Dr. Wright's Blog

Audiologist Martine Schlagintweit shares an in-depth view of tinnitus, its causes, and components of a successful tinnitus management program.

You will learn:

• The definition of tinnitus
• How often tinnitus occurs
• Causes of tinnitus
• Neurophysiological model of tinnitus
• Can tinnitus be cured?
• The components of an effective tinnitus management program

This talk was originally presented as part of the Healthy Hearing Online Expo.

Read the video transcript: 

Martine: Hello, everybody.

Doran: Nice to see you. So yeah. So, I just want to say a couple words about your presentation. I mean, it's often misunderstood, so that's one of the reasons why we chose this as a topic. A lot of questions around what it is, the cause, the cure, so I'll turn it over to you for our Tinnitus presentation.

Martine:  Thank you so much, Doran. Thank you for that introduction. Good afternoon, everyone. And thank you so much for joining us today at the Healthy Hearing Expo, our first virtual Healthy Hearing Expo, no less. I'm excited and so honored to present to you today, because tinnitus is one of the main reasons that people interface or seek audiological care. And it's a symptom that can have such a huge impact on people's quality of life. So, it's a great topic for us to discuss today.

What you’ll learn about tinnitus today

A couple housekeeping things here first: Through this presentation, we're going to define what is tinnitus. And we'll also look at how common tinnitus is, and identify the known causes for this symptom. Next, we'll unpack the neurophysiological model of tinnitus, which is the way that tinnitus is best explained by science today. And in the latter half of the presentation, we're going to talk about whether tinnitus is curable, and outline the journey of effective and successful tinnitus management.

It's my hope that, by the end of this talk, our audience will be able to define tinnitus, and explain it using basic physiology and the neurophysiological model, will be able to identify the common causes of tinnitus, and understand effective management strategies for tinnitus. But also, it's important that you walk away today with the knowledge of when it's important to consult your physician if you have tinnitus.

What is tinnitus?

So, what is tinnitus? Simply put, tinnitus is an involuntary perception of sound that comes from inside your head or ears, and which lacks an external source. Now, as a point of interest, the Latin root of the word tinnitus means to tinkle, which sounds kind of pleasant. But it's most often described as a ringing, buzzing, roaring, hissing, or even whooshing sound that comes from inside your head. Tinnitus is also typically associated with really negative emotions and reactions like you see in this Edvard Munch painting, titled The Scream, here, which actually many people believe to make reference to the experience of tinnitus. So, that's kind of interesting.

Now, tinnitus is a symptom. It is not a disease in and of itself. And it's incredibly common, especially among individuals with hearing loss. In fact, about 10 to 20 percent of North Americans, and about 85% of people who also have hearing loss, report chronic tinnitus. The prevalence increases with age and severity of hearing loss. And more men report tinnitus than women. And this actually relates to the leading known causes of tinnitus being noise exposure and hearing loss, both of which are more common among the male population.

Now, that being said, only about one in five people that have tinnitus are bothered by their tinnitus. And that 20% reports negative comorbidities that present with or as a result of their tinnitus. And these can be things like sleep disturbances, difficulty concentrating, social withdrawal, and in the more severe cases, emotional disturbances like anxiety and depression. I'm going to go back here. I'm interested to note, just because tinnitus is so common and we do have quite a few people in the audience today, who of our audience has tinnitus? So, I'm going to launch a poll here. And you're welcome to respond with the box that jumps up on screen. So, let's give that a couple minutes. Whoo, we're almost at 100%. Climbing...

Okay. So, let's give this another 10 seconds here. We've got about half of our audience responding. Okay. Five, four, three, two, one. Okay. I'm going to end polling there. And I'm going to share those results with you. So, we can see that about 80% of our audience today, of those that responded, actually experience some tinnitus. So, that gives you an indication that it is such a common, common symptom that many of us do experience at times. I'm just going to stop that there, and I'm going to close out that poll. And now, the problems in our audience may actually exceed that of the regular population.

What causes tinnitus? 

And that may be because most of the clients that seek our services have hearing loss. And many of those clients have also been exposed to noise, which is the root cause of their hearing loss. Now, we know that noise exposure and hearing loss are the top known causes of tinnitus. But we should clarify that noise exposure alone, even if it doesn't cause a permanent hearing loss, can still cause tinnitus. And it often does. I don't know if anybody here has ever been to a concert, and afterwards, when they get home, their ears are just ringing as a result of having that noise exposure.

Other common causes of tinnitus include degenerative changes associated with aging; head, neck, or back injury; and medication side effects. And things like excessive ear wax, middle ear pathology, ear infections, temporal mandibular joint issues, and stress have also been demonstrated to cause tinnitus. So, we can see here that tinnitus has so, so many causes. And part of that likely relates to the fact that the auditory system only has so many symptoms available to it that it can present with, when things are changing or going wrong with it.

So, you can get tinnitus, dizziness or vertigo, hearing loss, pain in the ears, a sense of coldness or pressure, but that's about it. And so, that tinnitus is your auditory system communicating with the rest of the brain and body that things are going a little differently. Now, we've defined tinnitus as a symptom, and the experience of tinnitus as a symptom. But what actually is the tinnitus? What is responsible for our experience of that tinnitus? And essentially, tinnitus is the auditory nerves coding for sounds that are not present in our environment. So, in that sense, we can think of tinnitus as this extra neural activity that's present in our auditory pathway, which the auditory cortex, or the part of the brain that deals with sound, is correctly analyzing as a ringing, buzzing, or hissing noise. 

Is tinnitus real?

Now, I'm interested to know, more as a point of interest, because I don't think there's great consensus on this in the field... But I'd like to know, from all of you, whether you think that the sound that people hear when they experience tinnitus is real, based off of this description we've just given. So, I'm going to add that as a poll. And feel free to vote, okay? And we'll let that go for about 20 seconds. Ooh, we're divided. I love it, contention in the audience. Okay. All right, 10 more seconds here. Let's see if we can get most of our audience voting. We're up to 70%. Let's see. All right. So, I'm going to end polling here. And I'm going to share those results with you.

And I'm delighted to know that most of our audience agrees with me that the sound that people hear when they have tinnitus is real. And the reason that I think that is because our auditory nerve is sending signals, up to the auditory cortex in the brain, that mimic that of sound. And that is very similar to the way it does so when there is an external sound. So to me, that is a real sound that people are hearing, whether or not other people can hear it too. So, I'd like to introduce you to the neurophysiological model of tinnitus in just a moment here. But in the meantime, I want to talk about the two different types of tinnitus.

Types of tinnitus

There's subjective tinnitus, or sensory neural tinnitus, which is thought to originate in the inner ear and central auditory pathways. So, those are the auditory nerves. And this is the most common type of chronic tinnitus. And subjective tinnitus is going to be the main focus of our presentation going forward. But we need to give objective tinnitus its moment as well, okay? Objective tinnitus is a sound that originates inside the body. It can be amplified, heard, or recorded by an observer. So, it is a real sound that we can even record and play for others.

Everyone should have some degree of objective tinnitus, because our physiological processes, like swallowing, digesting, popping our ears, etc. actually make sound. And that is sound that is generated inside the body. But in problematic cases, this type of tinnitus can be associated with injury, infection, or abnormalities to the anatomy of the middle and inner ear like, for example, twitching of our middle ear muscles, which we can then hear as a ticking sound. In these cases, treatment with medical or surgical intervention is often indicated. And most of the time, it will actually cure the tinnitus.

And so, that's why it's a really good idea to have your tinnitus observed and evaluated by an audiologist when you first notice it, because that may be you.

The neurophysiological model of tinnitus

You may be experiencing objective tinnitus that would benefit from medical intervention. Next, we're going to come back to our subjective tinnitus. And I'd like to introduce you to this neurophysiological model. It's the most established scientific description of how tinnitus is generated and perceived by the auditory system. So, Figure A here reveals the entire auditory network involved in the perception of tinnitus. Whereas, Figure B and C separate that out into what's called the Upper and Lower loops.

