Tinnitus is a phantom sound perception described as ringing, hissing, clicking, swishing, buzzing, static, whistling, crickets, wind, pulsing, and machine noise, among others. The sound may be perceived as coming from the ear/s or within the head. Tinnitus is not a disease, but primarily a benign subjective sound frequently caused by conditions that create hearing loss such as noise exposure, medication reactions, or aging. For most, tinnitus is not a significant issue and over time it is naturally decreased and is habituated. For some it can be bothersome, but rarely debilitating. Infrequently, doctors can hear sound coming from around the patient’s ear or neck. These conditions are examples of objective tinnitus and represent a medical condition.
Tinnitus can also be associated with benign sound hallucinations as reported by nearly 10% of the moderate to profound hearing impaired. From tinnitus and the isolation hearing loss causes, senior patients can hear familiar voices, music, or sound memories. These signals come from tinnitus being misrouted and miscommunicated to memories within the brain. They are not considered unpleasant or debilitating. These are much different than those who hear undesirable voices and negative messages because of schizophrenia.
Tinnitus is frequently (40% of patients) accompanied by problems of sound tolerance and discomfort. These conditions include; hyperacusis, a condition of extreme sound tolerance difficulty where normal sounds are unpleasantly loud; misophonia, a condition that causes patients to have a dislike for certain sounds associated with negative memories; and phonophobia, a fear of all sounds, especially those that are loud or occur without warning. Therapies for all of these conditions are available from specialists in tinnitus care.
Noise Exposure, Acoustic Trauma, Barotrauma (Scuba Diving or Airplane), Hydrotrauma (Ear Washing), Whiplash or Head and Neck Injury, Stress Induced, Substance Abuse, Smoking, High Impact Aerobics, Loose Hair in the Ear Canal.
Occurrence of Tinnitus
According to the American Tinnitus Association (http://www.ATA.org), 50 million cases of tinnitus exist in the U.S. and over 250 million worldwide. Categories of tinnitus severity can be divided into three groups:
1. Those that habituate the sound and have no significant reaction (36 million)
2. Those that have a significant problem and seek a medical consultation and Audiological care for management (15 million).
3. Those that are debilitated and have a crisis and need a team of specialists (2 million). To learn more about extreme cases of tinnitus see The Hearing Journal on “Debilitating Tinnitus“.
Although tinnitus is frequently reported by those with hearing loss approximately half of all patients report no hearing loss.
Human Reaction Patterns to Tinnitus
The response to tinnitus in humans can range from unimportant and unnoticed to debilitating and life altering. This range occurs even though when thousands of patients are tested, the loudness of the tinnitus is almost always matched within the same soft level of 20 decibels or less above the hearing threshold (a whisper is 30 decibels). In some cases of tinnitus, the loudness may be louder than 20 dB due to active disease or injury within the inner ear. Some medical problems requiring treatment, such as Meniere’s disease, or a condition of sudden sensorineural hearing loss can cause ear fullness and higher levels of tinnitus in the initial or acute stages.
For those with bothersome tinnitus, what makes it appear to be so loud and noticeable, fluctuate, or disappear at times is how the brain views or attends to the internal sound and reacts to it. In the absence of active disease, tinnitus retraining and management training is recommended. This should include an evaluation of central auditory processing and when needed auditory skills training to help with concentration and communication problems.
What’s the Brain Doing?
Fortunately for most patients, the brain looks at tinnitus as an inconsequential noise and self-limits the perception as just another sound like breathing or chewing. This may be because everyone has some tinnitus as our hearing systems constantly sends a impulses to brain as a status reminder of how the nerves are working. To demonstrate this, researchers Heller and Bergman in the 1950′s put subjects in an anechoic chamber (Picture from Orfield Laboratories Inc.). Soon thereafter, most participants could hear tinnitus even though they had normal hearing. It is common for people to develop tinnitus for a variety of reasons, but should the ear signal become too prevalent in the brain because of unusual and emotional circumstances, there are changes in the brain’s network that will need to be reset. When patients are told that nothing can be done to help them and proper care is not provided, this can cause an undo emotional response in some patients making recovery worse. “You mean I have to live like this forever and there is no cure?”
