Managing Your Tinnitus: Tinnitus Activities Treatment


How you can benefit from Tinnitus Activities Treatment

This year at the Healthy Hearing Expo Audiologist Martine Schlagintweit focused on Tinnitus Activities Treatment, which includes counselling of the whole person and considers individual differences and needs.


Today, I'll be talking about managing your tinnitus and to get started, I'd like to keep things general with an overview of what tinnitus is and the more general principles of management for this symptom. And then we'll dive into Tinnitus Activities Treatment, which is a behavioural treatment for tinnitus. And we'll talk about how we use this system at Oak Bay Hearing Clinic and Broadmead Hearing Clinic.

The photo you see here on the top right of the screen is a joke that was passed along to me by a client who successfully manages their tinnitus and who has seen us for tinnitus management. And I think this is a really, really important thing to touch on. And that is that tinnitus can be an unpleasant and chronic symptom for a lot of people, but it's okay to have a bit of fun with it and to integrate humor into healing. I think that's such an important step that we can take to kind of make the ride with tinnitus a bit more pleasant. By the end of today's presentation, I'd like everybody to have a comfortable knowledge of what tinnitus is and to have some familiarity with the types of tinnitus, because there are two different types of tinnitus. And it's also important to me that we all walk away from here today with an understanding of the goals of tinnitus treatment and management. And ideally, you'll also have some insight into Tinnitus Activities Treatment and how that's implemented here at our clinic.

3 tinnitus principles

So to really define tinnitus, we have to meet three pre-main principles.

  1. Tinnitus has to be heard, you can't smell it, you can't see it, you can't taste it. This is a hearing phenomenon.
  2. Tinnitus is involuntary. So tinnitus is not something that you can produce intentionally. It's sort of just something that happens in your body.
  3. Tinnitus is in your head.

So it's not created by an external sound source. It is a sound that's perceived through the auditory system then the auditory neural tract...the nerves running between the ear and the brain and inside of the auditory cortex in the brain, are coding for sound when there's no sound present in the environment. And a lot of people will actually describe that as a phantom sound.

Who has tinnitus?

So let's start with a quick poll here. How many people in our audience have tinnitus? Can you see the poll there? I see a lot of people doing hand raising. That's great. I'm going to submit my response to the poll, which is yes. I'm seeing a 100% yes rate here and I'm seeing tons of hands up in the audience. So I can see that pretty much everybody watching this presentation is experiencing tinnitus and that might have been the motivation for why they're joining us today. So I see a 100% response rate. So tinnitus is actually incredibly common. About 50 million people in the United States and 10 to 20% of all North American individuals experience chronic tinnitus or report chronic tinnitus.

About 80% of people with hearing loss have tinnitus. And we actually call this the 80/80 rule because 80% of people that have hearing loss have tinnitus and 80% of tinnitus patients also have hearing loss. So that's what that vice versa situation and that's called the 80/80 rule. And part of why that might actually be the case is because both tinnitus and hearing loss may share a causative factor or might share a cause that causes both of these symptoms or gives rise to these symptoms. And does anybody know what that could be? I'm going to launch another poll here and you can respond in the poll and let's launch that. So let's see if anybody can guess what the most common cause of tinnitus and hearing loss is.

Let's see here, getting nine responses, it's creeping up. So hopefully you guys have allowed the app to kind of give you a pop-up so that you can participate in the poll, can see about 12 responses there. You can also feel free to pop it in the chat if you'd like to, if that's a little bit easier for you, we'll let that run for another moment here. Good. So we're capping out at about 16 responses there. So the correct answer here, which most of us came to is actually noise exposure, noise exposure is the most common cause of both tinnitus and hearing loss. Stress is certainly a factor when it comes to tinnitus, but generally, it is not a causative factor, it's what's called an exacerbating factor. So stress makes it a lot worse, but it doesn't typically cause the tinnitus.

Most tinnitus isn't bothersome

So the majority of people with tinnitus are actually not bothered by their tinnitus and they really only notice it in quiet spaces or when they take a pause in a really quiet area. Some examples of that might be when they're reading or upon waking up in the night. But these people say that they hear it, but it does not affect their quality of life. A very small subset of people that report chronic tinnitus are bothered by it. And that's about three to 5% of people with tinnitus. And that group will report a significant disturbance to their quality of life. And they're often quite distressed by the experience of tinnitus. It's annoying to them, it's aggravating. It prevents them from engaging and participating fully in their day-to-day life. Often it will have an effect on their relationships and kind of maintaining their mood throughout the day.

And touching on that, about half of the people with bothersome tinnitus experience kind of concurrent psychological or psychiatric conditions such as depression, anxiety, or they've recently experienced a really stressful experience or crisis. And a pretty typical story for me in the clinic is to have a new patient come in. They're there for a tinnitus evaluation and they might sit down and start off with a story like this.

