Tinnitus Today • Summer 2021 by Tinnitus Today

TINNITUSTODAY Vol. 46, No. 2, Summer 2021

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

What to Do About Tinnitus

Treatments • Interventions • Science

How to Help a Child With Tinnitus Pros and Cons of Telehealth Tinnitus Care How the ATA Sparked Investigation of Sound Therapy

A publication of the

Visit & Learn More About Tinnitus at ATA.org

Your Tinnitus Association Wins Gold Dear Friends and Subscribers, We’re thrilled to announce that Tinnitus Today magazine and Conversations in Tinnitus podcast won four awards—two from EXCEL and two from Digital Health—which is a tremendous honor that underscores the importance of sharing the voices of people with tinnitus, such as yourselves, and those of researchers determined to put an end to tinnitus. “We’re incredibly grateful to our contributors, editorial advisory board, design team, and others who contribute to making each issue and podcast a success,” said Torryn Brazell, CEO of the American Tinnitus Association and publisher of Tinnitus Today magazine. “Our mission, your stories, and the voices of many other people dedicated to communicating about tinnitus make a difference.” Awards are based on content, format, success in reaching the targeted audience, and overall quality. The EXCEL Awards are the largest and most prestigious program recognizing excellence and leadership in association media, publishing, and communications. The Spring 2020 magazine issue Tinnitus in a Time of Chaos: Calming the Mind, which addressed the significance of mental health access for tinnitus, was awarded Gold for Single Topic Issue. Tinnitus Today magazine also walked away with Bronze for General Excellence for the three issues published in 2020.

“This year’s EXCEL Award winners deserve special praise for producing outstanding work in the midst of a global pandemic resulting in quarantine and remote work,” said Jeff Joseph, president and CEO of Software Information & Industry Association, which oversees the Annual AM&P Network EXCEL Awards, now in its 41st year. “Our honorees overcame these challenges, truly representing the ‘best of the best’,” he said in a press release. The 23rd annual Digital Health Awards, which honor the best in digital health resources, awarded Bronze to ATA’s Conversations in Tinnitus podcast Exploring Noninvasive Neuromodulation for Tinnitus Relief, which discussed the science behind neuromodulation with tinnitus researcher Hubert Lim, PhD. To listen to the podcast, which is hosted by John Coverstone, AuD, and Dean Flyger, AuD, visit www.ATA.org and click "podcasts". Tinnitus Today magazine also received a Merit award. “The awards are a critical reminder of the importance of supporters of the ATA. We are here because individuals support our mission, communication and education efforts, and research funding,” said Jill Meltzer, former chair of the ATA Board of Directors. “Our members and donors make everything possible. And together, we make a difference.”

Table of Contents SPECIAL FEATURES

04 |

Understanding Tinnitus to Improve Your Journey: The Terms, Treatments, Interventions, and Science

20|

Vol. 46, No. 2, Summer 2021

Train the Brain to Tackle Tinnitus With Cognitive Behavioral Therapy and Mindfulness

SCIENCE & RESEARCH NEWS

hat Research 25 | WReveals About

Taming Tinnitus From Home

ound Therapy Study 36| SFades Out Tinnitus With Nature Sounds

Pros and Cons of 16| The Telehealth for Tinnitus

Ongoing Search for 48 | The Links Between Covid-19

Care

and Ear Health

onsidering Covid-19, 50 | CVaccines and Tinnitus TINNITUS TOOLS & RESOURCES

innitus Q & A: 11 | TWhat Should I Do if My Child Complains of Ringing in the Ears?

30 |

innitus Q & A: Tinnitus T Can Be Unsettling, but It Is Seldom a Symptom of Serious Disease

attery-Powered Tools 44 | BFuel Reduction in

potlight on Patient 55 | SProviders innitus 62 | TSupport Group Listings

THE ATA TURNS 50

verybody Has Their 32 | EFavorite Sound:

The Evolution of Tinnitus Masking Over the Last 50 Years

Hearing Loss, Tinnitus, and Noise Pollution

38| TofhetheCreation Tinnitus

Functional Index Questionnaire: A Tribute to Mary Meikle, PhD

eframing Tinnitus 52 | RThrough Hypnotherapy

Remarkable Career 43| TofheMary Meikle, PhD: The ATA’s First Grant Recipient and Leading Tinnitus Researcher

PERSONAL STORIES

y Unexpected 13 | MTinnitus

Transformation Using InternetBased Cognitive Behavioral Therapy

eaceful 28 | PCoexistence

With Tinnitus Through Meditation

a Mild Covid-19 46 | Was Infection Behind Blaring Tinnitus?

 FROM THE BOARD CHAIR

Working Together for a Better Future

David Hadley, MBA Chair, Board of Directors

I am honored to have the opportunity to write to you as the new chair of ATA’s Board of Directors. After 24 months of fantastic leadership under Jill Meltzer, AuD, the ATA is poised for great things in the coming fiscal year. From a research perspective, labs are reopening and we will be funding exciting new grants. Financially, we are in a healthy place as membership and donor dollars are up solidly over the last 12 months. We have also expanded our capability to provide support to people struggling with tinnitus. I would be remiss not to mention that the ATA staff has done an incredible job throughout the pandemic. In the midst of all this positive news, you might be wondering who I am and how I got here. From a high level: I live in San Francisco, am a proud husband and father, and work at a technology company. My passion has always been playing guitar, and when I was young, I did not make an effort to protect my hearing. As a result, I have been living with tinnitus for almost half of my life and it has caused me many moments of despair, worry, and frustration. Like many of you, I joined the ATA principally because I wanted to fund meaningful research for a cure, and that remains my overarching goal as board chair. We will solve this together. My door is always open and I look forward to hearing from you at tinnitus@ata.org over the course of the next year. Thank you for being a valued member of the ATA. Best,

MANAGING EDITOR Joy Onozuka American Tinnitus Association PUBLISHER Torryn P. Brazell, CAE 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 SunTrust Bank PO Box 424049 Washington, DC 20042-4049

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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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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.

FROM THE PUBLISHER 

ATA BOARD OF DIRECTORS David Hadley, MBA, San Francisco—Chair Gordon Mountford, CPA, South Pasadena, CA— Vice Chair Ron Zagel, Grand Rapids, MI—Treasurer Robert Travis Scott, Baton Rouge, LA— Assistant Treasurer Stelios Dokianakis, AuD, CH-TM, Holland, MI— Secretary Jill Meltzer, AuD, 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 University of Nottingham, United Kingdom 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

Finding Balance When Everything Seems Off Kilter Over the past 50 years, the American Tinnitus Association has been at the center of building an understanding of tinnitus and, most importantly, of how to provide relief for people struggling with it. Though we don’t have cures for most types of tinnitus, we do have a plethora of tools at our disposal that we can use to help cope with and manage tinnitus, from sound therapy to stress reduction techniques, hearing aids, maskers, and support groups. There are options, which means there are choices. To help you better understand choices in tinnitus management, the ATA has brought together articles in this issue that reflect the voices of researchers, audiologists, and tinnitus patients who understand the tinnitus journey and which tools might help. The closer we adhere to research-based approaches, the less likely we are to experience an unnecessary detour or hit a pothole that sets us back as we continue our tinnitus journey. As scientific knowledge, programs, and research evolve, we see that not everything is fixed and not every tool has the necessary research behind it yet. Hence, we proceed cautiously with “new” treatments and seek guidance from trusted sources. Here at the ATA, we also don’t always have the answer to the many questions we receive each day, such as how Covid-19 is affecting the auditory system and tinnitus, in particular. We’re counting on researchers to provide answers going forward. In the meantime, we must rely on evidencebased treatment and management techniques, a network of support, and hope that human ingenuity will continue to bring us better management options and possible cures. You, too, can play a part in positive change by sharing your story with the readers of Tinnitus Today (email editor@ata.org), by donating to tinnitus research, by joining or starting a tinnitus support group (email tinnitus@ata.org), or by educating your physician about tinnitus management tools. Changing the oft spoken line “Get used to tinnitus because there’s nothing you can do” begins with being involved and sharing your voice on living with tinnitus and managing it successfully. And if you’re not at that point, we hope you’ll reach out to us at tinnitus@ata.org for help.

Torryn P. Brazell, CAE 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.

Richard Tyler, PhD University of Iowa, Iowa City, IA USA Fan-Gang Zeng, PhD University of California, Irvine Irvine, CA USA

TINNITUS TODAY SUMMER 2021

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Understanding Tinnitus to Improve Your Journey: The Terms, Treatments, Interventions, and Science By James A. Henry, PhD, and Kathleen F. Carlson, PhD

Tinnitus is an invisible condition. It cannot be measured directly, and there are no official standards for its clinical care. Any clinician can claim to be a “tinnitus expert”. People who have tinnitus, especially new-onset tinnitus, often find themselves at a loss for where to get help. They typically search the internet for “tinnitus,” “tinnitus treatment,” “tinnitus cure,” or something similar. The websites that appear may present valid information, but many websites make claims that whatever they are promoting can “cure,” “silence,” or “alleviate” tinnitus. And then, while searching, people are also confronted by the ubiquitous popup ads that make similar claims. Which claims are true and which are not? The answers partly depend on what all these words mean. Inconsistent terminology and definitions are a concern with almost everything that is written about tinnitus — books, websites, peerreviewed publications, and articles like the one you are reading now. The American Academy of Otolaryngology — Head & Neck Surgery Foundation (AAO-HNSF) published its Clinical Practice Guideline: Tinnitus, which 4

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includes suggested terminology and definitions.1 The AAO-HNSF distinguishes “primary” from “secondary” tinnitus. It also distinguishes “recent-onset” from “persistent” tinnitus, and “bothersome” from “nonbothersome” tinnitus. In this article, we will review how these terms are defined by the AAO-HNSF, and we will define additional terms that are relevant to understanding tinnitus and what to do about it. Having a common understanding of the meanings of these terms is important to navigating and properly interpreting the countless products and services for tinnitus that appear on the internet and elsewhere. We’ll also provide information that enables readers to be aware of the scientific evidence for available therapies, understand the nuances of tinnitus therapies in general, and become more informed in knowing how to go about receiving clinical care for tinnitus.

Terminology and Definitions Primary Versus Secondary Tinnitus People complaining of tinnitus usually have primary tinnitus, which is the focus of this article. Primary

tinnitus is phantom sound in the head or ears that is generated within, and perceived within, the brain. It is a stream of abnormal brain activity that gives rise to the phantom sound. The exact cause of primary tinnitus is not currently known (research is ongoing), but its onset can often be associated with certain factors (referred to as “exposures”). Primary tinnitus is most often associated with exposure to loud noise, but it can be caused by chemicals that are toxic to the auditory system or by one of many medical conditions. It can even be triggered by stress. Secondary tinnitus, which is relatively rare, is an actual sound that is produced somewhere in the head or neck because of some mechanical or vascular irregularity that generates the sound. The sound is detected by the inner ear and processed by the brain as for any external sound. The most common type of secondary tinnitus is pulsatile, which is typically perceived as a “whooshing” sound that pulses with the heartbeat. Although pulsatile tinnitus is usually diagnosed as harmless, serious conditions may underlie it. Non-pulsatile secondary tinnitus can include middle-ear (behind the eardrum) muscle spasms and eustachian tube dysfunction. Middlewww.ATA.org

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ear muscle spasms can cause buzzing, clicking, or crackling sounds, or the sound of a beating drum. Eustachian tube dysfunction typically produces clicking or popping sounds, along with a feeling of fullness/pressure in the ears and muffled hearing. If any of these symptoms of secondary tinnitus are experienced, it is essential to visit a physician who specializes in the ear (usually an otolaryngologist, also known as an ear, nose, and throat — ENT — doctor).

Persistent Versus Recent-Onset Tinnitus Persistent tinnitus is also referred to as chronic tinnitus. Persistent tinnitus has been experienced for at least six months. Why six months? Because most trials of tinnitus therapies require participants who have experienced tinnitus for long enough to be reasonably sure that the tinnitus is stable (that is, unlikely to change). Tinnitus of shorter duration (less than six months) is recent-onset tinnitus, which some might call acute tinnitus. Recent-onset tinnitus is thought to be more labile, meaning it is more likely to fluctuate in intensity, or to completely disappear, relative to persistent tinnitus.

Bothersome Versus Nonbothersome Tinnitus Numerous studies have revealed that, out of every 100 adults, between 10 and 15 have persistent, primary tinnitus.2 Studies have also shown that, for about 80 percent of those who have tinnitus, the tinnitus is not bothersome enough to seek professional help — hence the term nonbothersome tinnitus. That of course does not mean that the 80 percent are not at all bothered by their tinnitus. Nor does it mean that the 80 www.ATA.org

percent would not choose to get rid of it if that were possible. Everyone with tinnitus wants a cure! One way to think about bothersome versus nonbothersome tinnitus is to determine where a person with tinnitus would fall on a scale from 0 to 100 — from “not at all bothered” (score = 0) to “extremely bothered” (score = 100). The Tinnitus Functional Index (TFI), which is written about elsewhere in this issue of Tinnitus Today (see page 38), is intended to assist in making such a determination.

Tinnitus Assessment The first step in receiving clinical care for tinnitus is to receive an assessment and determine the extent of the symptoms. Assessment of tinnitus has been covered in detail elsewhere3 and we will mention just a few key points. It is highly common for people with tinnitus to also have hearing loss. A hearing evaluation by an audiologist is therefore essential to identify and address any hearing problems. Normally, a comprehensive tinnitus assessment is not necessary. Our recommendation is to complete the one-page Tinnitus and Hearing Survey together with the hearing assessment, which, combined, usually provides sufficient information for the audiologist to know how to proceed to address any hearing loss or tinnitus concerns.4 The Tinnitus and Hearing Survey also screens for a loudness tolerance problem (hyperacusis), which is often experienced along with tinnitus. The AAO-HNSF recommends an evaluation by an otolaryngologist for anyone with tinnitus.1 Depending on the characteristics and severity of the tinnitus, and any concurrent

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(comorbid) symptoms, it may be necessary to seek emergency care services or to be evaluated by a behavioral health clinician.3

Tinnitus Cure? Claims abound on the internet for products or procedures that will cure tinnitus. Some words that commonly appear are “proven,” “cure,” “mute,” “breakthrough,” “relief,” “reverse,” “truth,” and “remedies.” What is the reality of these claims? Scientists have been diligently trying to discover a cure, but there is currently no cure for tinnitus. What that means is, no method has been discovered that will safely and reliably eliminate the sound (or sensation) of tinnitus. Further, no method has been discovered that will reduce the loudness of tinnitus on a permanent basis (a “partial cure”). So, any claim on the internet, or elsewhere, for a product or procedure that will cure tinnitus is false. That can be difficult to accept, but please read on.

Tinnitus Intervention/Therapy Intervention for tinnitus generally refers to any services provided following a tinnitus assessment that are needed by patients whose tinnitus is significantly bothersome following the assessment. Intervention (or therapy) is the umbrella term for any clinical services intended to reduce reactions to tinnitus and assist in achieving a quality of life that is minimally affected or unaffected by the tinnitus. Intervention includes treatment and management.

Treatment Versus Management The previous issue of Tinnitus Today includes an article explaining the distinction between tinnitus “cure” and tinnitus “management.”5 It is disappointing — to say the least —

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that a cure for tinnitus does not yet exist, but that’s where management comes in. Management of tinnitus means recognizing that the tinnitus may not go away anytime soon, while taking positive steps to lessen its impact on daily life. Although the words management and treatment are often used interchangeably, it is helpful to distinguish between them. Treatment implies mostly one-way action from clinician to patient — the clinician makes the decisions, conducts any procedures, and the patient complies. Stated differently, the clinician treats and the patient receives the treatment. Management involves directed selfcare, meaning the patient learns and applies skills and strategies to lessen the symptoms. The clinician teaches these skills and provides any support (and/or therapeutic devices) that might be needed. An individual can learn selfmanagement skills without a clinician’s help if the necessary information is available from a book, video, or website.

Methods of Tinnitus Treatment Different methods of treatment, using our definition of tinnitus treatment above, include acupuncture, hypnotherapy, biofeedback, offlabel medications (antidepressants, antianxiety drugs, antihistamines, anticonvulsants, anesthetics, etc.), over-the-counter substances labeled specifically as treatment for tinnitus, nutritional supplements (zinc, vitamins B12 and C, magnesium, ginkgo biloba, etc.), homeopathic remedies, repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), deep brain stimulation, vagus nerve stimulation, and temporomandibular joint (TMJ) 6

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“Management of tinnitus means recognizing that the tinnitus may not go away anytime soon, while taking positive steps to lessen its impact on daily life.” treatment (www.ata.org/managingyour-tinnitus/treatment-options).

Tinnitus Management Methods Different methods of management, using our definition of tinnitus management above, include cognitive behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), acceptance and commitment therapy (ACT), other counseling and psychological interventions, Progressive Tinnitus Management (PTM), Tinnitus Retraining Therapy (TRT), Tinnitus Activities Treatment (TAT), and innumerable forms of sound therapy (for example, hearing aids, earlevel sound generators, hearing aids with built-in sound generators, sound machines, sound and sleep apps, and notched-music devices) (www.ata. org/managing-your-tinnitus/treatmentoptions).

Hierarchy of Scientific Evidence When faced with so many possibilities for tinnitus treatment and management, how is a person supposed to decide what to do? We rely on the scientific literature to determine the strength of evidence of different interventions. The scientific literature contains only peer-reviewed articles, meaning articles that have gone through the process of critical review by expert scientists (peers). Articles that are accepted for

publication following peer review are published in scientific journals, and those articles become part of the scientific literature. An article that has not gone through peer review is considered mainly an editorial, or opinion article. That is not to say that non-peer-reviewed articles lack validity. They just don’t stand up to scientific scrutiny to the same degree as peerreviewed articles. Figure 1 shows the hierarchy of scientific evidence, from “weakest” evidence at the bottom of the pyramid to “strongest” evidence at the top. The strongest evidence comes from meta-analyses and systematic reviews. A meta-analysis is a quantitative analysis of data from multiple scientific studies that all addressed the same basic question — like analyzing the results of all studies as if they were one study. A metaanalysis often provides a more certain answer to the question than individual studies can. A systematic review is the process of comprehensively (and systematically) searching the scientific literature to identify all qualified studies that are relevant to a particular topic and then synthesizing the results of those studies. A systematic review may or may not include a metaanalysis. Study designs that are often the focus of systematic reviews are www.ATA.org

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randomized controlled trials, which themselves comprise the second strongest form of scientific evidence (see Fig. 1). A randomized controlled trial provides stronger evidence than other types of studies primarily because the research participants are randomized into different therapy (or program, etc.) groups that can be compared, thereby helping balance differences among people who may otherwise self-select into one treatment or another, causing bias, a form of error. A randomized controlled trial thus minimizes research bias in study results. Research bias is not the same as human bias but can be caused by human bias. Error in research results can also be caused by chance (also known as random error), though the effects of random error on study results can often be minimized by including larger numbers of participants in a study. Systematic

reviews are designed to use an objective and transparent approach to summarize all of the relevant studies with an aim to identify, for each study, risk of bias/error in the data, analysis, and conclusions and, across studies, the overall strength of evidence for a particular therapy type. Systematic reviews reach conclusions regarding the evidence of efficacy and effectiveness for healthcare interventions. These conclusions can then serve to inform healthcare policyand decision-making.

What Do Systematic Reviews Say About Interventions for Tinnitus? Cognitive Behavioral Therapy (CBT) In 2014, the AAO-HNSF published “the first evidence-based clinical guideline developed for the evaluation and treatment of chronic tinnitus”1 (The interested reader can access

Figure 1. How to Evaluate Scientific Claims Hierarchy of Scientific Evidence Strongest Metaanalyses & systematic reviews Randomized controlled trials Cohort studies Case-control studies Cross sectional studies Animal trials & in vitro studies Case reports, opinion papers, and letters

Weakest thelogicofscience.com

www.ATA.org

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the AAO-HNSF Clinical Practice Guideline: Tinnitus at www.entnet. org/content/clinical-practice-guidelinetinnitus. A plain language summary is also available on the same website.) Following a systematic review, the only intervention the AAO-HNSF recommended for bothersome tinnitus was CBT. Similarly, between 2007 and 2016, four separate tinnitus clinical guidelines were published in Europe, which, together with the AAO-HNSF guideline, were summarized by Fuller et al.6 All of these guidelines agreed that CBT had the strongest evidence of benefit and was therefore the only method “recommended” for tinnitus intervention. The objectives of cognitive behavioral therapy for tinnitus are: (1) the cognitive part: assist in rethinking tinnitus as a manageable problem, and (2) the behavioral part: teach and encourage the use of coping skills (such as stress reduction, relaxation, and distraction strategies) to self-manage effects of tinnitus.7 CBT involves numerous therapeutic components that are distinctly different, and it has not been established which components are the most effective for tinnitus management.8 CBT can be delivered in group or individual sessions, can involve different numbers and lengths of sessions, and can be conducted in person, via telehealth, or online.7 CBT is normally delivered by behavioral health providers (counselors, social workers, psychologists). Unfortunately, relatively few behavioral health providers offer CBT specifically for tinnitus, and it can be difficult if not impossible to find one in any given TINNITUS TODAY SUMMER 2021

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area. Audiologists typically provide tinnitus services — can they provide CBT for tinnitus? For audiologists to perform CBT, they must undergo substantial training in CBT and gain clinical experience supervised by a licensed behavioral health provider.9 Achieving this expertise is unlikely for most audiologists. Audiologists can teach some of the CBT coping skills, for example, relaxation training, but delivering all of CBT would be outside of their scope of practice without proper training and supervision.

Sound Therapy The use of any type of sound for the purpose of reducing the emotional and functional effects of tinnitus is referred to as sound therapy. Does sound therapy have research evidence showing its effectiveness? Yes and no. According to all the guidelines mentioned above, sound therapy is at best considered an “option” for intervention because of the lack of strong research support for it.6 We have written elsewhere, however, arguing that sound therapy has more efficacy evidence than it is given credit for in systematic reviews.10 The explicit purpose of our previous writing was to describe the different sound therapy methods available for audiologists to use as options in tinnitus management. (Note that the article is a narrative review, which, though informative, does not carry the weight of evidence of a systematic review.) In our article10 we pointed out that our own randomized controlled trials showed benefit for different methods of sound therapy, including hearing aids (both with and without a sound generator), masking, Tinnitus Retraining Therapy (TRT), Progressive 8

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Tinnitus Management (PTM), and specialized sound therapy devices. In addition to our own trials, many studies over the past 50 years support the effectiveness of sound therapy in general. A “state of the art” review of sound therapy methods concludes, “We believe that many of the sound therapies identified could be effective when selected for the right patients at the right time and appropriate context. To do this we suggest careful assessment and then use of an individual care plan.”11 Considerable evidence, from both clinical and research studies, supports the effectiveness of sound therapy for tinnitus management. Although systematic reviews have not recommended sound therapy, it is known that sound has been used to obtain relief from tinnitus for hundreds of years.12 It is natural for people to discover on their own that tinnitus is less bothersome in the presence of certain sounds.13 Audiologists routinely recommend sound therapy to their patients. It is important to be aware, however, that evidence does not support any one method of sound therapy being more effective than any other method.11,14 It is therefore most prudent to use sound therapy that is low or no cost before considering more expensive options.

Other Methods of Tinnitus Intervention Books have been written about different methods of tinnitus intervention. We listed many of these methods above, each of which has been claimed to be effective. Costs range from free to very expensive. Any of these methods will be helpful for some people, but scientific evidence is lacking for almost all of them. There

is no harm in trying a particular tinnitus therapy provided there is no risk of adverse side effects and that it can be done at no cost or very little cost. An important consideration regarding any form of intervention is the potential for producing nonspecific effects.

