Textbook of Tinnitus: Interview with Aage R. Moller, PhD

http://www.audiology.org/news/Pages/20110210.aspx
Here is an interview with a co-author of this "Textbook of Tinnitus"

Douglas L. Beck, AuD, speaks with Dr. Moller about his newly co-authored book, Textbook of Tinnitus.

Academy:
Good morning, Aage. It’s a pleasure to speak with you again.

Moller:
Hi, Doug. The pleasure is mine.

Academy: By way of disclosure, I’d like to mention we’ve been friends for more than 20 years, and the vast majority of everything I know and ever learned about intraoperative monitoring came from observing you in the operating rooms back in Pittsburgh in the mid-1980s. I very likely stole your monitoring techniques and rationale, views, powerpoints, and probably some scrubs from the OR, too!

Moller:
That’s fine, Doug. You were an attentive student—keep the scrubs!

Academy:
Thanks. Okay, well now that we’ve got that out of the way, I recently had the honor of reading your new book, Textbook of Tinnitus. It is absolutely extraordinary.

Moller:
Thanks, Doug.

Academy:
And although I’ve read quite a few books on tinnitus over the last few decades, I must say that this is the most comprehensive and clearly the most recent authoritative text on the subject. However, before we get into the book, I would like to give the readers a brief overview as to your background, as you’ve been a pioneer and a breath of fresh air with respect to audiology and auditory physiology for more than a few years. And I believe you started your career in Stockholm?

Moller:
Yes, I did start in Stockholm at the Karolinska Institute in the department of physiology where I did many projects—but the work I did on the cochlear nucleus was particularly interesting for me, and that much later became the foundation of a special edition of the journal Hearing Research.

Academy:
Right, and you became the editor of Hearing Research for quite a while?

Moller:
Yes, I actually started the journal and I was the editor for 27 years and resigned it just a few years ago.

Academy:
And when did you move to the United States?

Moller:
Well, my wife and I were invited to move here 33 years ago. She’s an otolaryngologist. Together, we joined the department of otolaryngology at the University of Pittsburgh, School of Medicine, and we stayed there until 1983. At that time, I became a professor of neurological surgery at the University of Pittsburgh and remained there for some 15 years.

Finally, we moved to The University of Texas at Dallas where I became a professor of cognition and neuroscience some 13 years ago. So then, while we were in Pittsburgh, I continued my work on the auditory system, working in great detail on frequency selectivity of the cochlea over a large intensity range using recordings from single auditory nerve fibers and mathematical analysis of the recorded impulse pattern made it possible to examine the function of the cochlea in the range between soft and loud—near normal listening levels.

Academy:
And while you were at Pittsburgh, you published some extraordinary and seminal work with regard to intraoperative monitoring, which is actually how we met. I was at the House Ear Institute trying to figure out the best intraoperative protocols and techniques, and trying to learn and understand skull base anatomy—and I had the good fortune to be sent to observe you in the operating room. I think you monitored about 25 skull base cases over the two weeks I was visiting. I learned so much I thought my head was going to explode.

Moller:
Yes, well that was an exciting time and place. As you may recall, the ABR work done prior to those days was based on animal studies, and so applying animal data to humans was a problem—so we wanted to see if the animal data made sense in terms of what we saw and measured in the operating room, with respect to the neural generators of the ABR. And there was very little information about how to apply this knowledge to the operating room.

Academy:
Yes, that was an exciting time. Everybody involved in intraoperative monitoring—and pretty much everyone involved in skull base surgery, acoustic neuromas, microvascular decompression, and vestibular nerve sections—eventually cycled through your operating rooms. It was the Grand Central Station of neurophysiology. I still have my copy of the paper from some 25 years ago in which you and Dr. Jannetta explored the likely human generator sites of the ABR based on your work in human auditory physiology and your recordings in the operating room. That publication was an instant “classic” as you made physiologic recordings from humans, directly from their auditory nerves during surgery—and that made all the difference.
Of course, another huge contribution of yours was the development and refinement of the techniques used to monitor the facial nerve intraoperatively, specifically during acoustic neuroma surgery, and the very significant impact these techniques have had on thousands of people across the globe. Of course, we can probably talk about intraoperative monitoring and your enormous contributions to the knowledge base…but let’s switch gears and spend a few moments on tinnitus and the new book.

