Dr. Carter from WS Audiology on tinnitus management.
What is tinnitus?
Let’s talk about some tinnitus data first and then the causes of tinnitus, and then tinnitus management. We’ll go into counselling, relaxation, amplification, sound enrichment, as well as other tips and tricks.
What is ringing in the ears? The medical term is tinnitus. Tinnitus is the perception of sound or noise within the ears when there’s no external sound source. It’s not a disease, as some people might think. It’s more a symptom with underlying causes.
The most common cause of is hearing loss. You often tinnitus described as a buzz, hum, whistle, roar, crickets, falling water. It can be a myriad of things. It’s diverse in its experience within each person.
What does it sound like? The most common is like a tea kettle whistling. It’s a very high-pitched whistle sound. It’s around a the 4000hz area of our hearing range. Others might hear a rumbly buzz, like a constant static or a distortion. It can very in loudness and duration. Some people have it all the time, some only have it for a period of the day. It depends on the individual.
Nearly one third of people report some form of tinnitus. Not necessarily continuous but enough that it’s present in their life. Ten to twenty percent report long-term tinnitus. Seventy five percent are not bothered by their tinnitus, while twenty five percent are. In Canada, about 5 million people experience constant tinnitus. 360,000 Canadians suffer from tinnitus that is causing them some distress and having a negative impact on their quality of life. For people with hearing difficulties, 70-80% report some form of tinnitus. The correlation increases as the hearing loss increases in severity.
Some known causes of tinnitus include noise exposure, hearing loss, earwax against the ear drum, fluid in the ear or TMJ. TMJ is an issue with your jaw, tension and a dental issue. Also, a head or neck injury. There’s a myriad of potential causes, a lot of different types of underlying things that could bring about tinnitus. Often, it’s hard to know what the cause is.
Hearing loss and tinnitus
The brain is always looking for input because it’s in that state of wanting stimulation. When it doesn’t get input from the auditory system, it tries to turn up the volume to see if something is present. Tinnitus is the brain’s reaction to impaired hearing. The auditory system is trying to detect something there. That’s why using a hearing aid can help because you’re stimulating the brain and the auditory system, so the brain doesn’t have to. Compensation for hearing loss provides the input the brain is seeking.
One half to one percent of the population is severely affected by their tinnitus. It has a major impact on their life – sleep deprivation, depression, anxiety. Some people have trouble habituating to their tinnitus.
A good example of habituation is a refrigerator fan. You can habituate to those sounds in your life. What stops habituation? A novel stimulus could district it. The more we focus on our tinnitus, the more it’s recognized by the brain, and we become attuned to that stress response. This is the stress cycle. You have the emotional response, some hormones are released, it increases stress level and increases the perception of tinnitus. It really builds and can be annoying to be stuck in this cycle.
So, what do we do? In tinnitus therapy, the goal is to reduce the impact of tinnitus on everybody life by habituating patients to the tinnitus. We’re trying to break the cycle of stress and tinnitus response.
In tinnitus therapy there are four major components: Education, counselling, hearing aids, and stress reduction. It helps to try to normalize the experience. You’re not the only one with this difficulty. I’ve had patients say, ‘I think I’m going crazy’ or ‘I’m hearing a sound nobody else is hearing’. Normalizing helps bring down that stress level. Counselling helps to bring down worries. There’s no cure or surgery or magic pill for tinnitus but there is help with the habituation process.
Another piece of the puzzle is stress reduction. We talked about the stress cycle. Some relaxation methods to try include deep breathing, muscle relaxation and guided imagery.
Deep breathing is the simplest form of relaxation. We can all take a deep breath now – in through our nose, out through our mouth. What we do by having a deep breath is reducing our blood pressure level and that stress response, letting our body know it’s not a time for tension. We’re OK, we’re safe. It’s available anywhere. We breathe anywhere we go – hopefully! It’s one of the best ways to lower stress.
This is a deep breathing exercise – I will talk through it here. We won’t go through it. It’s a bit more – you get into the rhythm of breathing. You are exhaling through the mouth and inhaling through the nose. You can do it for four seconds. It suggests holding for seven seconds. You can build up to this. And then exhale from your mouth for eight seconds.
