Ga.

Brittany, ATA CEO Torryn Brazell, Jenni and Jennifer at Texas Roadhouse in Yorktown, Va.

“Some days in life are truly life changing. I absolutely believe Sara’s [TinnAP] call yesterday was a life changer for the best. I will never be able to adequately express my gratitude of thanks to her and to you, [Joy].”

—John C., March 4, 2022 www.ATA.org

Sara Downs, AuD and ATA board member, at Texas Roadhouse in Duluth, Minn.

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IN

Kent Taylor Texas Roadhouse Tinnitus Research Grant

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The American Tinnitus Association Board of Directors is proud to announce the inauguration of the annual Kent Taylor Texas Roadhouse Tinnitus Research Grant.

Kent Taylor statue outside the Texas Roadhouse headquarters in Louisville, Ky.

Center, John Minnebo, ATA board member, with Roadhouse staff Tina, Shawna, Ashley, and Chandler at their location in Bradenton, Fla.

Fatima Husain, PhD and ATA Scientific Advisory Committee chair, with Alyssa Leal at Texas Roadhouse, Champaign, Ill.

Texas Roadhouse CEO Jerry Morgan and Torryn Brazell, ATA CEO, admire a Texas Roadhouse Louisville Slugger bat stamped with their company logos.

2nd row, 3rd from left, Julie Prutsman, AuD and ATA board member, celebrates tinnitus awareness at Texas Roadhouse in Parker, Colo.

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www.ATA.org

ATA NEWS 

Peter Amerman, James Vagnoni, James Conklin, managing partner of Texas Roadhouse on Irvington Rd. in Tucson, Ariz., and Cynthia Amerman, president of Adult Loss of Hearing Association.

Trudy Jacobson, ATA member and Tucson Tinnitus Discussion Group leader, with Texas Roadhouse staff at their location on Wilmot Rd. in Tucson, Ariz.

ATA member Laura Pratesi, AuD and leader of Clermont Tinnitus Support Group, with her husband, son, and mother.

ATA member Peter Vernezze at Texas Roadhouse on Wilmot Rd. in Tucson, Ariz.

Mental Health and Emergency Support Kareem, Areeyon, Alex Tankersley, AuD student, Sonia Hamidi, AuD and leader of the ENT Institute Support Group, Kaede Sasahara, AuD student, with Texas Roadhouse staff at their location in Buford, Ga.

Clermont support group members Peter Rivkees and Alicia Camacho and support group leader, Laura Pratesi, AuD, outside Texas Roadhouse in Clermont, Fla. www.ATA.org

There are times when tinnitus distress is so severe that mental health support is the best intervention. Many people with severe tinnitus have had dark moments in which they’ve felt overwhelmed but have overcome them through mental health support, either short term or ongoing. Help begins by asking, so don’t hesitate to reach out to a friend, loved one, or the ATA for assistance.

Mental healthcare can be found through one’s physician, employer healthcare benefits, county services, and crisis hotlines, including the National Suicide Prevention Lifeline, which can be reached at 1-800-273-8255. The U.S. Department of Health and Human Services oversees the Substance Abuse and Mental Health Administration, which has extensive state-by-state, city-by-city listings of support services, which can be found on its website at https://www.samhsa.gov/.

Psychology.com maintains a therapy finder directory that includes descriptions of services and expertise and that can be accessed at https://www.psychology.com/therapist.

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ATA NEWS

Joseph Trevisani, ATA board member, with managing partners at Texas Roadhouse in Teterboro, N.J. Stelios Dokianakis, AuD and secretary of the ATA Board of Directors with Texas Roadhouse staff at their Grandville, Mich., location.

Sutton and Darby are excited to dig in to Texas Roadhouse takeout from Jonesboro, Ark.

ATA CEO Torryn Brazell, left, with Ciera and Dawn at Texas Roadhouse in Yorktown, Va.

Casey Dennison, managing partner, with Joy Onozuka, ATA staff, and Jillian Angilletta, at Texas Roadhouse in Chantilly, Va.

Brian Lofman, ATA board member, with Tim Lund, managing partner at Texas Roadhouse in Union City, Calif.

The ATA, the nation’s only nonprofit dedicated exclusively to serving the tinnitus community, is proud to offer a range of ongoing support services and guidance through its platform. Our gratitude for support and discussion group leaders and peer-to-peer telephone/email volunteers is immense. Through their dedication, countless people connect with others in the tinnitus community who understand their needs and fears. It’s a safe space for individuals to find and build community at every stage of their journey.

• The ATA’s network of independent support groups, many of which meet online, can be accessed at https://www.ata.org/managing-your-tinnitus/support-network/support-group-listing • Peer-to-peer volunteers provide telephone and/or email support for individuals. Volunteers represent a range of individuals with lived experience and insight. To access volunteers, see https://www.ata.org/managing-yourtinnitus/support-network/telephoneemail-support-listing. When calling, please confirm whether it’s convenient for the volunteer to talk.

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www.ATA.org

TINNITUS RESOURCES 

Navigating the healthcare system can be difficult, especially when dealing with a condition like tinnitus that lacks a definitive cure and differs between patients. The American Tinnitus Association (ATA) developed the Patient Navigator to help people find the best approach for their tinnitus. The Patient Navigator is suitable both for those

PATIENT NAVIGATOR

with recent sudden-onset tinnitus and those with a history of tinnitus that has become bothersome or has not been addressed.

Visit your primary care provider (PCP) and audiologist

Stay calm

If your tinnitus continues beyond a week, becomes bothersome, starts to interfere with your sleep and/or your concentration, or makes you depressed or anxious, seek medical attention from a trained healthcare professional.Your PCP should be able to diagnose/rule out certain causes of tinnitus, such as obstructions in the ear canal or temporomandibular joint dysfunction (TMJ), and provide a referral to the appropriate specialist. If no underlying medical issues are found, see an audiologist for a hearing assessment and evaluation of tinnitus treatment options.

Tinnitus can be frightening, especially if it develops without warning, or without a clear trigger. It is important to stay calm because it is seldom indicative of a life-threatening medical condition. *If your tinnitus symptoms were triggered by a traumatic physical event (head/neck damage, concussive trauma, etc.), you should seek immediate medical care.

*Please refer to ATA’s Patient Intake Flowchart available at www.ATA.org

Know your treatment options ATA encourages patients to utilize its website to research tinnitus management options and to ask the questions listed below. Become a proactive participant in determining which management option best addresses your condition and needs: • What tests do they suggest? What are the tests designed to reveal?

• What is their diagnosis?

• Have they ruled out physical causes of tinnitus: TMJ, head/neck trauma, tumors, etc.?

• Are they familiar with all current tinnitus management options?

• Which tinnitus management option is best for your situation? Do they offer this service?

• Which tinnitus treatments do they use in their practice?

• What is their treatment plan for you? Can they provide this service or refer you to another provider?

• How much will treatment cost? How many visits are likely needed?

Is treatment covered by your insurance?

• Do they have any additional information for you to review?

• Is their advice based on the American Academy of Otolaryngology’s Clinical Practice Guideline: Tinnitus?

Consider seeing a behavioral health therapist Current estimates suggest that 48-78% of patients with severe tinnitus experience depression, anxiety, or some other behavioral disorder. A trained behavioral health therapist can often help mitigate the negative emotions accompanying bothersome tinnitus. There are behavioral and educational treatment programs for tinnitus management. General psychological therapy may also be beneficial.

Commit to action Once you and your healthcare provider identify the best management option, fully commit to completing the treatment protocol. Many of the best tinnitus management therapies, including Cognitive Behavioral Therapy (CBT) and Tinnitus Retraining Therapy (TRT), require ongoing, active patient participation, over a 6-12 month period.

Do not accept “learn to live with it” diagnoses Many patients are misguided when told by healthcare providers that nothing can be done for tinnitus. While there is no cure at this time, there are evidence-based treatments that can significantly reduce the effect of tinnitus on daily activities and improve quality of life. If a medical professional says nothing can be done, get a second opinion from a hearing healthcare professional trained in tinnitus management.

Self care Patients can improve their condition through general wellness and relaxation practices: • I ncrease Relaxation. Patients often report tinnitus becomes less burdensome through regular activities designed to be relaxing, like yoga, meditation, and listening to music.

• Sleep. Tinnitus often disrupts sleep, so create a sleep strategy. This might include sound machines, radio static, or a fan to mask the sound of tinnitus. Reduction of caffeine, alcohol, and other drugs that might inhibit sleep is recommended.

Create a support network Patients who are successful in managing tinnitus often have strong support networks, which might include a spouse, family, or friends who’ve been educated about tinnitus. A tinnitus support group can provide a forum among compassionate people facing similar challenges. ATA can assist in locating local tinnitus support groups or connecting you with Help Network Volunteers who are willing to share their own experiences with tinnitus via one-on-one phone calls or email correspondence.

* The ATA Patient Navigator is designed to apply to the broadest array of tinnitus cases. While most patients would be well served following this approach, the sound and effects of tinnitus are unique to each patient, so some patients may require a different approach. © 2022 American Tinnitus Association

www.ATA.org

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 PERSONAL COMPASS

By Cortney Davis

Ice cubes clatter in my glass. Nearby, a narrow stream crashes in a waterfall.

Closer, other things: the squeal of a neighbor’s chain saw; a mosquito flying in tune with my refrigerator’s hum.

I try to sing along, but the whine makes me want to gouge my ears, stick my fingers in to find the motor that needs oil, the gears that spin the metal plates too fast— not like droning bees, more like a drawn out, starry moan.

Don’t believe everything you hear, my father said when it started happening to him— the almost-forgotten gnash of army tanks in 1943, the buzz of soldiers laughing outside a bivouac.

It’s genetic. Just learn to live with it.

I hear thunder; engines that roar just before their plunge into glass and stone.

It’s the endless shriek of shattered windows; it’s an endless, supersonic scream of sound.

People with tinnitus may often be acutely aware of all sounds since we live with a sound that, for many of us, never goes away.

If we are blessed with the ability to hear, we know that sounds can be beautiful and soothing or distressing, sparking anxiety.

It’s difficult to explain to anyone without chronic tinnitus what living with it is like—especially since we all might hear a variety of sounds, loud or soft, continuous or discontinuous. This poem is my attempt to pin down a few of those sounds.

—Cortney Davis

Cortney Davis is the author of five poetry collections, most recently Daughter (Grayson Books) and I Hear Their Voices Singing: Poems New & Selected (Antrim House Books). Her honors include an NEA Poetry Fellowship, three CT Commission on the Arts Poetry Grants, two CT Center for the Book Awards, and six Books of the Year awards from the American Journal of Nursing.

Cortney served as the first poet laureate of Bethel, Connecticut, 2019–2021. http://www.cortneydavis.com

29th Annual International In-Person/Online Conference

Management of the Tinnitus & Hyperacusis Patient

ND DIAMO OR SPONS

The 29th Annual International Conference, Management of the Tinnitus & Hyperacusis Patient is scheduled to be held June 16-17, 2022, at the University of Iowa. The educational event is intended for otologists, audiologists, hearing aid specialists, and other healthcare professionals providing clinical services for tinnitus patients. Topics include an overview of current evaluation practices, management strategies, and research. Presentations are given by leading researchers, practitioners, and leaders in advocacy and include the latest developments in the areas of medical treatments, neuroscience, sleep therapy, noise-induced hearing loss, and hyperacusis.

The conference, which is being held in person and online, is intended to increase the knowledge and skills of clinicians; however, it is open to patients and their families, with the understanding that no individual diagnosis or treatment will be offered.

For more information, visit the University of Iowa’s website: https://medicine.uiowa.edu/oto/education/conferences-and-events/ international-conference-management-tinnitus-and-hyperacusis

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www.ATA.org

Photo Credit: Jon Gordon

Tinnitus

TINNITUS RESOURCES 

Open Earbuds and Bone Conduction Headphones: Stream While Hearing the World Around You

By Joy Onozuka

Inspired by teens wearing only one earbud and athletes calling for earbuds that don’t put them at risk of being hit by cars, various electronics manufacturers came out with open-ear wireless earbuds and headphones. These products expand streaming options that don’t cancel out surrounding environmental sounds beyond bone conduction headphone options, which have been on the market for a while.

For folks with tinnitus and minimal hearing loss, or misophonia, open earbuds and bone conduction headphones are an affordable substitute for more expensive maskers prescribed by audiologists.

When looking at open earbuds or bone conduction headphones, consider the following: • The return policy. Before buying anything, check the return policy and buy only from stores or websites that offer at least a 30-day money-back guarantee.

• Fit. Everyone’s ear shape is different, so finding a comfortable fit can be challenging. If you wear glasses, masks, or safety helmets, the open earbuds should accommodate that as well. www.ATA.org

• Sound quality. Many open-ear wireless headphones use bone conduction technology to transmit sound directly to the inner ear, which requires a tighter fit and lacks the crisp audio quality of traditional earbuds. Higher-end manufacturers, such as Bose and Sony, produce open earbuds that send soundwaves through the air, which deliver a more natural listening experience. If you’re using the earbuds and headphones at home or while working, better sound quality may be important to you.

• Cost. A search on Amazon.com for “open-ear headphones” brings up dozens of options priced between $25 and $300. Check reviews and consider how often and where and what you’ll be using them for, since battery life and sound quality will matter more to some than others, depending on the situation.

• Sound levels. Noise-canceling earbuds enable users to stream music and podcasts at lower volumes, which may help to protect hearing.

Open-ear buds are—by design— competing with the sounds around us, so keep the volume

low, remembering that the intention when using them is to hear what’s going on around you.

• One earbud. Because of their closed-fit design, earbuds block out many sounds. Nonetheless, the teens had it right that wearing one earbud may do the trick in streaming soft sounds while remaining tuned in to the environment around you. So, if your tinnitus is only in one ear and you’re in a safe indoor or outdoor environment, try one closed-fit earbud in either ear to see whether it’s comfortable and versatile enough to provide effective masking at a low volume. *The American Tinnitus Association does not recommend or endorse products for tinnitus relief, so please use discretion when buying devices for such purposes.

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 PERSONAL STORY

The Music Didn’t Stop With Tinnitus Music is my life. I’ve worked in the industry for nearly fifteen years and have played guitar and produced music since I was a teenager. Taking care of my hearing has been a top priority not only for the sake of my job but also for my quality of life.

I’ve played many of the world’s iconic stages and venues. With audiences of 10,000 and more, the sounds I’ve been a part of creating from the stage must be executed at a volume that creates an enjoyable experience for everyone, from the front row to the nosebleed seats.

While everyone on stage does their part to protect their hearing as they give repeat performances night after night, the experience for the audience is often much different since hearing protection isn’t necessarily on people’s minds. And despite all my efforts to protect my hearing over the years, my experience with tinnitus illustrates that things can go wrong, even when you’re doing everything right.

On Monday, October 26, 2020, I woke up with very loud ringing in my ears that has persisted in some way, shape, or form ever since. Fortunately, I don’t have any hearing loss, and an ENT even confirmed I had “excellent hearing.” Despite the initial good news that my hearing was perfect, I was extremely stressed daily by the tinnitus to the point of tears. It felt 20

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as if my entire life as a creative, not to mention my love of music as a listener, was coming to an abrupt halt at a time when my career and creative fluidity were truly flourishing.

The nonstop tinnitus necessitated me taking a few months off from making music and leaning into my home life. I changed my eating habits, exercised as often as possible, and put more focus into my daily meditation practice. As I bettered both my physical and mental health, the tinnitus was less and less noticeable.

I also learned I have many friends who also experience tinnitus, some of whom are also in the music industry.

All these efforts, paired with being able to relate to others with the same

condition, brought me immense inner peace.

In a quest for answers about what caused my chronic tinnitus, the best explanation came from an allergist.

She mentioned it’s not uncommon for tinnitus to flare up after a round of antibiotics. Before my tinnitus started, I was prescribed a heavy regimen of antibiotics over the course of a month to help relieve the onset of cellulitis, which I developed from a bug bite.

Photo Credit: Chelse Kornse

By Doug Showalter

Doug performs with country music singer and songwriter Cam, as the opening act for Eric Church. www.ATA.org

PERSONAL STORY

make today is better than ever and I’ve been able to flourish, despite the overwhelming feeling of hopelessness that hit me at the end of 2020.

In my view and experience, tinnitus can be understood as an indicator of extreme or aggravated stress, so I encourage anyone experiencing it to begin a self-care journey ASAP to explore how reducing stress may make your tinnitus less intrusive.

It’s my hope that eventually science will lead to proper and consistent relief for anyone experiencing tinnitus.

While we wait for more effective treatment options and eventual cures, my journey has shown me that—with the proper tools and mindset—it can be controlled and managed. For me, better habits, greater confidence, and determination to live well, despite the unwanted added sound, has made all the difference.

I wish all of you the best on your journey to find what gives you relief from unwanted sound.

Doug Showalter is an American music producer, songwriter, and artist based in Nashville, Tennessee. Career highlights as a professional musician include touring internationally and performing many times on late-night and morning television talk shows with artists such as Van Hunt, actor Jared Leto’s band 30 Seconds to Mars, and platinum-recording country artist Cam. Doug played acoustic guitar on Cam’s triple-platinum hit song “Burning House” and was part of her touring band from 2014 to 2018.

Performance highlights include playing Bonnaroo Music Festival, Red Rocks Amphitheater opening for Eric Church, Madison Square Garden opening for Sam Smith, and Nissan Stadium alongside Lady Antebellum.

Photo Credit: Chelse Kornse

Ultimately, the antibiotics, mixed with the stress of the modern world, seem to have triggered and cranked up the tinnitus volume.

These days I take zero risks in the studio. I now wear custom earplugs while playing live drums, attending concerts, or in any situation where I feel my comfort is compromised by loud noise. I also make sure to get plenty of sleep, not drink much alcohol, and monitor my stress and anxiety closely through the help of therapy and my aforementioned meditation practice.

I feel extremely lucky that I’m able to continue to work with some of the biggest artists in the industry and spend nearly every day creating and utilizing my hearing skills to their maximum potential. For a musician, hearing is everything!

Though it may seem odd or hard to understand, I’ve grown appreciative of my tinnitus experience and the lessons it’s taught me. The music I

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Doug opening for George Strait with Cam at T Mobile Arena.

Support the American Tinnitus Association

by Shopping at When you’re shopping for friends and family on Amazon, the American Tinnitus Association hopes you’ll link your shopping account to , the online retailing company’s generous program that enables you to shop and contribute to your favorite nonprofit organization at the same time. Amazon pays all program expenses and donates half of a percent of the cost of your eligible purchases to your favorite earmarked charity. Won’t you choose the American Tinnitus Association to help us advance tinnitus research and treatments? https://smile.amazon.com/ch/93-0749558

www.ATA.org

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 TINNITUS RESOURCES

Tinnitus Q & A The Best Earplug Depends on the Situation and Sound

By LaGuinn Sherlock, AuD, ATA Tinnitus Program Advisor

Question: I have tinnitus and hyperacusis, which has left me fearful of being in public spaces, from taking a walk outside to going to the grocery store, without earplugs. Even though my audiologist told me to be careful about overusing earplugs, because that can make my hyperacusis worse, I’m terrified of unexpected loud sounds. Is it really harmful to wear earplugs whenever I go outside?

Do high-fidelity earplugs work for people with hyperacusis? How do I really know how much the volume is reduced wearing any type of earplug since everyone’s ear canal is different?

LaGuinn Sherlock, AuD: It is not unusual for people with tinnitus and hyperacusis to be phonophobic, that is, afraid of sound. Sudden sounds can be startling, setting off a reaction that can leave you feeling irritable, anxious, even physically ill. Your audiologist is correct, however, in warning you about overusing hearing protection. The effect of chronic overprotection has been shown to make people MORE sensitive to sound.1 It is unlikely that hazardous noise occurs in the grocery store, although unexpected loud sounds may indeed occur (e.g., someone 22

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drops something on the floor or the overhead announcements are uncomfortably loud for you). Avoidance behavior can increase your reaction to brief, uncomfortable sounds. Reacting to these sounds activates the stress response, increasing your heart rate and releasing the stress hormone cortisol. Relaxation exercises, such as deep breathing and imagery, can help to interrupt the stress response and enable you to participate in regular activities. A great article describing the stress response and importance of learning relaxation strategies is described here: https://www. verywellmind.com/what-is-a-stressresponse-3145148 To address your concern about how well a given earplug works, an audiologist can conduct a test to see how much your hearing protection devices (HPDs) attenuate sound and can assist you with proper placement. Foam and silicone earplugs that expand to completely close off your ear canal provide really good protection, but may not be as comfortable or provide adequate sound quality for long-term use.

But again, you want to avoid longterm use, EXCEPT when you are in an environment with hazardous noise levels.

Q: With the relaxation of pandemic restrictions, I’m back to enjoying live music events. My problem is the last concert I attended was louder than expected, causing my tinnitus to become much louder. A few days have passed with no change in the loudness of my tinnitus. Am I stuck with this, or can I expect the volume to decrease in the weeks ahead? Should I see my ENT physician about this? What type of hearing protection should I get for concerts in smaller venues, such as nightclubs and outdoor pavilions?

LS: It is not unusual for tinnitus volume to increase following loud noise exposure. It has been well established that loud noise can damage delicate structures in the inner ear. With repeated exposure, the damage can become permanent, resulting in hearing loss. Generally, an increase in tinnitus volume will subside within about two weeks, but the time course of recovery is difficult to predict. It is very important to allow your ears to “rest” after noise exposure to aid in the recovery process. A change in existing tinnitus, caused by noise exposure, does not necessarily mean you need an appointment with your ENT. However, if you notice a change in your hearing, a hearing test is highly recommended.

www.ATA.org

TINNITUS RESOURCES 

Hearing protection devices (HPDs) that filter incoming sound in order to maintain sound quality, such as musicians earplugs, are designed for musical events. Standard filter strengths are 9, 15, and 25 dB; the higher the number, the more protection you receive. Musicians, or filtered, HPDs can be customized to fit your ear securely, increasing the probability of optimal sound reduction. Your audiologist can make ear impressions, which you can use to order musicians earplugs from your audiologist, or you can send them to the manufacturer of your choosing.

Some manufacturers offer in-home ear impression kits (typically using digital technology to take a picture of your ear canal that’s used to re-create it in the lab).

Q: I’ve had tinnitus for about seven months, which has been a struggle to manage. I don’t want to miss out on being with my family and friends at sporting events, but I can’t follow conversations while I’m wearing foam earplugs. I’m also not sure how much protection foam earplugs really have at a stadium with a lot of loud fans. Are custom earplugs better? Will I be able to hear better with them without the risk of further hearing damage? How long do they last?

