Dr. Lia Best - Utilizing Widex Zen Therapy to Effectively Manage Tinnitus

Introduction by Dr. Erin Wright:

Good morning, everyone.  Thank you for coming to our ninth annual healthy hearing Expo.  My name is Erin Wright.  I'm one of the audiologists, one of five audiologists, at Broadmead and Oak Bay Hearing Clinic and we're proud to sponsor this community event so people can gather a little bit of information, learn a little bit about topics like tinnitus and hearing loss, speak directly to the actual hearing‑aid manufacturer reps, collect a bit of information.  So thank you guys for taking this opportunity.

I'd like to just start also by thanking Oticon.  Oticon sponsored the realtime captioner for the event and so we have this wonderful captioner in the corner who's so speedy, she can keep up with my speedy talking.  At the end they give us the transcripts for the talk and we put them on our website, so if you forget something, you can go back on the website and read through the transcripts of each talk.

So the next talk is being done by Dr. Lia Best.  So Lia is one of the audiologists who works in the Broadmead Hearing Clinic location.  She's been there for five years and she has researched this topic ‑‑ or this talk in collaboration with one of the audiologists that works for Widex Canada.  So Widex has a patented particular method of managing tinnitus that Lia is going to be talking about today.  So welcome, Lia.  (Applause)

Lia Best:

Hi, everybody, welcome.  I first of all want to make sure this mic is positioned okay.  Everyone at the back can hear me okay?  Good, got a thumbs‑up.

Welcome.  Many of you are here because you either have tinnitus yourself or know somebody who has tinnitus or you're not sure what tinnitus is and you thought you'd come and learn a bit more about it, but hopefully you'll be able to take some valuable information away today. 

So we'll just do a brief intro about tinnitus, but I'm sure many of you do know a little bit about it already.  And we'll talk mainly about a certain type of tinnitus management called Widex Zen Therapy. 

So just briefly, what is tinnitus?  Well, tinnitus is a perception of sound that cannot be attributed to an external source.  It's often described as ringing, humming, buzzing, or roaring noises.  Could also be music.  And it's really important to note that it's involuntary, it's not something that we have conscious control over.  It can vary in volume and pitch, it can be intermittent or constant, but the point is it's coming from somewhere in the head. 

The typical causes of tinnitus are hearing loss and noise exposure and we also know that those are connected because noise exposure can also cause hearing loss.  70 to 85 per cent of people with hearing loss will report having some tinnitus and there are other kinds of conditions that can cause hearing loss other than noise exposure, such as age‑related changes in the ear and conditions like Meniere's disease or maybe a viral attack of the ear.  But it can also be associated with head injury, thyroid problems, muscle tension in the head and neck, certain medications and high blood pressure, and sometimes I put stress on this slide, but it's important to consider stress not as a cause, but as something that might exacerbate or make tinnitus worse from time to time.  And we'll talk a little bit more about that. 

So many of you are here because you are experiencing hearing loss or know somebody that is.  The most common form of hearing loss is something we call sensorineural hearing loss and this is either ‑‑ for example could be age‑related or maybe noise‑induced hearing loss, and in this case there's usually some sort of damage to the outer and possibly the inner hair cells.  So you can see in this picture healthy hair cells on one side, the damaged hair cells on the other side.

So one theory is that tinnitus might be the results of these damaged hair cells sort of misfiring, because you can see they're not gone, they're still there, but they just don't look as good as they should.  They're not standing upright, they're a little bit bent and some are, you know, missing. 

What they think might be happening is there's an increase in neural activity along the auditory nerve as a result of these misfirings of the hair cells.  But this is probably not the whole story because even people that have a severed auditory nerve, so maybe no function of the auditory nerve, are still dealing with tinnitus and it might feel like it's coming from that ear.  So the bigger answer to this, or the other theory is that it's more likely to be abnormal neural activity coming from the brain in the auditory part of your brain. 

