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OCR for page 117
5
StancIarctizing Procedures
A desirable goal is widespread adoption of a standard
procedure for measuring and evaluating tinnitus, and it
would be particularly nice to be able to put forth that
standard procedure here. Unfortunately, such action is
premature. Too little is known about crucial aspects of
tinnitus behavior to be able to specify the best pro-
cedures for assessing it. Instead, we can offer only
some suggestions about what a standard procedure of the
future might include.
MEDICAL EXAMINATION
As has been noted several times in this report, tinnitus
is itself not a discrete disease entity; rather, it is a
symptom that is produced by many known and unknown causes
and diseases. For this reason, it is wrong to begin by
treating the symptom, whether with drugs, tinnitus
maskers/instruments, or whatever. m e first step should
always be to try to diagnose and treat the underlying
cause. Of course, some causes of tinnitus are themselves
not treatable, given current knowledge, and palliatives
for the tinnitus are the only recourse. m is fact does
not exempt the clinician from the obligation to try to
establish the underlying disorder. m is section is
intended only to indicate the wide variety of possible
causes to be considered by the responsible physician--
and should not be taken as a complete guide to diagnosis
or treatment.
Ever since the introduction of tinnitus maskers/
instruments as a palliative for problem tinnitus there
has been concern in some quarters that eliminating this
symptom may be "covering up" an important sign of a seri
117
OCR for page 118
118
ous medical problem--for example, an eighth-nerve tumor.
This concern may be exaggerated, because no present treat-
ment of tinnitus eliminates it permanently; the concern
also appears to be based on logical considerations, not
on widespread experience or even anecdotes about such
occurrences (see, for example, Miller, 1981). However,
even if documented instances of a serious illness being
obscured by effective treatment of tinnitus are rare, the
point is well taken. Just as patients complaining of
tinnitus deserve complete audiological examinations, they
also deserve medical examinations that emphasize those
general bodily problems that are known to be associated
with tinnitus. Of course, all of the general physiologi-
cal abnormalities that may produce tinnitus have yet to
be identified, but we are able to indicate certain items
that deserve attention.
1. Blood pressure. The commonly observed variations
in tinnitus with stress and the blood Pressure changes
_ _
known to accompany stress imply that altered m~croc~rcu~a-
tion in the cochlea may be the basis for some tinnitus.
Treating the tinnitus with a masker/instrument or other
agent may be less direct than treating the blood pressure
problem itself.
2. Kidney function. It is commonly asserted that the
ear is like the kidney in that both structures are con-
cerned with maintaining normal electrolyte concentration
gradients. This similarity between the two structures
causes them to react similarly to certain agents. Thus,
verification of normal kidney function seems advisable in
sufferers from severe tinnitus.
3. Drugs. The medical examination should establish
what drugs--both physician-prescribed and self-
prescribed--the patient takes, and on what schedule(s).
Aspirin and other salicylate-bearing agents are obvious
ones to eliminate if possible, but other drugs, or com-
binations of drugs, may be responsible for a particular
individual's tinnitus, and attempts to relate the onset
of tinnitus episodes to patterns of drug usage may be
worthwhile. If there is a suspicion of the tinnitus
being drug induced, a further step would be to prescribe
substitute drugs for short periods of time and observe
any effects on the tinnitus.
4. Diet and allergy. These are probably very infre-
quent causes of tinnitus, but verification of a balanced
diet, and suggestion to the patient to be alert to pos-
sible temporal associations between tinnitus episodes and
exposures to common allergy-producing agents, cannot hurt.
OCR for page 119
119
5. Other conditions. Goodey (1981) and Schleuning
(1981) argue that a general medical examination for a
tinnitus sufferer should also include tests for infections
of the head, neck, and teeth; hypothyroidism; hyperthy-
roidism; early diabetes; hypoglycemia; disturbance of
serum lipids; high blood viscosity; autoimmune disease;
vasospastic disease; meningitis; multiple sclerosis; and
migraine.
AUDIOLOGICAL EXAMINATION
Many hearing specialists believe that a complete audio-
logical examination should precede the prescribing of any
form of treatment for tinnitus, but this is not universal.
