Trying to Connect the Dots Between Diet and Tinnitus and Hearing Loss

TINNITUSTODAY To Promote Relief, Help Prevent, and Find Cures for Tinnitus Vol. 45, No. 2, Summer 2020

Lifestyle Choices That Can Limit the Impact of Tinnitus

10 Tips to Help Manage Tinnitus

Medications That Can Cause Tinnitus

How Your Personality Influences Tinnitus Treatments

Can Marijuana Decrease Tinnitus Distress?

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By Jeannie Karlovitz, AuD things as remember tinnitus that the ATA I’ve worked with tinnitus patients management is here for for fifteen years so I understand and treatment you in various the personal struggles and deep options, and capacities! frustrations that so many people who in their local If you don’t feel encounter when seeking help and community might comfortable calling, basic answers about their tinnitus. be able to help. draw on our resources Too often people are told incorrectly Just as I’ve that can be found at www. that since there’s no cure, they’ll encountered in private ATA.org To access Tinnitus have to go home and just learn to practice, I’m often the first Today magazine, which has live with it. That false statement is healthcare professional to actually authentic personal stories, easy-to- devastating for some — shattering listen and hear a person’s thoughts understand research summaries, and all sense of hope — and certainly and fears about having tinnitus. many other helpful articles, join the prolongs the time that it takes for To be clear, we’re not providing ATA. If you think that your individual many people to get effective help. medical advice or pretending to membership doesn’t really matter, think So, when I had the opportunity to join have all the answers in these brief again. The other thing that impressed the American Tinnitus Association’s calls. But everything we share is me during my three years on the board Board of Directors, I didn’t hesitate from a place of compassion, deep is that the ATA is almost 100 percent because it’s a nonprofit dedicated to understanding, and informed by funded by individuals, meaning the the person with tinnitus, from helping evidence-based research. And since ATA is only able to continue its mission people find qualified healthcare each advisor has knowledge of and through your support. So, thank you for professionals to funding seed grant experience with effective treatment the opportunity you gave me to serve research that might someday help programs, such as tinnitus retraining as a volunteer! tinnitus patients. therapy (TRT), tinnitus activities During my three years with the treatment (TAT), and progressive Jeannie Karlovitz, ATA, I worked with an amazing tinnitus management (PTM), we’re AuD, works as an audiologist at array of people from very different able to speak from experience that Advanced Hearing backgrounds, which reminded me help and improvement for even the Solutions in Exton, that we’re more effective working in a most debilitating tinnitus cases are Pennsylvania. She diverse setting that has clear goals. possible. specializes in the management of The program that won my heart is On occasion, I’ll receive an tinnitus, hyperacusis, and misophonia. She the Tinnitus Advisors Program (TinnAP), email from someone I spoke with served as a member of the ATA’s Board of which was launched about two and weeks or months earlier, saying Directors from June 2017 to July 2020. She is also a member of the ATA’s Tinnitus Advisors a half years ago and modeled on Dr. how much the call helped put them Program, which answers calls from people Jack Vernon, the ATA’s co-founder, on a positive path to restoring their experiencing tinnitus distress. She received her setting aside time on Fridays to answer quality of life. That brings me such undergraduate degree in speech and hearing questions from callers. Today, TinnAP is joy and relief. sciences from the University of Maryland, College Park, her master’s from the University staffed by tinnitus trained audiologists The TinnAP is one example of of Maryland, and her Doctor of Audiology who take turns one day a week, how the ATA is working every day degree from Salus University. Karlovitz is a Monday through Sunday, providing to improve the lives of people member of the American Academy of Audiology, free, one-time 15-minute consultations with tinnitus. So, no matter where Pennsylvania Academy of Audiology, American Speech-Language-Hearing Association, and that help a person understand such you are in your tinnitus journey, Tinnitus Retraining Therapy Association. 2 TINNITUS TODAY SUMMER 2020 www.ATA.org Table of Contents Vol. 45, No. 2, Summer 2020

PERSONAL STORIES SPECIAL FEATURES The Link Between 30| Diet and Hearing Loss Teenage Hopes Do Dietary Factors 16 | Challenged by 06| Significantly Tinnitus Influence Tinnitus? When My Tinnitus 36 | Went Viral, Life The Role of Diet in Changed 11| Tinnitus and How to Decide If Hearing 50 | Personal Sound Hearing Options Health Amplification 52 | Beyond Hearing Products Are Right Aids Could Diabetes for You 18 | Be Behind Your Hearing Loss YOUR HEALTH and Tinnitus? Changes to Diet 22 | and Exercise Can Improve Tinnitus SCIENCE & RESEARCH NEWS Exploring Insomnia in 53 | People With Tinnitus What Does Research Quieting the Mind | and Tinnitus With 21 | Tell Us About Exercise TINNITUS TOOLS & RESOURCES 24 and Tinnitus? Exercise In Pursuit of Quiet: Trying to 33 | The Quest Before 29 | Connect the Pandemic the Dots Between Moving Online With Diet and 46 | Zoom for Tinnitus Tinnitus Support and Hearing Loss What Do Diets and Tinnitus Therapy Can Your Personality 26| Have in Common? 32 | Influence Tinnitus Treatment? Grieving Over 38| the Loss of How Can We Tame Silence Does Tinnitus 47 | Tinnitus in Tough 34 | Truly Interfere Times? 10 Tips to With Hearing? How Do We Help Manage Tinnitus 40| Know If Covid-19 Has a Negative Can Marijuana Decrease Tinnitus Support Impact on Tinnitus? 44 | Tinnitus Distress? 54 | Group Listings Common Gender Differences in Spotlight on Patient Medications Tinnitus Treatment 42| 45 | | Providers That Can Cause Outcomes 56 Tinnitus  FROM THE BOARD CHAIR Lifestyle Choices Unique to the Individual MANAGING EDITOR In this summer issue we are looking at lifestyle in Joy Onozuka American Tinnitus Association general and more specifically its tinnitus impact. Forsome people — and that is the operative phrase here — diet PUBLISHER and lifestyle can have a negative, positive, or no apparent Torryn P. Brazell, CAE American Tinnitus Association impact on tinnitus perception or annoyance. And for some people (lucky or not) there are clear identifiable PODCAST PRODUCER AND WRITER tinnitus triggers, such as exposure to loud noise or salty John A. Coverstone, AuD Sentient Healthcare, Inc. snacks, that exacerbate tinnitus. In more than 40 years as an audiologist, I have yet to come across a person with EDITOR-AT-LARGE tinnitus who has discovered a magical elixir of food or drink Robert Sweetow, PhD University of California, San Francisco that provides consistent tinnitus relief. Someday we might be able to recommend a research-based tinnitus diet that EDITORIAL ADVISORY PANEL James A. Henry, PhD Jill Meltzer, AuD reduces the sound of tinnitus, but we aren’t there yet. National Center for Rehabilitative Auditory Chair, Board of Directors Research has shown that stress and anxiety can exacerbate Research (NCRAR) tinnitus, and in the age of the coronavirus we are all U.S. Department of Veterans Affairs experiencing more stress just trying to avoid Covid-19. Gail M. Whitelaw, PhD We know that exercise is good for the brain and body, Department of Speech and Hearing Science and that anything that compromises cerebral blood flow The Ohio State University can negatively impact tinnitus and hearing loss. But for DIGITAL DESIGN & PRODUCTION TEAM some people exercise is a challenge, because the physical JML Design, LLC

exertion causes their tinnitus to increase temporarily ADVERTISING (emphasis on temporarily). But the fear is always there… Tinnitus Today is the official publication of the what if it doesn’t quiet down this time? What if it stays American Tinnitus Association. It is published louder? Again, the enigma of tinnitus. three times per year in April, August, and December and mailed to members and We also know that exposure to nature is good for our donors. The digital version is available online health. Right now in Chicago, where I live, the weather is at www.ata.org. To grow your company’s beautiful, inviting us to be outside; and when I’m outdoors, brand reach, contact [email protected].

my tinnitus is far less noticeable. Many people — not just ATA HEADQUARTERS some — share this view that being outdoors is indeed American Tinnitus Association “good” for tinnitus. I have often recommended that tinnitus 8300 Boone Blvd, Suite 500 Vienna, VA 22182 USA patients use apps that feature nature sounds to reduce the T: 800.634.8978 (Toll Free) sound of tinnitus, but for me, they hardly compare to the T: 202.800.6590 real experience of listening to the sound of waves lapping www.ata.org on the shore or birdsong or the wind in the trees. Our TO GIVE TO THE ATA evenings are now filled with the cacophony of crickets and American Tinnitus Association other noisy characters, some of which blend quite well with PO Box 424049 or even mask my tinnitus. So, take a walk, keep the faith, Washington, DC 20042-4049 do something for someone else because it might make you The American Tinnitus Association is a non- feel good and forget your tinnitus, if even for a moment. profit 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.

ADVERTISEMENT Publication of any advertisement does not in any way or manner constitute or imply ATA’s approval or endorsement 4 TINNITUS TODAY SUMMER 2020 of any advertised product or service. FROM THE PUBLISHER 

ATA BOARD OF DIRECTORS Jill Meltzer, AuD, Chicago, IL—Chair Fostering a Lifestyle John Minnebo, MBA, Philadelphia, PA—Vice Chair Bar-Giora Goldberg, San Diego, CA—Secretary of Self-Care David Hadley, MBA, San Francisco—Treasurer Ron Zagel, Grand Rapids, MI—Assistant Treasurer The coronavirus pandemic swept away simple life Shahrzad Cohen, Aud, CH-TM, pleasures that I took for granted, from hugging friends Sherman Oaks, CA and family, grabbing a cup of coffee, to attending concerts. Stelios Dokianakis, AuD, Holland, MI These small but significant things that I once enjoyed are Phillip Gander, PhD, Iowa City, IA no longer “safe” and I’m forced to weigh the risks and Michael E. Hoffer, MD, FACS, Miami, FL benefits of interacting with others. It’s unhealthy because we Allan C. Mayer, Jr., MBA, Manson, WA need people, routines, and positive experiences to keep us Gordon Mountford, CPA, South Pasadena, CA grounded, to make us feel whole. To manage the ambiguity Robert Travis Scott, Baton Rouge, LA and added stress, I’ve turned to self-care, something I didn’t LaGuinn P. Sherlock, AuD, Bethesda, MD— Immediate Past Chair always prioritize prior to the pandemic. It’s an inexact art, but Robert M. Traynor, EdD, MBA, Ft. Collins, CO it is helping. I hope you too will embrace a self-care routine Torryn P. Brazell, CAE Joseph Trevisani, New York, NY as an essential tool to help manage tinnitus and the novel Publisher Ted Turesky, PhD, Boston, MA stressors connected to Covid-19. Melissa Wikoff, AuD, Atlanta, GA Like tinnitus, self-care is unique to the individual, and Jinsheng Zhang, PhD, Detroit, MI what works for me won’t necessarily work for you. There Torryn P. Brazell, Vienna, VA—Ex-officio are, however, tried-and-true things — similar to widely The opinions expressed by accepted tinnitus management tools such as sound therapy HONORARY DIRECTOR contributors to Tinnitus Today William Shatner, Los Angeles, CA — that we can draw on daily to strengthen ourselves are not necessarily those of mentally and physically. the publisher or the American ATA SCIENTIFIC ADVISORY COMMITTEE Some of it is common sense and is backed by decades of Tinnitus Association. This Michael E. Hoffer, MD, FACS—Chair publication provides a variety University of Miami Health System, research: healthy diet and exercise. While evidence showing of topics related to tinnitus for Miami, FL USA the effect of diet and exercise on tinnitus isn’t clear cut, partly informational purposes only. Carey D. Balaban, PhD because research is limited in this area, these do make a ATA’s publication of any adver- University of Pittsburgh, Pittsburgh, PA USA difference for many people with tinnitus. Like tinnitus, there’s tisement in any kind of media Shaowen Bao, PhD no magic pill that can take the place of daily lifestyle choices, does not, in any way or man- University of Arizona, Tucson, AZ ner, constitute or imply ATA’s Christopher R. Cederroth, PhD such as taking a 10-minute walk or adding another serving approval or endorsement of Karolinska Institute, Stockholm, Sweden of summer vegetables to your plate, that promote long-term any advertised product or Marc Fagelson, PhD improved mental and physical health. service. ATA does not favor East Tennessee State University, While I’m still discovering my “best” recipe for daily or endorse any commercial Johnson City, TN USA product or service. self-care, I’ve found using light therapy in the morning, Fatima T. Husain, PhD University of Illinois, Urbana-Champaign, biking on sunny afternoons, and listening to mindfulness Champaign, IL USA podcasts makes it easier for me to ignore tinnitus, dial Mark S. Mennemeier, PhD down my reaction to stressful news, and fall asleep more University of Arkansas, Little Rock, AR USA quickly at night. I hope this issue of Tinnitus Today magazine Maria Rubio, PhD, MD helps you discover and embrace self-care as an essential University of Pittsburgh, Pittsburgh, PA USA management tool for living well during these challenging Tricia Scaglione, AuD University of Miami, Plantation, FL USA times and for managing tinnitus in good times and bad. Roland Schaette, PhD UCL Ear Institute, London, England Grant D. Searchfield, PhD University of Auckland, Auckland, New Zealand Jeremy G. Turner, PhD Illinois College, Jacksonville, IL USA Richard Tyler, PhD University of Iowa, Iowa City, IA USA Fan-Gang Zeng, PhD University of California, Irvine, TINNITUS TODAY SUMMER 2020 5 Irvine, CA USA  SPECIAL FEATURE

Do Dietary Factors Significantly Influence Tinnitus?

By Martin Hofmeister, PhD We owe the Greek physician exposure; ototoxic medications; Rufus of Ephesus (c. 80–150 AD) vascular problems; genetic Background for a precise description of auricular predisposition; temporomandibular anatomy of the ear. In his work for disorders; or as a consequence of Tinnitus is a common and novice physicians, De Corporis Humani other diseases, such as Ménière’s multifactorial condition that requires Partium Appellationibus, he used the disease — that requires careful medical careful medical assessment words “helix”, “antihelix” and “tragus”, assessment and management.3,6 and management. Many people which are the anatomical terms that The necessary multidisciplinary with tinnitus believe foods can are still in use today.1 As the founder management of patients with exacerbate or reduce their of the systematic anamnesis, Rufus tinnitus includes strategies such as perception of the condition, but of Ephesus also knew (and practiced) hearing aids, sound therapy, cognitive the research on the relationship that a detailed nutritional history, behavioral therapy, psycho-educational between diet and tinnitus is limited. especially questions regarding the counseling or neuromodulation; Objective relationship between symptoms however, potentially beneficial lifestyle The aim of this article is to and food intake or certain foods, is modifications are generally not used 3,4,6,7 review the available literature on essential for patient management and so far. For example, important 2 the efficacy of a healthy diet, use has timeless validity. Many people and effective recommendations such of dietary supplements, caffeine with tinnitus also believe that certain as “patients who have tinnitus should restriction and salt restriction for foods can trigger/exacerbate or even stop smoking” are rarely shared with 8 managing tinnitus. improve their symptoms. But does those in primary care settings. altering diet significantly change the Introduction risk or severity of tinnitus? Follow Healthy Eating There is very weak evidence Tinnitus (from the Latin tinnire, to Healthy fiber-rich dietary patterns that dietary quality affects tinnitus ring), the perception of phantom sound and regular physical activity are symptoms, and further high-quality in the head or ears in the absence of recommended for tinnitus patients 9–11 analytical studies are needed. On a corresponding external acoustical and all other patients. In this way, the other hand, the research is source, is a common disorder in the the body is supplied with all of the clear that dietary supplements general population.3–5 Depending important food components, which is are ineffective in reducing tinnitus on the applied diagnostic criterion also relevant for the undisturbed inner- symptoms and should therefore for tinnitus, the prevalence rates in ear biochemistry and function, and thus not be recommended by clinicians. adult populations vary from 11.9–30.3 for hearing. For example, the desirable There is also no supporting empirical percent.5 We know that tinnitus is daily portion of whole grain oats not scientific evidence for the commonly a multifactorial condition — brought only stabilizes blood sugar levels but advocated restriction of caffeine and on by factors including age; noise also contains abundant magnesium dietary salt for tinnitus patients. and zinc, the two minerals that have a

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major role in neural and central auditory evoked otoacoustic emissions and and inconsistent in this observational pathways. When considering causes of worse pure tone thresholds.18 study. In a recent report from the tinnitus, healthcare professionals should In a recently adjusted cross- Korea National Health and Nutrition therefore think about disturbances sectional analysis of the National Examination Survey (n = 7,621), of carbohydrate and lipid metabolism Health and Nutrition Examination tinnitus-related annoyance was — such as diabetes mellitus, Survey (n = 2,176), participants with significantly associated with lower hyperinsulinemia, and hyperlipidemia healthier diets (measured by the intake of water (P = 0.038) and — that have a negative impact on healthy eating index) had a lower protein (P = 0.009).20 the inner ear with their microvascular incidence of persistent tinnitus than Some small dietary intervention complications (e.g., thickening of those with poorer dietary practices trials have been shown to reduce the capillaries of the stria vascularis (odds ratio [OR]: 0.67; 95 percent tinnitus symptoms in patients with and in the endolymphatic sac).9,12–17 confidence interval [CI]: 0.45, 0.98; metabolic disorders.9,12–15,17 For For example, Spankovich et al. have P = 0.03).19 An examination of the example, Lavinsky et al. evaluated observed that higher cholesterol and subscales of the healthy eating index the efficacy of nutritional treatment dietary fat intakes are also significantly showed, in particular, a significant in 80 patients with associated associated with lower amplitudes of relationship between reported odds of tinnitus and hyperinsulinemia. A persistent tinnitus and both healthier long-term high-protein low-sugar fat intake (OR: 0.69; 95 percent CI: diet, including restriction of fatty 0.49, 0.99; P = 0.04) and fruit intake foods, resulted in a significant (OR 0.61; 95 percent CI: 0.41, 0.91; P reduction of tinnitus symptoms in = 0.02). hyperinsulinemic patients when There are currently only two other compared to participants who did reports of relationships between not follow the dietary management dietary factors and tinnitus in larger (relative risk 5.34; 95 percent population-based studies.10,20 In a CI: 1.85, 15.37; P = 0.000003), U.K. cross-sectional analysis with regardless of tinnitus intensity.14 171,722 participants, McCormack It may therefore be helpful for et al. observed a slight reduction tinnitus patients to monitor their in odds of persistent tinnitus with individual dietary patterns in order increased fish consumption (once to identify potential foods or food or more per week), egg avoidance, groups that aggravate or reduce their and higher intake of caffeinated symptoms.10,21 However, the few coffee.10 Conversely, higher intake of published nutritional studies have been fruits or vegetables and bread, and characterized by several methodological avoidance of dairy, were associated weaknesses, including lack of control with a small increased report of group and no randomization. persistent tinnitus. A lower odds of A systematic review or randomized bothersome persistent tinnitus was well-controlled trial on the link only detectable among participants between healthy eating and tinnitus when wholemeal/whole grain bread has yet to be performed. Overall, was consumed rather than white there is very weak evidence that diet bread (OR 0.86; 95 percent CI: quality affects tinnitus symptoms, and 0.79, 0.94; P = 0.001). The dietary further high-quality analytical studies associations were relatively modest are needed.

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Use of Dietary blood or urine tests. According to can cause a shortening of cochlear 31,32 Supplements Cochrane reviews, supplementation outer hair cells). However, there with ginkgo biloba or zinc does not is no supporting empirical scientific Dietary supplements relieve tinnitus symptoms and is no evidence for a caffeine restriction may contain vitamins, more effective than placebo (adverse recommendation. The few published minerals, herbs, or effects such as gastrointestinal studies on the link between caffeine other botanicals, amino disturbances, headache or allergic consumption and tinnitus are listed acids, and certain reactions may occur).25,26 Randomized, in Table 1. So far, only one properly other substances such as enzymes. double-blinded, placebo-controlled controlled investigation has been Because dietary supplements are trials also failed to show any effects performed.33 None of the studies legally classified as food, they do on the use of antioxidant agents for showed any significant improvement not need regulatory approval, and tinnitus management (e.g., vitamins C in controlling attacks or delaying thus come onto the market without and E, β-carotene, α-lipoic acid).27,28 progression in tinnitus patients regulatory scrutiny of safety, quality, Nonetheless, after medications with caffeine restriction. In three efficacy, and advertising claims. (45%) and hearing aids (9%), observational studies, higher caffeine Dietary supplements are readily dietary supplements (8%) are intake was associated with a lower available and are often labeled one of the most widely discussed prevalence of tinnitus.10,34,35 Of “natural”, but “natural” does not interventions in tinnitus management course, a causal relationship for a always mean “safe”. The use of with physicians, as shown by a protective effect of caffeine against dietary supplements by individuals cross-sectional analysis of the neuro-otological problems cannot be with tinnitus (mostly without medical representative 2007 National Health deduced from these observations. guidance) is popular: ginkgo biloba, Interview Survey.29 zinc, melatonin, and magnesium As a result of the clear research Salt Restriction are the most widely marketed data, the American Academy of Restriction of dietary supplements for tinnitus. For example, Otolaryngology — Head and Neck salt intake (sodium intake in an online survey by Coelho et al. Surgery Foundation contains the less than 3 g/day) is of 1788 tinnitus patients from 53 following evidence-based statement in recommended by many countries, 23 percent of participants its clinical practice guideline: “Clinicians clinicians as one of the reported using dietary supplements to should not recommend Ginkgo biloba, first-line treatments for treat tinnitus. Interestingly, 81 percent melatonin, zinc, or other dietary Ménière’s disease and is indicated that supplements are supplements for treating patients with based on anecdotal experience in ineffective for tinnitus or even make persistent, bothersome tinnitus”. 4 the 1930s.36–38 Salt is associated their tinnitus worse.22 with fluid retention and it is currently The lack of efficacy is unanimously Caffeine believed that a low-salt diet may confirmed by several systematic induce an increase in the plasma reviews and existing clinical guidelines Restriction aldosterone concentration, possibly for the treatment of tinnitus: dietary For many years, affecting the endolymph regulation supplements or herbs do not people with tinnitus and helping to maintain inner-ear improve the symptoms of people were advised to avoid homeostasis (endolymph absorption with tinnitus and can cause serious caffeine-containing drinks such as in the endolymphatic sac).38,39 side effects, especially if taken along coffee, tea, soft drinks, or energy 30,31 Recent international consensus with conventional medications (e.g., drinks. The main arguments are statements mention a reduced- blood thinners, antibiotics).4,6,7,23,24 caffeine’s stimulatory effects on salt diet as a lifestyle change for Dietary supplements may increase the central nervous system and a Ménière’s disease management,40,41 or decrease the effectiveness of potential interaction with central but there is currently no good medication and alter the results of auditory processing (e.g., caffeine

