Dr.George Thomas Kovai Hearing,Speech and Balance Centre
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Kovai Hearing Speech & Balance Centre,
7A, Artsan towers,
Ramanathapuram, ( South India )
Coimbatore - 641045
Telphone: 0422 - 4390909
Mobile:(o) 9994390909
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Dr. George has many publications in National and International medical journal and has presented many scientific paper at national and international level and conducted workshop and chaired many scientific meetings. He was involved in the intensive programme on pediatric audiology in Brussels Belgium. At present he is involved in the publication of a text book on Audiology and neurotology. The center has conducted Hearing aid camps for those with impaired hearing where free investigation were provided and hearing aids dispensed at discounted prices. The center is associated with many schools for the hearing impaired in the state and plays an active role in the management of the hearing impaired patients.
Dr.George Thomas with Medical Societies Dr.George Thomas with Medical Societies
National equiliobriometric
society of India
National equiliobriometric
society of India
  • Detect sound, discriminate it from others, separate it from the background, attend to it recognize it as familiar and comprehended its meaning.
  • Inability to decipher meaningful signals, learning difficulties, delayed language development etc., are the consequences.
  • Neurobiology and psychology of hearing is affected in CAPD leading to attention deficits, language delays and other dysfunctions including dyslexics, aphasics and hyperactive children.
  • PET and fMRI studies provide insight and degree of function in normal and abnormal stage.
  • Continued research has thrown light on the functioning of not only afferent system but also efferent system- role of olivocochlear bundle in hearing in noise.
  • It has been proved that the brain is more plastic in early stages of development through adolescence and even the adult brain is plastic. (Music, 2002)
  • Tonotopicity.
  • The earliest stage of central processing occurs at the cochlear nucleus, where the peripheral auditory information diverges into a number of parallel central pathways.
  • Next stage is at superior olivary complex were information from both the ears interact to help us localize sound in space.
  • Dr George Thomas Auditory Processing
  • The inferior colliculus of the midbrain is a major integrative center where auditory information interacts with the motor output.
  • The inferior colliculus is a relay center for information traveling to the thalamus and cortex, where more complex aspects of speech are processed.
  • The lateral lemniscus is the principal ascending auditory pathway in the brainstem and terminate in the inferior colliculus,and constitute the afferent bundle.
  • The primary auditory cortex Brodmann areas 41 and 42 lies on the transverse gyrus of Heschl.
  • Area 41 is a primary auditory reception area and receives its projections from the medial geniculate body.
  • Areas 42, 52 and 22 lie immediately adjacent and are auditory association areas. They receive signals from the primary auditory cortex and send projections to the occipital, parietal, and insular cortex. The association areas is responsible for more complex interpretation of sounds.
  • The primary auditory cortex are responsive to stimulation through either ear, their sensitivities are not identical.
  • The cortex is divided into alternate zones of two types. Half of these known as summation columns-excited by stimulation of either ear.
  • The other half known as suppression columns are excited by unilateral input but inhibited by stimulation of the opposite ear.
  • Summation and suppression columns extend at right angles to the axis of tonotopic mapping. Hence the auditory cortex are responsive to every audible frequency and to each type of interaural interaction.
  • Each auditory cortical area is reciprocally connected to a homotypic area in the contralateral hemisphere via projections in the corpus callosum.
  • A cardinal feature of the CANS is the extensive binaural representation of acoustic information at various levels resulting from the interaction of neural input from both ipsi and contra pathways.
  • Parallel with the neurons conducting information from the organ of corti to the auditory cortex, there are descending and efferent neurons that conduct impulses in the reverse direction, thereby providing multiple feedback circuits.
  • They modulate central processing and regulate the input from peripheral receptors similar to role played by the efferent vestibular system.
  • Cotico-geniculate fibers, which originate in the auditory and surrounding cortical areas and terminate in all parts of the medial geniculate nucleus.
  • Cortico-collicular fibers, from the same cortical areas to the inferior colliculi of both sides.
  • Cortico-olivary fibers, from the same cortical areas to the superior olivary nucleus.
  • Colliculo-olivary fibers, from the inferior colliculus to the superior olivary nucleus.