So the current most popular theory about why somebody might have tinnitus if they also have hearing loss is that the tinnitus is sort of a reaction from the brain to the lack of sound caused by the hearing loss.  So deprivation of sound sort of triggers a hyperactivity of neural activity in the brain.  The brain is searching for sound input that it's not getting and this increased activity is interpreted ed by the brain as sound, which we call tinnitus.  And we hear a lot about neuroplasticity now and how it's a good thing, but neuroplasticity is sort of taking place in this case and it's not necessarily a good thing, because what's happening is we're getting a change in neural activity and it changes the balance between the excitation and inhibition neurons in the brain and this kind of abnormal activity is being perceived as a sound. 

That's the most technical we'll get, so if anyone has questions about that, they can ask me later.

I like to think of tinnitus as more of a spectrum problem.  On one end of the spectrum, you'll have people that report having tinnitus that's not really bothering them.  They'd obviously rather not have it, but they're functioning just fine and they report they sort of tune it out.

On the other end of the spectrum you have people who are severely impacted by it.  It's affecting sleep, concentration, it's making them irritable, and they have a really hard time coping with it.  It might affect their job and overall quality of life.  And we find that about .5 to one per cent of the population are severely affected by their tinnitus.  There's a majority of people that are on the end of the spectrum where they're sort of habituating and able to tune it out and a small percentage that's not happening.  What we say is these people are having difficulty habituating to their tinnitus.

So what is habituation?  Habituation is something we do all the time.  It's the process of ignoring or being accustomed to a stimulus without conscious effort.  So you think about getting a new refrigerator and at first you think, "Wow, this refrigerator is humming a lot, it's really annoying," but after a few days, you don't notice it any more.  That's habituation.  Our brain has decided that's not an important sound and it doesn't need to focus on it and soon after that, you don't really notice it any more.

Another habituation is maybe the watch on your wrist.  Maybe you first got a watch the first time, you probably felt it all day and kept looking at it.  After that, you don't really notice that feeling of the watch until someone like me reminds you that it's there.

So those are all forms of habituation and our brains are very efficient, we don't want to be bombarded with stimuli all the time.  That would be really hard to function.  So that's ‑‑ that's what habituation is and that's what we're trying to do with tinnitus for people that are having a hard time tuning it out.

Now, it's important to not confuse habituation with ignoring.  When someone comes to us saying that they have tinnitus, we never say, "Oh, you just have to ignore it," because obviously that's not very helpful.  And ignoring sort of implies some sort of conscious will or ability to tune it out and if it was that easy, wouldn't everyone have been able to do that? 

So we're very careful not to say that it's ignoring or that it's something that you have to consciously be thinking about.  The more you consciously think about your tinnitus or about tuning out your tinnitus, the more you actually become aware of it.  So habituation is actually an automatic process.  It's something that we want to engage and activate, but not think about too much.  That's why it requires some help, some what we call therapy. 

I have an example about this habituation where I grew up in a small town by the ocean and there was a train that would go by at all hours of the day and when I was younger, I never noticed this train, but when my cousins came to visit, they'd say, "That train is so loud.  How come you can sleep through that?"  And now, when I go back and visit my parents, because I don't live there any more, I think, "Holy cow!  That train is so loud!"  But I ‑‑ living there, I never noticed it. 

So that's another way of thinking about habituation is it's unconscious, we don't consciously think about it, and that is something that is achievable when it comes to treating or managing tinnitus. 

So why is it that some people have a harder time habituating to their tinnitus?  Well, there is a very real phenomenon that's happening.  What is happening is it's called our fight or flight response.  So when a new stimuli is around us, our brain will quickly analyze whether it's something threatening or non‑threatening and for whatever reason, the brain might have triggered to analyze tinnitus as something negative or something that's potentially threatening, because at this point in time, we don't know if it's going to harm us, we don't know if it's going to get worse, we don't know if it means there's something really seriously wrong, and so the amygdala, which is the emotional ‑‑ kind of automatic emotional control centre of the brain, attaches some negative reaction to that tinnitus and it gets labelled as something negative.  And then the body reacts with a fight or flight response, because if there's something threatening in the environment, you want to know where it is at all times.  You want to be paying attention to it, you want to focus on it and you don't want to let it out of your sight, and that's something that our brain is doing sort of unconsciously all the time. 

