Coping with Tinnitus: Treatment Options Explored
The professionals at Advanced Hearing Aid Clinic and Advanced Hearing and Balance Institute believe that a comprehensive understanding of tinnitus will help individuals explore treatment options, learn new coping skills, and feel more positive about the future. All of our clinics subscribe to Progressive Tinnitus Management for treatment. Progressive Tinnitus Management is an all encompassing term which includes Tinnitus Retraining and Habituation Therapy, masking in some cases, extensive education and counseling, and sound management. We are also equipped to deal with phonophobia and other sound disorders.
Tinnitus is derived from Latin and means “to tinkle or to ring like a bell”. Tinnitus is a perception of sound in the ears or the head when no external sound source is present. Many individuals refer to it as “ringing in the ears”, “head noises”, or “high pitched sounds in the head”. Other forms of sound are described as hissing, roaring, pulsing, whooshing, chirping, whistling, rushing, booming, and clicking have also been described by individuals that suffer from tinnitus. In fact, over 50 different descriptions of sounds have been reported. While individuals may enjoy these sounds in nature, they are certainly more bothersome when they are coming from one’s own ears or head.
Most cases of tinnitus are subjective, meaning that only the person who suffers from tinnitus can hear it. While the perception of tinnitus is real, there is no external sound corresponding to the patient’s perception of sound, and thus tinnitus is classified as a phantom auditory perception.
However, there have been documented cases of objective tinnitus, where sounds can actually be heard from the ear.
Tinnitus can occur in one or both ears, constantly or intermittently, perceived to be occurring inside or outside the ear(s), be progressive, pulsing, or vary in intensity or pitch. Several different sounds may occur simultaneously. Most of the individuals that seek help suffer from constant tinnitus-24 hours a day for seven days a week.
Feelings of pressure (aural fullness) or pain in or around the ears may accompany tinnitus.
Individuals with more severe cases of tinnitus may find it difficult to hear, work, or sleep.
Although tinnitus does not cause hearing loss, tinnitus can interfere with one’s communicative ability. Some cases of tinnitus can involve hyperacusis or decreased tolerance of sound. Pawel Jastreboff estimates that 40% of individuals that suffer from tinnitus, have accompanying hyperacusis. Ordinary sounds may be perceived as being uncomfortably loud and harsh. Hyperacusis can occur without tinnitus. Tinnitus may accompany a number of other symptoms such as a feeling of pressure in the ears, unsteadiness, and dizziness. Many individuals suffer from tinnitus without any other accompanying symptoms. Tinnitus is not a disease. Tinnitus is a symptom common to many problems, both physiological and psychological.
Tinnitus can be very mild during the daytime but more noticeable in quieter situations (quiet room or bedtime), as daytime activities and surrounding sounds can act as a distraction and serve to mask or partially mask tinnitus. Increased activity in the absence of daytime sounds can seem to make the tinnitus louder although the intensity doesn’t actually vary. Tinnitus can also be extremely loud to the point where the individual may hear nothing else.
The occurrence and intensity of tinnitus may vary depending on several factors such as stress, diet, and noise exposure. Individuals may report similar characteristics of tinnitus but may be affected by it in a significantly different manner. The severity of tinnitus is related directly to an individual’s reaction to, and perception of the tinnitus. Until recently, tinnitus has not received sufficient attention, either in clinical practice or in research. Our clinicians are well versed in the neurophysiologic origins of tinnitus and hyperacusis in addition to the treatment of these disorders.
It is estimated that 25 million Americans experience tinnitus to some degree on an ongoing basis. Estimates of the prevalence of tinnitus vary widely from 7.9 million (Adams et al., 1999) to 37 million Americans (Noell and Meyerhoff, 2003). Pawel Jastreboff estimates that approximately 17% of the world’s population suffers from tinnitus which causes significant suffering in 4% of the general population. Further, he estimates that tinnitus occurs in 33% of the elderly.
The Canadian Tinnitus Association has estimated that 360,000 Canadians are annoyed by their tinnitus, and that approximately 150,000 find that tinnitus seriously impairs the quality of affected individual’s lives.
The Canadian Academy of Audiology estimates that 10 to 15% of Canadians suffer from tinnitus (approximately 3 million) with 20% of these individuals seeking help for their condition because their tinnitus is so severe that it is debilitating (approximately 600,000 individuals). Almost every individual has, at one time or another, experienced brief episodes of mild ringing or other sounds in the ear. It is estimated that 10 to 15% of adults have prolonged tinnitus and seek medical intervention (Heller, 2003). Studies have shown that tinnitus is more prevalent in females than males under the age of 50. Equal incidence occurs after the age of 50. Until recently, tinnitus did not receive sufficient attention, either in clinical practice or in research. While the perception of tinnitus is very real, there is no external sound corresponding to the patients’ perception of sound; thus, tinnitus can be classified as a phantom auditory perception.
