Tech Topic: Tinnitus | April 2015 Hearing Review
In conjunction with therapy and support materials, Tinnitus SoundSupport (TSS) encompasses ease of use along with flexibility and variety to promote an uncomplicated fitting process for the audiologist and significant relief for the tinnitus patient.
In 2013, over 1.1 million veterans received disability benefits connected to their tinnitus.1 Similar to previous years, tinnitus is the most common service-connected disability, impacting daily activities and quality of life. It is anticipated that the figures for veterans who report tinnitus as a service-connected disability will increase between 13% and 18% annually.2
As mentioned in previous literature, tinnitus can have a significant effect on an individual, including loss of sleep, depression, social isolation, and general well-being, and it can be so severe that it can affect job performance or cause suicidal thoughts.3 Most veterans report tinnitus following exposure to loud sounds, usually while on active duty, and is usually observed alongside hearing loss. Proper treatment that includes counseling, and the use of amplification and/or use of sound generators, can alleviate the symptoms related to tinnitus.In the VA, the most common counseling method used to alleviate tinnitus is Progressive Tinnitus Management (PTM).4 A patient-centered approach, PTM assists those with tinnitus using a hierarchal approach (Figure 1), including triage, audiologic evaluation, group classes, interdisciplinary evaluation, and individualized support. This hierarchal approach provides a path for clinicians to follow when managing a tinnitus patient, with each step providing more support to the patient as needed.
In the higher levels of PTM, the use of a sound generator is typically suggested following group education, as it is intended to provide soothing, background, or interesting sounds, dependent on which type of sound with which the patient finds relief. Sound generators have been used clinically to provide relief since the 1980s; however, limitations involving sound choices and sound shaping have been difficult to overcome in some products, leaving tinnitus patients less than satisfied. In the past several years, combination devices have become more common due to the comorbidity with hearing loss and have benefited audiologists when amplification alone did not alleviate the patient’s tinnitus.
Although there are many solutions available for tinnitus relief, not all provide ample flexibility to the hearing care professional or preferred sounds to the patient. Other specific features, such as the ability to adjust modulation or mute the microphone so only the sound generator is heard, are not commonplace in many devices. Not only is it important to have the flexibility and control to create an ideal setting to best assist a tinnitus patient, but it is paramount to ensure ease of use and confidence while creating a tinnitus solution specific to your patient.
In this paper, we will discuss Oticon’s tinnitus feature—Tinnitus SoundSupport™ (TSS)—as a means to help provide relief to the tinnitus patient while making the fitting process for the hearing care professional easy and intuitive.
Participants. Seven audiologists who serve veterans were asked to evaluate the Alta 1 Pro with Tinnitus SoundSupport™, as well as the implementation of TSS through Oticon’s Genie Software. Information was gathered through questionnaires and in-depth interviews. Audiologists who provided feedback ranged in having little experience to extensive experience with Oticon products and software.
Overall, 34 patients were seen by the 7 audiologists in 3 locations. Patients who were fit with TSS ranged in age from 24 to 95 (average age of 58), were either experienced (n=10) or new users (n=24), had hearing loss that ranged from mild to severe (Figure 2), and reported tinnitus between 6 months and over 40 years (Figure 3).
Fitting. Audiologists were asked to leave P1 as a hearing aid only program and enable TSS in P2 with or without the hearing aid microphone activated. Since the clinics that participated in this data gathering already had protocols in place, some chose to activate TSS in P1 while others chose to have more than one TSS programmed into the hearing aid (eg, broadband sounds in P2 and nature sounds in P3).
As a guide, clinicians were provided with a quick fitting guide and quick fitting checklist created by Oticon, although the majority of the clinicians used PTM. Once TSS was activated in the software, the clinician had the option to choose from a variety of sounds, labeled under Broadband (White, Pink, or Red) or Nature (Ocean 1, Ocean 2, or Ocean 3) sounds. Under Broadband sounds, the clinician had the option to adjust the signal level, the filtering of the sound using high-pass and low-pass sliders, and five modulation settings (Off, Tranquil, Mild, Spirited, and Bustling). Under Nature sounds, Oceans 1-3 have a random modulation setting, to better mimic the onset and offset of waves at the beach.
With both Broadband and Nature sound settings, the audiologist had three additional options: 1) the ability to link the two hearing aids together once the settings have been set; 2) to mute the hearing aid microphone such that only the wearer would be hearing the TSS sound that had been chosen; and 3) to activate Automatic Level Steering, a feature that would identify when sounds reached a particular level in the environment, and therefore allow TSS to taper since the environmental sounds would provide masking to the wearer instead.
Materials and interviews. The audiologists were asked to provide feedback in the form of interviews and written questionnaires. Questions included feedback on using the Oticon TSS feature, the ease of use of TSS, and their patient’s reaction to the TSS. The questionnaires were filled out by the clinicians after the patients were fit with Alta 1 Pro with Tinnitus SoundSupport™.