It's important to remember this is a primitive and adaptive process that we don't have control over and it's actually good that our bodies do this, because it's what keeps us alive.  It's what keeps us from eating a weird bug on a table that we don't know anything about.  We want to make sure that we have all the information and we know if this is threatening or not threatening.

So typical fight or flight responses are muscle tension, high blood pressure, high heart rate, quick breathing, slowing down digestion and then ultimately fatigue, because that's very exhausting.

The emotional response to an overactive fight or flight response is frustration, anger, irritation, stress, sleep problems, anxiety, despair, worry and depression. 

If you think of a time where you might be driving a car and you almost get in a car accident, but you don't, that first few minutes after that, right away, your heart rate increases and you feel your heart pounding and your palms get sweaty and you sometimes, depending on how bad it is, feel like you just have to pull over because that was so rattling.  That quick reactive response is your fight or flight response and that's a very hard state of mind or state of body to be in for a sustained period of time.  That requires a lot of energy and that's not really sustainable. 

So with tinnitus, the difference between tinnitus and a car accident, or a near‑car accident, is that it's one incident and then it goes away and then your body can recover and then you might feel a bit shaky the rest of the day, but the next day you're fine, whereas with tinnitus the threat doesn't go away like that, it's constant for a lot of people and it's there as a constant reminder of this potentially negative, threatening situation.

So your brain, your body, can't maintain the extreme fight or flight response, but it can maintain a moderate fight or flight response which is going to maybe affect your sleep and concentration.  You might find yourself a bit more irritable, have difficulty focusing on things, it might affect your job.  So these are all symptoms of somebody that's maybe in a more mild or moderate form of fight or flight all the time and that is still very fatiguing. 

So what happens with tinnitus and stress is that your auditory cortex is focusing on the tinnitus.  It's making it stand out above all the other sounds because it's important, it's something we have to keep an eye on.  And this hypervigilance to the tinnitus will sort of trigger a stress response in the brain.  It releases certain hormones that only come out when you're under stress, which therefore increase your stress level, which therefore increase your perception of your tinnitus and then retriggers the more negative or emotional reaction to it.

So we show it in the form of a circle here because it is kind what have we call a cycle of distress where one thing triggers the next and so on.  And we want to try to stop this. 

So to summarize the reason somebody might have trouble habituating is that the brain is purposely giving the tinnitus priority and that's not something that they have conscious control over, it just happened one day.  And now the tinnitus is interfering with concentration, it's interfering with sleep, it's being perceived as louder and then we're more aware of it and this all kind of reinforces a negative tinnitus reaction.

So when we talk about what can we do for tinnitus, one of the common questions people ask me is, "Well, is there a cure?  What can I do?  What can I take?"  And because it's not ‑‑ as we've seen, it's not one specific part of the body that's affected and it's not one specific cause that's causing this tinnitus or this reaction, there is nothing.  There is no drug you can take that will make this go away.  They are working on that, they are looking into ways to try to manage this in more of a pharmaceutical or more of a medical approach, but right now the most important thing we find as audiologists is to look at the emotional reaction and the stress component.

So we talk about it in terms of tinnitus management.  So tinnitus management teaches people how to have some control over their tinnitus.  It helps manage some of the negative reactions and the thoughts occurring in response to the tinnitus and our goal is not get rid of it, but our goal is to have habituation. 

So this is done through four components and this is not necessarily unique to Widex, but this is something that at our clinic, we kind of always think about these four tiers and whether somebody can benefit from all four of them or maybe just one or two of them, but the first one is education and counselling.  That is what I'm doing right now, providing information about tinnitus and about some of the ways we can help improve it:

Hearing‑aids to treat the hearing loss, if it's present;

Sound stimulation, which we'll talk about;

And stress reduction, which we just talked about, is a pretty big component here.