This takes some time! Some practice. Sometimes you are building up to this type of exercise. Then you can repeat it twenty times. The rhythm of this and the telling of your body that the stress – you are safe. You aren’t in that stress response, and you can relax. It’s very effective for tinnitus, stress etc. They are related of course.
So again, the key thing is exhaling for longer than you inhale. Even if you inhale for three seconds, hold for one second, that’s OK – exhale for four seconds. The exhale is longer. There’s been many studies showing the longer exhale is what gets your stress level down. So really cool to see that here and know it’s effective.
Another piece of the puzzle is muscle relaxation. Progressive muscle relaxation. What that is, is alternating between deliberately tensing a muscle group and releasing. So, I tense my fist and release – scrunch up my face and release it. The tension beforehand gets you into the greater relaxation after. It’s another exercise that can be done to help reduce the stress level.
Guided imagery is another technique. A way to get out of the moment and into a more pleasant space. For example, you can imagine you are on a dock in a relaxing area, you can think about seeing the lake, smelling the water, the sounds of the ocean.
Some of these techniques are available in tinnitus apps. There’s often a sound player to play pleasing sounds that help reduce tinnitus or stress around tinnitus. There are relaxation exercises and sleep exercises within a lot of these apps.
Hearing aids can help with tinnitus. They can compensate for hearing loss and help by minimizing the contrast between the sound and surrounding environment. Hearing aids help to embed the tinnitus sound in a normal world of sound. In one study of over 500 tinnitus patients, they were presented with a list of nine methods to treat tinnitus and asked how effective they were. The #1 effectiveness at 34% was achieved by wearing hearing aids. That’s one of the best methods to reduce tinnitus for some people. A close second is listening to music at 30%. Relaxation techniques were about 10%. For people who wore hearing aids and had tinnitus, 29% reported hearing aids alleviated all their tinnitus. They didn’t experience tinnitus anymore when wearing hearing aids. 66% reported that it was helpful in reducing the tinnitus most or all the time. With hearing aids, we are trying to make everything vibrant except the tinnitus. Then the contrast between the ringing or buzzing and the rest of the world is lessened. So, you notice the tinnitus less.
Sleep
Some people have tinnitus and trouble sleeping. You can’t really wear hearing aids to bed. It’s not recommended and can be uncomfortable. So, what do we do in that situation? Or if hearing aids didn’t work? There are some other options. First, good sleep hygiene; go to bed at a standard time, don’t exercise right before sleep, have a comfortable bedroom temperature, a bit cooler at night and close your curtains and drapes so you aren’t getting the light from outside. You don’t want to watch television, eat or read in bed because it sends your body mixed messages. Sleep on your back or side. Have a bedtime routine. Avoid food and drinks with caffeine. Use a fan or white noise machine for distraction if you have problems falling asleep.
Tinnitus and music
One study showed music helps people with tinnitus 30% of the time. Music stimulates the brain and produces a psychological change associated with stress reduction. There are many types of music you could listen to. In general, a slow tempo, quieter pitch with little overall change in the music can be very relaxing and can help with tinnitus. 30% of tinnitus sufferers felt music was helpful.
The one thing about music is that it’s not always available to us. We can’t always be listening to it. But we can access it if we have headphones or hearing aids. Hearing aids often have music or nature sounds or some other type of stimulation that can reduce the tinnitus.
Also, it doesn’t have to be music. It can be nature sounds such as the ocean, fire crackling, birds chirping. Something pleasing to you.
Fractal tones is another option. It’s like a wind chime. It doesn’t have a rhythm to it necessarily but it’s pleasing. The nice thing about the randomness of fractal tones is that your brain doesn’t get used to it, so it stays slightly novel, not like a melody where you hear it a few times in the song. It does not repeat itself.
The nice thing about it is that it is keeping your brain a bit focused on that pleasing sound and not as focused on the buzzing and chirping bird sounds happening for the tinnitus.
