1. Overview of tinnitus – including the role of hearing aids in tinnitus management A presentation for ENT specialists PIP_Tinnitus_Presentation V1.00/2014-03/XPl © Phonak AG / uncontrolled copy 8/3/2015Slide 1

2. Objectives To describe the key features of tinnitus To show how tinnitus is a substantial health burden To reveal the role of hearing loss in tinnitus To present the options for management, including the central role of hearing aids 8/3/2015Slide 2

3. What is tinnitus? Perception of sound but no external source Usually experienced as buzzing, hissing or ringing – Not fully-formed sounds e.g. speech or music – Not sound hallucinations experienced during bouts of mental illness – Occurs in one or both ears, or arising within the head It can have a profound effect on the sufferer “… perceived severity of tinnitus correlates closer to psychological and general health factors, such as pain or insomnia, than to audiometrical parameters …” (Zoger et al, 2006) Langguth B, et al. (2013) Lancet Neurol.12:920-930; Zöger S et al. (2006) Psychosomatics. 47:282-288. 8/3/2015Slide 3

4. Sound features of tinnitus NOISE CRITERIAPOSSIBLE FEATURES OnsetSudden, gradual PatternPulsatile, intermittent, constant, fluctuating SiteRight or left ear, both ears, within head LoudnessWide range, varying over time QualityPure tone, noise, polyphonic PitchVery high, high, medium, low Sounds experienced in tinnitus can vary according to several criteria: Langguth B, et al. (2013) Lancet Neurol.12:920-930. 8/3/2015Slide 4

5. Evaluating tinnitus severity At the other extreme, some patients suffer so much that daily living is difficult and they are unable to work. Others suffer a level of impairment between these two levels. Tinnitus is highly variable. Some patients are able to cope with the noise and their lives continue as normal. Langguth B, et al. (2013) Lancet Neurol.12:920-930. 8/3/2015Slide 5

6. The burden of tinnitus SCALE OF PROBLEM IMPACT TINNITUS RISK FACTORS A GROWING PROBLEM Tinnitus affects 10%–15% of the general population worldwide This is an estimated 280 million people Tinnitus limits daily living in 1%–2% of people with tinnitus Hearing impairment Increasing age Gender (male) Exposure to noise Increasing size of the elderly population Frequency of noise exposure in work and leisure environments Geocze L, et al. (2013) Braz J Otorhinolaryngol.79:106-111; Langguth B, et al. (2013) Lancet Neurol.12:920- 930; Roberts LE, et al. (2010) J Neurosci. 30:14972-14979. 8/3/2015Slide 6

7. Peripheral events lead to central neurological changes A range of peripheral events can lead to central neuronal changes that manifest as tinnitus Other factors can be involved in either the development or the persistence of tinnitus HEARING LOSS NOISE TRAUMA OTOTOXIC DRUGS AUDITORY NERVE ABNORMALITIES CENTRAL AUDITORY PATHWAY NEURONAL ABNORMALITIES TINNITUS ONSET TINNITUS PERSISTENCE Langguth B, et al. (2013) Lancet Neurol.12:920-930. 8/3/2015Slide 7

8. Brain response to auditory deprivation Patients with tinnitus exhibit enhanced auditory sensitivity This is caused by hyperactivity of the auditory central nervous system – Homeostatic pathways cause increased central ‘gain’ (i.e. sensitivity) in response to auditory deprivation to: 1. Maintain central nervous system activity during low sensory input 2. Ensure nerve activity is modulated to respond to changes in sensory input In patients with tinnitus and hearing loss, the tinnitus pitch and the hearing loss frequency spectrum are usually matched DECREASED SOUND INPUT INCREASED SOUND SENSITIVITY Hebert S, et al. (2013) J Neurosci 33:2356-2364; Langguth B, et al. (2013) Lancet Neurol.12:920-930; Norena AJ, Farley BJ. (2013) Hearing Res 295:161-171. 8/3/2015Slide 8

9. Tinnitus is a balance of sensory input and spontaneous activity The decreased input from the cochlea, due to outer hair cell damage, results in readjustments in the central auditory system resulting in abnormal neural activity including hyperactivity, bursting discharges and increases in neural synchrony. TINNITUS AUDITORY DEPRIVATION AND CENTRAL GAIN ALTERED SPONTANEOUS NEURONAL ACTIVITY Norena AJ, Farley BJ. (2013) Hearing Res 295:161-171. Kaltenbach JA. (2011) „Tinnitus: models and mechanisms“. Hear Res. June; 276 (1-2) : 52 – 60. 8/3/2015Slide 9