So there are several types of tinnitus management programmes.  Some of these you may have heard of, but there's tinnitus retraining therapy, neuromonic (phon.), progressive tinnitus management and various sound options.  The one I'll be focusing on today is called Widex Zen therapy.

So Widex Zen therapy was developed by Dr. Robert Sweetow in collaboration with Widex, which is a hearing‑aid manufacturer.  It's clinically proven to help manage the effects of tinnitus and promote relaxation and reduce stress.  It provides systematic guidelines for audiologists and patients.  It's based upon years of experience with a certain type of music called Widex Zen.  Widex Zen therapy uses this music as the main part of its tool for managing tinnitus.  It's unique in that they have done many studies to show its effectiveness and this kind of zen therapy is only found in this particular manufacturer's products.

So just recently, in June 2017, they came out with a more up‑to‑date version.  It also has an app that works with it.  So if anyone has a smartphone or tablet can actually right now, even, it's free, download the Widex Zen therapy app.

This app is meant to be used in conjunction with working with an audiologist, but you can still kind of use it right now if you want, and you can learn a bit more about it at the Widex booth out in the lobby, there. 

So Widex Zen therapy directly addresses the problem that can contribute to the distress caused by tinnitus patients that are on the extreme end of having difficulty with it.  So it addresses the hearing loss, it addresses the excessive stress response, the sleep deprivation and unhelpful thoughts and behaviours. 

And it's using these in a holistic approach, so they actually recommend incorporating all four of these but in varying degrees, depending on how much stress that person might be under.  So these four ways of dealing with it are counselling, amplification, fractal tones, which are their zen music, and relaxation. 

And why is this unique to other ‑‑ compared to other management approaches that are out there?  The one reason that it's unique is that there is all four of these developed into one plan, whereas some of the other manufacturers have maybe components of this, but maybe not all four of them, and it also addresses the three dimensions of the tinnitus distress component, which is the auditory part, the attention part and the emotional part.

So we'll talk first about the counselling piece, and not everybody needs in‑depth counselling around their tinnitus, but just information about why they might be experiencing it and that there are some treatments available can sometimes ease some of the worry and the fear around why they have it.

So we believe that knowledge is power.  Having accurate information about your hearing loss and about your tinnitus and ensuring that we've sort of medically ruled out any other potential causes for it is important in relieving some of the unknowns and some of the stress.  And counselling helps reduce worry and just knowing that there's help available is important. 

Sometimes we have to do a bit more in‑depth counselling and we use ‑‑ with Widex Zen therapy, they use elements of cognitive behavioral therapy.  So there's something called cognitive behavioral intervention which helps a client deal with some of the negative reactions or what we call thought errors around their tinnitus.  So ‑‑ and sort of challenge the validity of those thoughts and maybe replace them with alternative and logical thoughts and behaviours. 

So for example an event might be that somebody was invited to go to a social gathering and their first thought is, "Well, I can't go.  My tinnitus will get worse," and the feeling that's a result of that thought is sort of hopelessness, despair and frustration.  And that can lead to somebody maybe having a negative thought like, "My life used to be perfect before I had tinnitus and now it's horrible."  And the thought error here is that this is sort of all‑or‑nothing thinking and maybe another way to help someone reframe this is maybe, "Life is never perfect and I had some problems before and I still have some good things about my life now, like my grandchildren."

This is a very simple example, but this is a way to kind of help somebody work through some of the more distressing or more negative thought processes as a result of their tinnitus and this is something we can help with. 

Now, the second component is the amplification piece and obviously this won't make sense if somebody has tinnitus but no hearing loss, but for so many people, they also have hearing loss and that's why it's a very important piece of this framework. 

So we want to try to correct for the hearing loss as soon as we recognize that somebody is dealing with a deficit, and by doing this, we can restore some of that neural activity in the brain.  We can give the brain the sound that it's missing, the sound that it was searching for, and we can do this through something called sound enrichment, which is bringing in some of the sounds of the environment that somebody should benefit from hearing and maybe that, in itself, might help tune out the tinnitus, because they're hearing more of the environmental sounds that are actually there.