You don’t want to mask out your world. You want to hear people, to communicate. It’s keeping that brain stimulation focused on something more novel and pleasing, not the tinnitus sound.
Summary
To summarize, you can make use of sound with hearing aids and sound enrichment. Avoiding silence is very helpful for tinnitus because your brain is not constantly searching for auditory stimulation.
Some things can make tinnitus worse for certain people. Noisy areas, alcohol, nicotine, caffeine or sodium can increase some people’s tinnitus. Medications. You can talk to your doctor about that.
Try to be physically active. Allow breaks during the day to reduce stress. Improvement can take time, so be patient. Just because there’s no cure or magic pill or surgery, there is help out there.
Q&A
Question: What about hypnosis?
Dr. Carter: I haven’t seen studies that show there’s effective percentage of people who have had success that way. However, in school I learned there’s many people out there that have stress relief from hypnosis, from chiropractic care. There are many little bits of healthcare that have been associated with reducing stress, but not that link to tinnitus specifically.
Question: You said that no magic pill. I happened to see this on the internet about a magical pill. You can order it for whatever amount of money. So, I’m understanding, forget it? Don’t think about it?
Dr. Carter: Good question. The question was about magic pills on the TV or internet that help with tinnitus. There’s no magic pill. What those often do is maybe it’s a group of antioxidants, like vitamins sort of thing. It’s not necessarily bad, but there’s no science behind that. It gives a bit of false hope that way. That’s why I say no magic pill.
Question: Do you know if tinnitus persists or gets worse after total hearing loss?
Dr. Carter: Research shows that as your hearing gets worse, there is an association of tinnitus getting worse. It doesn’t mean there’s no hope. There’s lots of techniques that can help. The greater the hearing loss, the greater the tinnitus. There is that association.
Speaker: I’ve had tinnitus for years and years and didn’t know there was a cure. Then I went to a hearing seminar like this one. I went to my hearing office, and they realized I had tinnitus and hearing loss, which I didn’t know. They’re programmed to take care of the tinnitus and it worked. I don’t have tinnitus anymore. My question is, I’ve had hearing tests, and I’m told my hearing isn’t getting worse. I’m programmed again. But lately, I’m not hearing people. Could my program for tinnitus cause me to not hear?
Dr. Carter: Sometimes the tinnitus is set too loud so you’re masking some of the voices. So sometimes lowering that, so it’s audible but not prominent, could help with the tinnitus and so you’re still hearing voices. It’s not common but it can happen.
Speaker: Can you listen to different programs through ear buds?
Dr. Carter: Yes, you certainly can. Sometimes it cuts you off from sounds in the real world that help you in order to provide that stimulate the auditory system. The more it’s stimulated and not looking for sound, the better. It’s not closing it off. I wouldn’t do it all the time but there’s a place for that.
Speaker: You mentioned there’s no physiological cause. When I bend over why does the tinnitus amplify?
Dr. Carter: I’m not sure about you specifically, but tinnitus can change due to blood pressure changes. There can be that association for certain tinnitus sufferers. It’s rarer but it is a possibility.
Dr. Carter: One thing I like to mention to explain tinnitus, I don’t know if you’ve heard of phantom limb syndrome. Let’s say somebody has an accident and they don’t have their hand anymore. They can still feel pain in that hand. The nerve damage is causing the brain to think there’s pain there when there’s not. When hearing loss is present, there’s damage in the hair cells, in the cochlea. The brain is sending a message the sound exists when it doesn’t. It’s from damage in the hair cells. Some say tinnitus can be caused from hair cell damage that way.
Speaker: Is there a proven relationship between vertigo and tinnitus.
Dr Carter: One of the underlying causes of tinnitus can be Meniere’s disease. It can cause vertigo. So, there is an association.
Speaker: Is tinnitus ever one sided?
Dr Carter: Sometimes there’s the one-sided tinnitus. It is a classic sign of Meniere’s disease. It can flip from one ear to the next. It isn’t always the same ear. But typically – a more typical scenario is for both ears to have tinnitus. Excluding Meniere’s. It’s more common to have tinnitus on both sides for one side.