The succeeding questions were answered at the first follow-up visit: “Rate how beneficial your client found the Tinnitus SoundSupport™ for relief of their tinnitus,” and “How would your client rate the overall sound quality of the hearing aid apart from Tinnitus SoundSupport™?” An oral interview was conducted at the end of the data gathering, which lasted approximately 2 hours.
Selections. All patients had the option of being fit with either a RITE or miniRITE, though all patients were fit with miniRITEs. After the fitting appointment, patients came back as needed for follow-up, which ranged from several weeks to months. All clinicians were provided with training on the product and software prior to any fittings, and assistance during the fittings was provided, as needed.
Questionnaires. To gain a better understanding of the audiologists’ and patients’ thoughts on the TSS, the results were tabulated from three of the questions on the questionnaire the audiologists had filled out per patient. Not all participants had come back for their follow-up visit prior to the end of the data gathering, and therefore some participants did not answer the fourth or fifth question.
The results shown in Figure 4 were tabulated from audiologists reporting the ease of use of the TSS feature when being programmed. Audiologists reported “Very Good” in 75% of the fittings they completed on their patients, and “Good” in 25% of the fittings in terms of ease of use. Many also reported the software being intuitive, easy to activate, and easy to manipulate.
In Figure 5, results were tabulated indirectly from the patients by the audiologists during the follow-up visit with their devices, based on how beneficial the patients found TSS for relief of their tinnitus. A total of 77% reported that their relief from tinnitus using TSS was either “Good” or “Very Good,” with 15% being neutral about relief, and 8% rating relief as “Poor.” Similar to the previous question, patients reported benefit with the TSS, indicating that it was helpful for easing tinnitus, and that it helped when tinnitus was especially bothersome.
In Figure 6, results were tabulated indirectly from the patients by the audiologists during the follow-up visit with their devices, based on how they would rate the sound quality of the hearing aid apart from TSS. A total of 85% found the hearing aids to have either “Good” or “Very Good” sound quality, 4% being neutral about sound quality, 8% reporting “Poor” sound quality, and 4% reporting “Very Poor” sound quality. Of those who had positive remarks on sound quality, one patient reported feeling less stressed when wearing the hearing aids and noted a definite improvement in quality of life.
Of the 34 patients who tried the TSS feature, two chose not to continue with using the product. One had memory difficulties related to a traumatic brain injury that had occurred and could not remember the settings of the device. The other patient did not specify why he did not like the product, but did return the product saying it did not provide him with benefit.
Tinnitus Functional Index (TFI). One of the sites, which had 11 patients fit with TSS, provided pre- and post-TFI data. The Tinnitus Functional Index (TFI)5 provides hearing care professionals with a better understanding of the severity and negative impact that the tinnitus patient is experiencing. Using a number of tinnitus severity domains, the patient completes the index prior to treatment and then at follow-up appointments (eg, at 3 or 6 months).
Table 1 shows the pre- and post-scores of the patients who participated at one site. A decline in the post-score of 13% or greater is considered clinically significant improvement. The average pre-score was 75.6% and the average post-score was 45%, yielding an average improvement in tinnitus relief of 30%. In some cases, such as Participant 3 and Participant 7, there was improvement as large as 64% and 53%, respectively, following several months’ use of the hearing device. Participant 8, the patient with the least amount of improvement, noted that he was “thrilled” with the devices and that they provided him with “great benefit.” The audiologists who worked with him speculated that the smaller improvement in score compared to the rest of the patients could have been due to the lower pre-score on the TFI. Overall, all but one of the patients at this clinical site improved clinically significantly using the TSS device.
Interviews. Interviews were held with all the audiologists who had participated in the data gathering for TSS at their respective sites. These interviews lasted approximately 2 hours, covering areas related to TSS, the hearing device that housed TSS, implementation of TSS in the programming software, and support materials to accompany use of TSS.
Each year, it is reported that tinnitus-related disability increases at a rate of approximately 15% across the veteran population. With the numbers increasing annually for the need to provide services, it is paramount to be able to provide veterans with solutions that best fit their needs in terms of ease and relief, while providing the hearing care professional with a solution that is easy and flexible to implement.
TSS provided benefit to 32 of the 34 individuals who tried and kept the devices. Of the two that did not keep the devices, one was having difficulties with remembering how to use the device due to his traumatic brain injury; the other stated that he did not like the sound quality of the product and did not find relief in wearing the devices.
Another point to consider is how many people benefited from the amplification alone compared to amplification with TSS. In some of the cases, patients reported wearing TSS only a portion of the time, with the remaining time being amplification only—supporting the notion that hearing devices alone may provide tinnitus relief. However, the flexibility of wearing a combined hearing instrument with a sound generator supports the hearing care professional’s capacity to tailor the device to the specific needs of the patient with ease and flexibility, without compromising the sound quality of the hearing instrument.
