1. TINNITUS RETRAINING
THERAPY
Tarek Ghannoum , M.D.
Audiology Unit , ENT Department
Kasr Alainy Hospitals- Cairo University

2. TINNITUS

3. ANSI:-
Sensation of sounds without external
stimulus.
Ciba symposium on tinnitus:
Sensation of sound not brought about
by simultaneously applied mechano-
acoustical or electrical signals.

4. Jastreboff and Hazel:
The perception of sound that results
exclusively from activity within the
nervous system without any
corresponding mechanical, vibratory
activity within the cochlea and is not
related to external stimulation of any
kind.

5. Jastreboff, 1990:
50 million American.
12 million ask for help.
Axellson et al.(1989):
5% of Brazilian attending ENT clinics.
Pilgramm et al.(1999):
18.7 million German citizen.

6. *Different lines of treatment
have been proposed.
*Non is satisfactory.

7. For improper cure:
*Lack of accurate and different
mechanisms for tinnitus generation.
*Proper classification of tinnitus
patients.

8. Neuro-physiological model.
Auditory & Other Cortical areas
Perception & Evaluation (Consciousness, Memory, Attention)
Auditory Limbic System Reactions
subconscious Emotions
Detection / Processing
Auditory Autonomic Nervous System
Periphery
Source

9. TRT
* Retrain the reflexes involving the
connections between the auditory, the
limbic and autonomic nervous systems.
* Retrain the subconscious part of the
auditory pathway to block the tinnitus
signal which is causing annoyance.

10. Advantages of TRT:
*Is based upon a specific model, tested
and refined.
*Does not have side effects.
*Does not required frequent visits.
*Does not interfere with hearing aid use.
*Can be used in all patients.

11. TRT is not a cure.

12. Categorizing factors of tinnitus patients:
1- The strength and stability of the connections
between auditory cortex and limbic and
autonomic nervous system.
2-Hearing loss.
3-Hyperacusis and phonophobia.
4-Worsening of tinnitus as a results
of exposure to sounds.

13. Categories of tinnitus subjects:
Prolonged
Subjective
Hyper- sound Impact
Category hearing Treatment
acusis induced on life
loss
exacerbation
0 Low Counseling only
1 High Sound
generators set at
mixing point
2 Present High Hearing aid with
enrichment of
the auditory
background
3 Present Not High Sound
relevant generators set
above threshold
of hearing.
4 Present Present Not High Sound
relevant generators set at
the threshold

14. TRT:
1-Counseling.
2-Sound therapy.

15. Instruments:
- Noise generators.
- Hearing aids.
- Combination instruments.
- Table top, bed-side noise generators.
- Environmental sound sources.

16. Requirements:
* Never annoying.
* Neutral, not attracting attention.
* Not masking.
* Sufficiently above threshold.
* Used for extended periods of time.
* Easy to use and adjust, not occluding.

17. Rational for sound therapy:
- Reduce contrast of tinnitus V. Silence.
Interfere with detection of TRA.
- Reduce central auditory gain.
- Increase plasticity: allow habitation.

18. B.T.E. Sound
Generator
Open ear
mould

19. Custom Helix
MM4
MM5

20. Directive counseling:
1- Teaching.
*Auditory processing.
*Tinnitus mechanisms.
*Conditional response.
*Use stories.
2- Reclassification of meanings.
3- Reducing / abolishing reactions.

21. Beliefs about tinnitus:
* Tinnitus will get worse.
* Tinnitus will go on forever.
* Tinnitus is a physical disease or injury.
* There is no treatment.
* I will be deprived of sleep because of tinnitus.
* Tinnitus will make me go deaf.
* Tinnitus may be caused by a tumour.
* Tinnitus means I will have a stroke.
* Tinnitus means I can never have silence.
* My family and social life will suffer greatly.

22. How long does TRT take?
• Strong held beliefs take time.
• Repetition of training information is
needed.
• Process of habituation is gradual, needs to
be followed.
• Desensitization techniques take time.

23. * Average time: 8- 18 Months.
* Average number of visits ?

24. Evaluation of treatment outcome:-
Tinnitus Handicap Inventory (THI)

25. T H I (Cont.)
* Yes response : 4 points
* Sometimes response: 2 points
* No response: 0 point

26. T H I (Cont.)
Total scale range: 0- 100 points.

27. THI Subscales:
1- Functional subscale: The impact on every
day function.
2- Emotional subscale: a broad range of
affective response to tinnitus.
3-Catastrophic subscale: Patient desperation.

28. Handicap Severity Categories:
* No Handicap: 0-16.
* Mild Handicap: 18 -36.
* Moderate Handicap: 38-56.
* Severe Handicap: 58-100.

29. Improvement:
* Change from Category to a less severe
category.
* Pre and post intervention scores > 20 points.

30. Results:
* Sheldrake et al.(2002): 96%.
* Hazel (2003): 78%.
* Jastreboff (2003): 81%.
* Baguely(2005): 79%.

31. * TRT is not the only way to treat
tinnitus.
* Single element of TRT may help some
patients.
* The term TRT should be reserved for
the full treatment according to the
definition.