So I know I have a bit of high frequency hearing loss, but that's been there for a long time and I haven't done anything about it. And the hearing loss really doesn't bother me at all. And my ears have always actually rang. They've been ringing for about 10 years now. And again, that never really bothered me at all. And my hearing didn't bother me at all. I wasn't really aware of my ears, but then I crashed my vehicle last year. I didn't get hurt in the accident, but the experience really, really shook me up and I lost sleep over it for weeks. And then my tinnitus got super loud about a week and a half after the accident and it's been loud and bothersome ever since. And I just can't seem to ignore it now. So that's a very, very, very typical example of what somebody might present to the clinic and say when they are seeking tinnitus treatment or tinnitus management.

There are 2 types of tinnitus

Now, before we get any deeper into this discussion, I think it's really, really important that we differentiate that there are actually two types of tinnitus. The first is the far more common and most likely to be chronic type of tinnitus and that's called subjective tinnitus. So that's 95 to 98% of tinnitus cases and subjective tinnitus can be defined as the experience of sound when there's no identifiable sound source present. And only the person with subjective tinnitus can hear the sound of their tinnitus. The second type is called objective tinnitus. And this is rare, super rare. Objective tinnitus is a sound that is generated within the body and does have an identifiable source.

What causes tinnitus

It often stems from some sort of anomaly or occurrence or physical anomaly, such as a foreign body moving around in the ear canal. Sometimes that's problems with the eustachian tube. That's the tube that runs from your middle ear into the back of your throat. And sometimes that can fall open and you'll hear your own body sounds like breathing or swallowing. And occasionally, there's a situation where there might be small cracks in the bones lining the inner ear, which leads to people reporting things like they can hear their eyes rolling around in their head or the muscles of their neck sliding against each other.

Objective tinnitus can occasionally be treated medically or surgically. So a differential diagnosis for your tinnitus is super important. So if you're experiencing tinnitus, you've never had it evaluated, at the very least go for an audiological assessment to figure out if you're experiencing that subjective tinnitus, which is far more common, or objective tinnitus. So that kind of leads me into what should you do if you have tinnitus and what does a typical tinnitus care path look like?

3 steps to successfully assessing and managing tinnitus

Step one: medical clearance. So that's where your health professionals are going to use all of the diagnostic tools in their respective toolkits to determine if there's an underlying pathology or problem that is causing the tinnitus. And a thorough hearing test, questionnaires, and possibly some medical imaging may be a part of that process. And this step often involves consulting with some other professionals. Your Audiologist, your psychologist, your physician, in some cases, and you may even be referred on to an otolaryngologist or ENT surgeon, pharmacist, what have you.

Step two: treatment. That may look like medical intervention for an objective tinnitus case. In most cases, it's far more common that that's going to be a behavioural tinnitus program offered through audiology. Some sound therapy also offered through audiology and may involve some psychological intervention if the distress level associated with that tinnitus is high or you're having some psychological or behavioural issues related to the tinnitus.

Step 3: healing. Now, step three, we don't talk about this step a lot, but I think it's a really, really important and possibly the most important step. And that's our healing phase. So once you've completed a behavioural intervention program or tinnitus intervention program, where you've learned all these strategies to manage the tinnitus and you've started using sound therapy, using those strategies consistently, whenever you're noticing your tinnitus, is very important and that's your healing phase. So you've figured out what works for you and you continue to use those strategies on an ongoing basis to continually manage that tinnitus symptom. And that's where we can really see some relief.

Beware of scams

Something that I think is really important to acknowledge is that people with tinnitus can be a bit vulnerable to falling victim of scams or investing in products that claim to cure tinnitus with a complete lack of evidence to support those claims. A lot of those products are actually registered with the FDA as food products, and that's why they can make those claims in their advertising without facing any sort of punitive action by the FDA. It's completely unregulated that component. And unfortunately, the number of poorly researched and ineffective tinnitus cures and supplements by far outnumber the effective and well-researched programs that we actually do see some success with. Presently, no evidence supports the use of supplements, dietary changes, and not even any medications presently that have been demonstrated to successfully decrease the awareness or perception of tinnitus. Now, that being said, I'm not saying that this is not a treatable or manageable symptom. There are plenty of programs that are well-researched and have an excellent success rate, which we're going to speak about in just a moment here.

