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.