LS: Kudos to you for looking for options to continue doing activities you enjoy—this is key to managing tinnitus. The amount of sound reduction provided by a foam earplug can be as much, or greater, than that provided by a custom earplug. Hearing protection devices (HPDs) receive a noise reduction rating, referred to www.ATA.org

as NRR. The highest NRR is 33. The rating is determined in a laboratory setting and indicates the degree of noise attenuation for a properly fitted HPD. However, the NRR does not represent the actual decibel reduction in the real world. To estimate the actual reduction, you must essentially divide the NRR by 2 (there are more specifics to calculating real-world attenuation that depend on whether the noise is measured in dB A or dB C). For example, if you are attending a stadium event, with an estimated noise level of 105 dB, and using foam earplugs with an NRR of 29, your estimated exposure would be 90.5 dB. This is still quite loud! You could improve your protection from noise by combining earplugs and earmuffs.

Custom earplugs, without filtering (see answer above), will attenuate in a manner similar to foam earplugs, but the attenuation may be more reliable.

Custom earplugs will last longer than foam earplugs, but may shrink slightly over the course of one to two years.

Foam and silicone earplugs are available at your local drugstore. The advantage of silicone earplugs is that they can be washed and reused. For the best possible fit of hand-formed earplugs, roll them between your thumb and forefinger while applying gentle pressure in order to make the earplug small before placing it in your ear canal as deeply as you can. When the earplug expands, you should notice a reduction in noise. You should also notice that your voice sounds louder in your head. This is normal and expected. Another earplug style is referred to as flanged (double- or tripleflanged). This style is pushed into the ear canal until it feels secure.

It is indeed more difficult to understand speech when wearing foam earplugs. Another option to consider is electronic earplugs, which use circuitry to actively cancel steadystate noise, while providing some pass-through of nearby conversation.

Electronic hearing protection devices are the most expensive but may be a good investment for you. A great summary of hearing protection devices for different uses is described here: https://www.clearliving.com/ hearing/technology/earplugs/ LaGuinn Sherlock, AuD, is a licensed audiologist with over 30 years of clinical and research experience.

She started her career at Johns Hopkins Hospital, then spent nearly 20 years working at the University of Maryland Medical Center, home of one of the first tinnitus specialty clinics in the country. She currently works for the U.S. Army Public Health Center, in the Hearing Conservation and Readiness Branch, with duty at Walter Reed National Military Medical Center. Over the course of her career, she has provided clinical care to thousands of patients with tinnitus and has been involved in numerous research studies related to amplification, hearing protection, tinnitus, and hyperacusis. She has served on the board of directors of the American Tinnitus Association and continues to serve as an advisor with ATA’s Tinnitus Advisor Program.

1 C. Formby, L. P. Sherlock, S. L. Gold, & M. L. Hawley.

(2007). Adaptive recalibration of chronic auditory gain. Seminars in Hearing, 28, 295–302.

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What Is a Sound Tolerance Condition?

A Closer Look at Hyperacusis, Misophonia, Noise Sensitivity, and Phonophobia

By James A. Henry, PhD

Sound Tolerance Conditions Affect Millions of People The field of medicine addressing sound tolerance conditions— hyperacusis, misophonia, sound sensitivity, and phonophobia—is in its relative infancy. Although these conditions have always existed, it wasn’t until the last few decades that distinctions have been clarified between the different types, with terminology specific to each.

The following article reviews the different conditions—what they are, how they differ, how they are assessed, and how they are treated. The information is derived largely from the scientific literature, although the literature itself is inconsistent with respect to terminology and definitions.

The reader is encouraged to stay abreast of ongoing developments in the field, which will be summarized in future issues of Tinnitus Today.

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In today’s high-tech society, it is the norm to be surrounded by sound all day long—music, machines, TV, radio, traffic noise, crowd noise…and on and on. This stream of daily sound is just a fact of life and most of us are quite used to it. But that is not the case for everyone—sound is a significant problem for those who have a “sound tolerance condition,” meaning difficulty tolerating sounds that are comfortable for most people.

Sound tolerance conditions are varied and nuanced. Without distinguishing between the different types, people often refer to any sound tolerance condition as “hyperacusis,” although many different terminologies have been used.1 Hyperacusis is indeed the most common type; others include “misophonia” (pronounced mee-so-fonia) and “noise sensitivity.”

“Phonophobia” is a related condition.

Before describing these different types, it is important to point out complaints that are often confused with a sound tolerance condition.

What Is Not a Sound Tolerance Condition?

A sound tolerance condition is not the typical annoyance caused by everyday sounds such as a baby crying, a squeaky chair, “thumping” music from cars or next door, or hearing someone make a controversial statement. People are often irritated by these kinds of sounds, and many others, but such irritation does not rise to the level of a chronic condition that might benefit from professional help.

Users of hearing aids may complain that certain sounds are too loud when amplified. Such a complaint is not a sound tolerance condition but rather is simply an indication that the hearing aids need to be adjusted to achieve comfort with all amplified sounds.2 Loudness recruitment is often confused with a sound tolerance condition. Loudness recruitment, however, is a distinctly different phenomenon.3 It can be understood by thinking about the range between two levels (think “intensities”) of sound: the lower level at which a person just begins to detect the sound (the threshold of hearing), and the

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SPECIAL FEATURE

upper level at which sound becomes uncomfortably loud (the loudness discomfort level, or LDL). Loudness “grows” within this intensity range, which is called the “dynamic range.”

With hearing loss, the dynamic range is reduced, or compressed, so loudness grows at a faster rate than for the person with normal hearing.

This accelerated growth of loudness within the dynamic range, which is a natural consequence of hearing loss, is what defines loudness recruitment. It is not a sound tolerance condition.

What Is a Sound Tolerance Condition?

Hyperacusis Hyperacusis is physical discomfort or pain when any sound reaches a certain intensity level.

With hyperacusis, the upper end of the dynamic range (the LDL) is reduced, which is its defining feature. Most people can comfortably tolerate sounds as loud as power tools or a lawnmower (although they should be protecting their ears with earplugs or earmuffs). The person with hyperacusis cannot tolerate such high-intensity sounds and may only be comfortable with sound that is no louder than someone talking.

Sometimes even the human voice is too loud.

Hyperacusis and tinnitus are often co-occurring. It has been reported that up to 90 percent of people with hyperacusis also have tinnitus.4 And it is commonly reported that about 40 percent of people with

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tinnitus also have hyperacusis.5 This relationship appears to increase with greater tinnitus severity.6,7 One study estimated the occurrence of hyperacusis for people with severe tinnitus was as high as 80 percent.7 All of these prevalence estimates, however, depend on many variables, such as the questions asked to diagnose hyperacusis, and how the questions are interpreted by the individual. Notably, the prevalence of hyperacusis co-occurring with tinnitus, regardless of severity, has been reported to range from 7 percent8 to 79 percent.9

Misophonia Misophonia refers to intense emotional reactions only to certain sounds, regardless of their loudness.10 The person with misophonia typically cannot tolerate sounds made by the mouth or nose.

The most common examples of these oral and nasal sounds are chewing, breathing, lip-smacking, crunching, sniffling, and swallowing.11 Hence, these people often cannot remain at a table where others are eating.

Other sounds people make can trigger misophonic reactions, such as repeated clicking of a ballpoint pen, typing, and foot tapping. Problem sounds can include any sound in the environment that causes these same emotional reactions.12 The term misophonia, which means “hatred or dislike of sound,” was first introduced in 2002 by Drs. Margaret and Pawel (pronounced

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pah-vul) Jastreboff.10,13 The condition certainly existed prior to that but was referred to by a variety of terms.

Individuals with misophonia react with sympathetic nervous system arousal and emotional distress when exposed to trigger sounds.14 The dominant emotion is anger, although other emotions can include impatience, irritation, aggravation, disgust, and anxiety.10,15,16 The condition usually begins during childhood or adolescence10,17,18 and may be triggered by a particular person.17 It has been argued that misophonia is a psychological condition that may require treatment from a behavioral health provider,19 and that it is a distinct psychiatric disorder.16

Noise Sensitivity Noise sensitivity refers to general discomfort (annoyance or feeling overwhelmed) due to a perceived noisy environment. As for misophonia, noise sensitivity is not a loudness tolerance problem. That is not to say that a higher level of noise does not cause greater reactions, which very well may be the case.

A helpful way to understand noise sensitivity is to think about the person with post-traumatic stress disorder (PTSD) who is hypervigilant and “jumpy.” Such a person may react to just about any unexpected sound with a startle response. Or just background sound may cause anxiety. People with noise sensitivity are generally most comfortable in a quiet environment.

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People with noise sensitivity may have emotional reactions to sound, such as annoyance, and/or they may feel threatened by sound.20 Noise sensitivity is a fairly common trait, with estimates of its prevalence ranging from 20 percent to 40 percent.21 The condition ranges in severity from “low noise sensitivity” to “high noise sensitivity.”20 It has been estimated that the prevalence of people with high noise sensitivity (that is, those who are extremely noisereactive) is around 12 percent.22,23 It should be noted, however, that terminology and definitions have been inconsistent in both the clinical and research literature, making it difficult to compare and interpret studies in a consistent fashion.24

Phonophobia Phonophobia is in a different category than the other sound tolerance conditions. Phonophobia has nothing to do with reactions to sound but rather is a condition of anxiety due to the fear that a sound, or sounds, may occur that causes discomfort, pain, or anxiety. Phonophobia might be akin to the person with PTSD who has noise sensitivity and is fearful of sound becoming uncomfortably loud or annoying. People with phonophobia often do not want to venture outdoors because of the unpredictable nature of sounds in the outdoor environment. These sounds can involve loud cars and motorcycles, air brakes from a bus, people yelling, children screaming, and so on. It would be common for a person with phonophobia to wear earplugs and/or earmuffs when outdoors.

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A review of the literature reveals that phonophobia is a term that is often used to describe sound intolerance in migraine headaches.25–27 In those publications, the term is defined essentially as we have defined hyperacusis, that is, as a hypersensitive reaction to the loudness of sounds. One study provided a clear distinction between phonophobia and hyperacusis, which we quote here: “Phonophobia is defined as a persistent, abnormal,

Sound Tolerance Conditions in Brief • Hyperacusis is physical discomfort or pain when any sound reaches a certain level of loudness that would be comfortable for most other people.

• Misophonia refers to intense emotional reactions only to certain sounds (usually body sounds such as chewing and sniffling), regardless of their loudness.

• Noise sensitivity refers to general discomfort (annoyance or feeling overwhelmed) due to a perceived noisy environment, regardless of its loudness.

• Phonophobia has nothing to do with reactions to sound but rather is a condition of anxiety due to the fear that a sound, or sounds, may occur that causes discomfort, pain, or anxiety.

and unwarranted fear of sound. Often, these are normal environmental sounds (for example, traffic, kitchen sounds, doors closing, or even loud speech) that cannot under any circumstances be damaging.

Phonophobia may also be related to, caused by, or confused with hyperacusis, which is abnormally strong reaction to sound, occurring within the auditory pathways, in levels that would not trouble a normal individual”28.

How Is a Sound Tolerance Condition Assessed?

Need for Consistent Use of Terms and Definitions The terminology and definitions provided above are largely consistent with how these terms are defined in the scientific literature. The literature, however, also contains many inconsistencies. When writing about or doing an assessment for sound tolerance conditions, it is therefore important to always define the terms used.

Challenges Challenges to assessing sound tolerance conditions include the following: 1 The great majority of clinicians are neither trained nor experienced in diagnosing sound tolerance conditions.

2 The nuances involved with each sound tolerance condition are numerous and the distinctions between the different conditions are easily blurred.

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No standards exist for the clinical assessment of sound tolerance conditions.

Because of these challenges, it is suggested that clinicians at least become familiar with the different conditions, know how to screen for a sound tolerance condition, and be sufficiently knowledgeable to assist patients in understanding their complaint and making informed decisions.

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Screening for a Sound Tolerance Condition The Tinnitus and Hearing Survey is a one-page instrument that contains 10 items.29 The last two items screen for a sound tolerance problem. The first of these two items asks if the person has experienced sounds over the past week that were too loud or uncomfortable when they seemed normal to other people. Response choices range from “not a problem” to “a very big problem.” If any degree of a problem is noted, then the person is asked to “list two examples of sounds that are too loud or uncomfortable for you, but seem normal to others.”

The examples provided can be very revealing as to the nature of the sound tolerance problem, or if the person is just annoyed by sounds that would be annoying to just about anyone.

Further questioning is often necessary to properly interpret the responses.

If the person screens positive for a sound tolerance problem, then more in-depth assessment of the problem is warranted.

Sound Tolerance Interview The Sound Tolerance Interview was developed to diagnose hyperacusis,30 but has since been revised to also assess for misophonia, noise www.ATA.org

sensitivity, and phonophobia. Although a number of different questionnaires are available for assessing sound tolerance conditions, the Sound Tolerance Interview is highlighted here because it has been in use for more than 10 years, and the current version is appropriate for in-depth assessment of all types of sound tolerance conditions. The Interview focuses on functional effects, that is, how a sound tolerance problem affects everyday activities. With a good understanding of the different conditions, administering the Sound Tolerance Interview enables an informed and reasonably accurate diagnosis of sound tolerance conditions.

The Interview can be viewed or downloaded at this link: https://www. ncrar.research.va.gov/Documents/ SoundToleranceInterview.pdf

Loudness Discomfort Levels (LDLs) For assessment of sound tolerance conditions, it is often recommended to measure LDLs.1 It has been shown, however, that LDLs cannot be relied upon to accurately represent a person’s ability to tolerate sound in daily life.31–34 A further concern is that LDL testing can cause the type of discomfort that defines the complaint.35 That is, patients who are the least likely to be comfortable with LDL testing are the ones tested.

For these reasons, LDL testing is not normally recommended. The best indicator for establishing the degree of a sound tolerance problem, and to monitor progress during treatment, is the person’s subjective report—which is facilitated through a structured interview. The Sound Tolerance

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Interview was developed for this purpose.30

How Is a Sound Tolerance Condition Treated?

Regardless of the type of sound tolerance condition, treatment generally involves desensitization, which means systematic exposure to the types of sounds that are problematic to the person. It is important, however, to consider the possibility of psychological issues that may require the clinical services of a psychologist or other behavioral health provider. The specific treatment appropriate for an individual is based on a number of factors: 1 Does the person use hearing aids?

2 Does the person have tinnitus?

3 Is the condition primarily one involving the auditory pathways or are emotional reactions the primary concern?

4 How severe is the condition?

5 Can an audiologist provide the treatment, or should a behavioral health provider also be involved?

6 Is overprotection with earplugs and/or earmuffs a concern?

7 Is a fear response involved?

Treatment Based on Severity When assessing a sound tolerance condition, it is essential to determine whether the condition is “mild,” “moderate,” or “severe” with respect to how it affects the person. If mild or moderate, generally only minimal counseling is needed to teach patients how to use systematic desensitization.

Treatment for a severe sound tolerance condition is fairly rigorous

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and should involve close collaboration between clinician and patient.

Treatment of Hyperacusis Remembering that hyperacusis is a condition of the auditory system, treatment is specific to the auditory pathways. Hyperacusis is not in itself an emotional condition, but can certainly result in secondary emotional reactions.

Hyperacusis treatment with Progressive Tinnitus Management (PTM) was adapted from the approach used with Tinnitus Retraining Therapy (TRT).30,36–38 For both methods, treatment involves being in an environment of background sound 24/7 (and always at a comfortable level) to gradually increase the upper level (LDL) of the dynamic range.

Wearable (ear-level) sound generators are favored with TRT to provide a high degree of control of the sound exposure. The sound generators should be used during all waking hours, with some kind of bedside sound generator used while sleeping.

Treatment of Misophonia Treatment of misophonia is not so straightforward as it is for hyperacusis. With hyperacusis, the objective is to reduce the sensitivity of the auditory system. Treatment of misophonia attempts to reduce the emotional reactions caused by sound—usually soft oral and nasal sounds. Treatment targets the types of sounds that trigger the reactions, which may require counseling by a qualified psychologist or other behavioral health provider. There are few well-established, research-based 28

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treatments for misophonia.39 We focus here on TRT and cognitive behavioral therapy (CBT).

With TRT, the focus is to create a positive association with sound by paying attention to pleasant sound.36,38 Active listening to pleasant sounds is different from having sounds in the background that are essentially ignored. The intent is to promote positive feelings about listening to these sounds. Hyperacusis and misophonia often occur together. In such cases, treatment should include both desensitization of the auditory system to address the hyperacusis and active listening to pleasant sounds to address the misophonia.

A number of case studies were published that involved the use of CBT to treat misophonia, with successful results.40–42 In one trial, CBT was effective in treating 48 percent of 90 patients.18 The first randomized controlled trial of CBT for misophonia compared CBT to a wait-list control group and showed both short- and long-term efficacy of CBT.39 In that study, a specific protocol was described. Using that protocol, CBT can be implemented for treating misophonia in clinical practice.

Treatment of Noise Sensitivity Like misophonia, noise sensitivity is a complex condition that may or may not be amenable to a straightforward approach of using systematic desensitization with trigger sounds.

It appears that currently there are no treatments specific to noise sensitivity. An audiologist can certainly use systematic desensitization in the attempt to reduce reactivity to sound in general.

However, if the

condition is severe and comorbid with other psychological conditions, then a qualified psychologist or other behavioral health provider would need to be involved in both assessment and treatment of the condition.

Treatment of Phonophobia A sound tolerance condition is not phonophobia if there is no fear involved.36–38 People can be fearful that certain sounds will cause damage to the auditory system or cause their hyperacusis or tinnitus to become worse. These sounds that are feared, however, are generally harmless.

Treatment for phonophobia involves specific counseling regarding the benign nature of sounds that cause fear and developing an understanding that the auditory system needs sound for healthy functioning. With TRT, the identical sound-therapy protocol is used for phonophobia as for misophonia.

Summary The field of medicine addressing sound tolerance conditions is in its relative infancy. Although these conditions have always existed, it wasn’t until the last few decades that distinctions have been clarified between the different types, with terminology specific to each. The present article reviews the different conditions—what they are, how they differ, how they are assessed, and how they are treated. The information is derived largely from the scientific literature, although the literature itself is inconsistent with respect to terminology and definitions. The reader is encouraged to stay abreast of ongoing developments in the field, which will be summarized in future issues of Tinnitus Today. www.ATA.org

SPECIAL FEATURE

James A. Henry, PhD, is a certified and licensed audiologist with a doctorate in behavioral neuroscience. He is employed as a Veterans Affairs (VA) Rehabilitation, Research & Development (RR&D) Senior Research Career Scientist at the VA RR&D National Center for Rehabilitative Auditory Research (NCRAR) located at the VA Portland Health Care System. He is also Research Professor in the Department of Otolaryngology—Head and Neck Surgery at Oregon Health & Science University. For the past 25 years, he has devoted his career to tinnitus research. His overall goals are to develop and validate clinical methodology for effectively helping individuals with bothersome tinnitus and to increase accessibility to evidence-based tinnitus care.

1 K. Fackrell, I. Potgieter, G. S. Shekhawat, D. M. Baguley, M. Sereda, & D. J. Hoare. (2017).

Clinical interventions for hyperacusis in adults: A scoping review to assess the current position and determine priorities for research. BioMed Research International, 2017, 2723715.

2 L. P. Sherlock & C. Formby. (2017). Considerations in the development of a sound tolerance interview and questionnaire instrument. Seminars in Hearing, 38(1), 53–70.

3 K. Radziwon, B. D. Auerbach, D. Ding, X. Liu, G. D. Chen, & R. Salvi. (2019). Noise-induced loudness recruitment and hyperacusis: Insufficient central gain in auditory cortex and amygdala. Neuroscience, 422, 212–227.

4 H. Aazh, D. McFerran, R. Salvi, D. Prasher, M. Jastreboff, & P. Jastreboff. (2014). Insights from the First International Conference on Hyperacusis: Causes, evaluation, diagnosis and treatment. Noise and Health, 16(69), 123–126.

5 P. J. Jastreboff, W. C. Gray, & S. L. Gold. (1996).

Neurophysiological approach to tinnitus patients.

American Journal of Otology, 17, 236–240.

6 D. Raj-Koziak, E. Gos, J. Kutyba, H. Skarzynski, & P. H. Skarzynski. (2021). Decreased sound tolerance in tinnitus patients. Life (Basel), 11(2).

7 C. R. Cederroth, A. Lugo, N. K. Edvall, et al. (2020).

Association between hyperacusis and tinnitus.

Journal of Clinical Medicine, 9(8).

8 W. Hiller & G. Goebel. (2007). When tinnitus loudness and annoyance are discrepant: Audiological characteristics and psychological profile. Audiology and Neuro-Otology, 12(6), 391–400.

9 R. Dauman & F. Bouscau-Faure. (2005). Assessment and amelioration of hyperacusis in tinnitus patients.

Acta Otolaryngology, 125(5), 503–509.

10 D. B. Palumbo, O. Alsalman, D. De Ridder, J. J. Song, & S. Vanneste. (2018). Misophonia and

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potential underlying mechanisms: A perspective. Frontiers in Psychology, 9, 953.

11 M. Siepsiak, A. Sliwerski, & W. Lukasz Dragan. (2020).

Development and psychometric properties of MisoQuest—A new self-report questionnaire for misophonia. International Journal of Environmental Research and Public Health, 17(5).

12 H. A. Hansen, A. B. Leber, & Z. M. Saygin. (2021).

What sound sources trigger misophonia? Not just chewing and breathing. Journal of Clinical Psychology, 77(11), 2609–2625.

13 M. M. Jastreboff & P. J. Jastreboff. (2002).

Decreased sound tolerance and Tinnitus Retraining Therapy (TRT). Australian and New Zealand Journal of Audiology, 24, 74–81.

14 M. Erfanian, C. Kartsonaki, & A. Keshavarz. (2019).

Misophonia and comorbid psychiatric symptoms: A preliminary study of clinical findings. Nordic Journal of Psychiatry, 73(4–5), 219–228.

15 R. Rouw & M. Erfanian. (2018). A large-scale study of misophonia. Journal of Clinica Psychology, 74(3), 453–479.

16 I. Jager, P. de Koning, T. Bost, D. Denys, & N. Vulink.

(2020). Misophonia: Phenomenology, comorbidity and demographics in a large sample. PLoS One, 15(4), e0231390.

17 M. Edelstein, D. Brang, R. Rouw, & V. S. Ramachandran. (2013). Misophonia: Physiological investigations and case descriptions. Frontiers in Human Neuroscience, 7, 296.

18 A. Schroder, N. Vulink, & D. Denys. (2013).

Misophonia: Diagnostic criteria for a new psychiatric disorder. PLoS One, 8(1), e54706.

19 S. Taylor. (2017). Misophonia: A new mental disorder? Medical Hypotheses, 103, 109–117.

20 D. Shepherd, M. Heinonen-Guzejev, K. Heikkila, et al. (2015). The negative affect hypothesis of noise sensitivity. International Journal of Environmental Research and Public Health, 12(5), 5284–5303.

21 M. Heinonen-Guzejev. (2008). Noise sensitivity: Medical, psychological and genetic aspects. Helsinki University Press.