And 66.6 per cent of people report that hearing‑aids relieve their tinnitus most to all of the time. 

I like to think of an analogy where you might be in a dark room with one candle and you think of that one candle as your tinnitus and if you walk in that dark room, that's all you see is that one candle, that tinnitus, but if you were to put a hundred candles in that room or flip on the lights, you no longer are aware of that one single candle, that one tinnitus.  There's other things to look at, there's a brightness in the room that you will not notice that any more, and that's a way that amplification works to help blend in tinnitus into the background. 

So the part that's really unique to Widex is the fractal tones, which they call zen.  It's a unique sound programme that is patented and only available in the Widex hearing‑aids.  The hearing‑aids are generally pretty discreet and inconspicuous and they provide acoustic stimulation as well as relaxation.

So they've done several studies to look at the zen tones and we'll talk about that in a moment, but one of the thoughts that comes up at this phase is sort of why would we add more sound?  If somebody is dealing with tinnitus, why would we throw in a bit more noise for them?  And there's a few reasons for that, but the main thing is that amplifying environmental sounds might not be enough to support somebody dealing with really significant tinnitus and sound therapy gives you some control over it because you can choose the volume, you can choose the type of sound, you can turn it on and off and just having a bit of control over some of these background sounds translates to that control that you might feel you're lacking from having tinnitus. 

And choosing a sound that is more positive or even just emotionally neutral can have a big difference in sort of reshaping that negative reaction to the tinnitus, turning something that is quite negative into something that's more positive. 

So fractal ‑‑ fractal zen tones are unique in that they are fractal tones, which means they are non‑repetitive, they are familiar, but they never repeat themselves and they're not predictable, and this is important because the brain is really good at tuning out something that is kind of predictable and boring, and so if it's always a little bit interesting, your brain is always a little bit interested in how these tones are changing. 

It's important that they are soft in the background and that they have a relatively slow tempo and there's no vocals.  There's no voices you have to hear. 

I'll just play a couple of examples of some of the more popular choices, but there actually are five different types of sounds. 

 

(Playing the fractal tones).

 

Okay.  I don't know how to turn it off (laughter).  There we go.  Okay.  So this is an example of the audiologist's computer programme.  So they can take a look at these different kinds of zen chimes and maybe alter the tempo and the pitch and the volume from ear to ear and we'd have the choice of maybe turning the hearing‑aid microphones on to also amplify ambient sounds or turn the microphones off if that's what we want to do.

So the point is it can be customizable to the individual and no two people are the same and no two people are experiencing this the same, so we really want to figure out what would be important to you and what can we do to make this more manageable? 

And the goal is to sort of set it so they're in the background, so you're not distracted by them when you're trying to have a conversation with somebody and theoretically you should be able to turn them off or on if you need to.

They are meant to sort of support you when you don't have other auditory distractions around, but you'll notice, even for that brief snippet, they are quite relaxing, they kind of have a slow tempo that matches sort of a resting heart rate, so even sometimes I'll listen to it when I am doing a bit of work, or preparing for this talk, I had them on in the background, because I felt that was quite relaxing to listen to.

So speaking of relaxation, this is the fourth component to Widex Zen therapy.  Stress, we know, can make tinnitus worse and reducing stress is really essential to this component.  Now, we can't avoid stress.  Stress is going to happen and it's going to exacerbate our tinnitus, but finding ways that you can manage the stress, and whatever that means for you, or whatever you can do, is worthwhile to investigate, but in the Widex Zen therapy protocol, they recommend doing deep breathing exercises, progressive muscle relaxation, guided imagery and sleep management strategies, and all of these can be found on their app, but they're also things that if you don't have a smartphone or don't have a tablet, I can still ‑‑ or we can still give you information on how to go about doing that.

