UCSF Tinnitus Center – Troy Cascia, AuD – #03

Troy Cascia, Au.D.
Probably the biggest thing is the understanding that tinnitus is manageable. I mean, the reason why they’re seeking help is because they’ve tried everything they feel they have no hope. They’re worried they’re anxious about their future. How can I live like this? Right? I get to tell patients You know what, you don’t have to live like this. It’s not going to be like this forever. You know, we don’t have a way to make that sound go away yet, but you were born with an ability your brain was born with an ability to handle this. We just have to teach it how.

Ben Thompson, AuD
Hey everyone, this is Dr. Ben Thompson here with pure tinnitus. Have you ever wondered what it would be like to see one of the leading tinnitus specialists in a major hospital in California? That’s a question that I’m sure you’ve maybe thought about before because you’re looking for some help with your tinnitus. And some professionals are just more qualified than others. So I’m grateful and humbled to bring on a guest here from San Francisco area in California. And this is a direct mentor of mine, someone that I’ve developed a close relationship with, says Dr. Troy kashia, who is a Doctor of Audiology in California. And I want to introduce Troy who is going to be on here for this podcast episode number three, for the pure tinnitus podcast series. Troy is a lead senior audiologist at the University of California, San Francisco Medical Center, UCSF, which is one of consistently one of the top 10 hospitals in the country in the United States. Troy has worked at UCSF since 2002. And he currently performs diagnostic auditory evaluations, hearing tests, auditory rehabilitation, hearing aid and assistive device selection and fitting and comprehensive tinnitus and hyperacusis counseling. I’ve been with Troy working as a student and now working as a professional knowing Troy, where patients come from far and wide to work with him to get tinnitus support to work on their hyperacusis as well. Troy has also been previous adjunct instructor, faculty teacher, a professor at the University of Pacific Doctor of Audiology program, teaching courses on the diagnosis and management of tinnitus, hyperacusis and other sound tolerance disorders. I was a student of choice in some of these courses, and I learned a lot I can say with certainty that pure tinnitus would not be what it is without Troy and his dedication to teaching younger audiologists like myself about what he’s learned, and what the research shows for tinnitus. Finally, Troy has previously been a president of the California Academy of Audiology. And with all this beautiful, big introduction, I welcome Troy. And I would like to ask Troy how you’re doing. And if you could please explain to us what’s going on at UCSF in recent times during Coronavirus.

Dr. Thompson interviews Troy Cascia of UCSF Medical Center

Troy Cascia, Au.D.
Yeah. Well, thank you for inviting me. I’m really excited to be here. Yeah, so we’re, you know, we’re hanging in there. When the whole pandemic started back in March. It was difficult. We basically had shut down the clinic for all but emergency cases, you know, sudden losses or if they’re not seen immediately, they could have permanent, permanent hearing loss. And we’re doing some work from home via telehealth, and so, there’s not a lot that we can do remotely at this time with audiology, but that’s expanding. Many hearing aids have remote programming capability. So we were able to do some programming, but also tinnitus counseling, we can do that remotely. So that was one thing that really thrived during the pandemic when we were when our physical office was closed. And we were working from home we were able to continue doing tinnitus counseling fortunately, probably back in June, we we opened back up we’re just about at full capacity now. So we’re, we’re still doing remote probe remote appointments for people who can do that. We want to limit traffic but we are open for in person visits.

Ben Thompson, AuD
Good. Thank you. Yeah. For anyone who knows my personal journey I studied at UCSF in the audiology residency program and Troy was one of my mentors, one of the leading audiologist there at the time. I definitely learned a lot from him. And the greater UCSF institution is one that give the Services provides medical care based on evidence, right, any good hospital is doing their kid is doing their care and directing appointments. based on the current research, the evidence based literature and Troy for you, how does that affect the way that you counsel treat tinnitus, and the way that you’re you have to keep learning because new research comes along.

Troy Cascia, Au.D.
Yeah, absolutely. You know, I’ve been doing this for quite an A number of years. And, you know, I will say that when I was asked to teach the courses that you attended, it really required me to pour through the literature and, you know, look at the more recent scientific evidence and research about tinnitus. And so, but it’s constantly changing. And that’s fortunate, because as you know, as most of your viewers know, you know, right now, we don’t have a one size fits all, you know, let’s put this in your ear and your tinnitus will go away. We don’t have anything like that yet. And we’re working towards that. So definitely great that there’s a lot of research going on in tinnitus. But, yeah, it’s definitely an ongoing thing. And we have a number of tinnitus providers now in our clinic, and we meet semi regularly to discuss different aspects of tinnitus research and different treatment protocols and different materials and things like that. So yeah, it’s definitely an ongoing process, continuous learning.