10. Tinnitus and hearing loss Most patients with tinnitus have some degree of hearing loss 75%–90% OF PATIENTS WITH OTOSCLEROSIS HAVE TINNITUS ABOUT 80% OF PATIENTS WITH IDIOPATHIC SENSORINEURAL HEARING LOSS HAVE TINNITUS “Hearing loss is a hidden disability and to have tinnitus is sort of like a double whammy” Family physician with moderate tinnitus, Canada Axelsson A, Ringdahl A (1989) Br J Audiol 23:53-62; Ayache D, et al (2003) Otol Neurotol 24:48-51; Nosrati- Zarenoe R et al (2007) Acta Otolaryngol 127:1168-1175; Sobrinho PG et al. (2004) Int Tinnitus J 10:197-201; Schaette R et al. (2012) PLoS One 10.1371/journal. pone.0035238. 8/3/2015Slide 10

11. Tinnitus and distress: a vicious cycle Experiencing sound in the absence of an external stimulus can be emotionally upsetting This reaction can make the sounds appear worse This results in a vicious cycle of worsening tinnitus and increasing distress TINNITUS EMOTIONAL DISTRESS Schaette R. (2012) Phonak Focus 42. 8/3/2015Slide 11

12. Other psychological associations with tinnitus Tinnitus is associated with increased levels of psychological problems – 24/90 (26.7%) versus 5/90 (5.6%) for age-matched controls without tinnitus HYPOCHONDRIA HYPERACUSIS COGNITIVE IMPAIRMENT TINNITUS ANXIETY DEPRESSION SLEEP PROBLEMS Andersson G, McKenna L. (2006) Acta Otolaryngol Suppl. 556:39-43; Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Jackson J, et al. (2013) Int J Audiol. E-pub ahead of print; Langguth B, et al. (2013) Lancet Neurol.12:920-930. 8/3/2015Slide 12

13. r = correlation coefficient between severity of tinnitus and prevalence of depression and anxiety (higher r = stronger correlation) HADS: Hospital Anxiety and Depression Scale; NS: non statistically significant; SCID: Structured Clinical Interview for DSM-III-R Anxiety and depression correlate with severity of tinnitus TINNITUS (ALL SEVERITIES), N=80 HIGH-RISK OF CHRONIC, DISABLING TINNITUS, N=144 rPrP Current minor depression (SCID)0.42<0.00010.43<0.0001 Major depression (SCID)0.410.00020.39<0.0001 Current anxiety disorder (SCID)0.12NS0.280.0010 Current multiple anxiety disorders (SCID) 0.01NS0.260.0023 Current depression and/or anxiety disorders (SCID) 0.42<0.00010.48<0.0001 Depression (HADS)0.300.00790.38<0.0001 Anxiety (HADS)0.350.00180.45<0.0001 Total (HADS)0.360.00140.46<0.0001 Zöger S et al. (2006) Psychosomatics. 47:282-288. 8/3/2015Slide 13

14. Other tinnitus-associated problems SLEEP PROBLEMS COGNITIVE IMPAIRMENT HYPERACUSIS Sleep disturbance is common in patients with tinnitus In particular, the time taken to achieve sleep may be lengthened in tinnitus patients Insomnia and tinnitus- associated distress can work together in a worsening spiral to adversely affect psychological wellbeing Patients with tinnitus can exhibit depressive functioning and/or anxious vigilance Cognitive performance can be worse among tinnitus sufferers versus controls in the absence of depression and anxiety Hyperacusis is an oversensitivity to certain sound frequencies or volumes It is common among tinnitus sufferers and may be a consequence of tinnitus In an age-matched control study, 60% of tinnitus sufferers reported hyperacusis, compared to 20% of controls Hyperacusis is measureable in tinnitus ears with and without hearing loss Andersson G, McKenna L. (2006) Acta Otolaryngol Suppl. 556:39-43; Bastos de Magalhaes SL, et al. (2003) Int Tinnitus J. 9:79-83; Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Hebert S, et al. (2013) J Neurosci. 33:2356-2364; Jackson J, et al. (2013) Int J Audiol. E-pub ahead of print; Langguth B, et al. (2013) Lancet Neurol.12:920-930; Wallhäusser-Franke E, et al. Sleep Med Rev. 17:65-74. 8/3/2015Slide 14

