Description:

Tinnitus is a prevalent and often debilitating symptom that affects millions worldwide. Despite its frequency, clinicians frequently struggle with its management due to the heterogeneity of causes and responses to treatment. This Instruction Course is designed to provide a clear, concise, and practical guide for managing tinnitus patients in real-world clinical settings. It will focus on decision-making strategies, categorizing patients, and selecting appropriate interventions.

The session is divided between three expert clinicians. The first speaker, Dr. Maryam Sadeghijam, will focus on patient profiling and clinical decision-making. Drawing on audiological, psychological, and subjective patient data, she will demonstrate how to formulate an individualized treatment strategy and determine the most appropriate therapeutic direction. The second speaker, Dr. Ahmad Reza Nazeri, will present an overview of current treatment modalities—including counseling, sound therapy, hearing aids, cognitive-behavioral therapy (CBT), and neuromodulation— and explain how to match each approach to specific patient profiles. The third speaker, Mevlüde Işık, will focus on neuromodulation in tinnitus, with an emphasis on transcranial direct current stimulation (tDCS). This section will briefly cover the clinical rationale for tDCS, patient selection criteria, and its role as an adjunctive tool within multimodal tinnitus management.

Outcome objectives:

By the end of this course, participants will be able to:

- Integrate audiological, psychological, and subjective assessments to guide treatment planning
- Select personalized management strategies using a structured clinical algorithm
- Compare counseling, sound therapy, CBT, and neuromodulation based on patient profiles

Structure of session:

Part 1 – Clinical Decision-Making in Tinnitus Management

Speaker: Dr. Maryam Sadeghijam

- Quick overview of tinnitus subtypes (e.g., subjective vs. objective, chronic vs. acute, bothersome vs. non-bothersome)

- The essential components of initial assessment: audiological, psychological, and subjective evaluations

- Clinical decision-making models based on patient profiles

- Simple checklists and red flags to guide early-stage planning

Part 2 – Treatment Options and How to Match each approach to Specific Patient Profiles

Speaker: Dr. Ahmad Reza Nazeri

- Concise review of core management approaches:

· Counseling and patient education

· Sound therapy and hearing aids

· Cognitive Behavioral Therapy (CBT)

· Mindfulness-based interventions

· Neuromodulation

- Comparative table of approaches: strengths, limitations, ideal patient types

- Common pitfalls in choosing or applying treatments

- A brief, actionable algorithm for everyday clinical decision-making

Part 3 – Neuromodulation in Tinnitus: Practical Use of tDCS

Speaker: Mevlüde Işık

-Neurophysiological basis of neuromodulation in tinnitus

-tDCS in tinnitus management:

. Core mechanisms and main cortical targets

. Commonly used stimulation protocols and safety considerations

-Patient selection and clinical integration:

. Tinnitus profiles most suitable for tDCS

. Influence of severity, chronicity, and treatment resistance

Background:

1- Shannon entropy measures for EEG signals in tinnitus

2- An increase in the auditory steady-state response amplitudes after a period of listening to binaural beat stimuli in tinnitus patients: a pilot study

3- Does tinnitus lead to chaos?

4- The hypothetical relation between the degree of stress and auditory cortical evoked potentials in tinnitus sufferers

5- Use of some relevant parameters for primary prediction of brain activity in idiopathic tinnitus based on a machine learning application

6- Persian Version of the Hyperacusis Questionnaire: Psychometric Evaluation and Prevalence Determination

7- A preliminary study on the reliability of the persian version of the tinnitus functional index in a military population

We will try to have a review on all treatment possibilities for Hearing Impaired children. The topics that we will try to cover are as below:

Hearing Aid candidacy will explained for both children and infants.

How to decide for switching to CI is a very important decision that must be made ASAP.

The application of Bone Conduction hearing aids for pediatric population. (both conventional & implantableas).

Treatment programes for children with confirmed diagnosis of central auditory processing disorderes. Different kind of treatments will be explained ( dichotic training/spatial training/ time or frequency training/word based training /….).

This instructional course focuses on physiologic techniques, specifically Auditory Brainstem Response (ABR) and Auditory Steady-State Response (ASSR) for accurate auditory threshold estimation in infants and young children. Special attention will be paid to tone burst and chirp-evoked ABRs, comparing their utility with standard click stimuli. The course will provide clinical decision-making strategies for choosing stimulus types, managing calibration issues, and integrating physiologic results with limited behavioral data. The session will conclude with a brief overview of behavioral estimation methods to highlight a multimodal approach.

Learning Objectives:

- Differentiate between click, tone burst, and chirp stimuli in ABR and understand their use in frequency-specific threshold estimation.
- Apply chirp ABR in clinical settings, especially in infants, considering calibration and latency differences.
- Use ASSR as a complementary or alternative tool for auditory threshold estimation.
- Integrate physiologic results with limited behavioral observations to guide diagnosis.
- Apply decision making protocols in medically complex or time constrained pediatric cases.

Course Outline:

1. Introduction (2 min): Importance of accurate auditory threshold estimation in pediatric diagnostics.

2. Stimulus Comparisons in ABR (8 min): Click vs. tone burst vs. chirp; frequency specificity, temporal synchrony, and recording efficiency.

3. Chirp ABR in Practice (6 min): Clinical benefits, limitations, calibration issues, and interpretation strategies.

4. ASSR Applications (5 min): Role in bilateral threshold estimation, especially for profound hearing loss and auditory neuropathy.