Ben Thompson, AuD
Now, tell me for our listeners who are wondering, what what would I get from going to an evidence base, large Medical Center, what would I get from this kind of tinnitus specialist who’s well trained? What would I get if I went to them instead of just going to my normal primary care doctor, going to the average audiologist or going to an ear, nose throat doctor?

Troy Cascia, Au.D.
Okay, well, let’s see. Well, let’s start with what would happen if he went to these other folks. If I will say that a lot of people, a lot of providers, primary care, and audiologists even don’t specialize in tinnitus, some EMTs do specialize in tinnitus as well. But let me see how I can put this primary care physician, they’re not going to have a lot of, I think, information that will be that will be helpful for someone who’s significantly bothered by their tinnitus, they may be able to provide some management tips for people who just kind of mentioned it. And they probably be trained as well to, if there were some concern about a health condition that might be causing their tenants to make appropriate referrals. But they wouldn’t be doing I don’t think intensive therapies for tinnitus, EMTs, they’re going to look at it, they’re an important EMT is an important ear, nose and throat position is an important part of the team. Because anytime someone presents with tinnitus, we want to make sure a that it’s not being caused by something of pathology that needs medical attention, right, we want to address that, if that’s the case, we also there are rare cases of tinnitus that are treated that are caused by something that can be treated. So if it is that something like an ear infection, right, oh, I develop this ear infection. Now I hear a noise, when they hear when the ear infection is treated, everything goes back to baseline. So we want to make sure that any of those situations that the medical attention is received, and that’s what most EMTs are going to be focusing on is the treatment aspect of it.

Ben Thompson, AuD
And that’s quite important, because once we have that foundation, then we can have more confidence in the next steps where you come in right.

Troy Cascia, Au.D.
Definitely, definitely, you know, I will also say that part of the the thing about tinnitus that makes it so for word for it pernicious, I guess, you know, just that makes it so difficult to manage is the psychological component. And if you have fears surrounding the tinnitus and fears, what is causing this, what’s going to happen, having those fears allayed are resolved by seeing an ear nose and throat specialist that’s a huge step in your brain, basically allowing the tinnitus to be there not fighting it and learning to live with it and coexist with it. As long as your brain is trying to protect you and freaking out over this, it’s going to make it harder to adapt. So so they’re definitely an important part of the team. Other audiologists you know, not all audiologists specialize in tinnitus. Not all audiologist have a lot of background. I’d say probably any audiologist is going to be able to like a primary care physician give you some tips, right? This is these are some things that you can do to minimize your awareness of tinnitus. But for people where the tinnitus is really bothersome, it takes takes a bit more than that, right? It’s like if I could have done it already, I would have right I need the next step. And so yeah, so audiologists who specialize in tinnitus can kind of take you to that next level talk about the psychological reasons and causes for why this tinnitus for some people is so tenacious and hard to hard to ignore You know, the situation, your situation, I guess was in where you were, you actually got two courses in tinnitus that were full semester courses. Most people most audiologists don’t get that, I’ll just say, right, it’s a, they get a little bit of an introduction to it, but most don’t get that deep of an understanding of tinnitus. So the people who specialize in it, they really need to make a conscious effort to learn more and to want to focus in this area. And so you know, and I guess I can say also that not all audiologists specialize in that it’s a people have a lot of different reasons, I guess, for going into audiology. And I think, for for some people, tinnitus patients, it’s a little challenging for audiologist to work with, especially if you don’t have the background. Because you’re dealing with not only hearing, you’re dealing with emotion, and you’re dealing with psychology, and that’s outside the scope of what most of us are trained for. And, you know, definitely deeper level of psychology, we want to involve a licensed psychologist. But a trained audiologist can kind of give you the building blocks and explain how this works and can make referrals to those psychologists if needed. But that’s what we provide at UCSF and other you know, tinnitus centers around the country, really creating a customized treatment plan for a patient when the tips that are provided by your PCP or by your regular audiologist aren’t enough, right. The specialists audiologist who specialized in tinnitus have, you know, we want to make sure that all of your needs are being met that you’ve had your medical needs met, right? Have we gotten this checked out by an EMT? And we’re also trained to understand Oh, you’ve got this sound quality to your tinnitus? Hmm. Have you thought about getting this test done? Because it could be related to that? Or, Oh, you’ve only got it on one side, maybe we should get this test done, because the unilateral tinnitus could be, you know, related to this condition. So you know, that’s one aspect getting the medical needs assessed, getting your psychological needs assessed, right? Is this something that you can do on your own? Do you need additional help with this? Can we refer you to a psychologist? Do you need medication for an anxiety disorder that’s going to make your tinnitus more difficult to manage?