22 I. van Kamp, R. F. Job, J. Hatfield, M. Haines, R. K. Stellato, & S. A. Stansfeld. (2004). The role of noise sensitivity in the noise-response relation: A comparison of three international airport studies.

Journal of the Acoustical Society of America, 116(6), 3471–3479.

23 H. Booi & F. van den Berg. (2012). Quiet areas and the need for quietness in Amsterdam. International Journal of Environmental Research and Public Health, 9(4), 1030–1050.

24 D. Shepherd, M. Heinonen-Guzejev, M. J. Hautus, & K. Heikkila. (2015). Elucidating the relationship between noise sensitivity and personality. Noise and Health, 17(76), 165–171.

25 R. W. Evans, T. Seifert, J. Kailasam, & N. T. Mathew.

(2008). The use of questions to determine the presence of photophobia and phonophobia during migraine. Headache, 48(3), 395–397.

26 J. Kalita, U. K. Misra, & R. Bansal. (2021).

Phonophobia and brainstem excitability in migraine. European Journal of Neuroscience, 53(6), 1988–1997.

27 J. V. Vingen, J. A. Pareja, O. Storen, L. R. White, & L. J. Stovner. (1998). Phonophobia in migraine.

Cephalalgia, 18(5), 243–249.

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28 Z. A. Asha’ari, N. Mat Zain, & A. Razali. (2010). Phonophobia and hyperacusis: Practical points from a case report. Malaysian Journa of Medical Science, 17(1), 49–51.

29 J. A. Henry, S. Griest, T. L. Zaugg, et al. (2015). Tinnitus and Hearing Survey: A screening tool to differentiate bothersome tinnitus from hearing difficulties. American Journal of Audiology, 24(1), 66–77.

30 J. A. Henry, T. L. Zaugg, P. M. Myers, & C. J. Kendall.

(2010). Progressive Tinnitus Management: Clinical handbook for audiologists. Plural Publishing.

31 T. L. Zaugg, E. J. Thielman, S. Griest, & J. A. Henry.

(2016). Subjective reports of trouble tolerating sound in daily life versus loudness discomfort levels.

American Journal of Audiology, 25(4), 359–363.

32 M. Anari, A. Axelsson, A. Eliasson, & L. Magnusson.

(1999). Hypersensitivity to sound—questionnaire data, audiometry and classification. Scandinavian Audiology, 28(4), 219–230.

33 P. R. Filion & R. H. Margolis. (1992). Comparison of clinical and real-life judgments of loudness discomfort. Journal of the American Academy of Audiology, 3(3), 193–199.

34 G. Goebel & U. Floetzinger. (2008). Pilot study to evaluate psychiatric co-morbidity in tinnitus patients with and without hyperacusis. Audiological Medicine, 6, 78–84.

35 D. M. Baguley & D. J. Hoare. (2018). Hyperacusis: Major research questions. HNO, 66(5), 358–363.

36 J. A. Henry, D. R. Trune, M. J. A. Robb, & P. J. Jastreboff. (2007). Tinnitus retraining therapy: Clinical guidelines. Plural Publishing.

37 J. A. Henry, D. R. Trune, M. J. A. Robb, & P. J. Jastreboff. (2007). Tinnitus retraining therapy: Patient counseling guide. Plural Publishing.

38 P. J. Jastreboff & J. W. P. Hazell. (2004).

Tinnitus retraining therapy: Implementing the neurophysiological model. Cambridge University Press.

39 I. J. Jager, N. C. C. Vulink, I. O. Bergfeld, A. van Loon, & D. Denys. (2020). Cognitive behavioral therapy for misophonia: A randomized clinical trial.

Depress and Anxiety, 38(7), 708–718.

40 J. F. McGuire, M. S. Wu, & E. A. Storch. (2015).

Cognitive-behavioral therapy for 2 youths with misophonia. Journal of Clinical Psychiatry, 76(5), 573–574.

41 R. E. Bernstein & J. H. M. Ettema. (2013). A brief course of cognitive behavioural therapy for the treatment of misophonia: A case example. Cognitive Behaviour Therapist, 6, e10.

42 T. H. Dozier. (2015). Counterconditioning treatment for misophonia. Clinical Case Studies, 14, 374–387.

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 PERSONAL STORY

When Sounds Make You Angry or Annoyed Understanding Misophonia Through Tinnitus Retraining Therapy

By Jeannie Karlovitz, AuD

Do the sounds of people eating, drinking, chewing, or breathing make you feel annoyed, distressed, or even angry? Have family and friends called you overly sensitive? If so, you may have a condition called misophonia, or, literally, “hatred or dislike of sound.”

I learned about misophonia in 2009 at a Tinnitus Retraining Therapy (TRT) conference for audiologists and other professionals. I was there to improve my knowledge of tinnitus and hyperacusis to better help my patients.

Little did I know that I, too, would be helped when, at the conference, Drs. Pawel Jastreboff and Margaret Jastreboff gave a name to my own sound sensitivity issues.

As a teenager, I often overreacted to sounds, a personal trait remembered by my family with one part nostalgia and one part annoyance.

As an adult, I would react very negatively to my spouse if he tapped his spoon in his cereal bowl. He and my children teased me for being too sensitive to sounds, yet they would make accommodations for me. I wanted to change, too, to lessen my negative reactions to trigger sounds.

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Learning about misophonia made change possible.

At the TRT conference, the Jastreboffs reported that their work with patients who had tinnitus and sound sensitivity led them in 2001 to name and define misophonia as a subset of decreased sound tolerance, which involves an abnormal connection among the auditory, limbic, and autonomic nervous systems.1 Until recently, not much research has been done since the Jastreboffs’ groundbreaking work. However, in 2017, Sukhbinder Kumar and colleagues showed that “misophonia is associated with abnormal activation, functional connectivity, and structural changes in the brain and heightened autonomic responses of the body.” According to Kumar et al., “Misophonia is an affective sound processing disorder characterized by the experience of strong negative emotions (anger and anxiety) in response to everyday sounds.”2 After the TRT conference, I did my own reading and soon found that the research corresponded not only with my personal experience but also with many of my patients’ experiences.

As an audiologist, I have witnessed

how misophonia negatively affects my patients’ personal and family lives.

Parents have reported to me that their child can no longer eat with them because the child becomes enraged by the sound of chewing or slurping. Adult patients struggle with concentration at work because they are bothered by the sound of keyboard typing or pens clicking. Students in middle school through college have complained of the inability to think in the classroom when other students chew, drink, cough, or sniffle. Adult males have reported that they struggle interacting with their spouses or children because they cannot stand the breathing sounds of their family members. People with misophonia experience strong and instantaneous reactions to the types of sounds that go unnoticed by the general population. Many suffer daily and, at some point, some seek help.

I learned that while there is no cure for misophonia, there are management strategies for improving one’s life. Some techniques are aimed at retraining the brain to respond less viscerally, while others are aimed at reducing stress so it’s easier to cope with trigger sounds.

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PERSONAL STORY

For those of you who have tinnitus, many of the management strategies for misophonia (see box) also help in the management of tinnitus. Both conditions can undermine one’s quality of life, negatively affecting thoughts and emotions, concentration, and sleep. Retraining the brain to consider tinnitus as a neutral sound and retraining the brain to consider trigger sounds as neutral is the goal.

But it does not happen overnight with either condition. It takes time and practice utilizing multiple management strategies to get to a point where you may wake up one morning and realize that you are not reacting so strongly to your tinnitus or to your trigger sounds.

I tried some of these strategies, and I have experienced positive results. When driving in the car with

my family, I often use ear-level sound generators to reduce the awareness of trigger sounds in the car. The sound generators give me something else to listen to and focus my attention on. If you don’t have maskers, headphones with reduced noise canceling allow you to hear what’s going on without being triggered by random sounds. When eating with my son, I incorporate thought-restructuring strategies to reduce my annoyance. I talk to myself in my head and remind myself that he is not trying to annoy me. I also remind myself that he has a physical anomaly that causes his jaw to click when he eats food. This helps to bring down my negative reactions to that sound.

I worked a full year on reducing my negative reaction to my husband

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tapping his spoon in his cereal bowl.

I decided to incorporate a listening exercise I learned at a subsequent TRT conference—listening to a soft trigger sound in the presence of a louder, enjoyable sound. I listened to a favorite TV show while my husband ate his cereal. Over time, I found that my reaction to the tapping lessened as I learned to focus my attention on the TV show rather than the tapping.

I have shared these strategies with my patients and they have had similar positive results. None of my patients has been cured of misophonia, but most have experienced some level of improved quality of life (ranging from mild to significant improvement). There are other types of treatments that I have not mentioned in this article. I have no experience with them, but

Management Strategies for Misophonia 1 Educational counseling about the auditory system and how our brain processes sound, which can be provided by an audiologist with training in tinnitus 2 Sound therapy, utilizing pleasant sounds, to decrease awareness of trigger sounds ■ Can be played in the background, on earphones, or through hearing aids or maskers. Use whatever is affordable and most effective but doesn’t interfere with your ability to communicate 3 Thought restructuring to ■ change negative thoughts to neutral or positive thoughts

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■

slowly retrain the brain to consider trigger sounds less aversive/more tolerable

4 Relaxation exercises, such as ■ deep breathing ■ progressive muscle relaxation ■ guided imagery 5 Attention control exercises ■ Learning to move attention away from trigger sounds and onto something else 6 Consultation with mental health provider who specializes in ■ cognitive behavioral therapy (CBT) ■ dialectical behavioral therapy (DBT)

■

mindfulness

7 Regular exercise 8 Examples of practical solutions for certain triggers: ■ Use of sound therapy (see above) to reduce awareness of trigger sounds ■ Use of plastic utensils and plates when dining to minimize dish sounds ■ Use of sunglasses to decrease awareness of visual triggers ■ Use of rubber soles/heels to decrease stepping sounds ■ Use of lower ringtone/ vibration on cell phone

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you can research them by perusing the websites listed below.

Because misophonia diagnosis and treatment is an emerging field, be sure to ask practitioners about their specific training in the management of misophonia. If you work with an audiologist, he or she may recommend a management plan to incorporate sound therapy, relaxation exercises, attention control exercises, or a consult with a mental health provider to address the possibility of related anxiety and depression, as well as thought-restructuring exercises for misophonia management.

Jeannie Karlovitz, AuD, works as an audiologist at Advanced Hearing Solutions in Exton, Pennsylvania. Dr. Karlovitz specializes in the management of tinnitus, hyperacusis,

Misophonia Resources Jastreboff Hearing Disorders Foundation—www.tinnitus-pjj.com Misophonia Association—https://misophonia-association.org/ Misophonia Treatment Institute—https://misophoniatreatment.com/ Sensitive to Sound—www.sensitivetosound.com Tinnitus Practitioners Association—www.tinnituspractitioners.com

and misophonia. She’s a former member of the ATA’s Board of Directors.

She received her undergraduate degree in speech and hearing sciences from the University of Maryland, College Park, in December 1987. She earned her master’s from the University of Maryland in May 1990, and her Doctor of Audiology degree from Salus University in April 2009. Dr. Karlovitz is a member of the American Academy of Audiology, Pennsylvania Academy of Audiology, American Speech-Language-Hearing Association, and Tinnitus Retraining Therapy

Association. She initiated the Tinnitus Program at her clinic after attending her first of three TRT courses. She is passionate about helping patients suffering from tinnitus, hyperacusis, or misophonia regain their quality of life.

1 P. J. Jastreboff & M. M. Jastreboff. (2014).

Treatments for decreased sound tolerance (hyperacusis and misophonia). Seminars in Hearing, 35(2), 105–120.

2 S. Kumar, O. Tansley-Hancock, W. Sedley, et al.

(2017). The brain basis for misophonia. Current Biology, 27, 527–533.

Medical Disclaimer The content in Tinnitus Today magazine is intended to provide helpful health information for the general public. It is made available with the understanding that the American Tinnitus Association (ATA) is not engaged in rendering medical, health, psychological, or any other kind of personal professional services.

The magazine content should not be considered complete and, therefore, does not cover all physical conditions or their treatment as it relates to tinnitus and tinnitus management.

The ATA always recommends that you consult and work with a medical, health, or other competent 32

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professional when considering the best course of tinnitus management.

This begins with a medical examination to rule out possible underlying medical causes for tinnitus. If you’re interested in adopting guidance/suggestions made in the magazine, you should discuss this first with your medical provider before doing so.

Any information about drugs and supplements contained in the magazine is general in nature, and does not cover all possible uses, actions, precautions, side effects, or interactions of the medicines mentioned. The content of the magazine is not intended as medical advice for individual problems or for

making an evaluation for pursuing a particular course of action.

The ATA and authors of articles in the magazine specifically disclaim all responsibility for any liability, loss, or risk, personal or otherwise, which is incurred as a consequence, directly or indirectly, of the use and application of any of the content in the magazine. www.ATA.org

SCIENCE & RESEARCH NEWS 

How the Brain Responds to Sounds Tied to Misophonia Summary by John A. Coverstone, AuD

Misophonia is a sound tolerance condition that is characterized by strong emotional and physical reactions to specific sounds that others would generally find tolerable.

People with clinical misophonia usually have an intense physical reaction described as a visceral response, which results from experiencing significant discomfort.

We might relate to misophonia by imagining sounds that cause most of us to recoil, such as fingernails scraping on a blackboard. Those with clinical misophonia, however, experience these types of reactions to basic activities observed in others who are, for example, chewing, washing dishes, or typing on a keyboard.

Kumar along with a group of researchers from the United Kingdom and the University of Iowa were interested in determining whether misophonia responses would be visible on medical images.1 They used functional magnetic resonance www.ATA.org

imaging (fMRI), which measures changes in blood flow in the brain.

The brain needs oxygen to perform its work, and fMRI works on the principle that active areas of the brain demand greater blood flow to replenish oxygen that is used up.

The neural mechanism Kumar and colleagues wanted to study involved mirror neurons, which are a set of nerves in the brain that are known to direct certain muscle movements.

They become active when performing certain actions, but also when seeing someone else performing the same action. These mirror neurons were first discovered by di Pellegrino and colleagues at the University of Palma (he is currently at University of Bologna) and published in 1992.2 In that study, di Pellegrino noticed that some of the same neurons that were active when monkeys performed common tasks were also active when the monkeys watched the researchers perform the same tasks.

He described this mirroring effect,

which has been replicated in years since. Kumar and colleagues wanted to see whether this effect was true for people experiencing misophonia as well.

Seventeen people with misophonia were evaluated. It was confirmed that they had misophonia for sounds of orofacial actions, such as chewing, eating, or breathing. Some people have a type of misophonia that is triggered only by a particular person (often due to interpersonal problems). Study candidates were therefore screened to make sure they reacted to sounds regardless of who produced them—or even if presented with the sound alone. Candidates completed the Misophonia Amsterdam Questionnaire and needed to score high enough to be categorized as having moderate TINNITUS TODAY SPRING 2022

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or severe misophonia. Another 20 individuals without misophonia were recruited for the control group. At the end of the study, a few participants were excluded because of an inability to obtain quality images, leaving 16 people with misophonia and 17 without.

All participants were scanned while in a resting state—meaning no stimuli were presented during scanning. Those with misophonia were compared to those without it.

They were also compared to a group of individuals with misophonia from a previous study who had been scanned with fMRI while being subjected to potentially triggering

sounds. Some differences were significant when comparing scans.

The group of people with misophonia who were scanned in the resting state showed increased connections between the area of the brain responsible for facial movements and both the auditory cortex and the visual cortex. This suggests that people with misophonia have stronger connections between perceived sounds and images and parts of the brain that control face and mouth movements.

Participants in the prior study (those subjected to potentially triggering sounds) showed increased connectivity between the auditory cortex and the facial motor area when any sounds were presented.

This implies greater synchrony between these areas of the brain. Stronger connections with or without external

stimuli suggest that the brain is prewired to respond to trigger sounds.

Increased activity in the orofacial motor area of the brain was also noted when participants heard sounds identified as triggers for misophonia. Further, the orofacial motor area was activated proportionally to the amount of distress reported for misophonia.

These results were interpreted as meaning the orofacial motor area was mirroring actions observed in others.

This is a common effect and occurs in normal, healthy people as well.

People with misophonia, however, appear to have stronger mirroring of trigger sounds.

These results do not explain all misophonia, as people often have reactions to other types of sounds, such as someone typing on a keyboard, tapping a pen, or other repetitive sounds. However, if this mirroring action can explain even part of the misophonia response, it may provide an avenue to treatment to lessen the related symptoms.

1 S. Kumar, P. Dheerendra, M. Erfanian, E. Benzaquen, W. Sedley, P.E. Gander, M. Lad, D.E. Barniou, T.D. Griffiths. (2021). The motor basis for misophonia. Journal of Neuroscience, 41(26), 5762–5770.

2 G. di Pellegrino, L. Fadiga, L. Fogassi, V. Gallese, & G. Rizzolatti. (1992). Understanding motor events: a neurophysiological study. Experimental Brain Research, 91(1), 176-180.

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www.ATA.org

SPECIAL FEATURE

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When a Sports Head Injury Triggers Unexpected Auditory Issues When a concerned parent reached out to the ATA about his daughter’s ongoing avoidance of family meals and social events because of sound, following a severe sports-related concussion, we reached out to two experts in the field for more information on this complex, but not necessarily uncommon, phenomenon.

By Sarah M. Theodoroff, PhD, and Marisa Palandri, OTR/L

Concussion is a highly prevalent condition. Based on emergency department visits in the United States, every year an estimated 1 to 2 million sports-related concussions occur in school-age children and over 3 million adults are seen because of a traumatic brain injury.1,2,3 The rates of mild traumatic brain injuries (i.e., concussions) every year continue to increase. It is noteworthy that at least one out of five adults who sustained a concussion have symptoms that persistent one month after the injury.4 There are multiple post-traumatic auditory issues to be aware of, some that can be directly attributed to a concussion, while others are secondary to the trauma. Regardless of their etiology, any report of auditory issues should be monitored so that appropriate treatment plan(s) can be put in place. Unfortunately, many auditory symptoms go undetected by healthcare professionals working with patients who have sustained a concussion. Partially, this is due to lack www.ATA.org

of standardized screening tools and the reliance on patients to self-report symptoms. The purpose of this article is to increase awareness of auditory issues associated with concussion and provide guidance on assessment and management in the hopes of improving time from injury to clinical recovery.

The initial evaluation of a patient who has had a concussion includes • obtaining a thorough case history, • performing a clinical interview to document symptoms and assess their severity, • neurological and cognitive testing, • vestibular and motor function testing, and • performing mental health screening.5 An emerging approach in the assessment process is to categorize patients using “clinical profiles,” which account for clusters of symptoms according to five concussion subtypes: Cognitive, Ocular-Motor, Headache/ Migraine, Vestibular, and Anxiety/ Mood. Recently, there has been momentum to include an Auditory subtype as a sixth category.6,7

The primary auditory symptoms associated with concussion are tinnitus, noise sensitivity, hyperacusis, and hearing difficulties.7,8 Tinnitus is a ringing, roaring, or buzzing in the ears or head that lasts for at least five minutes. When head and neck maneuvers, forceful muscle contractions, or jaw movements trigger or exacerbate the loudness or pitch of the tinnitus, then somatosensory tinnitus is suspected. In these instances, an interprofessional approach to assessment and management involving a physical therapist and audiologist is appropriate to address both the tinnitus and underlying musculoskeletal issue simultaneously.

Noise sensitivity describes an increased reactivity to everyday sounds that encompasses a range of psychological attributes, often including annoyance or feeling overwhelmed by the sounds in the environment. This phenomenon describes reduced tolerance to ambient sounds, such that all sounds in the environment are attended to.

In complex listening environments, typically, we can shift our attention to focus on only what we want to listen to and ignore other sounds around us.

After experiencing a head injury, this is no longer an easy task for the brain to do. Often, there is “too much noise” to accomplish everyday tasks without TINNITUS TODAY SPRING 2022

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SPECIAL FEATURE

getting overwhelmed and fatigued (e.g., sitting in a coffee shop, busy restaurants, grocery shopping).

Hyperacusis describes a decreased sound tolerance driven by the perceived loudness of ordinary sounds. It often includes physical discomfort and sometimes pain when listening to sounds that are at moderate or low intensity levels.

Moderate-to-low intensity levels correspond to the volume of a conversation in quiet, which most people find tolerable. It is important to note and monitor any reported sound sensitivity, whether it be hyperacusis, noise sensitivity, or another type of decreased sound tolerance, and determine whether it is associated with a comorbid condition such as headache, because posttraumatic headache often includes a cluster of sensory sensitivities (sound, smell, touch, etc.). Because of the heterogeneity of symptoms, it is important to consider whether auditory symptoms co-occur with another concussion subtype or present by themselves so that the treatment plan can be targeted to best meet the needs of the patient.

Routine assessment and monitoring are key because although many sports-related concussion symptoms resolve within a month, other patients experience prolonged recovery beyond three months.5,9 There are multiple factors that can contribute to prolonged recovery (e.g., younger age, symptom severity, medical history).10 Concussion symptom severity can be exacerbated by a variety of stressors (physical, psychiatric, cognitive, emotional), which is why it is important to monitor the patient’s symptoms that are present immediately after the injury, as well as symptoms that present later. It

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is possible these symptoms were also present initially after the injury but went unnoticed. Often, after primary symptoms resolve, other symptoms come to the forefront. For example, it is common for noise sensitivity and hearing difficulties in complex listening environments to become more noticeable after other symptoms resolve and patients start being more active again. Because patients may find articulating their complaints and experiences difficult, it is important to include screening questions for auditory conditions at initial and follow-up visits so that they do not go undetected.

A common screening question is, “Do you have difficulty tolerating everyday sounds because they seem too loud or bother you for other reasons?” Any response of “yes” should be followed by asking for examples as well as finding out whether ordinary sounds cause any pain or physical discomfort. For patients who experience any type of decreased sound tolerance, it is important to counsel on appropriate use of hearing protection. It is always recommended to use hearing protection when exposed to loud sounds (lawnmower, power tools, rock concert), but extreme caution is advised when using hearing protection when these sounds are not present.

After a head injury, sometimes patients have difficulty processing all the stimuli in their environment and all sounds are perceived as “too loud.” Hearing protection is sometimes used in these situations with the thought that it will help, but instead it should be closely monitored because extended use of

hearing protection in quiet can make the auditory system more sensitive, not less. Therefore, extreme caution is advised when using hearing protection in quiet places (classrooms with few students, libraries, walking outside down a quiet street).

Because of the reliance on selfreport, it is not uncommon for auditory issues to first be revealed when patients start working with occupational therapists. It is usually at this stage in recovery that barriers to activities of daily living are reevaluated and sound avoidance behaviors are discovered. Specifically, occupational therapists address skills related to community reintegration such as driving with distractions and overall tolerance to the work environment and/or school environment. The act of grocery shopping is an example of a reintegration skill that is evaluated by occupational therapists.

