Many of us are familiar with what hearing loss is, as this is a common diagnosis, especially among older populations. We can all think of a family member or an older friend who has a hearing loss. Tinnitus is less understood and not as commonly discussed but yet, it is more prevalent than hearing loss. Tinnitus is often referred to as “ears ringing”, but it can be a variety of noises and does not have to be a ringing sound.
There are two types of tinnitus: objective tinnitus and subjective tinnitus. Objective tinnitus is when our inner ear of hearing is producing sound response or echoes, which are then audible to the listeners around them. Subjective tinnitus is hearing a noise without the presence of an auditory stimulus and can be ringing, buzzing, hissing, or whooshing. Subjective tinnitus is more common, and typically what we think of when referring to tinnitus. One specific form of medically concerning tinnitus is pulsatile tinnitus. This is when you hear your tinnitus in beat with your own heartbeat within your ear. This can often be associated with a glomus tumor, which is a vascularized growth within your middle ear space, therefore this can be considered an audiology emergency. If you are experiencing this form of tinnitus, be sure to seek medical attention from an Ear Nose and Throat physician immediately.
The severity of tinnitus ranges depending on the person. Some people can go throughout their day and never notice their tinnitus while others are greatly bothered by it. Although we do not know exactly where tinnitus is generated, the theory is that it is associated with the limbic system within our brain. The limbic system is responsible for your “fight-or-flight response” and our emotions. Therefore, this can cause many people with tinnitus to become bothered and on-edge. When their tinnitus is present, their brain and body activate this response and create a negative reflex, telling the listener that their tinnitus is dangerous, bothersome, and damaging to their life.
Tinnitus can be primary, meaning that it occurred spontaneously by itself, or secondary, meaning it occurred in response to another medical condition. Secondary tinnitus is common and can occur in response to hearing loss, noise exposure, ototoxic medications, allergies, TMJ, Lyme disease, or an accident involving trauma to the head. If tinnitus is spontaneous in nature, it may resolve itself within the first 90 days. If the tinnitus continues past this period, then it is most likely going to be a permanent condition.
There are many disabling symptoms of tinnitus. It can impact one’s ability to fall and stay asleep. It can interfere with your performance of work duties and has led to premature departure of a job or a complete change of career. It can also cause people to stop doing things that they love, especially if they are quiet activities. People often report they no longer enjoy reading, sewing or crocheting, playing cards or board games. This can affect overall mental health, as people often report they no longer feel enjoyment from those activities. Sometimes people with tinnitus, also, report that their tinnitus becomes so loud that it interferes with conversations and their ability to hear the things around them. Although, physically, tinnitus is not covering surrounding sounds, your attention cannot be drawn from your tinnitus interfering with your ability to concentrate. If you or a loved one are experiencing tinnitus, especially debilitating tinnitus, please reach out to a loved one, your primary care physician, or even the American Tinnitus Association Tinnitus hotline, 800-784-2433.
Documenting your tinnitus and the effect it has on your life is a very important step for your treatment plan. You should start by scheduling a diagnostic hearing and tinnitus evaluation with an audiologist that specializes in tinnitus. This may include certification in Tinnitus Retraining Therapy (TRT), American Tinnitus Association (ATA), or and the American Board of Audiology (ABA). Pure tone audiometric testing includes obtaining thresholds (or the softest sound you can hear) of hearing for low, medium, and high frequency sounds. Speech recognition testing is completed to get insight into the connection between the ears and our brain, and how well a listener can understand words. This typically includes repeating recorded words to obtain both a threshold level and an accuracy score. Speech recognition thresholds (SRTs) are obtained to determine the lowest volume needed for the listener to repeat 50% of the spondaic words (balanced) correctly and help determine validity of pure tone testing. Word recognition scores (WRS) are obtained to determine percent accuracy of words when presented at a comfortable listening level. If there are concerns for the outer or middle ear disorder, including fullness, ear pain, or an ear infection, tympanometry can be completed. This test involves presenting a low tone noise that creates pressure within the ear canal to test the motility of the eardrum. Additional testing includes otoacoustic emissions (OAEs) and acoustic reflex testing. OAEs are commonly used as a hearing screener as it provides a pass or fail result and is testing the function of the outer hair cells within our permanent inner ear of hearing. Acoustic reflex testing tests our middle ear reflex arc that includes connections to the lower level of the brainstem. This test is commonly used when there is concern for abnormal growths along the auditory nerve.
Once the hearing evaluation is complete, the next step is to complete a tinnitus evaluation. While there is currently no way to objectively test for tinnitus, there are several protocols to measure the patient’s subjective perception of tinnitus sound, pitch, and volume. Specifically, the doctor may test pitch and loudness matching, minimum masking level, and loudness discomfort levels. Pitch and loudness matching allow the patient to subjectively match their tinnitus to the closest available sound. Minimum masking is then completed to determine whether outside noise can cover the tinnitus, meaning the brain can focus on other stimuli when given the opportunity. Loudness discomfort levels are usually incorporated for patients who has sound sensitivity and determine the highest volume of pure tone sounds and speech a patient can hear before it becomes overwhelming.
The audiologist will, also, have you fill out questionnaires like the Tinnitus Handicap Inventory (THI) and Tinnitus Hyperacusis Questionnaire (THQ) which helps describe your symptoms, effect it has on your life, and categorize the severity of the tinnitus. These questionnaires are beneficial as they can be repeated throughout your treatment to determine effectiveness.