15. Tinnitus management options Currently, there is no cure for tinnitus, but management is possible HEARING AIDS DRUGS SOUND THERAPY TINNITUS EVIDENCE BASED TINNITUS MANAGEMENT APPROACHES e.g. TINNITUS RETRAINING THERAPY COUNSELLING COGNITIVE BEHAVIOURAL THERAPY Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Langguth B, et al. (2013) Lancet Neurol.12:920-930; Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762 8/3/2015Slide 15

16. Hearing aids are central to tinnitus management Reports of the use of hearing aids in the management of tinnitus go back over 60 years Because hearing loss is often associated with tinnitus, at least partial restoration of hearing should help to reduce the central gain in auditory perception that is a feature of tinnitus A recent scoping review of studies of hearing aids in tinnitus revealed that 17/18 publications showed improvements in tinnitus symptoms by fitting hearing aids “The majority of studies reviewed support the use of hearing aids for tinnitus management. Clinicians should feel reassured that some evidence shows support for the use of hearing aids for treating tinnitus …” Shekhawat et al, 2013 Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762 8/3/2015Slide 16

17. Interventional studies of the benefits of hearing aids A scoping review identified 11 interventional studies of hearing aids Six types of tinnitus evaluation were used: – THI x 4; THQ x 1; TRQ x 1; TSI x 1; TQ x 1; VAS x 3 Up to 50% reduction in tinnitus severity 10/11 studies showed improvements >10% THI: Tinnitus Handicap Inventory; THQ: Tinnitus Handicap Questionnaire; TRQ: Tinnitus Reaction Questionnaire; TSI: Tinnitus Severity Index; TQ: Tinnitus Questionnaire; VAS visual analogue scale (various) Tinnitus measurement tool Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762 8/3/2015Slide 17

18. Patient and hearing-care professional surveys of the benefits of hearing aids STUDY 1STUDY 2STUDY 3STUDY 4 Binaural hearing aids provided benefit in 66% (47/71) of tinnitus patients 65.5% of patients with frequent tinnitus reported improvements with hearing aids 41.4% reported disappearance of symptoms Fitting a hearing aid was the most frequently reported benefit of visiting a specialised tinnitus clinic Reported by 34.9% of patients Audiologist- reported tinnitus relief after fitting a hearing aid – Minor to major relief in 60% of cases – Major relief in 22% of cases Scoping review identified 4 survey studies Shekhawat GS, et al. (2013).J Am Acad Audiol. 24:747-762 8/3/2015Slide 18

19. Masking level and tinnitus reduction Retrospective study of 70 patients with tinnitus in Australia Tinnitus severity measured using the tinnitus reaction questionnaire (TRQ) Overall, 51% of patients experienced “clinically significant” change (≥40% change in TRQ score) McNeill C, et al. (2012) Int J Audiol. 51:914-919. 8/3/2015Slide 19

20. Psychological and behavioural support INTERVENTIONDESCRIPTION Counselling and education Delivered in person, to groups and via the internet Variable results may depend on personal characteristics Cognitive behavioural therapy Designed to modify maladaptive behavioural and emotional responses One-to-one and group settings, delivered by psychologists or psychiatrists, or via internet Statistically significant reductions in severity of tinnitus symptoms (P<0.05) Relaxation therapyMay help reduce tinnitus symptoms and depressive symptoms Hoare DJ, et al. (2011) Laryngoscope 121:1555-1564; Langguth B, et al. (2013). Lancet Neurol.12:920-930 8/3/2015Slide 20

21. Drug options for tinnitus management No approved drugs (European Medicines Agency [EMA] or US Food and Drug Administration [FDA]) Some psychopharmacological agents may help reduce the severity of psychological issues associated with tinnitus, and some may also lessen tinnitus symptoms DRUG CLASSEXAMPLES OF DRUGS USED IN TINNITUS Antidepressantstricyclics, selective serotonin reuptake inhibitors Antipsychoticssulpiride Mood stabilisersgabapentin, valproate Sedatives/hypnotic s benzodiazepines Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Langguth B, et al. (2013) Lancet Neurol.12:920-930 8/3/2015Slide 21

22. The need for multidisciplinary care Tinnitus management should include hearing aids with appropriate frequency ranges together with psychological support and education This requires a multidisciplinary care team – GP, ENT specialist, psychologist/psychiatrist and hearing-care professional As a leading supplier of hearing aids, Phonak can be another member of your team, helping your patient to have the optimal hearing aid for their situation 8/3/2015Slide 22

23. Thank you. Contact information Phone: Email: Website: 8/3/2015Slide 23