  • Colliculo-cochleonuclear fibers, from the inferior colliculus to the dorsal and ventral cochlear nuclei. xcept for the cortico- collicular projection, which includes both crossed and uncrossed fibers these descending pathways are ipsilateral.
  • 2 to 3% of children with a 2 : 1 ratio between boys and girls. (Chermak 2001)
  • The prevalence rate in older adults is higher.
  • Central hearing loss - lesion exists in the cochlear nucleus up to auditory cortex.
  • Hemispheric Lesions
  1. Auditory Agnosia - Impaired reorganization of non verbal sounds and noises. The ability to comprehend speech is retained. These patients may present with a sudden inability to understand spoken language, repeat spoken words, or write from dictation.
  2. Cortical deafness there in an inability to recognize auditory stimuli. The patients present clinically as if they were deaf and may pay little attention even to loud noises.
  3. Brainstem Lesions may be due to cerebrovascular disease, tumor, inflammation or demyelination.
  • History.
  • Pure-tone thresholds.
  • Speech thresholds and discrimination in noise.
  • Pure-tone threshold in white and narrow band noise.
  • Masking level difference.
  • Gap detection of temporal resolution.
  • Otoacoustic emissions.
  • Dichotic listening tests.
  • Normal PTA hearing thresholds-significant history of chronic otitis media.
  • Inconsistent response to auditory stimuli-unable to follow auditory instructions.
  • Difficulty with auditory localization skills-inability to tell how close or distant the source of the sound and inability to differentiate soft and loud sounds. These children become frightened and upset when exposed to loud noise.
  • Difficulty with auditory discrimination-deficiencies in reading, spelling and phonemic synthesis and difficulty understanding speech in background noise.
  • Difficulty with auditory memory-unable to follow multiple instructions.
  • Poor listening skills-decreased attention distractibility in listening situations.
  • Difficulty understanding rapid speech or persons with and unfamiliar dialect.
  • Frequently request that information be repeated.
  • Significant reading problems, poor spelling and poor handwriting.
  • Articulation and language disorders.
  • Inattentive
  • Distracted
  • Hyperactive
  • Fidgety or restless
  • Hasty or impulsive
  • Interrupts or intrudes
  • Difficulty hearing in background noise
  • Difficulty following oral instructions
  • Poor listening skills
  • Academic difficulties
  • Poor auditory association skills
  • Distracted
  • Inattentive
  • PTA.
  • Tympanometry.
  • Speech audiometry.
  • Only distorted speech materials called sensitized speech tests can identify central auditory lesion.
  • Distortion can be accomplished by including high or low-pass filtering that reduces the range of frequencies (filtered speech testing).
  • Speech in background noise.
  • Interrupting the speech at different rates and by increasing rate of presentation (time-compressed speech).
  • When a central auditory disorder is present speech intelligibility is poor.
  • These sensitized speech testing is extremely powerful and forms the basis of all behavioural and speech tests of central auditory function.
  • Duration Patterns Test (Music et al.1990)
  • Auditory Fusion Test (McCroskey and Keith 1996)
  • Speech-in-noise testing.
  • Low pass filtered-word test in which speech is degraded by the removing part of the frequency spectrum. Some consider this as a test of auditory closure that is defined as the ability to understand the whole word or message when part is missing.
  • Other test being pediatric speech intelligibility test, time compressed speech etc.,
  • Dichotic speech testing is typically administered to determine hemispheric dominance for language shown by asymmetrical ear responses and to assess neuromaturational development of the auditory system.
  • Dichotic listening tests involve the simultaneous presentation of different acoustic stimuli to the two ears.
  • Dichotic tests are generally administered at comfortable listening levels under earphones.
  • The listener is required to repeat or write what is heard.
  • Abnormal performance on dichotic tests indicates delays in auditory maturation, underlying neurological disorganization or damage to auditory pathways.
  • Dichotic Digits
  • Dichotic Words
  • Dichotic Spondees
  • Dichotic Sentences
  • Dichotic Syllables, Digit Sentences
    The masking level difference (MLD) refers to the difference between thresholds obtained under two binaural masking paradigms termed homophasic and antiphasic.
