Tinnitus is a phantom sound perception described as ringing, clicking, swishing, buzzing, static, whistling, crickets, wind, pulsing, and machine noise amongst others. The sound may be perceived as coming from the ear/s or within the head. Tinnitus is not a disease, but a benign subjective sound frequently caused by conditions that create hearing loss such as noise exposure or aging. Unlike subjective tinnitus, in some rare cases doctors can hear sound coming from a patient’s ear or neck. These conditions are examples of objective tinnitus and frequently represent a medical complication.
Tinnitus can also be associated with benign sound hallucinations as reported by about 10% of the hearing impaired. These voices, music, or sound memories are miscommunicated within the brain and clearly heard by the listener, but considered not unpleasant or debilitating.
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 and uncomfortable; 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 with or without warning. Therapies for all of these conditions are available from specialists in tinnitus care who also treat sound tolerance spectrum disorders.
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 with hearing loss, the loudness of tinnitus may be perceived louder than 20 dB due to changes within the inner ear. Furthermore, in every case, tinnitus does not fluctuate within the ear unless there is active ear disease, such as Meniere’s disease. What makes tinnitus appear to be so loud and noticeable, fluctuate, or disappear at times is how the brain views or attends to the internal sound event and reacts to it.
What’s the Brain Doing?
Fortunately for most patients, the brain looks at tinnitus as an inconsequential noise in the background and self limits the perception as just another sound like the hum of a refrigerator or the L passing by; unnoticed for the most part. This may be because everyone has tinnitus as our hearing systems constantly send a signal to brain as a status reminder of how the neurology is working. Consequently, there is already a signal for the ears in the system and changes to that system are typically adaptable. To demonstrate this, rearchers Heller and Bergman in the 1950′s put subjects in an anechoic chamber (Picture from Orfield Laboratories Inc.). Soon thereafter, almost everyone heard their tinnitus even though they had normal hearing. It is normal for people to develop noticeable tinnitus for a variety of reasons, but should the brain hyper-monitor the ear signal because of unusual and emotional circumstances, there are changes in electrical activity that occur throughout.
What initially increases tinnitus, in most cases, is hearing loss as 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. It should be noted that even though no noticeable hearing loss is observed in half of the tinnitus patients, some degree of outer sensory hair cell loss or damage has occurred. Measurement with Otoacoustic Emission has repeatedly demonstrated this observation. This is the same objective test that is used for newborn hearing screening.
What makes tinnitus chronic and annoying comes from the fact that subconsciously this new event is over monitored because it is perceived as a threat and when the conscious brain becomes aware, the tinnitus is already tuned in from memory and put into view. Subconscious activity is a natural process for humans and other 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. 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, post traumatic stress disorder, inability to cope with the ongoing tinnitus, a fear of tinnitus, and a variety of other life situations. This develops a vicious cycle of awareness, regardless of the cause. For this reason in some cases, the assistance of cognitive behavioral therapy (CBT) can be very rewarding.
Causes of Tinnitus
Conditions that may cause tinnitus as reported by the Tinnitus Practitioners Association (http://www.tinnituspractitioners.com), the American Tinnitus Association (http://www.ATA.org), the American Academy of Otolaryngology (http://www.ENTNET.org), the National Institutes on Deafness and Other Communication Disorders (http://www.nidcd.nih.gov/Pages/default.aspx), and the American Academy of Audiology (http://www.Audiology.org) include the following:
Meniere ’s disease, Diabetes, Hypertension, Hyperthyroidism, TMJ (Jaw Joint), Vascular Disease, Drug Induced, Ear Disease, Tumors, Neuromas, Neurological Disease, Cardiovascular Disease, Hearing Loss, Post Surgery Reactions, Allergies, Anemia, Otosclerosis, Ear Wax.
Noise Exposure, Acoustic Trauma, Barotrauma (Scuba Diving or Airplane), Hydrotrauma (Ear Washing), Whiplash or 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 reaction (36 million)
2. Those that have a significant problem and seek professional care (15 million)
3. Those that are debilitated and have a crisis (2 million)
Although tinnitus is frequently reported by those with hearing loss approximately half of all patients report no hearing issues, although it is believed that in almost all cases of tinnitus, some degree of inner ear hair cell damage exists as the generator of the event.
Tinnitus is a very complex problem that can involve the brain if one develops a high reaction to the occurrence. Initially becoming too anxious over having the tinnitus, worrying about its cause, or if it will last forever are behaviors that are to be avoided. However, should tinnitus become chronic, annoying, sound loud and uncomfortable, be unable to ignore, be present 24/7, prevent sleep, or be worrisome, patients should see an ENT physician or Audiologist for evaluation.
After seeing tinnitus patient for many years, I would like to suggest that each patient at the onset start managing their tinnitus using some simple tips:
- Don’t panic, stay calm, be relaxed, and have patience. Tinnitus is not a disease. Remember that whether the tinnitus goes away or not, it is ultimately manageable with and most of the time without help. Don’t listen to health care providers that suggest that nothing can be done about your tinnitus, unless they identify your type as the common non-reactive tinnitus that will typically abate to be an inconsequential sound or be completely habituated without consequence. Should your brain have a reaction to tinnitus, Certified Tinnitus Practitioners, Tinnitus Retraining Therapists, Otolaryngologists, and Neuropsychologists who specialize in tinnitus have a variety of treatments and frequently work as a team with amazing success for those in need.