Consider all the environmental stimuli encountered when shopping for groceries: the lighting in the store, walking and pushing a cart, ambient sounds (squeaky wheels, multiple conversations, overhead announcements, the parking lot). These skills involve multiple sensory systems (visual, auditory, and somatosensory) that need to work together to integrate and process information. Often people do not realize the degree of sensory overload that can happen in these situations. Additionally, some patients report sleep disturbances related to noise sensitivity and/or tinnitus, which occupational therapists assess as part of the evaluation process and in creating a treatment plan with the patient.

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Multiple strategies can be used to slowly reintegrate sounds back into our environment in a safe and healthy way. Common management approaches include behavioral therapy options (e.g., cognitive behavioral therapy and mindfulness) and sound desensitization approaches. One approach of sound desensitization is to reintroduce different types of sounds in stages. The patient starts with introducing low-level ambient sounds and then progresses to layering sounds, which simulates the experience of a natural setting.

Additionally, occupational therapists address how reintegrating sounds into our daily routine should include incorporating other sensory systems (e.g., visual, and vestibular inputs) simultaneously for a more comprehensive approach. In this manner, occupational therapists are well-situated to layer sensory experiences for patients.

It is unfortunate that sometimes a patient’s concerns related to noise sensitivity are dismissed by healthcare providers. Therefore, it is imperative to increase the healthcare community’s awareness about these auditory symptoms and what can be done. In conclusion, to best meet the needs of patients who have experienced a concussion, it is imperative to screen for auditory symptoms not only at the initial visit but also at follow-up visits.

When these symptoms are present, follow-up assessment is needed to understand the patient’s perspective regarding possible impact on their daily functioning as well as their motivation and readiness pertaining to the best treatment approach to take to meet their health needs.

Acknowledgments This work was supported by the Department of Veterans Affairs, www.ATA.org

Veterans Health Administration, Clinical Science Research & Development Merit Award (NURF008-19F; PI: Theodoroff) and resources and the use of facilities at the VA Rehabilitation Research and Development, National Center for Rehabilitative Auditory Research (Award# C2361-C; PI: Feeney), at the VA Portland Health Care System in Portland, Oregon. The content does not necessarily represent the views of the U.S. Department of Veterans Affairs, Department of Defense, or United States government.

Sarah M. Theodoroff, PhD, is a research investigator at the U.S. Department of Veterans Affairs, Rehabilitation Research and Development, National Center for Rehabilitative Auditory Research (NCRAR), located at the VA Portland Health Care System and an associate professor in the Department of Otolaryngology—Head and Neck Surgery at Oregon Health & Science University. Her research focuses on the poorly understood perceptual consequences of noise, specifically tinnitus, hyperacusis, and noise sensitivity. Her work is informed by her clinical background and aims to improve patient-centered clinical protocols and increase awareness of the needs of patients with these auditory conditions among healthcare professionals and the general public.

Marisa Palandri, OTR/L, CLT, CDRS, works in outpatient Occupational Therapy at Oregon Health & Science University in Portland, Oregon.

She has worked with clients with neurologic impairments, including brain injury and concussion, for over 10 years in outpatient and acute care settings. Marisa also serves as executive director for Bridges, training

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clients with neurologic impairments to return to driving safely. Her passion is in helping clients return to community-based settings, including school, work, and driving. She has a clinical interest in improving awareness of sensory sensitivities after neurologic impairment or concussion for her clients, coworkers, and the medical community.

1 M. A. Bryan, A. Rowhani-Rahbar, R. D. Comstock, et al., & Seattle Sports Concussion Research Collaborative. (2016). Sports- and recreationrelated concussions in U.S. youth. Pediatrics, 138, e20154635.

2 K. Sarmiento, K. E. Thomas, J. Daugherty, et al.

(2019). Emergency department visits for sports— and recreation-related traumatic brain injuries among children—United States, 2010–2016. Morbidity and Mortality Weekly Report, 68(10), 237–242.

3 V. G. Coronado, L. C. McGuire, K. Sarmiento, et al.

(2012). Trends in traumatic brain injury in the U.S. and the public health response: 1995–2009. Journal of Safety Research, 43(4), 299–307.

4 N. D. Silverberg, M. A. Iaccarino, W. J. Panenka, et al., & American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest Group Mild TBI Task Force. (2020). Management of concussion and mild traumatic brain injury: A synthesis of practice guidelines. Archives of Physical Medicine and Rehabilitation, 101(2), 382–393.

5 J. Doperak, K. Anderson, M. Collins, & K. Emami.

(2019). Sport-related concussion evaluation and management. Clinics in Sports Medicine, 38(4), 497–511.

6 A. Lumba-Brown, M. Teramoto, O. J. Bloom, et al.

(2020) Concussion guidelines step 2: evidence for subtype classification. Neurosurgery, 86(1), 2–13.

7 S. M. Theodoroff, M. Papesh, T. Duffield, et al.

(2022, March). Concussion management guidelines neglect auditory symptoms. Clinical Journal of Sport Medicine. 32(2), 82-85. https://www.doi.org/10.1097/ JSM.0000000000000874 8 R. M. Knoll, S. D. Herman, R. J. Lubner, et al. (2020).

Patient-reported auditory handicap measures following mild traumatic brain injury. Laryngoscope, 130(3), 761–767.

9 K. G. Harmon, J. R. Clugston, K. Dec, et al. (2019).

American Medical Society for Sports Medicine position statement on concussion in sport. British Journal of Sports Medicine, 53(4), 213–225.

10 J. T. Arnold, E. V. Franklin, Z. G. Baker, M. Abowd, & J. A. Santana. (2021, June 22). Association between fear of pain and sports-related concussion recovery in a pediatric population. Clinical Journal of Sport Medicine. Advance online publication. https://www. doi.org/10.1097/JSM.0000000000000951

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SPECIAL FEATURE

We Need to Share Our Tinnitus Journey to Build Acceptance

By John Capecci, PhD

Until recently, I had shared with only one person—my spouse—what living with chronic tinnitus is like.

For reasons I’ll explain shortly, this is somewhat ironic. But first: here’s my experience.

One sunny fall morning a dozen years ago, I woke and rose to get out of bed. Immediately, the room began spinning. I keeled to the right and collapsed onto the carpet. I closed my eyes, crawled to the bathroom and threw up.

Lying on the cold tile floor, I couldn’t focus; my eyes rolled in their sockets, and my brain felt loose in my skull. I had intense vertigo and no idea why.

Then, out of nowhere, came a high-pitched tone. Electrical, vibrating. A single, sustained eeeeeeeeeeeeeeeeeeeeee in my right ear or, strangely, somewhere behind it.

For the past 12 years, that screech hasn’t stopped. Not for a single moment.

It’s there while I’m driving, watching movies, and talking to clients. It’s there when I close my eyes to sleep and if I open them in the middle of the night.

In the years leading up to that fall morning, I had gradually lost my ability to hear high-pitched sounds: birds, crickets, alarms. On that morning, my brain apparently decided I needed to hear these sounds and other high pitches after all, so it compensated by turning on the screech. It’s as though half my head is a noisy electrical power plant that the other half must listen to 24/7.

Many of the 50 million Americans experiencing some form of tinnitus do not find it troubling and/or may experience it only briefly. But for roughly 20 million, me included, the condition is chronic and burdensome.

For about 4 million, it’s debilitating, resulting in insomnia, severe depression and anxiety, isolation, and even suicidal thoughts.

“Until recently, I had shared with only one person—my spouse—what living with chronic tinnitus is like. For reasons I’ll explain shortly, this is somewhat ironic.”

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I’ve experienced some of the more common burdens: bouts of sleeplessness, depression, irritability, and intense, even painful, reactions to everyday sounds.

Though the screech I hear is constant, it doesn’t prevent me from working or living a full life because I am able to ignore it much of the time.

Occasionally, wearing hearing aids helps because they amplify external sounds that distract me from the screech; getting adequate sleep and managing stress also help reduce the sound’s intensity.

This does not mean that I am able to “turn it off.” The instant I think about the eeeeeeeeeeeeeeeeeeeeee, it’s there, sometimes dialed back in volume and sometimes—like right now, because I’m focusing on it to describe it—it’s blaring.

Fortunately, my tinnitus is not debilitating. But listening to it nonstop for more than a decade, even in the background of my consciousness, is exhausting. I want the noise to stop.

So do millions of others.

Choosing to Speak Out Recently, I decided to share my experience of tinnitus publicly—first among family and friends, then more widely via social media and other platforms—and to become a vocal advocate for tinnitus awareness, www.ATA.org

SPECIAL FEATURE

research, support, and, ultimately, a cure.

But as I said at the start of this article, it’s somewhat ironic that it has taken me 12 years to step into this advocacy role—especially given what I know about the power of personal stories to create change.

For more than two decades I have coached thousands of individuals on how to share their stories publicly to advocate for causes they care about— whether that means raising awareness or money, passing new legislation, or helping others change behaviors.

With a colleague, I even authored a how-to book on the subject and founded a communication training firm to support organizations and their advocates who want to share personal stories for maximum impact.

Why, then, had I not explored my own experience for its potential to make a difference?

People come to public advocacy via different paths and for different reasons. Making the decision to share our personal stories as advocates places us at the threshold between the private and the public, a space where we encounter feelings about what is and is not appropriate to share, what makes a “good” story, what we risk by speaking out, and more.

As I reflected on and explored my own path to advocacy, I learned that I was not alone in my hesitancy to speak out.

Those of us with tinnitus and other so-called invisible illnesses—such as arthritis, heart conditions, depression, mental illness, intestinal disorders, and many other conditions—often feel uncomfortable speaking about them because of the disconnect between www.ATA.org

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“Personal stories from lived experience have the power to move others from apathy to empathy to action. We can create real change by working together to raise awareness.” how we look on the outside and what may be going on inside.

A recent survey of tinnitus patients revealed that the majority of us do not freely share how tinnitus impacts our lives, not even with the people closest to us.1 Reasons include: • Not wanting to burden others • Fear that people may not see tinnitus as a life-impacting condition or instead think that it’s all in our heads (actually, it is—in our brains) • Not wanting to go through what I am at this moment: bringing the screech to the forefront of consciousness by discussing it I’ve had these same thoughts myself—and they kept me from speaking up. In fact, when I shared early drafts of this article with three friends I’ve known for decades, I realized how rarely I spoke about my tinnitus. Their responses in all three instances were “John, I had no idea.”

Living with tinnitus significantly impacts quality of life for millions of Americans. And yet, we rarely talk about those impacts outside of our close relationships or the privacy of support groups. As a result, tinnitus is often dismissed as a common minor ailment, with research into finding a cure—and the funding for it—lagging far behind that for other illnesses and conditions.

This is precisely why we need to share our stories. Personal stories from lived experience have the power to move others from apathy to empathy to action. We can create real change by working together to raise awareness. Not simply raising awareness that tinnitus exists—most everyone knows about “ringing in the ears”—but by raising awareness of how severely it impacts the quality of life for millions. So: If you, too, are living with tinnitus: Consider whether you might talk more openly about the impact it has on your life, especially if you experience chronic tinnitus. I offer some tips for getting started in the sidebar.

If your tinnitus is not chronic, and you have experienced it only temporarily or are not overly bothered by it, become an ally for others. Be sensitive to those who have chronic, troubling tinnitus. Rather than simply noting “I had tinnitus once, too” or “I have it, too, but it doesn’t bother me,” offer support by letting them know you understand what they’re struggling with. Help them convey to others how tinnitus impacts lives.

If you don’t have tinnitus, you probably know someone who does, so recognize that they may be experiencing much more than they let on: emotionally, psychologically, and physically. If they’re open to talking TINNITUS TODAY SPRING 2022

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about their tinnitus—and if it’s not painful for them to do so—ask what it’s like and offer support. Let them know that you know that it’s not in their head. Share with others what you know and what you learn from those with tinnitus.

Finally: point people to www.ATA.org for information, resources, and the opportunity to directly impact research and shorten the path to a cure by

contributing. Together, we truly can make a difference.

John Capecci, PhD, and his colleague Tim Cage are coauthors of Living Proof: Telling Your Story to Make a Difference (https://www. livingproofadvocacy. com/new-book) and cofounders

of Living Proof Advocacy (https://www. livingproofadvocacy.com/), a communication training firm that helps individuals and organizations tap the persuasive power of spoken personal stories to create change.

Contact them at info@livingproofadvocacy.com 1 H. Goedhart, M. Vesala, & S. Harrison. (2018). How tinnitus can affect your relationships, employment, and social life. Tinnitus Today, Summer 2018, 56–61.

Retrieved from https://www.ata.org/sites/default/ files/Summer-2018-56.pdf

Five Tips for Sharing Your Tinnitus Experience

1

Start by focusing on your message and goal. Rather than asking, “What should I tell?” or “How should I express my experience?” begin instead by asking, “What do I want people to know and do?” Having a clear focus helps you decide what and how much of your experience to share. It also helps move your audience—whether listeners or readers—from empathy (for you and your experience) to action (how they can help millions with tinnitus).

In sharing my story with you here, I focused on the importance of conveying the impact of tinnitus, with the goal of urging you to join me in doing so to advocate for more awareness.

2

Use language that is visual and specific. Take time to find words, phrases, or analogies that help your audience truly understand your experience. Draw upon your senses to describe what something feels like, looks like, or sounds like. Although you’re sharing real-life stories and want to be conversational and authentic,

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they still require some crafting in order to engage others.

Try out your ideas on others; it’s the only way to know whether your language is having an impact. For my story, I was intent on describing exactly what the screeching tone sounds and feels like to me. My friends let me know that the “noisy electrical power plant” analogy helped them understand.

3

Use your fast-forward button.

Rarely will you (nor should you) walk others through every detail of your experience. Instead, decide what important moments of your story are the “living proof” of your message and fast-forward to them.

Use transitions such as, “Three years later…” and “One evening…” as well as statements that summarize large chunks of time, as I did with “In the years leading up to that fall morning…”

4

Don’t expect your stories to do all the heavy lifting. Your lived experience is a powerful tool you can use to create empathy

and understanding in others. But stories aren’t magic. They need to be enveloped in facts and statistics.

This is especially true if you’re trying to reach readers or listeners who have no experience or knowledge of what tinnitus is. You may need to first offer education in order to increase awareness.

In another draft of my story, one aimed at a more general audience than the readership of Tinnitus Today, I included much more information about how tinnitus isn’t something everyone can easily ignore, how it originates in the brain, the variety of ways people experience it, and the kinds of research that is being done.

5

Give clear calls to action. When you share your stories as an advocate, you do so because you want people to take action, which they are more likely to do if what you ask of them is clear, specific, and within their power.

“Help us find a cure” is less effective than a specific request to “Visit ata.org and click on ‘Donate,’” or “Please join me tomorrow.”

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TINNITUS RESOURCES 

Tinnitus Q & A What Type of Masking Works?

By Becca Kane, AuD, ATA Tinnitus Program Advisor

Question: I am having a hard time finding a masking noise that matches my tinnitus, which is a low-pitch roaring sound. What type of sound should I use for masking?

Becca Kane, AuD: In general, when people use the term “masking” they are referring to using an external sound to temporarily reduce the perception of tinnitus. It is the assumption that when you try to mask the tinnitus, you are trying to match your tinnitus pitch exactly or set a volume that covers your tinnitus completely, but this is not the case.

It’s very likely that you will utilize different sounds for different tinnitus scenarios. Many people prefer a relaxing sound for evening but during the day may benefit from using music, television, or a podcast to act as the masker, depending on what they are doing. During the day, sound with content provides a mental distraction as well as an auditory distraction. For

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evening, a steady, soothing sound without content, such as an ocean sound, is better to facilitate sleep.

Regardless of what sound you choose, you should set the volume where it blends with, but doesn’t completely mask, your tinnitus and then go about whatever activity you have in mind. Your brain will hear both but will engage with whatever you’re playing. This may look like listening to your favorite podcast while taking a walk or putting on music while doing laundry. You should be able to hear a bit of your tinnitus peek through whatever sound you choose. Once you choose a sound of your liking and set the volume, try to not adjust the settings. It will take trial and error in different settings to see what is most effective at reducing your perception of tinnitus in that moment.

There are many tinnitus apps you can download on your smartphone.

Since your tinnitus has a lower pitch to it, you may do well with mixing different sounds together to achieve

relief. Frequently used tinnitus apps can be found on our website: https://www.ata.org/sites/default/ files/SoundTherapy_Apps_Page.pdf The delivery method of the masking sound is also a factor. Some people prefer a speaker, headphones, headphones with noise cancelation, or even specially designed headphones for sleep such as SleepPhones (https:// www.sleepphones.com/).

Rebecca Kane received her AuD from James Madison University, Virginia, in 2007. She was the lead in establishing the Duke Tinnitus Clinic, connected with the Duke Medical Center in Durham, North Carolina, where she worked for 13 years. She has presented on electrophysiology, tinnitus, and hyperacusis at various local and national conferences. Her publications have focused on utilization of an integrative medicine approach for tinnitus management.

She currently provides remote support for tinnitus patients in her role as a Tinnitus Advisor for the American Tinnitus Association.

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How Do Veterans Access Tinnitus Clinical Services at VA Hospitals?

By James A. Henry, PhD, and Catherine Edmonds, AuD

In the last issue of Tinnitus Today, we published an article describing what the Veterans Health Administration (VA) is doing about tinnitus.5 That article reviewed some of the tinnitus research that has been conducted at the VA Rehabilitation Research & Development (RR&D) National Center for Rehabilitative Auditory Research (NCRAR). The article concluded, “This brief review should leave no doubt that the VA has substantially supported tinnitus research for many years, and continues to do so.”

Epidemiology studies have shown consistently that, out of every 100 adults, 10 to 15 experience tinnitus.1 Studies have also shown that about one in five of those who experience tinnitus are bothered by it to the point that clinical services would be warranted.2,3 United States military veterans are no exception from these

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proportions.1,4 Clearly, many veterans require clinical services for their tinnitus. The purpose of the present article is to address how veterans can go about receiving clinical services for their tinnitus.

Clinical Practice Recommendations Made by VA Clinicians and Researchers In 2015, VA posted a statement and an accompanying clinical “decision tree” to describe the audiologic care provided to veteran patients reporting tinnitus (https://www. ncrar.research.va.gov/Documents/ TinnitusPracticeGuidelines.pdf).

The recommendation, which was based on Progressive Tinnitus Management (PTM),6 was developed by a working group that consisted of VA tinnitus experts, including audiologists, researchers, and a psychologist. The effort took into account the clinical practice guideline published by the American Academy of Otolaryngology—Head & Neck Surgery Foundation (AAO-HNSF),2 but focused on procedures that were used with PTM. PTM provides an organized structure for delivering interdisciplinary clinical care that is adaptable to meet a patient’s individual needs.7 The AAO-HNSF guidelines describe a more compartmentalized

(nonintegrated) approach of making specific recommendations for different clinical manifestations.2 The following is a description of the VA recommendations, along with summaries of what VAs are doing with respect to the different components of tinnitus management.

Referral: Procedures for referring patients at the clinical point of contact.8 Referral can be to emergency care, mental health, otolaryngology, and/or audiology. The default referral would be to audiology.

Veterans enrolled in the VA for healthcare can directly refer themselves to audiology to initiate care for tinnitus. Veterans can also report their tinnitus to any of their VA healthcare providers for referral for the appropriate services. Veterans who are enrolled to receive VA services have the advantage of access to interdisciplinary tinnitus services, which may include audiology, psychology, and otolaryngology.

Audiologic Evaluation: Involves a standard audiologic assessment and brief tinnitus assessment.9 Inherent in the audiologic assessment is a hearing aid assessment, as warranted, and referral to mental health or otolaryngology, as warranted. Different questionnaires are suggested, including the Tinnitus and Hearing Survey10 and the Tinnitus Functional Index,11 to quantify the effects of www.ATA.org

TINNITUS RESOURCES 

tinnitus on the patient. Hearing aids are provided as appropriate and the patient is assessed to determine whether tinnitus-specific intervention is required.

VA audiologists perform routine hearing assessments, including questioning patients about tinnitus and assessing for hearing aids if indicated.

Some audiologists conduct a tinnitus evaluation, which would include any of a number of tinnitus questionnaires, and possibly tinnitus psychoacoustic testing (tinnitus loudness match, tinnitus pitch match, and testing for minimum masking level). Hearing aids are provided, as appropriate, for veterans with hearing impairment and may also be part of the tinnitus plan of care for using sound to help reduce awareness of tinnitus.

Skills Education: Educational counseling to teach self-help skills.12 The education sessions can be conducted as group workshops or one-on-one between clinician and patient. Coordination with a mental health provider is important to provide skills education based on cognitive behavioral therapy (CBT) coping skill techniques.

Veterans who have completed an audiologic evaluation and who require intervention specific to a tinnitus problem may be offered different options. Some VAs offer group or individual PTM workshops, while others offer different tinnitus interventions, including but not limited to various forms of sound therapy,13 Acceptance and Commitment Therapy (ACT),14 Mindfulness-Based Stress Reduction (MBSR),15 Tinnitus Activities Treatment (TAT),16 and Tinnitus Retraining Therapy (TRT).17 www.ATA.org

Interdisciplinary Evaluation and Support: Comprehensive tinnitus assessment that is reserved for patients whose tinnitus needs are not met after completing an audiologic evaluation and basic intervention.6 An interdisciplinary evaluation involves in-depth assessment by both an audiologist and a psychologist to determine the root of why tinnitus is still so bothersome to the patient.

Veterans who continue to be bothered by tinnitus after receiving the tinnitus care offered at their facility may have the opportunity to receive one-on-one tinnitus management for as long as necessary from their audiologist and/or mental health provider. These further services may include any of the methods mentioned above (sound therapy, ACT, MBSR, TAT, and TRT).

Recommendations If you are a veteran seeking tinnitus care, we can make the following recommendations: Start by making an appointment with audiology. When you make the appointment, ask to meet with an audiologist who specializes in tinnitus management, if available.

Regardless, you will still receive a comprehensive hearing evaluation and may be evaluated for amplification (hearing aids), if appropriate. Hearing aids may be recommended, which will help with hearing loss but may also provide sound therapy for bothersome tinnitus. Completing a tinnitus questionnaire will be helpful, and we recommend the Tinnitus and Hearing Survey10 to assist in avoiding any confusion between hearing difficulties and effects of tinnitus.

However, your audiologist may have

other helpful tinnitus questionnaires available to assess how your tinnitus is impacting you.

If fit with hearing aids, it is important to follow up with your audiologist if realistic expectations of amplification are not met and you are including your hearing aids as part of your plan to use sound for tinnitus management. You may have the option of using your hearing aids to “stream” signals from your smartphone that would serve as “enhanced sound therapy.” Combining amplification from hearing aids with the streaming function can be very effective in achieving relief from tinnitus.