Specific and Nonspecific Effects Specific effects of treatment are targeted and predictable effects of a treatment on some health condition. Specific effects are unique to a given treatment. They are objective and measurable. Specific effects are common in medicine, especially the use of drugs that target certain receptors and cause predictable and reliable responses. As examples, insulin lowers the level of blood glucose; hormone levels in hypothyroidism can be restored by synthetic thyroid hormones; and cortisone shots can relieve nerverelated back pain. Or, a future drug may eliminate (cure) the tinnitus sensation by successfully targeting the underlying mechanism that causes the sensation. These are all specific effects of treatment, as opposed to nonspecific effects. A nonspecific effect is any improvement in a health condition resulting from the expectation that an intervention will be beneficial. Nonspecific effects are due to factors that are not unique to the intervention. Nonspecific effects may or may not be objective and measurable. A therapeutic effect can be a combination of both specific and nonspecific effects. Even a drug that has known specific effects can also cause nonspecific effects that enhance the benefits of the drug. Nonspecific effects are common to most types of therapy. However, www.ATA.org

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it can be difficult if not impossible to distinguish between specific and nonspecific effects from a particular therapy. For example, it has long been debated whether spinal manipulation performed by chiropractors results in specific or nonspecific effects. A systematic review of the literature concluded that the success of spinal manipulation was due mainly to nonspecific effects.15 Many contextual factors can raise hopes of positive outcomes of an intervention. The “patient-clinician relationship” is perhaps the most influential within the context of office visits. The patient-clinician relationship can create bias, especially if the clinician has a persuasive personality and expresses assurance of the intervention’s efficacy. Further, a patient can be motivated to change behavior simply by receiving interest, care, or attention from a clinician.16 In a different context, many people with tinnitus seek help from the internet, and their expectations can be raised by positive marketing and advertising that they are exposed to.

Placebo Effects Nonspecific effects and placebo effects are often thought to mean the same thing. However, there is a slight difference. As described above, nonspecific effects are a consequence of almost any form of therapy, and they are difficult to distinguish from specific effects. Placebo effects are improvements in a health condition that result from what is clearly known to be an inactive or inert treatment. The classic example is the sugar pill. There is nothing in the pill that would cause any effects—the pill is inert. However, if a person has the expectation that www.ATA.org

the pill has a beneficial effect, for example to reduce pain, then any benefit from taking the pill (reduced pain in this case) is unquestionably a placebo effect. A placebo-controlled trial is a study that is conducted to determine whether some treatment works better than the placebo effect. These are usually drug studies in which one group takes the drug and a second group takes an identical-looking sugar pill. Both groups are told the drug should be helpful, which may create an expectation of benefit. No difference in results between groups would mean the drug works no better than placebo. Many placebo-controlled trials have been conducted to evaluate drugs and dietary supplements for treating tinnitus. No drug or supplement has been shown to work any better than placebo.1 Such proof is needed before anything can be claimed to be a cure for tinnitus. The placebo effect is a powerful and well documented effect in health care. “It’s the brain convincing the body that a fake treatment was the real thing” (www.health.harvard. edu). The effect is commonly seen for conditions that are modulated (regulated) by the brain, such as anxiety, depression, pain perception, and—tinnitus. It has been argued that placebo effects could be the reason that most interventions for tinnitus have shown good success rates.17 We need to assure the reader there is nothing wrong with an intervention having nonspecific or placebo effects. In fact, placebo effects are acknowledged and desirable in all healthcare disciplines. These effects are explained by the “mind-body connection,” which means changing

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thoughts can change how the body reacts and functions. This is a scientifically documented fact.18 It is also a basic principle of intervention with CBT.

Steps to Receiving Clinical Care for Tinnitus A step-wise approach is recommended for any person experiencing tinnitus.19 Unless referral is needed to emergency care or behavioral health, examination by an otolaryngologist is best practice. Otherwise, it is essential to have a hearing evaluation by an audiologist. The audiologist should do a routine hearing assessment, and we recommend administration of the Tinnitus and Hearing Survey.20 The Tinnitus and Hearing Survey adds only a few minutes to the audiologic exam and provides key information to determine whether tinnitus-specific intervention is needed. The following is a simplified list of the steps of tinnitus care that are recommended for any person complaining of tinnitus.

Assessment • Examination by an otolaryngologist • Hearing evaluation by an audiologist • Brief tinnitus assessment by the audiologist using the Tinnitus and Hearing Survey • If receiving intervention following the assessment, complete the Tinnitus Functional Index (TFI) before the intervention

Intervention (if needed) • Have hearing aids (ideally with built-in sound generator) fitted if needed for hearing loss (hearing aids can be helpful for tinnitus TINNITUS TODAY SUMMER 2021

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•

• •

•

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even if the hearing loss is relatively mild) Obtain general information about tinnitus (attend a tinnitus education class if available) Learn and apply CBT skills with guidance from a qualified clinician Use sound therapy (start with free or low-cost options; experiment with different types and sources of sound) Complete the TFI following the intervention and compare results to the pre-intervention TFI score to determine whether there was improvement and, if so, how much

Conclusion We have reviewed what we consider to be key information to understanding tinnitus and what to do about it. Hopefully, this information will be helpful to serve as a guide to any individual who is seeking care for tinnitus. The American Tinnitus Association is a good starting point to “take the tinnitus journey” without getting waylaid by pursuing expensive therapies for which there is no research-based evidence. Stories abound from patients who have gone from doctor to doctor and from clinic to clinic, trying many expensive procedures and devices in the process. All of this can be avoided by becoming educated and making informed decisions. Our experience with tinnitus management suggests that those who suffer from bothersome tinnitus can learn to cope with its effects in a way that brings comfort and maximizes functioning.

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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. Kathleen F. Carlson, MS, PhD, is trained in injury epidemiology and health services research, and has been conducting research with the U.S. Department of Veterans Affairs since 2006. She is a Core Investigator with the Health Services Research Center of Innovation and the National Center for Rehabilitative Auditory Research at the VA Portland Health Care System, and an Associate Professor of Epidemiology at the Oregon Health & Science University-Portland State University School of Public Health. Dr. Carlson’s research uses a public health lens to examine the spectrum of injuries among veterans, from the epidemiology of intentional and unintentional injuries to the rehabilitation of those with traumatic brain injury and other combat-related trauma. Her current projects focus on epidemiology and sequelae of traumatic brain injury (TBI), TBI and its cooccurrence with tinnitus, access to hearing health services, and the prevention of violence and other injuries. Dr. Carlson completed her BS in Biology at Oregon State University and her MS and PhD in Environmental Health and Epidemiology at the University of Minnesota, Minneapolis, Minnesota.

1 Tunkel DE, Bauer CA, Sun GH, et al. Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. Oct 2014;151(2 Suppl):S1-S40. 2 Henry JA, Reavis KM, Griest SE, et al. Tinnitus: An Epidemiologic Perspective. Otolaryngol Clin North Am. Apr 30 2020;53:481-499. 3 Henry JA, McMillan L, Manning C. Multidisciplinary tinnitus care. The Journal for Nurse Practitioners. 2019;15:671-675. 4 Henry JA. Distinguishing between hearing loss, tinnitus, and hyperacusis: A recommended tinnitusevaluation protocol for audiologists. Tinnitus Today. 2020;45(1):22-27. 5 Henry JA. Considering tinnitus management versus cure. Tinnitus Today. 2021;46(1):10-11. 6 Fuller TE, Haider HF, Kikidis D, et al. Different Teams, Same Conclusions? A Systematic Review of Existing Clinical Guidelines for the Assessment and Treatment of Tinnitus in Adults. Frontiers in psychology. 2017;8:206. 7 Schmidt CJ, Kaelin C, Henselman L, Henry JA. Need for mental health providers in Progressive Tinnitus Management: A gap in clinical care. Federal Practitioner. 2017;34(5):6-9. 8 Cima RF, Andersson G, Schmidt CJ, Henry JA. Cognitive-behavioral treatments for tinnitus: a review of the literature. J Am Acad Audiol. Jan 2014;25(1):29-61. 9 Aazh H, Moore BCJ. Effectiveness of AudiologistDelivered Cognitive Behavioral Therapy for Tinnitus and Hyperacusis Rehabilitation: Outcomes for Patients Treated in Routine Practice. Am J Audiol. Dec 6 2018;27(4):547-558. 10 Henry JA, Quinn CM. Sound therapy for tinnitus: options for audiologists. Perspectives of the ASHA Special Interest Groups, SIG 8. 2020;5:669-683. 11 Searchfield GD, Durai M, Linford T. A State-of-the-Art Review: Personalization of Tinnitus Sound Therapy. Frontiers in psychology. 2017;8:1599. 12 Stephens SDG. Historical aspects of tinnitus. In: Hazell JWP, ed. Tinnitus. London: Churchill Livingston; 1987: 1-19. 13 Dobie RA. Overview: suffering from tinnitus. In: Snow JB, ed. Tinnitus: Theory and Management. Lewiston, NY: BC Decker Inc.; 2004: 1-7. 14 Hoare DJ, Searchfield GD, El Refaie A, Henry JA. Sound therapy for tinnitus management: practicable options. J Am Acad Audiol. Jan 2014;25(1):62-75. 15 Ernst E. Does spinal manipulation have specific treatment effects? Fam Pract. Dec 2000;17(6):554556. 16 Sedgwick P, Greenwood N. Understanding the Hawthorne effect. BMJ. Sep 4 2015;351:h4672. 17 Dobie RA. Clinical trials and drug therapy for tinnitus. In: Snow JB, ed. Tinnitus: Theory and Management. Lewiston, NY: BC Decker Inc.; 2004: 266-277. 18 Astin JA, Shapiro SL, Eisenberg DM, Forys KL. Mind-body medicine: state of the science, implications for practice. J Am Board Fam Pract. Mar-Apr 2003;16(2):131-147. 19 Henry JA, Zaugg TL, Myers PM, Kendall CJ. Progressive Tinnitus Management: Clinical Handbook for Audiologists. San Diego, CA: Plural Publishing; 2010. 20 Henry JA, Griest S, Zaugg TL, et al. Tinnitus and hearing survey: a screening tool to differentiate bothersome tinnitus from hearing difficulties. Am J Audiol. Mar 2015;24(1):66-77.

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TINNITUS RESOURCES 

Tinnitus Q & A What Should I Do if My Child Complains of Ringing in the Ears? By Becca Kane, AuD, ATA Tinnitus Program Advisor

Question: My daughter began complaining about hearing noise in her ears, which she describes as highpitched ringing that’s constant. How do I get her evaluated? Becca Kane, AuD: Tinnitus can be a symptom of congenital hearing loss, hearing loss due to noise exposure, chronic ear infections, neurological disorders, head trauma or traumatic brain injury (TBI), and other diagnoses accompanied by balance problems. As such, it’s important to have your child’s tinnitus evaluated. An appointment with your pediatrician is a good starting point. It’s also recommended that your child see an audiologist and otolaryngologist (ENT) to have an audiogram to determine whether there is hearing loss that could be present along with tinnitus. The physician may also recommend a workup to see if there’s an underlying cause of the tinnitus and possible hearing loss.

“Does your tinnitus sound like a note on a piano?” or “Does your tinnitus sound like crickets?” www.ATA.org

Q: How do I talk to my child about her tinnitus? BK: If you have ever had tinnitus, it may be helpful to tell your child that you’ve also experienced this phenomenon. Hearing that someone else close to them has encountered tinnitus may help children feel less scared about their own tinnitus. It may also be constructive to help children describe their tinnitus by likening it to more familiar sounds they can identify in their environment, such as “Does your tinnitus sound like a note on a piano?” or “Does your tinnitus sound like crickets?” This unexpected and unwanted “visitor” may become less scary to them the more they’re able to comfortably talk about it. Family support is key. Children often want to be validated, especially with a symptom such as tinnitus that is invisible to the outside world. Q: How can I help my middle-schoolage son deal with tinnitus? I’m worried because he’s withdrawing from his friends and social activities, including sports. I don’t know what to do. BK: Management of tinnitus for children is similar to that for adults, with the overall goal to retrain the brain to perceive tinnitus as an insignificant sound. The following steps can be useful in aiding that process and reducing the intrusiveness of tinnitus:

• Use sound enrichment to reduce tinnitus awareness in bothersome scenarios. It may be helpful as the parent or caregiver to anticipate when your child will be in a quiet and therefore potentially difficult scenario to manage. For instance, during homework time, the tinnitus may be distracting for your child, making it hard for him to concentrate. Having background sound that diminishes the tinnitus but that’s not engaging — such as music without lyrics — can be helpful. • Work together with your child to identify sounds that he perceives as helpful at reducing his awareness of tinnitus in various situations. • Set your child’s bedroom up for sleep success by finding the right background noise conducive to good sleep. For instance, use a fan to produce low-level background noise and experiment with a sound machine or tinnitus app to find soothing or relaxing sounds to facilitate sleep. Environmental sounds such as ocean waves are a popular choice. Ultimately, the sound should be something your child finds relaxing. TINNITUS TODAY SUMMER 2021

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You should encourage your child to return to normal extracurricular activities. It may be that he must slowly work on increasing how long he feels comfortable in different environments, but a gradual reentry into a normal and familiar routine can lessen the impact of tinnitus on his quality of life. It’s helpful to ask yourself as the parent or caregiver what is preventing your child from viewing the tinnitus as an insignificant sound. Is there underlying anxiety or depression? Is he experiencing a heightened stress response to the new and unwanted noise? If yes, an evaluation with a pediatric psychologist would be an important component of lessening the negative emotional reaction to tinnitus. Learning to separate the symptom — tinnitus — from the emotional reaction is an acquired skill. Working

with a professional who utilizes cognitive behavioral therapy (CBT) or mindfulness-based stress reduction (MBSR) techniques, for example, would provide an opportunity for him to learn and practice a variety of coping strategies. Some families note that their child begins to wear earplugs in social situations out of fear that outside sound will make their tinnitus worse. It’s recommended to protect hearing in loud situations such as at concerts, fireworks, and while mowing the lawn. And it’s also important to monitor the volume and length of use when listening to music or podcasts with headphones. But, otherwise, use of earplugs for normal everyday activities isn’t recommended. You can connect with local providers who specialize in tinnitus

to take an effective multidisciplinary approach to lessen the impact of tinnitus distress on you and your family. The ATA’s healthcare database on www.ATA.org can serve as a resource for finding these connections to facilitate appropriate care. 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.

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 12

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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

PERSONAL STORY

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My Unexpected Tinnitus Transformation Using Internet-Based Cognitive Behavioral Therapy By Jordyn Costosa

When I was five years old, I remember lying in my bed at night and hearing ringing in my ears. I wondered what it was, and I ended up telling myself that it was my brain making a noise so I would never be alone in silence. As such, I viewed my tinnitus as a comforting friend. One day when I was 10 years old, I overheard my father talking to my grandmother about the ringing in his ears. After hearing that conversation, I told my parents that I have always heard ringing in my ears, and they explained that I have “tinnitus.” I didn’t understand that tinnitus was not normal, so it didn’t bother me. Around age 12, however, that changed when I was taken to see an otolaryngologist and audiologist about my tinnitus. Those appointments made me realize that not everyone has the condition. I didn’t have hearing loss or any other underlying health condition that might have triggered it, so they couldn’t tell me the cause. From that point onward, tinnitus was a source of annoyance and anger, not comfort; it became a burden. I would sit in a quiet room trying to study and find myself focused on the www.ATA.org

high-pitched frequency that would not leave me alone. When I tried to fall asleep, I would only hear my tinnitus. The hardest time for me was during standardized testing in middle school and high school, and during exam week in college, because the silent testing environment made it hard to concentrate. I loved hearing a pencil drop, a page turn, and even a student coughing because it gave me a splitsecond escape from my tinnitus. I envied my brother and others who were able to hear silence. I longed for that experience, if even for a moment. To avoid my tinnitus, I drowned it out by playing music in the background, never sitting in a silent room unless I had to, and always running my fan on high when I went to bed. Tinnitus controlled my life, and I spent so much time worrying about how to avoid being in silence. All that changed during the Covid-19 pandemic lockdown, when I took an online audiology class with Professor Ali Danesh, PhD, of Florida Atlantic University. The class helped me revisit and recalibrate my relationship with tinnitus. When the course touched on the topic of tinnitus, I shared with Professor Danesh that I’ve had tinnitus

for as long as I can remember. He suggested that I try iCBT for tinnitus (internet-based cognitive behavioral therapy), which is designed to teach people with bothersome tinnitus techniques from cognitive behavioral therapy to diminish tinnitus distress. At first, I was skeptical about whether internet-based CBT would actually enable me to “ignore” my tinnitus. But being confined to home during quarantine, as opposed to spending my days on campus, had made my tinnitus much more noticeable, so I decided to try the program. Learning how to apply positive psychology to my tinnitus changed how I felt when there was limited background noise for me to rely on to relieve me from the sound of my tinnitus. The program showed me that, although I am not able to stop the ringing, I can change the way I feel about it and recognize more objectively how it is affecting me, which is a stark change from the way I felt about my tinnitus between the ages of 13 and 21. The program emphasized that tinnitus cannot control my life, and the first step in diminishing its importance starts with knowing that tinnitus TINNITUS TODAY SUMMER 2021

 PERSONAL STORY

“I am also more positive than I was prior to taking the program, which I didn’t anticipate. When I first looked at the modules and saw that it was teaching acceptance of tinnitus and positive thinking, I felt frustrated by what I perceived to be a mind gimmick. But once I took a step back and looked at the big picture, I realized the program wasn’t based on becoming resigned to tinnitus — just living with it or being more positive about it — but rather was about freeing the mind of the power assigned to tinnitus. Each step brought me closer to understanding that I have power over my tinnitus and that it cannot take away anything from me or from any aspect of my life. Framing tinnitus this way makes me think more highly of myself and gives me a more positive outlook on my tinnitus as well as my life.”

cannot control you. This realization enabled me to manage my tinnitus by changing my mindset. In the Behavioral Experiment module, for instance, I completed a worksheet on negative thoughts that I imagined would arise during certain activities, causing me to become annoyed, angered, or distracted. One negative thought was “I cannot enjoy reading a book in a quiet setting.” Part of the exercise was a “method of experiment,” which asked me to do what I imagined would bother me. That process helped me understand how tinnitus actually impacted me during this time because I first had to predict the impact of tinnitus on a scale of 0 to 100 percent, with 0 being not at all and 100 being all the time, then assess the actual impact of tinnitus using the same scale after the activity. Prior to the experiment, I thought that reading in a quiet environment would affect me 30 percent. I gave it 30 percent because I would not 14

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be reading in a silent environment. Reading in an environment that included background sounds from a fan, people having a conversation in another room, and birds chirping outside my window, I realized my tinnitus actually affected me only about 5 percent of the time. My tinnitus annoyed me when I lost focus on my reading. But if I stayed focused on what I was doing, my tinnitus never entered my thoughts. One of the most beneficial modules for me was “Positive Psychology in Tinnitus Management.” I learned about human strengths and virtues, such as temperance, wisdom and knowledge, and humanity, to name a few. I had to rate myself on six strengths and virtues, explaining why I rated myself the way I did. I also wrote down five distinct strengths and how I’d use them in the future. This process helped me see that nothing — especially my tinnitus — can weaken my strengths and who I am as a person. Tinnitus cannot change my work ethic or the

love I have for my family. It cannot take away my ability to read or take away my understanding of a television show that I might be watching at night in my room. My tinnitus does not control me or any other aspect of my life, so why not change my mindset to accepting something I can’t prevent or stop? Today, I am able to take away more positives than negatives when my tinnitus is louder than normal. For instance, prior to taking the course, whenever my tinnitus was louder than normal as I was trying to fall asleep, I would become very frustrated. This frustration then caused me to become more alert and resulted in me being tired the next day. With the skills I gained from the program, I handle the situation differently. Instead of becoming frustrated, I recognize that, although the ringing is present, I actually am tired, I am in a comfortable bed, and I am surrounded by cool air. None of these factors can be taken away from me or altered by my tinnitus. www.ATA.org

PERSONAL STORY

I’ve realized that tinnitus does not control my life, cannot physically change my situation, or will not diminish any of my abilities. The program pushed me to recognize that if I continue to let my tinnitus take over different aspects of my life — my thoughts, emotions, and behavior — it will continue to affect me negatively. I use the techniques to focus deliberately on positives. I live a good life, I have amazing friends and family, I am grateful for all that I have, and tinnitus cannot affect any of that. This was the most critical concept I took away from the program. The program also made me reflect on my early experience with tinnitus as a child, which caused me to have a transformative realization about the effectiveness of the CBT techniques. I rediscovered the usefulness of my original view of tinnitus. Today, I’m able to perceive tinnitus as an old friend providing comfort, not a burden. Drawing on my childhood thoughts, I am able to say that I am not “alone,” because my “friend” (tinnitus) is with me. In a way, this outlook makes me feel special and gives me a whole new mindset. Had I not taken the program, I would never have revisited my childhood relationship with tinnitus and found a way to release the control I had given to tinnitus over my thoughts, emotions, and behavior. I am also more positive than I was prior to taking the program, which I didn’t anticipate. When I first looked at the modules and saw that it was

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teaching acceptance of tinnitus and positive thinking, I felt frustrated by what I perceived to be a mind gimmick. But once I took a step back and looked at the big picture, I realized the program wasn’t based on becoming resigned to tinnitus — just living with it or being more positive about it — but rather was about freeing the mind of the power assigned to tinnitus. Each step brought me closer to understanding that I have power over my tinnitus and that it cannot take away anything from me or from any aspect of my life. Framing tinnitus this way makes me think more highly of myself and gives me a more positive outlook on my tinnitus as well as my life. The techniques I practice have changed how I live with tinnitus and helped me learn how to deliberately put tinnitus on the backburner. Better yet, the iCBT course taught me to have a more positive outlook on my life and has enabled me to handle various life situations — beyond tinnitus — differently from how I would have prior to the program. With lockdown in the rearview mirror, I am stronger today thanks to this course. This past April, Jordyn Costosa graduated with a Bachelor of Arts in languages, linguistics, and comparative literature, with a concentration in linguistics. An aspiring speech-language pathologist, she will be attending a graduate program for communication sciences and disorders in the fall. Although she is looking forward to gaining experience in working with a variety of clients in all age groups, her goal is to work with children within the school system.

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iCBT for Tinnitus The program described in this article can be accessed at www. icbt4tinnitus.com. It’s currently available through audiologists registered to use the program as a complementary intervention to their tinnitus services or to offer it to patients as a standalone treatment approach. It was developed by Hashir Aazh, PhD, an audiologist specialized in tinnitus, hyperacusis, and misophonia at Royal Surrey County Hospital in the United Kingdom, in collaboration with Brian C. J. Moore, PhD, an emeritus professor of auditory perception at the University of Cambridge’s Department of Psychology, and Fiona Seaman-Thornton, DClinPsy, a clinical psychologist at Royal Surrey County Hospital. The iCBT modules include: 1 Assessment 2 Introduction to CBT for Tinnitus 3 Behavioral Experiment for Tinnitus 4 Challenge Your Negative Thoughts 5 Diary of Thoughts and Feelings 6 Positive Psychology in Tinnitus Management 7 Final Assessment

For more information on other internet-based cognitive behavioral therapy programs, see page 22.

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The Pros and Cons of Telehealth for Tinnitus Care By Marc Fagelson, PhD

It may be that the first human ever bothered by tinnitus was simultaneously bothered by the lack of help they received from family, friends, and if such things existed, the opinions of local healthcare providers. From that moment until the present, the prevalence of tinnitus has outpaced the availability of care providers. Add psychological distress and mental health considerations that often complicate the tinnitus experience, and the ability to access effective care becomes a challenge that some patients would rather forgo than pursue. About 20 years ago, Gerhard Andersson, a Swedish professor of clinical psychology, coauthored 16

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two groundbreaking papers that investigated the utility of cognitive behavioral therapy (CBT) programs tailored for delivery through the internet. The first focused on headache; the second, on tinnitus.1,2 Both studies demonstrated, as compared to face-to-face contact, the efficacy of CBT was maintained when offered on an internet platform. This accomplishment is even more impressive when we consider that the 2002 study provided, remotely, a psychological intervention for distressing sensory events whose severity relied in part upon mental health status. It is a credit to the authors that these publications remain relevant today with regard to their methodology as well as the opportunities they represent for

patients experiencing healthcare challenges. Remote service provision may be provided synchronously — essentially face-to-face but from remote locations — or asynchronously, using prerecorded materials or modules scripted a priori that patients access at their own pace.