Causes of Tinnitus
Tinnitus can be a symptom of a condition that is related to many forms of hearing loss, or it may exist without hearing loss. Tinnitus is not a disease. Tinnitus is a symptom that may result from a number of medical conditions. Tinnitus may result from age-related hearing loss (presbycusis typically begins after the age of 55), ear injury, or a physiological condition.
Tinnitus may have a physiological or biochemical origin. Common causes of tinnitus include impacted wax near the tympanic membrane (eardrum), hearing loss, exposure to excessive noise (either ongoing or one time noise trauma), head/neck trauma, whiplash, large doses of ototoxic drugs such as aspirin (over 200 medications have tinnitus as a listed potential side effect), problems in the neck or jaw, or any type of physical or emotional stress. Less common causes include a non-malignant tumour on the vestibular nerve (vestibular schwannoma), a fixation of the middle ear bones, or other relatively rare medical conditions. The following blood vessel disorders MAY cause pulsatile tinnitus.
Atherosclerosis is a large buildup of cholesterol and other fatty deposits in major blood vessels close to your middle and inner ear. The blood vessels lose some elasticity and therefore the ability to flex and expand with each heartbeat. This causes the blood flow to become more forceful and turbulent, making it easier for the ear to detect heart beats. High blood pressure, including hypertension and factors that increase blood pressure such as stress, alcohol, and caffeine, may make tinnitus more noticeable. Repositioning your head may cause the sound to disappear. Narrowing of the carotid artery or jugular vein can result in turbulent blood flow and head noises. Malformation of capillaries, also called arteriovenous malformations, can occur in the connections between arteries and veins which can result in head noise.
Individuals with normal hearing can also suffer from tinnitus. Having tinnitus does not mean that one will lose their hearing.
Although there are many theories about how sounds in the ears or head are produced, the exact process is not fully understood. The most widely accepted theory, when tinnitus occurs with hearing loss, is damage in the cochlea. More specifically, damage to outer hair cells. Many researchers believe that when the structure of the hair cell collapses, random stimulation of the auditory pathways occurs. More current research of Martin Pienkowski, suggests that tinnitus results from a locking of spontaneous neuronal firings at the level of the cochlea and brainstem. All individuals have spontaneous neuronal activity, however; in individuals with tinnitus, the “locking” of this activity enhances the sound signal.
Protect your Hearing from Damage
Within the auditory system, thousands of auditory cells maintain an electrical charge. Microscopic hairs form a fringe on the surface of each auditory cell (Outer Hair Cells-OHC and Inner Hair Cells-IHC).
When healthy, the hairs on top of the hair cells move as a result of the pressure of sound waves moving through the fluid in the inner ear. Both the inner and outer hair cells are connected to the auditory nerve through the basilar membrane. Depending upon the movement of the cochlear fluids from sound stimulation, different hair fibers are put into motion. The movements of these hairs cause the auditory cell to discharge electricity to the auditory nerve, which is connected to the auditory center of the brain. The brain translates these electrical impulses into sounds, which we recognize and understand. As a consequence, these hair fibers are essential to our hearing ability.
When these hair cells are damaged, they move randomly in a constant state of irritation. They are unable to hold their charge and leak random electrical impulses to the brain where it is interpreted as noise. The nerves that carry impulses to the brain are adjacent to the base of the hair cells but are not quite embedded into the basilar membrane. 90% of the nerves derive from the inner hair cells (despite the fact that they are smaller in number). Each inner hair cell has approximately 10 nerve endings attached to it which results in approximately 30,000 nerve fibers that transmit the electrical equivalents of the sound waves to the brain.
Tinnitus Treatments: First Steps
The First Step in Getting Help
Since tinnitus is a symptom, the first step in finding some form of resolution should be to try to determine or diagnose the underlying cause. A comprehensive medical examination can rule out causative factors related to blood pressure, kidney function, drug intake, diet and allergies. Unfortunately, the cause of tinnitus cannot often be identified, so, in some cases, the tinnitus itself may need to be treated.
Our doctoral level audiologists have taken post-graduate training in tinnitus and tinnitus management. Patients can call and arrange for a comprehensive tinnitus evaluation. We will need a complete list of current and past medications and an in-depth description of the tinnitus, including when it happens, and what seems to make it worse.
Before the advent of Tinnitus Retraining Therapy and Tinnitus Habituation Therapy, most health care professionals would tell sufferers to “learn to live with it” and that “there is nothing that we can be done”. We now know that there is much more to understand and do about this problem. Tinnitus treatments serve to restore life to the pre-existing tinnitus level.
What Does our Testing Involve?
Our clinics have one of the most comprehensive protocols for tinnitus assessments in Canada. Our Audiologists will perform an otoscopic examination of your ear canals to ensure there is no wax or debris buildup in the ear canals.
The first test involves conventional pure tone testing to determine if there is a hearing loss. The intensity and frequency of the tinnitus will also be measured as closely as possible.