Audiologists are trained to know whether referral to otolaryngology is indicated, which would normally be due to symptoms of somatic/ secondary tinnitus (which is real sound caused by some irregularity in the head or neck, such as the sound of pulsing blood through a constricted blood vessel). Otolaryngologists will then follow up on the referral by conducting an examination and any medically necessary testing to aid in the diagnosis and/or management of tinnitus.

Many VA audiologists are highly specialized in providing tinnitus services, but they may not be nearby.

It may be possible to first undergo the basic audiologic services at your local VA and then work with a tinnitus specialist via telehealth. VA is very committed to providing clinical services via telehealth, so this is increasingly becoming a convenient option to deliver care directly to the veteran without them having to leave home or work.

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Another option is to email with tinnitus experts to receive educational information (not tinnitus care). In this regard, the NCRAR website contains numerous materials that are designed to provide educational counseling and information to veterans who are struggling with, or have questions about, tinnitus (https://www.ncrar. research.va.gov/ForVets/Index.asp).

This website contains brochures, a self-help workbook,18 and videos of the five counseling sessions that are conducted with PTM Level 3 Skills Education.

Conclusion We have described various tinnitus services available in the VA healthcare system for veterans who are interested in accessing tinnitus care.

Standardization does not yet exist for providing tinnitus services anywhere in the United States, and so VA medical centers are also not standardized in their approach. Fortunately, VA audiologists are directly accessible to veterans to provide tinnitus services, and there are audiologists at every major VA facility, as well as at many of the VA outpatient clinics.

Audiologists may be able to provide all of the services necessary, or they can refer patients to otolaryngology and/or psychology as necessary.

Many audiologists, psychologists, and researchers within the VA specialize in tinnitus management. If you are having trouble getting ahold of one, you might contact audiology at your regional VA medical center and ask for contact information. If you are unable to get ahold of anyone, then you can contact the NCRAR at ncrar@va.gov or 503-220-8262, ext. 55568.

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James A. Henry, PhD, is a certified and licensed audiologist with a doctorate in behavioral neuroscience. He is employed as a Veterans Affairs (VA) Rehabilitation, Research & Development (RR&D) Senior Research Career Scientist at the VA RR&D National Center for Rehabilitative Auditory Research (NCRAR) located at the VA Portland Health Care System. He is also Research Professor in the Department of Otolaryngology—Head and Neck Surgery at Oregon Health & Science University. For the past 25 years, he has devoted his career to tinnitus research. His overall goals are to develop and validate clinical methodology for effectively helping individuals with bothersome tinnitus and to increase accessibility to evidence-based tinnitus care.

Catherine Edmonds, AuD, is an audiologist at the Bay Pines VA Hospital in Bay Pines, Florida. She received her Master of Science degree from the University of South Florida and Doctor of Audiology degree from Arizona School of Health Sciences.

Dr. Edmonds provides clinical services, precepts doctoral students, and is the tinnitus subject matter expert for the Bay Pines VA Healthcare System. In addition to her clinical work, Dr. Edmonds is a member of the VA/ DOD Tinnitus Working Group, VA Tele-Audiology Advisory Team, and the National Center for Rehabilitative Auditory Research (NCRAR) workgroup updating the Progressive Tinnitus Management clinician handbook and patient workbook. She has also completed systems redesign projects at her VA facility and earned her Lean/Six Sigma Green Belt certification in January 2022.

1 J. A. Henry, K. M. Reavis, S. E. Griest SE, E. J. Thielman, S. M. Theodoroff, L. D. Grush, & K. F. Carlson. (2020). Tinnitus: An epidemiologic perspective. Otolaryngologic Clinics of North America, 53, 481–499.

2 D. E. Tunkel, C. A. Bauer, G. H. Sun, et al. (2014).

Clinical practice guideline: Tinnitus. Otolaryngoly— Head and Neck Surgery, 151(2 Suppl.), S1–S40.

3 H. J. Hoffman & G. W. Reed. (2004). Epidemiology of tinnitus. In J. B. Snow (Ed.), Tinnitus: Theory and management (pp. 16–41). BC Decker.

4 R. L. Folmer, G. P. McMillan, D. F. Austin, & J. A. Henry. (2011). Audiometric thresholds and prevalence of tinnitus among male veterans in the United States: Data from the National Health and Nutrition Examination Survey, 1999–2006. Journal of Rehabilitation Research and Development, 48(5), 503–516.

5 J. A. Henry. (2021). What is the Veterans Health Administration doing about tinnitus? Tinnitus Today, 46(3), 4–7.

6 J. A. Henry, T. L. Zaugg, P. M. Myers, & C. J. Kendall.

(2010). Progressive Tinnitus Management: Clinical handbook for audiologists. Plural Publishing.

7 C. J. Schmidt, C. Kaelin, L. Henselman, & J. A. Henry. (2017). Need for mental health providers in Progressive Tinnitus Management: A gap in clinical care. Federal Practitioner, 34(5), 6–9.

8 J. A. Henry, L. McMillan, & C. Manning. (2019).

Multidisciplinary tinnitus care. Journal for Nurse Practitioners, 15, 671–675.

9 J. A. Henry & C. M. Quinn. (2019). Clinical protocol to promote standardization of basic tinnitus services by audiologists. American Journal of Audiology, 28(1S), 152–161.

10 J. A. Henry, S. Griest, T. L. Zaugg, E. Thielman, C. Kaelin, G. Galvez, & K. F. Carlson. (2015). Tinnitus and Hearing Survey: A screening tool to differentiate bothersome tinnitus from hearing difficulties.

American Journal of Audiology, 24(1), 66–77.

11 M. B. Meikle, J. A. Henry, S. E. Griest, et al. (2012).

The Tinnitus Functional Index: Development of a new clinical measure for chronic, intrusive tinnitus.

Ear and Hearing, 33(2), 153–176.

12 J. A. Henry, T. L. Zaugg, P. J. Myers, C. J. Kendall, & M. B. Turbin. (2009). Principles and application of counseling used in Progressive Audiologic Tinnitus Management. Noise and Health, 11(42), 33–48.

13 J. A. Henry & C. M. Quinn. (2020). Sound therapy for tinnitus: Options for audiologists. Perspectives of the ASHA Special Interest Groups, SIG 8, 5, 669–683.

14 V. Z. Westin, M. Schulin, H. Hesser, et al. (2011).

Acceptance and Commitment Therapy versus tinnitus retraining therapy in the treatment of tinnitus: A randomised controlled trial. Behaviour Research and Therapy, 49(11), 737–747.

15 M. Arif, M. Sadlier, D. Rajenderkumar, J. James, & T. Tahir. (2017). A randomised controlled study of mindfulness meditation versus relaxation therapy in the management of tinnitus. Journal of Laryngology & Otology, 131(6), 501–507.

16 R. S. Tyler, S. A. Gogel, & A. K. Gehringer. (2007).

Tinnitus Activities Treatment. Progressive Brain Research, 166, 425–434.

17 P. J. Jastreboff & J. W. P. Hazell. (2004).

Tinnitus Retraining Therapy: Implementing the neurophysiological model. Cambridge University Press.

18 J. A. Henry, T. L. Zaugg, P. J. Myers, & C. J. Kendall (Schmidt). (2010). How to manage your tinnitus: A step-by-step workbook (3rd ed.). Plural Publishing.

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SCIENCE & RESEARCH NEWS 

Exploring Biomarkers for Tinnitus Loudness and Distress

Summary by John A. Coverstone, AuD

Tinnitus may have many triggers and may affect people in different ways. Some of these are common and may create a vicious cycle of sorts.

For instance, people with tinnitus often report difficulty sleeping, but not getting enough sleep makes tinnitus worse. Another common trigger/ effect is stress, which is very prevalent in people with bothersome tinnitus.

Those who are distressed by tinnitus feel the stress of the condition—and often not being able to make it go away—which causes further stress.

Laura Basso and colleagues at the University of Berlin, Germany, wanted to see whether biomarkers might be present in those feeling distressed from tinnitus.1 A biomarker is a substance within the body (protein, enzyme, chemical) that is produced in a specific circumstance or situation. www.ATA.org

They studied the hormone cortisol and a protein called brain-derived neurotropic factor (BDNF).

Cortisol is a common hormone in the body that is produced in greater amounts during times of stress. Virtually every cell in the body responds to cortisol in some fashion, including shutting down nonessential functions and preparing for increased activity. This is the basis for the body’s fight-or-flight response to threats.

BDNF is a protein that affects nerve function. It sits in the gap (synapse) between nerve cells and plays a role in growth, development (such as whether a cell will differentiate into an auditory nerve cell or a vision cell or a memory cell), and cell maintenance.

BDNF regulates plasticity (change) of nerve synapses, which is vital for learning and forming memories. More recently, the role of BDNF has been

studied for its role in regulating stress hormone signaling in the brain.2 Ninety-one individuals with tinnitus were included in this study. They were given hearing tests and completed a number of questionnaires, including the Tinnitus Questionnaire, Perceived Stress Questionnaire, Hospital Anxiety and Depression Scale, and State-Trait Anxiety Inventory, among others.

Hearing was tested and tinnitus was matched for loudness and pitch.

Participants were characterized by how often tinnitus occurred, whether the onset of tinnitus was associated with stress, whether tinnitus was influenced by stress, whether they experienced hyperacusis (abnormal sensitivity to the loudness of sounds), and whether they used hearing aids.

Hair samples were taken from each participant to analyze levels of cortisol and BDNF. All of the other measures were studied to determine TINNITUS TODAY SPRING 2022

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how well they predicted increases or decreases in levels of these two substances. Results showed that increased tinnitus loudness was associated with increased cortisol levels and decreased BDNF levels.

Tinnitus distress was correlated with decreased levels of BDNF. Although not addressed in this study report, it should be noted that all of these relationships were correlations and did not indicate cause and effect.

For instance, does tinnitus distress provoke a stress response of higher cortisol levels and lower BDNF levels or is a person with these levels of cortisol and BDNF more prone to tinnitus distress? Those kinds of questions could be answered in a future study that includes a control group and/or longitudinal data from individuals who have new-onset tinnitus (which is more likely to be performed with animals than humans).

Non-tinnitus relationships were discovered also. The researchers kept track of when samples were collected and found that sampling in the Fall, as well as increased body mass index (BMI), and less smoking all correlated with higher cortisol levels. BDNF showed positive effects for hearing aid use and quality of life resulting from better physical health. BDNF levels were negatively correlated with smoking and prior traumatic experiences.

The researchers noted limitations of the study, including small population size, which limited the number of participants meeting certain criteria (such as seasonal effects, smoking, and hearing aid use). They noted that tinnitus-matching data were taken from audiological records, with sometimes substantial time (average of almost 2 months) between audiology data collection and hair sample collection. They also noted

that a control group was not included in this observational study. A control group in a larger study would enable comparison of data to determine if statistically significant differences exist between groups. Such comparison is particularly important if a study is attempting to establish clinically useful norms.

Despite the limitations, these researchers believe their data show potential for a biomarker-based approach to measuring tinnitus loudness and distress. They also showed the importance for future studies to account for factors that may confound test results.

1 L. Basso, B. Boecking, P. Neff, P. Brueggemann, E. M. J. Peters, & B. Mazurek. (2022). Hair-cortisol and hair-BDNF as biomarkers of tinnitus loudness and distress in chronic tinnitus. Scientific Reports, 12, 1934. https://doi.org/10.1038/s41598-022-04811-0 2 M. Notaras & M. van den Buuse. (2020).

Neurobiology of BDNF in fear memory, sensitivity to stress, and stress-related disorders. Molecular Psychiatry, 25, 2251–2274. https://doi.org/10.1038/ s41380-019-0639-2

What Is Masking?

Masking refers to the use of sound to reduce the perception of tinnitus by playing some other pleasant, calming, or nonintrusive sound, such as ocean waves, white noise, classical music, or any other sound that helps a person focus, relax, and tune out tinnitus.

When you are using a masking device, hearing healthcare providers usually recommend that you set the volume slightly below the sound of your tinnitus so that your brain hears both sounds. This is thought to aid habituation. Although masking cannot 46

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reduce or eliminate tinnitus, it can reduce awareness of it.

Maskers are devices that can be used to reduce the perception of tinnitus. They can take the form of table-top sound machines/generators, sleep headbands and pillows with speakers, earbuds, hearing aids equipped with masking features, or over-the-ear devices (maskers) without the hearing aid function.

For those with hearing loss, most hearing aids come equipped with

maskers, so ask your audiologist about options.

For those without hearing loss, consider consumer electronic devices, which are less expensive than overthe-ear maskers. These include bone conduction headphones and openring earbuds, both of which allow you to hear sounds around you while streaming masking sound. Regular noise-canceling earbuds also work, but they can be uncomfortable to wear for extended periods or inappropriate to wear in certain settings. www.ATA.org

SCIENCE & RESEARCH NEWS 

Can Covid-19 Infect the Inner Ear? Summary by John Coverstone, AuD

A number of common viruses are known to affect the inner ear (cochlea) and cause hearing or balance problems. These include viruses that have been largely eradicated following vaccination efforts, such as polio, measles, mumps, and rubella.

These also include viruses still active in society, including cytomegalovirus, herpes simplex, and Epstein-Barr.

A question frequently discussed by audiologists and ear, nose, and throat physicians since 2020 is whether SARS-CoV-2, the virus responsible for the Covid-19 pandemic, can also cause hearing loss, tinnitus, or vertigo.

This question has largely remained unanswered as most published accounts of hearing and balancerelated problems have been individual case studies or have described only a few cases. The early evidence was complicated by the fact that some medications used to treat Covid-19 infections were themselves toxic to the ear. Further, Covid-19 affects the upper portion of the respiratory system, which often affects the eustachian (yoo-stay-shun) tube, the small passage that connects the middle ear space to the throat and results in plugged ears when the tissues around it swell. In early 2021, investigators Almufarrij and Munro of the University of Manchester reviewed studies published through December www.ATA.org

2020 that addressed the effect of Covid-19 infection on the inner ear.1 They found that quality evidence was lacking and there was an absence of studies with control groups. As a result, no firm conclusions could be made.

Investigator Jeong and colleagues at Harvard Medical School and Massachusetts Eye and Ear Institute attempted to answer this question by studying the ear directly. Their study included 10 adult patients with confirmed Covid-19 diagnosis and hearing or dizziness/vertigo symptoms that developed within 3 weeks after infection. All 10 patients revealed hearing loss when tested, most with severe loss. Nine of the 10 experienced tinnitus, and six

experienced vertigo lasting several days. MRI was performed with each patient. All MRI results were normal with the exception of one patient showing inflammation in the inner ear and surrounding area. This finding was considered to be consistent with Covid-19 infection.

The researchers were also able to gather sample inner ear tissue from six patients who had surgeries to remove portions of the vestibular labyrinth (balance organ) in the inner ear or tumors growing near the ear.

None of these patients previously had Covid-19. The samples were used to study whether mechanisms are present that allow Covid-19 to infect inner ear tissue. They also gathered inner ear tissue from mice because TINNITUS TODAY SPRING 2022

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cochlea (hearing organ) sections from humans are difficult to obtain to study that portion of the ear. The samples from mouse ears were compared to the vestibular tissue samples taken from humans so they could determine if they included the same mechanisms to allow Covid-19 infection.

The researchers first analyzed the samples from human ears for genes that are known to promote entry of SARS-CoV-2 into human tissues. They found that inner ear tissues express an enzyme receptor named angiotensinconverting enzyme 2 (ACE2) receptor, which exists on cell surfaces. The ACE2 receptor provides the site that SARS-CoV-2 virus uses to attach itself to a cell using its now-famous spike

protein. The researchers also found two enzymes called proteases that allow SARS-CoV-2 to cut open (called cleaving) the cell surface and enter the cell. These are called transmembrane protease serine 2 (TMPRSS2) and FURIN and are known to essentially signal SARS-CoV-2 as to where to cleave the cell membrane and fuse the virus to the cell in order to gain entry.

Finding genes that are known to express enzymes crucial to SARSCoV-2 infection was important because it let the researchers know that cells in the inner ear contain the mechanisms that the virus uses to infect cells. Gaining entry to cells in our body is necessary in order for the virus to replicate. Next, the

ATA Research Grant Applications Are Open The American Tinnitus Association is currently accepting grant applications for its 2022 Innovative Research Grants Program, which includes the newly unveiled Kent Taylor Texas Roadhouse Tinnitus Research Grant.

Tinnitus researchers, with the overall goal of pursuing high-impact innovative projects that require preliminary data in order to apply for funding from larger agencies, are encouraged to apply, as are those working with underrepresented populations. Investigations may focus on such areas as treatment and intervention, measures in screening, and neurobiology/genetics. Applications for the first round of funding will be accepted through May 1, 2022, and are open to researchers anywhere in the world.

The ATA’s Scientific Advisory Committee conducts a peer review of grant proposals by which scientists with specific expertise assess the scientific and technical strengths of the proposals, including the potential impact on patients.

The ATA is the only non-profit patient advocacy organization committed exclusively to improving the lives of people with tinnitus through innovative research aimed at advancing better treatments and possible cures. The program also serves to attract more researchers to the field of tinnitus by offering young investigator awards.

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researchers wanted to know whether SARS-CoV-2 actually does infect inner ear tissue. They used the explanted tissue samples from surgeries and exposed them to the virus. Upon inspection, they found the tissue samples contained the virus.

Because the human tissue samples were from the vestibular system, auditory tissue samples from mice were used to study the possibility of Covid-19 infection in the cochlea. The researchers found that the same three gene expressions (ACE2, TMPRSS2, and FURIN) were present in the auditory portion of mouse ears and specifically in the cochlea. This finding has further implications for future research in this area, as it shows mice may be used as a substitute for human tissue samples. Using these data, the researchers were able to create models of SARS-CoV-2 infection and show the mechanisms that it may use to infect human inner ear cells and specifically the hair cells that serve as receptors for sound in the cochlea.

The finding that both vestibular and auditory cells are primed for infection by the SARS-CoV-2 virus allows more meaningful discussion of the possibility that hearing loss, tinnitus, and vertigo may result from Covid-19 infection. It also provides physicians with additional systems to monitor post-infection and may ultimately lead to treatments to mitigate the effects of Covid-19 infection.

1 I. Almufarrij & K. J. Munro. (2021). One year on: An updated systematic review of SARS-CoV-2, COVID-19 and audio-vestibular symptoms.

International Journal of Audiology, 60(12), 935–945. https://www.doi.org/10.1080/14992027.2021.1896793 2 M. Jeong, K. E. Ocwieja, D. Han, et al. (2021).

Direct SARS-CoV-2 infection of the human inner ear may underlie COVID-19-associated audiovestibular dysfunction. Communications Medicine, 1(1), 44. https://www.doi.org/10.1038/s43856-021-00044-w

www.ATA.org

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 PERSONAL STORY

From the Valley to the Mountaintop: Reclaiming Life on My Terms

By Anne Peel

In January 2019, I started my journey with tinnitus, which doctors said stemmed from progressive bilateral hearing loss caused by aging. But there’s more to the story. I didn’t protect my precious hearing along the way, attending loud concerts and engaging in recreational shooting.

That mix of lifestyle choices, leading to hearing loss, combined with an autoimmune condition and a sensitive nervous system has left me with both tinnitus and hyperacusis.

It has been a baffling and frustrating journey, with visits to various physicians, hearing aid fittings to improve my hearing while lessening the intrusive sound of tinnitus, X-rays of my neck, an MRI of my brain. The diagnostics confirmed that nothing, besides hearing loss, might be contributing to my tinnitus and sensitivity to sound. I am thankful, but…

Tinnitus made me believe lies about myself, my life, my loved ones.

I distanced myself from family and friends because I thought they felt they had to be quiet on my behalf, were afraid to laugh too loud, couldn’t 50

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have a good time around me because they feared it would trigger my tinnitus or cause me discomfort.

The world in my mind had become a scary and an untrusting place, where I stood waiting in fear, waiting with angst, for the next loud sound to strike. The sound might come from people, places, objects, or any random situation. My mind was gripped by skewed and unpleasant thoughts.

My mental and physical response to tinnitus and hyperacusis created an internal world that, reflecting back, was filled with false notions. As my brain recoiled from the tinnitus, I could feel my anxiety growing and triggering a fight-or-flight response that sometimes lasted for several hours; it was exhausting and depressing.

I felt there would be no end to this suffering.

Sometimes I was overtaken by dark thoughts, depression, and anxiety.

In such times, it was my precious husband, family, network of friends, and my dogs that kept me going.

Emotionally, tinnitus made me feel like a helpless, insecure, weak, sad, anxious, frightened human being.

Sometimes it made me feel I was going crazy—those were my days, my

nights, my moments at the bottom of the valley. Spiritually, I felt adrift; my compassionate God had left me to be punished by tinnitus for something I had unwittingly done.

Tinnitus quashed feelings of joy and made it hard for me to remember names or follow instructions. I was easily confused. The rattle, the clicking, the whooshing sound in my head and ears made it difficult to pay attention to people talking, especially in noisy spaces. I couldn’t bring myself to ask repeatedly what was being said so I pretended to understand. I felt alone among friends and families.

Loud noise lurked in my midst.

The noise in the grocery store was overwhelming. Then there were the leaf blowers, the lawnmowers—the list goes on and on.

My way out of this valley was guided by a therapist with tinnitus who practices cognitive behavioral therapy and mindfulness for tinnitus relief.

Those online classes and attendance in online support groups listed on the ATA website helped me regain my footing. I realized I could accept the sound, could feel joy again, could begin to “live” again.

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Unexpectedly, the climb up the mountain brought new insights, new meaning. Strangely, today I feel closer to God, am more empathetic toward others who are suffering and may need my help. I understand more about myself. I feel hope for the future.

By learning to slow down, to be mindful, to enjoy the moment, I realized that I am just traveling through earth on my way to wherever God may take me. When God is ready to bring me to my eternal resting place, I know there will be no more suffering.

I used to be afraid of death, but that fear is gone.

I will make the most of my time and live in peace and harmony with

myself and other travelers here on earth. I’m still a work in progress and have much more to learn about how to make peace with my mind, body, and emotions, especially anxiety and depression, when they’re triggered by tinnitus. But as I look down from the top of the mountain, I see how far I’ve come.

The Mindfulness for Tinnitus class, which gave me guidance, discussion, and homework, made me realize that tinnitus and hyperacusis had clouded my mind. In doing my homework—my “self” work—I realized I was resilient, could believe in myself again, could connect with other people living with tinnitus. Now,

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as I journey, I feel a higher power at my side that allows me to be with tinnitus, to see tinnitus as Wally in Where’s Waldo? My travels will be adventurous and unencumbered, with a backdrop so rich that tinnitus may be hard to find.

Share Your Story With ATA Readers Every day, people struggling with tinnitus turn to personal stories to understand what the future might hold. The stories are honest and don’t sugarcoat the challenges and time it often takes to learn how to manage and live with tinnitus.