Ben Thompson, AuD
Hey, Troy, do you think there’s a stigma with seeking help for a therapist or a psychologist?

Troy Cascia, Au.D.
You know, I, I do think so. I think that’s pretty. I think that’s pretty common. But you know, I will honestly tell you, through my own experience, it has, I haven’t had as much pushback from my patients, as I think I expected to get going into it. And again, going into it, I didn’t have a lot of experience at the beginning. I’ll be honest, I was kind of brought in, because nobody else in our team wanted to do it. And we needed somebody we needed to expand our team. You know, I was trained by one of the great tinnitus gurus, Robert suito. I know anybody has googled tinnitus research. He’s involved with a lot of tinnitus research. And he was the director of UCSF audiology for many years. And so he, he trained me. And, you know, I think as I was saying, a lot of audiologists are kind of afraid to get into that psychological part of it. And but once I’ve found that, what a profound effect it had on patients and how I should say how little resistance there was to, you know, I’ll do anything, you know, if this is what’s going to help me Yes, I’ll do it. And so I’ve, in my own experience, I’ve found that patients are not as there’s not as much stigma as I think I expected there to be. Yeah, it’s important.

Ben Thompson, AuD
It’s important to know, it’s important to know when it’s okay to ask for help.

Troy Cascia, Au.D.
Yeah, definitely.

Ben Thompson, AuD
And it’s a real thing. Go ahead.

Troy Cascia, Au.D.
Yeah. Oh, I’m sorry. Well, you know, I think people think of tinnitus being a hearing disorder, and it’s not really so much I mean, it affects your hearing system. But the people who are bothered by their tinnitus, it’s so much more than the sound right? Millions of people have tinnitus, and most of them are not bothered by it, right? Because their, their emotional system, their limbic system has classified it as not important. They don’t have to pay attention for the people who are bothered by it. Wow, their limbic system is lit up and won’t let them. It’s, you know, their limbic system is trying to protect them from this thing that it has. Has encoded as a inherently negative thing, even though it’s not physically harming me, right. But my brain has classified it as a negative thing. It’s trying to protect me It won’t let me forget that it’s there. Right. So the psychological component is such a huge part of it. And in my opinion, the most important part, it’s really, yeah. So, you know, psychology plays a huge part. And I think that people are willing to do what it takes to get to that next level.

Ben Thompson, AuD
Thank you for that. And I want to talk a little bit about you, because many patients who probably see you they don’t get to hear your own personal journey, you touched on it a little bit. So I’m curious to know, how you became a tinnitus specialist. And like you said, you have to have a certain desire to step into this role. So what was it for you about helping people with tinnitus that made you stay with it for numerous years?

Troy Cascia, Au.D.
Yeah, well, that is a good question. So um, you know, I think, in my distant past, before I became an audiologist, I actually so I always had sort of an aptitude for languages. And I, my first degree actually was in linguistics, I was always really fascinated with it. And but I also like working with kids and light teaching. And so I ended up being a teacher, kindergarten and first grade teacher in Oakland for a few years. And it was very challenging. I loved that the teaching aspect of it, but you know, 2730 kids at a time, that was a challenge. So I did that for a few years. And I reassessed, I said, Well, what can I do where I can work with language, and I can work with kids, but maybe one at a time, instead of 30 at a time. And so I decided to go back to school for speech pathology. And it’s a pretty common route for for audiologists, unless you have a family member with hearing loss or have hearing loss yourself or, you know, or a family member who is an audiologist. Most kids have never heard of Audiology, that’s not a career goal for most for most kids. They haven’t heard of it. So a lot of the current audiologists you know, what they started off as speech pathology majors and learned about audiology in that program, Speech and Hearing are, you know, they’re related. And so, in those programs, there’s a, excuse me a component on audiology. So that was kind of how I got involved in audiology itself. Um, but you know, as I said, I do have that background in teaching. And that’s one of the things that I really love about my job, about being an audiologist and not just for tinnitus, but for hearing as well. Hearing disorders. Hearing aids is the education component of it teaching people, this is what’s going on, this is what your hearing system is doing. This is why you’re having the problems you’re having. This is what’s available that can help and this is why it can help and kind of explaining to people you know how they can help themselves. And that is, that’s, I think, really what makes me love tinnitus counseling so much, because I feel like I’m giving information that’s really making a difference in someone’s life. Yeah, so I guess that’s, that’s it. Like I said, I did. I was, like I said, I was nervous about it at first, like many audiologists are, but once I dove in and started learning, I was learning as I was going and realizing, Okay, you know what, I actually know quite a bit. I was afraid maybe I’m missing something. Maybe there’s things that I’m not, you know, giving them but the more patients I saw, the more questions I answered. And they were very often the same questions over and over, you know, these are the things that people are concerned about. I found Okay, you know, what I know, I know more than than I thought I did. And, and then again, teaching that course, I learned more than I ever thought there was to learn about it.