    Dr.George Thomas Masking level differences
    • The test can be behavioral or electrophysiological, linguistic or non-linguistic.
    • Screening and diagnostic test procedures are available to assess theses functions.
    • The test battery is chosen based on a number of factors which include subject-related factors such as age, complaints, language level, intelligence and the test / facilities available in the clinic.
    • Minimum requirement for carrying out the tests are – calibrated audiometer, a CD player and a CD of the test material.
    • These patients experience difficulty understanding speech in the presence of competing messages, noise or reverberation.
    • They require repetition of material, a slower pace, or clearer speech production in order to comprehend.
    • In addition they appear inattentive or easily distracted and display an inability to immediately record information or to access stored auditory information.
    • Children with organic based problems, traumatic brain injury, or syndromes (e.g. Fragile X, autism) and children with poor progress are considered good candidates.
    • If the hearing loss greater than 30dBHL and OAEs are present, it may imply retrocochlear lesion.
    • The OCB is a part of the efferent auditory pathways and helps people to hear in noise.
    • The integrity of the MOCB can be evaluated by simply presenting a noise in the contralateral ear. Normal subjects-show suppression close to 3dB. Patients with AN/BS lesion show lack of suppression.
    • Useful in assessment of VIII nerve and lower brainstem lesions.
    Dr.George Thomas AR Testing
    • Each waveform peak represents neuroelectrical activity at one or more nuclei.
    • Lesions such as acoustic neuroma brainstem neoplasms and multiple sclerosis may result in poor or absent ABR waveforms. It is also a measure of CAPD at the brainstem level.
    Dr.George Thomas ABR
    • Occurs from 10 to 50 msec following stimulus onset.
    • The neural generators involve the primary auditory cortex, thalamo-cortical projections, inferior colliculus and medial geniculate body in the midbrain also outside the auditory pathway such a the reticular formation and multi-sensory nuclei of the thalamus.
    Dr.George Thomas MLR
    • MLR is a useful test in evaluating CAPD due to the location of neural generators.
    • MLR waveform latencies are not as sensitive as amplitude measures.
    • LLR reflect the activity of thalamus and auditory cortex-structures that involve the attentional, integrative and discriminative functions of the brain. They are also called the event related potentials.
    • The P300 response, occurs to rare or novel stimuli-odd-ball paradigm e.g. 1000-Hz tones may be presented 85% of the time. (frequent stimuli) along with 2000-Hz tones, which are presented 15% of the time (rare stimuli). The subject is asked to attend by simply counting the number of rate stimuli presented.
    Dr.George Thomas LLR
    • Mismatched negativity (MMN), a negative wave occurring at 200msec is a passively elicited response, not requiring attention or behavioral response. (Karus et al.) have shown CAPD deficits correlated to MMN abnormalities.
    • MMN waveform is derived by subtracting the evoked response waveform of the same stimuli from the evoked response wave form of the different stimuli.
    • The MMN is also elicited with an oddball-type paradigm, but, unlike the P300 response, the subjects, conscious, overt attention is not required.
    • MMN is considered as a pre-conscious, automatic response to stimulus change.
    • MMN appear to originate from the primary auditory cortex and association auditory cortex.
    • The limbic system and the primary auditory cortex seem responsible for the P2 response.
    • The P300 response seems to be linked to the hippocampus and the posterior temporal lobe.
    • Electrophysiological measures of auditory function provide objective evidence of CAPD and should be included in every audiologic test battery.
    • Tests of auditory memory require a child to recall auditory stimuli in terms of number and sequence.
    • Echoic memory-from which in any utterance can be immediately reproduced.
    • Short-term memory-where several items may be retained for a short while.
    • Long-term memory-permanent store thought to occupy a role in language development. (Library of references)
    • The management should be customised for each individual.
    • Modification of the environment to minimize the adverse listening conditions.
    • Use of compensatory strategies by the listener to “get around” the deficit and
    • Direct intervention (remediation technique) designed to enhance or improve auditory skills.
    • Modification of the classroom and recommendation for some type of assistive listening device.
    • Remediation activities that are used can be “bottom-up or “top-down” therapies.