Synchronous Intervention In the synchronous setting, a clinician and patient conduct a telephone or video meeting in which they may engage in dialogue regarding everything from case history to recommendations. Patients can complete intake forms and tinnitus, hyperacusis, and mental health questionnaires, and receive counseling www.ATA.org

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in real time. Screen sharing allows the clinician to support counseling with images pertaining to the patient’s test results, anatomy, tinnitus mechanisms, and demographics. Here, the patient must commit to a specific appointment time, but they attend the session from a site more convenient to them than the audiology clinic or hospital. Some patients report experiencing anxiety in medical settings3 and express a preference for accessing services from home. Patients could also attend sessions synchronously in a group (similar to a Zoom call). One advantage to such groups is that they tend to produce higher retention rates among patients, perhaps due to peer support or goodnatured peer pressure. In addition to requiring specific appointment times, limitations of synchronous counseling appointments include impediments to the exchange of information, such as low-quality images on the patient’s phone or computer. In our experience, the majority of veteran patients in a rural setting (i.e., one of the populations, it could be said, that remote healthcare targets) expect to conduct a synchronous tinnitus counseling session on their phone. In such cases, the reduced image quality of shared slides may degrade the patient’s experience. Further, when the clinician is masked, for example, as during a session at a clinic requiring masks, patients may experience greater difficulty understanding the clinician than they would encounter during face-to-face contact. The experience of conducting tinnitus counseling remotely in real time resembles that of video www.ATA.org

phone call with friends or family: not as good as being together, but at least problems can be discussed, information shared, and plans devised with mutual contribution and understanding. Patients may access several interventions for tinnitus through telemedicine or telehealth platforms that offer synchronous contact. For example, Progressive Tinnitus Management (PTM) was offered via telephone and internet for veterans.4,5 Several clinics in countries around the world offer versions of tinnitus retraining therapy (TRT) through interactions using telephones and telemedicine platforms.6 Results from such approaches to tinnitus management appear to maintain the fidelity and success rates of in-person interactions.

Asynchronous Interaction Asynchronous programs, such as those discussed by Andersson et al.,2 employ counseling and educational materials in sets of modules through which patients matriculate at their own pace. Asynchronous platforms may employ materials associated with, among others, CBT,2,3 mindfulness meditation,7 and acceptance therapy8 (see, additionally, Beukes et al. [2019] for review).9 Many interventions offer specific sets of “required” modules, while other studies include optional modules.3 In truth, all modules offered asynchronously are optional, and participants know it. In comparison to synchronous group meetings, patients who agree to complete a set of online modules appear less likely to do so

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without any peer support or peer pressure to maintain attendance.2 Unlike a synchronous consult, the modularized offerings lack the flexibility and spontaneity of a live discussion. However, the modules never forget to mention something that might be important to the patient. Most online programs consist of modules focused on specific elements of management, including, for example, masker use, hearing aid use (if appropriate), sleep hygiene, muscle relaxation, and hearing protection use. Other modules focus on anatomy and physiology, thereby offering reasonable, albeit bare-bones information regarding tinnitus mechanisms. Although online tinnitus management strategies are accessible to patients, their utility and the durability of their effects remain to be thoroughly researched. One major drawback related to research focused on internet interventions is that low participant retention and completion rates may hinder generalizing results to a wider patient population. These statements are not intended to dissuade potential participation but rather to reinforce the need for realistic expectations prior to embarking upon any intervention course. Andersson and colleagues identified a number of study limitations that would influence research conducted using the internet platform.2 Of primary importance, the authors caution that engagement of the participants requires monitoring, and they suggest consideration of participant motivation to complete the intervention prior to enrollment. To maximize intervention efficacy, participants would likely need to TINNITUS TODAY SUMMER 2021

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review study materials carefully, albeit without oversight from providers. Some participants might agree to the program, with good intentions, but withdraw without completing as a result of time limitations.

Additional Considerations We may be at an important intersection: If time bears out the current state of affairs, in which remote tinnitus service provision approximates the success of in-person contact, then tinnitus clinicians will need to either improve the success

of face-to-face interactions or devote substantially more time than at present to their use of internet platforms. This writer’s opinion is that the face-to-face appointment is the standard for our profession; however, the emergence of a viable alternative to the in-person appointment compels a thoughtful pause even as it produces an irrational gnashing of teeth. By definition, the use of an internet platform requires that the clinician abdicate control over the intervention. In asynchronous interventions, the materials are intended as a selfguided experience for the patient. It is probably counterintuitive for a

Table 1. Advantages and Disadvantages of Internet-Based Interventions for Tinnitus Method

Advantages

Research Considerations

Synchronous

• Intake form and case history can benefit from discussion and clarifications • Immediate identification of unique patient attributes (i.e., co-occurring medical or mental health condition) requiring onward referral or specialized management strategy • Can be linked to hearing aid/masker fitting and programming

• Different approaches to management may be implemented and compared • Standardization of sound therapy can be maintained

Asynchronous

• Patients may gain agency as they recognize the self-help nature of the modules • Access to clinical services unconstrained by patient health, mobility, or distance

• Potential for large data sets for analysis may support subtyping and targeted interventions • Small improvements noted by patients support engagement

Disadvantages

Synchronous

• Required technology, particularly in rural areas, may not be available or reliable • Despite remote connection, appointment time for patient is necessary

• Difficult to monitor adverse events

Asynchronous

• Lack of consistent personal contact with clinician may reduce patient engagement • External time commitments may change during the intervention, thereby hindering patient availability

• Patient self-selection may influence obtaining a random sample • Participants may not engage consistently; data analysis suffers from non-completers • Difficult to monitor adverse events

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well-practiced audiologist to willingly step back from administering direct care in favor of a self-paced psychological intervention. Hence the aforementioned gnashing of teeth. Indeed, face-to-face audiologic interventions outnumber those relying on internet delivery with regard to patient load and services rendered, suggesting: (1) audiologists value, and likely believe, patients receive more benefit from in-person contact; (2) selfefficacy for clinicians is higher in the clinic than it is when providing remote services; (3) most patients do not experience undue difficulty accessing in-person services, and anyway, they would rather travel to a clinic to seek in-person contact than complete a selfguided intervention; (4) audiologists hesitate to take up new technology, and anyway, the internet didn’t change much since 2002. It is probable that many patients would deny number 3, and a majority of audiologists would deny number 4. But it is clear by now that enhancing provider self-efficacy in the context of remote interactions will increase in importance with time. There is no need to reemphasize lessons learned from the pandemic; it is likely that other circumstances will emerge in the future that limit the movement and opportunities of at least the most vulnerable members of a population. Like it or not, if audiologists are to manage tinnitus in a manner that has the potential to be successful and sustainable, we will increasingly rely upon remote contact between patients and providers. “Like it or not” is the key statement in the sentence above because there is much to like and dislike about remote interactions between www.ATA.org

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patients and clinicians. Along with the examples above, Table 1 summarizes some advantages and disadvantages. Such considerations were taken into account nearly 20 years ago when Gerhard Andersson and colleagues presented an early attempt to employ psychological intervention for tinnitus using a telemedicine platform.2 Although they reported high dropout rates — characteristic as well of internet-based interventions for other health problems — the authors concluded that the platform provided patients care and information that they would not have otherwise been able to access. They suggested that online delivery of services for tinnitus would be most appropriate as an ancillary element to support clinical intervention rather than as the primary intervention. In this regard, investigators could not anticipate that the clinical endeavor of tinnitus management would be affected not only by pandemics but also by chronic challenges associated with a dearth of clinicians and an overabundance of patients. Tinnitus challenges both patients and providers. Perhaps we can paraphrase the old Catskills joke: One patient with tinnitus says to another: “Nobody has been able to help me

cope with my tinnitus,” to which the other replies, “Yes, and there are so few clinicians willing to try.” Marc Fagelson, PhD, is a professor of audiology in the Department of Audiology and Speech-Language Pathology at East Tennessee State University. He earned undergraduate and master’s degrees at Columbia University in New York City and his PhD at the University of Texas at Austin. His clinical and academic teaching includes hearing science, audiological evaluation, pathologies of the auditory system, and tinnitus management. He coedited Tinnitus: Clinical and Research Perspectives and a companion text, Disorders of Sound Tolerance, with Dr. David Baguley; both books were published by Plural. Dr. Fagelson has more than 40 publications and has presented more than 100 times at conferences and workshops. He opened the James H. Quillen Mountain Home VA Medical Center Tinnitus Clinic in 2001; the clinic has enrolled more than 1,000 patients. Dr. Fagelson provides extensive and collaborative counseling for patients, as well as a variety of sound therapy strategies, to support their ability to manage tinnitus. A substantial proportion of the veterans seen in the clinic experience tinnitus that is complicated by the influence of co-occurring psychological conditions, and in particular post-traumatic stress disorder. This challenging and underserved population is the focus of Dr. Fagelson’s research. He is also a member of the ATA’s Scientific Advisory Committee.

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1 L. Ström, R. Pettersson, & G. Andersson. (2000). A controlled trial of self-help treatment of recurrent headache conducted via the internet. Journal of Consulting and Clinical Psychology, 68, 722–727. 2 G. Andersson, T. Strömgren, L. Ström, & L. Lyttkens. (2002). Randomized controlled trial of internet based cognitive behavior therapy for distress associated with tinnitus. Psychosomatic Medicine, 64, 810–816. 3 E. W. Beukes, V. Manchaiah, A. S. A. Davies, P. M. Allen, D. M. Baguley & G Andersson (2018) Participants’ experiences of an Internet-based cognitive behavioural therapy intervention for tinnitus, International Journal of Audiology, 57:12, 947-954, DOI: 10.1080/14992027.2018.1514538 4 J. A. Henry, E. J. Thielman, T. L. Zaugg, et al. (2019). Telephone-based Progressive Tinnitus Management for persons with and without traumatic brain injury: A randomized controlled trial. Ear and Hearing, 40(2), 227–242. 5 J. A. Henry, E. J. Thielman, C. Kaelin, C. M. Quinn, & M.-C. Goodworth. (2020). Telehealthbased Progressive Tinnitus Management. Hearing Journal, 73(5), 32–35. doi:10.1097/01. HJ.0000666428.38843.10 6 P. J. Jastreboff & J. W. Hazell. (2004). Tinnitus Retraining Therapy: Implementing the Neurophysiological Model. Cambridge: Cambridge University Press 7 B. P. Fitzgerald, C. Stocking, M. Ralli & A. Sheppard. (2021). At-home meditation for tinnitus management. Hearing, Balance and Communication, 1–9. doi:10.1080/21695717.2020.18 70825 8 H. Hesser, T. Gustafsson, C. Lunden, et al. (2012). A randomized controlled trial of internet-delivered cognitive behavior therapy and acceptance and commitment therapy in the treatment of tinnitus. Journal of Consulting and Clinical Psychology, 80, 649–661. 9 E. W. Beukes, V. Manchaiah, P. M. Allen, D. M. Baguley, & G. Andersson. Internet-Based Interventions for Adults With Hearing Loss, Tinnitus, and Vestibular Disorders: A Systematic Review and Meta-Analysis. Trends in Hearing. January 2019. doi:10.1177/2331216519851749

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

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Train the Brain to Tackle Tinnitus With Cognitive Behavioral Therapy and Mindfulness By Bruce Hubbard, PhD

With an abundance of tinnitus management approaches available, it’s hard to know where to begin when considering options. Increasingly, cognitive behavioral therapy (CBT) and mindfulness are recommended. What are these approaches? How can they help with tinnitus? And how can they be accessed? As a board-certified cognitive behavioral psychologist who also has tinnitus, I am personally

“There’s nothing dangerous about hearing tinnitus. It’s how you hear your tinnitus that matters.”

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invested in getting you the best information to decide the right course of action.

What Is CBT and How Does It Help? Cognitive behavior therapy, also called cognitive behavioral therapy, or simply CBT, is a common treatment for stress-related conditions like anxiety, depression, and insomnia. CBT differs from most forms of therapy in that it is practical, short term, and evidence based. Dozens of studies have found that CBT significantly reduces tinnitus distress, as well as the anxiety, insomnia, and depression that often accompany tinnitus. Improvements in overall quality of life have also been shown. The results are so consistent that CBT is the only tinnitus treatment recommended in the U.S. and European clinical guidelines.1,2 CBT is based on the premise that it’s not your tinnitus — the loudness, pattern, or pitch — but how you respond to tinnitus that determines

your emotional course. Resisting, avoiding, and trying to control tinnitus promote distress and burn up precious time, money, and hope. Learning to accept and coexist with tinnitus reduces distress and frees up resources to devote to adapting and moving on. CBT consists of a set of skills — ways to think, act, and pay attention — to help you coexist with tinnitus, improve functioning, and fully rejoin your life. You won’t need to practice CBT skills forever. CBT gets you started on the path toward habituation, a form of neuroplasticity through which the brain gradually reduces its reaction to tinnitus. Through habituation, tinnitus becomes less important, more in the background, the same way we automatically learn to ignore road sound, a fan, the wind, and so on. At the highest levels of habituation, tinnitus is rarely noticed, if at all, even in quiet settings. CBT skills consist of cognitive and behavioral strategies. The cognitive part of CBT is based on the age-old

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wisdom that how you think about key events can strongly influence how you feel and behave. In CBT, you’ll take a careful look at your beliefs and expectations about tinnitus and your likely future with tinnitus. You’ll learn to base your beliefs on facts and guidelines, to correct misinformation that might be fueling fear and complicating recovery. For example, there is no evidence that reducing caffeine and alcohol helps, and giving these up, if you enjoy them, while struggling with tinnitus can make a difficult situation even harder. You’ll de-catastrophize tinnitus. It will not become increasingly louder until it’s all you can hear. And, contrary to the impression that people with tinnitus always suffer, studies show that most people are not bothered, that living with tinnitus gets easier over time, and that how distressed someone is has little or nothing to do with the actual severity of their condition (e.g., volume, pattern, pitch, hyperacusis, hearing loss). You’ll check your beliefs against your own objective observations. For example, you may already notice periods of a few seconds, minutes, or more when you are not aware of your tinnitus. This is evidence that your brain has already begun to habituate. Cognitive strategies are necessary but not sufficient to break the cycle of tinnitus distress. Changing behavior is the backbone of CBT. Tinnitus distress is characterized by avoidance. We try to avoid hearing tinnitus. We avoid “triggers” we rightly or wrongly suspect may make tinnitus worse. And we avoid settings that remind us of how radically our hearing may have changed. Avoidance may protect us in the short run, but in the long run, it damages lifestyle and starves

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“Cognitive strategies are necessary but not sufficient to break the cycle of tinnitus distress. Changing behavior is the backbone of CBT.” the brain of necessary opportunities to adapt and habituate. To habituate, your brain must be exposed to tinnitus under normal conditions. Only in this way will it learn that tinnitus is not important and stop sounding the alarm. In CBT, you will change your behavior by gradually turning toward avoided areas of life, cheered on by more reasonable, fact-based beliefs and expectations. A comprehensive CBT program for tinnitus includes these additional components: • relaxation exercises to reduce anxiety and improve sleep, • sound enrichment (self-guided or with an audiologist) to soften tinnitus perception, and • mindfulness (see below). These skills can be applied to aid the return to full functioning.

What Is Mindfulness and How Does It Help? Mindfulness is an ancient form of meditation introduced to the health sciences in the early 1990s by psychologist Jon Kabat-Zinn. Mindfulness is an acceptance approach used to help people make peace with parts of life that are unwanted but cannot be reduced or removed. Examples include illness, pain, ruminative thinking, fluctuating mood states, and challenging life

circumstances. Hundreds of studies have demonstrated the positive effects of mindfulness on physical and emotional health. Kabat-Zinn defines mindfulness as paying attention on purpose to what’s happening in the present moment (rather than dwelling on past or future), and without being driven by negative thoughts and judgments. By paying attention to the present moment, mindfulness goes against the conventional advice “never listen to your tinnitus” and “never be in silence.” Avoiding tinnitus may help in the short run, but in the long run avoidance can deepen fear and keep you trapped. There’s nothing dangerous about hearing tinnitus. It’s how you hear your tinnitus that matters. Hearing tinnitus through the filter of negative thinking, dwelling on what’s awful about tinnitus, reinforces distress. In mindfulness, you practice hearing tinnitus in an objective, emotionally neutral manner, free of the damaging bias of negative thinking. Instead of fighting and resisting tinnitus, you allow it to be present. In this way, the sounds of tinnitus, and any accompanying sensations, distortions, and tone loss, become more familiar, less threatening. And this is exactly what your alarm brain needs to promote habituation. Mindfulness practice also helps you

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develop attentional flexibility, the ability to allow tinnitus to remain in the background while you redirect attention to more important aspects of life. As your skill improves, mindfulness can be applied at times you are most apt to hear your tinnitus, such as when you’re trying to sleep, concentrate, or relax. In this way mindfulness can be directly employed to improve functioning and rejoin life.

A mindfulness program designed specifically for tinnitus was developed by psychologists Liz Marks, ClinPsyD, and Larry McKenna, PhD.3 Adapted from the work of Jon Kabat-Zinn, Mindfulness-Based Cognitive Therapy for Tinnitus, or MBCT-t, consists of eight weekly two-hour group sessions and 30 minutes of daily practice. In a study of 182 adults with chronic tinnitus distress, MBCT-t resulted in significant, reliable improvements. These improvements occurred

regardless of tinnitus severity or comorbidity (e.g., hearing loss, hyperacusis). The authors write: “As we become less attached to negative thoughts about tinnitus, the need to fight it lessens too. Over time it will become smaller, less threatening and a less significant part of life. Letting go of attempts to control tinnitus frees one from it.” Another program is MindfulnessBased Tinnitus Stress Reduction (MBTSR), which was developed by

Resources for Accessing CBT, iCBT, and Mindfulness for Tinnitus Given the effectiveness of CBT for tinnitus, it’s disheartening to learn that tinnitus is not part of standard CBT training, so most cognitive behavior therapists have never heard of tinnitus. Some audiologists familiar with tinnitus seek CBT training, but audiologists are not trained counselors and may never achieve the depth and breadth of experience necessary to effectively treat moderate to severe tinnitus distress with CBT. MBCT-t is new and not yet available outside the UK. So, what can you do?

CBT is essentially a self-help approach. The therapist teaches you what to do and gets you started. But you can also get started on your own by educating yourself about CBT for tinnitus. My webinar on Cognitive Behavior Therapy for Tinnitus Distress can be found at https://www. cbtfortinnitus.com/webinar My ATA Conversations in Tinnitus podcast interview can be heard at https://www.ata.org/podcasts/ episode-11-habituation-tinnitus-usingcognitive-behavioral-therapy

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The online Mindfulness-Based Tinnitus Stress Reduction program, developed by psychologist Jennifer Gans, can be found at https:// mindfultinnitusrelief.com Two self-guided online CBT for tinnitus programs are currently in development, one through my website, and the other at www.tacklingtinnitus.org If you feel the need for a guide, then find a qualified cognitive behavior therapist and have them review the relevant information on CBT for tinnitus. Cognitive behavior therapists who specialize in CBT for pain management may be best suited to help with tinnitus. You can find CBT therapists at www.ABCT.org and www.ADAA.org Acceptance and Commitment Therapy (ACT, pronounced like the word “act”) is a form of CBT that emphasizes mindfulness and taking courageous action to reverse avoidance. ACT therapists can be found at: https://contextualscience.org/ There are many excellent courses and apps that teach general mindfulness. These programs offer

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mindfulness for anxiety and pain, but they won’t teach you how to meditate with tinnitus. You can learn general mindfulness and apply it to your tinnitus through specific focus on mindfulness of sound, a traditional meditation practice that dates back thousands of years. There are numerous smartphone apps that teach mindfulness, including Calm, Headspace, Insight Timer, Ten Percent Happier. Mindfulness teachers can be found at: https://www.mbct.com/ https://www. umassmemorialhealthcare.org/ umass-memorial-medical-center/ services-treatments/center-formindfulness/mindfulness-programs/ mbct-8-week-online-live Helpful articles about MBCT-t can be found at: https://www. tinnitus.org.uk/Handlers/Download. ashx?IDMF=09151ba3-7a55-4f6fa9ed-8376d53f771e https://www.tinnitus.org.uk/Handlers/ Download.ashx?IDMF=2b83f18e0944-4617-939e-4d02e082969b https://www.frontiersin.org/ articles/10.3389/fpsyg.2020.00483/full

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psychologist Jennifer Gans. Derived from Kabat-Zinn’s Mindfulness-Based Stress Reduction (MBSR) course, MBSTR focuses more on general mindfulness. A significant advantage is that MBTSR is available online.

Conclusions When it comes to CBT and mindfulness, there is no need to choose one over the other. Many people find these approaches work well together. Most up-todate CBT programs include basic mindfulness training, and MBCT-t incorporates basic CBT. One study4 found that a form of CBT, Acceptance and Commitment Therapy, which incorporates elements of both

“You can think of these approaches as physical therapy for the brain.” CBT and mindfulness, significantly reduced tinnitus distress. Personally, I found the combination of CBT and mindfulness to be the solution for my tinnitus. In practice, CBT and mindfulness are simple but not easy. Both require patience, daily effort, and a healthy

Building a CBT and Mindfulness Self-Care Practice • CBT and mindfulness are essentially self-help approaches. The therapist or teacher shows you what to do and helps you get started. What you do on your own is ultimately more important than what happens in session or in class. • You can learn what to do and get started on your own by educating yourself about CBT and mindfulness. The resource section on the previous page offers some direction. • To learn to meditate with tinnitus, practice “mindfulness of sound.” This is a traditional meditation practice of centering nonjudgmental attention on any sound arising in the present moment, including tinnitus. Mindfulness exercises designed for persistent pain may also help. • Most local CBT therapists and mindfulness teachers will be unfamiliar with tinnitus. You can ask them to learn about tinnitus and direct them to the resources in this article. You can also seek a CBT therapist or mindfulness teacher who specializes in pain management, because many of the same principles apply to tinnitus. • It’s difficult to find a local MBCT-t class, but Mindfulness-Based Stress Reduction (MBSR) courses are much more common. These instructors are generally familiar with chronic pain. Many of the same mindfulness principles apply.

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dose of courage. With regular practice and application, the skills become more automatic, the pace of habituation picks up, and your job becomes much easier. You can think of these approaches as physical therapy for the brain. You’ll learn concepts and exercises that must be applied consistently over months and years for the full benefits to emerge. The role of the cognitive behavior therapist and mindfulness instructor is to train you in what to do and start you on your path to recovery. Bruce Hubbard, PhD, ABPP, is a board certified cognitive-behavioral psychologist who has tinnitus, hyperacusis, and high-frequency hearing loss. In 2005, when his tinnitus started, Dr. Hubbard experienced severe distress, but was unable to locate a qualified cognitive behavioral therapist to help. After coaching himself, he was able to habituate, which led him to found CBT for Tinnitus to help others. His mission is to provide evidencebased information and care to people who are distressed and bothered by tinnitus and related conditions. He has published and presented numerous papers on tinnitus distress, anxiety, and depression. His webinar Cognitive-Behavior Therapy for Tinnitus Distress, sponsored by the Anxiety & Depression Association of America, has garnered more than 160,000 views. Dr. Hubbard is a visiting scholar at Columbia University, Teachers College, in NYC, and a past president of the New York City Cognitive Behavior Therapy Association. 1 R. Cima, B. Mazurek, D. Kikidis, et al. (2019). A multidisciplinary European guideline for tinnitus: Diagnostics, assessment, and treatment. HNO, 67(Suppl. 1), 10–42. doi:10.1007/s00106-019-0633-7 2 D. Tunkel, C. Bauer, G. Sun, et al. (2014). Clinical practice guideline: Tinnitus. Otolaryngology – Head and Neck Surgery, 151(2 Suppl.), S1–S40. doi:10.1177/0194599814545325 3 E. Marks, P. Smith, & L. McKenna. (2020). I wasn’t at war with the noise: How mindfulness based cognitive therapy changes patients’ experiences of tinnitus. Frontiers in Psychology, 11, 483. doi:10.3389/fpsyg.2020.00483 4 V.Z. Westin, M. Shulin, 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. TINNITUS TODAY SUMMER 2021

SCIENCE & RESEARCH NEWS 

What Research Reveals About Taming Tinnitus From Home By Jennifer Gans, PsyD

Mindfulness for Tinnitus Management Mindfulness is a discipline to be cultivated throughout a person’s life. It involves a willful shifting of one’s attention or a systematic building of awareness to bring one’s attention to where the mind is at any given time. Thoughts, body sensations, and emotions are seen as mental events not to be analyzed or manipulated but rather to simply be noticed as fleeting events in the mind’s field of awareness. These mental events then recede from awareness, and the mind is brought back to the present moment. Other mind–body interventions such as relaxation techniques have the goal of bringing about a state of relaxation. Mindfulness practice, in contrast to CBT and relaxation training, posits a non-striving stance toward a particular outcome: it simply allows whatever is in one’s field of awareness to be witnessed without judgment.