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supporting evidence for this common vascular risk factor. There is likely a recommendation.42 The search positive association between tinnitus Martin Hofmeister, 47 PhD, is a nutrition yielded no systematic review and only and arterial hypertension. scientist at the a single randomized controlled trial. Consumer Center of Acharya et al. investigated Historical View the German Federal State of Bavaria three first-line treatment options The existing evidence for (Department Food and nutritional intervention of tinnitus of Ménière’s disease over three Nutrition), Munich, months in a double-blind randomized is not very good. As a result of a Germany. He received controlled trial (97 tinnitus patients clear lack of efficacy and the risk of his doctoral degree in nutritional science from side effects, clinicians should not the Technical University of Munich in 2004. Since with a mean age of 47.9 years were then he has worked on various nutrition and randomized into three groups): recommend dietary supplements exercise projects. His research and articles on • dietary sodium restriction and or herbs for treating patients with nutrition and exercise have been published in placebo tinnitus. There is also no supporting more than 180 publications, including national empirical evidence for the commonly and international scientific journals. He is also a • diuretics as amiloride 5 mg and reviewer of several international journals. furosemide 40 mg advocated caffeine and dietary salt • vasodilator as betahistine 24 mg. restriction recommendation for 1 Bujalkova M. Rufus of Ephesus and his tinnitus patients. The paper’s titular contribution to the development of anatomical No benefit could be found nomenclature. Acta Med Hist Adriat question can be seriously answered 2011;9(1):89–100. attributable to dietary salt only with “no”. Well-controlled 2 Hofmeister M. [Who was the founder of the restriction alone in terms of nutritional anamnesis? Rufus of Ephesus]. randomized trials are needed to clarify Ernährung & Medizin 2009;24(3):148–52. doi: hearing improvement, incidence whether healthcare professionals 10.1055/s-0029-1239950. or severity of vertigo, and tinnitus 3 Esmaili AA, Renton J. A review of tinnitus. Aust J should ask individuals with tinnitus Gen Pract 2018;47(4):205–08. score.43 However, a systematic about their eating habits (food 4 Tunkel DE, Bauer CA, Sun GH, et al. Clinical Cochrane review* to determine practice guideline: Tinnitus. Otolaryngol Head preferences, dislikes, etc.) as part of Neck Surg 2014;151(2 Suppl):S1–S40. doi: the effectiveness of a dietary salt 10.1177/0194599814545325. the physician–patient interaction. restriction for the treatment of 5 McCormack A, Edmondson-Jones M, Rufus of Ephesus would certainly Somerset S, Hall D. A systematic review of the Ménière’s disease is currently under reporting of tinnitus prevalence and severity. support this suggestion today — he Hear Res 2016;337:70–79. doi: 10.1016/j. preparation.44 would probably complement this with heares.2016.05.009. It should be noted that too much 6 Bauer CA. Tinnitus. N Engl J Med the instruction of a routine nutritional 2018;378(13):1224–31. doi: 10.1056/ salt in food is a worldwide problem. screening in patients’ electronic NEJMcp1506631. Australia consumes more salt than 7 Zenner HP, Delb W, Kröner-Herwig B, et al. clinical records in primary care and A multidisciplinary systematic review of the the recommended level of <5–6 hospital settings. It may sometimes treatment for chronic idiopathic tinnitus. Eur g/day. According to current data, Arch Otorhinolaryngol 2017;274(5):2079–91. doi: be useful for healthcare professionals 10.1007/s00405-016-4401-y. daily dietary salt intake is 10.1 g 8 Hofmeister M. Tinnitus patients: Do you smoke? to receive support from Rufus of for Australian men and 7.3 g for Aust J Gen Pract 2018;47(7):410. Ephesus’ Quaestiones Medicinales in 9 Ganança MM, Caovilla HH, Ganança FF, Serafini women.45 The main suppliers of salt F. Dietary management for tinnitus control in the assessment and management of patients with hyperinsulinemia – A retrospective are bread and processed foods,46 with tinnitus patients. study. Int Tinnitus J 1995;1(1):41–45. 70–80 percent of daily dietary salt 10 McCormack A, Edmondson-Jones M, Mellor D, et al. Association of dietary factors with presence found in breads/cereals/grains, meat *Clinical Practice Guideline: Ménière’s Disease, and severity of tinnitus in a middle-aged UK products and dishes, and cheese, but released in April 2020, does not include a salt population. PLoS One 2014;9(12):e114711. doi: recommendation for patients. However, it does 10.1371/journal. pone.0114711. also in ready-made meals, dressings/ recommend that patients with MD follow the American 11 Loprinzi PD, Lee H, Gilham B, Cardinal BJ. sauces and snacks/desserts. Heart Association's endorsement of limiting daily salt Association between accelerometer-assessed intake to 1500 mg and no more than 2300 mg. physical activity and tinnitus, NHANES 2005– Moderate reduction of dietary salt 2006. Res Q Exerc Sport 2013;84(2):177–85. doi: 10.1080/02701367.2013.784840. intake also helps to lower systemic 12 Pulec JL, Pulec MB, Mendoza I. Progressive hypertension, which is considered a sensorineural hearing loss, subjective tinnitus and

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vertigo caused by elevated blood lipids. Ear Nose 16 Kim HJ, Lee HJ, An SY, et al. Analysis of the adult population-based study. J Am Acad Audiol Throat J 1997;76(10):716–28. prevalence and associated risk factors of tinnitus 2011;22(1):49–58. doi: 10.3766/jaaa.22.1.6. 13 Basut O, Ozdilek T, Coşkun H, et al. [The incidence in adults. PLoS One 2015;10(5):e0127578. doi: 19 Spankovich C, Bishop C, Johnson MF, et al. of hyperinsulinemia in patients with tinnitus and 10.1371/journal.pone.0127578. Relationship between dietary quality, tinnitus the effect of a diabetic diet on tinnitus]. Kulak 17 Almeida TA, Samelli AG, Mecca Fdel N, De and hearing level: Data from the national Burun Bogaz Ihtis Derg 2003;10(5):183–87. Martino E, Paulino AM. Tinnitus sensation pre health and nutrition examination survey, 14 Lavinsky L, Oliveira MW, Bassanesi HJ, D’Avila and post nutritional intervention in metabolic 1999–2002. Int J Audiol 2017;56(10):716–22. doi: C, Lavinsky M. Hyperinsulinemia and tinnitus: A disorders. Pro Fono 2009;21(4):291–97. doi: 10.1080/14992027.2017.1331049. historical cohort. Int Tinnitus J 2004;10(1):24–30. 10.1590/S0104-56872009000400005. 20 Lee DY, Kim YH. Relationship between diet and 15 Sutbas A, Yetiser S, Satar B, Akcam T, Karahatay 18 Spankovich C, Hood LJ, Silver HJ, Lambert W, tinnitus: Korea National Health and Nutrition S, Saglam K. Low-cholesterol diet and antilipid Flood VM, Mitchell P. Associations between diet Examination Survey. Clin Exp Otorhinolaryngol therapy in managing tinnitus and hearing loss and both high and low pure tone averages and 2018;11(3):158–65. doi: 10.21053/ceo.2017.01221. in patients with noise-induced hearing loss and transient evoked otoacoustic emissions in an older hyperlipidemia. Int Tinnitus J 2007;13(2):143–49. Table 1: Studies on the Relationship Between Caffeine Consumption and Tinnitus Authors (Year) Study Design Sample Size Mean Age (Years) Outcome

A phase 2, pseudo- Caffeine abstinence had no effect on tinnitus randomized, double- severity, but acute side effects of caffeine Claire et al. (2010)33 66 59.2 blinded, placebo- withdrawal were noted (headaches and nausea) controlled crossover trial and might add to the burden of existing tinnitus

Daily intake of black coffee (about 2.5 cups Petersen Schmidt Transversal case-control 136 63.8 per day) had no influence on the degree of Rosito et al. (2011)51 study discomfort and quality of life of tinnitus patients

There is no justification for the universal restriction of caffeine intake as a treatment for Figueiredo et al. Contemporary longitudinal all patients with tinnitus; however, some groups 26 56.9 (2014)32 cohort study may benefit from consumption reduction (patients under 60 years with bilateral tinnitus and daily coffee intake between 150–300 mL)

Higher caffeine intake was associated with a Longitudinal and 65,085 (5289 lower risk of incident tinnitus in women (4–6 cups Glicksman et al. prospective study (18‑year incident cases 36.3 (at baseline) versus 1 cup of coffee per day); there was no (2014)34 follow-up) of tinnitus) association between decaffeinated coffee intake and incident tinnitus

171,722 (33,897 Higher caffeinated coffee consumption was McCormack et al. Cross-sectional study incident cases 57.1 associated with a small lower prevalence of (2014)10 of tinnitus) transient and persistent tinnitus

Figueiredo et al. Transversal case-control No association between tinnitus and caffeine 288 58.2 (2016)47 study consumption was detectable 13,448 (3642 Age groups (no National population-based Frequency of coffee consumption had an inverse Lee et al. (2018)35 incident cases mean age): 19–39, observational study correlation with tinnitus of tinnitus) 40–64, and ≥65

Complete list of references can be found by using the following link: https://www1.racgp.org.au/ajgp/2019/march/do-dietary-factors-significantly-influence-tinnitu *Clinical Practice Guideline: Meniere’s Disease was published April 2020. For more information, see https://journals.sagepub.com/doi/full/10.1177/0194599820909438

REPRINTED FROM AJGP VOL. 48, NO. 3, MARCH 2019 © The Royal Australian College of General Practitioners 2019

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The Role of Diet in Tinnitus and Hearing Health

A healthy diet and lifestyle are our of hearing loss. The cascade of gene that encodes best weapons in the prevention of biochemical effects created by L-gulonolactone oxidase cardiovascular disease, but what diabetes can lead to glycation, protein (GULO); primates (which about their impact on preserving hear- and lipid dysfunction, nitric oxide and include humans) had a ing health and lessening the impact glutathione dysregulation, glutamate mutation in the gene of tinnitus? To explore this topic, the excitotoxicity, and microangiopathy. that encodes GULO about 30 × 106 ATA talked to Christopher Spankovich, It is also likely that an individual who years ago, so we need vitamin C PhD, an expert in this field. develops type 2 diabetes has dietary from exogenous sources (e.g., food). and physical activity factors that Therefore, a rat model may not be the Joy Onozuka (JO): We all exacerbate risk for further pathology. best to look at dietary vitamin C and understand the importance of Most of our information on hearing outcomes, since their cells eating a well-balanced healthy diet specific nutrients and risk for make vitamin C on their own. to optimize our long-term physical acquired hearing loss comes from In general, research has focused and mental health. Based on your animal models, primarily rodents. on nutrients with antioxidant, anti- research, is there sufficient evidence This presents a limitation, as animals inflammatory, or anti-ischemic to propose a healthy hearing diet? do not necessarily share the same properties. Perhaps the simplest bioavailability of nutrients; species dietary change that appears to Christopher Spankovich (CS): can vary in regard to how they affect susceptibility to hearing loss Our diets do indeed influence our metabolize, utilize, and excrete is caloric intake. Simply restricting hearing health similar to how our nutrients. Let’s consider vitamin C. caloric intake can significantly reduce diets influence our overall health Vitamin C is an essential nutrient evidence of hearing loss and lead and risk for chronic disease. Yet, in humans (dietary required) and to increased longevity in a number the relationship of diet and specific has numerous roles in our cells: it of rodent models, but evidence in nutrients in susceptibility to hearing serves as an enzyme for synthesis of primates is still under study. Caloric loss and tinnitus (as with other neurotransmitter and neuropeptide restriction studies often reduce acquired disorders) is complicated hormones, is a cofactor in the overall calorie intake by approximately and influenced by an array of factors hydroxylation and maturation of 30 percent compared to normal (which influence each other) such collagen (healing of musculoskeletal intake but maintain adequate nutrient as our genetics, environment tissue), is an important water-soluble intake to avoid malnutrition. (including noise exposure), physical antioxidant, and helps to keep vitamin Other dietary factors that activity, lifestyle, and of course E in a reduced state. Most rodents have been considered include our overall health status (both (with the exception of guinea pigs) macronutrient intake (fats, physical and mental). For example, endogenously synthesize vitamin C, carbohydrates, protein) and various individuals with type 2 diabetes meaning they do not require a dietary micronutrients (e.g., B vitamins, have significantly increased odds source. This is all related to a specific vitamins C and E) and minerals

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(e.g., magnesium, zinc, selenium). example, vitamin D in milk. The first are nature-identical Numerous epidemiological studies food fortified was salt with iodine. synthetic. Back to have demonstrated relationships In the United States, true dietary our friend vitamin between specific nutrients and deficiencies in key nutrients are C. The most popular hearing health. Nevertheless, less common, much in part because form of vitamin C examining single nutrients is of accessibility, fortification, and is ascorbic acid, which is the same not without limitations, namely, supplements. However, certain as naturally occurring vitamin C. existence of interactions among nutrients are commonly considered Synthetic and food-derived vitamin C nutrients that create biochemical and inadequately consumed, including is chemically identical. However, fruits statistical collinearities. In addition to vitamins B6, B12, C, D, iron, and and vegetables that contain vitamin epidemiological studies examining magnesium. A perhaps greater C are rich in other micronutrients, population-level relationships, several issue in the United States is phytochemicals, and dietary fiber. The case-control studies in humans have excessive intake of unhealthy calorie- presence of these other factors may examined dietary cholesterol changes, dense foods that lack a variety of influence bioavailability compared folic acid supplementation, vitamin nutrients, which leads to a person to the synthetic supplement form.

B12 supplementation, and antioxidant being not only overweight but also For vitamin C specifically, this is supplementations. Many of these malnourished. not believed to be a meaningful studies have shown positive results difference in humans, but for but had caveats (for reviews, see JO: What are your thoughts on food other vitamins, such as vitamin E, Spankovich, 2015, and Spankovich & and supplements? food sources allow significantly Le Prell, 2020). For example, a folic improved bioavailability compared to acid fortification study was completed CP: We must consider the source of supplements. Another consideration in the Netherlands that showed some nutrients, food versus supplement. is the starting material for synthetic decreased risk for hearing loss, but First, how food is prepared and supplements is commonly coal tar, the study was completed at a time sourced is a consideration. A question petroleum, or acetylene gas that when foods were not fortified in I am frequently asked is whether goes through chemical processes the Netherlands and baseline folate organic food is more nutritious to duplicate the structure of the levels were about half of those found than conventional. In short, there isolated vitamin. Other supplements in the U.S. population (Durga et al. is minimal difference in nutritional that are not strictly synthetic can 2007). Thus, we find another factor, content, but it can vary by specific be food based (e.g., vegetable oils) adequate intake of nutrients or role foods. However, organic foods may or cultured through raw materials of nutritional deficiency. It should be have other advantages such as lower such as yeast/algae or bacterial noted that many foods are fortified, levels of pesticide residue. fermentation. It is important to meaning extra nutrients are added. For Supplements are a different story. note dietary supplements are not Most standard vitamin supplements regulated by the U.S. Food and Drug Administration and therefore the quality of products can vary tremendously. Also, studies on “If you eat healthy and exercise, a supplements for chronic disease overall do not show much benefit multivitamin is generally unnecessary. and some show possible harmful On the contrary, a multivitamin will not consequences. Rather than focusing on specific magically correct a poor diet or lifestyle.” nutrients, a likely more effective approach is to focus on dietary

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quality. Eating a multivitamin is generally unnecessary. system physiology, pharmacology, healthy diet will On the contrary, a multivitamin will not and nutrition. That training would include the nutrients magically correct a poor diet or lifestyle. be helpful for audiologists to feel described above, as well more confident in discussing factors as an array of other chemicals JO: Does the type of hearing loss beyond the ear. The truth is physicians important to health. Our group matter? need more training in nutrition also. previously examined dietary quality CS: Possibly. This is where a Unfortunately, most medical schools through a measure called the supplement may prove to be provide limited training on diet and Healthy Eating Index (HEI). The HEI beneficial. In general, a healthy diet nutrition. is a measure of how well a diet will likely be adequate in diminishing The ear is not separate conforms to the recommended risk for hearing loss as much as it from the rest of the dietary guidelines of the U.S. can. Where additional supplements body. What we eat and Department of Agriculture (USDA). may come into play is when there is a our physical and mental health The HEI has gone through several challenge to the system. For example, have important implications for revisions through the years as the numerous studies have shown that hearing, tinnitus, and balance. USDA guidelines are updated. In animals with diets supplemented brief, the HEI provides a score with antioxidants (e.g., vitamin E) JO: Why are people with diabetes more of 0 to 100 in regard to quality of can reduce risk for noise-induced prone to hearing loss and tinnitus? diet; higher scores indicate a diet hearing loss. However, the effects of meets USDA recommendations. antioxidants on age-related hearing CS: Diabetes causes a cascade of Putting aside whether you think loss have been less clear, with biochemical consequences that can USDA guidelines are correct or not, contradictory reports of protection lead to increased risk of hearing there is a relationship between and no protection. loss. To reduce risk, persons with a higher HEI and lower (better) diabetes should following the ABCs hearing thresholds (Spankovich & JO: Hearing loss has been ranked of diabetes management, eat Le Prell 2013, 2014). More recently, as the fifth leading cause of years healthy, exercise, and follow healthy Curhan et al. (2018) showed that lived with disability, ahead of hearing guidelines. This includes adherence to the Mediterranean other chronic conditions such as getting your hearing checked and diet and Dietary Approaches to Stop diabetes and dementia. Given that, monitoring it over time and using Hypertension (DASH) diet reduced should audiologists and doctors be hearing protection and hearing risk for hearing loss. discussing dietary strategies that conservation practices (turning down What do I recommend to patients? might enhance long-term hearing volume) to reduce risk of noise- Eat a healthy diet and exercise, and health with their patients? induced hearing loss. run any changes by your primary care physician. What is a healthy diet? CS: Audiologists could benefit from JO: Though there are no foods that Eat more vegetables, more fruit, and more training in basic biochemistry, cause tinnitus, many people find good sources of fat, such as fish, nuts, and seeds. Eat less processed foods, less fried foods, and less “The ear is not separate from the rest of the high-glycemic-index foods (e.g., foods with added sugar), and less red meat. body. What we eat and our physical and These suggestions are in general consistent with the DASH diet and mental health have important implications Mediterranean diet mentioned earlier. If you eat healthy and exercise, a for hearing, tinnitus, and balance.”

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biloba extract EGb 761 has been demonstrated to have some efficacy “Tinnitus can be perceived as an alarming compared to placebo; however, the quality of this evidence is low and and bothersome percept; let it be an alarm, hence the recommendation from rather, a wake-up call to start leading a AAO-HNS. Higher-quality research is needed. Also, a concern with Ginkgo healthier life and taking care of yourself.” is potential platelet inhibitory actions of the herb that can impair coagulation and thus concern for patients on that such things as salt, caffeine, tinnitus practice guidelines (2014) that anticoagulation medications. In and alcohol trigger or aggravate “clinicians should not recommend addition, there is no evidence that their tinnitus. What are your Ginkgo biloba, melatonin, zinc, or Ginkgo biloba cures tinnitus, though thoughts on that? other dietary supplements for treating some patients report reduced patients with persistent, bothersome severity. There are no randomized CS: Foods or beverages that cause tinnitus.” Despite that, patients are controlled trials of lipoflavonoids spikes in tinnitus often cause only sometimes told to take lipoflavonoids for tinnitus published in the peer- transient spikes. The majority of because they “might” help. As reviewed literature. I therefore do not work examining salt has focused someone who has worked with recommend them to my patients. on Ménière’s disease (MD), but the tinnitus patients and researched the I do recommend that my patients evidence of salt influencing Ménière’s role of diet on hearing health, what eat a healthy diet and exercise. They disease is fairly low (some patients would you like patients to know? should consult their primary care with MD are salt sensitive others not physician when making changes so much), though eating a low-sodium CS: The placebo effect related to to their diet and exercise regime. diet is not a bad thing. When it comes tinnitus is considerable, with reports Exercise-wise, you should do what is to caffeine and alcohol, the key is as high as 40 percent. The placebo within your ability, but be more active. moderation. Again, a cup of coffee or effect is when an agent with no active Will diet and exercise cure a glass of wine (not the whole bottle) substance creates a therapeutic effect tinnitus? No. Will it hurt it? Not is not likely going to lead to sustained due to psychophysiological factors. likely. If anything, eating healthy and changes in tinnitus perception. For Another consideration is the lack of exercising can improve overall health people who do experience a spike in an objective measure of tinnitus: and well-being, improve sleep, and tinnitus with coffee or alcohol, they we cannot objectively measure a improve the ability of a person to need to make a choice. I can enjoy change in the tinnitus signal; rather, effectively habituate to tinnitus. I my delicious cup of coffee in the we are dependent on the patient’s rarely see a tinnitus patient who is a morning and deal with the tinnitus self-reported perception and reaction. vegan marathon-running yoga fanatic. spike or can skip the coffee and not Of supplements, Ginkgo biloba has I see many who are have the spike. probably been studied the most. A overweight, eat review of the literature will show below average JO: Vitamins and minerals play a role contradictory findings, some studies quality diet, in hearing health. However, there’s showing benefit and others not. are on multiple no evidence that supplements have The variation in efficacy can be medications for any benefit for reducing tinnitus, related to the type of Ginkgo biloba, high blood pressure/ which is why the American Academy dosage levels, and having appropriate cholesterol/diabetes, of Otolaryngology — Head and Neck randomization and placebo-based and lead sedentary Surgery Foundation wrote in their controls in place. Namely, the Ginkgo lifestyles. Tinnitus can

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be perceived as an alarming and University of Mississippi Medical Center. He Curhan et al. (2018). Adherence to Healthful bothersome percept; let it be an obtained his MPH from Emory University, AuD from Rush University, and PhD from Dietary Patterns is Associated with Lower Risk of Hearing Loss in Women, J Nutr., 148 (6), p944-951. alarm, rather, a wake-up call to start Vanderbilt University. Spankovich is a leading a healthier life and taking care clinician-scientist with a translational Durga et al. (2007). Effects of Folic Acid Supplementation on Hearing in Older Adults: A research program focused on prevention of yourself. Randomized, Controlled Trial. Ann Intern Med 146, of acquired forms of hearing loss, tinnitus, Hippocrates said over 2,000 p1-9. and sound sensitivity. His research has years ago, “Our food should be our Spankovich & Le Prell (2013). Healthy Diets, been funded by industry, federal, and Healthy Hearing: National Health and Nutrition medicine. Our medicine should be professional bodies. He has published over Examination Survey, 1999-2002. Int J. Audiol 52, our food.” That remains true today. 60 articles and book chapters (41 in peer- p369-376. reviewed journals) and has given over 60 Spankovich & Le Prell (2014). Association Between Also, Mama Spankovich said while I national and international presentations. Dr. Dietary Quality, Noise, and Hearing: Data from was growing up, “Eat your fruit and Spankovich continues to practice clinically the National Health and Nutrition Examination Survey, 1999-2002. Int J. Audiol 53 (11), with special interest in tinnitus, sound vegetables and go outside and play.” p796-809. sensitivity, ototoxicity, hearing conservation, Pretty good advice also. Spankovich & Le Prell. (2020). The role and advanced diagnostics. He holds adjunct of diet in vulnerability to noise- faculty status with Salus University and induced cochlear injury and Christopher Nova Southeastern University and serves hearing loss, J. Acoust Soc Am, Spankovich is an as an associate editor for Audiology Today 146 (5). associate professor and the International Journal of Audiology. Spankovich. (2015). The and vice chair of He was recently elected to the AAA Board Role of Nutrition in Healthy research for the of Directors. He also provides consultant Hearing: Human Evidence. In J. Miller, C. Le Prell, and L. Department of services for medicolegal cases. Rybak (Eds). Free Radicals in Otolaryngology and ENT Pathology, p111-128. Communicative Sciences at the

Medical Disclaimer

The content in Tinnitus Today professional, when considering the magazine is intended to provide best course of tinnitus management. helpful health information for the This begins with a medical general public. It is made available examination to rule out possible with the understanding that the underlying medical causes for tinnitus. American Tinnitus Association (ATA) If you’re interested in adopting is not engaged in rendering medical, guidance/suggestions made in the health, psychological, or any other magazine, you should discuss this advice for individual problems or for kind of personal professional services. first with your medical provider before making an evaluation for pursuing a The magazine content should not be doing so. particular course of action. considered complete and, therefore, Any information about drugs and The ATA and authors of articles in does not cover all physical conditions supplements contained in the magazine the magazine specifically disclaim all or their treatment as it relates to is general in nature, and does not cover responsibility for any liability, loss, or tinnitus and tinnitus management. all possible uses, actions, precautions, risk, personal or otherwise, which is The ATA always recommends side effects, or interactions of the incurred as a consequence, directly or that you consult and work with a medicines mentioned. The content of indirectly, of the use and application of medical, health, or other competent the magazine is not intended as medical any of the content in the magazine.

www.ATA.org TINNITUS TODAY SUMMER 2020 15  PERSONAL STORY Teenage Hopes Challenged by Tinnitus

By Cindy Zhang

I am 16 years old, well-versed (-ish) in computers, strong enough to carry stacks of textbooks, and can run an eight- minute mile (if we’re generous). Unfortunately, I haven’t had a moment of silence in years. Fateful Night My tinnitus began when I was just in middle school. It slithered into my ears on an ordinary day in the middle of the night, and I remember thinking, Has this whisper always been here? As it turns out, that whisper hadn’t Strangely, I can only recall crying rest of the world. Instead of reaching always been there, and that whisper once during this time of grieving. out to friends and family, I remained would never leave. Unlike my tinnitus, my grief and panic silent about my tinnitus. In hindsight, To this day, the cause of my were silent, but they were potent it would have been far wiser to reach tinnitus remains ambiguous: Was it enough to convince me that tinnitus out and communicate, and I implore my constant use of headphones? had robbed me of my life. anyone dealing with tinnitus to do so. My days spent in band without For me, however, I scoured the internet hearing protection? My TMJ Words Saved My Life in search of a cure. What I ended up (temporomandibular joint disorder), During that tumultuous period, I with were patient stories — many, which I am still dealing with to this day? completely shut myself off from the many patient stories — with one Regardless of the cause, the onset of unifying theme: The power of the mind. tinnitus plunged me into darkness. At first, I couldn’t believe what I Day in and day out, I would fixate I learned how stress was reading, but my desperate heart on my ears, living in a state of denial exacerbates tinnitus. clung to those lessons and stories. My about my condition until I could no ——— longing for hope loosened the grip of longer do so. When it finally registered I learned how turning tinnitus tinnitus on my life. The change wasn’t that the hissing was not going away into something positive instantaneous, but I slowly began to any time soon, the full weight of that defeats its negative effects. take back my life, one moment at a realization struck me mercilessly, and I ——— time, harboring that newfound hope entered a period of purposelessness, I learned how life with that life was still possible. anxiousness, and hopelessness. tinnitus requires adjustment. Finally, there was a day when Above all, a deep sense of loss seized ——— everything clicked. Everything I had me. I felt like I had lost a part of my I learned life after tinnitus read online in the patient stories youth, a part of my life, and suddenly is possible. ——— became my truth. I can’t recall felt I was aging far too quickly. I felt like I learned about life. whether it was a birthday party or a my youth was over. trip to the mall with my friends, but on

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that day, I was completely immersed in my surroundings and happy. So “Instead of reaching out to friends and engaged with my life that I had forgotten the hissing noise in my ear. family, I remained silent about my tinnitus. I learned two lessons that day, which I fully embrace: In hindsight, it would have been far wiser to • First, that living — truly living — is the greatest cure for tinnitus. reach out and communicate…” • Second, that stories — real, raw stories — can renew one’s sense of Additionally, I’ve realized (as I’m hope and save a life. writing this, in fact!) that I have How I Cope neglected taking care of my TMJ, one Adjusting to life after tinnitus is thing I suspect caused my tinnitus. It’s as much a spiritual ordeal as it is a important to take care of conditions worldly one. that might make tinnitus worse. In the worldly sense, I use many Although there are lots of tinnitus strategies to cope with my tinnitus. management methods, focus on When I initially realized I had tinnitus, the power of the mind is what the first thing I did was buy a pair of brought me to a much better place. high-fidelity earplugs, which reduce It’s a state of constant spiritual loud noise while still allowing me to adjustment that is needed for me to hear clearly. I bring them with me manage this condition: whenever I know I might be exposed Live positively, live responsibly, Cindy is a high school student who enjoys to loud noise. and read. writing and spending time with her Mock Trial I’ve also learned to manage my Team. Though she is definitely future-focused, Tinnitus does not have to be a she says she will never forget the importance stress. When my tinnitus is louder condition that engulfs your life. If of organizations that help people overcome than it usually is, I step away from anything, tinnitus can teach you how challenges, such as the American Tinnitus Association. In her journey in life, she hopes whatever I’m doing and walk around a to live — and that, above all, is the to give back to the ATA since it helped her to little to clear my mind. truest form of youth. overcome tinnitus.

