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

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
    Tinnitus     – Patient Case History
    Consult      – Make sure to look at ALL 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   Fluctuate in Volume?
                                                   worse?
  Questions     Gradual/Sudden Onset?            Who do you live with?
                                                 What do you do for work?
                When did it start?
                                                 How many hours do you work?
     for        How would you describe sounds?
                Bad vs Good days?                Any increased stress levels?
                                                 Recent colds/viruses/surgeries?
                % Awareness?
 The Patient                                     Recent changes in medications?
                % Disturbance?
with TINNITUS   Does it affect sleep patterns?
                                                 Exposure to loud sounds?

                Underlying medical conditions?   Do you use ear protection?
                                                 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
                    – Sound sensitivity
                                                             disturbance
                                                           – THI
  Evaluation    – Financial considerations                 – TFI
                                                           – TLM and MML
(~90 minutes)       – Insurance coverage and
                      reimbursement                        – Ability to reduce medications
                    – V5261 –binaural behind-the-ear         and/or stress
                      instruments                          – Patient compliance (scale)
                    – E1399 – durable medical
                      equipment

– Reimbursement
                  Financial Considerations
                – Time/Visits
                     – Consult – 1 hour                   – Services
                     – Evaluation – 1 ½ hours                 – Consult – out of pocket
Office Visits        – Fitting – 1 hour                       – Evaluation – average
                                                                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
                                 inhibition                        – usually self pay, no
                                                                     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
                       (ELSG)                           – Oasis device with 2 phase
                                                          treatment*
                     – Table-top sound generators
                       (TTSG)                           – Phase 1: Training phase
                     – 24 hours – sound enriched        – Phase 2: Active treatment
                       environment                        phase
                     – 12-18 months of therapy          – Music embedded w/ BBN
Tinnitus             – >80% success rate in reducing
                       T awareness/disturbance
                                                        – Music works w/ limbic system
                                                          and autonomic nervous system
Sound Therapy        – Set devices to where still can
                                                          to relax the system
                                                        – 4 tracks
                       hear T – do NOT mask T
based on the         – Sounds from sound generators     – 2-4 hours a day
Neurophysiological     should never evoke annoyance
                       (may need to adjust during       – 6-8 months of therapy
Model of Sound         therapy)                         – >90% success rate in reducing
                     – Sounds should have no              at least 40% of T
                       meaning and no patterns            awareness/disturbance
                     – Set it and forget it             – Set device so can still hear T

– 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          – Set devices to where it is
                       comfortable
                                                        therapy
                                                      – Give patient control of
Therapy              – Do NOT worry about T at this     environments
                                                           – Controlled environment
based on the           time – it may change
                                                           – Pick OWN music
Neurophysiological   – Sounds from sound generators
                       should never evoke annoyance   – 3-week cycle and repeat
Model of Sound         (ABLE to adjust during
                                                      – Should NEVER be annoying
                       therapy)
                     – Sounds should have no          – Other phases may include a
                       meaning and no patterns          significant other
                     – 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 2nd 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

QUESTIONS & DISCUSSION

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      Email: nphillips@advancedotolaryngology.com
      @AudioDrPhillips
      @drnphillips @drnataliephillips
      Natalie Phillips