So, let's go in reverse here. I'm going to focus on Figure C first. This is the lower loop. And this demonstrates the subconscious pathway for tinnitus. And this involves the auditory periphery, so that's the ear, the nerve running from the ear, and the nerve fibers in the brain stem where they connect with what's called the limbic system. And the limbic system is the emotional center of our brain. It regulates the autonomic nervous system. And the autonomic nervous system is responsible for the body's state of fight or flight, or rest and digest. Okay?

And so, this subconscious pathway is the tinnitus being generated along the auditory nerve or in the ear, and communicating with that subconscious limbic system in the mid brain. In Figure B, we see our upper loop. And this is responsible for our cognitive processing and perception of the tinnitus. This loop also starts at the ear. But instead of stopping at the limbic system, it goes right up to the auditory cortex, which is the part of the brain that analyzes sound and assigns meaning to the sound. And then, the auditory cortex sends nerve projections down to the limbic system. And in this way, it further modulates our emotional and autonomic response to the tinnitus. Okay?

Now, the upper loop is most active during the initial stages of bothersome tinnitus, whereas the lower loop is most active during chronic tinnitus. So essentially, what's happening there is, as the person becomes aware of their tinnitus, cognitively aware of their tinnitus, they make decisions about whether this is a good sound or a bad sound, and may experience some confusion about where is this sound coming from. And that sends projections to the limbic system, or the emotional center, which starts to generate a reflexive response to the tinnitus, which impacts our whole body because it releases those autonomic nervous responses of fight or flight, and rest and digest.

Now, the block diagram can be a bit abstract. But I do like to include this figure here, because it shows you whereabouts these things are happening in the brain. Mind you, this figure in particular, is borrowed from research that actually looks at the brains positive response and reactions to music and pleasant sounds. Because incredibly, that process is very similar to the process involved in our reflexive responses to tinnitus. It's just that our emotional brain, the limbic system, has attached a label of threat to the tinnitus, whereas it has attached a label of friend, or pleasant stimulus, to the music.

Is there a cure for tinnitus?     

So, here is the million-dollar question that I'm sure everyone would like an answer to today. Is there a cure for tinnitus? And the short answer is no. There have not been any safe or consistent treatments for tinnitus that can act to silence the noise or sound that people perceive when they have tinnitus. We cannot actually change the tinnitus, but we can manage our reactions to it. And by changing our reactions to the tinnitus, we can make it less of a problem for us, and we can avoid the adverse psychological effects of tinnitus. So, the key there is to learn to manage your reactions to the tinnitus. And the goal is to live well and feel better, whether or not that tinnitus persists.

Paths to successful tinnitus management

So, the first step in successful tinnitus management is to have your hearing evaluated by an audiologist to determine an appropriate treatment plan. The audiologist will determine whether the tinnitus is suspicious for an underlying condition that could benefit from medical or surgical intervention. And in this case, they will provide a referral to your primary care physician to get that under way. Provided there are no treatable underlying conditions, they will work with you to develop a personalized tinnitus treatment plan. And depending on the audiologist, this may follow a more structured intervention strategy, or a blend of several. And we'll take a look at those interventions shortly.

But first, I'd like to talk about when it's appropriate to see your physician if you have tinnitus. Now, in most cases, having tinnitus does not mean you have to see your physician. But in the odd time, such as in the case of objective tinnitus, you can benefit from seeing a primary care physician, or ear nose throat specialist. And indications that this would be necessary include: sudden hearing loss and tinnitus presenting together; injury to the ear, causing tinnitus; weakness or paralysis of the face that accompanies tinnitus; vertigo or extreme dizziness; ear pain with the tinnitus; blood or drainage from your ear. That's never good; single sided tinnitus; and pulsatile tinnitus.

Your physician or ENT specialist may order medical imaging and other test to further investigate that tinnitus. And the objective of those tests is to identify any causes of tinnitus that may benefit from that medical or surgical intervention. And if nothing is found, that tinnitus is considered idiopathic, or without cause... or without identifiable cause is a better way to put that. And in that case, medical clearance is given for that tinnitus. Now, people are often very, very disappointed with the outcome of medical clearance for their tinnitus, because they perceive that news as being the practitioner telling them to learn to live with it, or just get over it. And that couldn't be farther from the truth, because what that medical practitioner is telling you is that their portion of the diagnostic process is compete, and your tinnitus is in a management stage.

So, how do we manage tinnitus? There is two main approaches for tinnitus management strategies. And the first is to eliminate or reduce the perception of the tinnitus. And the second is to modify the individual's reaction to the tinnitus. And most clinical interventions that are being used today actually use a bit of both of these approaches. Starting with tinnitus retraining therapy, this is one of the more structured methods of tinnitus management, and has been available since 1990. So, it's been around for 31 years now. And this method is based off of the neurophysiological model of tinnitus, which was actually developed by Jastreboff, and later Jastreboff and Hazel, which are the developers of this tinnitus retraining therapy.

The goal of this treatment is to promote perceptual habituation of the tinnitus, as well as emotional habituation of the tinnitus. Habituation refers to the brain's ability to filter out repetitive sensory information. An example of auditory habituation that you might experience in your day to day lives, or might have come across at some point, is if you live in a quiet rural area, or visit a quiet rural area, and then move to a home next to, say, a train station or some source of noise. You may initially be bothered by that source of noise, as the trains are passing by your residence. It might even wake you up at night or prevent you from concentrating on the quiet activities.

But as your brain habituates to that irrelevant and unimportant signal, what you find is that you barely notice the trains going by. So, the attention is not being given to that signal anymore. And you can return to your quiet activities without too much annoyance, and sleep right through the night. So, the theory here, with tinnitus retraining therapy, is that about 80% of people with tinnitus, so those 80% that are not bothered by their tinnitus, have successfully habituated to the signal of their tinnitus, and no longer experience a limbic and autonomic response when they become aware of that tinnitus.

But the other 20% that are bothered by it need a little bit of support and guidance in figuring out how to decrease those responses. And they do that, through directive counseling, to habituate that emotional response, so learning how to recognize when one is experiencing an emotional response to tinnitus, and also learning to recognize when one is experiencing an autonomic response to the tinnitus, so going into a state of fight or flight, and using strategies to calm the autonomic nervous system, and allow us to disconnect those two events in the auditory limbic system.

Mindfulness based tinnitus stress reduction     

Once the emotional response to tinnitus has been habituated, we can start to look at habituating the perception of tinnitus. And masking devices or hearing aids are heavily relied upon for the perceptual component of habituating tinnitus. Now, moving on to mindfulness based tinnitus stress reduction, I think that this is a really cool tinnitus management method. And it's adapted from from mindfulness based stress reduction, which developed by Jon Kabat-Zinn in the '70s. Now, this program was originally used to manage chronic pain and illness, and the adverse effects that go along with that. But Dr. Jennifer Gans is a psychologist down in California who best applied the concepts of mindfulness based stress reduction to the management of tinnitus in 2009.

And she had incredibly positive results. And it's unique from other tinnitus treatments because the point of entry does not actually have to be through audiology. And it's not actually necessarily delivered by these professions. Now, that's not to say that having your hearing tested, if you're going through mindfulness based tinnitus stress reduction, is not important. It's still going to be your first step. But engaging with this management program can be delivered by other professions like psychologists, counselors. And it's even offered as an eight-week online course now. The premise of mindfulness based tinnitus stress reduction is to reframe the individual's experience with bothersome tinnitus symptoms, using elements of yoga, relaxation exercises, and meditation.

And the purpose is to bring space between the perception of the tinnitus and our reaction to the tinnitus. So, it's not unlike TRT in that sense. It also encourages us to bring our reactions, judgments, thoughts, and feelings, and stories that our brain creates about our tinnitus to our awareness and evaluate them. So, instead of habituating the tinnitus, this method actually promotes taking an attitude of acceptance, and embracing the tinnitus. Finally, we have Widex Zen tinnitus therapy. And this is another form of tinnitus treatment or management that is based on a neurophysiological model of tinnitus, much like TRT.