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 tinnitus as a result of temporomandibular joint (TMJ) or other dental-related issues. Please send your story to [email protected] by Sept. 30. Suggested word length is between 500 and 800 words.

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Could Diabetes Be Behind Your Hearing Loss and Tinnitus?

By Robert M. DiSogra, AuD Without insulin, the body’s regular physical activity, losing cells would be starved, causing excess weight, and taking medi- The number of people in the dehydration and destruction of body cations. Medications for diabetes United States who have tinnitus is tissues. Cardiovascular, eye, dental, often change for individuals during approximately the same as those with kidney problems, and stroke could the course of the disease. Insulin diabetes or hearing loss. Almost three occur as well as hearing loss. can also be used to control blood times as many people are considered glucose in people with type 2 “pre-diabetic.” Details and incidence Types of Diabetes diabetes. figures can be found in the Centers There are three types of diabetes: • Gestational diabetes can occur for Disease Control and Prevention type 1, type 2, and gestational. during pregnancy but usually re- (CDC) National Diabetes Statistics • Type 1 is usually identified in solves after delivery. Report: 2020.1 young children (although adults, too, can have type 1). They must Diabetes Management What Is Diabetes? have insulin delivered by injection The CDC offers the Diabetes Self- Diabetes is a metabolic disease or a pump to survive. Management Education and Support caused by the body’s inability to • Type 2 is the most common. (DSMES) program to help people create or effectively use its own Approximately 20 percent of with diabetes learn how to take the insulin, which is produced in the people over age 65 develop type best care of themselves.2 pancreas. Insulin helps regulate blood 2. Many people with it can control sugar (glucose) levels — providing their blood glucose by following Hearing Loss and energy to body cells and tissues. a healthy diet and a program of Diabetes A microscopic blood supply in the inner ear (cochlea) nourishes the hair “Tinnitus from hearing loss that could be cells critical for transmitting sound to the brain. When there is too much related to diabetes should be of concern to glucose (sugar) in the blood in diabetes (hyperglycemia), persons under the age of 60. If the hearing the walls of these tiny vessels close in and loss has an unknown cause, there is a get narrower. The narrower the opening, possibility that the loss may be related the less oxygen that enters the cells, which to pre-diabetes or diabetes.” can lead to cell damage or death. The result is

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the outer hair cells do not function pharmacist or go online to www. properly. drugs.com or www.rxlist.com [not The term used to describe this an endorsement by the author or the narrowing or constricting of the blood American Tinnitus Association]. vessels in the inner ear resulting from There are more than 80 over- diabetes is microangiopathy (MI-cro- the-counter dietary supplements ann-gee-OP-uh-thee). This narrowing available that claim to help tinnitus — like age-related hearing loss — is a relief or even cure it.4 None are slow, gradual process. approved by the U.S. Food and Drug Speech and environmental sounds Administration (FDA) for tinnitus slowly become distorted. This can relief. Remember, user testimonials happen in all the speech frequencies are not a substitute for evidence- (loudness and clarity) or just the based research. high frequencies, where just the consonant sounds are affected. Diabetes Medications and Tinnitus Diabetes and Tinnitus DiSogra and Meece identified Because tinnitus is a symptom of a 75 FDA-approved medications for problem, establishing a cause is critical. diabetes management: 1 inhalant, 22 It is common knowledge that injectables, and 52 orals.5 tinnitus can occur from hearing None had tinnitus as a reported loss or it can be a drug side effect. side effect. Therefore, if you have This is why a person with tinnitus diabetes, tinnitus, and hearing loss, should discuss their tinnitus with the tinnitus is probably, if not more their primary healthcare provider, than likely, a side effect of the hearing • Continue taking your diabetes pharmacist, or audiologist. loss and not from your diabetes pills and insulin as usual. When the microscopic hair cells in medication. • Test your blood sugar every the inner ear do not function properly To view the complete diabetes four hours and keep track of the for any reason (I like the term “short drug list, go to https://drbobdisogra. results. circuit”), tinnitus can result. com/diabetes-rx-side-effects. The • Make sure that you have at least If you are younger than 60 years list, current as of May 1, 2020, also a two-week supply of your diabe- and have tinnitus with or without shows the side effects that could tes pills and insulin. some degree of high-frequency affect a balance assessment. • Follow the sick day guidelines for hearing loss, you may be at risk for people with diabetes.7 diabetes if the cause of the hearing Covid-19 and Patients The Juvenile Diabetes Research loss can be established. A 2018 study with Diabetes Foundation reports that PWD (type found that 55 percent of people under The coronavirus pandemic is still 1) are no more at risk of getting the age of 60 with diabetes had some with us. The CDC reports that all Covid-19 than non-diabetics but degree of high-frequency hearing loss three types of diabetes — type 1, recommends that blood glucose and compared to 20 percent of people type 2, and gestational — may put ketones be monitored more often with the same hearing loss who did people at a higher risk of severe illness 3 than usual. Also, the foundation not have diabetes. 6 from Covid-19. Therefore, the CDC does not recommend changing the For information about your recommends the following actions for patient’s medication schedule but medications’ side effects, speak patients with diabetes (PWD): recommends that they have more to your primary care physician or food available.8

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The American Diabetes Association PWD should monitor their blood 5 The Audiology Project: www. also recommends monitoring blood glucose/ketones more regularly and theaudiologyproject. glucose and ketones more often than have more than the usual amount com/education-materials 9 usual for PWD with type 2 diabetes. of supplies on hand during the References Both organizations also coronavirus pandemic. 1 Centers for Disease Control and recommend keeping enough As always, if you have any Prevention. (2020). National Diabetes Statistics Report: 2020. Atlanta, GA: CDC. diabetes supplies on hand questions about your hearing or 2 Centers for Disease Control and Prevention. Diabetes Self-Management Education and throughout the pandemic. tinnitus, speak to your physician or Support (DSMES) services. Retrieved from www. audiologist. cdc.gov/diabetes/managing/education.html 3 Hlayisi, V. G., Petersen, L., & Ramma, L. (2018). Summary High prevalence of disabling hearing loss in young Diabetes affects almost as many Robert M. DiSogra, to middle-aged adults with diabetes. International AuD, is an audiology Journal of Diabetes in Developing Countries. persons as the number who have Advance online publication. doi:10.1007/s13410- consultant in hearing loss. There is a wealth 018-0655-9 Millstone, NJ (USA). 4 DiSogra, R. M. (2015). Over the counter tinnitus of information about diabetes He currently holds relief products. (ESCO/Oaktree Products management that is available online faculty positions at publication. Out of print but available at www. the Department of drbobdisogra.com) from reliable sources, including 5 DiSogra, R. M., & Meece, J. (2019). Auditory and Audiology, University national adult and pediatric diabetes vestibular side effects of FDA approved drugs for of the Pacific, San diabetes. Seminars in Hearing, 40(4), 315–326. organizations as well as the CDC. Francisco, CA (USA), 6 Centers for Disease Control and Prevention. Tinnitus from hearing loss that and the Department of Communication (2020, May 14). Coronavirus disease (Covid-19): Groups at higher risk for severe disease. Sciences and Deafness, Kean University, could be related to diabetes should Retrieved from www.cdc.gov/coronavirus/2019- Hillside, NJ (USA). He is also the consultant ncov/need-extra-precautions/groups-at-higher-risk. be of concern to persons under the to The Audiology Project (see resource 5). html#diabetes age of 60. If the hearing loss has an Address all correspondence: 7 Nurko Rd., 7 Centers for Disease Control and Prevention. Millstone, NJ 08535; email: bobd1030@aol. (2019, August 1).Diabetes: Prevent complications. unknown cause, there is a possibility Retrieved from www.cdc.gov/diabetes/managing/ com; website: www.drbobdisogra.com. that the loss may be related to pre- problems.html 8 Juvenile Diabetes Research Foundation. (2020, diabetes or diabetes. Resources May 18).Coronavirus and type 1 diabetes: What All 75 medications approved by you need to know. Retrieved from www.jdrf.org/ 1 Diabetes Self-Management Education and coronavirus the FDA for diabetes management Support (DSMES) Services Program: www.cdc. 9 American Diabetes Association. Diabetes gov/diabetes/managing/education.html are not suspect as a cause for and coronavirus. Retrieved from https://www. 2 American Diabetes Association: www.diabetes.org diabetes.org/coronavirus-covid-19 tinnitus in persons with diabetes. 3 Juvenile Diabetes Research Foundation: www.jdrg.org 4 Association of Diabetes Care and Educational Specialists: www.diabeteseducator.org

More Resources from Dr. DiSogra Listen to Conversations in Tinnitus podcasts with guest speaker Bob DiSogra, AuD, on dietary supplements for tinnitus as well as ototoxicity and tinnitus. To listen, use the following links: • https://www.ata.org/podcasts/episode-8-part-1-over-counter-medications- tinnitus-relief • https://www.ata.org/podcasts/episode-8-part-2-ototoxicity-and-tinnitus Editor’s Note: Dr. DiSogra also authored Ototoxicity: Tinnitus as a Drug Side Effect for Tinnitus Today, Summer 2018, and Over-the-Counter Dietary Supplements for Tinnitus: Do They Really Help? in Tinnitus Today, December 2014.

20 TINNITUS TODAY SUMMER 2020 www.ATA.org SCIENCE & RESEARCH NEWS 

What Does Research Tell Us About Exercise and Tinnitus?

Answered by Fatima Husain, PhD habituating to tinnitus and also the higher levels of activity. In short, it’s good! That is, physical But exercise is not for everyone. exercise is good for dealing with The longer answer, therefore, is tinnitus after onset and throughout that we need more research to one’s life if tinnitus has become understand the nuances of what chronic. This is perhaps not surprising type of exercise and what duration given the latest research on exercise are suitable for a given individual and its favorable impact on aging reporting distressing tinnitus.3 For and myriad other chronic mental and some, breathing exercises and yoga physical health conditions. may be more their cup of tea. Others In a survey study we conducted may prefer running or team sports. some years back, adults reporting Yet others may eschew physical Fatima Husain, milder symptoms of tinnitus also exercise and relax by listening to PhD, is a cognitive reported higher levels of physical music or knitting or reading. All these and computational activity compared to those with neuroscientist by activities and hobbies have been training, with a special 1 bothersome symptoms. The survey found by individuals to be useful in interest in speech did not ask the question of whether helping them deal with tinnitus and and hearing. For the patients adopted more physical improving their quality of life. past 12 years, the major focus of her activity to combat tinnitus-related Patients seek out these activities lab has been the study of tinnitus. Her lab at the distress, but our findings revealed on their own, possibly trying different University of Illinois at Urbana-Champaign has that although tinnitus contributed ones, but with little input from their studied tinnitus using a variety of methods, from behavior and surveys to several types of brain to lowered quality of life, exercise healthcare providers. Again, more imaging. Dr. Husain’s goal is to better understand appeared to boost quality of life in research is needed to investigate the the brain-based mechanisms of tinnitus with the survey respondents. A second contribution of these activities and the a view toward testing and improving existing study using brain imaging found that manner in which they may be helping treatment options and eventually developing customized treatment plans. those reporting mild tinnitus and a person habituate to tinnitus and deal higher physical activity levels used with it on an ongoing basis. As we 1 J. R. Carpenter-Thompson, E. McAuley, & F. T. their limbic system less compared know, chronic tinnitus is not always Husain. (2015). Physical activity, tinnitus severity, to those with bothersome tinnitus and improved quality of life. Ear and Hearing, 36(5), the same, flaring up louder in times 574–581. and lower activity levels.2 The limbic of stress and sleeplessness. Exercise 2 J. R. Carpenter-Thompson, S. Schmidt, E. McAuley, & F. T. Husain. (2015). Increased frontal response system processes emotions, and and other activities are one way to may underlie decreased tinnitus severity. PLoS using it less on a routine basis moderate those flare-ups and have an One, 10(12), e0144419. 3 F. T. Husain, Y. Tai, & M. K. Finnegan. (2016). is probably a consequence of overall better quality of life. Emotional processing and non-auditory based interventions in tinnitus. Perspectives of the ASHA Special Interest Groups, 1(7), 13–23.

www.ATA.org TINNITUS TODAY SUMMER 2020 21  YOUR HEALTH

Changes to Diet and Exercise Can Improve Tinnitus

Although the evidence linking from rapeseed or olives, and limiting healthy eating, exercise, and tinnitus consumption of sugar and alcohol also MH: Some research has documented is limited at this juncture, the ATA helps. We also know that cutting out that higher levels of physical activity consulted a nutrition researcher to or limiting consumption of processed are associated with better hearing get his viewpoint on why we should foods makes a difference. acuity and lower levels of tinnitus make an effort. Unfortunately, it isn’t always clear distress.7–13 Unfortunately, specific to patients and physicians that lifestyle exercise intervention studies in this Martin Hofmeister (MH): So far, there’s changes take an average of eight weeks area are indeed rare.14,15 Nonetheless, limited evidence that dietary quality to become an integrated habit.5 Most exercise remains the cornerstone of affects tinnitus symptoms, so we need people don’t make it to that eight-week good health because it significantly more high-quality analytical studies.1 mark because they change too much reduces the incidence of a wide range But it’s well documented that a healthy, too fast (true for exercise as well), so of diseases, maintains motor skills, fiber-rich diet plays a positive role in start with small, incremental changes. and strengthens our mental health and overall well-being and helps prevent For example, a simple and effective sense of well-being. many diseases, including obesity, gout, tip for creating a long-term behavioral Movement is part of living, so diabetes, and cardiovascular diseases. change would be drinking two cups exercise should be viewed positively. Diabetes mellitus, for instance, is an of water (500 ml) before each meal It’s an evidence-based preventive independent significant risk factor for (beneficial effects include increased and therapeutic tool for reducing the acquired hearing loss and tinnitus.2 fullness, lower calorie intake, increased incidence of more than 30 different Considering that, being more concentration and performance). The chronic diseases, including many deliberate in food choices is important. mantra should be “I want and can well-known risk factors for developing Carrots, tomatoes, and apples not only implement a small change in everyday tinnitus and conditions associated provide important nutrients but also are life for eight weeks. And I know why with tinnitus symptoms such as low in calories. By adding nuts, whole I‘m doing it.”5 diabetes mellitus, hyperinsulinemia, grains (barley, brown rice, cracked Also, primary care physicians hypertension, rheumatoid arthritis, wheat, oatmeal), legumes (chickpeas, and other front-line healthcare anxiety, depression, and stress. So — lentils, peas, soybeans, and other professionals need to support patients please stand up! Right now? You don't beans), and fermented dairy products in their efforts to implement long- have to sit while reading Tinnitus Today. (yogurt, buttermilk, kefir), your diet term lifestyle behavioral principles Unfortunately, in everyday life, becomes part of what keeps you well, and goals for nutritional management. the numerous cardiovascular, mentally and physically. And it’s something that applies to hemodynamic, metabolic, These foods provide ample fiber, physicians themselves in their own endocrinological, immunological, brain- vitamins, minerals, and polyphenols, lives, considering that almost half of functional, gerontological, and positive which have a beneficial effect on the physicians are overweight or obese.6 psychological adaptations of regular intestinal microbiome, which improves muscle activity lose the fight against the immune system, mental health, and Joy Onozuka: Is there a strong the powerful physical law of inertia. cognitive function (keyword: microbiota- argument for exercise improving or Like changes in diet, changes in activity gut-brain axis).3,4 Eating healthy maintaining hearing health, even with can also be made in small steps done fats, such as vegetable oils derived limited research in this area? daily. Tinnitus patients, for instance,

22 TINNITUS TODAY SUMMER 2020 www.ATA.org YOUR HEALTH  are likely to benefit even from simple, G. Dinan. (2019). The microbiota-gut-brain axis. sensitivity among U.S. adults with diabetes. Research Physiological Reviews, 99(4), 1877–2013. Quarterly for Exercise and Sport, 85(3), 390–397. whole-body exercises, such as rising 4 Y. Du, X. R. Gao, L. Peng, & J. F. Ge. (2020). 11 J. R. Carpenter-Thompson, E. McAuley, & F. T. Husain. from a chair and sitting back down again Crosstalk between the microbiota-gut-brain axis and (2015). Physical activity, tinnitus severity, and improved depression. Heliyon, 6(6), e04097. quality of life. Ear and Hearing, 36(5), 574–581. — without using your arms — for 30 to 5 M. Hofmeister. (2017). One tablespoon of dietary 12 P. J. Haas, C. E. Bishop, Y. Gao, M. E. Griswold, & 60 seconds, twice a day. The key is to fiber more. Australian Family Physician, 46(12), 889. J. M. Schweinfurth. (2016). Relationships among 6 M. Hofmeister. (2017). Overweight/obese physicians: measures of physical activity and hearing in African do something each day. By consistently Data from different countries? Canadian Family Americans: The Jackson Heart Study. Laryngoscope, Physician Online. Retrieved from www.cfp.ca/ 126(10), 2376–2381. making simple and practical lifestyle content/63/2/92/tab-e-letters#overweight-obese- 13 J. A. Bazoni, A. C. M. Dias, C. L. Meneses-Barriviera, choices every day, 365 days of the physicians-data-from-different-countries L. L. M. Marchiori, & D. C. Teixeira. (2019). Possible 7 S. G. Curhan, R. Eavey, M. Wang, M. J. Stampfer, association between the lack of regular physical year, significant effects on conditions & G. C. Curhan. (2013). Body mass index, waist activity with tinnitus and headache: Cross-sectional associated with tinnitus symptoms circumference, physical activity, and risk of hearing study. International Archives of Otorhinolaryngology, loss in women. American Journal of Medicine, 23(4), e375–e379. can be realized (for example, increased 126(12), 1142.e1–8. 14 M. Cristell, K. M. Hutchinson, & H. M. Alessio. blood circulation to the brain). 8 P. D. Loprinzi, H. Lee, B. Gilham, & B. J. Cardinal. (1998). Effects of exercise training on hearing ability. (2013). Association between accelerometer-assessed Scandinavian Audiology, 27(4), 219–224. In my daily routine, I remind myself physical activity and tinnitus, NHANES 2005–2006. 15 Y. H. Song, S. M. Ha, J. S. Yook, & M. S. Ha. (2019). of the timeless advice expressed Research Quarterly for Exercise and Sport, 84(2), Interactive improvements of visual and auditory 177–185. function for enhancing performance in youth soccer more than 300 years ago by the 9 F. E. Gispen, D. S. Chen, D. J. Genther, & F. R. Lin. players. International Journal of Environmental (2014). Association between hearing impairment and Research and Public Health, 16(24), 4909. German general practitioner and lower levels of physical activity in older adults. Journal 16 F. Hoffmann. (1719). Thorough instruction on how medical professor Friedrich Hoffmann of the American Geriatrics Society, 62(8), 1427–1433. a person can maintain his health and free himself 10 P. D. Loprinzi, B. Gilham, & B. J. Cardinal. (2014). from serious diseases by sensible use of physical (1660–1742), who said, “Proper physical Association between accelerometer-assessed exercises and moderation as well as avoidance of activity surpasses all other medicines, physical activity and objectively measured hearing unhealthy air filled with harmful vapours. Fifth part. Halle, Germany: Renger. [German]. which one may recommend only for the preservation of health and for the safekeeping of diseases; and for this Benefits of Daily Exercise for People With Tinnitus purpose can rightly be called a universal • Exercise reduces stress hormones, such as adrenaline and cortisol, and medicine, because it not only removes increases the release of endorphins, causing a person to feel better the causes of the disease, but is also a physically and mentally, which helps reduce tinnitus distress. When reliable means for the real strengthening stress levels drop, the amplification of sound traveling within the auditory and well-being of the body.”16 pathway to the brain also decreases. The tinnitus therefore comes across a little quieter, gentler, and less intrusively. Martin Hofmeister, • Physical activity also mitigates common negative side effects of tinnitus, PhD, is a nutrition including restlessness, hopelessness, concentration problems, anxiety, scientist at the Consumer Center of and depression. Movement-related neurobiological adaptation processes the German Federal seem to play a key role in this, including the increased expression of brain- State of Bavaria derived neurotrophic factors, vascular endothelial growth factors, insulin- (Department Food and like growth factor 1, -endorphin, atrial natriuretic peptide, and serotonin. Nutrition), Munich, β Germany. He received Those who are more actively engaging their muscles are generally more his doctoral degree in nutritional science from balanced, relaxed, and better able to cope with stress. Hence, exercise the Technical University of Munich in 2004. Since makes it easier to cope with various stresses of everyday life — including then he has worked on various nutrition and exercise projects. His research and articles on tinnitus. It also has the benefits of improving self-confidence, self-esteem, nutrition and exercise have been published in and social interactions (community or club sports) and of shifting focus more than 180 publications, including national away from tinnitus. and international scientific journals. He is also a • Engaging our muscles stimulates the heart and lungs and significantly reviewer of several international journals. improves blood circulation. This increases the oxygen and nutrient supply