Experts also differ in their strength of feeling about the
necessity for a complete audiological examination when
the primary symptom is tinnitus (Shulman, 1981:205-207).
A complete examination would include, but not necessarily
be limited to, air- and bone-conducted pure-tone threshold
measures, speech threshold and discrimination tests, tym-
panometry and reflex testing, and site-of-lesion tests if
indicated.
Following these standard tests, the tinnitus itself
should be documented. The measures made should include,
but not necessarily be limited to, pitch and loudness
matches, a test of maskability, and a test for residual
inhibition. At present there exist numerous procedures
for making these various measures, and, unfortunately,
they do not always produce the same outcome. It may be
that particular methods will eventually prove more reli-
able and valid than others for particular forms of tin-
nitus, but at the moment it is premature to specify par-
ticular psychophysical procedures for the various measures
or for different forms of tinnitus. Nevertheless, it is
possible to make certain general recommendations about
measures and procedures.
1. Some tinnitus is said to be "masked" by sounds from
numerous locations across the spectrum and some by both
ipsilateral and contralateral waveforms. The use of
several tonal or narrowband maskers, both ipsilaterally
and contralaterally, would thus seem worthwhile, for it
may be that some tinnitus sufferers would be better served
by a masker waveform different from that most effective
against an external sound of the same frequency and band
width.
OCR for page 120
120
2. Similarly, residual inhibition should probably be
studied with several maskers, both ipsilaterally and
contralaterally.
3. It follows from the previous two recommendations
that testing should not be done using loudspeakers to
present the stimuli, but with headphones, and preferably
with headphones having a good seal, good high-frequency
response, and high intermural attenuation.
4. It is important that pitch matches be verified
with tests at octave frequencies above and below the
matched frequency, and since pitch matches are so diffi-
cult for unpracticed subjects, it would be advisable to
have a repeat determination either later in the exami-
nation session or at another time.
5. Because tinnitus is notorious for its variability,
both within and across days, it is important that the
current status of the tinnitus be established at the time
of the tinnitus examination. Specifically, the patient
should be asked whether the tinnitus being experienced is
typical, and, if not, how it differs and how greatly it
differs from the typical problem day. If the tinnitus of
the current day is judged to be sufficiently atypical,
the patient should probably be asked to return during a
more typical episode; otherwise, the measurements made
could be very misleading to the clinician attempting to
prescribe for the problem. In today's busy clinics, such
a procedure may be very inconvenient both for the patient
and the clinician, but the inconvenience and delay ought
to be offset in the long run by better diagnosis and
treatment.
6. A procedural suggestion made by the Oregon group
appears well advised: measures of tinnitus magnitude
should be made using procedures that involve only suc-
cessive increases in intensity, for the premature intro-
duction of high intensities could produce a residual
inhibition that would invalidate later measures. m e
suggestion applies, of course, to measures of tinnitus
other than magnitude measures; in general, stimuli of
long duration and relatively high intensity should be
avoided throughout the tinnitus examination.
7. Whenever possible, it would be advisable to report
loudness matches in both SL and SPL units.
8. Attempts to determine the monaural or binaural
nature of the tinnitus appear worthwhile. As noted in
the section n Is the Tinnitus Monaural or Binaural? in
Chapter 3, a binaural but asymmetric tinnitus can appear
to the patient as having a monaural origin, but such a
OCR for page 121
121
tinnitus will in many instances be much more resistant to
a (monaural) masker/instrument than will a truly monaural
tinnitus. One procedure for attempting to determine the
monaural/binaural nature of the tinnitus has already been
described (see "Is the Tinnitus Monaural or Binaural?" in
Chapter 3), and others could surely be developed. The
examiner must always remember that a person's tinnitus
may be composed of many different spectral components
(see "Quality of the Tinnitus" in Chapter 3) and that
some of these may be monaural, some binaural and approxi
mately equal in magnitude, and some binaural and quite
discrepant in magnitude. Ideally, the monaural or bin
-
aural nature of each of the components would be determined
along with their relative annoyances, so that an optimal
masker program could be chosen.
Additional measures and procedures that would be desir-
able will undoubtedly become clear as our knowledge of the
origins of tinnitus increases.
OCR for page 122
Representative terms from entire chapter:
audiological examination