What initially increases tinnitus, in most cases, is gradually developing hearing loss. The lack of a sufficient signal from the ears is amplified by the brain to compensate for the nerve damage; and tinnitus, the phantom sound is born. Unlike acute disease/injury cases that are sudden, gradual hearing loss cases must be evaluated for hearing aids and listening devices as the first line of defense.
What makes tinnitus chronic and annoying for some comes from the fact that subconsciously this new event becomes over-monitored because it is perceived as a threat. Subconscious activity is a natural process for humans and animals as we automatically evaluate and monitor the environment for new events and determine if they have positive, neutral, or negative consequences. It is innate for the species to protect one’s self and be prepared to fight or flee from danger. The sound of a rattle snake makes everyone scared. For those that tinnitus becomes debilitating and life altering, this subconscious reaction has gained heightened fear and anxiety driven by a high degree of emotional stress from events such as an automobile accident, whiplash, head trauma, divorce, financial loss, a death in the family, severe illness, a post-traumatic stress disorder, inability to cope or adjust to the ongoing tinnitus, being told nothing can be done, and a variety of other life situations. This develops a vicious cycle of awareness, annoyance, and anxiety regardless of the cause. Using cognitive actions to retrain the subconscious and reset the hearing network is the goal of all tinnitus therapies.
What Should I Do?
Tinnitus can be a very complex problem that may involve the brain if one develops a high over-reaction to the occurrence. Therefore, initially becoming too anxious over having tinnitus, worrying about its cause, or if it will last forever are behaviors and thoughts that are to be avoided. This is neither life threatening or unmanageable over time and may abate without harm in a few short months for most patients. However, if tinnitus is chronic, too annoying, too loud and uncomfortable, unable to ignore, is present 24/7, or prevents sleep, patients should see a Neurotologist or ENT Physician for a diagnosis, and an Audiologist for evaluation, measurement, sound therapy, and management.
The following suggestions will provide some direction and knowledge that each patient can use at the onset of their tinnitus and thereafter, as they work along with their Audiologist:
Don’t panic, stay calm, be relaxed, and have patience. Tinnitus is not a disease, but frequently a symptom of hearing change. For almost everyone, whether the tinnitus goes away completely or partially, it is ultimately manageable with and most of the time without any help. In the beginning tinnitus will be louder or for some cause sleeping issues, but as time passes it will gradually reduce. Don’t listen to physicians, Audiologists, or other health care providers that suggest that nothing can be done about your tinnitus. Tinnitus is a network issue that improperly connects our feelings and sound processing to this new body sound. Should anyone have a poor reaction to tinnitus, Audiologists (Certified Tinnitus Practitioners and Tinnitus Retraining Therapists), Neurotologist, Psychiatrists, and Psychologists and Neuropsychologists who specialize in tinnitus have a variety of treatments and frequently work as a team.
Don’t center your thinking time on the tinnitus and monitoring it. This only brings tinnitus out of memory and into the forefront. “Is it there?” If you don’t hear your tinnitus, don’t look for it because you will always find it! This needs to be treated in the same way one listens to their own breathing, ignore it.
Keep all your normal activities going and don’t quit. The brain will learn to downplay the tinnitus with time and stopping normal activities only feeds the fire. This is because activity combats tinnitus by controlling immediate memories forcing tinnitus to the background. For this reason, yoga, exercise, and mindfulness training can be helpful.
Stay away from loud sounds and noises and avoid exposure to firearms and similar sounds that are guaranteed to be too loud and damaging, regardless of ear protection. The Audiologist should be consulted to recommend the correct devices, and fit and measure the hearing protection. For other louder sounds such as industrial noise or home power tools, use properly fitted ear muffs with a Noise Reduction Rating (NRR) of 25 dB or more. Ear plugs, although rated in this same range, will not provide the same degree of protection in real life and at times only a fraction. In some cases, hearing protection will not be adequate to reduce the annoyance.