And I think it's important whenever we're recommending a particular way of treating something that it's evidence‑based, that we are recommending something that we have found, you know, people have studied it, they've looked at it or we have patient reports saying that it's helped them.  So as audiologists, we're always integrating both of those things, so information from the manufacturer, information from research that's being done and then also patient feedback, I think, is one of the most important things of what's working and what's not working. 

But here are some studies that have been done to look at this Widex Zen therapy and specifically the zen chimes.  Sweetow and Henderson‑Sabes ... white noise on tinnitus annoyance, the tinnitus handicap inventory, which is a questionnaire that rates how distressing it might be and relaxation, and they looked at 14 adults with hearing loss.  They found that 13 out of 14 rated their tinnitus as less annoying and 86 per cent of them found it was easier to relax when using the zen tones. 

And then a similar study found similar results.  They had clinicians that were experienced with tinnitus treatment.  They were asked to apply the treatment to hearing‑impaired subjects with tinnitus and measure the pre‑ and post‑treatment with the tinnitus reaction questionnaire, and a hundred per cent of the 49 respondents indicated a reduction in tinnitus distress.  But what I thought was most interesting is that the subjects that had the most severe tinnitus distress prior to treatment had the most beneficial effect. 

And then finally, a study by ... and colleagues found when they assessed effectiveness of zen tones on 48 tinnitus subjects with a range of tinnitus handicapping distress, the results showed a clinically significant reduction on the TRQ questionnaire on 90 per cent of the subjects and there was also, similar to the previous one, a greater trend for people that were having more distress to benefit more.

The ten per cent of people that didn't show any significant reduction also ended up having a really low score prior to treatment, so it wasn't distressing them as much as some of the other people. 

So when they did all these studies, they realized that zen tones can be effective for tinnitus management and that's kind of what inspired them to include them in the Widex Zen therapy. 

And so just to recap, the Widex Zen therapy uses four elements in one programme:  Counselling, amplification, fractal tones, which we call zen, and relaxation, and the goal is that we want to make tinnitus an irrelevant sound.  We want to try to induce habituation automatically.  And this helps reduce the negative thinking and improve quality of life. 

It's important to know that this isn't the only tinnitus management treatment that we do at the clinic.  We do elements of this and we pull from other areas as well, but this is one that is a bit newer and it's something that we're definitely paying a bit more attention to lately. 

And the important thing about managing your tinnitus is if you know that it's impacting your quality of life, it's important to schedule a comprehensive hearing test.  That's the number one most important thing to do.  From there we can figure out if there's any underlying medical issue or if it is hearing loss that might be attributing to your tinnitus.  So having an audiologist or somebody that can do a very thorough examination is probably the first thing you'd want to do and then you can be referred on to further medical investigation if needed. 

And an experienced hearing‑care professional that's trained in tinnitus management can really help you with this and the point is that there is something that can be done and that tinnitus management really does work. 

Thank you.  (Applause)

 

FROM THE AUDIENCE:  How do you know whose tinnitus is more severe? 

DR. LIA BEST:  Okay.  Good, yes.  I'm going to repeat some of the questions, but if anyone wants to duck out, they can.  The question was how do we know if someone's tinnitus is more severe?  And that's a great question.  So usually what we do when somebody comes in, if we know they're dealing with tinnitus, because that might be the main reason they phone, they'll say, "I have tinnitus," so we label it in the calendar so we know this person coming in has tinnitus.

And very first thing we often do is have you do a questionnaire called the tinnitus functional inventory or the tinnitus handicap inventory, there's two of them, and they just help us get a sense of how ‑‑ how much the tinnitus is impacting you in various aspects of your life.  So is it affecting sleep?  Is it affecting your social life?  Is it affecting your hearing?  And so there's little subcategories and we do that questionnaire to get a total score and we get some sub‑scores in the different areas to get a sense of how much it's distressing.

But generally speaking, people will tell you how much it's affecting them the minute they walk in.

FROM THE AUDIENCE:  Right. 

FROM THE AUDIENCE:  I have two questions for you, please.

DR. LIA BEST:  Okay.

