Tinnitus – Ringing in the Ears

What is Tinnitus?
Quite simply, tinnitus is the perception of sounds-often described as ringing, buzzing, humming, roaring, or whistling-that are not present in the external environment.

The term tinnitus does not refer to a single disorder, but rather describes a collection of symptoms that may have a number of different causes. Each person’s tinnitus experience is unique, and very real.

Over 50 million Americans experience tinnitus to some degree.1 And approximately 10 to 15 percent of adults have prolonged tinnitus requiring medical attention.2

For most people, tinnitus is a mild annoyance and may be temporary. However, more than 2 million American adults (1 to 2 percent of the population), experience severe, chronic tinnitus.

Because tinnitus can be a symptom of a more serious condition, any prolonged experience of tinnitus should be evaluated by an audiologist and a medical doctor.

Chronic tinnitus can affect a person’s work, family, and social life. It can interfere with sleep, make it difficult to concentrate or to relax, increase sensitivity to loud sounds and lead to anxiety and depression.

Tinnitus can be caused by a variety of factors and each individual case is unique. Tinnitus typically occurs in the auditory system as a result of hearing loss.

This hearing loss can result from exposure to loud noises, certain types of drugs and medication, middle ear infections, or other reasons.

In a small proportion of cases, tinnitus arises from a condition that requires medical or surgical intervention.

Once the tinnitus signal is generated in the auditory system, another part of the brain (the limbic system) attaches an emotional response to it. Similar to the “feeling” you get when you scratch your fingernails down a blackboard, tinnitus is more than just a perceived sound. Tinnitus can trigger anxiety and stress responses in the body which, in addition to the limbic system, also involves the autonomic nervous system.

Model of Tinnitus

Tinnitus and stress
Suffering from tinnitus can be stressful and this in turn can make it worse. So stress reduction is a vital element in effective tinnitus management.
Many people use music for relaxation and stress relief without ever thinking about it. In fact, music has a great influence on our body and psyche. Whether a certain piece of music is stressful or relaxing depends on a range of factors; for example, loudness and volume and sudden changes in pitch or tempo, and personal preferences and tastes.

 
Treatments for Tinnitus
Dr. Downs specializes in the treatment of tinnitus and is the only professional you’ll find north of the Twin Cities in Minnesota. Dr. Downs uses several methods of treatment for tinnitus including strategic hearing aid fittings, Tinnitus Retraining Therapy (TRT), and Neuromonics and counseling about lifestyle and stress management. Dr. Downs completed TRT training in 2001 with Dr. Pawell Jastreboff (creator of the treatment) at Emory University. In 2007 she was one of the first 60 practitioners in the U.S. to be trained to provide Neuromonics Tinnitus Treatment. Today she evaluates each patient individually and uses a blend of treatment methods customized to meet the needs of each person as no two people experience tinnitus in the same way.

 
Tinnitus Retraining Therapy
Tinnitus Retraining Therapy was developed in the late 1980′s by Pawel Jastreboff, Ph.D., Sc.D. While working at Yale University, Dr. Jastreboff developed his model of tinnitus which postulates the involvement of the limbic (emotional) and autonomic nervous systems in the perception of tinnitus. His research began with the ongoing effort at that time to describe the acoustics of tinnitus.

The expectation was that by describing the tinnitus exactly in terms of pitch and loudness, different categories would be established and specific treatments could be applied to each category with predictable outcomes. Instead of the expected results, however, researchers found something completely unexpected and very surprising.

Approximately 75% of all the people who experience tinnitus are not affected by it and they treat tinnitus like any other sound to which they can easily habituate. They hear it similar to the way we hear the sound of the refrigerator in our kitchen, of which we are not normally aware and when we do hear the sound, it is not bothersome.

The researchers found there is no difference in the acoustical characteristics of tinnitus between those who are not bothered by it and those who suffer from it!

This was a profound discovery and led directly to Dr. Jastreboff’s postulation of another cause for the distress caused by tinnitus. The physiological and psychological foundations of his tinnitus model are these:

1. The processing of information occurs on several levels for each sensory system, each level contributing to the final stage when a signal reaches the cortex.
2. The auditory system is closely connected with the part of the brain that controls emotions (limbic system) and the automatic response of the body to danger (autonomic nervous system).
3. Connections within the nervous system are continuously modified, resulting in the enhancement of significant signals and a decrease of neuronal response to irrelevant signals.
4. Sounds that are new, or associated with a negative experience, are treated as significant, evoke an emotional response that triggers the body to “fight or flight.” The repetition of these sounds results in enhancement of their perception and in a resistance of the perception to be suppressed by other signals. The repetition of signals not associated with positive or negative reinforcement results in the disappearance of a response to their presence, i.e., in habituation.

To understand how tinnitus develops, it’s helpful to understand how sound is processed in the auditory pathways. In the absence of noticeable sound levels there is still a high level of neuronal activity in the auditory nerve and pathway, but this activity is random. The nervous system filters out this activity and it is not perceived as sound. When we are exposed to a measurable amount of sound the activity within the auditory system increases and becomes more regular and synchronized. This activity undergoes extensive processing in several subcortical centers within the auditory pathways before reaching the cortex where perception of sound occurs.

This processing of information results in continuous changes of the connections within the brain that are involved in transmitting signals from the ear to the cortex. Repeated activations by a sound not associated with anything of significance will result in decreased activation of the cortical and limbic areas. On the other hand, sound associated with a significant event, particularly related to danger, will be enhanced and will strongly activate the cortical areas and emotional response. Our brain sorts sounds according to their significance, giving important sounds high priority and filtering out, or habituating, insignificant sounds. The rules controlling sorting priorities are in flux and change throughout an individual’s lifetime. TRT postulates that with the proper training one can enhance their perception of some sounds while training their brain to filter out other sounds.