Recent research has suggested that mindfulness-based approaches to living with tinnitus can be effective in helping people modify their perception of the sound, leading to reduced effects of tinnitus, less emotional struggle, and a greater sense of well-being. Specifically, Mindfulness Based Tinnitus Stress Reduction (MBTSR), an eight-week skill-building program developed and researched by the author at the University of California, San Francisco (UCSF), teaches participants how to develop more healthful and adaptive ways of relating to the unpleasant sensation of tinnitus. MBTSR includes in-depth tinnitus education and mindfulness skill building. Each week’s class integrates elements of deep breathing, gentle yoga, relaxation, and meditation to help people develop new, more effective ways to relate to the experience of tinnitus and stress in their daily lives. A pilot study published in a peerreviewed journal in 2014 suggested that MBTSR was a viable treatment for those with bothersome tinnitus.1

Conflict-of-interest notice to readers: The online program featured in this article was developed by the author and can be accessed for a fee. The author therefore stands to benefit financially if Tinnitus Today readers decide to purchase access to the program.

In the study, participants reported a reduction in tinnitus impact, depression, and anxiety while improving social functioning and overall mental health. Furthermore, results after one year showed a further decline in tinnitus distress.2 Based on those findings, an online version of the eight-week course (i-MBTSR) was developed, enabling access to anyone in the world with an internet connection.

Taming Tinnitus from the Comfort of Home In 2020, at the beginning of the first shelter-in-place order in the United States and elsewhere in the world, it became apparent that using an online platform for tinnitus care had the potential to reduce pressure on existing healthcare systems while providing meaningful tinnitus care from the privacy of one’s home. Artwork Credit: Melinda Beck

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 SCIENCE & RESEARCH NEWS

Between March 25 and June 9, 2020, the online eight-week i-MBTSR course, accessed at MindfulTinnitusRelief.com, was offered around the world at no charge to anyone struggling with tinnitus and hyperacusis. The course consists of eight weekly tinnitus lessons, guided meditation videos, audio recordings, and automated emails that subscribers complete at their own pace (minimum length eight weeks). Concurrently, a research study in coordination with Idaho State University was designed to learn from this group about the effectiveness of the course. The study also aimed to identify three factors: (1) who is an ideal candidate for an online mindfulness-based tinnitus treatment program; (2) what characteristics individuals have who are likely to complete the course; and (3) whether observable gains were maintained after the course was completed.

Covid-19 Pandemic Participants For assessment, the 561 people enrolled voluntarily in the i-MBTSR course and were asked to complete two assessment measures, the Tinnitus Functional Index (TFI) and Perceived Stress Scale (PSS) at the beginning, midcourse, at course completion, and finally, at six months post course completion. One hundred and one subjects completed the pre- and mid-assessment measures, and 45 completed the assessments at pre-, mid-, and post-assessment time points. The six-month follow-up measure was completed by 60 individuals.

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Participants’ TFI and PSS scores showed improvement by mid-course with even further reduction in tinnitus distress and perceived stress for those who completed the post-assessment measures. Improvements were maintained six months after course completion, indicating enduring symptom reduction.

Who Is an Ideal Candidate for Online Programs? One question that often arises both for hearing healthcare providers and for individuals seeking tinnitus relief is which management tool is most effective and for whom. Differences in subject characteristics such as age, gender, tinnitus duration, tinnitus intrusiveness, perceived stress, emotional distress, and sleep disturbance were considered in the Idaho State University study when investigating who would most likely benefit from the online i-MBTSR treatment. Results indicated no easily identifiable differences between groups. Variables such as age, gender, perceived stress, and tinnitus impact did not seem to differentiate those who chose to participate in the course. This tentatively leads us to believe that tinnitus patients with diverse backgrounds and characteristics may benefit equally from this program, making a referral to the course an option for a range of tinnitus patients with internet access. The group was unique in that participants were a sample observed during the Covid-19 pandemic, were self-referred to the program,

and were not a clinical sample (information on mental health status or audiologic factors beyond selfreport was not gathered). They were also able to access the course for free. A further question arises: Is this course more effective for individuals who have a meditation practice prior to entry? Future research may wish to see whether a post-pandemic sample responds differently to the course, whether having a meditation practice prior to entry affects outcome, and whether a clinical sample of participants who were evaluated and referred by an audiologist or other healthcare provider makes a difference in outcomes. High dropout rates can be a characteristic of treatment studies using the internet, especially for courses that are free. For this study, course completion rates were based on completion of the postassessment measure. However, the completion of forms was not mandatory and it is likely that additional participants completed the course content but failed to complete assessments. Therefore, the postassessment completion rate is likely not an accurate gauge of participant engagement and the true drop-out rate is difficult to determine from this study. Future studies may wish to track participant progress closely by monitoring participation and gathering information on actual time spent on course modules. While high dropout rates can be common for online programs, this should be contrasted with the accessibility and cost effectiveness of internet courses such as i-MBTSR.

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In Conclusion Based on our findings, the MindfulTinnitusRelief.com eight-week online course appeared to be an effective tool for a Covid-19 pandemic group of people impacted by tinnitus. The combination of written content and activities for relieving tinnitus anxiety and fear, accurate education on what tinnitus is and is not, and stress reduction elements of a mindful meditation practice likely all served to open the door to the tinnitus healing process. It was clear from this study that there is interest worldwide in accessible and inexpensive tinnitus interventions. Translation into other languages would increase access. Using an online platform to gain easy access to evidence-based tinnitus

treatment from the privacy of one’s home reduces the pressures on existing healthcare systems, which was particularly helpful during the Covid-19 pandemic period. These promising findings warrant further investigation into the acceptability, feasibility, efficacy, and effectiveness of the online MindfulTinnitusRelief. com course and others like it in reducing tinnitus distress and tinnitusassociated comorbidities using a randomized controlled trial. Jennifer Gans, PsyD, is a clinical psychologist specializing in the psychological impact of deafness and hearing on well-being. In her private practice in

San Francisco, Dr. Gans treats clients with tinnitus and other hearing-related difficulties. She completed research at the University of California, San Francisco (UCSF) in the Department of Otolaryngology’s Audiology Clinic on Mindfulness-Based Tinnitus Stress Reduction (MBTSR). She is the founder of MindfulTinnitusRelief.com, a selfadministered eight-week online skill-building course for learning how to shift tinnitus from “bothersome” to “non-bothersome”. She presents globally to audiologists, otolaryngologists, and hearing-health providers on how to integrate and give support to tinnitus patient counseling. 1 Gans, JJ, O’Sullivan P, Bircheff V. (2014) Mindfulness Based Tinnitus Stress Reduction Pilot Study. Mindfulness 5:322–333. 2 Gans JJ, Cole M, Greenberg, B. (2015) Sustained Benefit of Mindfulness-Based Tinnitus Stress Reduction (MBTSR) in Adults with Chronic Tinnitus: A Pilot Study. Mindfulness 6:1232–1234.

The End of Roaring Motorcycles? For many, Harley-Davidson motorcycles evoke images of bikers being heard long before they’re seen in the rearview mirror of a passenger car. The noise, resulting from illegally modified exhaust systems, are a bane for many and a badge of honor for riders who love the thunderous roar. Will the trend toward electric vehicles mean that loud hogs will eventually give way to silent rides? Harley-Davidson seems

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to think so, with the release of its LiveWire e-hog. According to Bloomberg, 35 percent of the motorcycle market in 2020 was battery-powered twowheeled machines, though most of that share was from sales of e-bicycles and scooters. HarleyDavidson is banking on its electric motorcycle as a “halo product” – an advanced model that generates sales from less expensive machines. And in an increasingly

crowded field of quiet two-wheeled machines, Harley is emerging as a leader thanks to rave reviews of LiveWire. The company has created a separate division to pursue further electric vehicle development, which is part of an effort to lure first-time buyers interested in a more tranquil, comfortable ride. For those who value quiet and preserving one’s hearing, it’s a welcome trend.

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 PERSONAL STORY

Peaceful Coexistence With Tinnitus Through Meditation By David Lewis

I was fortunate to have already been practicing meditation for several years when I started experiencing tinnitus. My tinnitus came on gradually and my meditation practice, with its emphasis on mindfulness of what is happening in the present moment, allowed me to see how tinnitus got worse when I was either tired or stressed. This was helpful. It also allowed me to accept this new reality in my life, along with the associated hearing loss. The tinnitus was not a welcome development, but I knew there was no cure, so my ability to bring acceptance to it has allowed me to coexist with it with some measure of equanimity. Every challenge we face in life is actually two challenges. The first is the event itself — a loss, a separation, a diagnosis, or tinnitus — and the second is our response to that challenge. I have found more often than not that I suffer more from my

“Letting go is not about trying to abolish our tinnitus but rather simply letting it be.” 28

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response, or reactivity, than I do from the original event. What I often hear from people with tinnitus is “I can’t stand it.” Well, that’s reactivity and it’s not particularly helpful. You are, after all, standing it. The sound itself isn’t harmful, but the stress you generate in reacting negatively to can be. The great American writer Maya Angelou said, “If you don’t like something, change it. If you can’t change it, adjust your attitude.” Meditation can help in adjusting our attitude about living with tinnitus. It is quite simply a way of learning to pay attention at a deeper level. Anyone can learn to meditate. There are classes and online resources widely available. If you have access to a qualified meditation teacher, you can even get instructions tailored specifically to tinnitus. Here are a couple of mindfulness meditation techniques that I find helpful in working with my tinnitus: First, I direct my attention to the tinnitus itself. Rather than avoiding it or wishing it would go away, I turn the full beam of awareness on the tinnitus, asking, “What is its nature?” Does it come and go? Does it decrease or increase in volume? Is it louder on one side than the other? This is making tinnitus a meditation object itself, just as many meditators use the breath. The breath is a good example because, like tinnitus, it is

always happening — we breathe in, we breathe out, we don’t try to stop it because we can’t. And yet we aren’t tearing our hair out exclaiming, “It just won’t stop!” It’s just breathing. And it’s just tinnitus; just a noise in our heads, no more maddening than breathing unless we make it so. Making tinnitus a meditation object can actually be quite helpful in cultivating sanity in our lives. If we learn to focus all of our awareness on our tinnitus (or our breath), even for a few minutes, we will be less caught up in our busy, judgmental, complaining mind. I have a doctor friend who always starts out his meditation by focusing on his tinnitus. He says it grounds him in the present moment and settles him in a peaceful place. He is using his tinnitus as an “anchor” to the present moment. Just as a boat’s anchor keeps it from drifting away with the tides, tinnitus can be used to anchor us in the present and prevent our overactive minds from drifting off into the past or the future. Tinnitus, in this context, can be a helpful tool in staying present. Rather than resisting it, imagine actually “inviting” tinnitus in to ground yourself in the moment and tap into peace. You can do this too! But sometimes, especially when we are new to meditation practice www.ATA.org

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(or new to tinnitus), focusing our attention on it feels like it is just too much. In this case, we use a different meditation technique. Instead of focusing our attention on our tinnitus, we focus on something else, like the breath. Focusing the whole of our attention on the breath is a classical meditation technique to take our mind off our obsessive thinking. But in this case, it can also take our mind off of our tinnitus. The tinnitus will not go away, but with our attention focused elsewhere, it might just fade into the background.

Both of these techniques require us to let go of our resistance to tinnitus, or the wish for it to just go away. This is helpful because wishing will not make your tinnitus go away and doing so is stressful. If anything, it makes the tinnitus worse. The practice of “letting go” is another valuable meditation technique in itself. Letting go is not about trying to abolish our tinnitus but rather simply letting it be. Accepting our tinnitus doesn’t mean that we have to like it any more than we like (or don’t like) breathing. We simply accept that “it’s like this.”

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I have found these meditation techniques to be enormously helpful in learning to live with my tinnitus. Would I accept a cure if it were available? You bet! But in the meantime, I’m happy to have made peace with it. David Lewis has been practicing meditation for 50 years and has lived with tinnitus for more than 20 years. He is retired and lives in San Francisco, California, where he teaches meditation classes, leads groups, and mentors meditation students.

Apps for Calming the Mind Apps are wonderful tools to augment therapy, foster habits that promote greater awareness of mood and breathing, and reduce the negative impact of tinnitus on sleep, concentration, and anxiety. The list below represents a limited selection of apps used for mental health support and tinnitus relief. Some are free, and others have fees that vary depending upon the subscription. Normally, a trial period allows you to test an app to see whether it meets your needs and expectations.

MyLife Meditation: Mindfulness | Stop, Breathe & Think | $9.99 monthly; iOS and Android MyLife app offers guidance and personalized daily meditations, beginning at three minutes in length in both English and Spanish.

Breathe2Relax | National Center for Telehealth & Technology | Free; iOS and Android The National Center for Telehealth and Technology created Breathe2Relax to help users learn to breathe and remind themselves to relax. The stress management tool teaches users a skill called diaphragmatic breathing, which can help decrease the body’s fightor-flight stress response.

Headspace | Headspace Inc. | $12.99 monthly; iOS and Android The Headspace app aims to help users develop mindfulness and meditation skills by using the app a few minutes per day. It has hundreds of meditations on everything from stress and anxiety to sleep and concentration. It also has a daily reminder to encourage practice, which can be helpful when getting started.

Calm | Calm Radio | $12.99 monthly; iOS and Android Apple named Calm the 2017 iPhone App of the Year. Calm is well regarded by tinnitus-trained audiologists and therapists for use by their patients struggling with stress, anxiety, and difficulties sleeping. It offers guided meditations, sleep stories, breathing programs, and relaxing music, making it useful for a variety of situations and concerns.

The ATA does not endorse products or treatments. The apps are intended only for informational purposes. If you are seeing a therapist and/or audiologist for tinnitus treatment, discuss which apps they recommend and why. www.ATA.org

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Tinnitus Q & A Tinnitus Can Be Unsettling, but It Is Seldom a Symptom of Serious Disease

Answered by Jan L. Mayes, MSc

Question: When my tinnitus started three years ago, I visited several physicians who provided no guidance and showed no concern about my condition. Over the last few months my tinnitus has been much louder, so I sought help again. This time I was told I might have an underlying medical condition, such as a slow-growing tumor. I burst into tears when I heard that! I’m scheduled for a CT scan in a few weeks. How am I supposed to calm myself down with this hanging over my head? Jan Mayes, MSc: It can be alarming to be told about a possible tumor after earlier tinnitus evaluations didn’t identify any concerns. But the fact remains that tinnitus is seldom a sign of serious disease. During evaluations, care providers including family doctors, ear, nose, and throat doctors (ENT), audiologists, or other hearing healthcare professionals check for red flags of possible, but rare, underlying medical conditions. They don’t routinely tell patients they’ve passed a red-flag screening, which can leave people feeling their tinnitus evaluations missed something. Red flags include signs of hearing system tumors that most often cause one-sided tinnitus with slowly worsening hearing in that ear. 30

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Imbalance is also possible. These rare, slow-growing benign tumors do not grow inside the brain or skull cavity. Acoustic neuroma, also known as vestibular schwannoma, is a tumor that grows in the inner ear space. Cholesteatomas are tumorlike growths in the middle ear space. Healthcare providers flag anybody with characteristics of a growth that might be causing tinnitus and refer them for medical follow-up, which can include imaging tests such as an MRI or CT scan. With tinnitus, many different causes often show similar characteristics. Most people referred for imaging tests do not have a tumor of the auditory (hearing) system. Tinnitus can be an unstable sound that goes up and down in loudness and changes tone or pitch. I’ve had to reassure many patients that these changes are common tinnitus features and not the result of a disease. For example, it’s normal to have sudden occasional bursts of loud tinnitus that last for several seconds. Many people can make their tinnitus sound change with head, jaw, or body movements. None of that means healthcare providers missed a critical condition. Tinnitus flare-ups are not a sign of progressive life-threatening illness. Tinnitus in one ear typically changes to being heard in both ears or in the head, because of how our brain processes

the tinnitus sound. It doesn’t mean a disease or tumor has spread from one ear to the second. If a growth is found, it is good to catch it early. Hearing system tumors are only fatal if left untreated. Left untreated, they can grow through the skull into the brain. I have never seen anyone who reached that point. In a few cases, patients had one-sided tinnitus and steadily worsening inner ear hearing loss and imbalance. Those patients had surgery to remove an acoustic neuroma. In another case, the patient had tinnitus and steadily worsening middle ear hearing loss in one ear. That patient had surgery to remove a cholesteatoma. After treatment, there is no longer a threat to life. In some cases, tinnitus is eliminated or improved. But some people still have tinnitus even if they lose hearing after surgery. Tinnitus itself is not a disease or life-ending condition. Scientists believe chronic tinnitus results from increased spontaneous activity of sound processing networks in the brain. As an analogy, a car engine may be idling but not heard from inside the car. When the engine is revved, then the engine is heard. Likewise, when the sound-processing nerve cells in the brain are “idling” (spontaneous activity) no sound is heard. With increased spontaneous activity of

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those same nerve cells, then a sound (tinnitus) is heard.”. Counseling is key to helping people understand tinnitus better. But healthcare providers must be careful not to dismiss people’s concerns about their tinnitus by telling them, “At least it’s not a serious disease” or “At least a tumor can be treated” or “At least it’s not deadly”. Although that might be technically true, it doesn’t take away from the fact that tinnitus can significantly affect a person’s wellbeing and quality of life. When you’re worried if tinnitus stems from a serious condition, it’s common to have questions. Those

concerns may depend on imaging test results, so it’s helpful to write questions down in advance to discuss during your next clinic or telehealth appointment with your audiologist or healthcare provider. Then, as hard as it is, do your best to put those thoughts out of your mind until the appointment. By worrying, those concerns grow, which can cause your tinnitus to increase. Whether there is a tumor or not, future appointments with hearing healthcare providers should include sharing strategies and treatment options available to help you cope with your tinnitus, including

information and approaches to manage stress and anxiety. Jan L. Mayes, MSc, has had tinnitus for more than 30 years. She is an award-winning author of nonfiction hearing health books. As a newly retired audiologist, Mayes continues to write about tinnitus, hyperacusis, and community noise impact on disability access, communication, and hearing wellness. In her spare time, Mayes enjoys writing dystopian fiction. To learn more, visit her website: www.janlmayes.com

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Everybody Has Their Favorite Sound: The Evolution of Tinnitus Masking Over the Last 50 Years By Grant D. Searchfield, PhD

“ Everybody has their taste in noises as well as in other matters.” — Jane Austen (English novelist, December 16, 1775–July 18, 1817) In the mid-1970s, Jack Vernon, PhD, developed the first combination aids (hearing aid and masker combined into one instrument) and opened the Tinnitus Clinic, the first dedicated to the condition. This marked an important milestone in the modern use of sound as a therapy for tinnitus. Sound therapy is the use of sound to reduce tinnitus or its effects. It began with the relatively simple observation of the benefit of covering tinnitus with another sound; it now includes sound-based strategies geared to modify specific brain activity believed to underpin tinnitus. In this article, you’ll learn how sound therapy is believed to work, and the different types of technology used for it. For simplicity, the modes of sound therapy are categorized as tinnitus relief, retraining the brain, and relaxation.

Tinnitus Relief Relief from tinnitus is obtained when a sound is played, and the

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tinnitus becomes less obvious. Sound is primarily used in this mode as an aid to gain a sense of control over the tinnitus. In the longer term, as long as the individual is coping well with tinnitus, the relief sounds may be used less.

Masking Tinnitus masking is the process of covering or partially covering tinnitus, replacing its perception with that of another sound. The 19th-century French physician Jean-Marie Itard (1775–1838) suggested using natural sounds to mask tinnitus such as those made by fires burning different wood types (for example, damp wood, producing a hissing sound, would mask high-pitched tinnitus). In the late 1940s, hearing aids were found to be beneficial for tinnitus masking. However, it was Dr. Vernon’s invention of ear-level hearing aid–style electronic maskers in the late 1970s (Figure 1) that enabled masking to be systematically implemented. Totally covering the tinnitus using sound from these devices was not always possible because sometimes the level of sound required would be unpleasant, and in some cases the masker would lose effectiveness over time. Partially masking the tinnitus became more popular. Richard Tyler, PhD, recommended maskers be set

Figure 1. Tinnitus Masker, 1980.

USA Patent 4,222,393 from Inventors: R Hocks; J Vernon. Assignee: American Tinnitus Association.

at “the lowest effective level” for partial masking. There are two broad mechanisms of masking: energetic masking and informational masking. Energetic masking occurs when a sound including the tinnitus pitch frequency directly suppresses activity. This is a simple process that occurs for sound-on-sound masking, but it cannot explain why sounds in the ear opposite to tinnitus or not including the tinnitus pitch can mask tinnitus. Informational masking, or “central masking,” happens because the brain has difficulty separating signals containing similar information. Tinnitus is not suppressed; instead the brain cannot extract tinnitus activity from the patterns of activity created by the masking sound. Marc Fagelson, PhD, has produced an animation to explain this process (https://www.youtube. com/watch?v=TnsCsR2wDdk). The ability of a sound to mask tinnitus varies between people, and no single masking sound has been www.ATA.org

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shown to be universally successful. The most effective maskers for many people are those with broad bandwidths that contain a wide spectrum of sound (sometimes called white noise) including the tinnitus pitch. Broad spectrum sounds such as rain-like noise and “surf” sounds are popular because they are effective maskers and quite pleasant to listen to. Masking can be achieved using hearing aids, ear-level tinnitus maskers, combination instruments, apps, and various types of sound-generating devices. Masking is normally provided with some counseling.

Lateral Inhibition An alternative approach to masking is to exclude sound frequencies in the tinnitus pitch region using a notch filter so that sound stimulates frequencies near, but not at, the tinnitus frequency. The sharp spectral edges created by notching sound may suppress overactive neurons at the tinnitus pitch. Music is often used for this treatment because it is also relaxing in a method known as “Tailor Made Notched Music.”

Retraining the Brain: Tinnitus Retraining Therapy and Habituation After a decade of experience with masking, researchers noticed that, for some patients, partial masking over time resulted in less tinnitus awareness. On the basis of these clinical observations and a neurophysiological model, Pawel Jastreboff, PhD, and Jonathan Hazell, MD, developed a counseling and sound therapy protocol that in the 1990s became known as www.ATA.org

Tinnitus Retraining Therapy (TRT). This therapy is based around the process of habituation. Habituation is a simple learning process that enables us to ignore familiar and uninteresting sound with experience. Habituation ensures we respond appropriately to stimuli that are important (like hearing our name in a crowd) while ignoring sounds that are unimportant (like the humming sound of a refrigerator or computer). The goal of TRT is to relegate tinnitus to being an uninteresting background sound. If tinnitus fades into the background of consciousness, it has become habituated. If TRT along with counseling for 6 to 18 months in a program of continuous sound therapy with hearing aids or broadband noise mixed with tinnitus is followed, the tinnitus may no longer be a problem — habituation of reaction — and, possibly, may result in an individual being unaware of tinnitus — habituation of perception.

Some sound therapies use patterned tones in an attempt to desynchronize the neurons coding the pitch of tinnitus; others use tones with the goal of reducing the number of neurons representing tinnitus. Such sound therapies target the tinnitus sound, hoping to turn it down or off completely rather than reducing reaction or focus on tinnitus. Some other sound therapies, as described below, may have greater effect on tinnitus reactions than on the tinnitus sound.