If you have tinnitus and problems sleeping, we’d like to hear from you. We’re also looking for stories from people who have tried various treatments and/or products for tinnitus relief. Please send your story to editor@ata.org by May 15. Suggested word length is between 600 and 900 words.

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Research Underway

Could Auditory Brainstem Response Eventually Serve as an Objective Measure of Tinnitus?

Summary by John A. Coverstone, AuD

The readers of Tinnitus Today are well aware that subjective tinnitus is an internal sound heard only by the person with the condition. It cannot be heard by other people and, so far, has not been reliably measured using clinical equipment. The ability to objectively (meaning without responses from the patient) measure a person’s tinnitus— even if only for some people—would be a significant step forward in tinnitus research. It could serve to validate those experiencing new tinnitus, could feasibly open new doors into understanding and diagnosing different origins of tinnitus, and could even open new paths to targeted treatment.

The most common assessment tool for testing the auditory nervous system is called auditory brainstem response (ABR), sometimes also called brainstem auditory evoked response (BAER). This tool measures brain waves (electroencephalography, or EEG) in response to sound presented to the ear. The most common stimuli are clicks, which are broadband—meaning they include many frequencies—and tone bursts, which are frequencyspecific stimuli. ABR measures how long it takes sound to travel through the auditory system in the brainstem (called latency) and how large the 52

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responses are at certain points (called amplitude). Significant points where signals jump from one group of nerve fibers to another group are labeled as waves I through V (1–5) on the EEG tracing. ABR has long been studied as a potential tool for measuring tinnitus because it measures neurological function, where tinnitus occurs.

Victoria Milloy from the University of Ottawa and her colleagues published a research review of ABR measurement for tinnitus in 2017.1 Their conclusion was that no consistent results could be identified across papers. The only finding with notable agreement across studies was a prolonged Wave I (which measures at the point where the auditory nerve receives signals from the inner ear). This finding was not noted in two of the 22 studies they reviewed, but those two studies were also the only papers to include subjects with hearing loss. The authors also noted that methodology was inconsistent across papers, including different stimuli, different criteria for subjects, and different ways of measuring and defining tinnitus.

A more recent review was published in Brain Sciences in 2020

by Ewa Domarecka and colleagues at Berlin University.2 They reviewed 36 studies of rats where tinnitus was induced by either noise exposure or

salicylates (aspirin is a salicylate) and narrowed those down to an analysis of measurements in 10 publications (four using noise to create tinnitus, six using salicylates). The only consistent change in ABR results was a decrease in Wave I, similar to what was observed in human subjects. When salicylates were used, Wave IV was increased. The authors reported that this corresponds in rats to a greater nerve response at the inferior colliculus (a primary hub of auditory information in the brainstem, with inputs from virtually all auditory pathways). In rats subjected to noise, the researchers saw a decrease in responses for all waves. Other changes in ABR responses were noted for specific parameters and subpopulations but were not consistent between studies or across subject groups. Again, methodologies differed significantly between studies, making direct comparisons difficult and potentially obscuring trends in results.

A large group of researchers led by Niklas Edvall at the Karolinska Institute in Sweden recently published a study of ABR results in human subjects in the Journal of Clinical Investigation.3 Their study compared ABR results from people with constant tinnitus to those with occasional tinnitus.

They first obtained more than 20,000 questionnaires from a national Swedish www.ATA.org

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health survey in order to study the transition from occasional to constant tinnitus. They also performed ABR measurement on subjects with both occasional and constant tinnitus, as well as on control subjects with no tinnitus.

Survey results showed a trend that is familiar to many audiologists: Those with occasional tinnitus have a risk of tinnitus occurring more frequently, and those with frequent tinnitus have a high risk of tinnitus becoming constant.

Once tinnitus becomes constant, the risk of it remaining constant is high.

The authors estimated that this progression of tinnitus would show differences in the brainstem. They performed ABR assessment on a group of individuals that included 136 people with constant tinnitus, 92 people with occasional tinnitus, and 177 people with no tinnitus. They found that Wave V latency (time from stimulus presentation to recording of

Wave V) was longer for those with constant tinnitus than for those with no tinnitus or occasional tinnitus. Wave V is arguably generated in humans from the connection of the lateral lemniscus (bundle of nerve fibers that transmits information about sound) with the inferior colliculus. Longer Wave V latency was true even when the authors controlled for age, hearing loss, presence of hyperacusis, and gender; that is, each of these factors was ruled out as a potential cause for the longer Wave V latency. (The authors did not indicate whether those experiencing occasional tinnitus heard it at the time the ABR was conducted.)

These results are generally consistent with findings of a smaller study in 2012 by Giulia Cartocci and colleagues at Sapienza University of Rome.4 That study showed greater latency between Wave III (connection of cochlear nucleus to superior olivary

complex) and Wave V. Basically, this means some part of the brainstem is not passing along the stimuli quite as effectively.

When looking across recent studies, there appears to be quite a bit of variation in methods and in outcomes. However, some patterns may be emerging that signal promise for a more objective measurement of tinnitus in the future.

1 V. Milloy, P. Fournier, D. Benoit, A. Noreña, & A. Koravand. (2017). Auditory brainstem responses in tinnitus: A review of who, how, and what? Frontiers in Aging Neuroscience, 9, 237.

2 E. Domarecka, H. Olze, & A. Szczepek. (2020).

Auditory brainstem responses (ABR) of rats during experimentally induced tinnitus: Literature review.

Brain Sciences, 10(12), 901.

3 N. Edvall, G. Mehraei, M. Claeson, et al. (2022, January 25). Alterations in auditory brainstem response distinguish occasional and constant tinnitus.

Journal of Clinical Investigation. Advance online publication. https://www.doi.org/10.1172/JCI155094 4 G. Cartocci, G. Attanasio, F. Fattapposta, N. Locuratolo, D. Mannarelli, & R. Filipo. (2012).

An electrophysiological approach to tinnitus interpretation. International Tinnitus Journal, 17(2), 152–157.

What Is the Auditory Brainstem Response (ABR) Test?

Human Ear Diagram The ear is made up of three parts: the outer, the middle, and the inner ear. The auditory brainstem response (ABR) test is used to evaluate the functioning of the cochlea (inner ear) and the brain pathways used for hearing, called the auditory neural pathway. The ABR test can help assess hearing loss and hearing loss treatment options.

It is a noninvasive, painless test in which an audiologist attaches electrodes to the patient’s forehead and ears to capture brainwave activity in response to sounds heard through earphones.

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Research Underway

Tinnitus Is More Than One Condition Why Creating Subtypes Helps Patients and Research

To better understand research aimed at identifying tinnitus subtypes and an objective measure for tinnitus, which would both enhance the ability to attract increased funding of research and improve tinnitus patient care, we touched base with Christopher Cederroth, PhD and ATA Scientific Advisory Committee member. Cederroth and a team of researchers recently published a paper that explored such themes through the use of auditory brainstem response (ABR) readings to distinguish between occasional and constant tinnitus, which might serve as a useful marker for subtyping tinnitus patients. (See page 52 for a summary of the investigation, which Cederroth partidipated in.)

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Joy Onozuka: In your most recent research, you suggested that it would be beneficial for tinnitus to be recognized as a neurological disorder.

Why is that?

Christopher Cederroth, PhD: Tinnitus today is considered more as a symptom rather than a disorder. I think this stems from the fact that we use the same word “tinnitus” for all the different forms and phenotypes of tinnitus that have been identified. Whether someone experiences tinnitus as a buzz lasting three seconds, or overnight after a concert, or 24/7 for more than 20 years, we call each of these dissimilar cases “tinnitus.”

If we look at past studies, the nuances, which we are now aware of,

were not taken into account. Tinnitus can be subjective and sometimes objective; can be pulsatile or not; can be intermittent, occasional, or constant; can be experienced as mild, moderate, or extremely severe; can last from a few seconds to decades.

Many of these forms are frequently perceived by the population (up to 30–35 percent) and may not reflect a state of permanent and nonremitting neural alterations.

Our work suggests that once tinnitus becomes constant and chronic, it is associated with neural changes in the midbrain that most likely become permanent. We thus believe that occasional tinnitus can be referred to as a symptom, resulting from a particular cause (defined or not), while constant and chronic

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tinnitus corresponds to a neurological disorder. Nonetheless, tinnitus should remain in the domain of the ear, nose, and throat physician, in my opinion.

Having constant and chronic tinnitus recognized as a neurological disorder might be significant in several ways, such as treatment being covered by health insurance, depending on your healthcare plan, attracting more government interest and funding for research, and providing patients with a sense that their condition is considered seriously. Having said that, I acknowledge that there are people who are greatly bothered by tinnitus, even when it’s occasional, so that would be an area that researchers would need to address in the future.

JO: Why is it important to define constant tinnitus as a subtype?

CC: The World Health Organization’s tinnitus definitions are very limited, which—from a clinical standpoint— makes it very difficult to identify what type of tinnitus a patient has been diagnosed with. For instance, sometimes people develop tinnitus following a concert or a night out dancing and they seek medical help to understand what’s going on. A few days later, their tinnitus vanishes. Nonetheless, they received a medical diagnosis of tinnitus, which

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was recorded in a medical registry or file. Another person received a tinnitus diagnosis after an ENT visit to address hearing loss. The tinnitus diagnosis was recorded, even if the person didn’t find it bothersome or wasn’t seeking help for it. Thus, the clinical and research fields need better evidence-based definitions.

Let’s take hypertension as an example of what I mean. Someone isn’t diagnosed with hypertension based on one measure of high blood pressure. A person with a high reading will be asked to return three or four times over the course of several weeks for new measurements so the physician can confirm what’s going on before making a diagnosis. I’d like to see tinnitus patients handled similarly so we understand when tinnitus is constant or not.

From a research perspective, defining constant tinnitus as a subtype is important because it is a defined subgroup of individuals with tinnitus that can be classified using an objective measure. This means that chronic tinnitus is sufficiently homogeneous for additional biomarker research. This is important for those of us testing for blood biomarkers or genetic variants. From a therapeutic perspective, this is also important because such a definition may improve the design of clinical trials since

it could be used for inclusion and exclusion criteria.

JO: Based on the ABR investigation, do you envision that becoming a standard tool when assessing tinnitus patients? What might that mean for future treatments and research?

CC: Yes, however not all clinical ABR systems are equally reliable.

When considering the assessment of individuals with tinnitus, this will require additional research. ABRs are affected by age, sex, hearing thresholds, and hyperacusis. Thus, one will not be able to directly assess tinnitus just looking at a raw ABR reading. It will probably take machine learning, or artificial intelligence, to determine with greater accuracy the likelihood of an individual having constant tinnitus.

Regarding treatments, having an objective biomarker should propel R&D in the industry. So far, the therapeutic pipeline has been blocked by lack of trust in questionnaire data that can be influenced by patients’ psychological state. Likewise, how much tinnitus can be influenced by the placebo effect remains unclear. Thus, having an objective readout, such as those from ABRs, would provide a means to further develop and test drugs to silence tinnitus.

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JO: The ABR study suggests that noise exposure can cause midbrain latency changes associated with tinnitus. What exactly does that mean? Should that inform our perspective about noise exposure in recreational settings?

CC: This suggestion was based on existing and published literature that showed similar changes in rodents that had been exposed to noise, which corresponded to what we found in participants’ Wave V latency changes. However, our data could not determine whether such noise exposure in our population caused the alterations we found. It is next to impossible to accurately measure the level of lifetime noise exposure of an individual, and self-reports are very unreliable. Nevertheless, our understanding of the dangers of loud noise and its impact on hearing and tinnitus should be used to increase prevention campaigns. Hearing is a precious resource that should be protected in the same way we look out for other areas of our health.

JO: Could you elaborate on the results suggesting that our current understanding of tinnitus and hidden hearing loss may be faulty?

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CC: Our study indeed suggested a negligible role of hidden hearing loss on tinnitus. However, while I am confident in the findings on Wave V latency, I remain cautious on the claims for Wave I amplitude, which is a surrogate for hidden hearing loss, a type of hearing loss that cannot be measured by a routine diagnostic hearing test.

We reported in our study that different clinical systems have different reliability when assessing Wave I amplitude. Reliability is tested by measuring the individual once, then performing the same measure a few weeks later to see whether the two measurements correspond. Here, we saw that one of the systems we used (ChartR from Otometrics) had poor reliability in measuring Wave I amplitude, whereas the other system (Eclipse from Interacoustic) was excellent, even when this was tested by the same audiologist. The article shows how distinct the ABR responses are between the two systems. We had fewer participants measured with the Eclipse than for the ChartR, unfortunately, which did not allow us to test the systems separately. It is thus possible that the lack of evidence from hidden hearing loss comes from the majority of the Wave I data collected with a less reliable system. In contrast, the

reliability of Wave V latency measures was good for both systems, and as a consequence, these are more robust results. I thus believe that while the contribution of midbrain in tinnitus is established, that of hidden hearing loss on tinnitus remains to be determined using an appropriate system such as the Eclipse, in which a test-retest reliability is evidenced to ensure the validity of the findings. This is what we are currently performing in a large clinical trial within the UNITI project (https://uniti.tinnitusresearch.net/).

JO: Are team members pursuing additional investigations to follow up on findings?

CC: There are two aspects we are investigating: one is whether ABR Wave V latency is a robust outcome measure to detect improvement in tinnitus in patients at a group level; and second, we are now investigating the possibilities of using machine learning for the diagnosis of tinnitus in single individuals.

Letters to the ATA The ATA encourages readers to send comments and questions about tinnitus and/or articles to editor@ata.org. Emails selected for publication may be edited for brevity, clarity, and grammar.

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By Jan L. Mayes, MSc

If our ears bled from exposure to loud noise, protecting hearing would undoubtedly be a public health priority.

No one would tolerate unregulated sound if we had such a gruesome illustration of how everyday sounds cause injury to our ears. But that’s not how hearing injuries show themselves. Instead, we have an invisible crisis of noise-induced hearing loss (NIHL) and tinnitus, which is showing up among all ages, including children. I and my colleague Daniel Fink, MD, who chairs the Quiet Coalition, identified harmful noise emissions from common offenders, including personal listening systems, home appliances and power tools, landscaping equipment, social and entertainment activities, and public transit systems.1 We make a case that immediate changes are necessary to stem the tide of invisible hearing damage that is clearly harming wide swathes of society.

Exposure to loud noise adds up over our life span, despite quiet periods between exposures, like damage from each puff of nicotine adds up for smokers over a lifetime.

The louder and more frequent the noise exposure, the faster and more severe the auditory damage. Besides injuring the inner ear, noise triggers www.ATA.org

hearing nerve degeneration and auditory brain changes. Such changes are linked to tinnitus, hyperacusis or decreased sound tolerance, and hidden hearing loss, a type of hearing loss that cannot be measured by a routine diagnostic hearing test, or problems understanding speech with noise in the background, even when hearing thresholds test within the “normal” range. NIHL typically develops within five to 10 years of harmful exposure.

In 1974, the U.S. Environmental Protection Agency (EPA) identified noise levels required “to protect public health and welfare with an adequate margin of safety.”2 This included a maximum daily average sound level of 70 decibels (dB) over a 24-hour period to prevent any measurable hearing loss over a lifetime. The EPA identified lower average noise levels needed for people to understand spoken conversations: 55 dB in outdoor public spaces and softer for inside homes, schools, and hospitals.

Noise-sensitive populations, including infants and children, people who already have tinnitus or hearing loss, and older adults, are at higher risk. Sensitive individuals can have more difficulty understanding speech in ambient noise and develop auditory problems faster or at lower noise exposures than adults with normal

Artwork by Codex Anatomicus www.codexanatomy.com

If Only We Could See the Damage of Noise Exposure

hearing. Until the brain matures in the late teen years, infants and children are more vulnerable to moderate and loud noise damage. Moderate noise exposures too low to cause NIHL can cause auditory brain changes linked to tinnitus, hyperacusis, and hidden hearing loss.

Humans haven’t always suffered noise-induced health damage.

Populations with limited exposure to modern-day noise maintained good hearing into their older years, as found among the Maabans in the Sudan.3 Common moderate-to-loud sounds among the Maabans included spoken conversations, weather sounds like heavy rain, noise from wooden tools used to harvest crops, and livestock bleating. The loudest sounds were emitted from humans shouting, babies crying, roosters crowing, or thunder clapping. High-level sound was recorded among younger Maabans engaged in entertainment, which included singing, playing a five-string lyre, and drumming on logs with sticks; they too retained good hearing, even after age 70. This is in stark TINNITUS TODAY SPRING 2022

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contrast to modern society, where hearing loss in older adults is too often wrongly blamed on “age” instead of a lifetime of widespread exposure to harmful noise.4 When I started out as an audiologist in the 1980s, NIHL was common in adults exposed to loud noise from military service, work environment, hobbies, and/or entertainment. NIHL in children and teens was rare. I mainly saw it in hunters.

Now exposure to loud noise begins early in life and adds up faster with each passing year. Manufactured and amplified noise sources identified almost 50 years ago are still too loud today, including vacuums, blenders, gas-powered lawn mowers, subways, road vehicles, and air traffic noise.5 We go to loud restaurants, wedding receptions, and sports events, usually without considering the auditory risk. Movie theaters set sound systems to unhealthy volumes, even for musicals and animated movies rated for younger audiences. Music is dangerously amplified at bars, nightclubs, and concerts. Noise exposure in everyday life is great enough to cause hearing loss among the public, not just in those with occupational noise exposure.1 Of all the modern-day sources of sound, personal listening systems have had the worst impact on public health.6 Keep in mind that the volume of sound from earbuds or headphones can be as loud as a rock concert. Nowadays, children as young as 3 years old can be seen wearing personal listening devices.

Children between the ages of 9 and 11 who frequently use earbuds and headphones are developing characteristic NIHL, with up to 69 58

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percent of children, teens, and young adults who used personal listening systems for music reporting auditory problems, including tinnitus and hyperacusis.7 Even with no NIHL, children listening at an approximate 50 percent volume setting for about an hour at a time are more likely to have tinnitus than nonusers.8 Eighteen to 25 year olds who reported listening at high volume said they had trouble understanding conversations at family dinners.9 The World Health Organization (WHO) now estimates that about 50 percent of children, teens, and young adults are at risk of NIHL from personal listening alone, which accounts for more than 80 million 12 to 35 years olds living in the U.S.6,7 Just imagine the reaction if their ears bled from noise injury.

Preventable noise-induced auditory problems carry high educational, social, economic, and healthcare costs. The WHO reports that hearing loss alone costs the global economy $750 billion each year.8 Early hearing loss—even mild—is linked to learning problems, social isolation, and poor mental health. People with tinnitus and hyperacusis are more likely to have anxiety, depression, and suicidal thoughts.9 Hearing loss and problems understanding speech-in-noise are each linked to a higher risk of developing dementia or Alzheimer’s.10,11 Individual impact is harder to measure. As an audiologist, my noiseexposed adult patients were often in tears. They longed for the time when music sounded good, when birds could be heard chirping, when tinnitus wasn’t a constant part of the backdrop. It took too much effort to understand conversations, or it was

too loud for comfort, so they isolated themselves socially. There were lots of communication breakdowns. One patient shared the embarrassment of buying red thread instead of the French bread that was asked for. Another confessed that he lost a friend by pretending to understand; “That’s nice,” he said, when his friend shared that his wife had died. I’ve always lived with hyperacusis and developed tinnitus following head trauma from a car accident. I wouldn’t wish them on my worst enemy, let alone a child or a teen.

Besides auditory damage, my colleague Dr. Fink points out that there are thousands of studies that show the damage of loud noise to our health, including preventable stress, disrupted sleep, cardiovascular disease, and early death. He likens the current noise-induced health crisis to the health crisis caused by chemical pollution, like pesticides and herbicides, that Rachel Carson wrote about 60 years ago in Silent Spring.12 Why is noise any different? Imagine today’s noise-exposed young people needing healthcare for tomorrow’s auditory, mental, cognitive, and physical health problems. These are often avoidable cases and costs.

Under the Clean Air Act of 1970 and later Quiet Communities Act, the EPA established an Office of Noise Abatement and Control.

Responsibilities included education, setting noise emission standards, and assisting local and state authorities with efforts as needed. Federal funding was cut in 1982, following attempts to regulate garbage truck noise emissions.13 Since then, sources of noise have largely gone unchecked,

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and we are peppered with harmful noise exposures as a common part of daily living.

Today, most people are unaware of auditory health risks from moderately loud noise exposure. Use of earplugs or earmuffs when engaged in noisy hobbies or entertainment isn’t the norm. Governments are planning “zero emission” solutions for climate change, like expanded public transit systems, while ignoring current noise emissions hurting public health, especially sensitive populations like children. I’ve measured harmful sound levels from traffic and landscaping equipment in my community and have found electric leaf blowers advertised as “quiet” that are still dangerously loud. Manufacturers falsely advertise 85 dB sound-limiting headphones as “safe” for children.

New noise sources like commercial delivery drones are likely proposed without thought for public health.

We need designated quiet zones for homes, schools, and public spaces.

Protective noise limits are critical for environmental sources like appliances, power tools, and public transit. Signs could warn the public about loud venues like concerts or stadium events where hearing protection is necessary. Some venues, such as restaurants or movies rated for children, could turn down the volume.

Personal audio systems are so high risk that noise control may never make them completely safe. Prevention approaches include restricting use of personal listening devices in childhood, safer listening habits, and output limit standards.

The WHO estimates public health interventions for hearing loss, including noise prevention and control, result in economic and healthcare www.ATA.org

benefits or savings of $7 to $15 for every $1 invested.8 Yet there is little public or political support to solve the noise-induced public health crisis.

Skopos Labs at govtrack.us predicts a 1 percent chance that the U.S. Senate will pass the Quiet Communities Act of 2021–2022 to fund the EPA Office of Noise Abatement and Control again.14 Without governmentmandated action plans and noise reduction targets, there is no reason to expect safer soundscapes in our future.

Maya Angelou said, “When you know better, do better.” We know rising noise levels from old and new sources have caused the current public health crisis. We know NIHL and tinnitus are becoming insidious childhood disorders with lifelong negative consequences. Noise control measures are effective and urgently needed to save our hearing health.

Without bleeding ears, will we ever start protecting current and future generations from harmful noise?

Jan L. Mayes, MSc, has had tinnitus for more than 30 years.

She is an awardwinning author of nonfiction health books. As a newly retired audiologist, Mayes continues to write about tinnitus, hyperacusis, and community noise impact on disability access, communication, and hearing health. In her spare time, Mayes enjoys writing horror paranormal fiction. To learn more, visit her website: www.janlmayes.com 1 D. J. Fink & J. L. Mayes. (2021). Too loud: Noise exposure in everyday life is causing hearing loss.

Hearing Journal, 74(10), 9, 10. https://www.doi. org/10.1097/01.HJ.0000795648.82072.99 2 Environmental Protection Agency. (1974, April 2).

EPA identifies noise levels affecting health and welfare [Press release]. EPA.gov. https://archive.