Moller:
Certainly.

Academy:
I love the simple note in the foreword, which says something like,

Strategy is about making decisions that impact the future—theworst thing you can do is not have an opinion and not make decisions. Success depends on our ability to learn and create value from what we learn….​

Nonetheless, the book is some 800 pages arranged in 95 chapters, of which you wrote 15 chapters. The book is divided into five unique sections: tinnitus basics, tinnitus etiologies, the tinnitus differential diagnosis, clinical characteristics of tinnitus, and management of tinnitus.

Moller:
Yes, we had some of the most talented co-authors, editors, and contributors to this book. I was honored to work with so many wonderful people who agreed to work so hard to produce this text, many of whom came from the Tinnitus Research Initiative (TRI).

Academy:
Did anything surprise you while going through the process of creating the Textbook of Tinnitus?

Moller:
Well, as you’ve indicated, the depth of the book is significant. However, the writing and editing process didn’t surprise me very much, but it reminded me of many things. First, tinnitus is not one thing, it’s many things. And when people say they want to cure tinnitus, it’s very much like saying you want to cure cancer or cure pain…the problem is cancer, pain, and tinnitus are not a single thing. They each have many forms, shapes, sizes, manifestations, and perceptions—and it may very well be different in each person who perceives it—so curing it with the same treatment is indeed a noble cause and a honorable goal, but remains unlikely.

The thing we can do quite successfully most of the time is manage it. For example, there are two components to tinnitus, the sound you hear, and the way it affects you. Two people can hear the same tinnitus sound; one may dismiss it quite readily, whereas the other person may be so severely negatively affected by the tinnitus that he/she cannot function. And quite often, tinnitus has absolutely nothing to do with the ear! We could easily get into a lengthy discussion about neural-plasticity, cognition, and perception, as well as our ability to impact these neural processes—all of which are very real.

Academy:
Well, I would love to do that, but I know we’re already out of time…just a few more comments if you don’t mind? I believe you’re writing a book at this time on pain?

Moller:
Yes, that will be my next book. Pain shares many attributes with tinnitus and I think you’ll find that quite interesting with regard to tinnitus and phantom limb sensations, in that, both sensory sensations occur in the absence of stimulation and these sensations can quite often be managed effectively over time through activation of neural plasticity.

Academy:
Yes, we’ll have to do this again after the pain book is published. One other note about patients with intractable pain or tinnitus, or dizziness, vertigo, headache, migraine or lower back pain, is they don’t appear sick to the rest of the world. These are all potentially debilitating conditions, but they’re all perceived subjectively and measuring them and treating them remains very challenging.

Moller:
Yes, I agree entirely. However, the important take-home point is the patient with tinnitus has an excellent chance of being effectively managed through professional channels.

Academy:
And, of course, the key is diagnosis first, treatment second.

Moller:
Yes, that’s the only way to proceed. Each patient needs to be thoroughly evaluated by the appropriate professionals such as the otolaryngologist, audiologist, neurologist, etc., and the dangerous issues and dangerous differential diagnosis must be ruled out before treatment starts, as some rare forms of tinnitus can be dangerous and only the professionals can evaluate the signs and symptoms and rule them out.

Academy:
And, finally, I really appreciate that the book has a whole section dedicated to the views of tinnitus from many professions. For example, chapter 23 is essentially about tinnitus as seen from the otolaryngologist, and the next chapter is from an audiologist, the next chapter is how the psychologist views tinnitus, then the neurologist, then the psychiatrist, then the neurosurgeon, the dentist, the pharmacologist, the neuroscientist and of course, tinnitus as viewed from the patient’s perspective.

And, the book also offers a chapter on each of the following with regard to tinnitus management: pharmacology, counseling, psycho-education, cognitive behavioral treatment, auditory training, retraining therapy, sound stimulation, neuromonics, middle ear and cochlear implants, neuromodulation, neurobiofeedback, transcranial magnetic stimulation, direct current stimulation, cutaneous stimulation, LASER therapy and more. Absolutely fascinating.

Thanks so much, Aage. It’s always delightful to spend time with you. Congratulations on the publication of Textbook of Tinnitus. This is an extraordinary book, and I give it my highest recommendation.

Moller:
Thanks very much, Doug. Always a joy speaking with you, too.