Interview with Dr. Natan Bauman, Inventor of Vivatone Hearing Aid

Topic: Vivatone VivaSet Fitting Software with Tinnitus Program

Dr. Paul Dybala: Hello everyone, this is Dr. Paul Dybala with Audiology Online, and today I am talking with Dr. Natan Bauman from Vivatone about their new tinnitus program. Dr. Bauman, could you start by telling us about yourself and your professional background?

Dr. Natan Bauman: It is really a pleasure to be able to talk to you and to share some information regarding tinnitus. To tell you about myself, I am originally from Poland, which is where I obtained a degree in engineering, specifically in electronics. I obtained my doctorate degree in audiology from Columbia University. I worked in several places, including the School for the Deaf in New York and as an audiologist in Toronto, Canada. After a couple of years, I came back to Connecticut, and I was the Director of the Hearing, Speech, and Language Clinic at Yale New Haven Hospital, with a faculty appointment at Yale Medical School.

In 1988, I decided to open my own private practice, and I have been in private practice since then. I currently own two private practices: one practice which deals with hearing-related problems and hearing aids and the other clinic devoted to tinnitus and hyperacusis treatment.

During my time in private practice, first, I invented the first open ear in-the-canal tinnitus device, which is now widely used for tinnitus treatment throughout the country. This device is actually being replaced with a new, receiver-in-the-ear (RITE) noise generator device and also a new combination tinnitus and hearing aid device based on the RITE principle, which I will discuss more later.

I was also fortunate enough to invent the Vivatone hearing aid, the first receiver-in-the-ear hearing aid with an open ear.

Other than that, I have three wonderful children and a lovely wife, which I feel are my best accomplishments outside of my professional career. Overall, I am a pretty busy person, and I love it.

Dybala: Well, thank you so much for taking the time to talk with me today amid your busy schedule. Vivatone is now introducing a tinnitus program option in their hearing aids. Could you give a basic explanation of what it is and how it works?



Bauman: Sure. Let me begin by saying that my research basically comes from personal clinical experience in my practice, working with patients, listening to what they say, and observing what helps and what does not help. Tinnitus is one area which captured my interest many years ago and I have been involved with tinnitus for quite a long time.

It is not a new concept that hearing aids, to some degree, help people who have tinnitus. They actually help at two different levels. At one level, they reduce the relative perception of the internal sound of the tinnitus by providing external sound. The other level is that when the brain is deprived of proper sound stimulation due to hearing loss, the brain has a tendency of increasing gain in the outer hair cells of the cochlea. By doing that, the auditory pathways inadvertently promote tinnitus. Therefore, amplification has been used widely for people who suffer from tinnitus and who obviously have some degree of hearing loss.

What we have noticed in the field of tinnitus is that, in some cases, when amplification is provided by a hearing aid that closes off the ear canals, the tinnitus gets worse. I was actually giving a presentation in Pittsburgh to prospective patients with tinnitus yesterday, when a gentleman told me, "Dr. Bauman, I am a little skeptical about hearing aids helping my tinnitus because I have two CIC hearing aids, and I know when I put them in the ears my tinnitus gets worse. And that is why I do not wear them."

Dybala: And why is that?

Bauman: This is because most of the time custom hearing aids produce what is known as an insertion loss, and they also produce an occlusion effect. Those two factors are very negative when working with tinnitus. Simply put, if there is an absence of sound in the environment, the presence of the hearing aid in the ear canal actually makes the hearing loss worse than what it really is, which is due to the insertion loss.

Because the auditory cortex receives less auditory information as a consequence of the aid blocking the ear canal, the tinnitus gets worse. The relative value of the tinnitus increases due to the decrease of the auditory input. We know that people complain of tinnitus particularly when it is quiet. The presence of a hearing aid in a very quiet environment makes that quietness worse.

A little bit of light in a very dark room is perceived as an extremely bright light;however, if you take the same light and present it in a lighter room, the same light is not perceived as being as bright. I relate this to tinnitus in quiet and say, "Let's brighten up your auditory room."