1 P. Dawes, K. J. Cruickshanks, A. Marsden, D. R. throughout the whole body, including the organs and tissues of the inner Moore, & K. J. Munro. (2020). Relationship between ear and the brain. diet, tinnitus, and hearing difficulties. Ear and Hearing, 41(2), 289–299. • Exercise improves sleep, which can be disrupted by tinnitus. 2 C. Spankovich & K. Yerraguntla. (2019). Evaluation and • Exercise strengthens the immune system and stimulates the release of management of patients with diabetes and hearing loss. Seminars in Hearing, 40(4), 308–314. anti-inflammatory substances. 3 J. F. Cryan, K. J. O'Riordan, C. S. M. Cowan, K. V. Sandhu, T. F. S. Bastiaanssen, M. Boehme,...T.

www.ATA.org TINNITUS TODAY SUMMER 2020 23  YOUR HEALTH

Quieting the Mind and Tinnitus With Exercise

By Rami F. Odeh, MS How can I find peace of and take an hour off from outside mind with exercise? distractions to focus only on yourself. There probably has not been a Get back to having fun! Avoid the “have to” syndrome more stressful and uncertain time Play! Do what you enjoy. We are defined by the “shoulds” than 2020. What we are dealing with in our life. We all know exercise is is scary and unsettling and has a good for us, but some days it might component of daily change that most be better to just take a relaxing day people are not equipped to handle. off and sit by the pool with a good, We spend so much of our day inspirational, and uplifting book! glued to our devices, being pushed and pulled by news and external Avoid following other circumstances that we have zero people’s programs control over, so it’s no wonder It’s fine to use a sample or ideas from an exercise program but adjust it for anxiety, depression, and stress levels What type of exercise is are at historical highs. And if you your goals and personal limitations. have tinnitus, the added stress can Learn to be intuitive about best to quiet my mind? make it worse, which is the last thing your stress Proper warm-up and cooldown we need to be dealing with during Learn your body’s stress signals. We One of the mistakes people make uncertain times. each react differently to stress, so with exercise (especially people over What can we do? get in touch with your body’s stress 40 years of age who need a longer It may sound like a weak platitude responses and adjust accordingly. warm-up and cooldown) is jumping that all we can do is control the things Find a partner (as long as right into their workout with no warm- in our life that we can control. they’re calm!) up. This induces an immediate rise We all know that exercise is one, Make sure your training partner brings in stress hormones and can actually if not the, best method to reduce you up and allows “grace” when you cause you to burn more blood sugar stress and quiet the constant chatter cannot make a workout, because and less body fat, which can lead to a and noise in our heads, which might flexibility in your workout schedule miserable workout and perhaps make be tinnitus or negative self-talk, matters. Don’t partner with someone you more stressed after the workout! during stressful and scary times. But too rigid who adds stress to your life! Make sure you warm up very slowly, how much is enough? How much is Leave your technology at home with a slow walk, gentle rolling on a too much? What type of exercise is Or leave it in the car, or at the very foam roller, easy biking, and so on for the best for stress relief and peace least put your phone on airplane mode at least five minutes at the beginning of mind? of each workout, and do the same to

24 TINNITUS TODAY SUMMER 2020 www.ATA.org YOUR HEALTH 

cool down your body at the end of adequate recovery time, even if that something every morning before every workout. means taking a one- or two-week break. breakfast), but allow yourself (and your Cardiovascular in aerobic zone What do you really enjoy? training partners) the grace to miss a Go at “conversation” pace while This should be your “core” exercise. workout, or change the time of day, if brisk walking in nature, swimming Bottom line, if you love any form the situation demands it. comfortably, slowly biking on a flat of exercise — swimming, running, Limited and consistent is better than road (NOT in traffic), and so on. Cardio weight training, dancing, walking, inconsistent high-volume exercise is one of the best forms of exercise hiking, scuba diving, and so forth I have seen much better results and a to quiet your mind and relax, but — that is what you could do. Don’t higher level of happiness and peace of make sure you exercise at a level do a form of exercise because you mind with clients who exercise 20 to where you can hold a conversation “should” or someone said it is the 30 minutes consistently versus those with someone. If you are so out best option for calorie or fat burning. who exercise once a week for 60 to of breath you cannot talk, you are If you like something, you are much 90 minutes. Inconsistent exercise can driving yourself into that stress- more likely to actually stick with it, actually cause more stress because hormone-inducing zone that will not be and exercising will be a way to escape it is such a shock to your body, and beneficial for long-term stress relief. the daily stress, not create another more injuries can occur because your If you have access to a heart rate stressor in your life because you don’t body is not ready for the demands that monitor, aim for 60–70 percent of your look forward to it. you’re placing on it. The goal is to just maximum heart rate. move, simply get outside — the rest Yoga How much should I do? will come organically. Yoga is a great option for quieting Allow for adequate recovery Rami F. Odeh your mind, just consider that it can Recovery is very individual. To founded FormWell be difficult for newcomers, so start determine whether you’re overtraining, Personal Fitness with an easy beginner’s class and measure your resting heart rate after Training, located progress slowly. And look for a class exercising. If it’s 10 beats above in Sandy Springs, normal, take a full day or two off and Georgia, in 1999. that emphasizes the importance of He has helped breathing, another important skill to resume exercise only when your heart more than 5,000 regulate stress. rate returns to normal. clients achieve their exercise and weight Consider stress levels in other Stretch class loss goals. In 2019, Stretch classes are another great areas of life he sold this business option, and many free classes are You can adjust your intensity to pursue his next dream career: motivational speaking, writing, available online. The goal is to hold depending on where your stress levels are. If things are going well, you might and coaching. He has dual master’s degrees, each stretch for at least 30 seconds. one in industrial psychology and the other in Again, it’s critical to warm up decide to push yourself to a higher exercise physiology, and is certified by the adequately for this activity. level of exertion. If you are super American College of Sports Medicine as a stressed, then it’s time to focus on health and fitness specialist. He also worked Weight training for 11 years for Northside Hospital in Atlanta calm, taking an easy hike in nature or a Lifting weights two or three times a as an exercise physiologist in the Outpatient walk in a quiet area. week is very healthy and something Weight Reduction Clinic and the Diabetes Education Department. He is an amateur everyone could do for health, but, Follow your intuition, not a rigid schedule triathlete, obstacle course racer, and trail again, don’t push yourself to the runner. His current life mission is to positively A schedule is great when things point where you start to feel a lot affect the lives of as many people he can, are going well, and it helps a ton of discomfort when your aim is to using speaking, coaching, and his three- with compliance. During high-stress volume series of published books: Quiet the destress. It’s key to give your body periods, it’s good to have a flexible Noise: A Trail Runner’s Path to Hearing God. schedule (for example, a goal to do

www.ATA.org TINNITUS TODAY SUMMER 2020 25  YOUR HEALTH

What Do Diets and Tinnitus Therapy Have in Common?

By LaGuinn P. Sherlock, AuD

Most of us have been on at least one diet in our lifetime, to lose weight, to manage a health condition such as diabetes or hypertension, or to simply feel healthier. As you know, diets differ in the type and quantity of food you can eat. Some diets restrict certain types of food, such as food high in fat. Some diets are limited to a given caloric intake. Whatever the case, you must follow the diet to achieve the desired outcome (e.g., losing weight, getting off medication). Some diets are “tinnitus diet” that is right for you, diet” should result in reductions in challenging and difficult to implement. one that is compatible with your awareness of your tinnitus, annoyance Everyone has a different tolerance lifestyle, your preferences, and your with your tinnitus, and difficulty with level for discomfort associated with a desired outcome. sleep, concentration, and/or mood. You given diet (like giving up potato chips Finding the right “tinnitus diet” should also notice an improvement in on a low-salt diet or pie on a weight- starts with realistic expectations. your overall quality of life. loss diet). Sometimes the desired Complete elimination of tinnitus is A number of “tinnitus diet” options outcome (e.g., losing 10 pounds) not realistic in most cases. However, can help you achieve the desired takes much longer (e.g., more than a noticeable reduction in how much outcome, namely, reducing the two weeks) than you want, which tinnitus bothers you, especially a effect tinnitus is having on your life. may affect your ability and motivation reduction large enough that tinnitus “Tinnitus diets” can be self-directed, to follow the diet. Having realistic no longer affects you every day, is a peer-supported, or professionally expectations about the outcome itself realistic goal. Several “tinnitus diet” directed by an audiologist or behavioral and the time course to achieve that options are available to help you meet healthcare provider, in the same outcome is important for maintaining that goal. way that diets can be self-directed adherence to the diet. It is important to keep in mind that or under the direction of a physician, What do diets have to do with not everyone with tinnitus needs to be nutritionist, or related provider. The tinnitus? Well, in much the same way on a “tinnitus diet”. If your tinnitus is desired outcome and the ability to that there are different diets with not affecting your ability to sleep or to follow the management protocol are different foods and schedules, tinnitus concentrate, and if it isn’t making you key to identifying the right “tinnitus management strategies involve feel irritable or depressed or anxious, diet” for you. different “foods” and “schedules.” I then a “tinnitus diet” probably isn’t Almost all “tinnitus diets” include will refer to the different strategies going to change anything. If, however, at least one of the following three as “tinnitus diets.” The key to a you are affected by your tinnitus, then components, which have been shown successful outcome is finding the dedicated adherence to a “tinnitus

26 TINNITUS TODAY SUMMER 2020 www.ATA.org YOUR HEALTH 

to be helpful in reducing the effect of primary factor affecting your sleep, management strategies (e.g., stress tinnitus on day-to-day living: concentration, and mood. Therefore, it reduction strategies) employed. The • counseling, is critical that you identify strategies to key to success is finding the “tinnitus • stress reduction strategies, and reduce your stress response and use diet” that works for you, which • sound enrichment. them as often as possible. Strategies depends in large part on identifying include deep breathing, progressive your desired outcome. For example, Counseling can be informational, muscle relaxation, walking, and one “tinnitus diet” might address interactive, or directive. Informational listening to relaxing music (see anxiety really well (e.g., CBT), but not counseling can help you understand appendix for more details). problems with hearing, or vice versa. what tinnitus is and, more importantly, Sound enrichment is another The most cost-effective “tinnitus diet” what it is not. A better understanding component of tinnitus management. should be attempted first. of tinnitus can help you change the Most people with bothersome tinnitus Earlier I mentioned that “tinnitus way you think about your tinnitus. tend to notice their tinnitus often diets” could be professionally Interactive counseling may better when in a quiet room. The goal of directed by an audiologist or address the way you think and feel sound enrichment is to reduce the behavioral health therapist. Table 1 about your tinnitus. Interactions perceptual contrast between sound is a comparison of “tinnitus diets” with others who have learned how in your environment (external sound) directed by audiologists. The chart is to manage their tinnitus may be and the sound of your tinnitus (internal not representative of all the “tinnitus beneficial as well. sound). The contrast is much larger diets” available, but those most The ATA website lists support when you are in a quiet environment commonly used are listed. Some groups and volunteers available and is therefore difficult for your brain of the “tinnitus diets” listed have to talk to you about your tinnitus not to attend to it. The more noticeable undergone randomized controlled (see appendix). Some tinnitus the tinnitus is, the more bothersome trials, some provide training for management therapies provide it can become. Sound enrichment audiologists and allied health directive counseling, a type of can be accomplished by using such professionals, and some have material counseling in which the healthcare things as fans, sound spas, and/or the readily available to you online. provider offers specific advice, use of hearing aids, ear-level sound With regard to the “foods” in guidance, and recommendations. generators, or cochlear implants. “tinnitus diets”, sound therapy is Some people respond better to this Enriching your sound environment will not essential but generally results in type of counseling, while others decrease the contrast and over time better outcomes. Hearing aids alone respond better to a more interactive will help you habituate to your tinnitus can be as effective as hearing aids and patient-centered approach. Non- so that you do not notice it all the combined with sound generators. The tinnitus-specific counseling, such as time. specifics of the counseling, which vary cognitive behavioral therapy (CBT), It is important to keep in mind from diet to diet, do not significantly can effectively reduce your reaction that no single method of tinnitus impact the outcome. In other words, to tinnitus and consequently improve management helps 100 percent of generic counseling can be as effective your overall quality of life. Also offered the people who use it. This is true as specialized counseling. What has are online tinnitus management also for other healthcare treatments been demonstrated repeatedly is programs based on mindful meditation and therapies. There are multiple that counseling of some sort plays a and CBT. approaches to tinnitus management, significant role in reducing the reaction It is important to understand that so if one “tinnitus diet” does not to tinnitus. if you have bothersome tinnitus, your work for you, try another. “Tinnitus Barriers to accessing audiological stress response is being activated all diets” differ in the content and style tinnitus management therapies the time when it shouldn’t be. The of counseling, the implementation exist, including affordability and stress response is activated by the of sound therapy, and the specific accessibility. These barriers can be perceived threat of tinnitus and is the

www.ATA.org TINNITUS TODAY SUMMER 2020 27  YOUR HEALTH overcome by utilizing counseling/ https://www.health.harvard.edu/staying-healthy/ understanding-the-stress-response informational materials that are LaGuinn P. Sherlock, AuD, has been https://www.uofmhealth.org/health-library/uz2255 available online and seeking practicing audiology (deep breathing exercise) behavioral health counseling that since 1991 and https://www.statnews.com/2019/08/12/chronic-pain- may be covered by insurance. has worked with journey-five-things-understand/ (chronic pain is similar to chronic tinnitus) The affordability of hearing aids is thousands of patients who have tinnitus, www.ata.org/managing with hearing aids (how hearing projected to improve with changes in both clinically and aids might help) FDA regulations that allow for over- in research. She the-counter hearing aids. Although has worked at Sources Consulted Johns Hopkins Medical Center and University OTC hearing aids are not yet available, Bauman, N. Tinnitus Practitioners Association. of Maryland Medical Center, and currently Retrieved from http://www.tinnituspractitioners.com other lower-cost options such as works for the Army Public Health Center at Henry, J. A., Schechter, M. A., Zaugg, T. L., & Myers, P. direct-to-consumer hearing aids are Walter Reed National Military Medical Center. J. (2008). Progressive audiologic tinnitus management. ASHA Leader, 13, 14–17. currently available. Sherlock is studying the effect of tinnitus on concentration, using reaction time and short- Jastreboff, P. J., & Jastreboff, M. M. (2000). Tinnitus In summary, many “tinnitus diets” term memory tests. She is former Chair of the retraining therapy (TRT) as a method for treatment are available. No one diet works for ATA’s Board of Directors and is a current Board of tinnitus and hyperacusis patients. Journal of the American Academy of Audiology, 11, 162–177. everyone. The outcome of the diet member. Sweetow, R. W. (2013). Integrated approach to tinnitus may not be exactly what you hoped management. Audiology Online. Retrieved from https:// for, but by adjusting expectations, Appendix www.audiologyonline.com/articles/integrated-approach- https://www.ata.org/managing-your-tinnitus/support- to-tinnitus-management-11598 you have every reason to believe that network/telephoneemail-support-listing Tyler, R. S., Gogel, S. A., & Gehringer, A. K. (2007). the right “tinnitus diet” for you will https://www.ata.org/managing-your-tinnitus/support- Tinnitus activities treatment. In B. Langguth, G. network/support-group-listing Hajak, T. Kleinjung, A. T. Cacace, & A. R. Møller (Eds.), improve your quality of life. Tinnitus pathophysiology and treatment (pp. 425–434). Amsterdam, Netherlands: Elsevier.

Table 1: “Tinnitus Diets” “FOODS” Generic1 TRT1,2 TAT 3 PTM1, 2,3 ITT CHaTT2 Audiological evaluation

Structured interview

Determination of handicap/functional impact

Tinnitus pitch/loudness

Informational counseling

Directive counseling

Interactive counseling

Development of coping strategies

Relaxation strategies

Sound enrichment

Hearing aids/maskers

TRT – Tinnitus Retraining Therapy (Jastreboff et al.) TAT – Tinnitus Activities Treatment (Tyler et al.) 1 – RCTs PTM – Progressive Tinnitus Management (Henry et al.) 2 – Provider training available ITT – Integrated Tinnitus Therapy (Sweetow et al.) 3 – Counseling materials available online CHaTT – Cognitive Habituation Tinnitus Therapy (Bauman et al.)

28 TINNITUS TODAY SUMMER 2020 www.ATA.org SCIENCE & RESEARCH NEWS 

Trying to Connect the Dots Between Diet and Tinnitus and Hearing Loss

Summary by John A. Coverstone more than five minutes at a time Eating foods with vitamin D or high and is currently experienced at least protein was associated with fewer Large population surveys some of the time. Hearing loss was reports of hearing loss. As may be provide a wonderful resource to based on self-reporting of difficulty expected, when the researchers study correlations among a great hearing. Approximately one-third of analyzed the data looking for number of factors at once. A group Biobank participants completed a test associations of diet with both hearing of researchers from University of of speech understanding in noise, loss and tinnitus, similar associations Manchester in the United Kingdom, and these results were found to be were found with the exception of in cooperation with the University of similar to self-reporting. Assessment vitamin B12 correlating with poorer Wisconsin, studied the relationship of diet consisted of a detailed hearing and high-protein diet no longer between diet and tinnitus and hearing questionnaire about 200 common being associated with hearing. loss by using the U.K.’s Biobank food and beverages consumed in Further research would be needed, resource.1 Biobank includes data on the previous 24 hours. Other health of course, to determine whether 500,000 U.K. residents, with the diet conditions were derived from prior the nutrients identified in this study questionnaire provided to the last medical diagnosis or common signs may make someone more or less 70,000 participants. Participants were and symptoms of the condition. susceptible to hearing loss and tinnitus adults ages 40 to 69 who completed Analysis of nutrients associated or perhaps whether a completely two to five questionnaires within with tinnitus indicated that people different factor may even be common a year’s time. The questionnaires eating foods with vitamin B12 were to each. Perhaps people who eat more included many questions about less likely to report tinnitus. People poorly are more social and exposed dietary habits and health conditions, who ate more fat, calcium, and to a greater amount of loud noise. including tinnitus and hearing loss. For iron tended to be more likely to Nonetheless, there appears to be a this study, the researchers selected have tinnitus. The researchers also correlation between diet and hearing 34,576 participants based on the added reported hearing difficulties loss and tinnitus. This study offers researchers’ requirements (completion as a variable to see whether dietary a stepping-stone to more advanced of both hearing and tinnitus questions, associations with tinnitus were research looking at whether and age between 40 and 69 years, dependent at all on hearing. However, how we might change diet to be less minimum completion of two dietary results did not change significantly. susceptible to these conditions. questionnaires, etc.). This suggests that any effects of diet Because of the format, respondents on tinnitus are independent of hearing. 1 P. Dawes, K. Cruickshanks, A. Marsden, D. Moore, & K. Munro. (2019). Relationship between diet, self-identified these conditions. Similar to tinnitus, eating fat and tinnitus, and hearing difficulties. Ear & Hearing, Tinnitus was described as ringing or saturated fat were linked with more 41(2), 289–299. buzzing in one or both ears that lasts frequent reporting of hearing loss.

www.ATA.org TINNITUS TODAY SUMMER 2020 29  SPECIAL FEATURE The Link Between Diet and Hearing Loss

Summary by John A. Coverstone, AuD Christopher Spankovich, PhD, at Research into curing hearing loss University of Mississippi continues to progress and show and Colleen LePrell, PhD, promise for restoring some degree at University of Texas at of lost hearing. At the same time, Dallas recently collaborated many researchers are looking at ways to provide a more thorough to strengthen our hearing system look at the relationship between in the hope that we might prevent diet and noise-induced hearing loss, hearing loss from occurring in the in the hope of providing guidance on University of Minnesota furthered first place. For many years, the U.S. healthy eating habits that support this study in 1982 by showing that military has invested in research healthy hearing.4 inhabitants of Easter Island who had into such drugs as D-methionine, They found that early research on lived only on the island their entire an amino acid that has been long this topic involved the relationship of lives had better hearing than island investigated by Kathleen Campbell, fat and cholesterol to hearing loss. natives who had lived in modern PhD, of Southern Illinois University.1 In animal models, high levels of civilization. This was attributed both More recent breakthroughs include either were associated with a greater to differing diets and greater noise the 2018 publication of St. Jude’s likelihood of damage from noise exposure in modern society. researchers’ discovery of an enzyme exposure. Deficiency of necessary Long-term studies of human that protects rats and mice from nutrients has also been shown to populations have shown similar hearing loss and the 2020 publication make people more susceptible to results. A notable study published of research from the University of hearing loss from noise exposure. in 2010 followed almost 3,000 Iowa and Washington University These are too many to list but include inhabitants of the Blue Mountains showing that a certain type of hearing important vitamins and minerals, such in Australia for three years, plus loss could be prevented by blocking a as magnesium and vitamins A, B12, C, follow-up for five additional years to chemical receptor in the ear.2,3 Other and E, among others. track mortality. This study showed research has shown positive effects Most of these studies came from poorer hearing in those with high of antioxidants and anti-inflammatory animal models because it is not ethical carbohydrate and sugar intake, agents in reducing the risk of hearing to manipulate nutrition in humans. estimated by increased glycemic loss from noise exposure. However, some human studies index. In another study, 65,000 However, while it may sound exist to support these findings. women were followed as part of the attractive to take a pill or an injection One study well known in audiology Nurses’ Health Study II by Brigham before attending that rock concert or circles involves the Mabaan tribe of and Women’s Hospital, Harvard engaging in a military operation with the Sudan, who, in general isolation Medical School, and Harvard T. potential combat, all this research from modern society, maintained a H. Chan School of Public Health. raises questions about the role of healthy diet and active lifestyle with Researchers found better hearing diet in hearing loss. D-methionine, for very little exposure to loud noise. present in women with higher intake instance, occurs naturally in certain In a 1962 study by Samuel Rosen of certain sources of vitamin A. animal products, including meat, of Mount Sinai School of Medicine, The study also reported that high eggs, and fish. Other nutrients that tribal members were found to have intake of vitamin C (often termed affect the resilience of our ears may normal hearing into their 80s. Marcos “megadoses”) was associated with yet be discovered. Goycoolea and others from the

30 TINNITUS TODAY SUMMER 2020 www.ATA.org SPECIAL FEATURE 

poorer hearing. This presents an restriction can be made for any will improve hearing health. This is important note that maximizing intake health benefits. a complex problem, though, and a of nutrients discussed in this article Although we can see promising solution will take time to achieve will not necessarily result in better outcomes in all this research, there with confidence. In the meantime, hearing. Other studies have found remains much to be done before any the best advice is to follow the U.S. that recommended intake of vitamin recommendations can be made for Departments of Agriculture (USDA) C was associated with better hearing the general population. As Spankovich and Health and Human Services at some pitches. and Le Prell point out, multiple (HHS) recommendations for a While a healthy diet is hopefully a confounding factors influence the healthy, balanced diet and to protect goal for each of us, some researchers effects of diet on hearing and hearing your hearing whenever loud noise is have studied the effects of poor loss. Many dietary substances have present. nutrition also. A study by Ulf Rosenhall been studied in isolation without and colleagues at the Karolinska looking at intake or levels of other 1 K. C. Campbell, R. P. Meech, J. J. Klemens, M. T. Gerberi, S. S. Dyrstad, D. L. Larsen,…L. F. Hughes. University Hospital in Stockholm substances. The interaction of roughly (2007). Prevention of noise- and drug-induced showed a relationship between 60 essential nutrients may play a hearing loss with D-methionine. Hearing Research, 226(1–2), 92–103. junk food and poorer hearing. The pivotal role in how much benefit 2 T. Teitz, J. Fang, A. N. Goktug, J. D. Bonga, S. Diao, R. A. Hazlitt,…J. Zuo. (2018). CDK2 inhibitors as researchers also found a positive is derived from them in our diet. candidate therapeutics for cisplatin- and noise- relationship between eating fish Further, relative levels of each may induced hearing loss. Journal of Experimental Medicine, 215(4), 1187–1203. and good hearing. Other studies, as need to be considered, as we saw 3 N. Hu, M. Rutherford, & S. Green. (2020). alluded to earlier in this article, have with vitamin C earlier. Moreover, Protection of cochlear synapses from noise- induced excitotoxic trauma by blockade of Ca2- shown poorer hearing correlated with diet cannot be completely separated permeable AMPA receptors. Proceedings of the higher body mass index and higher fat from other lifestyle choices. Exercise National Academy of Sciences, 117(7), 3828–3838. 4 C. Spankovich & C. Le Prell. (2019). The role of diet mass index, which may be viewed as a is intrinsically linked to the effects in vulnerability to noise-induced cochlear injury and consequence of a diet high in fats and of diet, as are any prescribed or hearing loss. Journal of the Acoustical Society of America, 146(5), 4033. processed sugars. over-the-counter medications and In addition to what people eat, supplements and possibly even the how much is eaten has also been unintended absorption of elements studied. The majority of research in our food, water, and air. Also, involving caloric restriction has been potential differences in gender and focused on life span/longevity, but age may influence recommended some studies have looked at hearing dietary changes. Last, the majority status as well. Spankovich and Le of studies summarized here involve Prell report that there appears to be animals, and we cannot assume a “tenting” effect, where moderate that dietary influences — positive or caloric restriction has shown benefit negative — will translate directly to for longevity and excessive caloric humans. In fact, the widely varied restriction is detrimental. The effect diets of animals probably indicates of caloric restriction on hearing has that they will not. been varied in different studies, As research continues and but this is unsurprising, because more human studies are longevity studies have demonstrated available, we may find different effects even just within sufficient evidence various strains of mice. Much more to support research will be necessary before specific dietary any recommendations about caloric changes that

www.ATA.org TINNITUS TODAY SUMMER 2020 31  SCIENCE & RESEARCH NEWS

Can Your Personality Influence Tinnitus Treatment?