    • Top-down therapy programmes include metalinguistic and metacognitive strategies.
    • Bottom-up programmes are based upon the notion that the listener’s ability to encode incoming signals is deficient and can be improved through adaptive training.
    • Auditory training is recommended to improve the process that are found to be less efficient in an individual eg. auditory training for auditory closure, dichotic listening.
    • Auditory training programme depends on a number of factors – younger the age of the subject, more will be the improvement observed.
    • Number of software programmes that are available.
    Tests are no available to assess various functions of the CANS and suitable therapy can be formulated based on the results of these tests.
    • The principle of the model is that central processors play a fundamental role. it suggests that the cochlea plays only a secondary role.
    • It proposes that the increased auditory gain during peroids of restricted sound input or due to cochlear damage may account for the tinnitus.
    • key suggestion being tinnitus becomes problematic because of improper activation of the brains limbic system (emotion, memory, learning) and the ans (fight or flight).
    • It is suggested that activation of these systems is due to sub cortical and cortical loop acting through associations developed as conditioned reflexes.
    • The starting point for the model, it uses a classical conditioning paradigm.
    • This states that when two or more sensations occur together then one alone, felt later, can evoke the memory of the other.
    • pavlov demonstrated that when a neutral stimulus (bell) is associated with another stimulus (food) that naturally provokes a reaction (salivation), the neutral stimulus can provoke the same reaction.
    • The natural stimulus is referred to as ucs. the neutral stimulus is the cs and the newly learned response is the cr.
    • The cr is weakened and disappears when the neutral stimulus is repeatedly presented without the intrinsically provocative stimulus. this process is referred to as extinction.
    • The neurophysiological model of tinnitus in humans suggests that tinnitus becomes problematic because it becomes associated with something negative (retirement, death in family, work problems)
    • Once it is associated with the negative emotional state, continuous tinnitus induces prolonged activation of the ans.
    • The negative reaction (ans) help to maintain the problem by strengthening the cr.
    Auditory & other cortical areas.
    Dr.George Thomas Jastreboff NeuroPhysiological Model
  • The source is usually near the periphery but any neuron in the auditory sub awareness pathway may contribute to the sounds heard.
  • what is perceived at conscious level is the neural activity present in the highest neurons in this pathway, subsequent to any processing, patten arranging, enhancement or attenuation that has gone on between ear and brain.
  • when irregularities of cochlear function exist, these may result in signals which are then imposed on the otherwise random activity of auditory neurons in the absence of sound.
  • The source of tinnitus in universal, it is unheard until sub awareness pattern recognition occurs, and only persists if only other criteria are fulfilled.
  • With the knowledge of auditory anatomy and physiology the patient appreciates that sounds are not heard until they reach the auditory cortex.
  • Every new sound has to be evaluated and classified before it may be ignored.
  • The sudden advent of a noise coming from within the head is alarming and leads to a belief that something is wrong.
  • Subsequently, message for help the patient can experience negative counseling (put up with it).
  • Frequently worst fears are not only confirmed, but strongly enhanced.
  • Once the patient understands the negative evaluation of tinnitus, it can be simply shown by the diagram that this will inevitably create an aversive response involving enhancement of limbic and autonomic function.
  • If the evaluation is strongly negative (brain tumour or madness) then a strong phobic or aversive reaction can result.
  • On the other hand only slight occasional annoyance may result from the loss of homeostasis, or tinnitus being seen as a minor territorial intrusion.
  • The response is ‘set’ in the subconscious, and cannot be ‘turned off’ at will;
  • The response will be triggered whenever the signal can be detected.
  • The connections are bi-directional and therefore the limbic/autonomic reaction from sub cortical detection of tinnitus enhance the response which in turn enhances detection, and so on, independent of conscious thought.
  • Enhanced detection leads to greater perception, and another vicious circle, strengthening the reaction still further. this is the mechanism by which tinnitus perception and reaction can increase without any change in the peripheral auditory system.
  • Top
    • After loud noise exposure patients feel that the situation is irreversible. it is important to demonstrate how the persistence of tinnitus is dependent on the aversive conditioned response continuing.
    • The response can be retrained and the problem can be solved.