Widex Zen tinnitus therapy

It was developed by a researcher named Robert Sweetow, in partnership with a team of scientists and audiologists at the Widex Audiological research department. This method is very similar to TRT in that it involves elements of counseling, habituation, and sound therapy for perceptual habituation. But it integrates a lot more cognitive behavioral intervention strategies into the counseling. And it operates under the assumption that attention is also a key component of tinnitus perception. So, I'm showing in our image here, there's four key areas of Widex Zen therapy that can be combined in varying degrees, depending on the case, to improve the quality of life for the individual experiencing tinnitus.

So first, it starts with a hearing test and initial intake interview, where counseling is provided. That can be information counseling about what tinnitus is, how it's generated in the auditory system. We can also start to integrate some cognitive behavioral intervention strategies here to minimize the distress, or challenge our perceptions and beliefs about the tinnitus because, when the brain is in distress, it is very difficult to think clearly. Next, we have amplification. And amplification is used to correct any concurrent hearing loss. And the basis for this is that research has demonstrated that the auditory nerve fibers that are not being stimulated reliably by sound receptors, due to hearing loss, increase their base rate of firing to compensate. And this is something called bursting.

And this leads to increased tinnitus perception, because what it's effectively doing is creating extraneural activity in the auditory pathway, which is basically our definition of tinnitus. Now, using hearing aids meets the threshold of the sound receptor, causing the corresponding nerve fiber to behave in a more normal way. And this also minimizes the contrast between the sound of the tinnitus, which comes from inside our head and in our body, and the ambient sound around us. So, that can provide a little bit of masking there. Fractal tones are a proprietary form of sound therapy developed by Widex. And there are six pleasant tone profiles that can be programmed into a Widex hearing aid.

And they tend to be more musical in nature, compared to other sound therapies. And they're effective in a few different domains. So number one, they're pleasant. And pleasant soothing sounds have a positive and calming effect on our autonomic nervous system. So, we're managing the autonomic response to the tinnitus right off the hop. Also, these tones were developed to address some of the drawbacks of the other existing sound therapies. So, when you use masking or sound therapy for tinnitus, we don't want to be swapping one annoying sound source for another. Right? So, using really loud static to cover up our tinnitus can be just as annoying, and can interfere with habituation of tinnitus just as much as leaving our tinnitus alone.

So, using that kind of Fractal Tone therapy, what we're doing is we're using a soothing sound, and we're not trying to cover up that tinnitus entirely. Finally here, we have scheduled relaxation exercises, which are integrated into the Widex Zen therapy program to address the contribution of stress, limbic, and autonomic activities' involvement in our perception of tinnitus, and our sense of intrusion based on that tinnitus.

Is one therapy more effective than another?

So, with all of these different intervention strategies, it makes us wonder which one is the most effective?And I know that's always been my question as a clinician, because I always want to make sure I'm giving my clients the best that is available. But the quick answer to that question is, none, or all of them, because 80% of people that engage with tinnitus management programs report significant reductions to the awareness or perception of their tinnitus. So, it actually gets quieter for them. And they report significant improvements to their quality of life. So, they're overall quality of life improves when they're engaging with those programs. Now, recent data reveals that none of the tinnitus management programs are more or less effective than the other. But they all provide that 80% kind of improvement that we see, where 80% of the population is improving significantly. So, the way I take this data is that it suggests that it's useful to participate in tinnitus management programs. But the specific program may not be so important. And that likely comes down to the fact that a lot of them share the same key elements or components.

And those are being that enriched sound environment, so minimizing the contrast between either tinnitus and the ambient sound, and also using hearing aids to treat any sort of underlying hearing loss. They all contribute a sense of habituation or awareness, so taking one of those approaches to live with the tinnitus, and not experience those reflective negative emotions and fight or flight response to the tinnitus. They all integrate an element of cognitive behavioral intervention. Whether they're outright in saying so or not, they do integrate those strategies. And all of them are non-curative. So, they're not looking to influence the tinnitus itself, but rather look at our reaction to the tinnitus.

Complimentary tinnitus management 

On a final note here, almost everybody that comes into the office with tinnitus, and that's being evaluated for their tinnitus, asks about medical or pharmacological treatments out on the market that are designed to treat tinnitus. And there has been a ton of research in this area over the last few years, unfortunately with very little success. Most pharmacological interventions aim to treat the negative adverse psychological effects that are secondary to the tinnitus. And so, in that sense, anti-depressants have been investigated, with little success.

Most interventions aim to treat concurrent illness, such as PTSD, anxiety, and depression. And those treatments that have been developed, most of them are in the category of anti-depressant. And they've shown clinically significant effect. However, that's believed to be because they actually modulate that limbic response, as well as the underlying condition, so the individual's health benefits as a whole, their mental health improves, and then they're better able to deal with that clinical signal, that clinical presentation of tinnitus.

What about natural remedies?

Now, there are infinite recommendations available, regarding the use of homeopathic remedies and vitamins, or supplements, or oils, or CBD, or what have you, for use of treating tinnitus, although there's an absolute dearth of evidence to support their effectiveness. And part of the reason for that is because natural treatments for tinnitus do not have to register with the FDA as a drug. They're actually registered as a food product, and they do not have to supply any evidence of efficacy, or really just even safety, for the treatment of tinnitus. So, be careful about what you read on the internet, especially if it is a supplement, a vitamin, essential oil, or any of that. And make sure that whatever evidence is provided is valid and not just marketing.

What about diet changes?

Now, diet changes are another thing that people often ask. A lot of people that experience tinnitus, that come into the clinic to be evaluated, are sitting down in my chair, and telling me, "I've cut out caffeine. I've cut out alcohol. I've cut out this. I've cut out that." And they're eating these really really restrictive diets that prevent them from enjoying a lot of their kind of meal times. And I want to encourage people to know that there actually hasn't been any evidence to suggest that changing the diet actually impacts the perception of tinnitus. In fact, a study published in 2010, focusing on the effects of abstaining, or skipping caffeine, on tinnitus, actually found that foregoing your regular caffeine intake made people suffer their tinnitus more, and their quality of life went down.

So, the message there is maybe don't skip your cup of joe if you're experiencing tinnitus. Now, all of that being said, most clinicians will take a perspective of, "If it helps and it doesn't hurt, then why not?" I myself have engaged with some of these complementary treatments. And while I didn't find great or vast improvement in my tinnitus, I also found that it wasn't harmful to my overall health. So, do check in with your physician to make sure that is the case, and if you want an engagement that you can go right ahead. All right. So, thank you so much for participating today. I'd now like to open up the floor for questions and discussion.

Questions & Answers

Doran: Martine, thanks so much. So, of course, we just had the power turned off to our entire building during Martine's presentation. So, that was fun. But I think we're back now. Martine, some people are just asking about the closed captioning, if we can re enable that. I think we can.

Doran: So, let me just talk about the presentation. You can tell that it is a complex issue. When we see what's happening when you Google this, there's all kinds of cures out there, and it will stop it immediately. As Martine outlined, and I like the way she said it... Is there a cure for tinnitus? No. There is no cure. And what is my best course of treatment? Also, unknown. Your best course is to try to all of these different techniques that have been shown, to mitigate your tinnitus.

And just like we talked about in Christine's presentation, it's not in the ear, right? It's the entire auditory pathway, the entire auditory processing, that's involved here. So, it's complex. There's no simple answers. There's no one pill you can take, Martine, to solve this. So, what can we do for people? You laid it out as kind of try these things and one of them may work for you. But no, there's no cure. I did get one question through. What is the pulsating tinnitus, pulsatile?

Martine:  That's a great question. So, pulsatile tinnitus is a specific type of tinnitus where the person does not hear a constant tone or a modulated tone, but actually hears the tinnitus fluctuating in time with their heartbeat. That's an example of cardiac synchronous tinnitus. So, as your heart beats, you can hear a whooshing or a beating in the ears. And that is what pulsatile tinnitus is.