So let's dive into some of those general principles of management. We're not talking about any specific behavioural program presently. We're just talking about those three steps to managing tinnitus successfully. So step one is going to be your audiological assessment for tinnitus. This allows us to identify the type of tinnitus, that's subjective or objective. We're going to detect possible issues requiring medical attention. And we're going to characterize the tinnitus and its impact on the person's quality of life, which helps us determine what the treatment plan will look like. Now, Audiologists, we start with the audiological assessment because Audiologists are perhaps the only health professional with the appropriate training and experience to evaluate tinnitus successfully. Tinnitus care doesn't actually fall into any other profession, scope of practice, other than maybe otolaryngologists. And that tends to be more for objective tinnitus. Now that being said, your audiologist is likely not going to be the only professional you consult with in regards to your tinnitus. You may see physician, psychiatrist, otolaryngologist, occupational therapists are often also involved as well.

Tinnitus evaluation

Now this is an example of what you might kind of go through in a tinnitus evaluation. So your Audiologist is going to take a thorough history. They're going to examine your ear canal. That's what this lady's doing here. We're going to do some pure tone testing. So that's just testing your sensitivity to the sounds. And then also some pressure tests or temp anthropometry to see how well your eardrum and middle ear bones are working together. And each component here is kind of helping us with the standard battery to see if there are underlying medical issues.

But in addition to those measures, we'll also have the patient fill out tinnitus specific questionnaires. It'll take four tinnitus characterization measurements. And on this side, it's a little bit blurry here, I hope you can see clearly, we have kind of our standard components of the audiogram there. And then at the bottom, that's usually where we write the results of our tinnitus characterization measurements. And we use those to determine the subjective pitch and loudness of the tinnitus. And we also determine how much masking sound is needed for the individual to become less aware of their tinnitus. And that helps inform our treatment.

So at this point, you would've undergone your audiological assessment. The Audiologist is going to make some referrals as needed. So that might be to a physician, again, psychiatric or psychological intervention. They may recommend to your physician that you see otolaryngology or ENT surgeons. And then we would determine the most appropriate treatment plan in terms of audiological management of the tinnitus symptom. So for some people with subjective tinnitus, that step's likely come to involve some degree of sound therapy and often participation in a behavioural tinnitus management program. So the goals of tinnitus treatment are not actually to get rid of the tinnitus itself. And there's a researcher named Moller who did a lot of in investigation into this in the 1980s. And I think that he really said this best. So I'm just kind of quote from here. And what he said was that tinnitus is not just one thing, it's many things.

So when people say they want to cure tinnitus, it's very much like saying they want to cure cancer or cure pain. And the problem that we have with that is that the cancer pain and tinnitus are all not one single thing. They're multiple entity things and each has many, many forms, shapes, sizes, manifestations, and perceptions, of the way you hear it. And further, it's important to realize that the perception of the tinnitus itself varies greatly from between each person that experiences it. So researchers like Moller, reasons that curing cancer, tinnitus or pain with a single solution, it is a noble cause and an honourable goal, but it's very, very unlikely to happen just because of the nature of the condition that we are trying to manage.

The goal of tinnitus treatment

So bearing that in mind, the goals of successful tinnitus treatment are to reduce the impact on quality of life that the tinnitus has for the individual and to habituate to the perception of tinnitus. And that is a fancy way of saying that getting to the point of being accustomed to the tinnitus, that the brain actually starts to filter out the sound of the tinnitus, just like it would with traffic noise outside of a window, or a noisy fridge or planes or trains taking off near your home, if you live close to a station.

And the best way to do that is through behavioural tinnitus management programs. And the one question that I get pretty much every time I see a new tinnitus client is, "Do these programs actually work?" And the shorter answer here is absolutely. Almost every single behavioural tinnitus management program that's well-researched has a document SID success rate and the most successful programs are based in cognitive behavioural therapy and cognitive behavioural therapy, or CBT is a type of psychotherapy in which negative patterns of thought and maladaptive behaviours about a trigger, in which in this case is tinnitus, are challenged in order to alter our unwanted behaviour patterns or address the mood challenges related to that trigger. And CBT, in combination with sound therapy, has the highest success rate out there for successfully managing tinnitus. And we see rates of about 80 to 87%. So that's a really, really good outcome if you're engaging with a treatment.

The realities of tinnitus treatment

Now, it's really important to talk about the realities of any treatment program. We can talk about that 80 to 87% success rate, and that's the success rate of achieving our two treatment goals. Number one is reducing the impact of tinnitus on the quality of life. And two is habituating to the tinnitus, but the reality of behavioural tinnitus management programs is that you are going to be working with a multidisciplinary healthcare team. So behavioural therapies tend to require patients to see multiple health specialists, that could be doctors, audiologists, other professions, and this can sometimes increase the complexity of the treatment as well as the cost of the treatment, whether that's done through the public or private system and kind of the onerous nature of it, because you will be going to multiple appointments in multiple places in some cases. We also have to consider the time and effort that behavioural therapies take because they often require multiple clinical sessions over several months or even years for some patients.