Ratings in terms of sound quality for the device were very well-received, with 88% of the patients finding the sound quality “Good” or “Very Good.” In previous surveys of 149 new and experienced participants who wore Alta Pro instruments, 95% of the individuals were satisfied in terms of sound clarity compared to the 79% of respondents who answered the same questions and 7-point Likert scale as the MarkeTrak VIII survey.6 The combination of good sound quality and the added feature of TSS makes Alta 1 Pro a logical solution for those interested in a combination device to assist in hearing and tinnitus needs.
Each site was provided with training on the product and software prior to any fitting, and each site was given any assistance that may have been needed during initial fittings with the product. When audiologists were asked to rate their experiences with TSS, many reported how easy the process was for not only fitting the hearing instrument, but using the software. Many reported in the comment section of the questionnaire that it was “easy” and “intuitive” to program the devices. One audiologist reported that the programming had “intuitive programming features” that provided “lots of options without being overwhelming.” As many VA audiologists report having shorter periods of time to provide treatment to patients, ease of use and intuitiveness are preserved without having to compromise confidence during the fitting process.
Many audiologists found the Nature sounds (Ocean 1, Ocean 2, and Ocean 3) to be the most commonly chosen sound. Of the 34 patients tallied, 24 had chosen one of the Nature-like sounds (13 chose Ocean 3, and 11 chose Ocean 1) and 10 chose one of the Broadband sounds (8 chose Red noise, 1 chose White noise, and 1 chose Pink noise).
The distribution of the Ocean sounds was interesting, as none of the patients chose Ocean 2 as their preferred sound and Pink noise was also the least chosen in the Broadband sound category. Both sound options had a 3 dB rolloff per octave in the high frequencies.
Another interesting note is how many patients chose Red noise as their preferred sound, which has similar rolloff characteristics as Ocean 3 (6 dB rolloff). Of the 8 patients who preferred Red noise, 6 had some degree of modulation in the program, which could potentially emulate the Ocean sounds. Including the Nature sounds as an option within the TSS feature is beneficial, as everything is integrated within Alta 1 Pro instead of using an intermediary device, such as a phone or other device, to get other sound options that could be desired by the patient. The additional flexibility provided by the Nature sounds gives both the clinician and patient an extra option to choose from before introducing the need for an intermediary device for other sounds.
Other features, such as modulation adjustment, the ability to shape the broadband sounds, and the ability to mute the hearing device microphone, were also well-received. For those audiologists who chose to use the different broadband sounds, they reported that it was easy to adjust the modulation and the shaping, and that the patients found that the adjustments were more comfortable. Some patients preferred to listen to TSS only (no amplification) at the end of the day to help them relax. The automatic level steering was not always activated with the patients; however, there were no reports of this feature sounding irregular or overcorrecting in complex listening environments.
With the number of features and the positive feedback from both audiologists and patients, Tinnitus SoundSupport™ has provided strong evidence that suggests ease of programming and flexibility for the clinician and exceptional user satisfaction for a combination device.
As demonstrated, of those who had positive remarks on sound quality, patients reported feeling less stressed when wearing the hearing instruments and noted a definite improvement in quality of life. Of those who commented on TSS itself, patients found it helpful for easing tinnitus, especially when the tinnitus was bothersome. In conjunction with Progressive Tinnitus Management’s patient-centered approach, Alta 1 Pro can provide the sound quality desired in a hearing aid, and a variety of sound relief to the tinnitus patient.
Oticon Inc thanks the audiological staff at Darnell Army Community Hospital, and the Veteran Administration Medical Centers in Tampa, Fla, and Brick, NJ, for their time, expertise, and support they provided during the data gathering of this project.
Department of Veterans Affairs. Compensation: Service-Connected Disability or Death Benefits . Available at: http://www.benefits.va.gov/REPORTS/abr/ABR_FY2013_Compensation_07172014.pdf
Hearing Center of Excellence. Stats & Figures. Department of Defense. Available at: http://hear¬ing.health.mil/HearingLoss101/StatsandFigures.aspx#foot09
Baigi A, Oden A, Almlid-Larsen V, Barrenas ML, Holgers KM. Tinnitus in the general population with a focus on noise and stress—A public health study. Ear Hear. 2011;32(6):787–789.
Henry JA, Zaugg TL, Myers PJ, Kendall CJ. Progressive tinnitus management. Washington, DC: NCRAR, US Dept of Veterans Affairs; 2012.
Meikle MB, Henry JA, Griest SE, et al. The tinnitus functional index: Development of a new clinical measure for chronic, intrusive tinnitus. Ear Hear. 2012 Mar-Apr;33(2):153-76.
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Annette Mazevski, AuD, PhD, is the Manager of Technology Assessment at Oticon Inc, Somerset, NJ. Prior to joining Oticon, Dr Mazevski worked in university, clinical, and private practice settings, providing care to both pediatric and adult populations.
Citation for this article: Mazevski A. Tinnitus SoundSupport: A flexible solution for both patients and hearing care professionals. Hearing Review. 2015;22(4):24-27.