Doran:  And the person asked... Because you mentioned it's in rhythm with your heart, is it caused by high blood pressure? Is there any correlation there?

Martine:  No. Pulsatile tinnitus can present with high blood pressure. Now, I will say that high blood pressure always puts you at higher risk of hearing loss. And it also puts you at higher risk of experiencing both subjective and objective tinnitus. And in the case of high blood pressure, you are a little bit more prone to experience that pulsatile tinnitus. But it's certainly not the only cause.

Doran:  Sure. And now, another person says, "Is it dangerous? Is pulsatile more dangerous than another type?"

Martine: No. I wouldn't... I really don't like to classify tinnitus as dangerous. Right? Because today, in our presentation, we've talked about what tinnitus is. Right? It's our auditory cortex coding for sound that does not originate outside the body. Right? It's just a symptom. In many cases, it's a benign symptom. And in other cases, it's the auditory system telling the rest of the brain and body that something is changing there. Now, pulsatile is not a dangerous form of tinnitus, but it is a form of tinnitus that can be objective. So, that's that type of tinnitus that can benefit from medical or surgical intervention.

So, that's why you want to catch that tinnitus with an audiological intervention, and have it diagnostically investigated through the medical health system.

Doran: Exactly. And you talked about stress as well. We have another question about stress in tinnitus. And I was struck by the fact that you said that stress can be a contributing factor in tinnitus. And tinnitus also causes stress. So, it seems to me like a pretty hard loop for some people to get out of.

Martine:  Yeah. That is a nasty little cycle, Doran. So, what's going on there is that, when we are stressed, when we experience stress, our limbic system and our autonomous nervous system work together to put us into that state of fight or flight. So, our body becomes primed to deal with that treat. So, our heart rate can go up. We secrete a bunch of cortisol, which is a hormone, a stress hormone, that cycles through the entire body, and basically tells your muscles, your visceral organs, everything, to get ready to fight/flight, or do something to get out of dodge there. Right?

And so, that is where stress kind of creates this problem that is very similar to the problem that tinnitus, or bothersome tinnitus, creates. So, when we're stressed, when we're in that fight or flight, our brain actually has a compensatory mechanism that makes us more tuned to signals that might be a threat, or maybe have a negative impact on our whole body's well-being. So, stress puts us into fight or flight. The fight or flight says we need to look out for more threats. And the limbic system goes, "Hey, I found a threat. It's the tinnitus." And all of a sudden, that tinnitus can get louder. And we can become more anxious. And we experience more of those systemic issues relating to that initial stress response.

Doran:  For sure. Yeah. So interesting to me, and so cutting edge as far as the science around mindfulness, mindfulness meditation, neuro plasticity. That all speaks to this kind of cutting edge stuff that a lot of really smart people are researching. So, we'll hopefully get some advancements, but no cure right now. Right?

Martine: Yeah. We certainly can't impact the perception of the tinnitus itself, but we can dissociate from that perception. We can manage our autonomic responses. And we can really learn to live well and live better with tinnitus.

Doran:  Sure. I mean, I wanted to also say easier said than done, right? We can do that in a lot of areas in our lives. It's easy to say, more difficult to do. We see some people with... They're really debilitated... and it's not over exaggerating there... debilitated by this condition.

Martine:  For sure. For sure. And that's why it can be so helpful to make that first point of contact, meet with an audiologist, have them provide you with some specific recommendations just to get you started on that path, whether or not you continue with them, or administer that yourself through the remainder there.

Doran:  For sure. Now, can you go over the sound therapy treatment again? I think we lost each other kind of in the middle of that. So, just briefly go on to sound therapy and what that does.

Martine:  Yeah. So, using sound to manage the tinnitus perception is something that's been kind of present in our management of tinnitus since the very beginning of when people started looking at possible management strategies. And there's a couple of different ways we can do that. And number one is that we know that hearing loss is one of the leading causes of tinnitus. Okay? We know that when the sound receptors in the inner ear have hearing loss, become they've become damn... are causing hearing loss because they've become damaged, they don't communicate as effectively with the nerve fibers underneath.

And the nerve fibers underneath have a compensatory mechanism that increases their resting rate. So, all of a sudden, a nerve factor that had a base line going "boop, boop, boop" starts bursting. And it goes, "boopboopboopboopboop" to self-stimulate, or compensate for the lack of sensitivity of the sound receptor. And that contributes to our sense of tinnitus. So, using sound on a basic case of tinnitus is going to mean treating your hearing loss, so using a hearing aid to treat that hearing loss, and to meet the sound receptor's threshold so that the nerve fibers start to respond a little bit more in a normal way. Okay?

So, that's one component of sound therapy, so treating hearing loss if it's present. Two is to use pleasant or soothing sounds that act to calm the autonomic nervous system. So, just as we have reflexive responses in the limbic or emotional brain, to the tinnitus, that are negative, we have reflexive responses in our limbic system and emotional brain that are positive. And those respond to things like soothing and environmental sounds, music, sounds with tonal qualities. So, we can introduce a little bit of that into our environment, whether it's played through a hearing aid or masking device, or whether you're just using speakers to play those signals off of an app or what have you.

Then, we can use a background sound. Background sound is just any sound that minimizes the contrast between the perceived tinnitus, which is the ringing or buzzing or noise that you hear as your tinnitus, and the environmental sounds in your ambient space. So, you want to use a little bit of ambient sound to kind of mask and minimize that contrast. Okay?

Doran:  Yeah. That's interesting. Again, we're going to go back to all treatments don't work for everyone. So, you're describing a lot of different things there. And we do offer TRT and other different mitigation techniques. But we really don't know, until a person starts to receive those treatments, what's going to work for that person, because it is so shockingly an individual thing.

Martine:  Yes, for sure.

Doran: Is there always hearing loss present when tinnitus is present? Always?

Martine:  No, actually. There's not. So, what I was talking about earlier in the slides was that, even just with noise exposure, for example, that doesn't cause a permanent hearing loss, we can experience tinnitus. Right? Because tinnitus is a symptom of the auditory system. It's extraneural activity in the auditory system. And that can originate from a lot of different things. Hearing loss is one of those things. Injury to the neck or back is another. You can have loud noise exposure, which then results in some residual tinnitus. That can either be chronic, or it can be temporary, such as after a rock concert or any concert that you go to where you've been exposed to loud noise.

Even things like lack of sleep and things like that can make us more aware of tinnitus in our body. And none of those things mean you have an underlying hearing loss.

Martine:  Thank you.

If you have questions about this presentation, or want to speak with an Audiologist about about tinnitus treatment programs, please call: Broadmead Hearing Clinic: 250-479-2969 or Oak Bay Hearing Clinic: 250-479-2921. Or request an appointment online.

Is hearing loss affecting daily life for you or somone you know?

Audiologist Christine Stangeland talks about what causes hearing loss, how it can affect daily life, the mental and physical consequences of leaving hearing loss untreated, and the benefits of better hearing.

This talk was originally presented as part of the Healthy Hearing Online Expo.

Read the video transcript:

Christine: So as you guys heard, my name is Christine. I'm an audiologist here at Broadmead and Oak Bay Hearing Clinic. I work out of our Oak Bay Clinic five days a week right now. So if you're ever looking for me, that's where you'll find me. So let's jump right into it. Today I'm going to be talking to you about, is hearing less affecting daily life for you or someone that you know? So we're going to start things off with a little bit of a poll just to gauge how you guys are feeling about this topic. So I'm just curious to see how many of you think, what percentage of adults between the ages of 40 and 79 have hearing loss? So I'm just going to get a poll going and you guys can actually vote on this.