One of our Audiologists will also perform tests of residual inhibition to try to determine what treatment method would be most beneficial to you. We will assess your middle ear system to ensure your eardrums and attached middle ear bones are functioning appropriately. Perhaps the most valuable test in our tinnitus protocol is that of Otoacoustic emissions testing. It will be done to assess the integrity of the cochlea (assess outer hair cell function) as damage to the cochlea typically can be detected before hearing loss is found with conventional testing.
Auditory brainstem response testing can be done to rule out tumors on the vestibular nerve, or anomalies within that area of the auditory system.
Typically, once a comprehensive evaluation has been performed, most individuals who suffer from tinnitus feel reassured and find it somewhat easier to adjust and adapt to the tinnitus. Individuals with mild tinnitus or longstanding tinnitus that is not life affecting generally do not require intervention or treatment. Most just need to be reassured that they do not have a rare disease, serious brain disorder, or are not going deaf. In such cases, individuals usually find that they can cope well with their tinnitus or can easily ignore it. Sometimes, further tinnitus treatment methods may be required.
Not all Canadian Audiologists are trained in tinnitus and hyperacusis management or the most recent therapeutic interventions. More recently, audiologic educational institutions have realized the significant prevalence of Tinnitus and Hyperacusis and have adopted minimal training in this area.
Coping with Tinnitus
Tinnitus, or our reaction to tinnitus may improve with time. This improvement is not the
result of physical changes, as damage to the auditory system that has been measured is
typically permanent and irreversible. Rather, many individuals learn to make adjustments
to lessen the symptoms of tinnitus. There are a variety of techniques that may reduce the
severity of the tinnitus while increasing your tolerance to it which include:
Avoiding possible irritants.
Tinnitus can be aggravated by excessive noise, nicotine, caffeine, tonic water that contains quinine, alcohol, and excessive doses of aspirin. Nicotine and caffeine constrict the blood vessels, which increases the speed of blood flow through the veins and arteries. Alcohol increases the force of blood by dilating the blood vessels, which causes greater blood flow, especially in the inner ear area.
If you work in loud noise or partake in loud recreational noise, wear ear effective ear protection. Noise- induced hearing loss may occur by a one-time exposure to a loud sound or by repeated exposure to loud sounds over an extended period of time. An individual cannot “toughen up” their hearing by repeatedly listening to loud noises. The effects of loud noises may exacerbate tinnitus in addition to further damaging hearing. Learn how to protect your hearing when you are in adverse listening situations. The stressful nature of some occupations can contribute to tinnitus, increase the severity of existing tinnitus, increase the individual’s reaction to the severity of tinnitus, and hinder coping mechanisms. Our Audiologists will be happy to discuss the most appropriate custom protection for the noise levels to which you are exposed.
As you can see below, there are a variety of types of hearing protection – all purpose, or custom that may be appropriate.
Partially mask the tinnitus.
In a quiet setting such as the bedroom at night, the use of a noise generator may be beneficial. Noise generators are recommended for Tinnitus retraining and Habituation Therapy. The noise generator creates a soothing surf, waterfall or rainfall sound that should be used at a level slightly below the level of the tinnitus.
Wear a hearing aid.
If the tinnitus is accompanied by hearing loss, hearing aids are an effective way to deal with tinnitus for a small portion of sufferers. Hearing aids amplify other sounds which draws attention away from the tinnitus. Hearing aids are used in Tinnitus Habituation Therapy.
Stress can exacerbate tinnitus levels. Learning relaxation techniques can be helpful if the tinnitus frustrates you.
Stress management (relaxation therapy, biofeedback, etc.) may provide relief. We can provide you with a list of psychologists who deal with stress management techniques and/or depression. Cognitive Behavioural therapy is also an effective addition for those that suffer from the deleterious effects of Tinnitus and Hyperacusis.
Deep breathing, hypnosis, biofeedback, systematic relaxation, therapeutic massage, yoga, and some forms of physical exercise such as swimming or walking can reduce tension, stimulate endorphins, and promote better sleep.
Tinnitus Retraining Therapy/Tinnitus Habituation Therapy.
With the proper mix of counseling and noise generators, tinnitus management can be very effective. Auditory retraining uses sound generators that are set to a level that is below the intensity of the tinnitus (just audible and not masking the tinnitus). When used for an extended period of time, it induces subconscious habituation so that the tinnitus is not perceived as an intrusive or disturbing presence. This method is also effective in reducing hyperacusis or sensitivity to sounds. In some cases, masking of tinnitus can be effective.
Our Audiologists are trained to help you to learn to cope with tinnitus, explore viable treatment/reduction options, or provide you with appropriate referrals.
Alternative approaches (naturopathy, acupuncture, vitamin, and mineral supplements) have been of limited use in treating or reducing tinnitus. In fact, there has not been one scientific study to date that has shown long-standing efficacy in the reduction of tinnitus with alternative approaches such as illustrated below.