    • The lower loop in the model describes a feedback system between the detection of tinnitus and limbic and ans activity. and this system operates at a sub conscious level without the need of conscious awareness.
    • The upper loop describes the feedback system again involving tinnitus detection, limbic and ans activity but also the conscious evaluation of tinnitus (beliefs about the significance of the noise).
    • The lower loop is dominant in the majority of tinnitus patients.
    • Once tinnitus is being processed centrally, any peripheral generator becomes unimportant in the perception activities.
    • The reaction will be strengthened by events that reinforce the association and weakened by the occurance of the neutral stimulus in the absence of the ucs or other reinforcement of the behaviour involved
    • Acquiring emotional significance tinnitus is given priority within our attention processing system.
    • This model also provides a basis for understanding and treating reduced sound tolerance.
    • The model also cites the classic heller & bergman study pointing to increased gain in the auditory system in the presence of reduced auditory input.
    • It further appeals to the theory of discordant damage to explain the imperfect relationship between hearing loss and tinnitus.
    • The source of tinnitus is related to the area where there is greatest difference between functional ihc and dysfunctional ohc.
    • The model has lead to the development of a treatment protocol called trt. the key element of this being passive extinction.
    • in trt the first step is to decrease the magnitude of the negative reinforcement over a period of time, i.e., to decrease activation from the cortical area by convincing the patient about the benign nature of tinnitus and by presenting tinnitus as a result of a positive helpful activity occuring within the auditory system.
    • This addresses the tinnitus through manipulation of the upper loop (cortical conscious, representation of tinnitus).
    • This element of trt is termed directive counselling. this has the effect of lowering the activation of the ans and therefore decreasing the negative reinforcement of the continuously present stimulus and so reducing the strength of the cr.
    • The second component is the sound therapy. the point of sound therapy is to increase the background neuronal activity and therefore the contrast between it and the tinnitus (changes the sn ratio).
    • In this way the strength of the tinnitus signal is decreased which inturn reduces the activation of the ans and other systems involved.
    • It is well established that the brain has an enormous amount of plasticity; it is constantly undergoing changes. every time we learn something new, small changes occur within the brain by way of modifications of neural connections.
    • Our brain has one shortcoming. it cannot handle too much information at the same time. it has to focus on one task at a time.
    • This problem is solved by the filtering capability of the nervous system. before any information reaches the cortex, it is assessed and evaluated without our awareness.
    • if information is classified as important, it is allowed to reach the level of the cortex at which conscious perception of the information occurs.
    • if it is judged as not important it is rejected. our brain is able to select sounds that are important and ignore those that are not important without being in anyway aware of this process.
    • the decision regarding importance is done in the sub cortical pathways of the nervous system.
    • our brain makes these decisions based on four factors.
    • if the signal is new, it attracts attention and triggers a reaction.
    • the brain makes decisions based on past experiences. if something was important to us because it was pleasant or unpleasant, that is having a clear emotional message, it is given priority.
    • it depends on what other task our brain is performing at that time. if we are involved in some activity, stimuli not related to this activity will be ignored. however if we are just relaxing unimportant stimuli that would normally be rejected will be drawn to our attention.
    • stimuli that are radically different from others being perceived at the same time, will be perceived. this last feature reflects the ability of our nervous system in focusing on an enhancing contrast.
    • If we can utilize this powerful feature of the brain to filter out signals that are not important then we may be able to remove tinnitus from our awareness.
    • If we can teach the brain to filter out the tinnitus sound the person will not be aware of the presence of tinnitus even if the tinnitus related activity is still present in the periphery and would normally be able to reach the level of the cortex where it wound be perceived as sound (secretary).
    • In neuroscience the disappearance of a reaction to a stimulus is called the process of habituation.
    • The method of handling tinnitus aimed at habituation of tinnitus perception is called neuro physiological approach to tinnitus, since it uses neuropsychological principles applicable to the cns rather than focusing on the source of tinnitus signal, which usually is in the inner ear.
    • The goal of the approach is to habituate tinnitus sound, example to create a situation in which the tinnitus is unaware for the majority of time, but still can perceive tinnitus if he or she focuses attention on the tinnitus sound.