So you should be able to see that poll right now. So I'll give you guys a couple of seconds just to get your answers in. It's awesome. I see lots of you guys responding already. This is really exciting. It's my first time doing an interactive webinar like this and having a poll feature where I can actually see you guys interacting given you're not here in the clinic with me. So this is really awesome. I do see the numbers changing a little bit more. So I'll give you guys a couple more seconds just to get those answers in. Right, I think things have stopped. So let's have a look at what you guys thought. So you guys should be able to see the results of the poll. The majority of you guys felt that the percent of adults with hearing loss of between the ages of 40 and 79 was in between 40 and 60%. And the awesome thing about that is that most of you guys were correct. Really well done you guys.

Hearing loss is common

So we know about 54% of Canadians age four to 79 have at least mild hearing loss in the high frequency range. That's a huge number. So the amount of people who have hearing loss within that age range, that can vary. It can vary a bit just based on your age itself and it can vary actually just based on your sex too. So let's dive into that a little bit more. So this really interesting figure comes to us from Stats Canada and basically what they had done was they pulled a bunch of people about if they thought they had hearing loss and then they measured if they actually had hearing loss. And we're going to dive a bit more into that discrepancy a little bit later, but first let's just have a look at the amount of people who do have hearing loss.

So we see that in general, 54% of people have hearing loss within that age group of 40 to 79. If we break it down by the person's sex, men are more likely than women to have hearing loss. 63% of men within that category versus 46% of women in that category. If we break things down by age and generally the younger people within that category, less hearing loss. So with people 40 to 59 years old, 38% of them had hearing loss. If we jump up to ages 60 to 69, 75% of people had hearing loss. You can see that prevalence of hearing loss is increasing with age. And if we move into that 70 to 79 years old category, a whopping 93% of people have hearing loss in the ages of 70 to 79. And that's just cutting off at 79. That's not extending into those later years in life.

Onset of hearing loss

So you can see that in general, men are more likely to have hearing loss than women. And just as you continue to age, that hearing loss is more and more likely to be more prevalent. So let's talk a little bit about hearing loss onset. How does this happen? So even though in rare cases, people can develop a sudden hearing loss. You might just wake up one day and have a hearing loss. That is not common. Most commonly hearing loss develops just really gradually and very slowly over time. Because this hearing loss is developing so slowly and so gradually over years, this becomes really hard to detect for the person who's developing hearing loss. Something that's quite common is often friends or family will actually notice the person is developing hearing loss first.

So it's quite common for me to ask somebody in the clinic, oh, what brought you in today? And a lot of them will be like, my wife, my husband, my kids, they think I have hearing loss. So very, very common for people's communication partners to notice the hearing loss before the person with hearing loss themselves. Interestingly enough, it actually takes on average seven years before a hearing loss makes communication difficult enough for somebody to feel motivated to do something about it. But there are some reasons that we don't actually want to delay things seven years. We want to treat hearing loss sooner rather than later. So first, what causes hearing loss? As you guys probably figured based on that graph we were looking at earlier, the prevalence of hearing loss with age, age is a huge contributing factor to hearing loss.

What causes hearing loss?

So our fancy term for age-related hearing loss is presbycusis. We see tons of people with presbycusis in the clinic. That's super common. Another really common factor that could cause hearing loss is significant loud noise exposure. So if you're somebody who works in the trades or you have really noisy hobbies like using firearms for example. You like to go to the shooting range and practice your target shooting a lot. If you're not protecting your hearing, you're at risk for noise related hearing loss. Some people genetically are just more susceptible to hearing loss than others. There are certain medications though quite rare are known to cause hearing loss as well or be associated with an increased risk of hearing loss.

Head injuries or skull fractures. Those are known to cause hearing loss as well or they can and it's not a guarantee, but it's something that could contribute to a hearing loss. Serious infections, especially in childhood can cause hearing loss and certain chronic health conditions, but you at a higher risk of hearing loss. So things like high blood pressure, diabetes, those are some health conditions we know do make it more likely for you to develop a hearing loss. So how can hearing loss affect daily life for you or for somebody you know who's experiencing hearing loss? So often what happens is... I told you that sometimes these patients come in and they say, "I'm only here because my partner thinks I need to be here. I think I'm fine." So what's that partner noticing that that person's not noticing?

How does hearing loss affect daily life?

So the person with the untreated hearing loss, typically their one-on-one communication skills are great. And there's a few reasons for that. But things that they may start noticing as their hearing loss develops is that they're having difficulty hearing in background noise. I have a lot of my patients say to me, "You know what? Sitting here talking to you, I have no problem, Christine. I hear you just fine. But if I go to the pub, forget it. Can't do it. I don't even like going to the pub anymore." So background noise more commonly becomes a problem sooner than listening in quiet environments. Some people, if they're not hearing well, that hearing loss is developing, they're going to start turning the volume up on listening devices. So the TV or the radio, that volume is going to start increasing and it's going to be louder than it needs to be for people with normal hearing.

Another thing that might happen is people will start missing sounds that are occurring say behind them. They don't have a visual cue and somebody starts talking to them. Maybe they're just not going to get the clarity that they need. They're going to hear that somebody is talking, but they're not going to know what they're saying or they might miss what somebody is saying from the other room. If somebody is in the living room and somebody else's in the kitchen, that cross room communication gets lost quite easily with hearing loss. In conversation, typically people who are developing hearing loss, they're just going to have to ask people to repeat more. There's just going to be more that's being said that they're missing. So they're going to ask, I'm sorry, what did you say? Can you repeat that? Or just another common thing is just mishearing or needing repeats on the telephone.

How we compensate for hearing loss

We know that the telephone already, the audio signal, the quality of that audio is certainly not comparable to hearing somebody in real life. So it's already degraded. And then if you're out of hearing loss on top of that, that can sometimes become unmanageable or people are going to need to turn the phone up to maximum or put it on speaker phone just to have it be usable for them. So what are some ways that people with this untreated hearing loss that they're not really aware of? How are they compensating for it? So people, as I touched on before, they'll start to withdraw. So maybe they won't go to a noisy restaurant if... I mean, it's COVID now, so we're not going. But if we pretend it's not COVID times, people will stop going to those noisy places. If their friends invite them to the pub, they might say, you know what, what if we do this at my house instead or I'll give it a miss because they know they just can't participate in the conversations the way that they would like to.

Another very common thing I hear from a lot of patients who come in is they're like, I can hear you just fine, Christine because you speak clearly. My son, my daughter, my wife, my whoever, they mumble. And if they didn't mumble, I would hear them just fine. But unfortunately the reality is it's sometimes there's mumblers. Don't get me wrong. There are. But once everybody in your life starts becoming a mumbler, that's usually a sign that it's not the other people in your life who are mumbler, it's you developing hearing loss and that's why it sounds like people are mumbling. Typically, that high frequency hearing loss we see with age or noise exposure affects the high tones first. You're going to lose the clarity first before you lose volumes. That's why it's easy to blame that lack of clarity on other people.

Another common thing is people with this high frequency hearing loss that's untreated are going to feel that people speak too fast. So what happens is because you have all this extra work to do because you're not hearing as well, you can't keep up with the conversation the same way. So if things are slower, it gives your brain more time to fill in the blanks. So another thing people are going to do is really rely on the context of the situation to fill in the blanks and try and piece together what they're missing. Something people will do, but you shouldn't do. You should advocate for yourself if you're not hearing well, but it's easy to fall into this pattern. I'm still guilty of this myself. It's not that you just pretend and you smile and nod and you're like, Mm-hmm (affirmative) And you have no idea what the other person said. Maybe you already asked them to repeat two times and you're embarrassed to ask them a third time. That's something that's still on very rare occasions happens to me.

So I completely understand that sometimes you're just like, you know what? We're just going to move on. And at the end of the day, that's not a great way to facilitate communication. And you do need to advocate for yourself if you're not hearing well. Another way that people with untreated hearing loss really compensate for this hearing loss is using visual cues. So even normal hearing people rely a lot on facial expression and lip reading. But if you have a hearing loss, you're relying on that that much more to get information from the person that you're speaking to. This is something that we've really seen an increase in difficulty for our hard hearing patients because of mask wearing because of COVID.