Use hearing protection for those with sound tolerance difficulty, sparingly. The Etymotic Research ER 9dB up to ER 25dB custom musician’s ear plugs or the ER 20dB standard plug may be worn intermittently to reduce daily noise that is too loud and uncomfortable such as going out in traffic, shopping, or a restaurant. It is important to avoid sounds that create headaches or pain as this supports subconscious sound fear. However, constant use of ear protection for everyday sounds to make the environment too quiet is not recommended because this is counterproductive to resetting the brain’s internal sound level. Avoiding quiet time and keeping up normal levels of daily noise are helpful in blending the tinnitus for an eventual reduction. An Audiologist will be able to determine the best practices in each case to raise the noise floor.
Don’t be in quiet environments and blend the tinnitus with other sounds. Using music on the radio or iPOD, or sound machines with ocean, running brook, and other acceptable noises, or conversation with environmental background noise such as wind or water sounds are recommended. Music is best when relaxation is part of the objective, therefore, country music, slow jazz, blues, classical, calypso, and similar beats are more relaxing to the body, especially if they mimic the heart rate at 60 beats a minute or 4/4 time for musicians. Carefully listen, follow, pay and switch your attention to each of the individual instruments or voices and exercise your brain. Keep the loudness of any sound therapy at approximately the same level or below your tinnitus, don’t mask it, and just blend it with other sounds. Comfortable levels of sound therapy teaches the brain to view tinnitus as just another body sound. Remember, the problem with annoying tinnitus is that it has become something too special to the subconscious and conscious activity can challenge and change this.
Don’t spend lots of time in support groups without a recommendation from your physician or Audiologist. Most patients who have severe or chronic annoying tinnitus should be in therapy, not solely in a support group that will only continue to keep the tinnitus in the forefront without treating the problem. However, as an introduction to tinnitus, the information can be enlightening and educating. Within 6 months of the onset of tinnitus, most patients who use therapy show significant improvement, this does not occur with support groups alone.
Don’t spend much time scanning the Internet for solutions or listening to other patient’s impressions of their tinnitus because we are all different and have our own means to resolve the issue. Cognitive distortions written on-line by untreated and the most afflicted patients cause more harm than good and can be completely misleading and harmful to others. Complaints of no benefit from treatments are limited to only a few debilitated cases connected to psychological complications. Another example is the success rate of pills on the internet. In fact, professional research that is reviewed by outside investigators supports none of the claims, except as a placebo or spontaneous recovery that would have happened anyway.
Get adequate sleep and take care of your body. If your tinnitus is causing you to lose sleep, speak to your physician. If there are headaches, migraines, balance or nausea issues, a specialist in neurology or psychiatry is indicated. If there is no sleep there is no reduction in tinnitus or hyperacusis. Get plenty of exercise to improve blood circulation, reduce salt and alcohol. Smoking is also something that decreases blood circulation, can be toxic to the inner ear, and increases tinnitus.
Daily Exercise has shown to reduce stress and the observance of tinnitus or hyperacusis. This is because stress and anxiety drive tinnitus to be louder. Physical exercise reduces this stress and changes the awareness of tinnitus because activities naturally provide distraction and diversion.
If you have a hearing loss and tinnitus, hearing aids and special listening devices such as Serenade Sound Treatment should be discussed with an Audiologist. In most cases, if hearing loss is present, hearing aids with the correct prescription are known to reduce or control tinnitus in approximately 60% of the cases when coupled with sound therapy and directive counseling.