FROM THE AUDIENCE:  One is you speak about a lot of research that's going on.  Where is the funding for the research coming, government versus industry? 

DR. LIA BEST:  So the question is where is the funding coming for the research, is it government versus industry?  I would say probably both, but I would say industry has a pretty heavy influence on some of the research because most of the products are coming from hearing‑aid manufacturers.

FROM THE AUDIENCE:  Yes. 

DR. LIA BEST:  But the government is very interested in this kind of research, so I guess they'd be the second most common.

FROM THE AUDIENCE:  The second question is if you note an increase in tinnitus, have you found out whether it's habitual or physical? 

DR. LIA BEST:  Okay.  If you note an increase in tinnitus, have we found out whether it's habitual or physical?  As in is it something the person's doing or something that is changing in their body; is that what you mean? 

FROM THE AUDIENCE:  Yes.

DR. LIA BEST:  Okay.  Well, I think it can depend on the person.  So we know that stress can sometimes aggravate somebody's tinnitus and make it seem louder.  Noise exposure can spike up tinnitus.  There's a lot of environmental factors that can make it louder, but also if somebody is dealing with a decline in hearing, that can also seem to make their tinnitus louder.  Or if somebody has something called Meniere's disease, which is characterized by sort of fluctuating hearing loss, when their hearing loss is down, their tinnitus is often up and then it kind of changes. 

So I'd say both would be the answer to that question. 

FROM THE AUDIENCE:  Would some of the funding in that regard, in this particular subject, come from insurance companies? 

DR. LIA BEST:  So the question is would some of the funding for that kind of research come from insurance companies?  I don't know the answer to that.  Yeah. 

FROM THE AUDIENCE:  What does ...

DR. LIA BEST:  What does zen therapy involve?

FROM THE AUDIENCE:  Yeah.

DR. LIA BEST:  All four of those components, so the counselling, amplification, the introducing the zen tones through the hearing‑aids and relaxation.  So usually we cover all of that in sort of the first appointment and then as the follow‑up visits go on, we introduce more layers to that protocol.  And it's unique to the person, so we wouldn't just throw it all at somebody if they weren't dealing with the hearing loss piece or if they weren't ‑‑ with the distress for their tinnitus, they may not need the counselling piece, but they may benefit from the sound therapy.  So it's sort of customizable.  Okay, go ahead.

FROM THE AUDIENCE:  Okay.  Two parts to the question:  Number one, if it is only within the Widex hearing‑aids, I mean my tinnitus is most noticeable at night when my hearing‑aids are out.

DR. LIA BEST:  Right.

FROM THE AUDIENCE:  So you take your hearing‑aids out at night, right? 

DR. LIA BEST:  So that is a good question.  So if this therapy is only built into the hearing‑aid, but at night you take the hearing‑aids out, you're kind of lost without it.  That's ‑‑ that's one of the reasons they came out with the app is that through the app, they can still play the sounds in more of an ambient way.  You can play it through a Bluetooth speaker or headphones that you sleep with or even just from the device itself on a low level.  But that's ‑‑ that's one way of kind of bridging the gap between taking them out and then going to sleep, because it does affect sleep quite a bit for a lot of people.

FROM THE AUDIENCE:  So if you get the app, download it into your iPad, for example, you really would just use that at night.

DR. LIA BEST:  Yes, generally.  Or just have a bit more options, because the ones that we programme in, there's only a few of them, but with the app, there's a whole range of different sounds, and the nice thing I like about the app, and it's a tool that ‑‑ excuse me, it's a tool that I use almost daily with people that have tinnitus, is that it's free.  You don't have to have Widex hearing‑aids to use the app and there's a lot of really good information on there, good counselling information, good research and good relaxation strategies.  I have it on my phone.  I don't have tinnitus, but I still throw on some of those sounds for relaxation and I do the deep breathing relaxation before I go to bed, so ‑‑ yeah.  You're welcome.  Roger? 

FROM THE AUDIENCE:  Yeah, you mentioned that ‑‑

FROM THE AUDIENCE:  What's the name of the app?