Synchrony and Reorganization

Music can result in muscle relaxation, slowing of heart rate, and decrease in blood pressure leading to improved mood and reduction in effects of stress. Music that induces positive feelings should be used in the management of tinnitus. Typically, orchestral music is used for reducing tinnitus; however, any music can be tried. A decade ago, one hearing aid manufacturer introduced fractal sound therapy (“Zen”) as an option in its hearing aids. Fractal sounds are complex, digitally rendered sounds that resemble musical chimes.

In the last decade some therapies have tried to target specific brain mechanisms that have been proposed to result in tinnitus. Groups of brain cells may become overactive or synchronized in their activity following reduced input from the ear, resulting in tinnitus. Sound may reverse the overactivity. With prolonged persistent exposure to sound, the brain cells may adapt their response to tinnitus, perhaps by reducing the connections between the hearing regions of the brain and the parts of the brain involved in conscious perception.

Relaxation Tinnitus can be an unpleasant experience and a contributing cause to, or consequence of, stress, anxiety, and depression. Counseling and psychology can teach us how to relax. Some music and nature sounds also have relaxing qualities. These sounds may activate regions of the tinnitus brain network associated with emotion.

Music

Nature Sounds Sounds that elicit positive emotions and happy memories can also aid TINNITUS TODAY SUMMER 2021

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relaxation. Water sounds (rain, waterfalls, ocean waves) and other nonthreatening nature sounds (e.g., gentle wind in trees, forest sounds) can be used alongside mental visualization to recall enjoyable and relaxing times. These sounds also contribute to masking, or placing the unreal tinnitus sound in a more normal context. My research group has successfully tried “morphing” sounds that start resembling tinnitus and then fade to a real-world sound. This treatment has been shown to change brain networks as well as reduce tinnitus distress, but it is unclear what its true action is — relief, relaxation, or retraining.

also have therapy sounds that can be turned on (see “Combination Aids” below). If hearing loss is too great to benefit from hearing aids, cochlear implants may be an option.

Figure 2. An image of a modern hearing aid that features tinnitus treatment options. Oticon More, courtesy of Oticon A/S.

Hearing Aids Hearing aids were the first practical device for sound therapy. Hearing aids come in different shapes and sizes for different types of hearing loss (Figure 2). They improve communication and redirect attention from tinnitus to real sounds, and speech — an information-carrying sound — provides informational masking. Hearing aids can lead to less social isolation. The use of hearing aids can be thought of as exercise for the ears; there is evidence that hearing aids can play a role in preserving cognition (thinking/memory) as we age. Most modern hearing aids 34

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Combination aids combine a hearing aid with a built-in tinnitus masker. Different masker sound options are available such as noise, surf-like sounds, or fractal (chime) sounds. Combination aids were once different from hearing aids; currently most hearing aids can also be used as combination aids by activating a setting. If the hearing aid amplification alone doesn’t help mask the tinnitus, then another sound can be added. This occurs most often when the hearing loss affects a wide hearing range.

Bluetooth Hearables

Sound Therapy Devices The range and complexity of sound therapy technology have advanced dramatically over the ATA’s 50 years. Some of the most popular types of tinnitus treatment devices are outlined below along with their primary modes of action. A good clinician should be able to guide people with tinnitus to the best therapy solution based on their tinnitus and needs for therapy.

Combination Aids

Cochlear Implants Cochlear implants are surgically implanted devices that overcome hearing loss by directly stimulating the hearing nerve. The implant transfers small electrical impulses that the brain interprets. These become an option for managing tinnitus when it is paired with a severe hearing loss. Cochlear implants help manage tinnitus in a similar way to hearing aids.

Tinnitus Maskers A tinnitus masker or sound generator is a small noisemaker, resembling a hearing aid, that is worn on or in the ear. They typically produce a hissing sound of variable intensity and frequency. These are used for masking, and long-term use may lead to habituation or reduced awareness of tinnitus. Maskers are used in preference to hearing aids when there is no hearing loss.

Bluetooth is the name for a standard type of wireless connection between electronics; many hearing aids are now Bluetooth capable. A hearing aid connected with a smartphone enables more masking sounds to be used. Recently, earphones with Bluetooth connections have emerged that also have simple hearing aids built in. Some hearables also have sensors for measuring body functions (e.g., heart rate). One day these sensors may be used to help tune sound therapy to body state (e.g., automatically suggesting relaxation sounds when the heart rate is high).

Tabletop Devices Simple tabletop sound machines can be obtained through electronics retailers and have been widely available since the 1990s. These devices typically allow the listener to choose from a range of pleasant nature sounds. At nighttime, these devices can be used with pillow speakers — small speakers designed

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to be placed under a bed pillow or incorporated into their own pillow.

Treatment-Specific Devices Some treatments use specialized devices to apply therapies based around a specific idea. These devices use a tinnitus-like sound during sleep in the attempt to retrain the brain, music and noise that are tailored to hearing loss for habituation, or patterns of tones to try to desynchronize brain activity related to tinnitus.

Apps and Online Sound Therapy Masking and sound apps are available to download from internet app stores. The sounds can be played through headphones or through Bluetooth hearing aids. Various sounds can be selected from music, nature sounds, and broadband noise.

The Future Sound therapy is not a cure for tinnitus, yet. The evidence for its effectiveness varies across studies and according to methods used. More research is needed, and to more exacting standards. Current evidence indicates sound therapy is a safe way to gain some control over and divert attention from tinnitus. The foundations for tinnitus sound therapy were set 50 years ago at the formation of the ATA and with Dr. Vernon’s efforts in developing wearable maskers. Is any sound “the best”? The answer is probably no. No single sound is the best for everyone, hence my use of the quote from the author Jane Austen at the top of this article. It appears that “everybody has their www.ATA.org

taste in noises as well as in other matters” includes tinnitus. Most current sound therapies have similar benefits. In the future we may be able to predict the types of sounds that will suit different types of tinnitus. At present if there’s a hearing loss, hearing aids should be considered. If a hearing aid trial proves unsuccessful, combining hearing aids with sound therapy using music or noise, maybe using an app, should be tried. The potential effect of masking can be estimated by listening to water running through a faucet tap (Jack Vernon’s “faucet test”). If a low-level sound covers the tinnitus, sound (for either relief or retraining) may be worth trying. As a general rule, the quieter the environment, the more likely it is that tinnitus will be heard; so, it makes sense that sound should interfere with tinnitus. Moving attention away from tinnitus is also likely to be a common factor in sound therapy benefit. Do new sound therapies affect tinnitus in the new ways that their developers propose, or are they variations of “new wine in old bottles”? Through various methods of recording brain activity and use of artificial intelligence, we are beginning to answer this question. My opinion, at this time, is that the various sound therapies share a common core set of mechanisms, but the way they are applied may suit some people more than others. Sound therapy is most likely to be successful as part of a comprehensive approach that includes counseling, such as TRT as mentioned, Dr. Tyler’s Tinnitus Activities Treatment, and Dr. James Henry’s Progressive Tinnitus Management.

My lab has begun testing a new sound therapy that combines many of the ideas described in this article along with tinnitus games and counseling personalized to individual characteristics. Therapies that use artificial intelligence to optimize sounds based on individual needs and tinnitus characteristics are likely to emerge in the next 5 to 10 years, which should improve the effectiveness of sound therapy for a wider number of people.

Disclosure of Interests Grant Searchfield has received research funding from several hearing aid manufacturers and is scientific director of Tinnitus Tunes (www.tinnitustunes.com), a subscription-based online tinnitus therapy resource.

Jack Vernon, Grant Searchfield and daughter, with Mary Meikle onboard Jack and Mary’s Sauvie Island houseboat circa 2004. Grant D. Searchfield obtained his PhD from the University of Auckland, New Zealand, where he is an associate professor in audiology. He is director of the university’s Hearing and Tinnitus Clinic and deputy director of the Eisdell Moore Centre for Hearing and Balance Research. He began his association with the ATA in 1995 as an attendee of the Fifth International Tinnitus Seminar in Portland, Oregon, where he first met Jack Vernon and Mary Meikle. Grant is a current member of the Scientific Committee of the Tinnitus Research Initiative and ATA Scientific Advisory Committee, and he is a past recipient of ATA research funding. His research for the last 20 years has focused on how to improve tinnitus sound therapy. TINNITUS TODAY SUMMER 2021

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Sound Therapy Study Fades Out Tinnitus With Nature Sounds Summary by John A. Coverstone, AuD

Clinicians continue to be somewhat limited in available options for helping people with tinnitus that isn’t linked to an underlying medical issue. Audiologists rely primarily on sound therapy and counseling for cognitive adaptation to tinnitus, and psychologists utilize cognitive behavioral therapy, mindfulness, and other counseling modalities to help patients cope with reactions to tinnitus sounds. Various devices have come and gone in recent years, but there is no evidence that any are more effective than general sound therapy. Researchers out of Auckland, New Zealand, used a new twist on sound therapy to attempt to recategorize tinnitus as less distressing within an individual’s brain.1 This treatment model is based on the theory that tinnitus, as an internally perceived sound, is different from external sounds heard in a person’s environment. For that reason, the brain pays extra attention to tinnitus, which results in increasing its importance in our minds and causing additional focus on the tinnitus sound.

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In the new research model, the researchers used a sound that was matched to a subject’s tinnitus and then gradually faded it into a nature sound that was more pleasing and reflective of real-world sounds for the subject. The three-month study was completed by 18 individuals, each of whom had persistent, nonfluctuating tinnitus that had been present for at least six months. More than half had not tried any treatment for their tinnitus. Participants completed audiological examination and a series of ratings to match tinnitus pitch, location in space, and bandwidth (smaller bandwidth is more like a tone, a larger bandwidth is more like noise). Participants then selected one of five environmental sounds (cicadas, a fan, water/rain, birds, water+birds) on the basis of its similarity to the tinnitus and personal preference. One-hour sound files were then generated for each participant in which the tinnitus-matched sound was gradually faded into the environmental sound over the entire hour. Electroencephalograms (EEGs) were recorded at five intervals: in quiet prior to the sound file playing, during the first 10 minutes of the sound file,

during the middle 10 minutes, during the final 10 minutes, and in quiet after the sound file was done playing. Participants were sent home with four sound files to use for the threemonth trial. The various sound files were used in a designated order and provided a progression that gradually emphasized the nature sounds in each successive file. Participants were to change the sound file at specified intervals. They started with a file that provided 100 percent tinnitus-matched sound morphing to 50 percent tinnitus-matched and 50 percent nature sounds, and ended with a file that morphed from 10 percent tinnitus-matched and 90 percent nature sounds to 100 percent nature sounds. The Tinnitus Functional Index (TFI) was given at the beginning of the trial, after two weeks, one month, two months, and at the end of the trial after three months. When comparing TFI scores, the most significant effect noted was time. Both overall scores and subtest scores increased when the test was given at later times. A measure of tinnitus severity was also provided, and later severity scores were lower than earlier scores. The Depression, Anxiety, and www.ATA.org

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Stress Scale was provided, but no significant changes were noted before and after treatment. The Positive and Negative Affect Scale was given to provide a rating of emotional states and indicated lower positive emotional states later in the trial for some sounds, particularly the fan sound and water+birds. Findings indicated that tinnitus changed subjectively for a small portion of participants. Some indicated that tinnitus changed in pitch, location, or quality. Analysis of EEG data allowed the researchers to map brain activity prior to, during, and after listening

to sound files. Activated brain regions corresponded to previous research. It was noted that greater involvement of both hemispheres was measured when sounds morphed into nature/environmental sounds. This was particularly true for brain areas involved in attention and discrimination of stimuli. Although participants appeared to show benefit from this approach, it is noted that the study included a small group of participants and did not have a control group. Because of this, it cannot be stated for certain that the treatment model used in this study was responsible for the measured

or perceived changes to tinnitus. It will be necessary to conduct a new and larger study in which some participants are given a non-morphing sound file and use white noise or other stimuli not matched to their tinnitus. However, benefit was shown for most participants in this study and this research may yield a new type of sound therapy to help minimize the intrusiveness of tinnitus. 1 M. Durai, Z. Doborjeh, P. J. Sanders, D. Vajsakovic, A. Wendt, & G. D. Searchfield. (2021). Behavioral outcomes and neural network modeling of a novel, putative, recategorization sound therapy. Brain Science, 11, 554. https://doi.org/10.3390/ brainsci11050554

28th Annual International In-Person/Online Conference

Management of the Tinnitus & Hyperacusis Patient The 28th Annual International Conference, Management of the Tinnitus & Hyperacusis Patient is scheduled to be held August 1213, 2021, 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 www.ATA.org

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, noiseinduced 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 DIAMO OR individual diagnosis SPONS or treatment will be offered. For more information, visit the University of Iowa’s website: https://medicine.uiowa.edu/ oto/sites/medicine.uiowa.edu.oto/ files/Tin%20Hyper%20Conf%20 Brochure%202021%20v40.pdf

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The Creation of the Tinnitus Functional Index Questionnaire

A Tribute to Mary Meikle, PhD The contributions of researcher Mary Meikle, PhD, (1934 – 2011), continue to impact tinnitus clinicians and researchers as well as patients struggling with tinnitus. This story demonstrates extreme attention to detail, and her commitment to conducting the highest-quality tinnitus research. She and her husband, Dr. Jack Vernon, were two of the earliest tinnitus researchers. I had the great fortune of spending six years in their lab (1988–1994) during my doctoral program at Oregon Health & Science University (OHSU). Dr. Meikle was my advisor, and Dr. Vernon was always a source of advice and ideas. They both had a tremendous impact on my career, and those six years focused my research on tinnitus from that point on. 38

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By James A. Henry, PhD

It is commonly reported that tinnitus affects between 10 and 15 of every 100 adults.1 In more scientific terms, the “prevalence” of tinnitus is 10–15 percent of the adult population. Much has been written about the distinction between the tinnitus sensation and reactions to the tinnitus sensation.2 The tinnitus sensation is the “phantom” sound that exists only inside the head. Reactions are the effects that the tinnitus sensation can cause, such as sleep disruption, concentration difficulties, and negative emotions (usually anxiety and/or depression). A cure for tinnitus would be some treatment that permanently reduces or eliminates the phantom sound.3 In spite of years of intensive research, no such cure has been discovered. In the meantime, numerous therapies exist that are intended to reduce reactions to tinnitus. By reducing reactions, a person can live a normal life without being unduly affected by tinnitus. The therapy with the strongest evidence of

effectiveness in the scientific literature is cognitive behavioral therapy (CBT).4,5 The use of sound to reduce reactions to tinnitus (sound therapy) also has considerable evidence backing it.6 For people seeking clinical care for tinnitus, one of the first steps is to complete a tinnitus questionnaire. The questionnaire provides an overall score (an index score) that indicates how much the tinnitus is responsible for causing reactions. An index score will typically range between 0 and 100, with zero meaning no reactions caused by tinnitus and 100 meaning the most severe reactions possible.

Tinnitus Research Consortium In 2003, the Tinnitus Research Consortium (a funding agency for tinnitus research supported by private philanthropy) announced a request for proposals to develop a new tinnitus questionnaire, which it stated would be named the Tinnitus Functional Index (TFI). Nine tinnitus questionnaires were already in existence, so why was

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yet another tinnitus questionnaire needed? The announcement explained that none of the existing questionnaires covered all the ways (dimensions) that tinnitus could affect a person. It also noted that the existing questionnaires differed in many respects (such as formatting, scaling of responses, and wording). Most noteworthy, none of the questionnaires was designed and tested specifically to maximize sensitivity to changes in reactions to tinnitus that may result from therapy. Sensitivity to change resulting from therapy is referred to as responsiveness. The Consortium’s Advisory Board and its chairman (James Snow, MD) stipulated numerous requirements for how the TFI would be constructed, most notably that the TFI would be validated for detecting responsiveness. The importance of responsiveness was not recognized until the 1980s, thus it was likely an unfamiliar concept to the researchers who had developed the previous tinnitus questionnaires. The concept of responsiveness in a questionnaire has since been the subject of extensive research.

Applying for Funding to Develop the TFI Mary Meikle, PhD, had been developing questionnaires at the Oregon Health & Science University (OHSU) Tinnitus Clinic for many years. These questionnaires were used to collect information from thousands of patients who attended the clinic, and data resulting from those www.ATA.org

questionnaires can be viewed online (http://www.tinnitusarchive.org/). The OHSU Tinnitus Clinic was located at the Oregon Hearing Research Center, which was directed by Dr. Jack Vernon, a founding member of the American Tinnitus Association. Dr. Meikle (along with me as co-principal investigator) submitted an application to develop the TFI, which was approved by the Tinnitus Research Consortium. The study was funded in 2004. There is much more to this story, which I will share to highlight Dr. Meikle’s extraordinary dedication to developing the TFI. She had retired from OHSU in 2000, and all of her work writing the proposal and developing the TFI was unpaid. She donated her time and expertise to this project. She was so meticulous in attending to every detail that she missed the deadline to get the proposal sent out by courier. That night she didn’t hesitate to take a redeye flight from Portland that arrived in Maryland the next morning. She continued working on the proposal while on the plane. When she arrived, she went to a local printing store to print and assemble the final documents. Then in a blinding snowstorm (as she described it), she drove across the Chesapeake Bay Bridge to the home of Dr. Snow. She knocked on his door and handed the proposal to him in person. She met the deadline.

Development of the TFI Once funded, development of the TFI required four years of intensive work involving five clinical sites and 20 investigators around the country, and

almost 700 tinnitus patients. The work was conducted in five stages:

Stage 1: Select the initial questions (items) This stage created TFI Prototype 1, which had several requirements: (a) high responsiveness for each item; (b) ability to address all major dimensions of tinnitus distress; (c) brevity; (d) scaling of response options for good resolution among options without being overly complex; (e) ease of use for patients; (f) ease of use for examiners; and (g) no mention of highly negative ideas, such as suicidal thoughts, feelings of victimization or hopelessness, or feelings of despair, dread, or suffering. So as not to reinvent the wheel, the team created the initial items by starting with the nine existing questionnaires. From those questionnaires, 175 items were identified as being most relevant. These items were sent to 17 tinnitus experts who had agreed to judge which dimension(s) each item represented and to rate each item for responsiveness (low, moderate, or high). After more steps, TFI Prototype 1 contained 13 dimensions, and 43 items were judged most relevant in addressing those dimensions and most likely to be responsive to change resulting from therapy.

Stage 2: Test Prototype 1 For stage 2, the goal was to evaluate TFI Prototype 1 with actual patients for responsiveness, the 13 dimensions, and its ability to scale the impact of tinnitus. The best Prototype 1 items would be used in Prototype 2. A total of 327 patients were enrolled (18 percent female) from patient populations at the TINNITUS TODAY SUMMER 2021

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five study sites. Tinnitus interventions varied widely between sites. Eight dimensions of tinnitus reactions were identified: (1) intrusiveness; (2) emotional reactions; (3) interference with concentration; (4) hearing difficulties; (5) sleep disturbance; (6) trouble relaxing; (7) reduced sense of control; and (8) reduced quality of life. Responsiveness was high for treatment-related changes in the TFI index score.

Stage 3: Create TFI Prototype 2 For TFI Prototype 2, 30 items were selected from Prototype 1 that covered all eight tinnitus dimensions and had maximal responsiveness.

Stage 4: Test TFI Prototype 2 Stage 4 used a new sample of 347 patients (18 percent female) to evaluate the 30-item Prototype 2 using methods that were similar to those used to test Prototype 1. The best Prototype 2 items were retained for the final TFI.

Stage 5: Create final 25-item TFI For the final version of the TFI, the bestfunctioning items were selected from Prototype 2, resulting in the removal of five items from the 30-item version. The final TFI includes eight subscales (representing the eight dimensions): Intrusive, Sense of Control, Cognitive, Sleep, Auditory, Relaxation, Quality of Life, and Emotional. Each subscale contains three items, except the Quality of Life subscale, which contains four items. All analyses used for evaluating Prototype 2 were repeated for the final version, using data obtained with the Prototype 2 sample. 40

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Publication of the TFI The next step was to get the study published in a high-quality scientific journal. Dr. Meikle took the lead in writing the article, which was submitted to Ear and Hearing on February 4, 2010. Peer review was performed by four reviewers who listed a total of 75 concerns they had with the article. Responding to each of the 75 concerns was a monumental task. Unfortunately, Dr. Meikle was beginning to experience symptoms of ALS (Lou Gehrig’s disease). She continued working on the article until her deteriorating health made it necessary for the coauthors to assume primary responsibility. The final deadline was February 4, 2011— exactly one year after the original submission. Dr. Meikle contributed right up until a few days before the deadline. During the last few weeks, her daughter Susan was by her side, relaying messages back and forth with the coauthors. On February 4, we started uploading the documents to the Ear and Hearing website, which continued until one in the morning of February 5. I sent an email message to Dr. Meikle informing her that the job was complete, which Susan read to her later. At 3:15 that afternoon, Mary was no longer with us.

TFI Awards and Use Since 2012 Every year, the journal Ear and Hearing announces its Editor’s Award: Outstanding Research in Audiology and Hearing Science. In 2013, they announced that the TFI publication7 had received that award. I, along with one of the article’s coauthors, Harvey Abrams, PhD, accepted the award

at the American Auditory Society Annual Scientific and Technology Conference, in Scottsdale, Arizona. Most of the credit, of course, goes to Dr. Meikle, the lead author and driver of the project from start to finish. When it was published, the TFI was also copyrighted with the copyright owned by OHSU. Because of the popularity of the TFI, OHSU had countless requests to use the TFI both for clinical and research purposes. It also received requests to translate the TFI into different languages, and to date I am aware of the TFI having been translated into at least 20 languages. As a result, the TFI received the “Top Copyright License Award for efforts in the licensing of the Tinnitus Functional Index,” presented at the 2019 OHSU Innovation Awards & Celebration. Because of its responsiveness to treatment-related change, as well as its other properties, the TFI has the potential to become the new standard for evaluating effects of tinnitus, both with clinical patients and in research studies. The TFI is available online, where it can be downloaded and printed (permission to use the copyrighted form is required from OHSU—no cost in most cases): http:// www.formstack.com/forms/?1265642Ir7f92V4rb. The TFI has been used to assess outcomes in numerous clinical trials around the world. Shortly after its publication, the TFI underwent formal evaluation, which validated some of its statistical qualities.8,9 Many other studies have since been published, providing further validation.

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TFI Scores As already described, completing the TFI results in an index score, which can range from 0 to 100. On the basis of data from the original study, the scores were divided (stratified) into five ranges of tinnitus severity. Because of the limited sample of patients, however, these ranges only served as a preliminary guide for interpreting TFI scores.10 A large group of patients experiencing tinnitus was needed to create more accurate reference values for interpreting TFI scores. A recent study was conducted to meet the need of developing reference values for interpreting TFI scores.11 The authors of that study refer to the TFI as “the gold standard in measuring tinnitus severity” (p. 654). They point out many advantages to using the TFI, including its responsiveness. After analyzing TFI scores from over 1,000 patients, they proposed the following grading system for interpreting TFI scores to assess tinnitus severity: • • • •

0–18 = low severity 19–42 = moderate severity 43–65 = upper-moderate severity 66–100 = high severity

The authors note that their findings are “similar to those of Meikle et al. (2012), with the difference relating to the names of the categories rather than the cutoff scores themselves. The current study reinforces the value and robust psychometric qualities of the TFI” (p. 660).11 Data from that

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study indicate that their proposed reference values are independent of a patient’s gender, age, duration of tinnitus, or hearing ability. Whereas these values will assist in evaluating tinnitus severity and recommending options for intervention, they should not be considered absolute with respect to their accuracy. What really matters is how tinnitus affects the individual. The systematic and careful construction of the TFI ensured that the TFI has good statistical properties. However, a TFI score should never take the place of a person’s self-assessment of the degree to which tinnitus is a problem. All of that is to say, the TFI is not perfect in assessing the severity of reactions to tinnitus. Of course, neither is any tinnitus questionnaire!