- Don’t center your thinking time on the tinnitus. This only brings tinnitus out of memory and into the forefront. If you don’t hear your tinnitus, don’t look for it because you will always find it!
- Keep all your normal activities going and don’t quit. The brain will learn to unattend with time and stopping normal activities only feeds the fire.
- 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. For other louder sounds such as industrial noise or home power tools, use properly fitted ear protection, ear muffs are my favorite 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. For those with sound tolerance difficutly, ER-25 custom ear plugs may be worn for listening to live music and when in bothersome noise, but for the most part, listening to normal sounds and developing a better tolerance is part of the treatment. Constant use of ear protection for everyday sounds are not recommended as this is conterproductive to resetting the brain’s internal volume control.
- Don’t be in quiet environments and blend the tinnitus with other sounds to change the contrast by including music on the radio or from an MP3 player, sound machines with ocean and running brook noises, and use fans, conversation, background noise, and other distracting sounds. 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 you musicians. To get some of natures sound right now, go to the American Tinnitus Association website and create and download your own score (http://www.ATA.org/songs) and start listening and relaxing. Carefully listen, follow, pay and switch your attention to each of the individual sounds you create and exercise your brain. Keep the loudness of any sound therapy at approximately the same level of your tinnitus, don’t mask it, and just blend it with other sounds. This teaches the brain to view tinnitus as just another sound. Remember, the problem with tinnitus is that it has become something too special.
- 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 view 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 need 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, decrease the severity, and manage the brain. Cognitive distortions by others about tinnitus can cause more harm than good and be completely misleading as to the need for treatment or the type to consider. For example, pills on the Internet are rampant, but the professional research that is reviewed by outside investigators support none of the claims, except placebo or spontaneous recovery.
- Get adequate sleep and avoid fatigue whenever possible. If your tinnitus is causing you to lose sleep, speak to your physician. Get plenty of daily exercise to improve blood circulation and keep your blood pressure under control. Reduce salt and alcohol and stay away from stimulants such as teas, coffee, and soft drinks. Smoking is also something that decreases blood circulation can be toxic to the inner ear and increases tinnitus and should be avoided if possible. I sometimes will have a cocktail or two and find that soon thereafter my tinnitus is louder. Since I know that I caused it to increase, the thought does not bother me and I just continue to habituate the signal. In fact, regardless of the cause of the tinnitus, habituation and self management is possible for most patients.
- If you have a hearing loss and tinnitus, hearing aids and special listening devices such as Serenade Sound Treatment should be discussed with your Audiologist.
- Do not seek treatment for tinnitus with a hearing aid dispenser. Dispenser training is only useful for the fitting of hearing aids and other personal amplifiers. Dispensers are technicians without advanced degrees in hearing health care and cannot diagnose tinnitus or other conditions, treat auditory processing disorders of the brain, or provide tinnitus therapy.
The Mystery of Tinnitus
The mystery of tinnitus has been partially unraveled to reveal that the brain’s involvement is responsible for our reaction to tinnitus, regardless of the type or cause in almost all cases. We have learned that subconscious factors associated with fear, anxiety, and life situations become deeply involved well before any conscious awareness occurs. We know that tinnitus is not a disease, but frequently a symptom of hearing loss and that the majority of patients will completely habituate their tinnitus or manage their annoyance without significant reaction or the need for treatment within a few weeks to a couple of months. For some with a subconscious reaction, should tinnitus become chronic, loud, and annoying, prevent sleep, or become debilitating and worrisome, an evaluation by an ENT physician and Audiologist is in order, especially if there is an additional issue with sound tolerance. The physician may dispense sleep and anxiety/depression medications, review your current medications for interaction, or recommend an MRI or other evaluations and treatments. Patient should be aware that over-the-counter drugs have not proven to be more effective than placebo. Most importantly, there are specific actions that tinnitus patients should take to reduce the effects and severity of tinnitus from the onset and foremost is to discontinue activities that cause hearing loss from noise exposure.
For those requiring therapy, a Certified Tinnitus Practitioner (http://www.tinnituspractitioners.com) or Tinnitus Retraining Therapist (http://www.tinnitus-pjj/referral.html.com) who will assess the cause of the tinnitus, evaluate the tinnitus reaction, determine the contributions of hearing loss, measure the tinnitus pitch and loudness, provide appropriate sound therapy including devices such as hearing aids, sound generators, Serenade, Neuromonics, and provide directive and supportive counseling to reduce and manage tinnitus awareness and annoyance while increasing relaxation. In some cases, the addition of a Neuropsychologist or Psychologist who specializes in tinnitus and hyperacusis may be recommended by your therapist to reduce the affects of life issues, provide cognitive behavioral therapy, and 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 with the exception of those patient’s in need of and fitted with a Cochlear Implant who have gained relief from tinnitus due to the electrical stimulation and without side effects. Research in tinnitus continues to provide a wealth of knowledge concerning the complex activity within the brain and treatments that change how the brain functions.