Ben Thompson, AuD
Thank you for sharing your personal journey there. You shared how you have this connection with education and educating people and in healthcare, it’s really important. There’s this term healthcare literacy of how much does someone know about different health conditions? Because that affects the way they seek medical care, it affects how they live with their conditions. And what have you learned for your tinnitus patients? What are the one or two aha moments or the education points or the take home messages that seem to come up over and over again, for people?

Troy Cascia, Au.D.
Um, well, I mean, one thing I’d like to say first, just about health care literacy is that, you know, it’s also it’s important to be really in tune with your patient because everybody’s coming from a different place. You know, I can talk in, you know, very complicated terms. You know, I’ve got someone who has a medical background is my patient and I can talk in medical terms with them. And then I’ve been As someone who has not had that kind of experience with, with that kind of vocabulary, right, so I need to change how I relay this information, meet the person where they are so that they can absorb the information I’m trying to provide. So being flexible there, I think is important. Some aha things, I think, probably the biggest thing is the understanding that tinnitus is manageable, you know, that people come. I mean, the reason why they’re seeking help is because they’ve tried everything they feel they have no hope. They’re worried they’re anxious about their future, how can I live like this, right? And I get to tell patients, you know what, you don’t have to live like this, it’s not going to be like this forever. You know, we don’t have a way to make that sound go away yet. But you were born with an ability your brain was born with an ability to handle this. We just have to teach it how. And this problem that you’re having this disruption in your quality of life is not going to be a lifelong long problem, even though we can’t make the tinnitus go away at this time. You’re not going to be as as affected by it forever. So instilling that sense of hope that things are going to get better, I think is the biggest thing. Gosh, what else? tinnitus is very complex. Everybody has a unique experience with tinnitus, even though we have just kind of general ideas about, you know, how we have a model of how tinnitus works and how we think tinnitus works. It works for many people, but it doesn’t apply to every single person. And so that’s also why we need to tailor the treatment and the discussion to each specific person because two people with the same will note no two people are going to have the same exact sound. It’s very subjective. No two people are going to have the same reaction or response to it. Some people I can’t do my work other people, I can’t get to sleep. Other people, I can’t do anything, right. I’m really just paralyzed with it. So tailoring it to what their needs are. And just understanding that it’s a very complex, complex symptom or a complex situation.

Ben Thompson, AuD
Yeah. That complexity part of it is the psychological nature. And how many people who would have ever thought that the sound you think is coming from your ear is affected by your stress levels? Or your emotions? No one? It’s not an intuitive connection. Right?

Troy Cascia, Au.D.
Exactly. Our body is connected, you know, all our different systems are connected. Our brain, all different parts of our brain are interacting with each other with tinnitus. And the, you know, as we said, mentioned earlier, it’s not just an auditory phenomenon, a hearing phenomenon, it’s very much psychological. And again, the stress for most people causes their tinnitus to increase. So those physiological changes in the body that happen when we’re stressed, make the tinnitus more prominent, and that change in tinnitus activates more stress, and more anxiety. So it feeds on itself. And it creates physiological changes in the brain, right? neurological changes, new connections are made in the brain that make it harder to habituate to it. So. Yeah, but again, a very, very unique experience for each person. And so finding out exactly what each person needs, where they are and what they need to, to get to improve. That’s part of the plan.

Ben Thompson, AuD
And you see multiple how many tinnitus patients on average, would you see in the average month or the average week?