Change in TFI Scores— How Much of a Change Is “Clinically Significant”? The TFI is considered an “outcome instrument,” meaning it is a questionnaire that is used to evaluate the effectiveness (outcomes) of therapy for tinnitus. Take, for example, a patient who uses ear-level sound generators (maskers) as therapy for tinnitus. The patient completes the TFI before using the devices (baseline assessment), and then again at some point during or after wearing the devices (outcome assessment). The difference between the two scores reveals whether there has been a change in the effects of tinnitus following the therapy. If the TFI index score becomes a lower number, then that would be considered improvement. The score going up (to

a higher number) would indicate a worsening of the tinnitus condition. Interpreting the amount of change in an outcome instrument resulting from therapy is an important field of scientific study. The question is, how to identify the minimum amount of change that would agree with actual change as reported by the patient. With respect to tinnitus, Dr. Meikle and her coauthors suggested that a reduction of at least 13 points in the TFI score indicated significant clinical improvement. This number was calculated in their study patients by comparing the TFI change score in relation to responses to the “global perception of change” question, which asks, “All things considered, how is your overall tinnitus condition now, compared to your first visit to this clinic?” Patients responded on a 7-point scale: • • • • • • •

1 = much improved 2 = moderately improved 3 = slightly improved 4 = no change 5 = slightly worse 6 = moderately worse 7 = much worse.

The 13-point recommendation is most appropriate for a sample of patients who are similar to those used in the TFI study. The amount of change required on the TFI before patients begin reporting that they feel better varies for different samples and interventions. The 13-point criterion, however, is generally appropriate for any sample of care-seeking adults with tinnitus. Determining the TFI meaningful-change score for an individual may be more challenging, but the 13-point criterion remains a good benchmark. Whether assessing TINNITUS TODAY SUMMER 2021

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meaningful change on the TFI for groups or for individuals, it is important to obtain global perception of change measures to most appropriately interpret the TFI change scores. The TFI’s responsiveness and other statistical (psychometric) characteristics have been criticized.12 We responded to those criticisms and explained why we believed these concerns are not justified.13,14 Importantly, the sample population used in the critical U.K. study was not evenly distributed across different levels of tinnitus severity. The majority of participants were only mildly bothered by tinnitus, which did not represent a typical sample of patients receiving therapy for bothersome tinnitus.

A Final Comment I have touted the value of the TFI as an evidence-based instrument for assessing reactions to tinnitus and changes in those reactions that result from therapy. In a previous article I wrote for Tinnitus Today,15 I explained that a key concern when an audiologist conducts a tinnitus evaluation is determining whether the tinnitus is bothersome. It would seem that a tinnitus questionnaire such as the TFI would be sufficient to make such a determination. The concern, however, is that people who have both tinnitus and hearing difficulty often blame the tinnitus for the hearing problem. When this occurs, responses to questions asking about effects of tinnitus can reflect primarily the hearing problem. Such a result then artificially elevates the index score, and it appears the tinnitus is more of a problem than it really is. For this reason, we do not recommend 42

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a tinnitus questionnaire such as the TFI to be used as part of the initial evaluation by an audiologist. Rather, we recommend a routine hearing test plus use of the Tinnitus and Hearing Survey.15 Results from such an evaluation enable the audiologist to determine whether the patient has a tinnitus problem, a hearing problem, or a combination of both. If the patient’s tinnitus reactions require therapy following the audiologic evaluation, then that would be the point at which the TFI would be administered (for a baseline assessment). It would be administered again during or after therapy to assess the effectiveness of the therapy (as an outcome assessment).

Conclusion I have traced the beginnings of the TFI with a focus on its primary developer, Dr. Mary Meikle. Without Dr. Meikle, none of this would have happened. It is amazing that she spent a long and productive career conducting tinnitus research, and that it wasn’t until during her retirement years that she initiated and fulfilled the project to develop the TFI. The project required many years of effort and has resulted in an instrument that is used extensively around the world. I fully endorse the TFI because of how it was developed specifically to be sensitive to change resulting from therapy and because it is so commonly used in clinical trials. For people whose tinnitus is at least a moderate problem, the TFI is very appropriate for this purpose.

1 J. A. Henry, K. M. Reavis, S. E. Griest, et al. (2020). Tinnitus: An epidemiologic perspective. Otolaryngology Clinics of North America, 53, 481–499. 2 J. A. Henry. (2016). “Measurement” of tinnitus. Otology and Neurotology, 37(8), e276–e285. 3 J. A. Henry. (2021). Considering tinnitus management versus cure. Tinnitus Today, 46(1), 10–11. 4 D. E. Tunkel, C. A. Bauer, G. H. Sun, et al. (2014). Clinical practice guideline: Tinnitus. Otolaryngology — Head & Neck Surgery, 151(2 Suppl.), S1–S40. 5 T. E. Fuller, H. F. Haider, D. Kikidis, et al. (2017). Different teams, same conclusions? A systematic review of existing clinical guidelines for the assessment and treatment of tinnitus in adults. Frontiers in Psychology, 8, 206. 6 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. 7 Meikle, M. B., Henry, J. A., Griest, S. E., et al. (2012). The tinnitus functional index: development of a new clinical measure for chronic, intrusive tinnitus. Ear Hear, 33(2), 153-176.” 8 K. Fackrell, D. A. Hall, J. G. Barry, & D. J. Hoare. (2013). UK validation of the Tinnitus Functional Index (TFI): Convergent and discriminant validity. Paper presented at the 7th International Tinnitus Research Initative Conference, Valencia, Spain. 9 N. Chandra. (2013). New Zealand validation of the Tinnitus Functional Index (unpublished dissertation). University of Auckland, New Zealand. 10 J. A. Henry, S. Griest, E. Thielman, G. McMillan, C. Kaelin, & K. F. Carlson. (2016). Tinnitus Functional Index: Development, validation, outcomes research, and clinical application. Hearing Research, 334, 58–64. 11 E. Gos, J. J. Rajchel, B. Dziendziel, et al. (2020). How to interpret Tinnitus Functional Index scores: A proposal for a grading system based on a large sample of tinnitus patients. Ear and Hearing, 42(3), 654–661. 12 K. Fackrell, D. A. Hall, J. G. Barry, & D. J. Hoare. (2016). Psychometric properties of the Tinnitus Functional Index (TFI): Assessment in a UK research volunteer population. Hearing Research, 335, 220–235. 13 J. A. Henry, E. Thielman, & T. Zaugg. (2017). Reply to: Psychometric properties of the Tinnitus Functional Index (TFI): Assessment in a UK research volunteer population. Hearing Research, 350, 222–223. 14 R. L. Folmer. (2016). Reply to: Psychometric properties of the Tinnitus Functional Index (TFI): Assessment in a UK research volunteer population. Hearing Research, 335, 236. 15 J. A. Henry. (2020). Distinguishing between hearing loss, tinnitus, and hyperacusis: A recommended tinnitus-evaluation protocol for audiologists. Tinnitus Today, 45(1), 22–27. 16 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.

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The Remarkable Career of Mary Meikle, PhD The ATA’s First Grant Recipient and Leading Tinnitus Researcher By Susan Griest, PhD

What a privilege and incredible opportunity it was to work almost 30 years with Jack Vernon, PhD, and Mary Meikle, PhD, as part of the Oregon Health & Science University (OHSU) tinnitus team! I was hired by Mary Meikle in 1983 to help develop what would later become the Tinnitus Data Registry (TDR). Over the years, Mary and I worked together analyzing and publishing data collected from over 2,500 patients seen at the OHSU Tinnitus Clinic, the first tinnitus clinic in the United States. When I first began my career at the OHSU Oregon Hearing Research Center (OHRC) (formally known as the Kresge Lab), I became concerned about what might be expected of me as I observed Jack Vernon and Bob Johnson implanting experimental devices in their heads and Mary Meikle taking large doses of aspirin to induce tinnitus. I thought that soon I, too, would be asked to do something similar. That never happened, but I was thoroughly impressed by the extent to which this group was willing to go in order to help people bothered by tinnitus. I was so fortunate to work with Jack Vernon, Bob Johnson, Bob Brummett, and all the others who worked at the OHRC over the years. But it was my honor and good fortune to work most of my career with Mary Meikle. Mary was my mentor, my colleague, and, most importantly, my dear friend. She distinguished herself as a leader in the www.ATA.org

area of tinnitus research, contributing notable advancements in our understanding of tinnitus and setting a higher standard for the way in which we measure the severity of tinnitus and the efficacy of tinnitus treatments. Mary’s work was impeccable and her dedication to the quality of her work was so strong that often she found herself making final revisions to a document right up to the deadline date of submission. She had found a post office nearby OHSU that was open until midnight and quite often would drive there to mail off her grant or report with a just-in-time postmark on the envelope. Once, Mary was working late into the night making final changes to a grant proposal and the end of the deadline day was approaching. She left the lab with plenty of time to make it to the post office before the clock struck midnight, but when she arrived at the post office it was closed. She had forgotten it was a holiday! Not to be deterred, Mary jumped in her car, drove to the airport, bought a plane ticket, flew cross country, and delivered the grant proposal to the front doorstep of the grant administrator. At that time, Jim Snow was the director of the Tinnitus Research Consortium, a nonprofit group that had sent out a request for proposals to develop the Tinnitus Functional Index (TFI). Needless to say, Dr. Snow was very impressed by Mary’s grit and determination to fly across the country to make the deadline and personally submit her grant proposal. Mary’s proposal for the development of the TFI

Susan Griest with Mary Meikle

was accepted, and the rest of the story is history! It was an incredible journey to be part of the heart and soul of Jack and Mary as they pursued a cure for tinnitus. They worked long and hard toward this goal. But Jack also believed that “all work and no play made Jack a dull boy.” He believed a balance of work and play contributed to creativity, longevity, well-being, and the overall success of the tinnitus team. A game of cribbage at lunch or heading to Sam’s Billiards for a game of pool after work all contributed to a sense of belonging and being part of the team. Food was also important at the OHRC: cookies served hot from the oven right to our desk, pie competitions, ice cream bars on a hot summer day, and frequent potlucks, with recipes finding their way into an annual OHRC recipe book. Together, Jack and Mary, who dedicated their lives to the sole purpose of finding relief for people bothered by tinnitus worldwide, contributed so much to our understanding of tinnitus today. Through the development of the OHSU Tinnitus Clinic, the American Tinnitus Association (ATA), tinnitus masking, Tinnitus Data Registry (TDR), Tinnitus Functional Index (TFI), and hours and hours of time spent with thousands of patients who visited the Tinnitus Clinic or called by phone, their work was led by a spirit of compassion and sincere interest in everyone who crossed their paths, not just those burdened by tinnitus but also those fortunate enough to be a part of their team. TINNITUS TODAY SUMMER 2021

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Battery-Powered Tools Fuel Reduction in Hearing Loss, Tinnitus, and Noise Pollution By Marion Patterson and Rich Patterson

Honeybees and noise share one thing in common: They trespass. A farmer can’t let cattle, pigs, sheep, or chickens forage off others’ land without permission, but apiarists aren’t constrained by property lines. Bees gather nectar and pollen from far and wide, usually to the delight of neighbors, who appreciate their pollination services. Honeybees are a welcome trespasser, but noise is not. On mild mornings, we sip coffee on our back deck, soothed by the gentle breeze and the delightful soft serenade of birds. Then — almost like clockwork — a neighbor fires up a lawnmower, a chainsaw, or a leaf blower that sounds like a magnum-force dentist’s drill. The noise assaults our ears and shatters any sense of tranquility, forcing us to retreat indoors. Musician Joan Baez reminded us, “Noise is an 44

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imposition on sanity, and we live in very noisy times.” Exposure to loud noise can lead to tinnitus and hearing loss, but there’s more. Loud sound increases anxiety, raises blood pressure, disrupts sleep, and can cause cognitive impairment. Research continues to uncover additional negative consequences of exposure to unwelcome noise. Nonetheless, our world continues to get noisier. Joseph Wood Krutch (1893–1970), a naturalist and drama critic, noted that with nearly every technological advance noise

increased as a by-product. He was right. For example, when cars and motorcycles replaced horses, people were bombarded by the unpleasant rumblings of traffic noise on what had previously been quiet streets. Today, noise permeates our lives, even in what should be the quiet sanctuary of home. Microwave ovens beep, phones ding, and children’s toys whir. Finding quiet is ever more difficult. There is good news. Krutch would likely have approved of new technology that promises to blunt

“Our new saws and drills were more powerful than our old ones, and we no longer needed to lug around extension cords and hunt for outlets to plug them in.” www.ATA.org

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the outdoor racket. Today’s cordless electric tools run so quietly that their noise rarely invades the quiet of a neighbor’s yard. “As an audiologist, I always encourage the prevention of hearing loss and tinnitus and inform people about loud noise hazards,” says Paige Wydola of Heartland Hearing Center in Cedar Rapids, Iowa. “Using quiet tools and equipment helps protect hearing health.” About ten years ago, we bought an array of then new-to-the-market cordless battery-powered carpentry tools. They were expensive, and we worried that they would lack the power of comparable corded electric ones. The concern was unfounded. Our new saws and drills were more powerful than our old ones, and we no longer needed to lug around extension cords and hunt for outlets to plug them in. Our new carpentry tools were so effective that soon we replaced our gas lawnmower, chainsaw, and hedge trimmer with ones fueled by electricity from rechargeable batteries. It was a change that we appreciate daily. “In comparison to gas-powered lawn and garden tools, batterypowered equivalents can have all the power of gas but are quieter,” says Gerry Barnaby, director of excitement at EGO, a company that sells a variety of battery-powered outdoor machines. “They are much more economical to operate, require little maintenance, produce no emissions, and start at the push of a button.” Before we switched to batterypowered equipment, we never ran our mowers or trimmers in the early morning out of respect for sleeping neighbors or those simply enjoying www.ATA.org

moments of stillness. That’s no longer a concern because even our closest neighbor can’t hear our quiet machines. As Barnaby states, the advantages of battery-powered machines extend beyond their low decibel levels. For instance, our mower lacks spark plugs and oil and fuel filters, so there’s nothing to replace and no need to store or burn gas. No longer do we breathe mower fumes. Yanking a gas engine’s starter rope — the bane of people with shoulder issues — is also eliminated. Just pop in a battery, push a button, and the tool instantly goes to work. We’re able to mow a quarter-acre lawn on one battery charge. Our spare battery charges faster than the power is drained from the one in use, so we’re able to work all day, if necessary, by alternating batteries. The photovoltaic solar electric system on our garage roof quietly creates electricity to charge batteries. It also powers our home’s lights, washing machine, and electronics. The surplus electricity the system produces flows from our home to the electric grid, softening our monthly utility bill. As quiet as our electric machines are, they don’t go unnoticed by neighbors. A few years ago, a neighbor saw — but couldn’t hear — us mowing and asked if he could borrow our battery-powered lawnmower. The next week, he sold his gas mower and bought an electric one. Next, he invested in an electric trimmer and chainsaw! Then the guy down the street followed suit. Noise that

once invaded our property from their machines has vanished. Although our neighborhood is becoming quieter, many families still use gas machines. We expect a gradual conversion as more people discover the effectiveness and ease of use of battery-powered equipment. It helps that battery-powered tools are squeezing out their noisy gaspowered counterparts on gardening and lawncare equipment aisles across the nation. Consumers have choices. As the trend continues, more people are more likely to make the switch as manufacturers develop ever more types of quiet, laborsaving batterypowered tools. We look forward to the Sunday morning when we hear only the gentle sounds of wildlife and the breeze as we sip coffee on the back deck, even as our neighbors mow their lawns. Rich Patterson is a member of the Circle of Conservation Chiefs and a past Outdoor Writers Association of America (OWAA) board president. He and Marion Patterson, both OWAA members, own Winding Pathways, LLC, a business devoted to encouraging people to create wondrous yards. For more information, visit www. windingpathways.com.

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 PERSONAL STORY

Was a Mild Covid-19 Infection Behind Blaring Tinnitus? By Dustin Godwin

About 14 years ago, I was hit in the head with a softball — a sudden fluke accident that robbed me of the ability to enjoy silence. For more than a decade, my tinnitus was mild, manageable, and confined to one ear. I could only hear it when the external environment was completely quiet. In the late summer of 2020, I was diagnosed with Covid-19. My symptoms were extremely mild. I felt a little achy, had a low fever, and that was about it. I told people it wasn’t as bad as the flu! Fast-forward to November 28 — almost three months to the day that I contracted the virus — I woke up to the sound of a blaring siren in my ear. My tinnitus was louder than it had ever been. That struck me as strange and it was annoying, but I thought it would be short-lived. A few days passed, but it got worse. A few weeks went by, and it became debilitating. I now had a siren in my head 24/7. The tinnitus was in both ears, not just my left ear. I wondered how this was possible. I wondered if it was the weather. I wondered if it was mold in the house. I wondered if my ears were clogged. My mind looked everywhere for an answer.

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As my concerns grew, so did my symptoms. Not only did I have a siren blaring in my head, I began suffering from anxiety, depression, paranoia, and insomnia. The insomnia got so bad that I was only sleeping two to four hours per night. Finally, my insomnia pushed me to a breaking point. I went four straight nights without sleep. My wife, who is a clinical dietitian, intervened, whisking me off to the emergency room. Doctors ordered a CT scan. They took blood samples. All in all, I was there about seven hours with nothing to show for it other than a big medical bill. At this point, I had quit my job, I was barely eating, I wasn’t talking to family and friends. Nothing made me smile. I started thanking God for the great life that I had, but I couldn’t go on like this. I was taking as many

antidepressants as allowed. I was taking Ambien, trazodone, melatonin, and other sleeping pills on a nightly basis. My wife stayed strong, but our relationship was going through something neither of us could have ever imagined. Without family and friends nearby, she seemed to be on the verge of a breakdown every single day. There was nothing I could do; I was in a ball on the floor, crying and praying for relief. In the days and weeks that passed, I had looked everywhere for help. I saw three therapists. I saw a psychiatrist. I saw a neurologist, who ordered an MRA and MRI to look for a cause for the unrelenting sound. I saw two ENTs. I saw a priest. I saw an audiologist. I reached out to the American Tinnitus Association (ATA). The only thing that really made me cling to hope was when I talked to Joy Onozuka and Sharzad Cohen, AuD, both of whom are associated with the ATA. They were the first people to understand what I was dealing with and share ideas on what things I could do to change my situation. There was a light at the end of the tunnel. Joy made it clear that I wasn’t alone. Dr. Cohen made it clear that it would get better. The two of them put things into perspective, and things started to shift.

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PERSONAL STORY

From the end of November until the beginning of March, I lived in my own personal hell. Almost as quickly as it came, the tinnitus faded. I started getting better sleep. I started eating better. With the help of my psychiatrist, I was able to find the right antidepressant. With the help of my therapist, I began talking things out. With the help of my wife, I started doing things I loved again. I started getting healthier: mind, body, and soul. I started to discover that life was worth living again. Don’t get me wrong, the tinnitus is still in my right ear and still slightly elevated in my left ear, but I now wake up with a plan and a purpose. I have hope that the tinnitus will either go down, or I will continue to manage it better. For me, cognitive behavioral therapy has helped immensely. At the very least, I will, well, get used to it. I can promise two things: first, having tinnitus sucks! It’s something that doesn’t have a cure. It’s something most people will never understand. It’s something that will always be there. Second, everything

can be okay! You will learn to manage it better. You will learn more about yourself and your tinnitus. What makes it worse? What makes it better? My advice is to write things down. There’s no getting around it, tinnitus almost killed me. Tinnitus has also made me a better person. It made me cut out the bad things in my life. I was and am so terrified that my bad habits may contribute to my agony. Some of the things that helped me include the following: • • • • • • • • • • • •

Praying Working out Eating healthy Getting a good night’s sleep Avoiding alcohol, sodium, caffeine, and sugar Meditating and yoga Setting goals Keeping a routine/schedule Staying away from quiet Taking walks Talking to a therapist Surrounding myself with loved ones

• • • • • • •

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Doing things I love Avoiding loud music Creating a sleep routine Staying positive Being outside Using lavender Staying educated about tinnitus

If you’re unsure of where to turn or want a few great ideas, reach out to the ATA. Dustin Godwin developed tinnitus following a softball injury 14 years ago. After spending 10 years in finance, he decided to pursue a master’s degree in either counseling or social work. He looks forward to helping others who suffer from tinnitus and/or hearing loss. Originally from St. Louis, Missouri, Dustin and his wife, Ellen, love watching the St. Louis Cardinals and the St. Louis Blues. They currently live in Winston-Salem, NC, where they enjoy going to breweries, wineries, and concerts. They also enjoy traveling, cooking, hiking, and biking together. When they’re not out exploring the city, they love spending time with their dog, Sadie.

What’s Your Story? 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 your tinnitus has been particularly problematic this year because of the stress associated with the pandemic, 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 September 30. Suggested word length is between 500 and 800 words.

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TINNITUS TODAY SUMMER 2021

 SCIENCE & RESEARCH NEWS

The Ongoing Search for Links Between Covid-19 and Ear Health By John A. Coverstone, AuD

Since Covid-19 was officially recognized as a pandemic, physicians and audiologists have received reports of hearing and balance symptoms that were potentially related to the disease. Some of the data on this relationship were published in journals, and many of those publications were expedited along with other Covidrelated research. This was done to quickly build a body of evidence to aid scientists and physicians in decisionmaking about patient care, public health, and prevention of infection from SARS-CoV-2, the virus that causes Covid-19 disease. Ibrahim Almufarrij, PhD candidate, and Kevin Munro, PhD, from Manchester University in the United Kingdom performed a review of articles describing the relationship of Covid-19 to auditory and vestibular (inner ear balance system) symptoms.1 Their summary and conclusions were published online in March 2021 by the International Journal of Audiology.

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As reported by the authors, symptoms that are possibly related to Covid-19 include various forms of hearing loss, tinnitus, hyperacusis, vertigo, and otalgia, or ear pain. Almufarrij and Munro included articles in their review if any of these symptoms were confirmed or suspected. They first performed database searches of medical journals and then used bibliographies from the identified articles to perform secondary searches for additional publications meeting their criteria. Of the 56 articles that were ultimately reviewed, about half contained case studies (a single person) or case series (an individual tracked over time), with the rest being cross-sectional studies (analysis of conditions or relationships across many people). Publications were rated for quality of evidence and analyzed according to condition(s) reported: hearing loss, tinnitus, vertigo, or otalgia. An “other” category included hyperacusis (hypersensitivity to sound), phonophobia (fear of sound), ear congestion, and ear

fullness. These “other” conditions were only reported in a few studies, however. Hearing loss was reported in 17 case reports and one case series, representing 28 total individuals. Thirteen cross-sectional studies reported hearing loss, although many used questionnaires rather than performing hearing tests. Questionnaires assess self-reported

“This number must again be viewed with caution, because selfreporting was typically used with no control group for comparison.”