This is the basis of TRT, training the brain to habituate tinnitus sounds and classifying them to represent a neutral, insignificant signal. To achieve this it is necessary to fulfill two basic conditions:

1. Removal of the negative association attached to tinnitus perception.
2. Preservation of tinnitus detection, but not necessarily perception, during treatment.

Signals that induce fear or indicate danger cannot and should not be habituated. We must not habituate sounds that provide warning signals. The decreased negative association of tinnitus is achieved through directive counseling. The patient is taught the basic function of the auditory system and the brain relative to tinnitus. Decreasing the reaction of the autonomic nervous system is a primary goal of the therapy.

The second condition is less obvious but equally important. In order to retrain the neuronal networks, it is imperative that tinnitus be detected. Retraining cannot be achieved for a signal that is masked or undetectable. Thus, for habituation oriented therapy, masking of tinnitus is counterproductive.

Low level, broad band sound is used to facilitate tinnitus habituation. Silence actually enhances tinnitus and patients undergoing TRT are advised to avoid silence. They should immerse themselves in a low level, emotionally neutral sound environment. TRT involves use of in-the-ear sound generators to provide this neutral sound environment. The sound generators are operated at a low enough level that the tinnitus can still be detected. Broad band sound contains all frequencies which gently stimulate the nerve cells in the subconscious networks allowing them to be more easily reprogrammed, or habituated, to no longer notice the tinnitus.

The sound generators are worn continuously and can be taken out for sleep or left in. The cost of the generators is about $2,200.00 to $2,600.00. The cost of directive counseling is added to this. Therapy typically lasts for 12 to 24 months.

It is nearly impossible to conduct a double-blind, placebo controlled study on TRT. It’s difficult to imagine how to construct a placebo that would seem like TRT but be totally ineffective. Because of this there is no wealth of clinical evidence as to its efficacy. Dr. Jastreboff claims that he has treated about 1,000 patients in his clinic at Emory University in Atlanta, GA and that 80% of these have experienced significant improvement. Dr. Jastreboff however does not define or qualify the term “significant improvement.” His website and contact information can be found at www.tinnitus-pjj.com

Neuromonics Tinnitus Treatment
Recapture everyday moments without disrupting your life. The Neuromonics Tinnitus Treatment is convenient and non-invasive, making it easy to use during regular daily activities.

A small, lightweight Oasis™ device with headphones delivers precisely designed music embedded with a pleasant acoustic neural stimulus. These sounds, customized for each user’s audiological profile, stimulate the auditory pathway to promote neural plastic changes. Over time, these new connections help the brain to filter out tinnitus disturbance, providing long-term relief from symptoms.

The Neuromonics treatment occurs over approximately 6 months, with many reporting some relief immediately. Throughout the treatment process, education and support are provided by a Neuromonics-trained clinician.

Before any treatment begins, a specially trained audiologist will meet with you to evaluate your tinnitus and hearing. After assessing your audiological profile, the audiologist will then discuss which treatment options are most appropriate for you, and whether the Neuromonics treatment can help.

If you both agree that Neuromonics can help, you will be fitted with the Oasis™ device. The device delivers an acoustic stimulus that is embedded in precisely designed relaxing music, and delivered at a low listening level. The stimulus is customized to your individual prescription, based on your audiological profile.

This phase helps relieve symptoms so that you can begin to experience control over your tinnitus while continuing treatment.

The Oasis™ device is worn for at least two hours per day (or longer, if preferred) during daily activities like reading, preparing meals or at the office.

This stage typically lasts about 2 months.

The goal of Stage 2 is to help the brain develop those neural connections that allow it to filter out tinnitus sounds. When this happens, relief continues even without regular use of the Oasis™ device.

In this stage, the device is used for at least 2 hours per day initially. Treatment times are then gradually reduced as tinnitus disturbance lessens.

This stage of treatment typically lasts about 4 months.

After a successful treatment program, your Neuromonics audiologist will work with you to develop a maintenance program you can use to continue to control your tinnitus on your own.

Many people do not feel the need to use the device after treatment. Those who do typically use it for short periods of time to help them maintain the benefits achieved.

 
Combination Devices for Sound Therapy

Inspired by the relaxing effect of certain types of music, Widex developed the Zen programs. Zen is a unique music program available in some Widex hearing aids. Based on what is known as fractal technology, Zen plays random, chime-like tones that can be used for relaxation and for making tinnitus less noticeable.

Dr. Downs can adjust each Zen program according to your preferences in terms of pitch, tempo and volume. Your hearing aid can also be provided with different programs to suit varying situations and purposes. For some hearing aid users, the effect of using Zen is immediate, but for most it will take some time.

Advice for dealing with tinnitus
The following advice can help you deal with tinnitus and its effects:

• Make use of sound. The amplified sound from your hearing aid for example, is often enough to make tinnitus less irritating.
• Avoid silence. For example, turn on the radio on when you’re home alone or listen to some music.
• Try to avoid the excessive use of alcohol, nicotine, caffeine and some types of painkillers.
• Be aware of food containing a lot of salt; it can worsen the effects of tinnitus.
• Try to be physically active or allow yourself some breaks during the day to reduce stress.

Next Steps
Call our office for a hearing and tinnitus evaluation with Dr. Downs. We will closely examine the tinnitus your hearing health, and how tinnitus is affecting your life. Dr. Downs will then make treatment recommendations customized to your tinnitus and your lifestyle.