5. Behavioral Correlation (5 min): How to integrate physiologic data with behavioral responses like VRA and BOA.

6. Decision Making Algorithms (4 min): Practical case based strategies and flowcharts for clinical use.

This instructional course focuses on physiologic techniques, specifically Auditory Brainstem Response (ABR) and Auditory Steady-State Response (ASSR) for accurate auditory threshold estimation in infants and young children. Special attention will be paid to tone burst and chirp-evoked ABRs, comparing their utility with standard click stimuli. The course will provide clinical decision-making strategies for choosing stimulus types, managing calibration issues, and integrating physiologic results with limited behavioral data. The session will conclude with a brief overview of behavioral estimation methods to highlight a multimodal approach.

Course Outline

1. Introduction (2 min): Importance of accurate auditory threshold estimation in pediatric diagnostics.

2. Stimulus Comparisons in ABR (8 min): Click vs. tone burst vs. chirp; frequency specificity, temporal synchrony, and recording efficiency.

3. Chirp ABR in Practice (6 min): Clinical benefits, limitations, calibration issues, and interpretation strategies.

4. ASSR Applications (5 min): Role in bilateral threshold estimation, especially for profound hearing loss and auditory neuropathy.

5. Behavioral Correlation (5 min): How to integrate physiologic data with behavioral responses like VRA and BOA.

6. Decision Making Algorithms (4 min): Practical case based strategies and flowcharts for clinical use.

With the global population aging, age-related hearing loss (ARHL) and its consequences on cognitive health have emerged as urgent clinical challenges for audiologists and otolaryngologists. This instructional course will examine the neurobiological links between ARHL and cognitive decline, outlining how changes in hearing can accelerate cognitive impairment and complicate diagnosis. We will review the latest clinical assessment tools for identifying cognitive issues related to hearing loss and discuss evidence-based strategies for auditory and cognitive rehabilitation. Special attention will be given to innovative uses of virtual reality (VR) in auditory training and cognitive rehabilitation, highlighting enhanced patient engagement and functional improvement. Real-world case studies will demonstrate the diagnostic and rehabilitative challenges unique to this population. Participants will learn skills to recognize and manage cognitive comorbidities in patients with ARHL and to integrate VR technologies into tailored audiological care.

The types of signals used in Auditory Brainstem Responses (ABR) can be examined in three groups: Click stimuli that include all frequency bands, Tone-Burst stimuli that include a narrow frequency band, and Chirp stimuli.

Chirp stimuli were developed to compensate for the cochlear wave delay problem when click stimuli are used in ABR. Chirp stimuli have a wide-band (like click stimuli CE-Chirp) form as well as narrow-band stimuli (like tone-burst stimuli Narrow Band CE-Chirp).

The Chirp stimulus was developed by Claus Elberling (2007) to compensate for the wave delay in the cochlea. Due to the specially adjusted temporal distribution of its components, CE Chirp stimulus simultaneously accesses characteristic regions of the basal membrane. Since all cochlear regions are simultaneously depolarized by the CE-Chirp stimulus, ABR waves with higher amplitude are obtained (1).

To eliminate the cochlear wave delay problem that occurs when a tone burst stimulus is used, the NB CE-Chirp stimulus (2). In addition, the Level Specific (LS) CE-Chirp stimulus type has been developed by creating different delay models according to the intensity level at which the developed CE-Chirp stimulus is sent.

Studies on CE-Chirp ABR: Khorsand Sabet et al. (2014) found CE-Chirp ABR wave V amplitudes to be larger than Click ABR in individuals with normal hearing (3). Stuart et al. (2014) reported that larger wave V amplitudes were obtained with the CE-Chirp stimulus at 30 dB nHL than with the Click stimulus in newborns (4).

Ferm et al (2013) found 1 and 4 kHz NB Chirp ABR thresholds to be approximately 5 dB better than tone pip ABR thresholds in infants undergoing newborn screening (5). Cargnelutti et al. (2017) found that in people with normal hearing, wave V amplitudes were larger with LS CE-Chirp ABR than with click ABR at 85 dB nHL (6).

This information in the literature shows that ABR performed with Chirp stimulus types can be used effectively to estimate behavioral hearing thresholds.

References

1. Elberling C. Auditory brainstem responses to a chirp stimulus designed from derived-band latencies in normal hearing subject. J. Acoustical Society of America November 2008;124 (5): 3022

2. Rodriques GR, Ramos N, Lewis DR. Comparing auditory brainstem responses (ABRs) to toneburst and narrow band CE-Chirp in young infants. Int J Pediatr Otorhinolaryngol. 2013 Sep;77(9):1555-60

3. Khorsand Sabet V, Mandavi-Zafarghandi ME, Safavi M, Sharifian M, Tabatabaee SM. Comparison of click and CE Chirp-evoked human auditory brainstem responses: a preliminary study. Aud 2014;23(4):69-76

4. A Stuart; Cobb, Kensi M. Effect of stimulus and number sweeps on the neonate auditory brainstem response. Ear and Hearing The Official Journal of the American Society 2014;35(5):585-588

5. Ferml L, Lightfoot G, Stevens J. Comparison of ABR response amplitude, test time, and estimation of hearing threshold using frequency-specific chirp and tone pip stimuli in newborns. Int J Audiol 2013; 52(6):419-423

6. Cargnelutti M, Cóser PL, Biaggio EPV. LS CE-Chirp® vs. Click in the neuroaudiological diagnosis by ABR. Braz J Otorhinolaryngol., 2017,Jun;83(3):313-317.