If sounds in the environment are relatively soft, and a hearing aid does not allow the user to hear the environment, to perceive the environment, and to be immersed in an auditory environment in a proper way, the auditory room is being darkened by physically having a hearing aid that plugs the entrance to the ear canal.

That is one shortcoming about custom hearing aids that plug up the ear. And that is why open-ear hearing aids have a better chance, with proper amplification, to help somebody who has tinnitus.

We now know that if we can provide adequate amplification with an open-ear hearing aid, then a person has a much better chance to become less aware of the tinnitus. There was some work done by the Luc Del Bo Group in 2006 in Italy, where they actually looked at tinnitus patients with open-ear amplification. They showed a very significant improvement in those patients when using open-ear hearing aids with TRT counseling.



Vivatone Open Receiver-in-the-Ear Device

I have noticed, anecdotally, from some of my patients who have tinnitus as a secondary problem to hearing loss that they would come back to me after using a Vivatone hearing aid and tell me that the hearing aids are working very nicely for hearing, but as an added benefit their tinnitus seems to have disappeared.

These stories made me wonder what I could do to help people with hearing loss and tinnitus and also help audiologists who are not familiar with formal tinnitus treatment.

Understanding the necessary spectral characteristics of sound and understanding that quite a few people who have tinnitus also suffer from different forms of loudness discomfort, whether this is hyperacusis, misophonia, phonophobia or recruitment, I designed a program that I felt might be beneficial to those people.

Dybala: And people saw more relief from tinnitus with this program?

Bauman: Yes. To study the tinnitus program option, I set up two groups of people. I had a group who wore Vivatone hearing aids programmed with a normal auto-fit setting, while the other group had my tinnitus program. After six months, the results showed that while the first group, who were only provided an amplification program, received some tinnitus relief;however, the patients who received the tinnitus program were helped significantly more than the first group. Based on that, I decided to put the tinnitus program into the Vivatone software.

Dybala: Very good. Is this tinnitus program option intended for anyone with tinnitus?

Bauman: That is a good point. I do not advocate that this tinnitus program, nor amplification, is appropriate for every person who suffers from tinnitus.

I have developed a list of requirements from my experience in the clinic which I modeled after Dr. Jastreboff's Tinnitus Retraining Therapy (TRT) questionnaire on subjective assessment of tinnitus to decide candidacy for this tinnitus program. I ask patients three questions on a 0 to 10 scale and a fourth question asking for a percentage of time of perceived tinnitus. For the first three questions, the patient must respond with a score of 5 or below to be a candidate, and for the fourth question, they must respond 50% or better to be a candidate.

The first question asks how they perceive their tinnitus, in terms of "annoyance level", on a scale of 0 to 10, where 0 is no annoyance at all and 10 is extreme annoyance. My second question pertains to "severity" of tinnitus on a scale from 0 to 10. My third question asks about the "effect of tinnitus on life" on a 0 to 10 scale, where 0 is no effect, and 10 means that their life is completely ruined. My last question asks the percentage of time they are aware of their tinnitus.

Now, I developed this around patients who came to my clinic for a hearing problem. As a general question, I asked my patients if they also were having problems with tinnitus. If they said they were having problems, my next main question was, before I even asked them about severity and annoyance and so forth, I asked them, "Would you like, if possible, to also reduce your tinnitus?"

When they said yes, then my four questions were asked. What is the severity? What is the annoyance level? What is the effect on life, and what is the percentage of awareness? If they fulfilled the aforementioned criteria, they qualified for the tinnitus program and were included in this study.

I did not talk to these people about any form of TRT counseling management at all. They were just given hearing aids and asked to wear the hearing aid for at least eight hours a day. I asked them to wear the hearing aid for the first month in the tinnitus program only at home.

The second program was the "Comfort and Noise" program, and patients were advised to use that program when they went out with their hearing aid.

