A 43-year-old medical professional suffered an exacerbation of a lower spinal condition related to scoliosis. During reparative surgery, apparently the dura of the spinal cord was punctured, resulting in a slow leak that affected the level of cerebral spinal fluid. It was estimated that the patient ended up with a 70 percent loss of the level of fluid surrounding her brain. Subsequently, the patient was supine in bed for a number of weeks and developed various significant symptoms, including audiological and vestibular conditions.

After another surgery to repair the dura leak, the patient slowly recovered from most of her symptoms with the exception of tinnitus and severe hyperacusis. She was referred to my clinic for an evaluation and treatment. Her case history revealed constant use of ear plugs to control sound exposure, avoidance of noisy settings, including the family dinner table and school activities, and complaints of pain related to sharper sound presentations, such as her children's voices.

The score on the Tinnitus Reaction Questionnaire (TRQ) was a 44/104, which placed her in a moderate level of severity in relation to tinnitus. Hearing was within normal limits, actually quite excellent, hovering between 0 dB and 5 dB, out to 6000 Hz. Then a distinct and unusual asymmetry was noted with the right ear dropping to a moderate loss at 8000 Hz, and plummeting to 90 dB at 16,500 Hz. The left ear showed moderate hearing loss through 10,000 Hz, then also dropped at 12,500 Hz and 16,000 Hz. The tinnitus was identified through a closed set choice test to be at 10,000 Hz in the right ear, with a volume of 4 dB SL. She was unable to be masked with either narrow band noise or broadband noise due to the lack of tolerance for louder sound presentations.

The hyperacusis was tested using the LDL approach with double-presentations at 5 dB interrupted increases using pure tones. Her dynamic ranges for the measurements (from auditory thresholds) were 50 dB in the lowest frequencies, 30 dB in the mid-ranges and 10 dB in the higher pitches. She had a profound degree of bilateral hyperacusis.

Luckily, the patient had a great sense of humor and, with her medical background, was able to work collaboratively and effectively. She expressed a strong desire to improve her situation and wanted to try two treatments-the Neuromonics "Oasis" tinnitus device combined with broadband signal generators developed for tinnitus retraining therapy (TRT) for Dr. Pawel Jastreboff.

She was fit with a set of Amplisound "Solace" generators at the first visit and the Neuromonics "Oasis" was ordered. She was counseled extensively about the purpose of each approach and how to set and use the generators. The fit was satisfactory, and she was committed to using the sound therapy units for part of each day. She was instructed to reduce the amount of time using the earplugs, and the first major concept in that part of the treatment program was to grasp the fact that even though sounds seemed loud and intrusive, there was no clinical basis for concern.

The tinnitus was an issue but was judged to be less severe than the hyperacusis. Her tinnitus was reactive to louder sudden sharp sounds, typical of those who have severe or profound hyperacusis. The decision was made to use the Neuromonics Oasis unit for relief from tinnitus and relaxation in the evenings, prior to sleeping.

The dual program has worked very well for this patient. She was able to wear the Solace units immediately and began to benefit from the broadband sound in her ability to tolerate more sound. In the first few weeks of this program, she was able to be comfortable in her home and even to spend time out and about in shopping environments. With weekly follow-up sessions for the first month, followed by regular follow-ups (1-2 times per month), she was able to fully utilize the sound generators during the day.

The use of the Oasis instrument was very helpful for her in the pursuit of relaxation and tinnitus recovery. She found it very useful for tinnitus relief as well as fostering habituation. Over the first six months of her treatment program, she has increased her LDLs by 20 dB on average per ear, her TRQ score is presently 12/104 and her overall situation has improved by more than 30 percent as to loudness perception, negative impact on lifestyle and overall tinnitus intrusion.

Marsha Johnson, AuD, owns and operates the Oregon Tinnitus & Hyperacusis Treatment Clinic in Portland, OR. She is an advisory board member of the Tinnitus Practitioners Association, www.tinnituspractitioners.com.