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SCIENCE & RESEARCH NEWS 

hearing difficulty, which is very subjective. Three studies included hearing tests and only one of those showed a significant difference between people with Covid-19 compared to people without Covid-19 (controls). The prevalence of hearing loss was calculated across papers and found to be 7.6 percent. This number should be viewed with caution, however. As the reviewers point out, most studies used selfreporting methods, which introduces large potential bias. Participants may be subject to recall bias where they incorrectly attribute hearing loss to more recent events. They may also be more aware of hearing difficulties because of increased use of masks by people around them. Sudden hearing loss was specifically investigated in a few papers, with mixed results. Some found an increase in cases of sudden hearing loss during the pandemic, whereas others found a decrease. Therefore, data on all forms of hearing loss related to Covid-19 should be considered inconclusive at this point. Eleven papers and 15 crosssectional studies investigated tinnitus. Descriptions of tinnitus, however, varied, making comparisons between studies difficult. The authors also noted that it was not always clear whether existing or new tinnitus symptoms were being described. Tinnitus was the most highly investigated condition and the average prevalence across papers was 14.8 percent. This number must again be viewed with

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caution, because self-reporting was typically used with no control group for comparison. Without a control group, incidence (new onset) of tinnitus cannot be confidently studied because we don’t know how many people without Covid-19 developed tinnitus or had tinnitus worsen. Therefore, symptoms of tinnitus may have occurred as a result of other factors, such as isolation or living in a world that is generally less noisy (conditions that tend to make tinnitus more noticeable). It is also possible that tinnitus was perceived to be more bothersome as a result of increased mental health problems such as anxiety, depression, or emotional distress, not to mention lower availability of counseling services when offices were closed. Vertigo was described in nine case studies and 11 cross-sectional studies and was the least common symptom reported. Studies were only included if spinning vertigo was reported, as this is strongly linked to vestibular/ inner ear function. Many of the published studies used questionnaires to indicate presence or history of vertigo. The prevalence of vertigo across papers was calculated to be 7.6 percent, although it was noted that many studies included patients with dizziness (no spinning sensation). This artificially increases prevalence because dizziness may arise from a wide variety of conditions that are not related to the ear. When studies including dizziness in their analysis

were excluded, the prevalence decreased to 3.4 percent. Ear pain was reported in five case studies and in nine cross-sectional studies. This is a rather broad description that could encompass many conditions, although four case studies (11 patients) indicated middle ear infections (otitis media) and one described an outer ear infection (otitis externa). The combined prevalence of ear pain was 13.1 percent. In summary, the reviewers found that currently published studies contained largely low-quality evidence. Researchers relied heavily on questionnaires and usually did not use control groups to compare those who became infected with those who did not. Therefore, many other factors may have contributed to perceived onset or worsening of ear problems. Because these studies were specifically conducted on pandemic data, participants’ lifestyles, occupational activities, and recreational activities were very different compared to prepandemic times. It is not surprising that comparing pandemic with prepandemic data only shows weak relationships. Further and better controlled research is warranted in this area to better determine the true effects of Covid-19 on the auditory and vestibular systems. 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. Advance online publication March 22, 2021. doi:10.1080/14992027.20 21.1896793

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 SCIENCE & RESEARCH NEWS

Considering Covid-19, Vaccines and Tinnitus Answered by Colleen Le Prell, PhD

Reports of tinnitus following Covid-19 infections and vaccination against Covid-19 have understandably raised concerns within the tinnitus community about the cause and the probability of experiencing a spike or newly onset tinnitus. For individuals who have struggled with tinnitus, such reports have contributed to vaccine hesitancy. To learn more about what researchers are considering about such cases, the American Tinnitus Association reached out to Colleen Le Prell, PhD, a researcher at the University of Texas at Dallas, in Richardson, Texas. Colleen Le Prell, PhD: It is very difficult to comment on this as there are no published data on the incidence of new tinnitus cases after vaccination. There is a report that was published in May 2021 by Formeister et al.1 investigating the incidence of new hearing loss after vaccination using data from the Vaccine Adverse Event Reporting System (VAERS).* That report found the incidence of new hearing loss cases to be no higher than, and perhaps less than, the rate at which new cases occur in the general population. It is possible that

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some cases go unreported, but the data are reassuring in that the vaccine was not associated with hearing loss in this report. The Formeister et al. report did not investigate the incidence of tinnitus or balance disorders, and we do not know if there will be an increase in the incidence of these other disorders relative to the general population. Additional research is warranted to understand whether new cases in vaccinated individuals occur at a higher rate than in the general population. Joy Onozuka: From your research and experience, do you believe inflammation is the primary cause of auditory issues related to Covid-19? CL: The literature to date suggests that an increased inflammatory response, sometimes referred to as a cytokine storm, is responsible for the damage to many tissues and corresponding health issues associated with Covid-19. There is a significant role for the inflammatory process in the inner ear after noise and other insults, and it is reasonable to speculate that an inflammatory response could be responsible for the auditory issues that emerge during or after Covid-19 infection. There are no

data that directly assess the cause of inner ear pathology at this time. These data all come from Covid-19 cases, not from vaccinated individuals. JO: Is it reasonable to assume that as the body’s immune system calms down in response to infection, tinnitus should resolve on its own? CL: Tinnitus has been suggested to be the result of outer hair cell loss, neural loss, hyperactivity of the neurons in the auditory periphery or central auditory system, and various other pathological conditions. We do not yet know what the cause of tinnitus associated with Covid-19 might be. A small study by Mustafa2 reported decreased otoacoustic emissions, suggesting outer hair cell pathology, which has been suggested in those with asymptomatic cases, but the level of evidence is still weak and tinnitus was not discussed as part of that report. Outer hair cells do not have a regenerative process, and if loss of outer hair cells were the cause of tinnitus, it is possible that tinnitus could be persistent. In contrast, the peripheral auditory nervous system has the potential for repair (regrowth of the neurons that connect to the inner hair cells), and thus tinnitus

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SCIENCE & RESEARCH NEWS 

might be predicted to be temporary if the peripheral nervous system has transient damage. Audiologists have various clinical tests that probe the function of different cells in the cochlea, and it is likely that new research studies will provide insights into the specific cells affected by Covid-19 and the duration of tinnitus deficits in the subset of patients reporting this symptom. As we move ahead, medical record reviews and audiology patient databases could be used to investigate the incidence of new symptoms in patients who were or were not vaccinated. JO: So, it’s too early in our understanding of Covid-19 and its many impacts on the body to draw conclusions? CL: Yes, we are too early in our understanding of Covid-19 to draw any conclusions. JO: Understanding that researchers don’t have access to audiograms of patients prior to contracting Covid-19 or getting the vaccine, will we ever be able to truly understand the link? The assumption here is too few people have had recent audiograms, which would enable researchers to determine hearing loss prior to becoming infected by the virus. CL: Right now, most of the case studies and retrospective reviews come from hospitalized patients with severe symptoms. As established

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patients return to their audiologists for continued care, new studies comparing the trajectory of hearing loss in patients who were or were not affected by Covid-19 will be possible, and improved understanding of these relationships will be possible. Although noise would need to be treated as a confounding factor, one could also imagine studies on the trajectory of hearing loss in noiseexposed workers who were or were not affected by Covid-19. New cycles of national epidemiological studies such as the National Health and Nutrition Examination Survey (NHANES) will almost certainly provide insights into risk factors for tinnitus, including Covid-19 infection or vaccination as new data cycles are initiated. Finally, there are longstanding longitudinal studies that have followed health and hearing measures in large populations over time and the incidence of new hearing loss, tinnitus, and/or balance disorders could be investigated in patients who were either infected with Covid-19 or vaccinated for Covid-19. New data are certain to emerge in the coming months and years.

Colleen Le Prell, PhD, is the Emilie and Phil Schepps Professor of Hearing Science at the University of Texas at Dallas, and Chair of the Department of Speech, Language, and Hearing. She has received research funding from NIH, the DoD, various foundations, and industry contracts. Clinical, translational, and applied research in her laboratory is directed at understanding and preventing noise-induced hearing loss. Le Prell previously served as President of the National Hearing Conservation Association and actively contributes to multiple professional organizations working towards the mission of hearing loss prevention. 1 E. J. Formeister, W. Chien, Y. Agrawal, J. P. Carey, C. M. Stewart, & D. Q. Sun. (2021). Preliminary analysis of association between COVID-19 vaccination and sudden hearing loss using US Centers for Disease Control and Prevention Vaccine Adverse Events 2 M.W.M. Mustafa. (2020). Audiological profile of asymptomatic Covid-19 PCR-positive cases. Am J Otolaryngol. 41(3):102483. doi: 10.1016/j. amjoto.2020.102483. Reporting System Data. JAMA Otolaryngoly — Head & Neck Surgery. Advance online publication May 20, 2021. doi:10.1001/jamaoto.2021.0869

* Established in 1990 and comanaged by the CDC and FDA, VAERS serves as an early warning system on the safety of vaccines authorized or licensed for use by the U.S. Food and Drug Administration. VAERS accepts reports from anyone, but a report does not mean that a vaccine caused an adverse event. Limitations of the system include underreporting, inconsistent data quality, and misattribution. If reports reveal a pattern, suggesting a vaccine might be causing a problem, other vaccine safety monitoring systems conduct follow-up studies.

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 TINNITUS RESOURCES

Reframing Tinnitus Through Hypnotherapy By Christine Deschemin

Modern-Day Hypnosis A blue-clad anesthesiologist injects a local anesthetic into the patient’s chest where the scalpel will make an incision. The patient is calm and can talk during the surgery. A few minutes prior, the same professional helped the patient relax and release stress through hypnotherapy. The medical team helped him imagine what he enjoys most: traveling and gardening. The patient is awake with his eyes closed. A nurse continues to guide him in his hypnotic journey while surgery takes place. It isn’t minor surgery. Today, the surgeon is operating on the patient’s heart, without morphine. Surgery with hypnosis happens multiple times a day in France, where hypnotherapy is increasingly replacing anesthesia. The scene described here echoes the first reported use of hypnosis for surgery in the Western world by the Scottish surgeon James Esdaile. He performed thousands of surgeries in the mid-1800s without anesthesia and was one of the earliest known practitioners of hypno-analgesia.

Beyond Hollywood clichés about hypnosis, hypnotherapy has scientific credence around the world. Hypnotherapy has been approved by many medical and psychological associations, including the American Psychological Association (APA) as early as 1958 and the American Psychiatric Association in 1961. Among the APA’s list of uses of hypnotherapy are pain management, depression and anxiety, stress, phobias, childbirth, and gastrointestinal problems.1 Medical professionals sometimes refer to hypnotherapy as “medical hypnosis.” A few years ago, that phrase might have raised eyebrows, but nowadays reputable institutions, such as the Mayo Clinic, have documented the various uses of medical hypnosis.

The Complications of Tinnitus The experience of tinnitus differs greatly among people, with some barely bothered by it and others driven to suicidal ideation. Even though hypnosis has been used for decades to help people with tinnitus, research on its efficacy as a tinnitus treatment is lacking. Hence, patients

are more likely to be encouraged to try hypnotherapy for stress, difficulties concentrating, sleep issues, depression, and anxiety, which often accompany bothersome tinnitus.

What Is Hypnosis? Hypnosis is a state of focused awareness similar to what you experience many times during a day. Athletes call it “flow.” Other high performers describe it as being in the zone. It is a very pleasant state to be in. Time flies as you are fully engaged in what you are doing. You do not need to achieve a special feat to enjoy the benefits of hypnosis. For instance, if you are reading a book and are so engrossed in the story that you do not notice what is happening around you, chances are that you are in a state of hypnosis or self-hypnosis. I use the words interchangeably because every state of hypnosis is a state of self-hypnosis. People can enjoy that natural state spontaneously while reading a book or watching a movie or playing a sport. And when someone is guided by a hypnotherapist or an anesthesiologist

Conflict-of-interest notice to readers: The app mentioned in this article was developed by the author and can be accessed for a fee. The author therefore stands to benefit financially if Tinnitus Today readers decide to purchase access to it and/or seek services listed on her website.

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trained in hypnotherapy, they can more easily enter that hypnotic state. When functional magnetic resonance imaging (fMRI) was invented in 1990, it ushered in a better understanding of hypnosis. Research showed that hypnosis is not placebo; it is real. Think of it as a way to rebalance different parts of your brain. Research shows that in a hypnotic state, the insula in the brain makes more connections with the executive center (dorsolateral prefrontal cortex), which would explain the enhanced somatic and emotional control during hypnosis.2 In other words, hypnosis allows us to leverage the mind–body connection. Though mindfulness and meditation have many benefits, they are used for general well-being, and only hypnosis has been allowed for use in operating rooms, which speaks volumes.

Studies on Hypnotherapy for Tinnitus Some studies have shown that hypnosis and, more importantly, self-hypnosis can be effective therapy for tinnitus. In 1990, researchers compared self-hypnosis with use of a brief auditory stimulus.3 A third group was not given any treatment. For the self-hypnosis participants, 73 percent experienced reduction of tinnitus during the sessions compared with 24 percent in the group that received brief auditory stimulus. The ratio of 3 to 1 in favor of self-hypnosis improved over the next two months: the participants who learned selfhypnosis reported improvement. The other groups did not. Two other studies released in 2007 from different research teams in Germany and Belgium showed that hypnosis was a promising treatment. www.ATA.org

The Belgian study concluded that 35 participants with tinnitus saw their tinnitus score improve when they learned to modulate the sound intensity and the tinnitus intensity within four to nine hypnosis sessions.4 The German study administered a 28-day treatment and measured the tinnitus severity before therapy, at the time of discharge, 6 months and 12 months later using the Tinnitus Handicap Inventory (THI).5 This study was much larger and included 393 patients. More than 90 percent and 88 percent of the patients with, respectively, subacute or chronic tinnitus experienced improvements. The assessment remained stable at the 6- and 12-month follow-ups. A study conducted in 2012 assessed the efficacy of hypnotherapy on tinnitus severity before treatment, after 1 week, after 3 months, and after 6 months.6 The 39 participants reported improvement in quality of life. Apart from the first study, which had a small sample group, the other studies were based on large enough groups to produce statistically significant results. Nonetheless, hypnosis for tinnitus was not included in the American Academy of Otolaryngology — Head & Neck Surgery Foundation’s Clinical Practice Guideline: Tinnitus, which was published in 2014, due to lack of adequate research.

Stress and Tinnitus Stress can modulate the perception of tinnitus, which has led many researchers to evaluate psychological treatment approaches to tinnitus, which include hypnotherapy and cognitive behavioral therapy. Stress stems from the perception of risk,

real or imagined. A stress reaction happens based on a series of beliefs we hold about the world around us. Short periods of mild stress are neither good nor bad. Stress can spur you to take action. But when it’s prolonged, it can cause a number of physiological changes that negatively impact health. In severe cases, a person with tinnitus often views tinnitus as a threat and spends considerable time focusing on it. In hypnotherapy for stress management, we focus on the root cause of the issue.7 A hypnotherapist will prompt you to express your thoughts and to take advantage of our natural selective attention to let go of that stress. In hypnosis, you are more likely to accept suggestions you crafted for yourself. These suggestions are created during your first session based on your history and goals.

What Makes a Hypnosis Session Successful? First, the patient must be willing to re-create that state of focused awareness. Hypnosis works when you learn to use your brain in ways that work for you. No one else can do that work for you. Second, the patient must choose the right hypnotherapist. Skills are obviously a prerequisite. In some places, such as the United Kingdom, there are no regulations governing who can call themselves hypnotherapists. In most of continental Europe, regulations are in place that ensure competency and best practices. In the United States, the situation differs from state to state. So, if you decide to see a hypnotherapist for tinnitus, do your research by asking where the hypnotherapist was certified and TINNITUS TODAY SUMMER 2021

 TINNITUS RESOURCES

licensed, if they had postgraduate training, which professional organizations they belong to, length of practice, fees, and insurance coverage. In addition to skills and experience, you need a strong rapport with the therapist, because you have to actively work with that person. You can only follow a guide if you feel comfortable doing so. You can also use self-hypnosis audios created by skilled hypnotherapists.8 But beware of apps that do not identify their creators. Many people seem comfortable listening to a meditation delivered by an unknown individual, but when it comes to hypnotherapy — a therapy approved by medical practitioners — you need to know who is behind it. Repetition is also key. Many times, a skilled hypnotherapist can help a person in one session, but it might take a few more sessions for others, depending on the person’s ability to reach a heightened state of awareness.

Christine Deschemin is a peak performance coach, certified hypnotherapist, and founder of the Renewed Edge Hypnotherapy Centre in Hong Kong. After a career in aeronautical engineering and finance, she foresaw the increased need for solution-focused wellness and became a certified hypnotherapist. She opened the first hypnotherapy center in Hong Kong. She also created the first self-hypnosis app in Asia, UpNow. Her UpNow.com website includes selfhypnosis audios. 1 Hypnosis today: Looking beyond the media portrayal. American Psychological Association. https://www.apa.org/topics/hypnosis/media 2 Heidi Jiang, Matthew P. White, Michael D. Greicius, Lynn C. Waelde, & David Spiegel. (2017). Brain activity and functional connectivity associated with hypnosis. Cerebral Cortex, 27(8), 4083–4093. https:// doi.org/10.1093/cercor/bhw220 3 Joseph Attias, Zecharya Shemesh, Chaya Shoham, Amnon Shahar, & Haim Sohmer. (1990). Efficacy of self-hypnosis for tinnitus relief. Scandinavian Audiology, 19(4), 245–249. doi:10.3109/01050399009070779 4 A. Maudoux, S. Bonnet, F. Lhonneux-Ledoux, & P. Lefebvre. (2007). Ericksonian hypnosis in tinnitus therapy. B-ENT, 3(Suppl. 7), 75–77. 5 U. H. Ross, O. Lange, J. Unterrainer, & R. Laszig. (2007). Ericksonian hypnosis in tinnitus therapy:

Effects of a 28-day inpatient multimodal treatment concept measured by Tinnitus-Questionnaire and Health Survey SF-36. European Archives of Otorhino-laryngology, 264(5), 483–438. doi:10.1007/ s00405-006-0221-9 6 Z. M. Yazici, I. Sayin, G. Gökku , E. Alatas, H. Kaya, & F. T. Kayhan. (2012). Effectiveness of Ericksonian hypnosis in tinnitus therapy: Preliminary results. B-ENT, 8(1), 7–12. 7 See this article on author’s website: Transforming your life with hypnosis downloads for stress and anxiety. UpNow. https://upnow.com/transformingyour-life-with-hypnosis-downloads-for-stress-andanxiety/ 8 For example: Heal yourself with self hypnosis audios. UpNow. https://upnow.com/

To read a personal story about the use of hypnotherapy for tinnitus, see “High-Intensity Tinnitus and Little Help: Finding My Way Back to Myself,” by Robert Travis Scott, in the Winter 2020 issue of Tinnitus Today, which outlines how a combination of therapy and hypnosis resulted in relief from bothersome tinnitus.

Apps to Aid Hypnosis and Meditation Harmony Hypnosis Meditation | Harmony Hypnosis Ltd | free, premium $7.99 monthly; iOS and Android Draws on hypnotherapy tools to address specific types of stress. Meditation sequences range from several minutes to an hour.

Mesmerize - Visual Meditation | Rockwell Ventures | $12.99 monthly; iOS and Android Unique audio-visual meditation app that combines calming psycho-acoustic music with guided meditations.

UpNow Hypnosis | Renewed Edge | $19.99 monthly; iOS and Android Promotes increased relaxation and adoption of behaviors that increase one’s sense of wellbeing.

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HEALTHCARE PROVIDERS

Spotlight on Patient Providers Professional Members Listing current as June 28, 2021

When making an appointment, please mention that you learned of the provider from the ATA, thereby ensuring that providers understand the importance of being a part of the ATA’s tinnitus patient provider network.

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 Madison, AL Susan Sheehy, AuD Alabama Hearing Associates Madison, AL

Alaska Emily McMahan, AuD, CH–TM Alaska Hearing & Tinnitus Center Anchorage, AK

Arizona Lynn Callaway, BC–HIS Affordable Hearing Solutions Green Valley, AZ Emily Densmore, AuD Sound Relief Hearing Center Scottsdale, AZ Judy Huch, AuD Oro Valley Audiology, Inc. Oro Valley, AZ www.ATA.org

Rachael Luckett, AuD Sound Relief Hearing Center Scottsdale, AZ

David Ferrera, CEO Sonorous Medical Lake Forest, CA

Sarah Pitrone, AuD Sound Relief Hearing Center Mesa, AZ

Gregory Frazer, AuD Pacific Hearing & Balance Center, Inc. Los Angeles, CA

David Velenovsky, PhD University of Arizona Tucson, AZ

Jennifer J. Gans, PsyD Mindful Tinnitus Relief San Francisco, CA

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 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 Jean M. Deiss, AuD, CH–TM VA Northern California Health Care System Martinez, CA David DeKriek, AuD Fidelity Hearing Center Cerritos, CA

Amit Gosalia, AuD West Valley Hearing Center Woodland Hills, CA Jennifer D. Hill, LPC Healing Hearts Counseling Encinitas, CA Tracy Peck Holcomb, AuD The Hearing and Speech Center of Northern California San Francisco, 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 Joshua Nitenson, AuD, CH–TM Kaiser Permanente Sacramento, CA Marni Novick, AuD, CH–TM Silicon Valley Hearing, Inc Los Gatos, CA Bruce Piner, AuD Hearing and Balance Center Encino, CA

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HEALTHCARE PROVIDERS

Samantha Ramirez, AuD Kaiser Permanente Redwood City, CA

Alison LaBrec, AuD Sound Relief Hearing Center Golden, CO

Maura Chippendale, AuD, CH–TM Chippendale Audiology Cape Coral, FL

Dena Riso, AuD Peninsula Hearing Center, Inc. San Diego, CA

Abigail McMahon, AuD Sound Relief Hearing Center Fort Collins, CO

Melissa Kipp Clark, AuD Suncoast Hearing Services Plus Bradenton, FL

Jane Rosner, AuD West Valley Hearing Center Woodland Hills, CA

Leah Mitchell, AuD Sound Relief Hearing Center Westminster, CO

Ali Danesh, PhD Labyrinth Audiology Boca Raton, FL

Mimi Salamat, PhD Dr. Mimi’s Audiology Clinic Walnut Creek, CA

Natalie Phillips, AuD Advanced Otolaryngology & Audiology Fort Collins, CO

Ericka DeVore, AuD All About Hearing/Lake Audiology & Hearing Aids Longwood, FL

William Stubbeman, MD TMS Psychiatry Los Angeles, CA

Drew Price, AuD Sound Relief Hearing Center Denver, CO

Kelly J. Dyson, AuD Suncoast Audiology, LLC Largo, FL

Christopher Sumer, NBC–HIS Coastal Hearing Aid Center Encinitas, CA

Julie Prutsman, AuD Sound Relief Hearing Center Highlands Ranch, CO

Melodi Fehl, MS ENT and Allergy Associates of Florida Boca Raton, FL

Benjamin Thompson, AuD Pure Tinnitus Berkeley, CA

Megan Read, AuD Sound Relief Hearing Center Highlands Ranch, CO

Lisa Gascay, AuD, CH–TM Rainbow River Hearing & Balance Inc. Dunnellon, FL

Brian Worden, MD Kaiser Permanente Woodland Hills, CA

Kenzie Reichert, AuD Sound Relief Hearing Center Highlands Ranch, CO

Karah Gottschalk, AuD NOVA Southeastern University Ft. Lauderdale, FL

Jackie Smith, AuD Sound Relief Hearing Center Highlands Ranch, CO

Megan Labbe, AuD St. Luke’s Cataract and Laser Institute Tampa, FL

Mandi Solat, AuD, CH–TM Audiology Services & Hearing Aid Center Laklewood, CO

Sara Miers, AuD Jacksonville Speech & Hearing Center Jacksonville, FL

Robert M. Traynor, EdD, CH–TM Fort Collins, CO

Kelly Murphy; AuD, CH–TM Murphy Hearing Aids of Sarasota Sarasota, FL

Colorado Brian Bennett, BC–HIS Colorado Hearing Montrose, CO Lindsay Collins, AuD Sound Relief Hearing Center Centennial, CO Terry Cummings, AuD, CH–TM Columbine Audiology and Hearing Aid Center Sterling, CO Samantha Ewing, AuD Sound Relief Hearing Center Westminster, 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 Tony Kovacs, AuD, CH–TM Sound Relief Hearing Center Fort Collins, CO

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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

Florida Indira Alvarez, AuD Palm Coast Hearing Center Palm Coast, FL Anne Carter, PhD, CH–TM Pasadena Hearing Care South Pasadena, 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

www.ATA.org

HEALTHCARE PROVIDERS

Georgia Laura Barber, AuD, CH–TM Augusta University Health–Audiology Associates Augusta, GA Christopher V. Campellone, HIS GoToHearing Gainesville GA Sonia Hamidi, AuD ENT Institute Buford, GA Jan Henriquez, AuD At Home Hearing Woodstock, GA Brian K. Jones, MEd Greater Atlanta Hearing Inc. Cumming, GA Liz Ramos, AuD, CH–TM ENT of Georgia/Advanced Hearing Atlanta, GA Nikki Weaver, AuD Fayette Hearing Clinic and Coweta Hearing Clinic Peachtree City, GA Melissa Wikoff, AuD, CH–TM Peachtree Hearing Marietta, GA