In my clinical study, the individuals using the tinnitus program reported statistically more improvement in annoyance level, severity, effect on life, and percentage of awareness than the group that only received amplification.

Dybala: Interesting! I understand that if patients report more than a 5 on your questions or the hearing loss is a secondary complaint to the tinnitus, you refer them to a TRT clinic for a more tinnitus-based program. Is this right?

Bauman: Very much so.

Another aspect to consider, and I do not yet have enough data to really support this, is that some patients have reported an improvement in hearing in noise once their tinnitus was reduced. I attribute this to the fact that the limbic system pays less attention to the tinnitus and more attention to the "primary" message.

We know that if we have two auditory signals which need to be processed cognitively at the same time, the more important one will receives a higher priority over the less important one. My point is that when people say they have a problem in noise, it might be because they are inadvertently paying more attention to the noise, because it is as annoying as their tinnitus.

I do not have the hard data to prove it, but when people become less aware of their tinnitus, it seems that they start paying less attention to the noise and paying more attention to the "primary" message.

This is actually hard to prove, because most of the time this perceived improvement in noise occurs after they have worn the hearing aid for a little bit;therefore, there is a possibility that there is an essential suppression of the secondary message any way due to the acclimatization process. This process may just become a natural one, not because of the fact that the tinnitus diminished, but because the changes in the Central Nervous System, the Limbic System, are responsible for suppression of the "secondary" message and therefore, more attention is paid to the "primary" message.

That said, I think the reduction in tinnitus plays some role in the fact people do better in noise.

Dybala: On that note, is it possible that by reducing the tinnitus, you may be reducing the stress so that people can more easily focus on the speech in noise?

Bauman: You are 100% right.

Dybala: Can you describe how the tinnitus program actually works?

Bauman: It is a program for amplifying environmental sounds;this is not a noise generator that is used with my other tinnitus devices specifically for tinnitus treatment. Instead, the hearing aid is designed to immerse the wearer in ambient environmental sound more than normal amplification would. There are actually some other prerequisites in terms of how to handle louder sounds, including changes in compression ratios, the kneepoint, and the MPO to make sure that louder sounds are not really disturbing to the tinnitus patient.

There are also a few other changes in the algorithm that are done in order to best utilize the ambient environment, in such a way to optimally help with tinnitus;however, for proprietary reasons, I cannot go into detail.

Dybala: What advice can you give audiologists when working with tinnitus and the Vivatone tinnitus program?

Bauman: Well, I think that the program itself is really relatively simple. The most important issue here would be for the audiologist to be able to correctly identify the right candidate for the tinnitus program, and if they are identified as individuals with severe tinnitus, an appropriate referral to a tinnitus center should be made.

I would also advise professionals not to tell their patients that nothing can be done for their problem;negative counseling actually contributes to making the tinnitus worse. Instead, we need to encourage the person to seek out help somewhere else. We really need to be positive about the available help and reassure about available help rather than telling the patient, "Well, I don't know what to do with this. So, you might just have to live with it."

Dybala: Natan, thank you so much for taking the time to speak with us today. I look forward to speaking with you in the future about similar topics. I encourage all of our readers to go to www.vivatone.com or the Vivatone web channel on AudiologyOnline at www.audiologyonline.com/channels/vivatone.asp for more information on Vivatone.

Bauman: Thank you very much for giving me an opportunity to share this with you, Paul. I really enjoyed it.

More About Vivatone

Based in the small town of Shelton, Connecticut, Vivatone introduced itself to the world in 2004 with the first Totally-Open-Canal (TOC) Receiver-in-the-Ear hearing aid. Over the last four years, Vivatone has continued to develop innovative designs and technology by adding a power receiver (VivaPower), wireless compatibility (Viva-Link), and now a program option for tinnitus relief. Through the contributions and insight of Dr. Bauman and the Vivatone team, Vivatone considers the patients' needs and strives to find a solution for their hearing problems.