DR. LIA BEST:  It's called the Widex Zen Therapy app.  Sorry, go ahead.

FROM THE AUDIENCE:  You mentioned that tinnitus can take several forms.  You also mentioned it can sound like music?  So if you get a song stuck in your head for three or four days at a time non‑stop, is this an example of tinnitus? 

DR. LIA BEST:  That's a good question.  He's asking if you get a song stuck in your head for two or three days at a time, is that a form of tinnitus?  And I would say probably not, but I have had a few clients say they have the same piece of a ‑‑ like maybe they're a musician and it's the same piece of this composition over and over and over with no break from it.

FROM THE AUDIENCE:  Yeah.

DR. LIA BEST:  That I think would be.  If you feel like you can't tune it out with other kinds of things, or if you don't have any relief from it, I think that would be probably a form of tinnitus.  Yeah.  Yeah?  Go ahead.

FROM THE AUDIENCE:  You mentioned in one of the slides that there's actually a disappearance of some of the ear hairs when they've been damaged.  What happens to them?  Where do they go? 

DR. LIA BEST:  So what happens to those hair cells?  Well, they kind of degrade, so they're actually ‑‑ they're highly metabolic cells.  We call them hair cells, but they're not hair at all, so if they are being damaged and they lose the nutrients they need to stand upright, they eventually wither away and they actually degrade or disappear.  Yeah.  I don't know where they go exactly, but they probably just get absorbed by the rest of the ear.  Yeah.  Yeah? 

FROM THE AUDIENCE:  Something that I didn't mention when I had a consult with you:  Has anyone experimented with either behavioral or cognitive therapy, trying to let you learn to love your tinnitus? 

DR. LIA BEST:  Yeah.  So (laughter) that's a great question.

FROM THE AUDIENCE:  It seems reasonable.

DR. LIA BEST:  He's just asking if there's been any kind of therapy, instead of trying to ignore it or trying to change it, but to maybe learn to love it, and I would say yes.  So there is a form of ‑‑ you might have heard of mindfulness as a kind of a way of counselling or a way of being present or being, you know, accepting of a difficult situation, and there is a programme geared towards tinnitus called mindfulness‑based stress reduction and it's kind of along those lines.  It's, "Well, we can't get rid of this, so how can we make the best out of this situation?"  And it's about sort of being present and being okay and maybe positively looking at it, and I think there's a lot of validity to that and a lot of people that are really finding it effective.

So we did a talk, actually ‑‑ if you go on our website, I think not last year, but the year before, we did a talk on mindfulness‑based tinnitus reduction.  So that is ‑‑ you will find some resources on the website, but if you even just Google that, you'll probably see a few people that are talking about that and doing that and it's something we recommend when people come in, too.  Yes, in the back, there? 

FROM THE AUDIENCE:  I believe your tinnitus ...  tinnitus being activated with changing weather or ‑‑

DR. LIA BEST:  The question was has anyone reported that their tinnitus has been affected by changes in weather or air pressure?

I've had people say that.  I don't know exactly the mechanism of that, because I think there's so many different potential underlying reasons somebody might have tinnitus, but yeah, I think that I've had that case before and with Meniere's disease, we had some people report that, you know, changes in pressure, seemed to affect them with their hearing, so it makes sense.

FROM THE AUDIENCE:  And air travel, too? 

DR. LIA BEST:  Yeah, with air travel.  Mm‑hmm.

FROM THE AUDIENCE:  Is music ear syndrome the same as tinnitus?

DR. LIA BEST:  Music ear syndrome? 

FROM THE AUDIENCE:  Yeah.  When you hear "Silent Night" all the time.

DR. LIA BEST:  That was similar to a question that was just asked about if you have a song stuck in your head.  I can answer the question.  And we can talk about that, too.  We've talked about that in clinic, too.

DR. ERIN WRIGHT:  Okay, thank you very much, Lia.  If anybody has any other questions for Lia, she is going to duck out that side door and you can go over there.  We're going to have the next talk by Gael (applause).