Troy Cascia, Au.D.
Oh, gosh, um, it can, it can vary. You know, I do also other things, right. So I do have hearing aid patients and actually a lot of my tinnitus patients become hearing aid patients because hearing aids are very effective treatment for many cases of tinnitus. But I have you know, tinnitus patients as well and I see hearing tests and do all sorts of different things. So I don’t do tinnitus exclusively. And, you know, again, it’s, it’s quite exhausting. To be that provider. I can’t do multiple tinnitus patient encounters in a day because it’s draining. I’m in the moment with that patient really just trying to connect for 90 minutes. And it’s, you know, it’s a little draining so I need to kind of space it out, but I’d say probably between five and 10 a month. I train students as well. We have three residents in our program who learn tinnitus as well. So, you know, we, that’s kind of changing this year, when when you were with UCSF, we had a very intensive training program for our residents right now it’s a little bit more, you know, not as not quite as structured, but but they’re still participating. So no seeing more patients per week and per month to help train the students as well.

Ben Thompson, AuD
And how many years have you been seeing tinnitus patients at UCSF?

Troy Cascia, Au.D.
I would probably estimate about 15 years. Yeah. And then Robert suito, again, was the director. For many years, he retired and I think in 2010, so I stepped up as the head of the tinnitus program in 2010. So I’ve been doing that for 10 years now training other audiologists, so that they can be providers and training our residents, and then teaching classes as well.

Ben Thompson, AuD
So I don’t know if you’ve ever thought about it like this before. But from what you shared, it seems like you’ve personally been involved with the tinnitus care of hundreds if not over 1000 patients.

Troy Cascia, Au.D.
Yeah, definitely hundreds, definitely hundreds. You know, I do keep a database of the patients who, at least who submit their intake packets. And yeah, there’s easily hundreds.

Ben Thompson, AuD
So this is the what you’re sharing is really the wisdom of of years and years of interfacing, talking and communicating, helping different people with all these different types of tinnitus, different ways it affects their life. Now, I want to use that expertise you have right now to share with our audience, our listeners. Now, a lot of our listeners, I know because I speak with them. A lot of our listeners either have a hearing test result that comes back normal hearing, or they have very slight high pitch, high frequency hearing loss. And I would like to open that up to you of how do you counsel that patient about the most effective treatment, specifically in terms of sound therapy or hearing devices?

Troy Cascia, Au.D.
Okay, so let’s see, I would say first of all, one, so one of the things that I try to let my patients know, without being too, you know, to flip about it is that it doesn’t matter what’s causing your tinnitus, it doesn’t matter how it happened, it doesn’t matter what it sounds like, it doesn’t matter how loud it is, all of the techniques that we use, will work regardless of that. So the trigger or the cause of the tinnitus is not as important, I think. Any sound that your brain perceives to be a negative stimulus it’s going to fixate on. So I think the psychological component, as I mentioned before, is the most important part. So that’s something that I really focus on. Now. We at UCSF do a program called tinnitus retraining therapy or TRT. And TRT basically is sort of an umbrella term for this program, which involves two main components the psychological component, and a sound therapy component. So psychological as I said, is the most important without teaching your brain that it’s okay for the tinnitus to be there, it will resist habituation, we want to get to the point where your brain perpetuates and doesn’t pay attention anymore. So while we’re working on that psychological component, though, we can Institute some sound therapy. Most people find that when they are in a quiet place, they noticed their tinnitus more, right, our brain is wired to pay attention to sound. our ears are for most of us open. And we’re born with open ears we have our brain is able to perceive sound in utero. So our hearing system is actually functioning before we’re born. And our brain has developed throughout our life with sound stimulation, that infrastructure, all the connections and the neurons in the brain have happened over our lifetime with sound stimulation. When that part of the brain is not receiving that stimulation or is not receiving a normal response. those neurons can tend to start firing on their own they produce their own sound because they’re no longer being stimulated from the outside. And I guess to take a quick step back, I point that out because even though somebody may have a normal technically normal audiogram Well, what’s a normal audiogram Well, it means that it’s the same responses that we would get from most, you know, adults with healthy hearing systems. There’s a range, you know of what’s normal, it could be anywhere between, you know, was lowest for adults 25 decibels up to zero decibels DB or even softer. You know, zero doesn’t mean no sound, it just means it’s the starting point. So we can actually hear softer than zero dB. You know, it’s possible that you used to have hearing at zero dB, and now your hearings at 20 db. And compared to other people, that’s normal, but it’s not normal for you. So your brain, which grew up with zero DB threshold is now not receiving those thresholds, something changed in your auditory system, and your brain notice that even though you may not notice it, and your brain is maybe reacting to that. So, you know, it’s just something that I try not to focus too much on why it’s happening, that you know, maybe a medical issue, and let’s have you check with the EMT, see if there’s anything, you know, going on there, but I’m more focused on how so you hear this sound, how do we get you to the point where you’re not noticing anymore. And with a sound therapy through TRT, the sound therapy part that basically involves providing a sound rich environment, so that the brain is receiving that information that it’s craving, it’s receiving the stimulation. And basically, so it has a job to do, you know, when the brain is sitting there idle, and it doesn’t have, you know, in the auditory part of the brain doesn’t have any stimulation, it will find whatever it can, oh, I hear a sound, I hear a ringing, I’ll focus on that. And without any contrast, without anything to compare it to your brain thinks that sound is super, super loud. So you know, and that starts the stress cycle. And it just kind of spirals out of control. With background sound and the environment, your brain realizes, oh, it’s not as loud as I thought it was, it’s really this loud, and I can still hear it. Right? The tenant to the background noise is not covering it up. But it’s not as loud as I thought it was. And I can handle this, right. So that’s the sound therapy part. And that I think is appropriate for people with minimal hearing loss or no hearing loss, even how we deliver that sound can vary from person to person.