Another way, I already touched on this, compensating for that untreated hearing loss is just turning up the volume on things. So you're going to turn that TV volume up. People are going to say to me, "Christine, I hear the TV volume just fine if I put it at 25." And maybe their partner is going to say, "Yeah, but we only needed, I only need at 15." So there becomes that discrepancy in the volume that people require.

Some consequences of hearing loss

So some consequences of hearing loss. We know that there's actually a lot of negative consequences of untreated hearing loss. We want to treat this hearing loss not seven years later when you really feel that communication is becoming unmanageable even in easy listening environments, we want to treat hearing loss as soon as possible. And the science backs that up. So what are some reasons that we want to treat this hearing loss and what could happen if we don't? So we know that untreated hearing loss is correlated with cognitive decline. So if you have mild hearing loss, you already have double the risk of developing cognitive decline. Another thing we could refer to that is dementia. If you have moderate hearing loss, your risk increases to triple the risk. And if you have severe hearing loss, you have five times the risk of cognitive decline, of developing dementia than somebody with a lesser amount of hearing loss. And that's huge.

When we have a look at reducing the risk of cognitive decline, of dementia, there's a lot of things. If we have a look here, a lot of things in your life that are risk factors. So early in life, less education, that's a risk factor for developing dementia. If we have a doubt, a look down here in the mid-life, things that can occur that are risk factors, hearing loss is our largest known potentially modifiable risk factor for dementia. So this is something you can manage in mid-life that may affect your cognitive wellbeing later in life. So not only is that huge, but it's awesome that we know that it's something that's potentially modifiable. We know that we can, almost always, treat this hearing loss. Some other consequences of hearing loss. Another one is fatigue.

So like I was saying earlier about when people feel that other people are speaking too fast for them, I mentioned that your brain has a lot more work to do because it's having to fill in the blanks. Because your brain is having to fill in those blanks, that takes a lot more energy. And because that takes a lot more energy, people with untreated hearing loss, we know, studies have shown this, their mental energy is going to fatigue way sooner in the day compared to somebody without hearing loss because they just are having to put so much effort into every single communication that they have throughout the day. There's also a lot of psychosocial and emotional effects of untreated hearing loss.

So we know that you're more likely to suffer from depression if you have untreated hearing loss, your stress levels increase, you're more likely to be frustrated in your everyday interactions because maybe communication is just not happening as easily as it could be. You're also more likely to be lonely, you're more likely to withdraw and you're more likely to suffer from social rejection as well. So there's a lot of negative things with this untreated hearing loss. Another thing, this one actually surprises a lot of my patients when I talked to them about this is you're actually at a higher risk of falls if you have untreated hearing loss. So we know that even just a mild degree of hearing loss, triples your risk of having an accidental fall. And as that hearing loss increases by 10 decibels, each 10 decibels your hearing loss increases, your fall risk increases 140%, huge.

Awareness of your environment

So this is often a big shock for people. And why is this the case? We don't 100% fully understand why this is the case, but what people realize is that when you have this untreated hearing loss in general, you just have less awareness from the environment. You're just not hearing if somebody is coming up behind you, maybe you're not overhearing somebody walking on the other side of the sidewalk or what have you. You're not hearing as well as you could be. Just not as aware. Another thing is we theorize that this affects down your spatial awareness. So that's just how your body perceives itself in space.

You can perceive if you hold your hand up. I know my hand is going higher. And we also know, again, touching on that fatigue aspect, because you're using so much more of your energy resources for hearing, less of those energy resources are getting devoted to other things including balance. So that's kind of what we theorize is going on and why you're at a higher risk of falls when you have untreated hearing loss. This is probably arguably one of the biggest consequences of untreated hearing loss or at least I feel so is that hearing loss doesn't just affect the person with hearing loss, it affects their significant others. So our fancy-dancy scientific term for this is third party disability.

So a third party disability is a disability of a family member due to the health condition of their significant other. So we know that there are negative consequences of untreated hearing loss for those significant others, for those communication partners. And a whopping 98% of people spouses reported some degree of third party hearing disability. So that's massive. That's not just a few people feeling negatively affected from their spouse or partner having a hearing loss that's untreated, it's almost all of them. There are some risk factors that make that more likely to occur. So lower relationship satisfaction overall is a risk factor for proceeding a third party disability, spousal age difference is also a risk factor for proceeding that third party disability as well as the spouse perception of their partners hearing disability.

The benefits of better hearing

So that all sounded kind of doom and gloom. But the good news is this is treatable. Hearing loss is manageable. Audiologists are here. Our whole profession is designed to help people manage their hearing loss. So what are the benefits of better hearing? At this point, I feel like it's pretty self-explanatory. You're going to improve your communication with other people. Well, communications become easier because you're not having to ask for less repeats. Both people involved in communication are not going to be as frustrated. It's not going to be as tiring. You're going to get more enjoyment out of watching TV or watching movies. Maybe now you're going to understand those British shows that are so hard to understand.

Maybe you're going to catch what they're saying now or you're going to get way more brilliance out of live music. Again, once COVID is over and we're allowed to go to concerts. That's something I personally am really looking forward to is just being able to attend live music again. You're going to get more out of it or catch more of the dialogue when you go to see a play or a musical. We know that it's going to improve your safety because we're reducing that fall risk. We're potentially reducing that risk for dementia, for cognitive decline. And we're going to just overall maintain our auditory processing skills.

So when I talk about auditory processing skills, your ears pick up sound, but your brain is actually responsible for hearing. Ears are just the pathway of getting sound to your brain. So it's your brain's job to decide what speech, what's music, what's noise, what should I focus on and what should I ignore. And we know that if you have untreated hearing loss because just in general, you're overhearing less, you're not overhearing background noises, basically your brain becomes weaker at filtering out background noise for you.

So another big reason we recommend treating hearing loss right away is to maintain those auditory processing skills. Keep your brain good at hearing this background noise so it knows to ignore it so that way you're not going 10 years without hearing your own footsteps and then when you get hearing aids, you're like, uh, I can hear my footsteps again. I can hear the paper... When I turn the newspaper, I can hear that again. And the longer you go without hearing those things, kind of the more overwhelming it is. Initially when you get hearing aids, we need to readapt to that and kind of undo all those years of not hearing basically.

So another great benefit of having better hearing is we're going to maintain those brain processing skills. So what should you do if you think you have a hearing loss, you're having some difficulty, you think somebody else in your life has a hearing loss, generally, when should you get it checked? Even if you don't perceive any hearing difficulties. And again, we know that in that age group of 40 to 79, 54% of people had hearing loss, only 6% thought they did. So if you're at age 50 and you have not had a hearing test, get it tested. The next thing is we do know that still when you're aged 50, the majority of people are still going to have normal hearing.

But the great thing is we're establishing a nice normal baseline for the future because we know that as you continue to age, that likelihood of hearing loss developing increases. So if you've never had a hearing assessment, just here's a little bit of what to expect. If you're coming in to talk to an audiologist, we're going to have a conversation with you about your health, your general health. We're going to ask you if you do have any specific concerns about your hearing loss. These are really great appointments to bring your spouse or your kids or whoever your significant communication partners, bring them with you because we know that 98% of those people also feel this hearing loss is affecting them.

Addressing hearing loss

So sometimes they'll come and they'll say, "You know what? I've noticed that you don't hear me if I'm not facing you." And sometimes that's something the person with hearing loss may not have noticed yet. Again, because it sneaks up so gradually, your brain just becomes really used to hearing with a hearing loss. So bring that family member with you so that we can have a discussion, not only with you, but with your communication partner about any specific concerns you have because at the end of the day, we want to help you. We want to know if TV hearing your British shows is your number one goal for hearing better. We want to know that so we can help you.