Summary by John A. Coverstone, AuD The researchers looked at the was anywhere from 2012 to 2017. effects of personality on tinnitus by Therefore, data from initial visit to Tinnitus is an auditory phenomenon comparing tinnitus questionnaire re-test in 2018 measured change heard only by the individual. Therefore, scores of patients who visited a in tinnitus distress over a one-year it should not be surprising that tinnitus clinic between 2012 and 2017. period, five-year period, or length psychological distress and disorders The same tinnitus questionnaires of time in between. This is a likely are generally understood to be were completed by patients in reason why time was a predictor of associated with tinnitus distress. 2018, as was the BFI2. The Tinnitus improvement in tinnitus. Tinnitus treatment must account for Handicap Inventory (THI) and Tinnitus These findings suggest that the psychological needs of the patient Questionnaire (TQ) were used to a patient’s personality is related and be targeted to each individual. determine any changes in tinnitus to changes in tinnitus over time. A distinct characteristic of all people distress between the time of visiting The same personality traits were is personality. Although this is not the clinic and 2018. In all, 388 patients generally associated with changes in formally assessed or used in directing were included in the analysis. They tinnitus whether the patient pursued tinnitus treatment, it would be fair to were separated into three groups: treatment or not. With additional say that personality to some extent “clinically improved,” “clinically stable,” study in this area, clinicians may be influences most clinical treatment. or “clinically worsened.” able to tailor tinnitus treatment to the A group of researchers at the The researchers found that patients personality type of a patient in order to University of Regensburg in Germany who scored higher in neuroticism achieve better outcomes. and the University of Zurich in were generally associated with Switzerland studied personality traits worsening tinnitus as measured with 1 J. Simões, W. Schlee, M. Schecklmann, B. Langguth, D. Farahmand, & P. Neff. (2019). Big five personality and how they relate to treatment both the THI and the TQ. Higher rating traits are associated with tinnitus improvement over outcomes for tinnitus patients.1 of extraversion (which is the opposite time. Scientific Reports, 9, 18234. The researchers note that several of introversion) was associated with models of personality traits exist, improvement in tinnitus distress over but they chose one that outlines five time on the THI (but not on the TQ) personality traits: agreeableness, when compared with scores of those conscientiousness, extraversion, in the “stable” or “worsened” groups. neuroticism, and openness. These Other personality traits were not were measured using a 60-item reported to have significant association questionnaire called the Big Five Index with tinnitus. 2 (BFI2). Age and gender were also The other item that predicted explored as factors associated with changes in tinnitus scores was time. tinnitus questionnaire scores. Each patient’s initial visit to the clinic

32 TINNITUS TODAY SUMMER 2020 www.ATA.org TINNITUS RESOURCES 

In Pursuit of Quiet: The Quest Before the Pandemic

Review by David M. Sykes of silence and noise in his book In without it. The film is a meditative Pursuit of Silence, which Patrick Shen acoustic journey that explores our Book: In Pursuit of Silence, by George turned into a documentary with the relationship with quiet and the impact Prochnik, 352 pp., Anchor Books, NY same title. that it has on our lives. Film: In Pursuit of Silence, directed by I was part of an organizing event* For many of us, reading is a Patrick Shen (2017) that featured Prochnik reading from his meditative act — and so is seeing this https://www.pursuitofsilence.com/ book before large audiences of noise- extraordinary film. So, as we inch our control engineering professionals. At way back to a new normal, take time Silence is a pipedream for anyone one of these readings was Shen, a to explore your relationship with quiet, with chronic tinnitus, unattainable yet fellow seeker of quiet who also has despite tinnitus. yearned for. And here we are more tinnitus. It was a privilege to introduce than halfway through 2020, emerging the two men and then watch them *Between 2010 and 2016, I worked with the MSF Memorial Trust to produce nine public outreach from a ghostly, pandemic-induced time stride off together toward the coffee workshops in major cities, including New York City, of silence and solitude that abruptly bar, talking animatedly. Later we San Francisco, Pittsburgh, London, and Tokyo, which were intended to bring attention to the 2011 report reduced environmental noise across helped Shen secure the money from the U.S. National Academy of Engineering, the planet by 35 percent — no planes, needed to produce his film, which was Technology for a Quieter America. no construction noise, no traffic, no released in 2016 and won awards and shouting, and no more cacophonous David Sykes is praise at international film festivals. lead author of the restaurants. What a strange and Though the book and the movie book Sound & wonderful difference. share the same title, they are Vibration 2.0 and a Like it or not, this “quiet period” completely different experiences. contributor to the National Academy was a gift, a once-in-a-lifetime Both are personal explorations of why of Engineering opportunity to travel back in time and quiet matters and what it’s like to report Technology revisit the preindustrial world. Was make silence a part of your life, as do for a Quieter America, the General Service Administration’s Sound Matters, and other this the dream of quiet we longed monks of many faiths as well as some books. He is vice chair of The Quiet Coalition for? Did it make your tinnitus better medical doctors, philosophers, and and cofounder of LARA, the Laboratory or worse? other seekers of solitude. for Advanced Research in Acoustics, at Many discovered that it’s not For Prochnik, the book was a Rensselaer Polytechnic Institute. A graduate silence we have been seeking, but of the University of California, Berkeley, with profound journey in search of what advanced degrees from Cornell University, peace and relative quiet. Long before “silence” is, who practices it, why he served as a member and officer of ATA’s the pandemic, George Prochnik it matters, and what life is with and Board of Directors from 2014 to 2017. explored the relational experience

www.ATA.org TINNITUS TODAY SUMMER 2020 33  SCIENCE & RESEARCH NEWS

Does Tinnitus Truly Interfere With Hearing?

Summary by John A. Coverstone, AuD To measure the effects of tinnitus that animals with no tinnitus can be on hearing, they had 45 people with conditioned to perform a task when One of the most common tinnitus complete a series of auditory they experience a break in an external complaints of people with tinnitus is tasks. They also had 27 people with sound. Then, if an animal develops how much it affects their hearing. This normal hearing and no tinnitus perform tinnitus during the experiment, is particularly true of individuals with the same tasks. Subjects performed researchers presume it will not bothersome tinnitus. However, even an array of auditory tasks, although change its behavior when there is a people with more mild conditions not all subjects completed all tasks break in the external sound because frequently comment about their because of time constraints. there is instead a persistent sound tinnitus impacting their ability to Tasks included: in the animal’s environment: tinnitus. understand others’ speech. • gap detection, in which an Therefore, no break in sound is Audiologists who specialize in individual identifies whether one or experienced. Researchers often use tinnitus know that tinnitus typically multiple stimuli are presented, this theory to determine whether occurs at just a few decibels above • frequency discrimination, which is animals develop tinnitus during the softest sound a patient can hear a measure of how different in pitch experiments. — called the hearing threshold. As a stimuli need to be before a subject Zeng and colleagues challenged result, clinicians believe that tinnitus can tell them apart, this theory for humans with the probably does not affect hearing • intensity discrimination, in which a assumption that other cues are itself as much as it distracts patients subject identifies whether stimuli present in conversation. They psychologically or causes them are different loudness, proposed that humans (but possibly to mistake the effects of hearing • masking tasks, which involve not animals) would have normal loss as tinnitus interference. (See identifying stimuli with noise gap detection even with tinnitus “Distinguishing Between Hearing present in the other ear, present. Temporal cues (spacing Loss, Tinnitus, and Hyperacusis,” by • temporal modulation detection, between words and pauses in James A. Henry in the Spring issue of in which a subject attempts to speech) are an important part of Tinnitus Today.) determine whether stimuli are verbal communication and some Fan-Gang Zeng, PhD, and his steady or modulated to varying believe tinnitus may affect speech associates at the University of extents, and understanding because it occupies California, Irvine, recently sought to • speech-in-noise testing, which the gaps in speech. The researchers take this idea a step further and see consists of repeating words or wanted to be sure that hearing loss whether the evidence shows tinnitus sentences with background noise did not contribute to decreased gap truly affecting hearing. Their research present. detection. They therefore chose 10 has been accepted for publication in One theory of tinnitus interference, control subjects and 11 subjects the Journal of Neuroscience. developed in animal research, is with tinnitus and compared gap

34 TINNITUS TODAY SUMMER 2020 www.ATA.org SCIENCE & RESEARCH NEWS 

detection at low frequency (500 Hz), had significantly better intensity and the score was calculated based mid-frequency (2,000 Hz), and high discrimination than the control group on the number of correct responses. frequency (8,000 Hz). No significant at 30 dB. Zeng thought this might be Words were presented with three difference was measured, so they a result of the more rapid increase in different background sounds then measured gap detection with loudness often people with hearing present: a noise sound, a competing stimuli set at the measured frequency loss experience. He studied this male speaker, and a competing of each subject’s tinnitus. They found effect further and was able to rule out female speaker. An age effect was that gap detection in those with hearing loss as the underlying factor. discovered when analyzing subjects’ tinnitus still did not vary significantly Instead, he stated that tinnitus might ability to understand speech in noise, from that of the control group. be the reason people performed better indicating that the aging process may Frequency discrimination was on intensity discrimination tasks than contribute to difficulty understanding measured at 30 dB (soft sound for did those in the control group. speech in the presence of noise. those with normal hearing) and 70 Another task involved presentation However, tinnitus did not contribute dB (loud-ish sound for those with of a tone with a broadband noise to any significant differences between normal hearing) above the person’s playing. The participant was tasked the groups. lower threshold of hearing. Stimuli with detecting the tone each time. Dr. Zeng has proposed an attention- were presented slightly above and A threshold was established at normalization model to describe below 500 Hz, 2,000 Hz, and 8,000 the softest point the tone could be people’s perception of the effect of Hz, as well as at the pitch of the detected. For this task, there was tinnitus on hearing. Essentially, the person’s tinnitus. Again, no significant likewise no significant difference in ear hears external sounds and they differences were found between the how people with tinnitus detected a are relayed up through the auditory control group and the people with short tone in the presence of noise nervous system to the brain. This is tinnitus when pitches different from compared with those in the control called a bottom-up processing strategy a person’s tinnitus were used. There group. However, a small but significant because sound begins at a lower level were some effects of hearing loss difference was found when comparing (the nerves connected to the ear) on frequency discrimination at 8,000 how much louder that stimulus and is carried upward to the brain. Hz, which is the pitch most likely to needed to be compared to the noise. Tinnitus, on the other hand, originates be affected by decreased hearing. This is called overshoot and was in the brain and is processed from the However, there were no significant compared for all subjects. It was noted top down. Zeng proposes that these differences in frequency discrimination for some conditions that the overshoot processing pathways may be separate between the normal-hearing control was greater for those with tinnitus. and each may be independently group and the people with tinnitus When the participants were asked modulated by attention. when stimuli were matched to to detect whether a stimulus was The data in this study shows that people’s tinnitus. modulated (think of a musician using tinnitus affects only a few of the Intensity discrimination was also vibrato), there was also no significant parameters studied, and only one of measured at the same loudness and difference between those with tinnitus those was a negative effect. The other pitches as frequency discrimination, and the control group. differences noted between people with loudness varied slightly above Lastly, people were asked to with tinnitus and the control group and below the target levels. The 30 dB repeat words presented in a noisy were an improvement in hearing and 70 dB targets were also relative background. This is a common test function. As a result, Zeng concludes to each participant’s hearing threshold. used in an audiology examination and that tinnitus does not affect hearing For most presentations, there were no has been shown to be an effective and understanding of speech. significant differences between those way to determine if someone has with tinnitus and the control group. hearing loss. For this task, people Zeng, F.G., Richardson, M. & Turner, K. (2020). Tinnitus does not interfere with auditory and speech perception. Interestingly, those with tinnitus repeated phrases the best they could Journal of Neuroscience. 2020(10): 1523.

www.ATA.org TINNITUS TODAY SUMMER 2020 35  PERSONAL STORY

When My Tinnitus Went Viral, Life Changed

By Yvonne Sopp been damaged. Moreover, it was so out of the realm of my thoughts that Two and a half years ago, a virus my hearing loss would be permanent Unfortunately, that window of time completely changed my life. It that I actually wasn’t particularly upset passed for me before I received the wasn’t named or feared or tracked upon hearing the news. I thought I most aggressive steroid treatment, like Covid-19. It was a normal bug, a would be prescribed something to and my hearing loss and tinnitus are common-seeming affliction, especially fix it, and I would be back to feeling most likely a permanent part of my life. for someone like me who works as a normal soon. Unfortunately, that The tinnitus I experience is a preschool teacher’s aide. In fact, the wasn’t the case. constant hissing — like the whooshing only reason I sought medical attention After several courses of steroids, sound you hear when you put your while I was sick was because I was antiviral medication, an MRI to rule ear up to a large seashell or listen to also experiencing a hissing and a out a tumor affecting my hearing, and a white noise machine. It never goes sense of fullness in my left ear. finally an injection of steroids straight away, but it does get louder and more I was leaving for Christmas vacation through my eardrum by a specialist, intense with stress, anxiety, fatigue, in a few days and wanted to feel better however, it was concluded that the and exposure to loud environments. before I left. The nurse practitioner virus had permanently damaged When the tinnitus gets more severe, I saw at Urgent Care told me there some of the hair cells in my inner ear. I often experience an ache in my ear, was fluid in my ear and prescribed Nothing could be done to reverse my which may be hyperacusis, although antibiotics. No worries, just an ordinary hearing loss and resulting tinnitus. that hasn’t been diagnosed. thing. I had an enjoyable vacation, but I learned later that with sudden When I first understood that my once home — despite feeling better in hearing loss, time is of the essence situation was most likely permanent, general — the hissing noise in my ear and it should be considered a medical I felt tremendous regret and sadness. persisted. emergency, similar to if you woke up Because I might have been able to When I finally saw an ENT after the one morning unable to see. If treated heal if I had been diagnosed properly holidays and my hearing was tested, with steroids within the first month in the beginning, I felt a level of I was told I had experienced sudden of sudden hearing loss, the hair cells responsibility for what I was going hearing loss in my left ear, most likely have a reasonable chance of healing through. What if in the beginning I had brought on by a virus. I honestly didn’t and hearing can often be restored. seen my primary care doctor instead have any sense that my hearing had

36 TINNITUS TODAY SUMMER 2020 www.ATA.org PERSONAL STORY 

of going to Urgent Care? Would a about having tinnitus for the rest of doctor have recognized my description my life and instead think only about of the hissing noise as tinnitus, when “It took a long dealing with the day at hand. It’s an the nurse practitioner had not? Why ongoing journey. And, though I still didn’t I realize that the fullness in my time for me to let hope for a medical breakthrough that ear was hearing loss rather than just go of the what-ifs will eventually silence my tinnitus, I’m the by-product of being sick? Would proud of how far I’ve come in dealing I have advocated for more expedient and accept that I with it so far. and aggressive care if I had? All these feelings of self-doubt did the best that I Yvonne Sopp loves compounded what I was going her job working as a preschool teacher's through. It took a long time for me to could with what I aide with four-year- let go of the what-ifs and accept that old children. She I did the best that I could with what knew at the time.” resides in San Diego, CA, and enjoys I knew at the time. I had no idea that spending time with a very healthy person could suddenly family, and traveling lose their hearing from what seemed trouble hearing them rather than to let as much as possible. like a common bug, so how could I them know I’m suffering from tinnitus. have expected more of myself? I’ve found that it’s really difficult to I think I’ve made peace with my explain to people what living with situation, although, perhaps like all tinnitus is like. People seem to either grief for things lost, I revisit it every so glaze over when you are telling them often. I let myself feel the sadness for about it or they tell you about the a little while and then try to move on time they experienced ringing in and get back to living. their ears, so they get it. My family has been very supportive It’s hard not to tell them that and I can tell them when my tinnitus unless you live with this all day, is acting up or I’m struggling with my every day, you really don’t get it. hearing. I find fractal tones helpful I know they are trying to relate when my tinnitus is particularly loud, and that comes from a place of so my family knows if they hear the kindness, so I try to receive their chimes, I might be having a hard day. goodwill, even though it doesn’t I haven’t told too many people always feel particularly helpful. about my situation, and when I do I stay active and busy, which helps it’s usually to explain why I’m having my tinnitus take a backseat to other more positive things. I try not to think

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www.ATA.org TINNITUS TODAY SUMMER 2020 37  YOUR HEALTH

Grieving Over the Loss of Silence

By Shelley F. Knight

Grief cannot be defined in one “For today, take time for you, be it to read simple sentence, because grief is not simple. It is a vast and complex a book, have a bath, journal your thoughts, topic, with equally vast and complex listen to a guided meditation, claim a day presentations in terms of signs and symptoms, longevity and intensity. of rest, cook yourself a wholesome meal. And grief is not exclusively triggered by death. Grief can ensue when we For today, nothing else matters but you.” lose anything we had an emotional connection to, including good health. In the case of tinnitus, our sense hopelessness, irritability, anger, frustrated, anxious, and depressed of diminished health can lead to a restlessness, insomnia, or a change in about what once was, our current grieving process, and because the our ability to communicate. We may reality, and our uncertain future. signs and symptoms of tinnitus experience a loss or lack of control, Our grief journey may go unnoticed are akin to grief symptoms, we are confidence, trust, or focus. by those around us, just as our often subjected to a compounded These signs and symptoms of invisible tinnitus does. Although it experience of grief when it tinnitus — or grief — can cause us to may be easy for some to dismiss accompanies tinnitus. struggle with basic activities of daily tinnitus because it’s not tangible, the The onset of tinnitus and its living, as well as hobbies, personal weight we carry in our daily lives with grief entanglements can affect us connections, work routines, and other the condition can feel overwhelming physically, mentally, emotionally, essential aspects of our lives. These and isolating. and socially. We may experience adjustments can lead to a decline in On the rare occasions we find the dizziness, depression, loneliness, our mental health, because we feel courage to share our feelings on the

38 TINNITUS TODAY SUMMER 2020 www.ATA.org YOUR HEALTH 

you may be reading my words from a place of great despair, please know that you are more capable than you know. If you find yourself in grief, because of tinnitus or loss of normalcy, know that you will come through this. As with any grief experience, we are not stagnant, and as reliably as the night turns into day, you have the strength to come through the dark and into the light. Your grief journey is as unique to you as your fingerprints, so how you overcome these challenging times will be based burden of chronic tinnitus, people are pandemic. Throughout my thirty-year on your life experiences — you have a typically unprepared to deal with our healthcare career, I have observed 100 percent success rate to date. diagnosis or our associated grief, and many presentations of grief, but with Do not aim to change your health they may downplay or dismiss our the coronavirus pandemic, a new and existence in one day; instead, daily struggles or compare them to form of grief is on the rise, one I refer choose one aspect of your life to their own struggles. We are told that to as isolation grief. This multilayered change: self-care. Self-care is not we will need to either get over it or form of grief can manifest in selfish care. It is a deliberate act to get on with it, or we’re provided with many ways, including as a feeling look after your physical, emotional, a plethora of suggestions that we of a loss of control in life as our and mental health before anything have already tried and tested without everyday choices are now dictated else. For today, take time for you, be success. This lack of understanding by governmental requirements. We it to read a book, have a bath, journal within our circle of connections can are isolated from the known world your thoughts, listen to a guided lead to feeling misunderstood, which around us, left home alone with the meditation, claim a day of rest, cook only consolidates the grief within us. unrelenting sound of tinnitus. yourself a wholesome meal. For today, Some of us will choose to isolate In addition, many of us are facing nothing else matters but you. ourselves and embrace sheer change in or loss of a job, income, determination to carry on with social interaction, access to medical Shelley F. Knight is our diminished sense of health, appointments, freedom of travel. a once-upon-a-time while others may fall deeper into Some of us have experienced a nurse turned author, the darkness of depression and supreme loss: the death of friends writer, and podcaster who provides an feeling overwhelmed, some even and family members. All of these are eclectic blend of contemplating suicide to put an end life-changing factors, and all of this clinical, holistic, and to the never-ending noise. while we endeavor to function with spiritual expertise Yet, when we are isolated tinnitus, where we are alone with our in her specialist subjects of positive from our circle of support, be it ongoing buzzing, ringing, whooshing, changes, spirituality, consciously or subconsciously, we humming, hissing, or whatever sound and grief. She is are still able to reach out to others we might hear, without the distraction author of Positive Changes: A Self-Kick Book, host of Positive and seek help during times of dire of our daily routine. Changes: A Self-Kick podcast, founder and host need and frustration. What I have observed is that no of Good Grief — Northampton Death Cafe, and However, this safety net has matter what life throws at us, we a freelance writer for international magazines. changed of late in the midst of the are stronger than we realize. While

www.ATA.org TINNITUS TODAY SUMMER 2020 39  YOUR HEALTH

How Do We Know If Covid-19 Has a Negative Impact on Tinnitus?