Idaho Christine Pickup, AuD Mt. Harrison Audiology & Hearing Aids, LLC Rupert, ID Tosha Strickland, AuD Strickland Ear Clinic Meridian, ID

Illinois Steve Bonzak, MS Health Traditions Chicago, 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 Stephanie Gutzmer, AuD Wholistic Hearing Care Wheaton, IL Lori A Halvorson, AuD Lake Forest Hearing Professionals Lake Forest, IL

www.ATA.org

Dawn Heiman, AuD Advanced Audiology Consultants Woodridge, IL

Lauren Mann, AuD University of Kansas Medical Center Kansas City, KS

Jill Meltzer, AuD, CH–TM Jill Meltzer, AuD Consulting PLLC Northbrook, IL

Susan Smittkamp, AuD, PhD Associated Audiologists Inc. Shawnee Mission, KS

Maria Morrison, AuD, CH–TM Geneva Hearing Services Geneva, IL Karen Pastell, AuD Prairieland Audiology, LLC Joliet, IL James H. Peck, HIS Life Hearing Health Centers Rockford, IL

Kentucky Vanessa L. Ewert, AuD Bluegrass Hearing Clinic Lexington, KY Ann Rhoten, AuD Kentucky Audiology & Tinnitus Services Lexington, KY

Louisiana

Jeanne Perkins, AuD Audiologic Services Glen Ellyn, IL

Catherine C. Lo, AuD The Hearing Clinic Thibodaux, LA

Daria Popowych, AuD North Side Audiology Group, Inc. Chicago, IL

Mary Miller, PhD Premier Hearing and Balance Hammond, LA

Alyssa Seeman, AuD Illinois State University Normal, IL

Ram Nileshwar, AuD The Hearing Center of Lake Charles Lake Charles, LA

Indiana Erica Person, AuD, CH–TM Flex Audiology Lawrenceburg, IN Elizabeth Zweigart, AuD Midwest Ear Nose & Throat Surgery Evansville, IN

Iowa Diana Kain, AuD Heartland Hearing Center Hiawatha, IA Beki Kellogg, AuD Hope Hearing & Tinnitus Center Hiawtha, IA

Elena Treadway, AuD Noel ENT Hearing Center Abbeville, LA

Maryland Chelsea Carter, AuD University of Maryland Medical Center Baltimore, MD Katelyn M. Leitner; AuD, CH–TM Hearing Assessment Center Nottingham, MD Christina Shields, AuD University of Maryland College Park College Park, MD

Massachusetts

Jill Nesham, AuD Professional Hearing Solutions by Dr. Jill Cedar Rapids, IA

Dierdre Anderson, AuD Audiology Network Services Salisbury, MA

Heather Thatcher, HIS Hope Hearing & Tinnitus Center Hiawatha, IA

Eugene Antonell, BC–HIS Hear Better Now Tinnitus & Hearing Center N. Dartmouth, MA

Kansas Bryne Gonzales, AuD NuSound Hearing & Tinnitus Center Topeka, KS Rebekah J. Highfill, AuD Ascension Via Christi Rehabilitation Hospital Wichita, KS

Nataliya Ayzenberg, PhD, AuD, CH–TM Moon Hearing Services, LLC Woburn, MA Judith Bergeron, BC–HIS, CDP Beauport Hearing Care Gloucester, MA

TINNITUS TODAY SUMMER 2021

HEALTHCARE PROVIDERS

Joni Skinner Bullough, AuD Hampshire Hearing & Speech Northampton, MA

Michael Robinette, AuD Michigan Ear Institute Farmington Hills, MI

Jennifer Mize, AuD ENT Physicians of North Mississippi Tupelo, MS

Collin Campbell, Lac Campbell Acupuncture and Herbal Medicine Clinic South Dennis, MA

Benjamin Wightman, AuD Sound Advice Audiology Livonia, MI

Rhonda Sage, MS ENT Physicians of North Mississippi Tupelo, MS

Theresa Cullen, AuD, CH–TM Cape Cod Hearing Center Hyannis, MA

Joel Young, MD Rochester Center for Behavioral Medicine Farmington, MI

Stephenie Warren, MS ENT Physicians of North Mississippi Tupelo, MS

Nancy Duncan, AuD, CH–TM Duncan Hearing Healthcare Fall River, MA Peter Harakas, PhD CBT Associates, LLC Lexington, MA Dana Mario, AuD Mario Hearing & Tinnitus Clinics Mansfield, MA Robert Mario, BC–HIS, PhD Mario Hearing & Tinnitus Clinics Cambridge, MA Karen L. Wilber, AuD, CH–TM Boston Childrens Hospital Boston, MA

Michigan Natalie Crossland, AuD, CH–TM Holland Doctors of Audiolology Holland, MI Stelios Dokianakis, AuD, CH–TM Holland Doctors of Audiolology 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 Michelle Rankin, AuD Rankin Audiology and Hearing, LLC Chelsea, MI

TINNITUS TODAY SUMMER 2021

Minnesota

Missouri

John Coverstone, AuD Audiology Ear Care New Brighton, MN

Laura Flowers, AuD Hearing and Balance Specialists of Kansas City Lee’s Summit, MO

Sara Downs, AuD Hearing Wellness Center Duluth, MN

Linda Guhe, MSW Mind Body Clinical Hypnosis St. Louis, MO

John Ehlen Hear Central Victoria, MN

Jay Piccirillo, MD Washington University School of Medicine Saint Louis, MO

Jason Leyendecker, AuD Audiology Concepts Edina, MN Laura Morrison, AuD, CH–TM White Bear Lake, MN

Nevada Robyn Edgson, BC–HIS Hearing Associates of Las Vegas Las Vegas, NV

New Jersey

Thomas Tedeschi, AuD Amplifon Americas Minneapolis, MN

Granville Y. Brady Jr., AuD East Brunswick, NJ

Jerry Zhou, PhD Hearing of America, LLC. Oakdale, MN

Jade Igbokwe, AuD, CH–TM NTI Audiology Jersey City, NJ

Mississippi Denise Boatner, MS ENT Physicians of North Mississippi Tupelo, MS Mollie Johnson, AuD ENT Physicians of North Mississippi Tupelo, MS

Valerie Kriney, AuD Northern Jersey ENT Associates Glen Rock, NJ William J. McDonnell, VSO Dept. of Veterans Affairs Mount Laurel, NJ Beth Savitch, MA Advanced ENT/Hear MD Voorhees, NJ

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.

www.ATA.org

HEALTHCARE PROVIDERS

Maria Elena Sosa, AuD DNC Ears Dumont, NJ

Rivka Strom, AuD Advanced Hearing NY Inc Brooklyn, NY

Nancy McKenna, AuD, PhD University of North Carolina Chapel Hill Chapel Hill, NC

Donna Szabo, AuD Innovative Hearing Solutions Westwood, NJ

Jennifer Sutton, AuD Hearing Evaluation Services of Buffalo, Inc. Williamsville, NY

Melissa Palmer, AuD High Point Audiological–Clayton Clayton, NC

Lori Trentacoste, AuD Island Better Hearing Inc. Melville, NY

Christina Seaborg, AuD Hearing & Balance Center Charlotte, NC

Claudyne Vielot, AuD Montefiore Medical Center Bronx, NY

Heather Sprague, AuD ENT & Audiology Associates Raleigh, NC

Erin M. Walborn–Sterantino, AuD Audiologic Solutions Rensselaer, NY

Emilee V. Tucker, AuD Carolina Ear, Nose & Throat — Sinus and Allergy Center, PA Hickory, NC

New Mexico Jeffrey W. Wise, AuD, CH–TM Expert Hearing Care Las Cruces, NM Catherine A. Worth, MS Capital Hearing Care Albuquerque, NM

New York Nicole Ball, AuD Hearing Evaluation Services of Buffalo, Inc Tonawanda, NY Carol Bass, MS All Ears Audiology Tinnitus & Hyperacusis Audiological Consulting Ithaca, NY Diana Callesano, AuD Hearing and Tinnitus Center Woodbury, NY Lois Cohen, LCSW, ACSW, BCD Tinnitus Counseling Northport, NY Bruce Hubbard, PhD CBT for Tinnitus, LLC New York, NY Tracey Lynch, AuD Island Better Hearing Inc. Melville, NY Sapna Mehta–Gertz, AuD Weill Cornell Medicine New York, NY Carolynne Pouliot, AuD Hearing Aid Works Audiology Rochester, NY Amy Sapodin, AuD Advanced Hearing Center Albertson, NY Leigh A. Sauerbier, AuD The Advanced Hearing Center Brooklyn, NY Jeffrey M. Shannon, AuD Hudson Valley Audiology Pomona, NY Alyssa Smyczynski, AuD Hearing Evaluation Services of Buffalo, Inc. Orchard Park, NY

www.ATA.org

Carolyn Yates, AuD Hearing Evaluation Services of Buffalo, Inc. Amherst, NY

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 Alicia L. Cristobal, AuD Hearing Health Care Services, PLLC Durham, NC Dawn E. de Neef, MD Carolina Ear, Nose & Throat — Sinus and Allergy Center, PA Hickory, NC Lisa Fox–Thomas, PhD UNCG Speech and Hearing Center Greensboro, NC Hannah Heet, AuD Duke Otolaryngology of Raleigh Raleigh, NC Julia Hubbard–Rossi, AuD Carolina Hearing and Tinnitus, PC Mooresville, NC Patricia Johnson, AuD UNC School of Medicine Chapel Hill, NC Kelly Knolhoff, AuD Birkdale Audiology Huntersville, NC

Gina Whritenour, FNP Robeson Family Health Lumberton, NC

North Dakota Mackensie Brandt, AuD Altru Professional Center Grand Forks, ND

Ohio Samantha Bayless, AuD, CH–TM The Hill Hear Better Clinic Cincinnati, OH Kristie Dannemiller–Smith, AuD Ascent Audiology and Hearing Barberton, OH Cathy Kooser, MSW, LISW Hillcrest Hearing & Balance Center Centerville, OH Eric Mounts, HIS Modern Hearing Solutions/Choice Hearing Center Canton, OH Richard Reikowski, AuD Family Hearing & Balance Center Akron, OH Eryn Staats, AuD Memorial ENT Marysville, OH Jeffrey P. Vehr, AuD Hearall Hearing Center Dayton, OH Babette Verbsky, PhD, CH–TM Hearing Connections Audiology Lebanon, OH

TINNITUS TODAY SUMMER 2021

HEALTHCARE PROVIDERS

Gail Whitelaw, PhD, CH–TM The OSU Speech–Language–Hearing Clinic Columbus, OH

Anthony Napoletano, HIS Lansdowne Hearing Lansdowne, PA

Kyle Woods, MA, CH–TM Modern Hearing Solutions/Choice Hearing Center Canton, OH

Jeannie Karlovitz, AuD Advanced Hearing Solutions Exton, PA

Oklahoma

Rhode Island

Christy L. Mitchell, AuD Choctaw Nation of Oklahoma Talihina, OK

Oregon

Holly Puleo, AuD Gateway Hearing Solutions Warwick, RI

South Carolina

Anna Forsline, AuD VA Portland Healthcare System Portland, OR

L. Margaret Kalady, AuD, CH–TM Kalady Audiology Beaufort, SC

Kristen Furseth, AuD, CH–TM Willamette ENT Salem, OR

Alexandra Tarvin, AuD Elevate Audiology Hearing and Tinnitus Center Easley, SC

James Henry, PhD National Center for Rehabilitative Auditory Research (NCRAR) Portland, OR

Jennifer Waddell, HIS Sound Hearing Care Simpsonville, SC

Todd Landsberg, AuD South Coast Hearing Center Coos Bay, OR Ha–Sheng Li–Korotky, AuD, PhD Pacific Northwest Audiology, LLC Bend, OR Erika Shakespeare, MSc Audiology & Hearing Aid Services La Grande, OR Sandi L.B. Ybarra, AuD Hearing Associates Eugene, OR

Pennsylvania Krista Blasetti, AuD York ENT Associates York, PA Gail Brenner, AuD Tinnitus & Sound Sensitivity Treatment Center of Philadelphia, PC Bala Cynwyd, PA

Jason P. Wigand, AuD LifeAloud, LLC Lexington, SC Angela Zuendt, AuD Greenville ENT Greenville, SC

South Dakota

Lacey Brooks, AuD North Houston Hearing Spring, TX Bethany Brum, AuD, CH–TM UT Southwestern Medical Center Dallas, 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 Alexandra C. Harris, AuD, CH–TM Callier Center for Communication Disorders Dallas, TX Mary Sue Harrison, AuD Today’s Hearing Katy, TX

Stephanie Wubben, AuD Stanford Hearing Aids Sioux Falls, SD

Margaret Hutchison, PhD, CH–TM Austin Hearing Services Austin, TX

Tennessee Tiffany Ahlberg, AuD Ahlberg Audiology & Hearing Aid Services Cleveland, TN Marc Fagelson, PhD East Tennessee State University Johnson City, TN

Linda Dallas, MEd Allentown Ear, Nose and Throat Allentown, PA

Andrea Plotkowski, AuD Ear, Nose and Throat Consultants of East Tennessee Knoxville, TN

TINNITUS TODAY SUMMER 2021

Theodore Benke, MD Benke Ear, Nose, & Throat Clinic Cleburne, TX

Carla S. Hoffman, HIS Hoffman Hearing Solutions Corpus Christi, TX

Courtney C. Guthrie, AuD 4 Bridges Audiology Chattanooga, TN

S. Diane Allen, PhD The Grove Counseling & Wellness Center Dallas, TX

Melissa E. Baker, MA Baker Audiology and Hearing Aids Sioux Falls, SD

Mindy Brudereck, AuD, CH–TM Berks Hearing Professionals Birdsboro, PA

Amy Greer, AuD, CH–TM Lemme Audiology Associates Ebensburg, PA

Texas

Paul Shea, MD Shea Ear Clinic Memphis, TN

Kristen Keener, AuD IlluminEar Tinnitus & Audiology Center Austin, TX Christina Lobarinas, AuD UT Southwestern Medical Center Dallas, TX Pedro Montano, MD McAllen, TX John Moring, PhD UT Health Science Center — San Antonio San Antonio, TX Rene Pedroza, AuD, CH–TM United States Department of Defense El Paso, TX Lisa Richards, AuD, CH–TM Callier Center for Communication Disorders Richardson, TX

www.ATA.org

HEALTHCARE PROVIDERS

Bradley Stewart, AuD ClearLife Hearing Care Allen, TX

Kathleen M. Hadsell, AuD Children’s Wisconsin Milwaukee, WI

Sabrina DeToma, AuD Salus Hearing Centre Vaughan, ON

Veronica Heide, AuD, CH–TM Audible Difference, LLC Madison, WI

Patrick DeWarle, AuD, CH–TM Winnipeg Hearing Centres Winnipeg, MB

Nicole Klatt, AuD Winding Creek Audiology & Hearing Aid Center Rothschild, WI

Heidi Eaton, AuD Argus Audiology Moncton, NB

Dan Malcore The Hyperacusis Network Green Bay, WI

Kimberly Eskritt, AuD Lambton Audiology Associates Sarnia, ON

Kimberly Abeyta, AuD Hearing Resource Center Fredericksburg, VA

Erin O’Leary, AuD AuD Hearing Lake Geneva, WI

Deborah R. Lain, MSc Hope For Tinnitus Calgary, AB

Ana Anzola, AuD Ascent Hearing McLean, VA

Samantha Sikorski, HIS, ACA Sikorski Hearing Aid Center, Inc. Spooner, WI

Carol A. Lau, HIS Sound idEARS Inc. Vancouver, BC

Theresa H. Bartlett, AuD Virginia Hearing Consultants Virginia Beach, VA

Nicole S. Smith, AuD Everclear Hearing Products Eau Claire, WI

Lucy Xie, HIS Bow River Hearing Calgary, A

Vermont Elizabeth Adams, AuD, CH–TM Univ. of Vermont–E.M. Luse Center Burlington, VT Stephanie Hollop, AuD Univ. of Vermont–E.M. Luse Center Burlington, VT

Virginia

Ann DePaolo, AuD The Audiology Offices, LLC Kilmarnock, VA Cooper Evans, AuD Evolution Hearing Richmond, VA Julie Farrar–Hersch, PhD Augusta Audiology Associates, P.C. Fishersville, VA

Ireland

U.S. TERRITORIES Puerto Rico Isamar Gonzalez–Feliciano, AuD Centro Audiológico e Interdisciplinario, Isamar González, Inc. Arecibo, PR

David Jara, AuD Alexandria, VA Kristin Koch, AuD Evolution Hearing Charlottesville, VA Fred W. Lindsay, DO Hampton Roads ENT and Allergy Hampton, VA

Washington Thomas A. Littman, PhD, CH–TM Factoria Hearing Center Bellevue, WA Dustin Spillman, AuD, CH–TM Audiologists Northwest Bremerton, WA

Wisconsin Hugo Guerrero, AuD Mayo Clinic Health System Onalaska, WI

www.ATA.org

INTERNATIONAL Argentina Susana A. Dominguez Hospital Italiano de Bs.As, Argentina CABA, BA

Australia Lynne Blackford, BSc MQ Health Speech and Hearing Clinic North Epping, NSW Minakshi Gupta, MA Mount Waverleye Michael Segal, MA Pristine Hearing Nollamara, WA

Canada Lacey S. Beierbach, HAP Connect Hearing Calgary, AB

Laurence McMahon, BComm Hypnosis Online Killarney, CO Kerry

Israel Noga Feiglin, MA Galfon Audiology Center Ltd. Haifa, Israel

Malaysia Wan Syafira Ishak, PhD Universiti Kebangsaan Malaysia, Malaysia Kuala Lumpur, KL

Taiwan Chin–Lung Kuo, MD, PhD DoctorKuo ENT Clinic New Taipei City, Taiwan Yumeng Shen Taipei, Taiwan

United Kingdom Lisa Caldwell The Hearing Coach Glossop, UK Maxine Harris Hi–Kent Maidstone, UK Alan Hopkirk The Invisible Hearing Clinic Paisley, UK

TINNITUS TODAY SUMMER 2021

 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.

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 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 The Palo Alto Tinnitus Support Group at Avenidas Contact: Ken Adler, Amy Nelson, AuD, Brandon Cyrus, AuD E: karmtac@aol.com E: Amy.Nelson@kp.org E: brandon@landmarkhearing.com 3rd Thursday of the month, 5:30–7:30 pm San Francisco Tinnitus Support/ Education Group Contact: Tracy Peck Holcomb T: 415–921–7658, ext. 35 E: tracy@hearingspeech.org

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

TINNITUS TODAY SUMMER 2021

Florida Daytona Tinnitus and Hearing Support Group Contact: Sal Gentile T: 813–503–1421 E: tvtinnitus@gmail.com

Maryland University of Maryland Tinnitus and Hyperacusis Support Group Contact: Christina Shields, AuD T: 301–405–5562 E: shields3@umd.edu FB: https://www.facebook.com/ UMDHearingSpeechClinic Meets quarterly.

Missouri St. Louis Tinnitus Support Group Contact: Tim Busche T: 636–734–4936 E: tbusche@stltinnitus.org

New Jersey South Jersey Tinnitus Support Group Meeting virtually via Zoom Contact: Beth Savitch, Erin Lustik E: tsg@advancedent.com 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

North Carolina Raleigh Tinnitus Support Group Contact: Saranne Barker, AuD T: 919–790–8889 E: info@rhatc.com 4th Thursday of the month, 6:00 pm

Pennsylvania Lehigh Valley Tinnitus Support Group Contact: Mary Brownsberger T: (610–776–3233, E: marbrownsberger@gsrh.org 2nd Tuesday of month, 5:30–6:30

Texas Dallas/Ft. Worth Tinnitus Support Group Contact: John Ogrizovich E: dfwtsg@yahoo.com Meets every 4–6 weeks, 10:00 am Houston Tinnitus Support Group Contact: Vinaya Manchaiah E: houstontinnitus@gmail.com San Antonio Tinnitus Support Group Contact: Matthew Randal T: 210–549–8579 E: atasg.satx@gmail.com

Virginia/DC/Maryland National Capital Region Tinnitus Support Group Contact: Elaine Wolfson, David Treworgy E: erwolfson@comcast.net E: david_treworgy@yahoo.com 3rd Tuesday of the month, 7:30 pm

Washington Seattle Tinnitus Support Group Contact: Keith Field T: 206–783–7105 E: Keith_r_field@outlook.com 3rd Thursday of the month, 7:30–8:10 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

www.ATA.org

TINNITUS RESOURCES 

IN-PERSON MEETINGS 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

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: drlaura@citrushearing.com 2nd Monday of the month, 1:00 pm RSVP required for social distancing

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 Meeting Aug 24, Sept 29, Nov 2, Dec 8 from 5:30 pm

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.

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

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

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.

www.ATA.org

*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 above 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-yourtinnitus/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 Kevin Willmann 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.

TINNITUS TODAY SUMMER 2021

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

 Gifts of stock

 Name ATA in your trust or estate

 Deferred gift annuities

 A sk ATA to create a Tribute Page in memory of a loved one

 Donations to ATA in lieu of flowers in memory of a loved one

 Gifts of real estate

 C onvert stock and/or real estate into a unitrust

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.

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

Annual Research Issue

9/15

10/1

12/1

December

Spring—Apr 2022

The Shifting Landscape of Hearing Devices

1/15

2/1

4/1

April

Summer—Aug 2022

Improving Sleep

4/15

5/1

8/1

August

Issue

Theme

Winter—Dec 2021

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

DEPT 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 7: Breakthrough Using Multisensory Stimulation to Reduce Tinnitus SUBJECT MATTER EXPERT: Susan Shore, PhD TOPIC: After 20 years of painstaking research, Dr. Shore made national headlines this year with groundbreaking research results that showed positive effects in tinnitus treatment using bimodal stimulation. She heads the team of researchers at the University of Michigan, where it was discovered that “touch”-sensitive (somatosensory) neurons in the auditory region of the brain become hyperactive and synchronized with each other

in guinea pigs and humans with tinnitus. The team’s preliminary studies found that bimodal stimulation, which calms neurons using speciallytimed multisensory stimulation, reduces tinnitus distress and loudness. In the fall, her team will begin the next phase of research, with the goal of replicating earlier results and gaining Food and Drug Administration approval for commercialization of the technique.

Episode 8: Over-the-Counter Medications for Tinnitus Relief SUBJECT MATTER EXPERT: Robert M. DiSogra, AuD TOPIC: In this two-part podcast, Dr. DiSogra, an audiologist for 39 years and frequent lecturer on the topic of tinnitus and ototoxicity, reveals what every person with tinnitus and every hearing healthcare professional should know about this largely unregulated industry, issues with ingredients, and the efficacy of the products. Promises of relief and the desire to try anything to quiet the sound of tinnitus have fueled a lucrative market for over-the-counter dietary supplements, or nutraceuticals, aimed at the millions of Americans bothered by tinnitus.

Episode 11: Habituation to Tinnitus Using Cognitive Behavioral Therapy

lives using cognitive behavioral therapy (CBT), mindfulness, and relational therapy strategies. He explains how CBT, acceptance commitment therapy (ACT), and mindfulness are applied to treatment of tinnitus and what patients should expect. As someone with tinnitus, Dr. Hubbard offers a unique perspective on the challenges and process of habituation, as well as the importance of early intervention. He also discusses the audiologist’s role and assessing when to refer a tinnitus patient to a mental-health provider.

Podcast 14: Does Diet Play a Role in Tinnitus and Hearing Health? SUBJECT MATTER EXPERT: Christopher Spankovich, PhD, MPH TOPIC: Dr. Christopher Spankovich discusses what research reveals about the role of nutrition on tinnitus and hearing health. As one of the few tinnitus researchers to investigate this critical topic, Spankovich is able to speak to the value of supplements versus certain types of diets, and what people can do today to better manage their tinnitus and overall hearing health. As a researcher and clinician, he also shares what he advises his patients when discussing diet and other lifestyle factors that can influence tinnitus.

SUBJECT MATTER EXPERT: Bruce Hubbard, PhD TOPIC: For more than 20 years, Dr. Bruce Hubbard has helped people improve their

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