So the results are cumulative and they actually do usually require that you fully complete the full course of clinical sessions. So it can be quite timely. And it does require a lot of effort to get there and to schedule those appointments and make sure that you're staying on task with them. And finally, we have our commitment, and this might actually be the most important factor. And that's just that all tinnitus management systems require the patient to embrace the treatment with an open mind, with positive expectations, and a willingness to participate fully in the activities and exercises to the best of their abilities. And simply put, that's you get out what you put in. So the more effort that somebody puts in towards it and is committed to the process and says, "You know what? This is going to work for me and I'm going to make it work for me." We really do see great success. But again, that does take that time and effort component. It takes a bit of diligence and discipline to actually go through with that.

Tinnitus management programs

Now there are many well-researched tinnitus behavioural management programs, every single one of them has been shown to be effective. We touched on that before, or at least the ones that are listed here, but at Broadmead Hearing Clinic and Oak Bay Hearing Clinics, we kind of reviewed all of the available programs and evaluated them for things like cost to the patient and the ability to customize the program to the patient's needs. And after doing that review, we selected Tinnitus Activities Treatment. So that's what we offer here at Broadmead and Oak Bay Hearing Clinics. Specifically, we chose Tinnitus Activities Treatment or TAT, as I refer to it, because it's one of the most well-researched programs. And it has these ongoing studies at the University of Iowa. So they're continually evolving this program and integrating new research to make it better so that you don't get this stagnated treatment that's really out-of-date.

It takes a highly patient-centred approach with a customizable format. So they do have a standard kind of flow of the treatment, but not everybody needs every single component and we can easily customize it to what the needs of the patient are. And it has really excellent activities that engage the patient and facilitate that commitment and compliance piece, which has been difficult for patients in the past. And not only that, but it's incredibly cost effective for our patients because the materials are provided free from the University of Iowa to the clinicians. And it's completely compatible with the requirements of third party insurers like Veterans Affairs Canada, and WorkSafeBC, which is important for a lot of our clients.

Tinnitus Activities Treatment

So some of the components here of Tinnitus Activities Treatment is that it is a behavioural tinnitus management approach. It's heavily based in CBT, or cognitive behavioural therapy. And it uses that CBT-based counselling in a picture format. So we use picture-based format to increase the kind of standardization across clinicians and make sure that the clinician doesn't skip over important concepts. And we kind of ensure that our sessions flow in an orderly way by engaging with that format. It does follow an incremental and learning-based approach, to explore the four key areas that tinnitus can have an impact on somebody's quality of life, those being thoughts and emotions, hearing and communication, sleep and concentration.

And with this program, we do use activities or homework, so to speak, and journaling, to engage with the patient, demonstrate their understanding of the key concepts that we cover with the program, and to track people's progress. It also is a really nice thing to look back on and completion of the course, if you do end up having a surge of your tinnitus, looking back at what were successful management strategies for you, you're not required to base this into your memory. You can actually look back over all the work that you did through the program and see what worked for you.

4 guiding principles

There's four key guiding principles to the TAT program. One is that we help the patients develop really realistic expectations for treatment. We provide informational counseling using pictures. So that's our picture-based counseling. We customize the program to meet the needs of each individual patient. So we take a very patient-centered approach because everybody's a little bit different in what bothers them about their tinnitus. And finally, we do advocate for the use of sound therapy through Tinnitus Activities Treatment. And we usually set this to the lowest level that provides relief for the patient.

Beyond that, TAT actually also fits very nicely into our three general guiding steps of tinnitus management. So our phase one is our assessment or medical clearance phase and with TAT, that means the standard audiogram that we discussed earlier with two questionnaires. So those are two tinnitus questionnaires. One is an open-ended questionnaire. 

So you have the patient list the problems that tinnitus causes in their life. And this gives us insight as to why the patient's there, what bothers them about the tinnitus and often helps us identify some treatment goals. And then we also use standardized questionnaires. There's four available. My favourite, I think that the kind of easiest for the patient and the easiest to interpret is the tinnitus activities questionnaire. These are standardized scored questionnaires, and they really do help kind of identify which area is the most problematic for the patient.

So that's that thoughts and emotions, hearing, sleep, or concentration areas. And they also help clinicians and patients communicate to other professionals who may not be as familiar with tinnitus management, what kind of impact the tinnitus is really having. And that can be super important, especially in cases of tinnitus developing after a motor vehicle accident or tinnitus developing after a workplace accident, or even after somebody's service, where they were exposed to tons of noise through serving with the military or Navy, or what have you. It kind of helps us demonstrate, "Hey, there's a real issue here. It's quantifiable. And this is how we talk about it. And this is how we demonstrate progress in our management program."

