Pawel Jastreboff: The treatment of tinnitus and decreased sound tolerance with TRT

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A subject highly relevant to tinnitus treatment, but still somehow underappreciated, as Pawel Jastreboff defined the Decreased Sound Tolerance (DST). The professor at the Department of Otolaryngology at the Emory University School of Medicine of Atlanta in USA was invited to the 7th TRI Tinnitus Conference to discourse about the role of Tinnitus Retraining Therapy (TRT) in relation with DST and tinnitus treatment, both from the point of view of hearing and clinical implications.

DST is present when a patient exhibits negative reactions as the result of exposure to sound that not evoke the same reactions in average listener. It can be the only problem or coexist with other complaints, for example tinnitus. “The results from our patients combined with information from the literature indicate that at least 1.5% of the general population shows DST requiring treatment, and it is present in over 60% of our tinnitus patients”, stated Jastreboff. Frequently, the impact of DST on patients worsens impact of tinnitus. “It prevents exposure to louder environments and participating avoidance in many life’s activities. Some patients report physical pain, strong discomfort, fear and develop anxiety and depression. In extreme cases, DST controls patients’life.”

According to his results, tinnitus, hyperacusis and misophonia can be successfully treated by TRT. Misophonia is more complex, it should be treated at the same time with hyperacusis/tinnitus, but in addition to specific counseling, patients are advised to follow one of four categories of protocols to create an association between a variety of sounds with something positive.

“Proper diagnosis is crucial in hyperacusis and misophonia, because even though patients’ reaction to sounds may be the same, their treatments are distinctively different, because there are different mechanisms behind both phenomena. An effective treatment for hyperacusis is not helpful for misophonia, and an effective treatment for misophonia is not helpful for hyperacusis. When DST accompanies tinnitus, its treatment is crucial to achieve successful outcome for tinnitus. In many the DST cases is possible to achieve it, it is total controlled or even cure”, assured the father of TRT.

The treatment in children

“TRT is an effective treatment for children with tinnitus and DST. The same management as for adults can be adjusted to treat children with proper counseling and sound therapies with same goals to achieve”, observed Margaret Jastreboff, President of Jastreboff Hearing Disorders Foundation of Columbia (USA). “The main differences are the counseling has to include both children and their parents. In case of the children, information would be very limited and descriptive with examples and very simply parameters. Parents have to get much more information and good explanation of the problems. Frequently they know the best what the child needs and adjust the treatments to their liking to help the child what is necessary is the best way in this case. In case of sound therapies children, once they discovered it is helpful, they respond to enrichment of environmental sound and use sound generators very well”.

In her speech some samples were offered to represent the general clinic situation. All children were seen by various specialists and treated for behavioral problem. Practically all of them were on sound medications of sleep, anxiety, depression or attention disorder of over-activity. With time, their reactions to sound became stronger frequently included more sound leading to ear over-protection enhance avoidance behavior including responses to visual cues. The most frequent problems are with certain sounds reported by children like silence, power tools, loud ringing, barking dogs, but also soft sound swallowing, breathing, chewing and smacking lips. And the most frequent reactions were irritation, tension, anger, wanting to escape, fear.

“Practically all children had sound improvements, but unfortunately the contact with them is limited, and once getting improvement they are disappearing. They choose at the end point, simply they have many other problems to deal with. It is difficult to make strong judgment about the outcome”, concluded Jastreboff.

INTERVIEW WITH PAWEL JASTREBOFF

How would you take stock of efficiency of TRT after more than 20 years of tinnitus research?

I’ve seen more than 2000 patients since 1990, and my results are over 80 up to 90% of people who are getting statistically significant improvement, and in the clinical activity we get the same improvement. But what is important not what I am seeing. You find close to 100 papers of other different people showing measure of higher effectiveness of TRT, including studies which were doing three or five years of follow-ups. This is very interesting, the positive effect of the treatment remains after some years from the beginning of the treatment, and moreover it is possible to observe certain improvements.

What are the main challenges in TRT treatment?

In the treatment, the main challenge is to adapt counseling properly. And a second challenge, which was pretty bad until recent, should be the instrumentation. About 70-80% of tinnitus patients, who suffer hearing loss, need, need optimal instruments, so called combination instrument, something which contains hearing aids and sound generator. But until now, the price of this type of instrumentation was simply too high for the patients.

You have spoken about hyperacusis treatment with TRT in your speech. What are the latest advances?

I think that a big change was introducing misophonia protocols. We introduced the last protocol, the level 4, a few years ago, but we were using protocol 1-2-3, which were weaker, still quite powerful and useful, but not that powerful for using now. Our much better understanding of these complex conditions of stimulus, which is creating with both counseling and sound protocol, and the implementation of the treatment are different, much more effective. For example, the lovely case of the patient I was training for 8 years before being able to help him, because this was before discovering misophonia and his tinnitus and DST did not change at all in the training. And two months after introducing protocol for misophonia started rapidly improving.

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Kristin Suleng

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