Troy Cascia, Au.D.
And so for someone who does have significant hearing loss, definitely hearing aids, you know, hearing aids are going to provide access to the sounds that are already around you, right, someone who’s got a moderate hearing loss across the board, they can’t hear normal conversational speech, they’re living in silence, basically all the time. And so putting on hearing aids, and now they have access to the sounds that are around them, oh, I don’t even notice my tinnitus anymore. Because I’ve got all this other sound around me. People who have normal hearing, or near normal, maybe very slight high frequency hearing loss, they don’t get that same kind of wow effect when they put hearing aids on because they can still hear things around them. However, you know, I think hearing aids can still help in a couple of ways. One way is that, you know, for people, especially people who have mild, high frequency hearing loss, right, they may not even perceive that they have a hearing loss there. But they found out when they had the hearing test, oh yeah, there’s a little dip there. That can affect how well or how much effort we have to put forth in following conversation, you know, very important speech frequencies are in those high, high frequency, high frequency range. And it’s the basically the crisp consonants that makes speech very sharp and intelligible. Without that you can hear people talking, you hear all the vibration law, but you’re not hearing much at the hissing and popping sounds that makes speech sound crisp. So you’re kind of having your brain is having to work extra hard to fill in those gaps. Well, that extra work is exhausting over the period of a day or you know your life. And so, by making listening less effortful, using hearing aids, even with a mild hearing loss helps you to to preserve that those cognitive resources and the you know, help you to preserve your energy so that you can manage your tinnitus better.

Ben Thompson, AuD
Thank you. Thank you for sharing that joy. And to expand on that a little bit. How does this relate to habituation and the golden question which many people want to know at this stage? How long should I be focusing on using a sandwich environment or putting on a device? If I’m just focused on getting to that habituation point in my tinnitus? What does the research show and what is your personal experience as a tinnitus provider show for how long people need to be in that process?