There are many treatment paths to take for tuning out your tinnitus, and it is important to work with your audiologist to find what is best for you. Hearing aids are a great first step for patients who have both tinnitus and hearing loss. Hearing aids also have additional tinnitus program capabilities, where fractal noise can be added for the patient to listen to in the background throughout their entire day. Newer technology also allows for streaming to the hearing aids; therefore, music and audio books can be used to provide relief from the tinnitus. Aside from the hearing aids, smartphone apps can be downloaded that are designed for patients with tinnitus. These apps provide sound enrichment, breathing exercises, and meditation guides to reduce bothersome effects of tinnitus.
Tuning the tinnitus out will be difficult at first, but eventually can become second nature. Think of it like riding a bike. In the beginning it is very hard to keep your balance, pedal, and break all at the right times. You may fall a few times, but you must keep back on the bike to learn. Once you have learned, it becomes muscle memory, and you are able to ride the bike for long periods of time. Habituation of your tinnitus can be done through relaxation and meditation, autogenic relaxation, visualization, or progressive muscle relaxation. Relaxation and meditation/autogenic relaxation focus on calming our limbic system and reducing the activity in our fight or flight response. This can then help reduce the effects of your tinnitus. Visualization is similar, except you focus on visualizing you getting through a day without being bothered by tinnitus. You visualize your own success with tinnitus treatment and that you can tune out the tinnitus. Progressive muscle relaxation is a guided meditation that teaches you to focus solely on individual body parts and how they feel. It will guide you to focus on your toes, fingers, hands, feet and move throughout your entire body. All of these require your full attention, taking it completely away from your tinnitus and teaching you to tune it out, even for short periods of time. Like riding a bike, this can be then learned to be extended to hours or even days.
If you need more assistance learning to tune out your tinnitus, a tinnitus masking device can be used. A tinnitus masking device involves using a device that introduces sound, typically white noise or some other calming sound, into the listener’s ear to help distract the brain from the tinnitus. Most often, tinnitus masking devices come in the form of hearing aids meaning they are ear-level-devices and can be worn throughout the entire day. The sound used should not be annoying or bothersome, but instead give you something with a neutral emotional response. It also should not be at a volume that is distracting, in fact, it should be barely audible. The goal is to make it like elevator music! Whenever we walk into an elevator, we notice the music right away. Usually, it has a soft melody and acts as a calming effect, and after you go up a few floors it is no longer noticeable. The elevator is not playing your favorite pop song that makes you want to sing and dance. The goal is just to play music in the background. The tinnitus masker works exactly like this. When you first put the masking devices on, you will notice the sound. After a half hour of wearing the devices, you will no longer pay attention to the sound, and you become less aware of your own tinnitus. You can then go about your day with the devices on and get through tasks that before you may have struggled with due to your tinnitus. The four main goals of tinnitus masking devices are to wear them consistently as needed, to have the sound be loud enough to be audible but not loud enough to interfere with daily activities, to use a sound that is not bothersome or annoying, and to be able to still hear your own tinnitus when thinking about it. When following these goals, tinnitus masking devices can be very successful in reducing that negative reflex created by the limbic system!
Hearing aids, Sound Therapy, and tinnitus “masking” devices are often discussed primarily when discussing treating tinnitus, but there are other lifestyle changes and techniques we can use as well. Tinnitus and your limbic system, or emotional response center in your brain, are closely connected which is why taking care of our emotional and physical health can have a positive influence in lessening the impacts of your tinnitus. Tinnitus management isn’t only in the field of audiology. Other helpful members of the healthcare community are mental health professionals. Reaching out to a mental health professional who can help provide guidance on how to manage your tinnitus. Most commonly, these professionals will provide Cognitive Behavioral Therapy (CBT) to change your negative reactions about tinnitus (I hate the sound, I am bothered by the sound, I cannot sleep because of it, etc.) into neutral emotions. They have the skillset to help you outside of the realm of hearing. If you do not have a mental health provider, reach out to your audiologist as they can make recommendations about clinics/providers that are familiar with tinnitus management and mental health blended techniques.
Preventing tinnitus starts with protecting your hearing. You can have a high-fidelity custom earplug, also known as Musician’s earplugs, made. These custom earplugs will be made according to your ear anatomy and protect your ears from further noise exposure. By limiting our noise exposure, we are helping prevent the tinnitus from becoming worse (louder or a more annoying pitch). These earplugs still allow non-damaging sounds to pass meaning you can still hear others while wearing them! You can also have annual audiometric evaluations completed to ensure no sudden shifts in hearing ability occur. Our ears age and change slowly, meaning we never expect to see a sudden decrease in hearing without cause.
Overall, alone, tinnitus can be very difficult to manage. But, when you navigate this space with the right team, tools, and exercises you can take control back of your life. You have tinnitus but your tinnitus doesn’t have control over you! If you are having a hard tinnitus day, step outside, take a walk, turn on your favorite music, give yourself a little grace that this may be one sign your brain is telling you that you need to slow down a little as you may be stressed or overwhelmed. It may also be a sign to reach out to your mental health provider or audiologist to update some techniques to deploy at-home for you to regain control of your tinnitus. It could be as simple as making a goal for yourself to have a few minutes to practice meditation before bed, put the phone down, and set yourself up for a good night’s rest so that you can face tomorrow well-rested. Tinnitus management doesn’t have to be complicated, it just needs to be what works best for you.