By Thomas L. Eby, MD, and Christopher Beyond quinine-based drugs, it is Spankovich, PhD plausible that illness from Covid-19 and other treatments may exacerbate Although much remains to be perception of tinnitus in patients learned about the variety of symptoms who already have this condition. caused by the Covid-19 virus, direct Persons with existing tinnitus may effects on hearing or tinnitus appear also experience exacerbation of their to be uncommon. One recent report with tinnitus, vertigo, or imbalance symptoms related to increased stress. from Egypt found minimal high- and in one case headache. All otologic The mental health effects of diminished frequency hearing loss associated symptoms except in one patient social interaction and depression/ with asymptomatic patients diagnosed resolved after cessation of the therapy. anxiety related to the cascade of with Covid-19; however, study design The cases of irreversible sensorineural events created by the pandemic (e.g., and lack of adjustment for age and hearing loss associated with unemployment, loss of family/friends, sex limit interpretation of the findings. hydroxychloroquine were in patients substance abuse) may make dealing It is plausible that treatments for the who had treatment over several years. with tinnitus even more difficult for virus may cause temporary tinnitus or Based on literature of patients persons with and without Covid-19. hearing loss and exacerbate existing treated for other conditions with Furthermore, persons with 1 tinnitus. Notably, treatment with synthetic quinine-based drugs, we can hearing loss may be frustrated by chloroquine compounds, which was expect potential otologic side effects communication difficulties created initially advocated for treatment, from these medications in patients by use of face masks in public and has the potential for this side effect. treated for Covid-19. During treatment, healthcare settings and attribute these Ototoxicity has also been reported patients may have mild hearing loss, issues to their tinnitus perception. For and should be monitored in Covid-19 sometimes unilateral with tinnitus, tinnitus, we recommend patients talk patients treated with these drugs. and possible dizziness or imbalance. with a knowledgeable provider about Chloroquine and hydroxychloroquine These symptoms should resolve with management strategies, including have been registered for more than 140 completion of treatment; however, it stress reduction, sound therapy clinical trials for treatment of Covid-19. will be important to monitor them and applications, and counseling or formal A recent review of support patients with these otologic therapy. Much of this information hydroxychloroquine ototoxicity in side effects and follow up with those can be provided to patients through France revealed 23 cases, but most whose symptoms do not resolve. telehealth. For patients with hearing only developed after months or years It is also worth noting that several loss and tinnitus, communication repair of treatment, which is longer than trials reported limited effectiveness of strategies, assistive listening devices the treatment approach in Covid-19 hydroxychloroquine in management of (hearing aid to smartphone apps), and 2 treated patients. Of the five patients Covid-19 and enthusiasm for its use is use of clear masks may be beneficial that developed symptoms within 14 waning publicly in the United States. days, hearing loss was associated

40 TINNITUS TODAY SUMMER 2020 www.ATA.org YOUR HEALTH 

in overcoming distortions in speech Zurich, Switzerland. He has multiple publications book chapters (41 in peer-reviewed journals) and created by use of masks. and is associate editor for Otolaryngology – Head has given more than 60 national and international and Neck Surgery. presentations. He continues to practice clinically with special interest in tinnitus, sound sensitivity, Thomas Eby, MD, ototoxicity, hearing conservation, and advanced Christopher is professor of diagnostics. He holds adjunct faculty status Spankovich, PhD, otolaryngology with Salus University and Nova Southeastern is an associate and neurology University and serves as an associate editor for professor and vice at the University Audiology Today and the International Journal of chair of research of Mississippi Audiology. He was recently elected to the AAA for the Department Medical Center. Board of Directors. He also provides consultant of Otolaryngology He is an otologist services for medicolegal cases. and Communicative and neurotologist, Sciences at the with more than 30 University of Mississippi Medical Center. He 1 M. W. M. Mustafa. (2020). Audiological profile years of experience, including an active clinical obtained his MPH from Emory University, AuD of asymptomatic Covid-19 PCR-positive cases. practice and interest in clinical research and American Journal of Otolaryngology, 41(3), 102483. from Rush University, and PhD from Vanderbilt otology education. He obtained his MD at the https://doi.org/10.1016/j.amjoto.2020.102483 University. Spankovich is a clinician-scientist University of Wisconsin and completed his 2 Chatelet JN, Auffret M, Combret S, with a translational research program focused Bondon-Guitton E, Lambert M, Gautier S. otolaryngology residency at Massachusetts Eye on prevention of acquired forms of hearing loss, Hydroxychloroquine-induced hearing loss: first case and Ear Infirmary, where he also did a research of positive rechallenge and analysis of the French tinnitus, and sound sensitivity. His research has fellowship in temporal bone pathology. He pharmacovigilance database [in French]. Rev Med been funded by industry, federal, and professional completed a neurotology clinical fellowship in Interne. 2017;38: 340-343. bodies. He has published over 60 articles and

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www.ATA.org TINNITUS TODAY SUMMER 2020 41  YOUR HEALTH

Common Medications That Can Cause Tinnitus

By Sharon E. Orrange, MD, MPH ringing in the ears. NSAIDs have Tricyclic Antidepressants been implicated as potentially Tricyclic antidepressants, Though relatively rare, tinnitus harmful to outer hair cells and including amitriptyline and can be a debilitating side effect of cochlear blood flow, but this occurs nortriptyline, are used to treat a handful of common medications, at higher doses for longer periods depression, anxiety, chronic pain, 1–3 so you and your physician should of usage. High-dose aspirin (6 to and migraines, but they may cause both take this potential adverse 8 grams per day) can cause tinnitus ringing in the ears. Amitriptyline reaction seriously, particularly and hearing loss that is reversible in particular has been reported since tinnitus treatment options with discontinuation of the drug. For to cause persistent tinnitus.5 This are limited. Medications known to this reason, if you take daily low- is an area worth discussing with cause tinnitus or hearing loss are dose aspirin (81–160 mg per day) or your physician because these are considered “ototoxic medications.” NSAIDs for short periods of time for older antidepressants and the Discontinuing these medications pain, it is unlikely you will experience newer selective serotonin reuptake can prevent tinnitus and hearing tinnitus as an adverse reaction. The inhibitor (SSRI) antidepressants loss progression, though the same goes for the similar COX- may be a better option without ringing may not always go away. 2 inhibitors such as meloxicam the tinnitus risk. In fact, SSRI For essential medications, such (Mobic), which appears to carry very antidepressants have been as blood pressure, chemotherapy, rare (<2% tinnitus) risk. studied (though not shown to and heart failure, the rare tinnitus have significant benefit) for the side effect is a risk worth taking. Benzodiazepine Anxiety treatment of tinnitus.6 For the treatment of pain, infection, Medications Know that case reports depression, and anxiety, however, Alprazolam (Xanax), diazepam exist for sertraline and alternative equivalent options are (Valium), and lorazepam (Ativan) paroxetine causing tinnitus, worth discussing with your doctor. are benzodiazepines, which are so discuss others in the SSRI Please note that tinnitus resulting helpful for the short-term treatment class (escitalopram, citalopram, from medications mentioned in of anxiety. Rather than causing fluoxetine, etc.). this article typically subsides with tinnitus while you are taking them, discontinuation of the drugs but in a complication of benzodiazepine Isotretinoin rare exceptions, as is the case with withdrawal is ringing in the ears and Isotretinoin (Accutane, Claravis, Gentamicin, the tinnitus may be most often occurs in folks who’ve Absorica, and others) is an oral permanent. Here is what you need been taking the drug for longer medication used for severe acne, to know. periods of time.4 For prevention of and its use may lead to tinnitus.7 benzodiazepine withdrawal–induced This is rare and resolves after Aspirin and NSAIDs tinnitus, tapering off the drug discontinuation, but starting with Aspirin and nonsteroidal anti- may help prevent this, and a dose other topical acne therapies or inflammatory drugs (NSAIDs), such reduction of 10 to 25 percent every hormonal methods instead may as naproxen (Aleve) and ibuprofen 4 weeks has been suggested. avoid this potential complication.8 (Motrin, Advil), are known to cause

42 TINNITUS TODAY SUMMER 2020 www.ATA.org YOUR HEALTH 

Loop Diuretics erythromycin, all have been reported completed a residency in internal medicine at the University of California, San Diego. Loop diuretics, such as to cause hearing loss and ringing in Dr. Orrange is currently the medical advisor furosemide (Lasix) and bumetanide the ears. Again, tinnitus appears to and blogger for GoodRx.com, a prescription be linked to higher doses used for (Bumex), are commonly prescribed drug price comparison website, and GoodRx 8 for swelling in the legs, heart failure, longer periods of time. If you are Care powered by Hey Doctor. She has and to lower blood pressure. Use prescribed one of these antibiotics appeared on The Doctors, Fox Sports West, for short-term use, your risk of The Ricki Lake Show, as well as many local of loop diuretics can cause tinnitus news outlets. but it is usually temporary. These are tinnitus appears to be very small. essential medications you wouldn’t n Ciprofloxacin 1 Halla, J. T., Atchison, S. L., & Hardin, J. G. (1991). stop without discussing with your Symptomatic salicylate ototoxicity: A useful The fluoroquinolone antibiotics indicator of serum salicylate concentration? Annals doctor. Here again, ototoxicity is ciprofloxacin (Cipro) and moxifloxacin of the Rheumatic Diseases, 50, 682–684. PMID: primarily seen in folks treated with 1958090 48. have been reported to cause 2 Furst, D. E., Blocka, K., Cassell, S., Harris, E. R., high intravenous or oral doses of 9-10 Hirschberg, J. M., Josephson, N.,...Paulus, H. E. tinnitus. However, there is some (1987). A controlled study of concurrent therapy loop diuretics, so you may discuss good news: Those reports have not with a nonacetylated salicylate and naproxen in with your doctor starting at the rheumatoid arthritis. Arthritis and Rheumatology, carried over to a similar antibiotic, 30, 146–154. PMID: 3548732 lowest possible dose and increasing levofloxacin (Levaquin). Cipro is 3 Brien, J. A. (1993). Ototoxicity associated with as needed. salicylates: A brief review. Drug Safety, 9, 143–148. prescribed for bacterial infections 4 Laskey, C., and Opitz, B. (2020). Tinnitus associated like urinary tract infections, acute with benzodiazepine withdrawal syndrome: Antibiotics A case report and literature review. Mental sinusitis, and pneumonia. Health Clinician, 10(3), 100–103. doi:10.9740/ n Broad-Spectrum Antibiotics mhc.2020.05.100 Gentamicin and Tobramycin 5 Langguth, B., Landgrebe, M., Wittmann, M., Sharon E. Orrange, Kleinjung, T., & Hajak, G. (2010). Persistent tinnitus Gentamicin and tobramycin are MD, MPH, is an induced by tricyclic antidepressants. Journal antibiotics used for the treatment associate professor of Psychopharmacology, 24(8),1273–1275. doi:10.1177/0269881109106929 of clinical medicine of severe bacterial infections and 6 Baldo, P., Doree, C., Molin, P., McFerran, in the Division of D., & Cecco, S. (2012). Antidepressants for are a well-known cause of tinnitus Geriatric, Hospitalist patients with tinnitus. Cochrane Database and vertigo, along with hearing and General Internal of Systematic Reviews, 2012(9), CD003853. Medicine at the Keck doi:10.1002/14651858.CD003853.pub3 loss. Widespread use of these two 7 Rosende, L., Verea-Hernando, M. M., de Andrés, School of Medicine antibiotics is limited because of the A., Piñeyro-Molina, F., Barja, J., Castro-Castro, of University of S., & Fonseca, E. (2011). Hypoacusia in a patient availability of alternative, less toxic Southern California. treated by isotretinoin. Case Reports in Medicine, agents with comparable efficacy. It She spends part of her time as the attending 2011, 789143. doi:10.1155/2011/789143 8 Zaenglein, A. L., Pathy, A. L., Schlosser, B. J., physician for medical students and residents is important to note that gentamicin Alikhan, A., Baldwin, H. E., Berson, D. S.,… during their medicine rotations at LAC+USC or tobramycin (Tobrex) eye drops Boyer, K. M. (2016). Bhushan guidelines of care Medical Center and Keck Hospital of USC. for the management of acne vulgaris. Journal of do not carry the tinnitus risk nor Dr. Orrange has an active private practice the American Academy of Dermatology, 74(5), in general internal medicine at The Doctors 945–973. does topical gentamicin cream or 9 Paul, J., & Brown, N. M. (1995). Tinnitus and of USC Beverly Hills and is a fellow of the ointment used for skin infections. ciprofloxacin. BMJ (Clinical Research), 311(6999), American College of Physicians. 232. doi:10.1136/bmj.311.6999.232b 10 Onoh, A., Linnebur, S. A., & Fixen, D. R. (2018). n Macrolide Antibiotics She received her BA in biology at the University Moxifloxacin-induced tinnitus in an older adult. Azithromycin and of California, San Diego, and a master’s degree Therapeutic Advances in Drug Safety, 9(4), Clarithromycin in public health at the Johns Hopkins University 219–221. doi:10.1177/2042098618754483 Azithromycin (Zithromax or the School of Public Health. She received her MD from the Keck School of Medicine of USC and Z-Pak) and clarithromycin (Biaxin) are antibiotics prescribed for bacterial infections, such as pneumonia, For more information on medications, supplements, and tinnitus, sinusitis, and bronchitis. In see Tinnitus Today, Vol. 43 (2), Summer 2018. addition to the older medication

www.ATA.org TINNITUS TODAY SUMMER 2020 43  SCIENCE & RESEARCH NEWS Can Marijuana Decrease Tinnitus Distress?

Summary by John A. Coverstone, AuD

Use of marijuana is increasing in the United States as more states legalize the drug for medical and/ or recreational use. As a result, people are able to experiment with months, with such individuals being noise exposure, age, smoking, the drug as a home remedy for a more likely to experience bothersome cardiovascular disease, hypertension, wide array of conditions. However, tinnitus than the general population in aspirin use, and diabetes. marijuana continues to be illegal by the survey. Other factors that were associated federal statute and formal research When considering people who with tinnitus and marijuana use after is therefore limited as a result of the used marijuana, tinnitus was not multivariate analysis included hearing unavailability of federal funding. found to be associated with either loss, history of work noise exposure, A pair of researchers at Stanford frequency or amount of the drug depression, and anxiety. This means University/Stanford Ear Institute used. When looking at individuals that these factors occurred more wanted to see whether an association with tinnitus, marijuana use was not frequently in subjects with tinnitus than between marijuana use and tinnitus associated with severity or frequency in the general population of the survey. 1 could be established. They used of tinnitus occurrence. Frequency of The nature of the association existing data from the 2011–2012 marijuana use also had no association between tinnitus and these conditions National Health and Nutrition with severity of tinnitus or how cannot be discerned from these data. Examination Survey in the United often tinnitus occurred. Similarly, the Instead, results indicate only that these States. They chose that year’s survey amount of marijuana used was not conditions occurred more frequently because it was the latest data set that associated with severity or frequency in subjects with tinnitus than they included hearing information at the of tinnitus occurrence. The authors did within the general population. For time. (Note: The 2015–2016 NHANES further noted that tinnitus was not instance, the association between data also includes hearing testing and associated with use of other drugs, having tinnitus and using marijuana questionnaires but was published including alcohol, cocaine, heroin, or does not imply which caused the other November 2019 — after this study was methamphetamines. — or even whether there is a cause- completed.) The researchers also conducted effect relationship between the two They pulled survey data for a multivariate analysis, which is traits. It may be possible that they are individuals aged 20–69, and included when the relationship between each related to a separate influence. information from 2,160 individuals one condition and multiple others Further research is necessary to in their study. In addition to hearing is analyzed (prior analysis was establish any cause-effect relationship test results and tinnitus, the authors univariate — relating one piece of that may exist. However, the presence looked at data for history of noise data to one other piece of data). of a significant association between exposure, smoking, marijuana use, This analysis continued to show tinnitus and marijuana does indicate alcohol and other drug use, mood, a relationship between tinnitus the need for additional research into depression, and more. and marijuana use, but many of benefits or risks that may occur with A relationship was found between the other associations indicated use of the drug. tinnitus and marijuana use among during univariate analysis no longer people who used marijuana at least showed a strong correlation with 1 Z. Qian & J. Alyono. (2020). An association between once per month in the preceding 12 marijuana use and tinnitus. American Journal of tinnitus. These included recreational Otolaryngology, 41(1), 102314.

44 TINNITUS TODAY SUMMER 2020 www.ATA.org SCIENCE & RESEARCH NEWS  Gender Differences in Tinnitus Treatment Outcomes

Summary by John A. Coverstone, AuD condition, before and after treatment, women using and again three months after treatment. both these A group of researchers from the The authors found that gender treatment University of Antwerp (Belgium) differences in TFI score varied across methods. recently looked at whether women different treatments. For treatments the Although and men respond differently to tinnitus authors called “orofacial physiotherapy,” the population treatment.1 They did this by analyzing women benefited more than men. was somewhat outcomes for an array of tinnitus This appears to align with previous small for each treatment methods performed at the data showing that temporomandibular treatment type, gender university hospital and comparing joint (TMJ) disorders were twice as effects were noted in most outcomes for men and women. prevalent in women than in men.2 This cases. More research would need to The university hospital uses a range effect may therefore reflect greater be performed with a larger population, of treatment options for tinnitus, incidence of the condition rather than but these results do indicate that including those used in this study: more effective treatment. men and women respond differently tinnitus retraining therapy with cognitive High-definition transcranial direct to different types of treatment. It behavioral therapy (TRT+CBT); tinnitus current stimulation (HD-tDCS) was used cannot be stated definitively that retraining therapy with eye movement to target an area of the brain called the men or women are helped more by desensitization and reprocessing dorsolateral prefrontal cortex. This area is a certain treatment type, because it therapy (TRT+EMDR); physical therapy associated with gating of sensory stimuli may be that one gender responds for those having problems with — in other words, it decides which more quickly while the other needs the neck or jaw; and high-definition stimuli we see and hear. One theory more time to experience effective transcranial direct current stimulation, of tinnitus is that the neural pathways treatment. Of course, choosing an or electrical stimulation of the brain. of the dorsolateral prefrontal cortex are appropriate treatment modality is also EMDR therapy has not been commonly damaged and therefore sounds that driven by other factors, such as type discussed in this publication. It would normally be blocked are allowed and severity of tinnitus and presence involves a patient being presented to enter the auditory cortex and be of an underlying psychological disorder. with emotionally charged memories in perceived. When analyzing data from Nonetheless, in the future the gender brief doses while they simultaneously HD-tDCS, there was a greater benefit to of the patient may play a role in focus on an external stimulus. The goal women than to men. The authors also determining the most effective or most is to lessen negative responses and noted a prior study that also showed that efficient treatment for tinnitus. decrease distress caused by negative tDCS is more effective in women.3 memories, experiences, or stimuli. Conversely, males in this study 1 A. Van der Wal, T. Luyten, E. Cardon, L. Jacquemin, O. M. Vanderveken, V. Topsakal,…A. Gilles. (2020). Sex The tinnitus treatment study included benefited more from TRT+CBT than differences in the response to different tinnitus treatment. 316 patients. The Tinnitus Functional did females. There is no expected Frontiers in Neuroscience, 14, article 222. https://doi. org/10.3389/fnins.2020.00422 Index (TFI) was used as the primary gender difference in the outcomes of 2 C. H. Bueno, D. D. Pereira, M. P. Pattussi, P. K. measure of tinnitus severity and Grossi, & M. L. Grossi. (2018). Gender differences in psychotherapy and so this finding is temporomandibular disorders in adult populational tinnitus improvement post-treatment. intriguing. Treatment provided using studies: A systematic review and meta-analysis. Journal of Oral Rehabilitation, 45, 720–729. A 13-point reduction in overall TFI score TRT+EMDR yielded no significant 3 E. Frank, M. Schecklmann, M. Landgrebe, J. Burger, P. was considered to be meaningful, differences in outcomes for men Kreuzer, T. B. Poeppl,…B. Langguth. (2012). Treatment of chronic tinnitus with repeated sessions of prefrontal based on prior research. Each patient and women. It should be noted transcranial direct current stimulation: Outcomes from completed the TFI, along with any other that significant improvement in TFI an open-label pilot study. Journal of Neurology, 259, 327–333. questionnaires that were relevant to their scores were found in both men and

www.ATA.org TINNITUS TODAY SUMMER 2020 45  TINNITUS RESOURCES Moving Online With Zoom for Tinnitus Support

By Trudy Jacobson drive home; that’s not only saved time and less wear and tear on our cars In 1965, AT&T’s Bell Telephone but also better for our environment. System advertised its long-distance Let’s hope the air remains clean as we service: “It’s the next best thing to navigate our new normal. being there.” Another reason I hope virtual Now, 55 years later, little did we tinnitus support groups will endure know how important that advertising is accessibility. You might not find a slogan would be for us during the support group in your city or even coronavirus pandemic. For those of have a tinnitus expert nearby. In my you can only really look at one person us who are living with tinnitus, it’s city, Tucson, Arizona, there was no at a time. With Zoom, you can see all especially vital to attend support groups such expert and no support group, so the participants. I love when someone with other people who can understand I started one last spring. We had our makes a statement, and all the heads the challenges we face every day. first group meeting in person, and right are nodding in agreement at the same Even with social distancing, most if after that, the pandemic hit. We have time! And to top it off, the quality of not all tinnitus support groups have not switched to virtual meetings now. sound and visuals are perfect. It’s been able to meet in person because of Better yet, meeting virtually lets you amazing if you think about it. concerns about the risk of transmitting join a group anywhere in the world. I Another plus is the ability to record the virus. Nonetheless, we need the have been in a group where most of the audio so nobody has to take notes. social interaction and support that us were in the United States and one Most hosts of meetings upload the these groups provide. Then along came person was in Mexico and another in audio file to their website or Facebook Zoom, a wonderful virtual platform Australia. The Australian was joining the page after the meeting. Also, people that allows us to be together from the meeting at 6 p.m. Arizona time, which who prefer to remain silent during the comfort and safety of our own homes. was 10 a.m. his time the next day! meeting can use the chat function to Since the pandemic began, I’ve Another advantage is being able ask questions and make comments. joined three virtual tinnitus support to participate even if you’re ill. Since If you would like to join our Tucson groups, and they are great! I feel that we know that Covid-19 (as well as the virtual group, we meet via Zoom the we can indeed get the closeness common cold and flu) is contagious fourth Monday of the month from 1 to we need in a safe way. True, you even before a person has obvious 2 p.m., MST. We might add an evening can’t hug people, but virtual hugs are symptoms, no one wants to risk meeting at a later date. Please email almost as good. infecting or being infected through me at [email protected] or call/text me at There are so many pluses to an optional gathering, no matter how (520) 982-7813. this method that I’m hoping virtual important it might be. No matter where meetings will continue even after Probably my favorite feature so far, you live in the the danger of meeting in person though, is the ability to see everyone’s world, we will subsides. The most obvious advantage, face at once (on grid screen). If you’re welcome you and of course, is not having to drive in a meeting, say, around a big table, would love to hear somewhere, find a parking spot, then your story!

46 TINNITUS TODAY SUMMER 2020 www.ATA.org TINNITUS RESOURCES  How Can We Tame Tinnitus in Tough Times?

10 TIPS TO HELP MANAGE TINNITUS

By Julian Cowan Hill, MA turns our ears into highly attuned ignore the hubbub in the background. antennae that listen so acutely that, Peacetime ears are very good at As the coronavirus spread across if we stay in this heightened state for filtering out all the irrelevant stuff. We the world, our lives were engulfed long enough, we end up listening to are not designed to hear the buzz of in fear of sickness, death, and sounds inside our head that normally our brains. unprecedented massive economic our brain ignores. Impulses along the With this in mind, how can we and social disruption. For weeks, auditory pathways can jangle into tame tinnitus during tough times? most of us were trapped at home, awareness, and faint sounds of ear The next page has 10 tips to help longing for this to be over. Clearly, this pressure popping or a distant heart you manage tinnitus during the was not going to be easy for people pulse can now be heard all too clearly. coronavirus pandemic or during other with tinnitus, a condition that’s often For the alarm bells to stop ringing, stressful times. influenced by stress, which triggers we need to come out of fight-or- a fight-or-flight response. Fearful flight and return to a sense of safety. Julian Cowan Hill has thinking and feeling trapped are often Normally, craniosacral therapy or a master’s degree in Core Process the main drivers that keep the tinnitus other hands-on body work can help Psychotherapy alarm bells ringing. ease us back into a more peaceful and is a registered In 1990, Pawel Jastreboff, PhD, a and grounded state. The more this craniosacral therapist. He had severe tinnitus professor at Emory University, shared happens, the more oversensitive for 20 years before his neurophysiological model of hearing resets itself and reverts back overcoming it and tinnitus, which showed the dramatic to peacetime mode. When we feel going on to help changes in our response to audio safe again, our ears ignore irrelevant others improve their cues when we feel threatened symptoms. In two decades of clinical practice noise inside and around us and only as a psychotherapist, craniosacral therapist, or trapped. Since then, we have latch on to sounds that matter. and tinnitus consultant, he has consolidated understood that our hearing is When we come out of fight-or- techniques, approaches, and practices that help inextricably linked to the fight-or-flight flight, we can read a book while people cope with tinnitus distress and remain on track to enjoy life. His Quieten app is based on response. ignoring sounds around us, we can those many years of learning and experiences. If there’s a lion out there, hearing fall asleep in front of a noisy TV, For more information, see https://www. the snap of a twig behind us may and we can focus on one-on-one quietenapp.com/. He also has published several books on managing tinnitus, which are available save us. In seconds, adrenaline conversations in a noisy pub and on Amazon.

www.ATA.org TINNITUS TODAY SUMMER 2020 47  TINNITUS RESOURCES 10 TIPS TO HELP MANAGE TINNITUS

TIP The first thing that helps islearning to self-soothe and consciously bringing your nervous system out of fight-or-flight mode. Gentle yoga or tai chi can help reduce the levels of activation and alertness. An hour a day can tip the balance significantly in your favor and gives you a healthy distraction from the 1 ringing or other tinnitus sounds that you might hear.