Troy Cascia, Au.D.
Yeah, um, so I think it In the program that we do, it’s a little bit more relaxed. We don’t necessarily have people following up with us like you need to come in, you know, every six months, we invite them, they’re able to come in if they need further counseling or need further suggestions for management strategies. But most patients, you know, they come in for their initial counseling session, we give them the information and help tailor a treatment plan for them, and invite them to come back if they need it. The research suggests that sound therapy can take, you know, 12 to 24 months to get to the point where you rarely think about the tinnitus if ever. What I like to remind people of is that well, first of all, for many people, they notice an immediate improvement after the initial session, right? Because they come in with all these questions and all these fears and all these worries. And now I have information I know what to expect, I know that there are things that I can do, I’m not at the mercy of the tinnitus, there are things that I can do today, with, with materials I have at home, to improve my situation. So that psychological relief, Oh, okay. My stress levels just went from here to here, right. And then my tinnitus went from here to here. So a lot of people find immediate relief. But no, it’s kind of like breaking any bad habit. I used to be a smoker. And I asked my patient, nobody out here in California smokes. So I asked my patients if they were ever smokers, no, no, I never smoked. Okay. Well, I was. And at first, it is hard, you know, the the physical addiction, the chemical addiction that I think goes away pretty quickly. It’s a psychological addiction. You know, I, I spent years and years and years where every time I would eat a meal, I would smoke a cigarette. So just the feeling of being satiated, triggers that that desire, or walking outdoors, I’d light up a cigarette. So fresh air in my face is a trigger, I need a cigarette. When I decided to finally quit, I had to consciously choose not to react that way, right not to respond not to link that, that sensation or that, you know, the word, you know, anyway, so I what I wanted to do with a, an action, I chose a different action, right, I chose to distract myself. And I needed to do that maybe every three minutes right or five minutes. At first, it was very strong, not you know, the neurons in my brain had built a pathway so that every time I experienced one of these stimuli, one of these situations, I automatically reacted with a craving for cigarettes. So it took time for me to consciously change my behaviors. And through time those connections broke down because I wasn’t using that pathway anymore. I created new pathways. And that’s what takes time.

Ben Thompson, AuD
Do you believe in neuroplasticity? Or what is neuroplasticity? That’s what you’re describing right? There is neuroplasticity?

Troy Cascia, Au.D.
Exactly. Yeah, exactly. The neurons, you know, we didn’t think that the you know, in the past, we didn’t think that the brain in adults could change or grow. In children, it grows exponentially fast. But for adults, we didn’t think it was possible. But research does show that the brain rewires itself. And that’s a good thing usually, right we want you know, if there’s an injury to the brain, a stroke or something like that, we want those the remaining neurons to be able to work around that injury and regain some of that function. So that’s why our brain is able to do that. And we can use that ability that that neuroplasticity to our advantage, right? The those negative connections that were made, we call that maladaptive plasticity. And so we want to change that and guide that plasticity. But it’s not something you know, we can’t just slap something on our ear and make it make it go, right. It’s something that you consciously have to do. And be consistent. You need to be consistent, persistent, and patient with it. And it will get better. It’ll get easier, right? After a few weeks. It’s like, Oh, you know, I’m really only thinking about my tinnitus a couple times a day now before I was thinking about it all the time. And when I think about it, it’s not quite as bothersome as it was before. And when I think about it, I’m not thinking about it as long anymore. Right, I forget more quickly. And then a few months down the road. Oh, you know, I’m only thinking about it a few times a week. Yeah, sometimes it’s really bugging me, but, you know, for the most part not. So when we’re talking about 12 to 24 months, that doesn’t mean it’s going to take that long before you get any relief. No I would expect relief very quickly, but that it gradually kind of arcs toward, toward getting to the point where you’re just not, not noticing it, if ever, hardly, if ever.

Ben Thompson, AuD
Amazing, Troy, thank you for sharing this. And again, to remind our listeners, this is coming from years of experience working with hundreds of different cases. So Troy’s knowledge here is summarizing the experience of many different people with different kinds of tinnitus, different sounds, different life stressors from different backgrounds, and what he’s sharing with us, what’s the take home message that can be applied to most cases. And I want to also invite anyone who’s listening right now, to leave a comment below if you have any additional questions or follow up? And I’ll try to answer them I studied under Troy, I’m not going to have Troy being answering these questions, because he didn’t sign up for that. But I will sign up to answer any questions you guys have, whether you’re someone with tinnitus, who has a follow up question from when we talked about, or you’re an audiologist, who maybe hasn’t had such a deep introduction to tinnitus, and has some questions of how you can use this with your patients in an everyday kind of setting. Troy, we’ve had a great conversation, and I could tell we could talk for hours about this.

Ben Thompson, AuD
Typically these tinnitus consultations at UCSF they they’re over an hour appointment. So what’s your advice to someone who’s on the internet looking for the quick answer? How does how does it really play out for them? The difference between working with someone who knows the ins and outs who can answer all your questions? How does that experience compared to someone who’s on the internet? Basically, looking at other individuals experiences with their own tinnitus? Do you think they’re sometimes brought down this rabbit hole that’s not serving them? What do you think? What do you think about that?