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epa.gov/epa/aboutepa/epa-identifies-noise-levelsaffecting-health-and-welfare.html 3 S. Rosen, M. Bergman, D. Plester, A. el-Mofty, & M. H. Satti. (1962). Presbycusis study of a relatively noise-free population in the Sudan. Transactions of the American Otological Society, 50, 135–152.

4 D.J. Fink. (2022). Is hearing loss an inevitable part of aging? Hearing Journal, 75(1), 28, 30. https://www. doi.org/10.1097/01.HJ.0000812700.73007.68 5 J. R. Goldsmith & E. Jonsson. (1973). Health effects of community noise. American Journal of Public Health, 63(9), 782–793. https://www.doi. org/10.2105/ajph.63.9.782 6 J. L. Mayes & D. J. Fink. (2021). Personal audio systems unsafe at any sound. Hearing Journal, 74(12), 36–38. https://www.doi.org/10.1097/01.

HJ.0000804864.64799.d3 7 C. M. P. Le Clercq, A. Goedegeburne, V. W. V. Jaddoe, et al. (2018). Association between portable music player use and hearing loss among children of school age in the Netherlands. JAMA Otolaryngol Head Neck, 144, 668-675 https://www.ncbi.nlm.nih. gov/pmc/articles/PMC6143000/ 8 W. Swierniak, E. Gos, P.H. Skarzynski, N. Czajka, & Skarzynski, H. (2020). Personal music players use and other noise hazards among children 11 to 12 years old. International Journal Environ Res Public Health, 17(18), 6934.

9 M. Gilliver, J. Nguyen, E.F. Beach, & C. Barr. (2017).

Personal listening devices in Australia: patterns of use and levels of risk. Seminars in Hearing, 38, 282-297.

10 Statista. (2022). Resident population of the United States by sex and age as of July 1, 2020 (in millions). Retrieved from https://www. statista.com/statistics/241488/population-of-theus-by-sex-and-age/ 11 D. Tordrup, R. Smith, K. Kamenov, M. Bertram, N. Green, S. Chadra, & WHO HEAR Group. (2022).

Global return on investment and cost-effectiveness of WHO’s HEAR interventions for hearing loss: A modelling study. Lancet: Global Health, 10(1), e52–e62. https://www.doi.org/10.1016/S2214109X(21)00447-2 12 M. Pienkowski. (2021). Loud music and leisure noise is a common cause of chronic hearing loss, tinnitus and hyperacusis. International Journal of Environmental Research and Public Health, 18(8), 4236. https://www.doi.org/10.3390/ijerph18084236 13 R. S. Thomson, P. Auduong, A. T. Miller, & R. K. Gurgel. (2017). Hearing loss as a risk factor for dementia: A systematic review. Laryngoscope Investigative Otolaryngology, 2(2), 69–79. https://www.doi.org/10.1002/lio2.65 14 J. S. Stevenson, L. Clifton, E. Kuzma, & T. J. Littlejohns. (2021, July 21). Speech-in-noise hearing impairment is associated with an increased risk of incident dementia in 82,039 UK Biobank participants.

Alzheimer’s and Dementia. Advance online publication. https://www.doi.org/10.1002/alz.12416 15 D. J. Fink. (2022). Another silent spring? [Editorial].

Hearing Journal, 75(1), 6, 7. https://www.doi. org/10.1097/01.HJ.0000812692.48032.66 16 S. A. Shapiro. (1992). Lessons from a public policy failure: EPA and noise abatement. Ecology Law Quarterly, 19(1), 1. https://www.doi.org/10.15779/ Z384N9B 17 H.R. 4892: Quiet Communities Act of 2021.

Retrieved from https://www.govtrack.us/congress/ bills/117/hr4892

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 TINNITUS RESOURCES

Tinnitus Support Group Listings People with tinnitus at every stage in their journey, from the first few days to many years later, can benefit from membership in a support group. Every tinnitus support group operates differently; but they all share a

passion for providing meaningful discussion and a caring environment where one can be understood through shared experience. Below is a list of groups and meeting dates, current at time of print.

IN-PERSON MEETINGS Each support group referenced here is independently operated and led by volunteers who wish to provide education and support to the tinnitus community.

The American Tinnitus Association (ATA) does not sponsor or endorse these activities and expressly disclaims any responsibility for the conduct of any independent support group or the information they may provide. ATA is not a healthcare provider and you should consult with a primary care physician or hearing healthcare professional for qualified medical advice on tinnitus and related disorders. *To allow for flexibility in planning, some groups do not or cannot schedule meetings far in advance. When we receive updates from support group leaders, we update meeting information in our online Events Calendar at www.ata.org. The information was provided to ATA staff at the time the magazine went to print; therefore, please confirm meeting details with the contact person prior to a meeting or reference our website at: https://www. ata.org/news/events.

This is a partial listing of support groups and scheduled meetings. A complete list can be found at https://www.ata.org/ managing-your-tinnitus/support-network/ support-group-listing. New groups continue to be added so please check the website for updates periodically.

If you’re interested in forming a group, please contact Joy Onozuka at tinnitus@ata.org.

If there isn’t a group in your area, ATA has an extensive network of volunteers who provide email and telephone support and educational information.

To connect with a volunteer in your time zone, see: https://www.ata.org/ managing-your-tinnitus/support-network/ telephoneemail-support-listing.

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Due to ongoing Covid-19 concerns, it is critical to contact the support group leader directly to confirm meeting information and personal protection requirements.

Information provided on the ATA website is provided by support group leaders and is subject to change.

Colorado Mesa County Tinnitus Support Group Community Hospital, Legacy Room 1 2351 G Road Grand Junction, CO 81505 Contact: Elaine Conlon T: 970–589–0305 E: conlonelaine@aol.com 3rd Wednesday of the month, 6:00 pm North Denver Tinnitus Support Group Broomfield Community Center Overland Room Contact: Melissa Golden T: 303–506–9389 E: mbaycon@hotmail.com

Florida Clermont Tinnitus Support Group Citrus Hearing Clinic, LLC 835 Seventh Street, Suite 2 Clermont, FL 34711 Contact: Dr. Laura Pratesi T: 352–989–5123 E: admin@citrushearing.com From May 9, meeting 2nd Monday of the month, 1:00 pm Sarasota Tinnitus Support Group Silverstein Institute 1901 Floyd St. Sarasota, FL 34239 Contact: Carmen Trotta, Tom Terrenzi T: 941–993–7616, 941–462–1311 E: sarasota.ata@gmail.com 3rd Friday of the month, 2:00–4:00 pm

Illinois Chicago Suburban Tinnitus Support Group Contact: Margie B. E: maggie318@yahoo.com

Massachusetts Boston Tinnitus Support Group Athan’s Bakery 407 Washington St. Brighton, MA 02135 Contact: Kevin Plovanich E: JKPMA@aol.com

Michigan Grand Rapids Individual Support Robert Ellis T: 616–949–4911 E: prohitter@att.net Holland Tinnitus Support Group Holland Doctors of Audiology 399 E. 32nd St. Holland, MI 49423 Contact: Stelios Dokianakis Website: https://holaud.com/contact/ T: 616–392–2222 E: info@holaud.com

New York Long Island Tinnitus Group Long Island Jewish Hospital 900 Franklin Ave. Valley Stream, NY 11580 Contact: Anthony Mennella T: 516–379–2534 E: aem830@verizon.net Currently not meeting. Contact group leader by email for support.

www.ATA.org

TINNITUS RESOURCES 

VIRTUAL MEETINGS Please email/call the point-of-contact person listed for information on upcoming meetings.

Arizona Tucson Tinnitus Support Group Contact: Trudy Jacobson T: 520–982–7813 E: trudyj@cox.net 4th Saturday of the month, 1:00 pm

California Los Angeles/Orange County Tinnitus Support Group Contact: Barry Goldberg E: bargold06@yahoo.com 3rd Saturday of month, 10:00 am The Palo Alto Tinnitus Support Group at Avenidas Contact: Ken Adler E: karmtac@aol.com 3rd Thursday of the month, 5:30–7:30 pm Sacramento Area Tinnitus Support Group Contact: Pat Clark E: sactinnitus@gmail.com 2nd Wednesday of the month, 6:30–8:00 pm San Diego Tinnitus and Hyperacusis Support Group Contacts: Michael J. Fischer, michaeljohnfischer@hotmail.com Loretta Marsh, lorettamarsh@hotmail.com David Phaneuf, djphaneuf@yahoo.com Tom Sutton, tomsutton63@gmail.com 1st Wednesday of the month, 6–7:30 pm San Francisco Tinnitus Support/ Education Group Contact: Tracy Peck Holcomb T: 415–921–7658, ext. 35 E: tracy@hearingspeech.org 3rd Thursday of the month, 3:00 pm Sign up for mailing list: https://www. hearingspeech.org/services/educationcounseling-programs/support-groups/

Colorado Denver Tinnitus Support Group Contact: Rich Marr T: 303–875–5762 E: r.marr@comcast.net 2nd Monday of the month, 7:00–8:30 pm

www.ATA.org

Florida Tampa Tinnitus Support Contact: Joel DeAngelis E: joel.deangelis70@gmail.com 3rd Monday of the month, 7:00 pm

Georgia The ENT Institute Tinnitus Support Group Contact: Sonia Hamidi, AuD, CH-TM T: 678–347–2123 E: shamidi@nsainstitute.com 3rd Thursday of the month, 6:00 pm

Maryland University of Maryland Tinnitus and Hyperacusis Support Group Contact: Christina Shields, AuD E: shields3@umd.edu Meets quarterly, dates and times TBD

Missouri St. Louis Tinnitus Support Group Contact: Tim Busche T: 636–734–4936 E: tbusche@stltinnitus.org 1st Wednesday of even months, 7:00–9:00 pm

New Jersey South Jersey Tinnitus Support Group Contact: Beth Savitch, Erin Lustik E: tsg@advancedent.com Meeting virtually via Zoom 1st Thursday of the month, 7:00–8:30 pm

New York Bronx Tinnitus Support Group Contact: Dr. S. Karie Nabinet T: 917–797–9065 E: kkwn12u@aol.com 1st Thursday of the month, 6:30 pm

Oregon VA Portland Health Care System Tinnitus Education Group National Center for Rehabilitative Auditory Research 3710 SW US Veterans Hosp. Rd. Portland, OR 97239 Contact: Bryan Shaw E: Bryan.Shaw2@va.gov

Pennsylvania Lehigh Valley Tinnitus Support Group Contact: Luke Ciaccio, PhD P: 610–776–3117 E: lciaccio@gsrh.org 2nd Tuesday of month, 5:30–6:30 pm

Texas Austin & San Antonio Tinnitus Support Group Contact: Matthew Randal T: 210–549–8579 E: atasg.satx@gmail.com Dallas/Ft. Worth Tinnitus Support Group Contact: John Ogrizovich E: dfwtsg@yahoo.com Meets every 4–6 weeks, Saturday, 10:00 am Houston Tinnitus Support Group Contact: Vinaya Manchaiah E: houstontinnitus@gmail.com

Virginia National Capital Region Tinnitus Support Group Contact: Elaine Wolfson, David Treworgy E: erwolfson@comcast.net E: david_treworgy@yahoo.com Meets monthly

Washington Seattle Tinnitus Support Group Contact: Keith Field T: 206–783–7105 E: Keith_r_field@outlook.com Last Wednesday of month, 6:30–8:00 pm

Wisconsin Madison Tinnitus Support Group Contact: Deb Holmen T: 608–219–0277 E: dholmenihearu@gmail.com 4th Wednesday of the month, 6:30–7:30 pm

HYBRID MEETINGS North Carolina Raleigh Tinnitus Support Group Raleigh Hearing and Tinnitus Center 10320 Durant Rd, Ste. 107 Raleigh, NC 27614 Contact: Saranne Barker, AuD T: 919–790–8889 E: info@rhatc.com 4th Thursday of the month, 6:00 pm Virtual and in-person access

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HEALTHCARE PROVIDERS

Spotlight on Patient Providers Professional Members Listing current as February 28, 2022

When making an appointment, please mention that you learned of the provider through the American Tinnitus Association, thereby ensuring that providers understand the importance of being a part of the ATA’s tinnitus patient provider network.

Inclusion in the ATA network does not constitute an endorsement or approval by the ATA, as the ATA does not endorse or recommend any specific tinnitus treatments or providers. The ATA maintains provider information in our magazine and on our website to assist people with tinnitus in finding a local provider for treatment and support that may be helpful.

COLOR KEY Purple: Audiology Green: Medical practitioner Blue: Hearing aid dispenser Orange: Therapist Pink: Complementary/Alternative Medicine practitioner Navy: Other

UNITED STATES Alabama Jennifer S. Koczor, AuD, CH-TM Eastern Shore ENT Clinic Daphne, AL Susan Sheehy, AuD Alabama Hearing Associates Madison, AL

Alaska Emily McMahan, AuD, CH-TM Alaska Hearing & Tinnitus Center Anchorage, AK

Arizona

David Velenovsky, PhD University of Arizona Tucson, AZ Peter Vernezze, MSW, PhD The Tinnitus Coach Tucson, AZ

Arkansas Kelley Linton, AuD, CH-TM Center for Hearing, Ltd Fort Smith, AR

California Kasra Abolhosseini, AuD Tustin Hearing Center Tustin, CA Melissa Alexander, AuD Alexander Audiology, Inc. Santa Monica, CA John Barrett, LAc The Acupuncture Wellness Center, Inc. Los Angeles, CA Joe Bartlett, BC–HIS Bartlett’s Hearing Aid Center Chico, CA Randall Bartlett, MA Tinnitus & Audiology Center of Southern California, Inc. Santa Clarita, CA Maryellen Brisson, AuD Hermosa Beach, CA Shahrzad Cohen, AuD, CH-TM Hearing Loss Solutions Sherman Oaks, CA David DeKriek, AuD Fidelity Hearing Center Cerritos, CA Gregory Frazer, AuD Pacific Hearing & Balance Center, Inc. Los Angeles, CA

Lynn Callaway, BC–HIS Affordable Hearing Solutions Green Valley, AZ

Jennifer J. Gans, PsyD Mindful Tinnitus Relief San Francisco, CA

Judy Huch, AuD Oro Valley Audiology, Inc. Oro Valley, AZ

Amit Gosalia, AuD West Valley Hearing Center Woodland Hills, CA

Rachael Luckett, AuD Sound Relief Hearing Center Scottsdale, AZ

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Tracy Peck Holcomb, AuD The Hearing and Speech Center of Northern California San Francisco, CA Beverly Lew, AuD Sound Advice Burbank, CA Peter J. Marincovich, PhD Audiology Associates Santa Rosa, CA Sara Mattson, AuD Rancho Santa Fe Audiology Rancho Santa Fe, CA Kirsten McWilliams, AuD, CH-TM The Hearing Solution Sacramento, CA Amy Nelson, AuD, CH-TM Kaiser Permanente Santa Clara, CA Janine Newkirk, AuD, CH-TM Stanford Health Care Menlo Park, CA Marni Novick, AuD, CH-TM Silicon Valley Hearing, Inc Los Gatos, CA Angela O’Boyle, AuD Hearing Associates Inc. Northridge, CA Bruce Piner, AuD Hearing and Balance Center Encino, CA Ashley Potter, AuD Humboldt Audiology Eureka, CA Brook Raguskus, AuD, CH-TM Pacific Hearing Service Los Altos, CA Samantha Ramirez, AuD Kaiser Permanente Redwood City, CA Dena Riso, AuD Peninsula Hearing Center, Inc. San Diego, CA Jane Rosner, AuD West Valley Hearing Center Woodland Hills, CA

www.ATA.org

HEALTHCARE PROVIDERS

Jessica D. Russell, MA The Hypnotherapy Centers Los Angeles, CA

Drew Price, AuD Sound Relief Hearing Center Denver, CO

Kelly J. Dyson, AuD Suncoast Audiology, LLC Largo, FL

Mimi Salamat, PhD Dr. Mimi’s Audiology Clinic Walnut Creek, CA

Julie Prutsman, AuD Sound Relief Hearing Center Highlands Ranch, CO

Melodi Fehl, MS ENT and Allergy Associates of Florida Boca Raton, FL

William Stubbeman, MD TMS Psychiatry Los Angeles, CA

Megan Read, AuD Sound Relief Hearing Center Highlands Ranch, CO

Lisa Gascay, AuD, CH-TM Rainbow River Hearing & Balance Inc. Dunnellon, FL

Christopher Sumer, NBC–HIS Coastal Hearing Aid Center Encinitas, CA

Kenzie Reichert, AuD, CH-TM Sound Relief Hearing Center Highlands Ranch, CO

Karah Gottschalk, AuD NOVA Southeastern University Ft. Lauderdale, FL

Ben Thompson, AuD Treble Health Berkeley, CA

Jackie Smith, AuD Sound Relief Hearing Center Highlands Ranch, CO

Megan Labbe, AuD, CH-TM St. Luke’s Cataract and Laser Institute Tampa, FL

Brian Worden, MD Kaiser Permanente Woodland Hills, CA

Mandi Solat, AuD, CH-TM Audiology Services & Hearing Aid Center Lakewood, CO

Sara Miers, AuD Jacksonville Speech & Hearing Center Jacksonville, FL

Roger Wunderlich, MD DSH-A Atascadero, CA

Robert M. Traynor, EdD, CH-TM Fort Collins, CO

Janice T. Powis, AuD Mind Over Tinnitus St. Augustine, FL

Colorado Morgan Ashby, AuD, CH-TM Sound Relief Hearing Center Westminster, CO Lindsay Collins, AuD Sound Relief Hearing Center Centennial, CO Terry Cummings, AuD, CH-TM Columbine Audiology and Hearing Aid Center Sterling, CO Julie Eschenbrenner, AuD Flatirons Audiology, Inc. Lafayette, CO Kaela Fasman, AuD, CH-TM Sound Relief Hearing Center Golden, CO Emily Hensarling, AuD, CH-TM Kaiser Permanente Lone Tree, CO Krisztina Johnson, AuD Hearing Associates New Castle, CO Tony Kovacs, AuD, CH-TM Sound Relief Hearing Center Fort Collins, CO Kevin McConnell, HIS Ideal Hearing Solutions LLC Lakewood, CO Abigail McMahon, AuD Sound Relief Hearing Center Fort Collins, CO Leah Mitchell, AuD Sound Relief Hearing Center Westminster, CO www.ATA.org

Connecticut Natan Bauman, EdD Auditory and Vestibular Institute of New England Hamden, CT Steven Lurie, PhD Torrington, CT

District of Columbia Patricia T. Demont, PhD Washington, DC

Delaware Megan E. Boehler, AuD Bayside Audiology & Hearing Aids Lewes, DE

Florida Indira Alvarez, AuD Palm Coast Hearing Center Palm Coast, FL Kelly Breese, AuD, CH-TM Murphy Hearing Aids of Sarasota Sarasota, FL Anne Carter, PhD, CH-TM Pasadena Hearing Care South Pasadena, FL Maura Chippendale, AuD, CH-TM Chippendale Audiology Cape Coral, FL Melissa Kipp Clark, AuD Suncoast Hearing Services Plus Bradenton, FL Ali Danesh, PhD Labyrinth Audiology Boca Raton, FL

Karthikeyan Sai, MD Palm Beach Kidney & Hypertension Wellington, FL Cindy Ann Simon, AuD South Miami Audiology Consultants South Miami, FL Mindy Stejskal, MCD The Hearing Center Pensacola, FL Susan E. Terry, AuD Broadwater Hearing Care St. Petersburg, FL Liz White, AuD Harbor City Hearing Solutions Melbourne, FL Kayla Wilkins, AuD Aspire Hearing and Balance Lakeland, FL

Georgia Laura Barber, AuD, CH-TM Augusta University Health–Audiology Associates Augusta, GA Christopher V. Campellone, HIS GoToHearing Gainesville GA Sonia Hamidi, AuD, CH-TM ENT Institute Buford, GA Jan Henriquez, AuD At Home Hearing Woodstock, GA Brian K. Jones, MEd Greater Atlanta Hearing Inc. Cumming, GA TINNITUS TODAY WINTER 2021

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HEALTHCARE PROVIDERS

Liz Ramos, AuD, CH-TM ENT of Georgia/Advanced Hearing Atlanta, GA

Karen Pastell, AuD Prairieland Audiology, LLC Joliet, IL

Ann Rhoten, AuD Kentucky Audiology & Tinnitus Services Lexington, KY

Nikki Weaver, AuD Fayette Hearing Clinic and Coweta Hearing Clinic Peachtree City, GA

James H. Peck, HIS Life Hearing Health Centers Rockford, IL

Kari A. Wickstrom, AuD Bluegrass Hearing Clinic Nicholasville, KY

Melissa Wikoff, AuD, CH-TM Peachtree Hearing Marietta, GA

Jeanne Perkins, AuD Audiologic Services Glen Ellyn, IL

Hawaii Amanda Seeley, AuD Advanced Pacific ENT Wailuku, HI

Idaho Christine Pickup, AuD Mt. Harrison Audiology & Hearing Aids, LLC Rupert, ID Tosha Strickland, AuD Strickland Ear Clinic Meridian, ID

Illinois

Alyssa Seeman, AuD Illinois State University Normal, IL

Indiana

Mary C. Chisholm, AuD Northwest Speech and Hearing Ltd. Arlington Heights, IL Nancy Congdon, AuD, CH-TM The Hearing Care Clinic Downers Grove, IL Phillip Elbaum, LCSW Stritch School of Medicine Loyola University, Chicago Deerfield, IL Dru A. Geraghty, MS Audiologic Services Glen Ellyn, IL Lori A. Halvorson, AuD, CH-TM Lake Forest Hearing Professionals Lake Forest, IL Dawn Heiman, AuD Advanced Audiology Consultants Woodridge, IL Jill Meltzer, AuD, CH-TM Jill Meltzer, AuD Consulting PLLC Northbrook, IL Janaan S. Moore, AuD Michigan Avenue Hearing Health Chicago, IL Maria Morrison, AuD, CH-TM Geneva Hearing Services Geneva, IL

TINNITUS TODAY SPRING 2022

Leanne Battler, AuD United States Army Fort Polk, LA Catherine C. Lo, AuD The Hearing Clinic Thibodaux, LA Mary Miller, PhD Premier Hearing and Balance Hammond, LA

Curt Esterline, HIS Concierge Hearing Healthcare New Haven, IN

Ram Nileshwar, AuD The Hearing Center of Lake Charles Lake Charles, LA

Erica Person, AuD, CH-TM Flex Audiology Lawrenceburg, IN

Elena Treadway, AuD Noel ENT Hearing Center Abbeville, LA

Elizabeth Zweigart, AuD Midwest Ear Nose & Throat Surgery Evansville, IN

Steve Bonzak, MS Health Traditions Chicago, IL

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Daria Popowych, AuD North Side Audiology Group, Inc. Chicago, IL