    • The tinnitus source or trigger is unchanged; but the signal that is normally perceived as tinnitus sound is blocked before it reaches the cortex and our awareness.
    • The patient should be told with full confidence that his or her tinnitus does not indicate any serious medical problem. tinnitus is a symptom and not a disease.
    • To get rid of fears and concerns that all patients have, an in depth explanation of the test results.
    • Strongly held beliefs and concerns like “nothing can be done for tinnitus” cannot be overcome in one session and may warrant many sessions.
    • Reassurance and improvement of the patient’s well being to be stressed at each session.
    • Full detailed explanation about removing the potential negative association of tinnitus is crucial. only then can habituation be induced.
    • Directive counseling is an essential part of the approach and differs from traditional counseling since it is aimed at actively changing the way the patient thinks about tinnitus.
    • Strong negative beliefs which the patient has about tinnitus like onset of deafness, madness or untreatable disease – these fears to be removed before tinnitus habituation is started.
    • A simple description of the neurophysiological model that shows what we know presently about the mechanism of tinnitus to be explained and try to convince the patient that his fears are groundless, being based on incomplete information.
    • As part of counseling, teaching the patient the relevant elements of both basis and advanced auditory physiology on how sound changes from sound waves in the air into electrical signals in the nervous system and which kind of mechanism of tinnitus might be appropriate in each particular case.
    • Encouraging the patient to avoid silence and high intensity sounds at the same time to have a sound enrichment environment.
    • Retraining therapy involving the rearrangement of neural connections in the auditory system and eventual habituation of tinnitus perception cannot be achieved overnight.
    • Although a few patients habituate rapidly once they understand what is involved, the majority require repeated instructions, with directive counseling and reinforcement of this information over a period of 12 to 18 months.
    • A strict system of follow-ups usually at 4 and 8 weeks, 3 months, 6 months, 12 months and 18 months, in addition to telephone contact.
    • Progress of treatment can be assessed using questionnaires and tinnitus handicap inventories.
    • Group discussion and meetings between tinnitus sufferers.
    • Conscious awareness of sound takes place near the surface of the brain when a pattern of electrical activity traveling up the nerve reaches a point just below the auditory cortex.
    • Nothing is heard until sound patterns is generated in the cochlea and reach the cortex of the brain.
    • Animals rely on their hearing to detect very small sounds of an attacker a long way off. these warning signals produce acute anxiety, prompting appropriate action to avoid attack. the so called survival reflex.
    • We respond in the same way to the sound of a motor car horn by automatically putting our foot back on the pavement.
    • Some sounds can be identified as warning signals while others can evoke a feeling of security or pleasure.
    • Certain sounds have special meaning (baby crying, sound of our first name) to which we respond in an automatic manner.
    • This happens after short learning period but the responses can remain strong throughout life.
    • These weak patterns of sound having great meaning can be detected by sub-conscious filters in the hearing pathways.
    • Between the ear and brain there are 2m nerve cells forming a neuronal network capable of sophisticated pattern recognition, enhancement and suppression of auditory signals.
    • The conditioned response also triggers activity outside the auditory system where there are large numbers of connections with the limbic system (emotion and learning).
    • Also activated is the ans prepared for body action (fight or flight).
    • Neuronal networks between ear and brain detect threatening sounds and activate a reflex response involving fear / annoyance and increase of body functions, to prepare for danger – the conditioned aversive response.
    • High levels of autonomic functions tense muscles, raise heart and breathing rates. the complete opposite to the state of relaxation.
    • Most of our day to day activity consists of a series of conditioned responses, executed in an orderly manner.
    • Hence each and every sound that we hear and learn the meaning has an emotional label attached to it which can change from time to time according to how we feel in ourselves and the context in which we hear it (neighbour's child)
    • 85% of tinnitus sufferers do not find it intrusive, disturbing or anxiety provoking.
    • The reason for this is not because the quality or loudness is different; in fact the tinnitus is of a very similar type of sound in those who are bothered by it.
    • The main difference is those who find it troublesome evaluate and perceive it as a threat rather than something of little or no consequence.