Do not seek treatment for tinnitus from a hearing aid dispenser. Dispensers are technicians and fitters and cannot diagnose tinnitus or other hearing conditions, treat auditory processing or comorbid tinnitus disorders affecting the brain, or provide tinnitus therapy. Dispensers are mandated to refer tinnitus patients to a physician, preferably an ENT physician for evaluation. This is because certain types of medical complications and benign brainstem tumors can cause tinnitus and improper testing or care can cause further discomfort or miss the opportunity to provide the correct diagnosis and treatment resulting in greater distress.
The Mystery of Tinnitus
We know that tinnitus is not a disease, but frequently a symptom of hearing loss or minor sensory changes in the ear. We know that there are different types of tinnitus based on the cause. We know that the initial onset of tinnitus is startling and disturbing for many, but for most as time passes the annoyance naturally decreases to becomes unimportant or absent. We know that the majority of patients will habituate or learn to manage their annoyance without the need for long-term treatment within a few weeks to a few months. We know that the brain develops a network that is responsible for both short and long-term reaction to tinnitus. We have learned that subconscious factors associated with fear, anxiety, and life situations and experiences can become deeply involved with tinnitus, especially those associated with more severe conditions such as trauma, acoustic shock, or PTSD. Over reacting and hyper-monitoring are responsible for increasing the perceived severity.
For some, should tinnitus become chronic, loud, and annoying, prevent sleep, or become debilitating and worrisome, an evaluation by a Neurotologist and Audiologist is in order, especially if there is an additional issue with sound tolerance or a sudden change in hearing, which requires immediate attention. The physician may dispense sleep and anxiety/depression medications, review your current medications for interaction, or in some cases, recommend an MRI or other evaluations. If the tinnitus is associated with a sudden hearing loss, treatments may include oral steroids, transtympanic steroid injections, hyperbaric oxygen treatments, and other therapies if not contraindicated. In some cases, in addition to hearing devices and sound therapies, the Audiologist will recommend cognitive behavioral therapy (CBT) or a visit to a psychiatrist who treats reactivity and anxiety disorders.
Patient should be aware that over-the-counter drugs have not proven to be more effective than placebo. Furthermore, although some patients may have reactions to certain foods that may affect them, changes in diet have not necessarily been proven to stop or significantly alter tinnitus or the need for treatment, although food allergies, smoking and alcohol have obvious effects. Most importantly, there are specific actions that tinnitus patients should take to reduce the effects and severity of tinnitus from the onset, foremost is to discontinue activities that surround high noise, such as firearms and loud music.
For those requiring therapy, a Certified Tinnitus Practitioner from the Tinnitus Practitioners Association who are certified Audiologists (http://www.tinnituspractitioners.com), specialists in tinnitus at various universities and clinics, or Tinnitus Retraining Therapists (http://www.tinnitus-pjj/referral.html.com) will provide diagnostic testing to assess the cause of the tinnitus, evaluate the tinnitus reaction, determine the contributions of hearing loss and other disorders, and measure the tinnitus pitch and loudness. The Audiologist will also measure central auditory processing to determine the extent of hearing network changes that create sound confusion and reduce concentration. They will also provide auditory training and sound therapies when indicated.
Certified Audiologists are trained to provide appropriate sound stimulation and sound therapies including devices such as hearing aids, sound generators, Serenade and Neuromonics, and directive, cognitive, and supportive counseling to reduce and manage tinnitus awareness and annoyance towards the goal of habituation. In some cases, the addition of a Neuropsychologist or Psychologist who specializes in tinnitus and hyperacusis may be recommended to reduce the effects of life issues and stress, provide cognitive behavioral therapy, and further develop relaxation and self-management skills. Furthermore, there are a number of experimental treatments dealing with magnetic and electrical stimulation that have promise as potential cures in the future, however, at the present time they remain outside of mainstream treatment. In those patients with profound hearing loss that are candidates for a Cochlear Implant considerable relief from tinnitus is reported. Research in tinnitus treatments and therapies continues to provide a wealth of knowledge concerning the complex activities within the brain and treatments that can change how the brain’s tinnitus network functions.