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Michael2133

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 #1 
Hi Dr. Nagler,

I had three questions that I was hoping you could provide your opinion on. I am in month three of tinnitus, hearing tests came back in normal ranges though I did have some exposure (twice) to uncomfortably loud noise in earbud headphones in the months/weeks prior (only thing I can think of) as well as a very stressful period of months.

1) Do you recommend avoiding all medications, particularly pain relievers or the occasional ativan/other sleep aid due to ototoxic effects?

2) I love to fish and have been invited to go out on the boat but am concerned of the noise exposure to the outboard motor. Would over the head noise cancellation headphones be all that is needed or should I avoid the boat altogether in the early stages?

3) The noise can be quite distracting and I was considering wearing headphones and playing some sort of white noise or music while working. I am scheduled to begin trt in September and wanted to see if this would affect the outcome in any way or if I should choose a different method of noise enrichment? I currently use a fan but it just doesn't blend in enough with the sound to provide relief.

Thank you for your advice and support!
Dr. Nagler

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 #2 
Quote:
Originally Posted by Michael2133
I had three questions that I was hoping you could provide your opinion on. I am in month three of tinnitus, hearing tests came back in normal ranges though I did have some exposure (twice) to uncomfortably loud noise in earbud headphones in the months/weeks prior (only thing I can think of) as well as a very stressful period of months. 

So you are three months into your own tinnitus odyssey. I am sorry you are having difficulty, but I am very glad this board can be here for you to help separate fact from fiction. And there is a LOT of fiction out there! If you have not already read through my article specifically written with tinnitus newbies like you in mind, you might CLICK HERE for starters.

Quote:
1) Do you recommend avoiding all medications, particularly pain relievers or the occasional ativan/other sleep aid due to ototoxic effects?

Just the opposite! In my opinion there are only a handful of drugs that should be avoided: CLICK HERE

Quote:
2) I love to fish and have been invited to go out on the boat but am concerned of the noise exposure to the outboard motor. Would over the head noise cancellation headphones be all that is needed or should I avoid the boat altogether in the early stages? 

No need to avoid the things you love like fishing. I agree that outboard motors can be loud, and I would definitely use ear protection while the motor is active. Earplugs are probably better than noise cancellation headphones in that setting - because you don't want your noise cancellation headphones to get ruined if they accidentally get soaked while you are out on the water.

Quote:
3) The noise can be quite distracting and I was considering wearing headphones and playing some sort of white noise or music while working. I am scheduled to begin trt in September and wanted to see if this would affect the outcome in any way or if I should choose a different method of noise enrichment? I currently use a fan but it just doesn't blend in enough with the sound to provide relief. 

Just so long as you do not completely mask your tinnitus, you should be fine in that regard. Don't get me wrong here, masking is wonderful if it's immediate relief that you are seeking. But if you are looking at beginning TRT within the next few months, you probably want to avoid masking because masking theoretically inhibits habituation, which is the goal of TRT.

Quote:
Thank you for your advice and support!

Glad to help.

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
Michael2133

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 #3 
As a follow up to the medication, I read in the recent ATA magazine that Ativan was in the top 20 FDA drugs with reports of tinnitus side effects. I didn't see any other benzodiazepine's on the list. Would it be recommended if one was to use these on occasion to request a different benzo than Ativan? The preference of course is to not use any of them more than is absolutely necessary. 

Also with regards to TRT, can one receive the benefits from this therapy even if their absolute volume is relatively low (I'm assuming as it can't be heard over the shower) while their perceived distress is relatively high?

Lastly, is it more common than not that once an individual completes TRT, that is all that would be necessary or is it common to have to repeat the therapy down the road?

Thanks again for your generosity!
Dr. Nagler

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 #4 
Quote:
Originally Posted by Michael2133
As a follow up to the medication, I read in the recent ATA magazine that Ativan was in the top 20 FDA drugs with reports of tinnitus side effects. I didn't see any other benzodiazepine's on the list.

Looks to me like there are actually three benzodiazepines on that list of drugs with tinnitus side effects: alprazolam (Xanax), clonazepam (Klonopin), and lorazepam (Ativan). Moreover, all three of those drugs are actually used from time-to-time in the treatment of tinnitus and tinnitus-associated distress. And often with very good results, I might add. So go figure.

Quote:
Would it be recommended if one was to use these on occasion to request a different benzo than Ativan? The preference of course is to not use any of them more than is absolutely necessary.

In terms of "tinnitus side effects" I think all benzodiazepines are roughly equivalent. I do agree with you that in general benzodiazepines should only be used when absolutely necessary, and then only under the guidance of a physician who is familiar with their use and who will monitor you closely.

Quote:
Also with regards to TRT, can one receive the benefits from this therapy even if their absolute volume is relatively low (I'm assuming as it can't be heard over the shower) while their perceived distress is relatively high?

Yes. Same as with CBT. All that matters is distress. 


Quote:
Lastly, is it more common than not that once an individual completes TRT, that is all that would be necessary or is it common to have to repeat the therapy down the road?

With TRT perhaps in 15-20% of cases you do have to "repeat the therapy down the road." But that said, TRT is like learning to ride a bike. The second time it is quicker and easier, generally taking at most one or two weeks. 


Quote:
Thanks again for your generosity!

Glad to help.

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
Michael2133

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Posts: 14
 #5 
Thank you Doctor. As a follow up to TRT, I read an interview with Dr. Pastreboff that in the early days, it took about a year on average to see results but that with revisions and modifications to the treatment, he felt that the length of time has been reduced down to a month. My question is that is there any continuing education associated with those who took his class so that they (and subsequently their patients) would benefit from the updates and revisions to the treatment he was referring to? Again, appreciate all you do.
Dr. Nagler

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 #6 
There have been a number of revisions and modifications, but I think you may be misinterpreting what Dr. Jastreboff has said. In some cases folks can begin to see some improvement in a little as a month, but the overall length of treatment has not been appreciably impacted.

I think that the single greatest change overall in TRT has to do with categorization in that it became apparent to Dr. Jastreboff over time that some Category 4 patients are actually more appropriately treated as Category 1 patients with tinnitus and misophonia.

At this point there is no formal provision for continuing education specifically in TRT. They used to offer follow-up courses (I myself took two of them - in 1999 and 2001), but as far as I know there have been no follow-up courses since 2001. Most TRT clinicians who are really into doing TRT "right" stay in touch with Dr. Jastreboff (or me!) informally to discuss their difficult cases.

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
Michael2133

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Posts: 14
 #7 
Apologies, I meant “begin” to see improvement I should have been more clear. Again thank you for all you do, words can’t express the gratitude I have for your willingness to do this and I hope to be able to do my part for the community one day as well..
Dr. Nagler

Owner
Registered:
Posts: 1,759
 #8 
Don't beat yourself up for not being more clear when the waters of tinnitus are so muddy to begin with!

Be well -

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
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