    • Those who consider tinnitus a threat are unable to do any thing but listen to it.
    • Even in mild cases of persistent irritating tinnitus a conditioned response is setup to the tinnitus sound (the sound evoked by background electrical activity in auditory nerve cells).
    • As this conditioned response occurs in the sub conscious part of brain, what you may be thinking about tinnitus any time, is irrelevant to the reaction produced.
    • It is the reaction to tinnitus which is important in creating distress. that is, the degree to which unpleasant feelings about it (ls) and increased tensions are experienced the tinnitus signal is detected (jastreboff model)
    • When tinnitus first emerges, it is a new signal. there are no memory patterns and no means of categorising it.
    • Any new experience tends to produce a feeling of discomfort due to a change in homeostasis. until proper evaluation has been undertaken of what tinnitus means it will be regarded under suspicion.
    • Some people fear that tinnitus means they have some kind of serious illness (brain tumour, mental illness).
    • These fears may be enhanced by professional advice – nothing can be done.
    • Powerful emotions like fear, anger and guilt are enhanced and consequently increased attention on the tinnitus occurs (vicious cycle).
    • In some patients extreme fear of tinnitus results in a phobic state (fear of spiders flying, etc.,).
    • In any phobic state a slow process of desensitisation has to be used, confronting the feared object and learning to tolerate it and then to accept as a normal phenomenon.
    • Successful tinnitus management occurs when tinnitus loses its sinister meaning however loud or unpleasant it begins to diminish.
    • Retraining the sub conscious auditory system to accept tinnitus as something that occurs naturally, and that it is not a threat or warning signal can take months or years.
    • Retraining involves the sub conscious part of the brain concerned with hearing, beyond the inner ear but before the act of conscious perception of sound takes place, sub conscious filters, neuronal networks are programmed to pick up signals on a “need to hear” basis.
    • Retraining therapy involves reprogramming or resetting these networks which are selectively picking up “the music of the brain” in the auditory system.
    • Although these are “nature sounds”, they become a problem because they have been identified as a threat, to the quality of life.
    • We need to learn that the sounds of tinnitus which we may interpret as distressing, affecting life quality, and seemingly unending are in reality the sounds of nature, coming from weak electrical signals in the auditory pathways which have always been there.
    • By appropriate directive counseling (or retraining) from professionals, we can change even strong held views that tinnitus is threatening and unpleasant experience which cannot be altered.
    • The presence of any continuous stimulus usually results in a process called habituation, whereby the individual response is less and less to the stimulus as long as it does not have any special negative meaning.
    • With tinnitus this means that it is no longer heard, even if it is listened for.
    • During the initial stages tinnitus becomes gradually less unpleasant (but may still be perceived as a loud sound). this process is called habituation of reaction.
    • Tinnitus becomes quieter for longer periods of time, and eventually disappears or becomes a natural part of the background “sound of silence” (habituation of perception). this cannot happen while tinnitus is still classified as a threat, or negative experience that demands further monitoring.
    • One way in which the ear does contribute to tinnitus is if there is a hearing loss this may be quite mild, or just in the high frequencies.
    • Any tendency to “straining to hear” can increase amplification of sound signals in the sub conscious part of the brain resulting in the tinnitus signal being picked up easily.
    • This is why it is important to correct any significant hearing loss with appropriate hearing aids as part of overall tinnitus Management.
    • Wide band noise is used at low intensities while the tinnitus can be heard at the same time.
    • Wide band noise contains all frequencies and therefore very gently stimulates all the nerve cells in the sub conscious networks allowing them to be easily programmed so that tinnitus signals are no longer detected.
    • It also reduces the contrast between tinnitus and otherwise total silence.
    • wngs on their own may give a temporary reduction in distress from tinnitus, but will not achieve long term habituation without the other essential elements of trt – teaching – demystification – reevaluation – desensitisation
    • Persistence of tinnitus depends upon the meaning attached to it but also to the contrast it creates with the auditory environment.
    • Contrast contributes greatly to the intensity of any perception (candle).
    • In all cases sound enrichment should be practiced.
    • Information, teaching and demystification of the tinnitus mechanisms are the most vital part of the therapy.

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