Once we talked about your concerns, we're going to do some listening tests. We're going to do some listening to beeps, but we're also going to do listening to speech tests so that we know how much clarity is in the hearing system. Once we've done all of our speech tests and our beep tests, we're going to have our results and we're going to review them with you. So we want to explain them to you in a way that makes sense and in a way that can clearly explain to you like if you do have a hearing loss kind of what kind of things that it would be impacting.

And then we're going to make a recommendation based on those hearing test results kind of the icing is if things are normal, we're probably going to say, "You know what? Things look awesome today. We've got a great baseline. Let's retest in a couple of years or sooner if you notice any changes." If there is a hearing loss, we're going to identify if that's a hearing loss that maybe does need medical or surgical attention or if it's a kind of hearing loss that needs treatment with hearing aids. And then we can walk you through that.

So definitely don't be afraid to come in and get a hearing testing if you've never had one. It's definitely a great thing to do even if you don't think you're having any problems. It's just so smart to have a baseline for the future because we know that or just about everybody, things are eventually going to change. And that's all I have for you guys today. So thank you so much for attending. I believe Doran's going to jump back on and we're just going to answer some questions if anybody has questions now.

Questions & answers

Doran:  Christine, that was great. So being in this industry for 20 years, there's a lot of themes in there that we hear in clinic every day. For the first one, what I like to think what we do is solve problems. And the biggest problem we solve I believe is hearing in noise. That's something you hear over and over again in the clinic. So for those people out there, it's not uncommon. It's very common. A lot of those themes that you had are common themes. So you get the same, I can hear you now, like what you said in clinic. We get that a lot from clients.

So there's a lot of recurring themes there, but also I want to say it's also an individual journey. And a lot of people, and you can attest to this, they may have the same exact hearing loss percentage-wise as someone else, but they are dealing with it or managing it in a totally different ways. So a person might have a very slight loss. They want aids, they really find them helpful and they changed their lives. Whereas someone with maybe more significant loss, they're not ready, it's not for them and they end up not purchasing hearing aids. So can you talk to them maybe a little bit?

Christine: Yeah, so just to reiterate for anybody, it sounds like basically the question is how come some people have more degree of hearing loss and they just don't feel like they're ready for hearing aids. Is that correct?

Doran: That's right.

Christine: Yes, that is a good question. I don't know if I have any science based answer for you just off the top of my head, but speaking from personal experience, definitely there's still a lot of stigma attached to having hearing loss. So there's a lot of people who are still worried that if they start wearing hearing aids, it means they're old or they're going to look old and people are going to think they're dumb. It's unfortunate and that's the reality of it.

And even for myself when I decided I needed to get hearing aids because I wasn't hearing people well, there was still a little bit of a medium like, oh, just... I don't know because people do have this negative reaction to it. But the really nice thing is once you do treat the hearing loss, then you see the benefit, it's like, oh, why was I so silly about this? Why did I have these hesitations? My life is so much easier now that I can hear and I don't have to put all this energy in. And it is very true what you said that some people can present on paper as having the same hearing loss, but have very different experiences.

And a large reason for that is not the amount of damage to their ears, it's their brain's ability to help filter out background noise and process speech for them. So we know that as you age, already you're... Even if you don't have a hearing loss just as you age, your brain's ability to process sound becomes less and less accurate. It's just not as precise as it used to be. So it could be these brain differences that are not measurable on the hearing test itself that account for these differences in how well or how slowly people adapt to hearing aids.

Doran: Yes, for sure. People think that hearing loss is just your ears and it's auditory processing. I know I'm old now and I'm not as smart as I used to be. I'm sure if I tried to take grade 12 chemistry, it wouldn't go that well for me. So some of it's ears, some of it's auditory processing, it's a whole system that your brain is trying to process these sounds that it can't quite hear well. So to you guys out there, I just want to say, if you have questions, I didn't mention this before, you can type them into either the chat or the question and answer that's at the bottom of those Zooms. Just go ahead and type those questions in and I'll pass them on to our panelist. We do have one coming through. It says, why is hearing loss more prevailing in men than women?

Christine:  Oh, that's a great question. So why hearing loss is prevalent more so in men than in women, it's not a biological reason, it's a lifestyle reason. So we just like gender stereotypically, the men are the guys who go to work in the ship yards or go work on construction sites. And just generally, men are putting themselves more into those environments where there is a lot of background noise compared to women. So it'll be interesting to see if that does change in the future as those kind of stereotypical gender roles maybe change as time goes on. But it's certainly not a biological factor, it's just an environmental and lifestyle factor.

Doran:  For sure. Another question is, what about telecoil hearing aids? So he's asking, do audiologists advocate for these telecoil hearing aids in places like the Royal theater and movie theaters? We're not aware of anywhere in Victoria that has that option. So can you speak to telecoil first of all, what that is and how it's used?

Christine: Yeah, so a telecoil is a specific type of technology that is present in some hearing aids. So basically, this telecoil, what it allows us to do is via magnetic induction basically placed down directly through hearing aids. So because that sound is going directly into your hearing aids, it's kind of like old-school Bluetooth streaming. You get this direct input, you're going to get better clarity and better signal resolution. So a telecoil can be used often for landline telephone use or as this person alluded to some theaters or banks or other businesses, they might have something called a hearing loop.

So you have to activate your telecoil to get the sound from the hearing loop into your hearing aids. It's definitely something that audiologists are aware of. I think some people used to think of that kind of as old school technology. There was kind of a phase where I feel like telecoils, at least in my opinion, they just weren't getting advocated for and they were getting put in less hearing aids. But I think people are starting to see the value in them again. I definitely know that there are some theaters that do have loop systems. Off the top of my head, I don't recall which ones, but I have had patients tell me they've gone to them and use their loop system.

Another awesome thing is I do know that some of our independent living places like the Cedars over on Cedar Hill Road, I know they had talked to me about getting a loop installed and just trying to find ways to help facilitate better hearing for their residents. So general in Canada, they're kind of under utilized. I think they do get utilized a lot more in Australia and Europe. But definitely not only audiologists were advocating, but you as the patient, you should definitely advocate for it where you go as well and help bring awareness that there are these easy technologies to use.

Doran: For sure. That's a good one. Another question from Ron and he's talking about he had a hearing test. Many clinics send those results through to their doctor. And then he was referred to as ENT, ear, nose and throat doctor, which as we know in Canada takes weeks and maybe months to see that guy. So I know this is a source of frustration for us. Can you just speak to the role of your primary care physician and your ENT in diagnosing hearing loss or what they might be looking for?

Christine: Yes, so as an Audiologist, it's our scope of practice to diagnose hearing loss and the non-medical management of hearing loss. Certainly then your primary care physician gets looped in more so if there's any, we call them red flags that come up when we're doing that, either that questioning of your ear health. In general health, there are some things that we know we want medically investigated or if something shows up on the hearing test that again, we believe should be medically investigated. It's not typical for age or noise related hearing loss.

So just one example of those things would be having a significant difference between your ears, their ability to hear. With age or noise related hearing loss, we expect both your ears to be pretty well the same. So just as an example, if somebody had come in and we saw a significant difference between their hearing, we would want to loop in their primary care physician. We want it investigated because we're wondering why, why is one ear worse than the other? Is something medically going on that could be treated or stopped to prevent this difference from occurring or getting worse?

Typically at that point, the primary care physician usually will refer on to the ear, nose and throat specialist. Certainly they're the experts in the medical management of ear, nose and throat diseases and disorders. So that's kind of where the ENT comes in and you're so right. The waitlist are unfortunately in Victoria very long. A lot of my patients have been telling me, it's going to take about a year for them to get it and see the ear, nose and throat doctor. But the ear, nose and throat doctor is going to be the one who can evaluate the health of the hearing or not the hearing system, but the structures of the ear and determine if there is anything that does need medical or surgical attention.