Tinnitus questionnaire

So this is an example of the tinnitus activities questionnaire. It's actually a 20 item list and you rate the statements in terms of their truth from 0 to a 100. So that gives us some very precise data points. And it allows us to kind of focus on which areas are most problematic for you. So kind of wrapping up our phase one for our TAT is we provide the thorough audiological evaluation. We do our tinnitus characterization measurements, and we provide referrals to other professionals as needed.

And then we do a little bit of an intro. So we familiarize the patient with their hearing test result. We provide information to them about tinnitus and we score the questionnaire to build the treatment. And this here is a typical outline for what treatment might look like. So depending on the questionnaire scores that you may need, all of these sessions, or maybe just a subset, like the introduction, sound therapy... Rebecca, we're getting to that. Thoughts and emotions and hearing and communication. Some people will require the sleep module, others, just the concentration. Again, this can be very, very flexible, and we do that based off of the evidence that you provide us with. So it's an evidence-based approach.

Tinnitus treatment

So coming in here to phase two, which is treatment. Sound therapy. So coming back to our 80/80 rule, about 80% of people with hearing loss have tinnitus and 80% of people with tinnitus have hearing loss. So sound therapy is a tool that we can integrate to treat actually both of those symptoms. So what we're essentially doing there is using masking, so some low level sound, to kind of partially cover the tinnitus. And we also use amplification. So that's treating a hearing loss using amplification or hearing aids to reduce the contrast between the tinnitus and the acoustic environment. And that helps promote habituation of the tinnitus and deals with the awareness of the perception of our tinnitus.

Usually for our masking, we're going to be using soothing or relaxing sounds to reduce the stress or anxiety related to the tinnitus, which originates in our limbic system. And then we also can use things like interesting sounds that kind of distract the patient from the tinnitus. So that's not at a lower order. It's kind of more higher ordered cognitive processing there. And you can do that using podcasts or radio shows or meditations, kind of something that requires active listening and attention. Now let's talk a little bit more about sound therapy. So coming back to that 80/80 rule, we know that tinnitus and hearing loss go hand in hand, but only about 50% of people who have tinnitus and a documented hearing loss use hearing aids. So I'm just going to start a poll here.

And I just want to know from our audience, if you were to attend a tinnitus evaluation and your audiologist came out with the results that you have a high frequency hearing loss that is likely causing your tinnitus and they recommend hearing aids to manage your tinnitus and hearing loss, would you use the hearing aids? So I'm seeing a lot of hands up. I'm going to take a look at the chat, because sometimes I think that the results of the poll can kind of go flying through there. All right. I'm seeing lots and lots of people responding here, 20 responses, great, climbing up there.

So we're at about a 100%, everybody that is responded to the poll. And I see a lot of hands up are saying, "Yeah, for sure. I would use hearing aids if my audiologist recommended it to manage my hearing loss and tinnitus." And with our data that we have, we know about 50% of people who receive that news and receive that recommendation actually follow through on it. So I think about half of us are maybe a little bit too confident in our positive yes response, but I will say that it's great to have the intent there because hearing aids are one of the most effective management strategies for tinnitus and sound therapy delivered through hearing aids is actually far more effective for populations with hearing loss than using sound played through Bluetooth speakers or pillow speakers or any other sort of external sound source.

Tinnitus behavioural program

So the other component here, it being a behavioural program. So we have the sound therapy and again, that's going to be our relaxing sounds. Sometimes that's going to be our information-based masking or even just amplification. We also have the behavioural components. So we're going to be introducing strategies and information about managing tinnitus in those four key areas, which are those thoughts and emotions, hearing, sleep, and concentration. Now the pro purpose here is to facilitate patient engagement with the program and encourage the commitment. So we do a really, really structured program where we're providing information in a module-based format. So those picture-based modules, and at the end of each module, we provide activities that we require the patient to complete before engaging with the next module.

So an example of a TAT activity is journaling and TAT is rooted in cognitive behavioural therapy, which also integrates tons and tons of journaling. Generally, we use journaling to identify patterns in our thoughts and behaviours surrounding our tinnitus and through journaling, we become observers of ourselves, objective observers of ourselves, where we kind of can see where our problems are, where we might be telling ourselves stories about the tinnitus that may or may not be true. We do kind of listing successful management techniques within our journaling. So a typical journal might look like, "On this day I was reading in a dead quiet space and my tinnitus felt really loud and intrusive at that time.