Instead of a lion, we now all face the invisible predator called Covid-19 and expose our ears to TIP threatening news bulletins that put us directly in touch with traumatic information. This needs to be limited as much as possible. Ten minutes of news in the morning is more than enough to keep us abreast of what’s important. Then we can recover, settle, and look after ourselves for the rest of the day. 2 Please stop exposing yourself to stressful information.

TIP Just 20 minutes of meditation or yoga can prevent us from being hijacked by anxious thinking and can open up a whole new way of being. Feeling trapped inside a noisy head can be overwhelming. Now is the time to learn to shift the focus out of your head and into the body. This very real alternative helps pull 3 our attention away from the ringing and negative thinking patterns, and also settles the nervous system.

TIP You need to take better care and be kind to yourself to help your nervous system settle. Don’t give yourself TIP a hard time or demand too much of yourself just now. With heightened stress levels, it is important to pace 4 yourself. If in doubt, do things that relax you, get out, go for a walk, have a bath, take a cold shower. 9

TIP Many people with tinnitus feel very afraid and threatened when they first develop symptoms. This is often compounded when they go online and read no end of horror stories that further trigger the alarm bells. 5 Please avoid negative information about tinnitus like the plague.

48 TINNITUS TODAY SUMMER 2020 www.ATA.org TINNITUS RESOURCES 

Stay clear of moaning and groaning No Ce oel Le to lie ith it groups who are stuck in negativity and ead-ased Tining entered DOO o iteet promote the “No Cure Model.” Please stop ctstohic thohts FEAR talking about how bad your tinnitus is and oy elto eosess reinforcing this with others. If you come estlessess oo slee ITOR TIP across a health practitioner who tells you NO LIT CURE i s s o i t i o there is nothing you can do about tinnitus, c oi te oi os leave immediately. They cannot help you. REEE 6 Don’t fall into the trap of practicing the No RESONSE BULLYING Cure Model. LOUDER RINGING & SENSITIVITY

Aim for well-being. You need to move into a positive mindset. Learn from people who have gotten TIP better. Listen to positive tinnitus stories. Destress and settle your nervous system, and you will feel better, manage better, and the sound will pipe down. Do the things you love doing, activities that relax you and make you feel connected to others. The brain’s ability to refresh itself and learn new patterns, known as 7 neuroplasticity, works well when we move toward positive experiences that help us feel safe and relaxed.

Use this time to learn techniques and strategies to help calm the mind, relax the body, and focus your TIP attention, including simple practices such as clenching and relaxing, walking meditation, tapping, running commentary technique, and slow movement that can settle your mind and body with practice. Use this time to build your toolbox and skills that help you let go of tinnitus and stay present instead of being 8 hijacked by catastrophic thinking. Find tools that work for you and practice them.

Develop understanding and learn that tinnitus can be a temporary stress-related symptom. When we have a good understanding of how this symptom works, it feels much less threatening and the way TIP forward starts to make sense. Treat tinnitus as a healthometer and learn from its feedback. When it pipes up, consider what may have caused this. When it backs off, learn from this useful feedback and try implementing lifestyle changes, approaches, and practices that keep you going in this direction. 9 As the world opens up after lockdown, you will probably know how to be safe interacting with other people regarding the virus. My advice is not to accelerate too quickly into a fast paced life again. Instead, keep a firm foot in self-care, drawing on such tools as yoga or tai chi and self-soothing.

TIP Eat a healthy diet and avoid ingesting too much salt, sugar, and stimulants such as coffee, tea, and 10 alcohol. In moderation they are fine, but too much can be activating.

www.ATA.org TINNITUS TODAY SUMMER 2020 49  SPECIAL FEATURE How to Decide If Personal Sound Amplification Products Are Right for You

shows patients that an audiologist is a up to a moderate degree of hearing healthcare provider who recommends 2 solutions for improved communication, By Danielle J. Frank, AuD, and loss. Many people with hearing loss not simply someone who sells a device. Emily Francisco, AuD are not ready to pursue traditional hearing aids for a variety of reasons, Evaluating and Personal sound amplification even when they may be a good products (PSAPs) are defined by the candidate. Individuals who want a Selecting PSAPs U.S. Food and Drug Administration device for occasional use, who cannot A wide variety of PSAPs are on (FDA) as wearable electronic justify the cost of hearing aids, and the market, with a range of available amplification devices that are who have other personal reasons for features. For individuals looking marketed to consumers with normal bypassing hearing aids may look for to purchase a PSAP, it may seem hearing to amplify environmental alternative options to improve their overwhelming to sort through these sounds during recreational activities.1 communication. PSAPs can serve as options to find a device. Researching These devices are available for a stepping stone for people who need devices on the internet or asking for purchase online or in stores and do hearing help but who are not yet ready recommendations from friends or not require consultation with a hearing for hearing aids. professionals can initially help narrow care professional. PSAPs vary greatly Traditionally, audiologists have been the search; some audiologists may in price, ease of use, and technological skeptical of PSAPs, concerned that be able to provide information and capabilities, providing a variety of they are low-quality amplifiers that guidance that will streamline the options for access to and success do not provide benefit for patients selection process. It is important to with these devices. Some devices also and are not labeled by the FDA for research all aspects of the device require use of additional technology, use to treat hearing loss. For the past and confirm that the device features such as a smartphone or tablet. year, the Department of Audiology at will help meet the communication Individuals with normal hearing Massachusetts Eye and Ear (MEE) has needs and goals of the individual. who experience difficulty hearing been dispensing PSAPs in the clinic For example, if a person is looking to in situations with background noise and learning that these concerns are increase volume solely for one-on- may benefit from the noise reduction not always borne out. The process has one conversation, the features they capabilities and directional microphones revealed that some PSAPs can provide may find beneficial could be different found in some PSAPs. Additionally, a subset of patients with access to from those of a device for a person these devices have been shown to improved communication or tinnitus looking for better communication provide benefit to individuals outside of management, which allows them to in a variety of environments with their marketed population — explicitly serve a wider range of people with a streaming capabilities for music and to adults with hearing loss. PSAPs broad spectrum of needs. PSAPs can tinnitus management. If a device is not differ from hearing aids in several also benefit audiologists by providing providing benefit, customers have the ways (see sidebar) but have been another option they can present to their ability to return the device during the shown to have enough amplification patients. Counseling patients about manufacturer’s trial period. to provide audibility to individuals with all of the options available to them For audiologists looking to dispense PSAPs in the clinic, it is important to

50 TINNITUS TODAY SUMMER 2020 www.ATA.org SPECIAL FEATURE  thoroughly evaluate the devices to with hearing loss in addition to tinnitus, consider PSAPs a viable and affordable determine which PSAPs will best serve turning up the volume in the pitch range option for tinnitus management. their patient population. Knowing your where they have hearing loss may help population helps you choose devices them hear better and may also reduce that suit your patients in terms of the perception of their tinnitus. price, ease of use, and adjustment ability. Once audiologists have PSAPs and the Future of identified prospective devices, they can Hearing Health contact PSAP manufacturers to either PSAPs have been around for obtain a demo device or purchase a many years, but their technology and device for evaluation. Once received, accessibility have improved in recent audiologists should create their own years. It is also relatively new for Emily Francisco, AuD (left), is a clinical audiologist at Mass. Eye and Ear. She evaluation protocol, which may include audiologists to consider offering these completed her doctorate in Audiology at electroacoustic evaluation to assess devices to patients. As professionals Northwestern University in Evanston, IL. maximum output and distortion, along continue to evaluate the capability Danielle Frank, AuD (right), is also a clinical audiologist at Mass. Eye and Ear. She with test box or real ear measures to of these devices, their usefulness completed her doctorate in Audiology at assess programmability. The PSAPs for people with different types of Rush University in Chicago, IL. Both Emily that do not live up to expectations can hearing problems will continue and Danielle are involved with evaluating and be returned during the manufacturer’s to be uncovered. For individuals working with PSAPs at Mass. Eye and Ear and were a part of the introduction to dispensing trial period. Devices that show promise with tinnitus, PSAPs can provide these devices at their clinic. can be kept and used for demonstration amplification of environmental sounds with interested patients. and can stream masking sounds from 1 Center for Devices and Radiological Health, Food devices with Bluetooth capability, and Drug Administration. (2009). Regulatory Requirements for Hearing Aid Devices and Personal PSAP Capabilities which may provide benefit by reducing Sound Amplification Products. Washington, D.C.: perception of the tinnitus. Whether U.S. Department of Health and Human Services. and Tinnitus 2 C. Smith, L. A. Wilber, & K. Cavitt. (2016). PSAPs Different capabilities integrated into you’re working with a professional or vs hearing aids: An electroacoustic analysis of performance and fitting capabilities. Hearing these devices will appeal to different navigating this process on your own, Review, 23(7). individuals with specific needs. The features available in some PSAPs may be beneficial for people who experience PSAPs and Hearing Aids: What’s the Difference? tinnitus, an off-label use according to the FDA. One such feature of PSAPs is the ability to stream sound from other PSAPs Hearing Aids devices over a Bluetooth connection, • Electronic devices that • Durable medical equipment meaning audio from smartphones, amplify sound intended to compensate for computers, tablets, and other devices • Can be purchased over the impaired hearing with a Bluetooth connection can stream counter without assistance from • Purchased from a licensed wirelessly to the PSAP. For tinnitus a professional professional (e.g., an audiologist) patients, streaming tinnitus maskers • Meant for occasional use; battery • Meant for full-time use; battery or sound therapy from a preferred life typically lasts for hours life typically lasts for days application is possible as a part of their • One size fits most, with some • Personalized fit for both physical tinnitus management plan. companies providing different and acoustic fit Many PSAPs also allow the user sized ear pieces • Range in price, but are more to manipulate the frequency, or pitch, • Range in price, but are less expensive than PSAPs response of the device. Users have the expensive than hearing aids • Offer a variety of capabilities, ability to increase overall volume and/ • Offer a variety of capabilities, including Bluetooth connectivity or specifically manipulate the low, mid, including Bluetooth connectivity and rechargeability or high frequencies. For individuals and rechargeability

www.ATA.org TINNITUS TODAY SUMMER 2020 51  PERSONAL STORY

Hearing Options Beyond Hearing Aids

By David Swan however, was tired of me saying talking to “What?” every few minutes, and the my wife If you’ve lived with tinnitus or spike was driving me crazy. When my became normal hearing problems for long, you’ve audiologist told me it wouldn’t hurt to again. (She says the probably tried a number of things to try a PSAP, I turned to the internet to PSAP saved our marriage.) remedy the situation. I recently turned research my options. My tinnitus is better too. The to something that I had never imagined There’s a vast number of choices, distortion caused by exposure to loud as an option: a personal sound with prices ranging from less than $20 sound in the movie theater faded, amplification product, or PSAP. to several hundred (and unless the allowing me to listen to music without I suddenly found myself in the website says otherwise, they’re usually cringing. To be clear, I’m not suggesting market for a PSAP when both my sold individually, not in pairs). Most the PSAP cured that, but I believe it hearing aids started having trouble are designed for people with mild to facilitated the process by providing the about the same time the coronavirus moderate hearing loss; however, you amplification that my failed hearing aids was spreading across the United will find some aimed at people with could not. My only complaint is that the States. The hearing aid for my right severe hearing loss. Some reviewers domes and earpieces don’t fit my small ear had almost no function, making swore their PSAPs worked better than ear canals well. conversation a struggle, while the expensive, professionally fitted hearing Though PSAPs are not my long- control button for the left-ear hearing aids. Other reviewers were emphatic term solution, they have filled a need aid got stuck, leaving me unable to that they did not, writing “DO NOT at a difficult time without damaging lower the volume. With the shutdown BUY. NOTHING BUT TROUBLE.” my hearing as I had feared they causing some businesses to close their I settled on a Walker’s HD Elite, could. Until I can be fitted for a new doors permanently, I was afraid to send which fell in the middle price range set of hearing aids, I’ll keep using them in for repair, fearing I’d never get and had mostly five-star and four-star them. If you think PSAPs might be them back. Since they were shy of ratings on Amazon. It has a mic, battery right for you, talk to your doctor three years old, my insurance company compartment, and simple volume and/or audiologist before buying declined to pay for replacements. control, along with a plastic sound tube something, do your homework to In the midst of this, my tinnitus had and a set of domes and foam earpieces understand what they can and can’t spiked and everything sounded harsh (similar to earplugs). The product do, and be sure they won’t harm your and distorted. Prior to the shutdown, manual says it boosts high frequencies hearing. I had foolishly gone to a movie with with 50 decibels of power, while blaring sound without earplugs. This protecting the user’s hearing from loud Dave Swan is sound was different from the high- noises “such as muzzle blasts.” a writer, editor, blogger, and former pitched tones I’d been hearing and had Compared to what I’m used to, broadcast journalist. managed pretty well since developing these are low-tech. But they work for He experienced mild, tinnitus about 15 years ago. me. Though they’re not calibrated to my occasional tinnitus for a number of years Yes, I knew about PSAPs but had specific hearing loss, they boost the before it became never considered any over-the-counter frequencies that need it most, which constant in 2005 for reasons that are unclear. devices because I worried they might makes a big difference in my quality He and his wife live in Atlanta, where he’s a do more harm than good. My wife, of life. Right away, watching TV and member of the Atlanta Tinnitus Support Group.

52 TINNITUS TODAY SUMMER 2020 www.ATA.org SCIENCE & RESEARCH NEWS  Exploring Insomnia in People With Tinnitus

Summary by John A. Coverstone, AuD Analysis indicated that 70 percent of loudness was not a good predictor of patients had some form of insomnia: sleep problems. This may be due to the When tinnitus is bothersome, it 30 percent had mild insomnia, 28 per- subjective loudness of tinnitus being a can often interfere with sleep. At the cent had moderate insomnia, and 18 smaller factor in its effects on people same time, providers specializing in percent had severe insomnia. Analysis than is tinnitus annoyance, anxiety, or tinnitus recognize that getting sleep is of data indicated a significant associa- depression. The effect of tinnitus on an important part of any treatment for tion of tinnitus and insomnia. Insomnia the individual’s life was also not a good tinnitus. When we don’t sleep well, our was also associated with anxiety and predictor of insomnia, nor was hearing ability to control reactions to stimuli depression. Patients having tinnitus acuity, age, or gender. is impaired, as is our tolerance for and hyperacusis tended to have more More research is needed to further unwanted stimuli. Lack of sleep can severe sleep problems than those with explore some of these relationships. create a vicious cycle in which tinnitus tinnitus alone. This is consistent with Defining the aspects of tinnitus that prevents good sleep and lack of sleep prior studies reporting higher rates of may contribute to insomnia can only worsens tinnitus symptoms. insomnia among people with sound help clinicians develop better plans of Researchers in the United Kingdom tolerance problems. However, further treatment to help patients with bother- performed a retrospective study to ex- analysis of this relationship indicated some tinnitus. amine aspects of insomnia in patients that hyperacusis itself is a poor predic- with tinnitus and hyperacusis.1 Data tor of insomnia. Reference were gathered from 444 patients with In further analysis, the data showed 1 Aazh, H., Baguley, D., & Moore, B. (2019, April 22). tinnitus or hyperacusis seen at a spe- Factors related to insomnia in adult patients with correlations between insomnia and tinnitus and/or hyperacusis: An exploratory analysis. cialist center in the U.K. National Health tinnitus annoyance and between Journal of the American Academy of Audiology. doi:10.3766/jaaa.18020 Service from 2013 to 2016. Patients insomnia and tinnitus were selected if they completed audio- handicap, as well as logical examination and questionnaires for anxiety and de- for insomnia, tinnitus and/or hyperacu- pression. Tinnitus sis, and anxiety and depression.

www.ATA.org TINNITUS TODAY SUMMER 2020 53  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 somewhat 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. To reconfirm dates and times, please email/call the point-of-contact person listed.

Support Groups Holding Online Zoom Meetings

If your regular support group is not meeting The Palo Alto Tinnitus Support Missouri virtually during the coronavirus pandemic, Group at Avenidas consider joining a virtual one to stay connected St. Louis Tinnitus Support Group Meeting virtually until further notice with other members of the tinnitus community. Meeting virtually until further notice To join a meeting that fits your time schedule, Contact: Ken Adler, Amy Nelson, AuD, Contact: Tim Busche email the point of contact listed below. Brandon Cyrus, AuD T: 636–734–4936 E: [email protected] Arizona E: [email protected]. E: [email protected] Tucson Tinnitus Support Group E: [email protected] Meeting dates and time: Aug. 5, Oct. 7, Meeting virtually until further notice Dec. 2, 7–9 pm Contact: Trudy Jacobson 3rd Thursday of the month, 6:30–8:30 pm. T: 520–982–7813 Texas Colorado E: [email protected] Dallas/Ft. Worth Tinnitus Denver Tinnitus Support Group 4th Monday of the month, 1–2 pm. Support Group Meeting virtually until further notice Meeting virtually until further notice Contact: Rich Marr California Contact: John Ogrizovich T: 303–875–5762 Los Angeles/Orange County Tinnitus E: [email protected] E: [email protected] Support Group Meeting Saturdays, every four to eight 2nd Monday of the month, 7–8:30 pm. Meeting virtually until further notice weeks, from 10 am. Contact: Barry Goldberg Maine/New Hampshire/Vermont E: [email protected] Washington Maine/NH/VT Virtual Tinnitus & Sept. 19 Seattle Tinnitus Support Group Hyperacusis Support Group Meeting virtually until further notice San Diego Tinnitus and Hyperacusis Contact: Mark Rossnagel Contact: Keith Field Support Group E: [email protected] Meeting virtually until further notice T: 206–783–7105 Meeting dates and times TBD Contact: Michael J. Fischer, Loretta E: [email protected] Marsh, Dave Phaneuf, Tom Sutton Maryland 3rd Thursday of the month from E: [email protected] 7:30–8:45 pm. University of Maryland Tinnitus and E: [email protected], Hyperacusis Support Group T: 858–484–9267 Meeting virtually until further notice If you’re interested in forming a group, please E: [email protected] Contact: Christina Shields, AuD contact Kevin Willman at [email protected]. E: [email protected] T: 301–405–5562 If there isn’t a group in your area, the ATA 1st Wednesday of the month, 6–7:30 pm. E: [email protected] has an extensive network of volunteers who FB: https://www.facebook.com/ provide email and telephone support and UMDHearingSpeechClinic educational information. To connect with a volunteer in your time zone, see https:// Meeting dates and times TBD www.ata.org/managing-your-tinnitus/support- network/telephoneemail-support-listing.

54 TINNITUS TODAY SUMMER 2020 www.ATA.org TINNITUS RESOURCES 

Other Support Groups

Due to the coronavirus, it is critical to contact Georgia New Jersey support groups directly to verify meeting dates and times, and personal protection requirements. Atlanta Tinnitus Support Group South Jersey Tinnitus Support Group Information on www.ata.org is provided by Dekalb County Public Library Advanced ENT/HearMD support group leaders. Dunwoody Branch, Meeting Room 1020 North Kings Highway, Ste. 201 California 5339 Chamblee Dunwoody Rd. Cherry Hill, NJ 08034 San Francisco Tinnitus Support/ Dunwoody, GA 30338 Contact: Beth Savitch, Erin Lustik Education Group Contact: Erica Caplan E: [email protected] Hearing and Speech Center of Northern CA E: [email protected] Meeting dates and times TBD. 2nd Floor Conference Room Email support provided until in-person 1234 Divisadero St. meetings resume. New York San Francisco, CA 94115 Bronx Tinnitus Support Group Contact: Tracy Peck Holcomb Illinois Mediator Church T: 415–921–7658 Chicago Suburban Tinnitus Conference Room E: [email protected] Support Group 260 W. 231st St. Meeting dates and times TBD. Contact: Margie B. Bronx, NY 10463 E: [email protected] Contact: Dr. Karie Nabinet Colorado Meeting dates and times TBD. T: 917–797–9065 or 718–410–2301 Denver Tinnitus Support Group E: [email protected] Lutheran Medical Center Maryland 1st Thursday of the month from 6:00 pm. 2nd Floor Learning Center, Classroom #1 DC & MD Tinnitus Support Group The Long Island Tinnitus Group 8300 West 38th Potomac Audiology Long Island Jewish Hospital Arvada, CO 80033 11300 Rockville Pike, Suite 105 900 Franklin Ave. (Meet in the lobby before Contact: Rich Marr Rockville, MD 20852 going down to conference room.) T: 303–875–5762 Contact: David Treworgy, Gerry Baill, Ann Valley Stream, NY 11580 E: [email protected] Ramsey Contact: Anthony Mennella Meeting dates and times TBD. E: [email protected] T: 516–379–2534 E: [email protected] E: [email protected] Florida E: [email protected] Meeting dates and times TBD. Clermont Tinnitus Support Group Meeting dates and times TBD. Citrus Hearing Clinic North Carolina 835 7th Street Suite 2 Massachusetts Raleigh Tinnitus Support Group Clermont, FL 34711 Boston Tinnitus Support Group Raleigh Hearing and Tinnitus Center Contact: Laura Bradley Pratesi, AuD Athan’s Bakery 10320 Durant Road, Suite 107 T: 352–989–5123 407 Washington St. Raleigh, NC 27614 E: [email protected] Brighton, MA 02135 Contact: Saranne Barker, AuD, 2nd Monday of the month from 1:00–2:00 pm. Contact: Kevin Plovanich Sheri Mello, AuD E: [email protected] Sarasota Tinnitus Support Group T: 919–790–8889 Silverstein Institute Meeting dates and times TBD. E: [email protected] 1901 Floyd St. Michigan Meeting dates and times TBD. Sarasota, FL 34239 Holland Tinnitus Support Group Contact: Carmen Trotta, Tom Terrenzi Oregon T: 941-993-7616, 941-462-1311 399 E 32nd St. Holland, MI 49423 VA Portland Health Care System E: [email protected] Tinnitus Education Group T: 616–392–2222 3rd Friday of the month from 2:00–4:00 pm. National Center for Rehabilitative Auditory E: [email protected] Research Email and chat support provided until in- 3710 SW US Veterans Hosp. Rd. person meeting resume. Portland, OR 97239 Contact: Bryan Shaw E: [email protected] Meeting dates and times TBD.

www.ATA.org TINNITUS TODAY SUMMER 2020 55  TINNITUS RESOURCES

Other Support Groups

Pennsylvania Virginia to the tinnitus community. The American Tinnitus Association (ATA) does not sponsor Lehigh Valley Tinnitus Support Group Northern Virginia Tinnitus nor endorse these activities and expressly Support Group Meeting location TBD disclaims any responsibility for the conduct Contact: Ed Kozelnicky Northern Virginia Resource Center for Deaf of any independent support group or the T: 610–797–7251 (H), 610–739–6675 (C) & Hard of Hearing Persons (NVRC) information they may provide. ATA is not a 3951 Pender Drive, Ste. 130 Meeting dates and times TBD. healthcare provider and you should consult with Fairfax, VA 22030 a primary care physician or hearing healthcare Contact: Elaine Wolfson, Marian Patey professional for qualified medical advice on Texas E: [email protected] tinnitus and related disorders. Houston Tinnitus Support Group E: [email protected] Some groups do not or cannot schedule Business Center, Village at West University Meeting dates and times TBD. meetings far in advance to allow for flexibility Apartments in planning. We post support group meeting 5151 Edloe St. Wisconsin information on our online events calendar at Houston, TX 77005 ATA.org, which is provided to us by support Contact: Vinaya Manchaiah Madison Tinnitus Support Group group leaders. The above information was T: 409–466–0427 Madison Masonic Center provided to ATA staff at the time the magazine E: [email protected] 85 S Stoughton Rd. went to print; therefore, please confirm Madison, WI 53714 Meeting dates and times TBD. meeting details with the contact person prior to Contact: Deb Holmen a meeting or reference our website at: https:// San Antonio Tinnitus & Hyperacusis T: 608 219 0277 www.ata.org/news/events Support Group E: [email protected] This is a partial listing of support groups and Contact: Matthew Randal Meeting dates and times TBD. scheduled meetings. A complete list can be Email: [email protected] found at https://www.ata.org/managing-your- Meeting dates and times TBD. tinnitus/support-network/support-group-listing Each support group referenced here is New groups are added on a regular basis so independently operated and led by volunteers check the website periodically for updates. who wish to provide education and support