Troy Cascia, Au.D.
Yeah, definitely. So you know, the internet is a great tool, if it’s used properly. But it can also be dangerous. I think. I’ve mentioned before that tinnitus is a unique, subjective experience. So what you’re experiencing is not what other people will be experiencing. It can be helpful as well, the fact that it’s so unique and subjective can be isolating, and that can be uncomfortable and unpleasant. But and so wanting to reach out and talk to other people who are experiencing it as well. That can be it can be something that you may want to do however, doing it on the internet like that, and chat groups and Facebook pages that can sometimes get very negative, right? So people focusing on how miserable they are and how difficult of a time they’re having. and misery loves company, right? So everybody’s really getting down. And that enhances really, the tinnitus, the the stress that is making your tinnitus worse. So there are support groups that are out there. I’d recommend people getting involved with American tinnitus Association, they can get you connected with different resources in your area. But these support groups, you want to find one that’s that is facilitated either by an audiologist or a psychologist who specializes in tinnitus, because they’re going to keep this group focused in a positive direction in a constructive direction. Right, what not like how miserable are you? But what have you done? That’s how that’s worked? What can I try? You know, what are some things that are available? Let’s have a discussion, what have you learned, and so helping each other up rather than dragging each other down, I think is very important. One other thing about looking for quick answers on the internet or elsewhere. Be careful because I think that there are a lot of people out there who prey on tinnitus sufferers. They prey on their desperation, and they prey on their ignorance. And what I mean by ignorance is not understanding what’s going on what’s causing my tinnitus, oh, here, take this pill that’s going to, you know, restore blood flow to your cochlea, that’s what’s causing it. Well, you have no evidence of that, you know, tinnitus is very complex. If it’s hearing loss related than blood flow to the cochlea is a little too late, those cells are dead, right? So blood flow now is not going to make a difference. So and there’s no government regulation of those types of things. So they can say whatever they want, they can claim whatever they want, and they don’t have to provide proof. And people say, Oh, well, you know, I have nothing to lose. And that may be the case, you know, besides $50 or $100, or whatever they’re charging, but You know, they’re really, they’re really preying on that desperation. So, you know, the there is no quick fix. And I’m sorry to say I wish there was and like I said, they’re doing research to try and get it. But we don’t have a quick fix. But we do have a, we do have a management system, and you’ve already got it in your brain. And, you know, if we explore that, you will find relief.

Ben Thompson, AuD
Yeah, absolutely. Having a system that is based in evidence and science can create confidence and like you said earlier, persistence, and consistency. If it’s based in these protocols that have worked for a majority of people, then let’s, let’s tune out the online noise. Let’s tune out the possibility of looking for a cure in the next six months. Because there can be real steps you can take this week this month this year. zactly that’s huge for people to understand.

Troy Cascia, Au.D.
Yeah. And you know, I want people to hold out hope you know, I there like I said a lot of research I think they will come up with something someday I hope but don’t believe a claim just because someone says it. We need to be informed consumers and you know, not just wishing that it’s true doesn’t make it true. So yeah,

Ben Thompson, AuD
Troy it’s been amazing to host you here. This is the pure tinnitus podcast. This is podcast number three. Take a look at some of our other previous podcasts I’m sure you’ll enjoy what’s there. It’s all relating to tinnitus and audiology, hearing loss science. And Troy I want to ask you How can someone find you if they want to work with UCSF or if they potentially want to see you in the San Francisco area?

Troy Cascia, Au.D.
Sure. Um, so Oh, gosh, you know, honestly, I don’t have I don’t have my website, the UCSF website but if you do search for UCSF tinnitus clinic, our website will come up and we do have a an online intake packet. So we do require that you fill out this information we want to know what you’re experiencing with your tinnitus where the problems are, how you know when it started, how long you’ve been dealing with it etc. and and then submit it and we will contact you about setting up a visit. We let’s see. You can also contact call our clinic at 415-353-2101.

Ben Thompson, AuD
Thank you so much for being here tonight. It’s been a true pleasure. And like I said earlier, Pure Tinnitus is an online education source for all things tinnitus. Really, I can honestly say this would not be where it is today without your guidance as a mentor to me working as the professor in the classroom and then in person in the clinic at UCSF so many things to you good sir, for all that work.

Dr. Ben Thompson, Au.D.

Dr. Ben Thompson, Au.D.

Dr. Ben Thompson is an audiologist in California and founder of Pure Tinnitus. Dr. Thompson has a comprehensive knowledge of tinnitus management. He completed his residency at University of California at San Francisco (UCSF) and is a past board member of the California Academy of Audiology. Via telehealth, Dr. Thompson provides services to patients with hearing loss and tinnitus.

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