So I implemented my sound therapy strategy. So that might be switching a mode on a hearing aid or using a Bluetooth speaker to play some low level sound while I was doing my reading. And my tinnitus was far less noticeable after that." So we would then know from the journal on that date that using low level sound or masking was effective for that person. We also provide concentration exercises because our concentration on sound is actually modulated consciously when we allow it to be. So we can do some exercises where we're focusing on specific sounds in our environment and then refocusing on our tinnitus and then focusing on the other sounds. And we can actually observe how our brain can shift its attention.

A few questions...

"How do you categorize pulsatile tinnitus?"

Now pulsatile tinnitus can be subjective or it can be objective. So that is actually a really great question, that kind of highlights why it is so important to have a tinnitus evaluation with somebody that is qualified to provide that service. In some cases, pulsatile tinnitus is objective. So we see that in cases where there is a blood vessel that is in close proximity or has kind of migrated to sit right next to the auditory nerve. So that's one condition that we see. We do also see glomus tumors sometimes, where there's a little kind of net of blood vessels that sit on the eardrum and they kind of pulse as the blood flushes through them. So that's pulsatile tinnitus. Usually, we would send somebody for medical imaging if they had pulsatile tinnitus. And if that came back clear, then we would classify it as a subjective form. So that's how that's diagnosed thermally.

"How long does the TAT program usually run?"

So that is a great question. We usually do about one session per month or each session is separated by two weeks to a month. So there's a total of six sessions that can take place. Most people get that completed within six months. Not everybody needs every session though. So we do see people going through that program a bit faster, Judith. Rebecca, great question. "How much do these programs cost?" So the cost of a Tinnitus Activities Treatment program at Broadmead Hearing Clinic... I'll just pop you back to the end here. For the initial evaluation is $150.

Each of the modules is an hour long and it costs $150, if ear level sound generators are prescribed. So that's for somebody that has normal hearing. If you have normal hearing and tinnitus, then ear level sound generators cost $1,800 for a pair. If you do have hearing loss, we would recommend using a hearing aid. So you would be looking at the cost of whatever hearing aid is recommended. We would not typically charge extra for the tinnitus modules at that point, because we could do that with our follow-ups for the hearing aid fitting.

"How long, from start to finish, does the TAT program take?"

And again, that can be completed within six months. Somebody asks, "Are tinnitus sounds both high frequencies and low ones?" And absolutely, tinnitus can sound like so many different things. I've heard people describe their tinnitus as the low rumble of a truck going by, and others will describe it as the high pitched whine of a mosquito flying by their ear.

"I've had tinnitus for four months and I know it comes and goes, but I haven't had a single event in over three weeks, is this normal?"

And in this case, the individual says that their tinnitus is tensor tympani and stapedius myoclonus. So that can be a form of objective tinnitus. That's actually a very interesting form of objective tinnitus. One that I could sometimes record with my equipment here. Usually, there's different triggers that can cause that just like any myoclonus or even an eye twitch can occur. So I would recommend checking in for an appointment on that one, but intermittent tensor tympani and stapedius myoclonus is actually quite typical. It doesn't usually stay for months and months. It doesn't tend to be chronic.

"Please discuss medications causing tinnitus."

Anne, I'm not going to go into a full discussion of medications causing tinnitus because I think that it's really, really important to integrate the best professionals to do that. And usually, I would like to invite a pharmacist for that. Medication can sometimes contribute to tinnitus. Usually it's a side effect. It's very typical in aminoglycoside antibiotics, cisplatin, which is a cancer treatment. We also have heart and blood pressure regulation medications often will cause a little bit of tinnitus as a side effect and the most common one, actually, that surprises a lot of people is aspirin will cause tinnitus as well. It also causes hearing loss while you're using it. So Anne, there you go.

"Why does the tinnitus level rise and fall at different times?"

And then the subsequent question was, "Can tinnitus get worse with sleep deprivation?" And the answer to both of those questions is kind of similar. Number one, yes. So tinnitus level will rise and fall. Often, this is actually not related to the level of neural activity in the auditory tract. It's the limbic system or the hippocampus in the limbic system, which is part of the brain, that filters or monitors our sensory information. So at any given moment, we have so much sensory information coming at us. We have sights, we have smells, we have sounds, we have sense of clothing on our bodies, our sense of touch. And some of that is monitored consciously. And some of that is monitored subconsciously. And our subconscious system is basically just taking in all this information and deciding what amount of that information needs to be made conscious or needs your attention.

And usually, the things that get our attention are perceived as things that might be a threat to our wellbeing, things that are unexpected, things that are scary or things that are new to us. Tinnitus can often fall into one of those characterized and be misidentified by the limbic system in our brain as something that's really important, just like a fire alarm or what have you would be. And that comes down to our habituation. So over time, we can actually learn different responses to the tinnitus. So we experience tinnitus and nothing bad happens or we experience tinnitus and we have a really bad day, and that kind of leads to different outcomes or different responses to the sound of the tinnitus. But generally, what's happening there when our tinnitus gets loud or becomes more noticeable is our limbic system stops filtering out that tinnitus.