Spotlight on Patient Providers

Professional Members Neal Sorenson, BS UNITED STATES Moore Audiology Listing current as July 14, 2020 Sun City, AZ When making an appointment, please mention Thea Wickey, AuD that you learned of the provider from the ATA, Alabama Sound Relief Hearing Center thereby ensuring that providers understand the Susan Sheehy, AuD Scottsdale, AZ importance of being a part of the ATA’s tinnitus Alabama Hearing Associates patient-provider network. Madison, AL Arkansas COLOR KEY Alaska Kelley Linton, AuD Center for Hearing, Ltd Purple: Audiology Emily McMahan, AuD Alaska Hearing & Tinnitus Center Fort Smith, AR Green: Medical practitioner Anchorage, AK California Blue: Hearing aid dispenser Arizona Kasra Abolhosseini, AuD Orange: Therapist Lynn Callaway, BC-HIS Tustin Hearing Center Tustin, CA Pink: Complementary/Alternative Affordable Hearing Solutions Medicine practitioner Green Valley, AZ Melissa Alexander, AuD Judy Huch, AuD Alexander Audiology Navy: Other Oro Valley Audiology Inc. Santa Monica, CA Oro Valley, AZ Randall Bartlett, MA Jonathan Ramirez-Lira, AuD Tinnitus & Audiology Center of Southern California, Inc. Sound Relief Hearing Center Valencia, CA Scottsdale, AZ

56 TINNITUS TODAY SUMMER 2020 www.ATA.org HEALTHCARE PROVIDERS

Troy Cascia, AuD Katarzyna Tarnowska, PhD Sharon Rophie, AuD UCSF Health San Jose State University Harbor Hearing PA San Francisco, CA San Jose, CA Palm Harbor, FL Shahrzad Cohen, AuD Benjamin Thompson, AuD Cindy Ann Simon, AuD Hearing Loss Solutions Pure Tinnitus South Miami Audiology Consultants Sherman Oaks, CA Berkeley, CA South Miami, FL Arthur Corpus, PA Brian Worden, MD (ENT) Mindy Stejskal, MCD Sharp Rees-Stealy Medical Group Inc. Kaiser Permanente The Hearing Center Chula Vista, CA Woodland Hills, CA Pensacola, FL Jean M. Deiss, AuD Anne Marie Taylor, AuD VA Northern California Health Care System Colorado ALPHA Audiology Martinez, CA Lindsay Collins, AuD Panama City Beach, FL David DeKriek, AuD Sound Relief Hearing Center Susan E Terry, AuD Fidelity Hearing Center Centennial, CO Broadwater Hearing Care Cerritos, CA Kaela Fasman, AuD St. Petersburg, FL Jerilyn Dutton, AuD Sound Relief Hearing Center Liz White, AuD Salient Sounds Audiology Golden, CO Harbor City Hearing Solutions La Jolla, CA Abigail McMahon, AuD Melbourne, FL Gregory Frazer, AuD Sound Relief Hearing Center Kayla Wilkins, AuD Pacific Hearing & Balance Center Inc. Fort Collins, CO Aspire Hearing and Balance Los Angeles, CA Natalie Phillips, AuD Lakeland, FL Jennifer J. Gans, PsyD Advanced Otolaryngology & Audiology Mindful Tinnitus Relief Fort Collins, CO Georgia San Francisco, CA Mandi Solat, AuD Laura Barber, AuD Amit Gosalia, AuD Audiology Services & Hearing Aid Center Augusta University Health-Audiology Associates West Valley Hearing Center Lakewood, CO Augusta, GA Woodland Hills, CA Nikki DeGeorge AuD Connecticut Tracy Peck Holcomb, AuD Fayette Hearing Clinic and Coweta Hearing Clinic Hearing and Speech Center of Northern California Steven Lurie, PhD Peachtree City, GA San Francisco, CA Torrington, CT Brian K. Jones, MEd Greater Atlanta Hearing Inc. Kent Holtorf, MD (Integrative) Florida Holtorf Medical Group Cumming, GA Anne Carter, AuD El Segundo, CA Christin Brooke Means, AuD Pasadena Hearing Care North Georgia Audiology Malvina Levy, AuD South Pasadena, FL Hearing and Speech Center of Northern California Suwanee, GA Maura Chippendale, AuD San Francisco, CA Otis Whitcomb, MA Chippendale Audiology Cobb Hearing Aid Services Sara Mattson, AuD Cape Coral, FL Rancho Santa Fe Audiology Marietta, GA Melissa Kipp Clark, AuD Rancho Santa Fe, CA Melissa Wikoff AuD Suncoast Hearing Services Plus Peachtree Hearing Amy Nelson, AuD Bradenton, FL Kaiser Permanente Marietta, GA Ali Danesh, PhD Santa Clara, CA Labyrinth Audiology Idaho Marni Novick, AuD Boca Raton, FL Silicon Valley Hearing Inc Christine Pickup, AuD Brooke Davidson, AuD Los Gatos, CA Mt. Harrison Audiology & Hearing Aids, LLC Baptist ENT Specialists Rupert, ID Charles Steven Peltz, MFT Jacksonville Beach, FL Steven Peltz, MFT Tosha Strickland, AuD Ericka DeVore AuD San Francisco, CA Strickland Ear Clinic All About Hearing/Lake Audiology & Hearing Aids Meridian, ID Bruce Piner, AuD Longwood, FL Hearing and Balance Center Wilson DuMornay, MD Illinois Encino, CA Broward ENT Services Nancy Congdon, AuD Jane Rosner, AuD Fort Lauderdale, FL The Hearing Care Clinic West Valley Hearing Center Kelly J. Dyson, AuD Downers Grove, IL Woodland Hills, CA Suncoast Audiology, LLC Phillip Elbaum, LCSW Mimi Salamat, PhD Largo, FL Deerfield, IL Dr. Mimi's Audiology Clinic Melodi B. Fehl, MS Walnut Creek, CA Lori A. Halvorson, AuD ENT & Allergy Associates of Florida Lake Forest Hearing Professionals William Stubbeman, MD Boca Raton, FL Lake Forest, IL TMS Psychiatry Lisa Gascay, AuD Los Angeles, CA JoAnn Harano, AuD Rainbow River Hearing & Balance Inc. Loyola University Health System Christopher Sumer, NBC-HIS Dunnellon, FL Chicago, IL Coastal Hearing Aid Center Margaret Richards, AuD Encinitas, CA Maria Morrison, AuD The Hearing Center Geneva Hearing Services Pensacola, FL Geneva, IL

www.ATA.org TINNITUS TODAY SUMMER 2020 57 HEALTHCARE PROVIDERS

James H Peck, HIS Maryland Shannon Radgens, DO Life Hearing Health Centers Red Cedar Ear Nose & Throat & Audiology Rockford, IL Chelsea Carter, AuD Owosso, MI University of Maryland Medical Center Jeanne Perkins, AuD Michelle Rankin, AuD Baltimore, MD Audiologic Services Ascent Audiology & Hearing Glen Ellyn, IL Christina Shields, AuD Chelsea, MI University of Maryland College Park Alyssa Seeman, AuD Michael Robinette, AuD College Park, MD Illinois State University Michigan Ear Institute Normal, IL Massachusetts Farmington Hills, MI Karrie Slominski, AuD Dierdre Anderson, AuD Indiana Henry Ford Health System Audiology Network Services Laura L. Fragomeni, AuD West Bloomfield, MI Salisbury, MA Reid Hearing Center Benjamin Wightman, AuD Eugene Antonell, BC-HIS Richmond, IN Sound Advice Audiology Hear Better Now Tinnitus & Hearing Center Erica Person, AuD Livonia, MI N. Dartmouth, MA Flex Audiology Lawrenceburg, IN Nataliya Ayzenberg, AuD Minnesota Moon Hearing Services, LLC John Ehlen Woburn, MA Iowa Hear Central Diana Kain, AuD Judith Bergeron BC-HIS Victoria, MN Beauport Hearing Care Heartland Hearing Center Jason Leyendecker, AuD Gloucester, MA Hiawatha, IA Audiology Concepts Beki Kellogg, AuD Joni Skinner Bullough, AuD Edina, MN Hampshire Hearing & Speech Hope Hearing & Tinnitus Center Laura Morrison, AuD Northampton, MA Hiawtha, IA Stillwater Medical Group-Health Partners Jill Nesham Theresa Cullen, AuD Stillwater, MN Cape Cod Hearing Center Professional Hearing Solutions by Dr. Jill Dr. Thomas Tedeschi, AuD Hyannis, MA Cedar Rapids, IA Amplifon Americas Heather Thatcher, HIS Peter Harakas, PhD Minneapolis, MN Hope Hearing & Tinnitus Center CBT Associates, LLC Hiawatha, IA Lexington, MA Missouri Richard Tyler, PhD Robert Mario BC-HIS Laura Flowers, AuD University of Iowa, Dept. of Otolaryngology — Head Mario Hearing & Tinnitus Clinics Hearing and Balance Specialists of Kansas City & Neck Surgery Cambridge, MA Lee's Summit, MO Iowa City, IA Karen L. Wilber, AuD Linda Guhe, MSW Shelley Witt, MA Boston Childrens Hospital Mind Body Clinical Hypnosis University of Iowa Hospitals & Clinics Boston, MA St. Louis, MO Iowa City, IA Michigan Jay Piccirillo, MD Washington University School of Medicine Kansas Terese Alsum, AuD Saint Louis, MO Bryne Gonzales, AuD Kaczmarski Hearing Services NuSound Hearing & Tinnitus Center Wyoming, MI Nevada Topeka, KS Stelios Dokianakis, AuD Robyn Lofton, BC-HIS Lauren Mann, AuD Holland Doctors of Audiology Hearing Associates of Las Vegas University of Kansas Medical Center Holland, MI Las Vegas, NV Kansas City, KS MaryRose Hecksel, AuD Elana Walker, AuD Michael Schneller, HIS Audiology & Hearing Aid Center VA Southern Nevada Healthcare System Focus Hearing Lansing, MI Las Vegas, NV Overland Park, KS Beckie Kaczmarski, AuD Susan Smittkamp AuD Kaczmarski Hearing Services New Jersey Associated Audiologists Inc. Wyoming, MI Catherine Ahrens Berke, BC-HIS Shawnee Mission, KS Angela Lederman, MS Ahrens Hearing Center Hear Now Audiology & Tinnitus Center Fair Lawn, NJ Kentucky Clinton Township, MI Granville Brady Jr., AuD Ann Rhoten, AuD East Brunswick, NJ Kentucky Audiology & Tinnitus Services Lexington, KY Please note that the American Tinnitus Association does not verify providers’ certifications Louisiana and expertise in tinnitus treatment. The list is meant expressly for informational purposes Mary Miller, PhD and should not be construed as the ATA’s endorsement of the providers listed. The ATA Premier Hearing and Balance strongly advises anyone using the list to check practitioners’ websites and tinnitus services Hammond, LA 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.

58 TINNITUS TODAY SUMMER 2020 www.ATA.org HEALTHCARE PROVIDERS

Valerie Kriney, AuD Saranne Barker, AuD Oklahoma Northern Jersey ENT Associates Raleigh Hearing & Tinnitus Center Glen Rock, NJ Raleigh, NC Suzanne Kimball, AuD University of Oklahoma Health Sciences Center Beth Savitch, MA Susan Bergquist, MS Oklahoma City, OK Advanced ENT/Hear MD Heritage Audiology Voorhees, NJ Wake Forest, NC Teresa M. Mazza, AuD Landrum ENT Donna Szabo, AuD Hannah Heet, AuD Ada, OK Innovative Hearing Solutions Duke Otolaryngology of Raleigh Westwood, NJ Raleigh, NC Christy L Mitchell, AuD Talihina Hearing Clinic Kelly Knolhoff, AuD Talihina, OK New York Birkdale Audiology Nicole Ball, AuD Huntersville, NC Oregon Hearing Evaluation Services of Buffalo, Inc Nancy McKenna, AuD Anna Forsline, AuD Tonawanda, NY University of North Carolina Chapel Hill VA Portland Healthcare System Carol Bass, MS Chapel Hill, NC Portland, OR All Ears Audiology Tinnitus & Hyperacusis Melissa Palmer, AuD Kristen Furseth, AuD Audiological Consulting High Point Audiology Willamette ENT Ithaca, NY Clayton, NC Salem, OR Alyssa Beaton, AuD Caroline Pittman James Henry, PhD Hearing Evaluation Services of Buffalo, Inc. UNCG Speech and Hearing Center National Center for Rehabilitative Auditory Orchard Park, NY Greensboro, NC Research (NCRAR) Diana Callesano, AuD Sandra Royle-Tabak, AuD Portland, OR Hearing and Tinnitus Center CarolinaEast Ear, Nose & Throat Todd Landsberg, AuD Woodbury, NY Morehead City, NC South Coast Hearing Center Collin Campbell Christina Seaborg, AuD Coos Bay, OR Campbell Acupuncture Hearing & Balance Center Ha-Sheng Li-Korotky, AuD New York, NY Charlotte, NC Pacific Northwest Audiology LLC Lois Cohen, LCSW Gina Whritenour, FNP Bend, OR Tinnitus Counseling Robeson Family Health Northport, NY Lumberton, NC Pennsylvania Craig Kasper, AuD Lisa Blackman, MA New York Institute for Hearing and Balance Ohio A Hearing Healthcare Center New York, NY Samantha Bayless, AuD Philadelphia, PA Tracey Lynch, AuD The Hill Hear Better Clinic Gail Brenner, AuD Island Better Hearing Inc Cincinnati, OH Hearing Technology Associates LLC Melville, NY Neil Cherian, MD Bala Cynwyd, PA Katherine Maffetone, AuD Cleveland Clinic Mindy Brudereck, AuD ENT & Allergy Associates Gates Mills, OH Berks Hearing Professionals Manhasset, NY Sarah Crow, AuD Birdsboro, PA Amy Sapodin, AuD Modern Hearing Solutions/Choice Hearing Center Amy Greer, AuD Advanced Hearing Center Canton, OH Lemme Audiology Associates Albertson, NY Sarah E. Curtis, AuD Ebensburg, PA Leigh A. Sauerbier, AuD Sounds of Life Hearing Center, LLC Jeannie Karlovitz, AuD The Advanced Hearing Center Concord Twp, OH Advanced Hearing Solutions Brooklyn, NY Cathy Kooser, LISW Exton, PA Rivka Strom, AuD Hillcrest Hearing & Balance Center Melissa Reitnour, MA Advanced Hearing NY Inc Centerville, OH Valley Forge ENT/Pinnacle ENT Brooklyn, NY Eric Mounts, HIS Phoenixville, PA Jennifer Sutton, AuD Modern Hearing Solutions/Choice Hearing Center Hearing Evaluation Services of Buffalo, Inc. Canton, OH Rhode Island Williamsville, NY Joseph Pietrolungo, DO Holly Puleo, AuD Lori Trentacoste, AuD Summa Health Gateway Hearing Solutions Island Better Hearing Inc Chagrin Falls, OH Warwick, RI Melville, NY Babette Verbsky, PhD Carolyn Yates, AuD Hearing Connections Audiology South Carolina Hearing Evaluation Services of Buffalo, Inc. Lebanon, OH Margaret Kalady, AuD Amherst, NY Jeffery Vehr, AuD Kalady Audiology Alexandra Zweig, AuD Hearall Hearing Center Beaufort, SC New York Institute for Hearing and Balance Dayton, OH Alexandra Tarvin, AuD New York, NY Gail Whitelaw, PhD Elevate Audiology- Hearing and Tinnitus Center The OSU Speech-Language-Hearing Clinic Easley, SC North Carolina Columbus, OH Jennifer Waddell, HIS Jennifer Auer, AuD Kyle Woods, MA Sound Hearing Care Audiology Attention & Tinnitus Care PLLC Modern Hearing Solutions/Choice Hearing Center Simpsonville, SC Concord, NC Canton, OH

www.ATA.org TINNITUS TODAY SUMMER 2020 59 HEALTHCARE PROVIDERS

South Dakota Elly Pourasef, AuD Memorial Hearing Inc. INTERNATIONAL Melissa Baker, MA Houston, TX Baker Audiology and Hearing Aids Argentina Lydia Ramanovich, AuD Sioux Falls, SD Dallas Ear Institute Susana A. Dominguez Lindsey Jorgensen, AuD Frisco, TX Hospital Italiano de Bs.As,, Argentina University of South Dakota, Communication Capital Federal, BA Bradley Stewart, AuD TINNITUS Sciences & Disorders TODAY ClearLife Hearing Care Vermillion, SD Australia Allen, TX Stephanie Wubben, AuD Lynne Blackford, BSc Crystal D. Wiggins, AuD Stanford Hearing Aids MQ Health Speech and Hearing Clinic Bay Area Audiology Sioux Falls, SD Macquarie University, NS Webster, TX Michael Segal, MA Tennessee Vermont Pristine Hearing Tiffany Ahlberg, AuD Nollamara, WA Elizabeth Adams, AuD Ahlberg Audiology & Hearing Aid Services Univ. of Vermont—E.M. Luse Center Cleveland, TN Burlington, VT Cynthia Ellison, AuD PeterBelgium Van Ostaeyen Stephanie Hollop, AuD Franklin Hearing Center ReSilence Psychepolis Univ. of Vermont-E.M. Luse Center Franklin, TN Schoten, AN Burlington, VT Andrea Plotkowski, AuD Canada Ear, Nose and Throat Consultants of East Tennessee Virginia Knoxville, TN Patrick DeWarle, AuD Ana Anzola, AuD Winnipeg Hearing Centres Paul Shea, MD Hearing Doctors Winnipeg, MB Shea Ear Clinic McLean, VA Memphis, TN Kimberly Eskritt, AuD Theresa Bartlett, AuD Lambton Audiology Associates Virginia Hearing Consultants Texas Sarnia, ON Virginia Beach, VA Diane Allen, PhD Deborah Lain, MSc Ann DePaolo, AuD The Grove Counseling & Wellness Center Hope for Tinnitus The Audiology Offices LLC Dallas, TX Calgary, AB Kilmarnock, VA Theodore Benke, MD Carol A. Lau, HIS Margaret Cooper Evans, AuD Benke Ear Nose & Throat Clinic Sound ID Ears Inc. Evolution Hearing Cleburne, TX Vancouver, BC Richmond, VA Lacey Brooks, AuD Julie Farrar-Hersch, PhD North Housting Hearing Malaysia Augusta Audiology Assoc., P.C. Spring, TX Wan Syafira Ishak, PhD Fishersville, VA Bethany Brum, AuD Program Audiologi, Fakulti Sains Kesihatan Virginia Lindahl, PhD UT Southwestern Medical Center Kuala Lumpur, KL Virginia Lindahl, Therapy and Psychological Testing Dallas, TX Alexandria, VA Norway Christie Cahill, AuD Sandra Michele Ochoa, MA Family Hearing & Sensory Neural Center Wisconsin Huntsville, TX Oslo, 03 Hugo Guerrero, AuD Mary Sue Harrison, AuD Mayo Clinic Health System Taiwan Today's Hearing Onalaska, WI Katy, TX Chin-Lung Kuo, MD Veronica Heide, AuD DoctorKuo ENT Clinic Jamie Hawkins, AuD Audible Difference, LLC New Taipei City Clarity Hearing Madison, WI Conroe, TX Dan Malcore United Kingdom Kristen Keener, AuD The Hyperacusis Network Hashir Aazh, PhD IlluminEar Tinnitus & Audiology Center Green Bay, WI Hashir Tinnitus Clinic Austin, TX Samantha Sikorski, HIS Guildford, Surrey Christina Lobarinas, AuD Sikorski Hearing Aid Center, Inc. Lisa Caldwell UT Southwestern Childrens Health Specialty Spooner, WI The Hearing Coach Dallas, TX Nicole Smith, AuD Glossop Cynthia Lockhart, HIS Everclear Hearing Products Alan Hopkirk Carrollton, TX Eau Claire, WI The Invisible Hearing Clinic Pedro Montano, MD Paisley McAllen, TX West Virginia Rene Pedroza, AuD Erin Wells, AuD United States Department of Defense Mountain Ears Hearing Clinic, LLC El Paso, TX Parkersburg, WV

60 TINNITUS TODAY SUMMER 2020 www.ATA.org TINNITUSTODAY Editorial Calendar

Tinnitus Today magazine is a print and electronic media magazine published in April, August, and December, and circulated to 25,000+ ATA contributors, donors, patients, supporters, researchers, and healthcare professionals.

The magazine editorial team empowers readers with information, including up-to-date medical and research news, feature articles on urgent tinnitus issues, questions and answers, self-help suggestions, and letters to the editor from others with tinnitus. Strong service journalism, compelling storytelling, first-person narrative, and profiles are presented in a warm, vibrant, and inviting format to encourage readers to reflect, engage, and better understand a medical condition that affects millions.

Editorial Digital Issue Issue Theme Copy Due Photos Due Ad Close Launch Mailed

Winter—Dec 2020 Annual Research Issue 9/15 10/1 10/1 12/1 December

Spring—Apr 2021 Causes of Tinnitus 1/15 2/1 2/1 4/1 April

Summer—Aug 2021 Hearing Aids 4/15 5/1 5/1 8/1 August

Editorial Calendar is subject to change.

To advertise, contact: [email protected]

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 decision- making, 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 Tune In to Conversations in Tinnitus 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, cohosted by John A. Cover- stone, AuD, and Dean Flyger, AuD, while you work out, take a walk, relax at home, or commute to work. To access and learn more about this unique and compelling series, visit our website at www.ata.org. To enhance listening comprehension and accommodate those with noise sensitivity, transcripts are available with each podcast.

ALL PODCASTS ARE FREE AND OPEN ACCESS

Podcast 14: Does Diet Play a Role in Tinnitus and Podcast 16: Exploring Noninvasive Neurosensory Hearing Health? Tinnitus Treatment SUBJECT MATTER EXPERT: Christopher Spankovich, PhD, MPH SUBJECT MATTER EXPERT: Hubert Lim, PhD TOPIC: Dr. Spankovich discusses the influence of nutrition on hearing TOPIC: Dr. Lim, a leading scientist and thought leader in auditory health and tinnitus, based on extensive research on the subject. He outlines neuroscience, discusses the research and development of non-invasive what everyone should know about how nutrition can contribute to better bimodal neuromodulation for treatment of tinnitus. He explains the scientific hearing or hearing problems. As a researcher and clinician, he also shares concept and the research being conducted, which is aimed at developing recommendations he makes to patients so they can better manage their a treatment that decreases the perception of the tinnitus sound and the tinnitus and overall hearing health. negative emotional reactions caused by it. Podcast 15: Does Tinnitus Retraining Therapy Podcast 17: Understanding the Problem of Painful Improve Quality of Life? Hyperacusis SUBJECT MATTER EXPERTS: Roberta Scherer, PhD, and Craig Formby, PhD SUBJECT MATTER EXPERT: Bryan Pollard, BA TOPIC: Drs. Scherer and Formby guide us through the decades-long journey TOPIC: Bryan Pollard, founder of the nonprofit Hyperacusis Research, to conduct the first and only phase III trial of tinnitus retraining therapy, an explains what it is like to live with noise-induced pain and what is known influential habituation-based treatment protocol for alleviating the negative about this often overlooked condition. As someone who lives with painful reactions to tinnitus. The researchers explore findings that highlight the hyperacusis and tinnitus, Pollard provides unique insight into the struggles, importance of sound enrichment and working with a caring and qualified his mission to increase research on the condition, and the importance of healthcare provider. developing tools to enable sufferers to return to a more normal life, without fear of setbacks.

To subscribe to the print or digital issue of Tinnitus Today, which is published three times a year, visit www.ata.org or email [email protected]