Managing the Patient with Tinnitus and Sound Sensitivity Natalie - PowerPoint PPT Presentation

Managing the Patient with Tinnitus and Sound Sensitivity Natalie Phillips, Au.D. Senior Audiologist, Advanced Otolaryngology and Audiology

WHO IS OUR PATIENT?

Important Things to Consider WHY do you want to start tinnitus management and/or treatment?

Important Things to Consider WHAT types of options would you like to provide?

Is there a market Important Things to Consider for tinnitus and/or sound sensitivity management in my area? Do I have resources in my area for appropriate referrals?

THE NEXT STEP…

The – Audiogram BASIC – Tymps/Reflexes Evaluation – OAEs (optional) – Tinnitus Consult and/or HA Consult

– Consult (~ 60 minutes) – Audiology Consult code – 90032 – Paid for your time spent – Narrows down who needs amplification vs who is a TRUE tinnitus patient My Experience – Evaluation (90 minutes) – Tinnitus Evaluation - 92625 – Loudness Balance Test - 92562 – SN Acuity - 92575 – Directive Counseling - 92626 (First hour) – Paid for your time spent – Order devices at this appointment IF the next step

– Questionnaires – TRQ, THI, TFI – Depression/Anxiety Scale – Patient Case History Tinnitus – Make sure to look at ALL Consult including: – Hearing Loss (~ 60 minutes) – Tinnitus – Sound Sensitivity – Important to RANK to lay out strategy for therapy

BASIC QUESTIONS: ADDITIONAL QUESTIONS: Does T affect… RE/LE/Both/Head? - Concentration? QRA? Work? Intermittent/Constant? - When you leave loud area, is it Case History worse? Fluctuate in Volume? Questions Who do you live with? Gradual/Sudden Onset? What do you do for work? When did it start? How many hours do you work? for How would you describe sounds? Any increased stress levels? Bad vs Good days? Recent colds/viruses/surgeries? % Awareness? The Patient Recent changes in medications? % Disturbance? with TINNITUS Exposure to loud sounds? Does it affect sleep patterns? Do you use ear protection? Underlying medical conditions? What treatments have you tried? WHY is T a problem?

Oversensitivity to sounds? Physical discomfort? Case History When did it start? Questions What types of sounds? All sounds or certain ones? for Do you use ear protection? The Patient with SOUND Does SS affect or prevent or affect you from normal SENSITIVITY everyday activities? Have you tried anything specific to treat your SS?

– Statistics and Definitions –Tinnitus and Sound Directive Sensitivity (Hyperacusis, Misophonia, Phonophobia) Counseling – Heller and Bergman – tie in hearing loss – Neurophysiological Model of Sound – Management and Treatment available – Give CPT Codes, ICD-10 Codes to have patient check on insurance coverage – Give Pricing range for device(s) and therapy – Further appointment(s) if agreed upon

– Questionnaires – TRQ – THI – TFI – Tinnitus Evaluation (add to BASIC Evaluation) – Ultra high-frequency thresholds (up to 12 kHz) – OAEs The Tinnitus – LDLs Evaluation – Tinnitus/Sound Sensitivity parameters (~90 minutes) – TLM – BBN MML – NBN MML – Residual inhibition – Directive Counseling with spouse and/or family members – Discuss options and strategy for management and treatment specific to patient’s needs

– Tinnitus Loudness Match (TLM) Tinnitus – BBN MML Parameter – NBN MML Testing – LDL – Residual Inhibition

Treatment Considerations Treatment Considerations – What are you treating? – Patient motivation and lifestyle – Tinnitus – TRQ, % awareness and % The Tinnitus – Hearing loss disturbance – Sound sensitivity – THI Evaluation – TFI – Financial considerations – TLM and MML (~90 minutes) – Insurance coverage and – Ability to reduce medications reimbursement and/or stress – V5261 –binaural behind-the-ear – Patient compliance (scale) instruments – E1399 – durable medical equipment

– Reimbursement Financial Considerations – Time/Visits – Services – Consult – 1 hour – Consult – out of pocket – Evaluation – 1 ½ hours Office Visits – Evaluation – average – Fitting – 1 hour reimbursement ~ – Follow-up appts $481.34 – 1 week, 2 week – 30 min – Devices – 1 month, 3 month, 6 – sound month, 12 month – 1 generators/combination hour devices – insurance – Repeat benchmark coverage applies testing of TLM, BBN – durable medical MML, NBN MML, equipment LDLs, residual – usually self pay, no inhibition ins coverage – ave insurance $1800-2000, one insurance paid $4800

Neurophysiological Model of Sound Resource: Pawel Jastreboff, Sc.D.