And usually, we find that in quiet spaces where there's not a lot of other external auditory information coming at us, we become quite a bit more aware of the tinnitus. Another situation is if we've had a stressful day and then we finally sit down and try to relax. Our limbic system is a bit hyperactive in that case, we have quite a few more stressed hormones flowing through our body. And so our tinnitus is perceived as loud. Our limbic system doesn't filter it out. Similarly, a lack of sleep, sleep deprivation will also make our tinnitus louder or contribute to our sense of tinnitus being annoying because our limbic system is not as efficient at filtering out that tinnitus when we have a lack of sleep. Ron has asked, "Does tinnitus increase with age?" We actually have some evidence that yes, but not because tinnitus is part of our natural aging process.

Usually, it's that hearing loss is part of our aging process and about 80% of cases of hearing loss will present with some tinnitus. So that's why we see more tinnitus in a higher age group there, Ron. "Does high blood pressure affect tinnitus?" Sometimes. Yes, that is a great question there, Trisha. Sometimes it does. Sometimes we get something called venous hum. Venous hum is a condition in which the blood flowing through our veins actually makes noise. And that's a form of objective tinnitus. Sometimes our blood pressure will change and will actually kind of face a situation where our nerves are just being activated by the rushing of blood in that area. So we get a little bit more spontaneous activity in our auditory nerve fibres.

"Are extreme low frequency sounds a problem?"

So Lynn, I'm not going to answer that same question. What I'm going to say here is that loud sounds are a problem. Noise exposure can be a problem. So whether that loud sound is high pitch or whether it's low pitch, if we are exposed to really, really loud sounds, especially impulse noise, like a jackhammer or a kind of repeated... Some people are shooting guns recreationally, or what have you, loud sounds are problematic and they will often cause tinnitus. They will sometimes cause a temporary hearing loss, which recovers, but the tinnitus remains. And sometimes they'll even cause a permanent hearing loss at the same time. Low frequency sounds, we don't worry too much about the pitch component. Low frequency sounds can just be annoying because they can travel so far. They have a long wavelength and they can kind of pass through concrete and things like that.

"Does low blood pressure affect tinnitus?"

I would describe this as blood pressure affects tinnitus. If you have your what's called homeostasis or a healthy blood pressure that stays within a given range, if we fall outside of that range, if it goes high, we can expect some tinnitus. If we go low and we experience what's called presyncope or before we faint, right before we faint because our blood pressure has gone so low, we will often experience quite a bit of tinnitus in that situation. And that's just because your nerves are going, "What is going on here? There is such low blood pressure. I'm not getting the oxygen I need." And they start to spontaneously fire quite a bit. You'll also notice that the body starts to sweat. We feel really uncomfortable. Sometimes get a bit dizzy and have to sit down in that situation. So yes, blow blood pressure can contribute to a sense of tinnitus. Ear pain or pressure.

"How is tinnitus related to otosclerosis?"

Otosclerosis, absolutely. Tinnitus is actually one of the first symptoms of otosclerosis. Otosclerosis is a condition in which our auditory bones or our ossicles, which are in the middle ear, start to fix themselves in place. They become very stiff and they no longer transmit as much sound through to the cochlea, which is our sensory organ of hearing. In that situation, what we see happening is there's a cellular process where our bone actually starts to become spongy in the early stages. And that changes the way that sound is transmitted to the cochlea, that interferes with the transmission of sound from the outer hair celAnd the movement of our ossicles or ear bones moves the fluid in the cochlea and the cochlea is our inner ear. And inside of our cochlea, we have things called hair cells. And those are our sound receptors. And the disruption of the little projections that look like hairs is what tells the hair cell or the sound receptor to send a message to the nerve fibre that is connected to it that a sound has occurred and to create activity or nerve activity, which is then interpreted by the brain. But our hair cell communicates with that nerve fibre by releasing chemicals and the chemicals are absorbed by the nerve fibre. And that's what tells it to become I'll show you this here. So the way we hear is that we have a sound source of vibrating in the environment that creates sound waves, which enter our outer ear and are kind of amplified because our outer ear is a resonator. Those sounds vibrate our eardrum and the bones attached to the eardrum and our ear filled space.

When we develop otosclerosis or when we have strange ear pressure or we have fluid behind our eardrums, that whole system is thrown a little bit out of whack. It changes the way that ear bones move in the socket, in the inner ear or the joint. And that kind of disrupts the way the wave travels across our hair cell, the hair cell then releases chemicals in a kind of more abnormal way. That's called synaptopathy. And we end up with this kind of net increase in spontaneous neural activity. So we can look here. This is a good example of this.