Louisiana

Iowa

Maryland Chelsea Carter, AuD University of Maryland Medical Center Baltimore, MD

Diana Kain, AuD Heartland Hearing Center Hiawatha, IA

Katelyn M. Leitner, AuD, CH-TM Hearing Assessment Center Nottingham, MD

Beki Kellogg, AuD Hope Hearing & Tinnitus Center Hiawatha, IA

Candice Ortiz-Hawkins, AuD Capital Institute of Hearing & Balance Silver Spring, MD

Jill Nesham, AuD Professional Hearing Solutions by Dr. Jill Cedar Rapids, IA

Yael Schonfeld, AuD Chesapeake Ear, Nose & Throat Owings Mills, MD

Heather Thatcher, HIS Hope Hearing & Tinnitus Center Hiawatha, IA

Christina Shields, AuD University of Maryland College Park College Park, MD

Kansas

Massachusetts

Bryne Gonzales, AuD NuSound Hearing & Tinnitus Center Topeka, KS

Dierdre Anderson, AuD Audiology Network Services Salisbury, MA

Rebekah J. Highfill, AuD Ascension Via Christi Rehabilitation Hospital Wichita, KS

Eugene Antonell, BC–HIS Hear Better Now Tinnitus & Hearing Center N. Dartmouth, MA

James Mangimelli, AuD Atchison, KS

Nataliya Ayzenberg, AuD, CH-TM Moon Hearing Services, LLC Woburn, MA

Kentucky Vanessa L. Ewert, AuD Bluegrass Hearing Clinic Lexington, KY

Judith Bergeron, BC–HIS, CDP Beauport Hearing Care Gloucester, MA

www.ATA.org

HEALTHCARE PROVIDERS

Joni Skinner Bullough, AuD Hampshire Hearing & Speech Northampton, MA

Michelle Rankin, AuD Rankin Audiology and Hearing, LLC Chelsea, MI

Collin Campbell, LAc Campbell Acupuncture and Herbal Medicine Clinic South Dennis, MA

Benjamin Wightman, AuD Sound Advice Audiology Livonia, MI

Theresa Cullen, AuD, CH-TM Cape Cod Hearing Center Hyannis, MA Nancy Duncan, AuD, CH-TM Duncan Hearing Healthcare Fall River, MA Kenneth Grundfast, MD Boston University School of Medicine/ Massachusetts Eye and Ear Boston, MA

Joel Young, MD Rochester Center for Behavioral Medicine Farmington, MI

Minnesota John Coverstone, AuD, CH-TM Audiology Ear Care New Brighton, MN Sara Downs, AuD Hearing Wellness Center Duluth, MN

Peter Harakas, PhD CBT Associates, LLC Lexington, MA

John Ehlen Hear Central Victoria, MN

Dana Mario, AuD Mario Hearing & Tinnitus Clinics Mansfield, MA

Jason Leyendecker, AuD Audiology Concepts Edina, MN

Robert Mario, BC–HIS, PhD Mario Hearing & Tinnitus Clinics Cambridge, MA

Laura Morrison, AuD, CH-TM White Bear Lake, MN

Shannon O’Rourke, AuD Cape Cod Hearing Center Hyannis, MA Karen L. Wilber, AuD, CH-TM Boston Children’s Hospital Boston, MA

Michigan Natalie Crossland, AuD, CH-TM Holland Doctors of Audiology Holland, MI Stelios Dokianakis, AuD, CH-TM Holland Doctors of Audiology Holland, MI Allie Heckman, AuD, CH-TM Michigan Medicine–University of Michigan Ann Arbor, MI MaryRose Hecksel, AuD Audiology & Hearing Aid Center Lansing, MI Angela Lederman, MS Hear Now Audiology & Tinnitus Center Clinton Township, MI Nina Lopatin, MA Direct Hearing West Bloomfield, MI Shannon Radgens, DO Red Cedar Ear Nose & Throat & Audiology Owosso, MI www.ATA.org

Gayla Poling, PhD Mayo Clinic Rochester, MN Thomas Tedeschi, AuD Amplifon Americas Minneapolis, MN Jerry Zhou, PhD Hearing of America, LLC Oakdale, MN

Mississippi Denise Boatner, MS ENT Physicians of North Mississippi Tupelo, MS Mollie Johnson, AuD ENT Physicians of North Mississippi Tupelo, MS

Jay Piccirillo, MD Washington University School of Medicine Saint Louis, MO

Nevada Robyn Lofton, BC–HIS Hearing Associates of Las Vegas Las Vegas, NV

New Jersey Granville Y. Brady Jr., AuD East Brunswick, NJ Jade Igbokwe, AuD, CH-TM NTI Audiology Jersey City, NJ Valerie Kriney, AuD Northern Jersey ENT Associates Glen Rock, NJ William J. McDonnell, VSO Dept. of Veterans Affairs Mount Laurel, NJ Marion Rollings, PhD Holistic Health Counseling Center LLC Hillsborough, NJ Beth Savitch, MA Advanced ENT/Hear MD Voorhees, NJ Donna Szabo, AuD Innovative Hearing Solutions Westwood, NJ

New Mexico Susan Allshouse, AuD Wendy Gallegos Audiology Corrales, NM Jeffrey W. Wise, AuD, CH-TM Expert Hearing Care Las Cruces, NM Catherine A. Worth, MS Capital Hearing Care Albuquerque, NM

New York

Jennifer Mize, AuD ENT Physicians of North Mississippi Tupelo, MS

Nicole Ball, AuD Hearing Evaluation Services of Buffalo, Inc Tonawanda, NY

Rhonda Sage, MS ENT Physicians of North Mississippi Tupelo, MS

Lois Cohen, LCSW, ACSW, BCD Tinnitus Counseling Northport, NY

Stephanie Warren, MS ENT Physicians of North Mississippi Tupelo, MS

Bruce Hubbard, PhD CBT for Tinnitus, LLC New York, NY

Missouri Laura Flowers, AuD Hearing and Balance Specialists of Kansas City Lee’s Summit, MO

Harriet Jacobster, AuD Lyric Audiology New Windsor, NY

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HEALTHCARE PROVIDERS

Tracey Lynch, AuD Island Better Hearing Inc. Melville, NY

Alicia L. Cristobal, AuD Hearing Health Care Services, PLLC Durham, NC

Heather Malyuk, AuD Soundcheck Audiology Cuyahoga Falls, OH

Sapna Mehta–Gertz, AuD Weill Cornell Medicine New York, NY

Lisa Fox–Thomas, PhD UNCG Speech and Hearing Center Greensboro, NC

Heather Maze-Smith, AuD Maze Hearing, LLC Bellefontaine, OH

Carolynne Pouliot, AuD Hearing Aid Works Audiology Rochester, NY

Goutham Gosu, AuD Hearing Solution Center Charlotte, NC

Amy Sapodin, AuD Advanced Hearing Center Albertson, NY

Hannah Heet, AuD, CH-TM Duke Otolaryngology of Raleigh Raleigh, NC

Eric Mounts, HIS Modern Hearing Solutions/Choice Hearing Center Canton, OH

Leigh A. Sauerbier, AuD, CH-TM The Advanced Hearing Center Brooklyn, NY

Julia Hubbard–Rossi, AuD Carolina Hearing and Tinnitus, PC Mooresville, NC

Jeffrey M. Shannon, AuD Hudson Valley Audiology Pomona, NY

Patricia Johnson, AuD, CH-TM UNC School of Medicine Chapel Hill, NC

Alyssa Smyczynski, AuD Hearing Evaluation Services of Buffalo, Inc. Orchard Park, NY

Nancy McKenna, AuD, PhD University of North Carolina Chapel Hill Chapel Hill, NC

Amanda Snell, AuD Finger Lakes Audiology, PLLC Horseheads, NY

Melissa Palmer, AuD High Point Audiological–Clayton Clayton, NC

Randall Solomon, MD Long Island Mental Health Port Jeff Station, NY

Stan Phillips, MD South Lake Hearing and Tinnitus Center Huntersville, NC

Jennifer Sutton, AuD Hearing Evaluation Services of Buffalo, Inc. Williamsville, NY

Michael B. Slater, AuD South Lake Hearing and Tinnitus Center Huntersville, NC

Anna Forsline, AuD VA Portland Healthcare System Portland, OR

Lori Trentacoste, AuD Island Better Hearing Inc. Melville, NY

Heather Sprague, AuD ENT & Audiology Associates Raleigh, NC

Kristen Furseth, AuD, CH-TM Willamette ENT Salem, OR

Claudyne Vielot, AuD Montefiore Medical Center Bronx, NY

Emilee V. Tucker, AuD, CH-TM Carolina Ear, Nose & Throat—Sinus and Allergy Center, PA Hickory, NC

Bryan J. Greenaway, AuD, CH-TM Pacific University Hillsboro, OR

Erin M. Walborn–Sterantino, AuD Audiologic Solutions Rensselaer, NY Carolyn Yates, AuD, CH-TM Hearing Evaluation Services of Buffalo, Inc. Amherst, NY

Ohio

North Carolina Jennifer Auer, AuD Audiology Attention & Tinnitus Care, PLLC Concord, NC Saranne Barker, AuD, CH-TM Raleigh Hearing and Tinnitus Center Raleigh, NC Susan Bergquist, MS Heritage Audiology Wake Forest, NC Jennifer Clarke, AuD Audiology of Southpoint Durham, NC

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North Dakota Mackensie Brandt, AuD Altru Professional Center Grand Forks, ND

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Richard Reikowski, AuD Family Hearing & Balance Center Akron, OH Eryn Staats, AuD Memorial ENT Marysville, OH Babette Verbsky, PhD, CH-TM Hearing Connections Audiology Lebanon, OH Gail Whitelaw, PhD, CH-TM The OSU Speech–Language–Hearing Clinic Columbus, OH Kyle Woods, MA, CH-TM Modern Hearing Solutions/Choice Hearing Center Canton, OH

Oregon

James Henry, PhD National Center for Rehabilitative Auditory Research (NCRAR) Portland, OR Todd Landsberg, AuD South Coast Hearing Center Coos Bay, OR

Samantha Bayless, AuD, CH-TM The Hill Hear Better Clinic Cincinnati, OH

Erika Shakespeare, MSc Audiology & Hearing Aid Services La Grande, OR

Sarah E. Curtis, AuD Sounds of Life Hearing Center, LLC Concord Township, OH

Sandi L.B. Ybarra, AuD Hearing Associates Eugene, OR

Kristie Dannemiller–Smith, AuD Ascent Audiology and Hearing Barberton, OH Cathy Kooser, MSW, LISW Hillcrest Hearing & Balance Center Centerville, OH

Pennsylvania Krista Blasetti, AuD York ENT Associates York, PA

www.ATA.org

HEALTHCARE PROVIDERS

Gail Brenner, AuD Tinnitus & Sound Sensitivity Treatment Center of Philadelphia, PC Bala Cynwyd, PA

Courtney C. Guthrie, AuD 4 Bridges Audiology Chattanooga, TN

Alexandra C. Harris, AuD, CH-TM Callier Center for Communication Disorders Dallas, TX

Mindy Brudereck, AuD, CH-TM Berks Hearing Professionals Birdsboro, PA

Andrea Plotkowski, AuD Ear, Nose and Throat Consultants of East Tennessee Knoxville, TN

Rachel Higginbotham, AuD Estes Audiology Hearing Centers, Boerne, TX

Linda Dallas, MEd Allentown Ear, Nose and Throat Allentown, PA

Paul Shea, MD Shea Ear Clinic Memphis, TN

Amy Greer, AuD, CH-TM Lemme Audiology Associates Ebensburg, PA Jennifer Isayev, AuD Audiometrics, Inc. Bryn Mawr, PA Jeannie Karlovitz, AuD Advanced Hearing Solutions Exton, PA Anthony Napoletano, HIS Lansdowne Hearing Lansdowne, PA

Rhode Island Holly Puleo, AuD Gateway Hearing Solutions Warwick, RI

South Carolina Todd Gibson, AuD Lake Murray Hearing Lexington, SC Alexandra Tarvin, AuD Elevate Audiology Hearing and Tinnitus Center Easley, SC Jennifer Waddell, HIS Sound Hearing Care Simpsonville, SC Jason P. Wigand, AuD LifeAloud, LLC Lexington, SC

South Dakota Melissa E. Baker, MA Baker Audiology and Hearing Aids Sioux Falls, SD Stephanie Wubben, AuD Stanford Hearing Aids Sioux Falls, SD

Tennessee Tiffany Ahlberg, AuD Ahlberg Audiology & Hearing Aid Services Cleveland, TN Marc Fagelson, PhD East Tennessee State University Johnson City, TN

www.ATA.org

Texas S. Diane Allen, PhD The Grove Counseling & Wellness Center Dallas, TX Amanda Ammerman, PA-C Austin Regional Clinic Austin, TX Theodore Benke, MD Benke Ear, Nose, & Throat Clinic Cleburne, TX Arica Black, AuD The Hearing Doctor Lubbock, TX Lacey Brooks, AuD North Houston Hearing Spring, TX Bethany Brum, AuD, CH-TM UT Southwestern Medical Center Dallas, TX E. Suzanne Carter, LPC-S Private Practice San Antonio, TX Kristen Crawford, AuD ClearLife Hearing Care Allen, TX Heather Dean, AuD Burleson Audiology Clinic Burleson, TX Shannon Frugia, AuD, CH-TM Southeast Texas Ear Nose & Throat Beaumont, TX

Carla S. Hoffman, HIS Hoffman Hearing Solutions Corpus Christi, TX Margaret Hutchison, PhD, CH-TM Austin Hearing Services Austin, TX Susan Hyman, AuD Hyman Hearing Beaumont, TX Kristen Keener, AuD IlluminEar Tinnitus & Audiology Center Austin, TX Christina Lobarinas, AuD UT Southwestern Medical Center Dallas, TX Rene Pedroza, AuD, CH-TM United States Department of Defense El Paso, TX Elly Pourasef, AuD Memorial Hearing Houston, TX Lydia Ramanovich, AuD, CH-TM Dallas Ear Institute Frisco, TX Lisa Richards, AuD, CH-TM Callier Center for Communication Disorders Richardson, TX Christie Spencer, AuD Fort Bend Hearing Sugar Land, TX Bradley Stewart, AuD ClearLife Hearing Care Allen, TX Crystal Wiggins, AuD, CH-TM Memorial Hearing Houston, TX

Please note that the American Tinnitus Association does not verify providers’ certifications and expertise in tinnitus treatment. The list is meant expressly for informational purposes and should not be construed as the ATA’s endorsement of the providers listed. The ATA strongly advises anyone using the list to check practitioners’ websites and tinnitus services before scheduling appointments. Please note that the list includes hearing aid dispensers because hearing aids can be helpful to some people in the management of their tinnitus.

TINNITUS TODAY WINTER 2021

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HEALTHCARE PROVIDERS

Utah Layne Garrett, AuD Timpanogos Hearing American Fork, UT Jessica Lui Nelson, BC-HIS Timpanogos Hearing Spanish Fork, UT Lindsey Tubaugh, AuD Little Heroes Pediatric Hearing Clinic Layton, UT

Vermont Stephanie Hollop, AuD, CH-TM Univ. of Vermont–E.M. Luse Center Burlington, VT

Virginia Kimberly Abeyta, AuD Hearing Resource Center Fredericksburg, VA Ana Anzola, AuD Ascent Hearing McLean, VA Theresa H. Bartlett, AuD Virginia Hearing Consultants Virginia Beach, VA Ann DePaolo, AuD The Audiology Offices, LLC Kilmarnock, VA Julie Farrar–Hersch, PhD Augusta Audiology Associates, P.C. Fishersville, VA Kristin Koch, AuD Evolution Hearing Charlottesville, VA Fred W. Lindsay, DO Hampton Roads ENT and Allergy Hampton, VA

Washington Anne Harvey, AuD University of Washington Medical Center Montlake Seattle, WA Thomas A. Littman, PhD, CH-TM Factoria Hearing Center Bellevue, WA Dustin Spillman, AuD, CH-TM Audiologists Northwest Bremerton, WA

Wisconsin Jon Douglas, AuD, CH-TM University of Wisconsin Tinnitus and Hyperacusis Program Madison, WI

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TINNITUS TODAY SPRING 2022

Hugo Guerrero, AuD, CH-TM Mayo Clinic Health System Onalaska, WI Veronica Heide, AuD, CH-TM Audible Difference, LLC Madison, WI Nicole Klatt, AuD Winding Creek Audiology & Hearing Aid Center Rothschild, WI Dan Malcore The Hyperacusis Network Green Bay, WI Erin O’Leary, AuD AuD Hearing Lake Geneva, WI Melinda O’Meara, HIS Defatta ENT Altoona, WI Mandy Rutta, AuD Gundersen Health System La Crosse, WI Samantha Sikorski, HIS, ACA Sikorski Hearing Aid Center, Inc. Spooner, WI

Wyoming Brendan Fitzsimmons, MD St. John’s—Lander Lander, WY

U.S. TERRITORIES Puerto Rico Isamar Gonzalez–Feliciano, AuD Centro Audiológico e Interdisciplinario, Isamar González, Inc. Arecibo, PR

INTERNATIONAL Argentina Susana A. Dominguez Audiologist Buenos Aires

Australia Crystal Atkins Hearsmart Hearing Solutions Warrandyte Lynne Blackford, BSc MQ Health Speech and Hearing Clinic North Epping, NSW Paul B. Davis, PhD, MAuDSA Tinnitus TeleCare Suffolk Park, NSW

Canada Lacey S. Beierbach, HAP Connect Hearing Calgary, AB Ronald Choquette, AuD, CH-TM Montreal University Audiology Clinic Montreal, QC Sabrina DeToma, AuD Salus Hearing Centre Vaughan, ON Patrick DeWarle, AuD, CH-TM Winnipeg Hearing Centres Winnipeg, MB Heidi Eaton, AuD Argus Audiology Moncton, NB Kimberly Eskritt, AuD Lambton Audiology Associates Sarnia, ON Deborah R. Lain, MSc Hope For Tinnitus Calgary, AB Carol A. Lau, HIS Sound idEARS Inc. Vancouver, BC Larena Lewchuk, MClSc Audiology Clinic of Northern Alberta Edmonton, AB Lucy Xie, HIS Bow River Hearing Calgary, AB

Ireland Laurence McMahon, BComm Hypnosis Online Killarney, CO Kerry

Malaysia Wan Syafira Ishak, PhD, CH-TM Universiti Kebangsaan Malaysia, Malaysia Kuala Lumpur

Serbia Milena Tomanic, MD, PhD Faculty of Medicine, University of Belgrade Novi Beograd

United Kingdom Lisa Caldwell The Hearing Coach Glossop, UK Maxine Harris Hi–Kent Maidstone, UK Alan Hopkirk The Invisible Hearing Clinic Paisley, UK www.ATA.org

TINNITUSTODAY Editorial Calendar Tinnitus Today magazine is a print and electronic media magazine published in April, August, and December, and circulated to 25,000+ ATA contributors, donors, patients, supporters, researchers, and healthcare professionals.

The magazine editorial team empowers readers with information, including up-to-date medical and research news, feature articles on urgent tinnitus issues, questions and answers, self-help suggestions, and letters to the editor from others with tinnitus. Strong service journalism, compelling storytelling, first-person narrative, and profiles are presented in an inviting format to encourage readers to reflect, engage, and better understand a chronic condition that affects millions.

Editorial Copy Due

Photos Due

Ad Close

Digital Launch

Issue Mailed

Improving Sleep

4/15

5/1

5/1

8/1

August

Winter–Dec 2022

Annual Research Issue

9/15

10/1

10/1

12/1

December

Spring–Apr 2023

Advocacy

1/15

2/1

2/1

4/1

April

Issue

Theme

Summer–Aug 2022

Editorial Calendar is subject to change.

To advertise, contact: tinnitus@ata.org

MISSION AND CORE PURPOSE The mission and core purpose of the ATA are to promote relief, help prevent, and find cures for tinnitus evidenced by its core values of compassion, credibility, and responsibility.

CORE VALUES AND GUIDING PRINCIPLES Compassion: Evidenced in a spirit of hope reflected in the commitment to finding a cure, preventing the condition, and supporting those affected by the condition.

Credibility: Evidenced in accurate information from reliable sources, transparency in decisionmaking, and an earned reputation for trustworthiness.

Responsibility: Evidenced in patient-centered advocacy by a collaborative community of forward thinking leaders accountable to its mission and members. www.ATA.org

c/o Truist Bank PO Box 424049 Washington, DC 20042-4049

Open Access ATA’s Conversations in Tinnitus, with John A. Coverstone, AuD, and Dean Flyger, AuD ATA PODCASTS ARE FREE AND OPEN ACCESS

Tune In to Stay Abreast of Tinnitus Research and News The American Tinnitus Association’s podcasts are available 24/7 to help you stay abreast of tinnitus research and other tinnitus topics. Just like listening to music on your smartphone or computer, you can tune in to Conversations in Tinnitus podcasts, while you work out, take a walk, relax at home, or commute to work. To access and learn more about this unique series, visit our website at www.ata.org. To enhance listening comprehension and accommodate those with noise sensitivity, transcripts are available with each podcast.

These are only a few of the episodes from our podcast library.

Episode 16: Considering the Psychophysiological Elements of Tinnitus SUBJECT MATTER EXPERT: Christopher Spankovich, PhD, MPH TOPIC: Dr. Christopher Spankovich discusses how tinnitus interventions should address both the psychological and physiological impact of tinnitus on patients. He explores how nutrition, emotional health, and physical health all play a role in mitigating the negative impact of tinnitus. He

also discusses the importance of helping patients understand the power of sound to elicit positive or negative emotions, aside from the tinnitus sound, in order to facilitate habituation. Noting that not all patients believe or accept the psychological component of tinnitus, Dr. Spankovich encourages providers to assess what best fits the needs of individual patients, taking into consideration their specific challenges, what the patient believes, and what he/she is likely to respond to, rather than focusing on a one-size-fits-all approach.

Episode 13: Understanding Preferences for Loud Music SUBJECT MATTER EXPERT: Elizabeth Beach, PhD TOPIC: Dr. Elizabeth Beach discusses large-scale research that reveals why clubs, bar, and music venues are playing music at higher volumes than what most people prefer. And while it might seem easy to raise awareness that results in quieter recreational music venues, Beach says it’s complicated, so safe listening initiatives require support at various levels to achieve change. As head of the Behavioral Sciences Department at the National Acoustics Laboratory in Australia, she studies recreational noise in the music and entertainment industry, strategies for encouraging safe listening for staff and patrons, and how to motivate young adults to protect their hearing.

The ATA has earned the 2022 Platinum Seal of Transparency from Candid (formerly GuideStar and Foundation Center), illustrating the ATA’s commitment to sharing our strategy, metrics, and achievements with members and donors.

To subscribe to the print or digital issue of Tinnitus Today, which is published three times a year, visit www.ata.org or email tinnitus@ata.org