Doran: Yes. I mean, that's a tough one for us because sometimes we see there's often valid reasons for you to go see your ENT and some pretty scary medical reasons, but often a doctor will just refer through just because that's what they do. So if you've been referred, you want to definitely go to that. But if it is just hearing loss, can we say you don't need to see an ENT for that or-

Christine: Absolutely, if there's no red flags on the case history and there's no red flag conditions apparent on the hearing test, absolutely you do not need to see an ear, nose and throat specialist and you don't need necessarily to consult with your primary care physician. You can just proceed directly with hearing aids. And something that sometimes people don't realize is even if we do find those red flag conditions like the difference between the ears, often we will send a medical clearance forum to the family doctor anyways and say, hey, in the meantime, this hearing loss needs addressing, can we proceed with hearing aids while we wait? And often they'll come back with a yes. Sometimes they'll come back with a no. But we try to work together with them so that we're not delaying that treatment if we know that that hearing loss is most likely to be permanent and not medically correctable.

Doran: That's great. Okay, I've got another question from Lynn. She's asking, what effects do cell phones have? And what strikes me is people's interpretation of how they get hearing loss. It's a duration as of a low noise. A lot of times people have the misperception like, oh, I went to one rock concert and now I have hearing loss. It was one big blast and that's not always the case. Is it?

Christine:  No, that's certainly not always the case. I don't... Off the top of my head, I haven't encountered any stays that say, cell phone use significantly impacts your hearing thresholds. That's just not something that would raise my alarm bells if you were telling me that you had been exposed to loud noise. I just don't think your cell phone is... You're going to be using it that long enough or that loud enough for it to make a difference.

Doran: One last question, a good one from Barry is that the tax implications, the CRA implications, people are trying a lot of times for us to get us to fill out the disability tax credit form to get that tax deduction. How does that typically work, Christine?

Christine: Yes, so I guess, there's two things. One is that hearing aids in general, they are considered a medical expense. So you can claim the most as a medical expense when you're doing your income taxes. With regards to income tax, I am no expert. That's kind of where my knowledge ends. Definitely consult with an accountant or somebody who specializes in that if you're not sure of how that process works. Secondly, there is a disability tax credit for hearing loss if you have a disabling hearing loss. The tricky thing with that is that their criteria is quite strict. Ultimately, the judgment is up to them, not up to us as the audiologist. But they will ask questions like can this person understand you at least like, I can't remember what it was, like for example, 50% of the time, even with hearing aids.

Doran:    Right.

Christine:  .. in the ideal listening situation?

Doran:  That's right.

Doran: And that's key there.

Doran: ... That it is aided as well. It's not without hearing aids, I can't hear. We can aid that person. That's important, right?

Christine: Exactly.

Christine:  It's your aided performance. So the majority of patients who we see on a daily basis, I would be saying, yes, I can communicate with them more than whatever percent of the time. If they're aided, no problem. They don't have that disabling level of hearing loss. We can still fill out that form, you can still submit it for judgment, but just be aware that their criteria is you basically have to be unable to communicate even with hearing aids even face-to-face one-on-one. So it is quite a strict criteria.

Doran: That's great. One more question because it's also a good one is that does it take a certain amount of time for your brain to adapt to your new hearing aids? That's a great one.

Christine: That's a great question. And the answer is yes, it absolutely takes some time and that can vary for people. So for myself, personally when I started wearing hearing aids, I felt like I adapted fairly quickly. I have a younger brain. So that kind of works in my favor. I was all about getting hearing aids once I decided I needed them. So for myself, personally I felt like I was adopted within the first week. I felt it was pretty easy. The majority of patients I would say are pretty adapted within the first two weeks. When we fit you with hearing aids, we typically like to see you two weeks out for a follow-up to see how that adaptation process is going. So it's even majority of people are adopted by two weeks, but there are some people where we know it's going to take four, six, maybe even eight weeks, maybe longer. That's not the majority of people that just individual brain differences, differences in the amount of hearing loss, differences in the amount of time that hearing loss has been untreated can all factor into that acclimatization period.

Doran:  For sure. I mean, that's a great point in that a lot of people think they'll put these things in their ears and bang, normal hearing. That's not what happens. It's not normal hearing, it's aided hearing with the hearing aid. So we want to make sure we set those expectations, which you do quite well in the clinic. I don't know what their expectations are. Another technique that we use is to step people up. So when we first program your hearing aids, we may not step it down a notch. You haven't been exposed to all of these environmental sounds for a number of years. So to hear the toilet flush or the car go by or the garbage disposal. Those are jarring sounds. And again, we're talking about auditory processing here. A lot of what your auditory processing does is filter noise and speech in a noisy. You don't need to hear, you don't even realize you don't hear the car go by, right?

Christine: Yes.

Doran: Guess what? All of a sudden, we amplify everything and that's going to be overwhelming to a lot of people. So we do have the ability and do quite frequently step up. And that's why we want to follow-up shortly thereafter and able to step up that volume because yeah, your brain has to get used to that. Again, it hasn't heard those sounds in years.

Christine: Totally, and something that's so cool about hearing aids these days, a lot of people don't know we have this technology. But for example, say instead of starting you at 100% of the prescription, we started at 80%. If you're doing well at that follow-up, we can just set the hearing aids to automatically slowly over time increase you to 100%. And we as the audiologist, we get to set that. So maybe I'm going to give it two more months to get you from 80% to 100% every single day just a fraction of a percent louder. The hearing aids are just going to automatically increase that volume. So the great thing about it being gradual is you're not going to perceive that change, but we're going to get you to the spot to optimize your hearing. Just the same way your hearing loss gradually deteriorates and you don't notice it changing. The same thing occurs when we then introduce the hearing aids and we can start-

Doran: Sure.

Christine: ... automatically increase.

Doran: Sure, and another big part to that is you got to wear your hearing aids. If you're going to lecture people, it's going to be, but these things in your ears when you wake up and take them out right before you go to bed because even though you may perceive, oh, I don't need to hear anything for the next hour or so or I'm just hanging out at home alone, it's your auditory processing system. Your whole brain is getting used to those noise, ignoring some, amplifying others. Your brain is going to do that. So I know Christine agrees, where your hearing aids all the time, 100% of the time, your brain will eventually compensate for those loud sounds.

Christine: Yeah, something our patients don't always know as well is that our hearing aids actually do tell us when we see you for a follow-up how much you've been wearing them. So don't lie. We're going to see on average, we don't get a day by day breakdown, we don't get geo tracking, nothing fancy like that, but just on average, how much you're wearing the hearing aids. So we want to see that typically be 12 plus hours a day to consider that full-time wear.

Doran: For sure. And another kind of unrelated question, but good is, what are we doing for COVID safety around here?

Christine: Oh geez, COVID.

Doran:  Who knows? It's been extensive. It's been a year long for us. We have an extensive protocol of all the things you'd want to see. It's weird to see Christine without a mask right now. I haven't seen her face in like a year. I am not in clinic. I'm working from home. So we're doing all of these things that we need to be doing in order to keep our customers safe. So rest assured. All those protocols that you'd like to see in any healthcare setting, we are adhering to those.

Christine: And something in hearing aid technology that's quite new as well as you've got new hearing aids is the ability for remote programming. So that's a great thing that we can offer to our patients who want to be able to... They just need a quick adjustment and they don't want to come to the clinic. They can do that from the safety of their home. So if that's the case and you do have hearing aids and you're wondering if that's an option, reach out to your audiologist and we'll be able to let you know, yes, is that an option or no? Are the hearing aids new enough to have that feature? And if so, we can guide you through getting that set up if we ever need it in the future.

Doran:  For sure. And another thing I want to mention is our delivery service. If you need batteries or domes or anything for our customers, it is free delivery right now. So we're happy to drop those off at your front door. Okay, Christine, I think that's it. Thanks so much for that presentation. It was well laid out.

Christine: Thanks for having me. Then thank you guys for attending. It's been so great to be able to engage, even if it's not in-person. We'll get one day. We'll be there one day - eventually.

If you have questions about this presentation, and need to speak with an Audiologist, please call: Broadmead Hearing Clinic: 250-479-2969 or Oak Bay Hearing Clinic: 250-479-2921. Or request an appointment online.