What we see here is we have normal hearing. Our auditory nerve fibres are actually never dormant. We have spontaneous activity on the nerve, which we typically don't hear, but we can measure it using something called otoacoustic emissions. When we have hearing loss and no tinnitus, what we see is that we have less spontaneous activity because we've often lost some nerve fibres. So there's less fibres to carry that information. But we actually see a net reduction in the spontaneous activity if we have hearing loss with no tinnitus. But when we have hearing loss and tinnitus, we actually see an increase in the spontaneous activity of the nerve fibres So you would think that we'd see less because we're not getting as much activity from the sound receptors, but we actually see this net increase and that spontaneous activity on the nerve fibres, that increase is actually interpreted by the brain as sound. So that's what that tinnitus really is and what it's doing.

TAT picture modules

I do have some examples here that I just like to show you that these are examples of what the picture modules offered through Tinnitus Activities Therapy are, these are some pulled directly from some of the modules, which I've actually used to answer some of the questions so we can see that it is a helpful resource there. What we can see here is when we kind of talk about habituation and talk about different reactions to sound, is that our brain can learn a response to a sound. So in this case, we have a doorbell and a reaction can be neutral.

So if we have a sound like a doorbell and we don't have a great emotional reaction to it, then it's probably not going to bother us. We're going to just go investigate. If we have a sound and then a consequence that is adverse or scary or unexpected and unpleasant, then that doorbell is going to produce anxiety for us. And the next time we hear a doorbell, we might be a little bit wary of going and answering that door because we had a bad experience the previous time. We can actually learn a new response.

So if we have one of these neutral sounds like a doorbell, which in and of itself, that sound doesn't carry a whole lot of information. And then we have a consequence that is positive or pleasant and that we enjoy. Then we can change our experience of that sound. We can interpret things differently and we can say, "Okay, this sound was very negative for me in the past when I had that negative experience. Now I recognize that I've heard this sound and other consequences can arise from that sound. So I no longer have this adversarial reaction to it. I can neutralize that.

Keeping in mind here, that things that capture our conscious attention are things that are unusual, things that are important, so signals and alerts, or things that are scary or unexpected. And we tend to notice things that fall into those categories and we tend to ignore or filter out things that are not important, or don't fall into these four categories. So examples here could be a loud refrigerator. That's a sound that it's unimportant. It doesn't carry a whole lot of information for us, it's not scary, it's not unusual, what have you. And what we'll see there is that our brain will filter that out, our limbic system does that very effectively. Situations where we have something scary or unexpected, if we hear a lion roar or a dog bark very close to us that we weren't expecting, we generally cannot ignore it. It grabs our attention very quickly.


And there's also situations where we can hear sounds that we're exposed to, and we can monitor that information for something that might be important, but we don't have to attend to every single sound in the environment consciously. So that's an example of a crowd. So we also have our tinnitus and attention. So we have to consider our two types of attention here. We have subconscious and conscious attention. Our brain monitors background sounds all the time. This is normal. It's a subconscious process. We're usually not aware of that. We only really pay attention to the important, strange, fearful sounds. And those tend to be monitored more closely, or when those are in our environment, we tend to be a little bit more alert to the sounds or if we're expecting a certain sound, that doesn't happen at a predictable time.

If we can reinterpret the tinnitus as an unimportant sound, what we'll see is that we pay less attention to it. And over time, our brain recognizes that there is no unexpected or poor consequence that arises from the tinnitus. So we become less bothered by it. And our limbic system in our brain is less likely to closely monitor that sound. And then we eventually habituate to it and actually have to get to a point where we have to pause what we're doing, think about the tinnitus and listen for it to be able to hear that sound.

This is where I'm going to leave things for today. I think that it's important to always appreciate just how complex the process is for the way that our brain interprets sound. We kind of have all these different steps along the pathway, where we have the sound being coded into neural code by the cochlea, it then travels up our brain stem for subconscious monitoring. And that's our limbic system, which decides whether those sounds are going to be consciously perceived or heard and interpreted and get our attention. And then we have these adjacent processes. So we have emotional reactions to the sound, whether we want to or not. And we also have experience or memory with sounds that contribute to the way that we interpret given sounds.

We can consciously monitor and change the way that our brain interprets information. And that is a key component that we look to with Tinnitus Activities Therapy. 

If you want to know more about Tinnitus Activities Treatment, schedule a Hearing Evaluation with an Audiologist. Please call: Broadmead Hearing Clinic: 250-479-2969 or Oak Bay Hearing Clinic: 250-479-2921.