Tinnitus Retraining Therapy Neuromonics – Ear-level sound generators – Oasis device with 2 phase (ELSG) treatment* – Table-top sound generators – Phase 1: Training phase (TTSG) – Phase 2: Active treatment – 24 hours – sound enriched phase environment – Music embedded w/ BBN – 12-18 months of therapy Tinnitus – Music works w/ limbic system – >80% success rate in reducing and autonomic nervous system T awareness/disturbance Sound Therapy to relax the system – Set devices to where still can – 4 tracks hear T – do NOT mask T based on the – 2-4 hours a day – Sounds from sound generators Neurophysiological should never evoke annoyance – 6-8 months of therapy (may need to adjust during Model of Sound therapy) – >90% success rate in reducing at least 40% of T – Sounds should have no awareness/disturbance meaning and no patterns – Set device so can still hear T – Set it and forget it

– Consider ALL: Hearing loss, Tinnitus, Sound Sensitivity – dictates IMPORTANT how you START and strategize therapy – Pt should NEVER strain to hear POINTS – Sounds should NEVER evoke annoyance to Remember – Sounds should be easy to ignore and not engage the cortical level for of the brain – therefore, NO patterns and NO meaning TINNITUS – Sounds should NOT sound like their own tinnitus – Set it and Forget it - for Tinnitus protocol ONLY Sound Therapy – Sound Sensitivity protocol may be different*

Hyperacusis Misophonia – Ear-level sound generators – Table-top sound generators – Music therapy – 24 hours – sound enriched – Different phases dependent on environment patient need Sound – 3-6 months of therapy – Can couple with other DST Sensitivity therapy – Set devices to where it is comfortable – Give patient control of Therapy environments – Do NOT worry about T at this – Controlled environment based on the time – it may change – Pick OWN music – Sounds from sound generators Neurophysiological – 3-week cycle and repeat should never evoke annoyance Model of Sound (ABLE to adjust during – Should NEVER be annoying therapy) – Other phases may include a – Sounds should have no significant other meaning and no patterns – If need to protect ears from sounds, use earmuffs OVER – Do NOT take out ELSG

Patient Therapy Scenario: Hearing Loss (1st), Tinnitus (2nd) can be used for tinnitus patients – Make sure to check numbers reported on questionnaires – Set up for amplification with a device that can be used for tinnitus therapy (back-up) – Fit as you would for amplification – Tinnitus OPTION: (can start whenever you need to) – Give as 2 nd program to use as needed – Set up T sounds to be used – recommend BBN – Make sure pt can hear sounds on default ON – Make sure sounds you choose is NOT annoying to pt – Instruct to use as needed – Make sure do NOT mask tinnitus – Make sure VC on this program is ONLY for T sounds

Tinnitus Management Success Rates Neuromonics Oasis Published Clinical Success Outcomes 100% 90% 95% 80% 84% 78% 70% 69% 60% 50% 40% 30% 20% 10% 0% 40% reduction in T awareness 40% reduction in T disturbance 5 dB reduction in MML 5 dB improvement in LDL

Tinnitus Management Success Rates Neuromonics Oasis Published Clinical Success Outcomes compared to 1 st year and 5 th year in multi-specialty clinic 120% 100% 95% 100% 86% 84% 83% 80% 78% 80% 69% 82% 82% 71% 60% Neuromonics 64% Year 1 40% Year 5 20% 0% 40% reduction in T 40% reduction in T 5 dB reduction in 5 dB improvement in awareness disturbance MML LDL

Tinnitus Management Success Rates Neuromonics Oasis compared to TRT in Clinic 120% 100% 100% 100% 100% 100% 83% 75% 80% 88% 74% 67% 60% 56% Neuromonics TRT 40% 48% 42% 20% 0% Reduction in TRQ Average reduction in Reduction in T Average reduction in Reduction in T Average reduction in TRQ awareness T awareness disturbance T disturbance

Case Studies

J.G. –Workman’s Comp Tinnitus - 60 yo male fireman referred by WC – injury on the job 2 years prior, hit his head, choked, and loss oxygen for about 1 minute - Pt has T, headache, eye problems, vestibular issues since - Seen by outside clinic – ENT/Audiology practice - MRI of IAC - normal - Fit with Oticon Ria 2 Pro Ti Mini RITEs to help with his T, but it is not helping - (NOTE: with Mini RITE style – no toggle switch, would have to make sure to un-sync binaural sync to adjust ears independently) - Pt currently working with brain injury specialist and neuropsychologist