Tinnitus is a perception of sound often described as a ringing, buzzing, or humming in the ear or head region. Usually, though not always, tinnitus is a symptom of hearing loss and affects millions of people.
For some, tinnitus can be associated with depression, anxiety, sleep disturbances, interference with concentration; all which can be made worse stress.
There are many potential causes of tinnitus including noise exposure, physical injury (e.g., head trauma, whiplash), ear disease, muscle spasms, circulatory changes, side-effects of medication, neural disease, and aging. A medical assessment is essential to determine potential causes and treatments.
However, in most cases the dominant cause of tinnitus is hearing loss, specifically damage to the inner ear. Tinnitus is not a disease itself; it is a side effect.
Tinnitus and hearing loss: What’s the connection?
Hearing loss can be related to damage or obstruction in the external ear (example: plug of ear wax), middle ear (example: fluid behind the eardrum due to an ear infection), or the inner ear (example: damage to those hair cells due to noise exposure, aging, etc.). Tinnitus is usually related to the damage to the inner ear, which is the most common type of hearing loss, called sensorineural hearing loss.
Hearing loss is usually gradual and can be insidious, meaning you may be unaware of it, or the damage may be only minor that it has limited effect on your daily life. For example, we can have damage to those hair cells, which accumulates over time from getting older, noise exposure, etc. While this gradual damage accumulates the central areas of our system change to try to compensate for the loss. This is where the tinnitus is created. Even mild hearing damage can result in tinnitus.
There is spontaneous neural firing happening in our nervous system all the time, but normally the brain ignores this and only responds when there is a pattern due to external stimulation. When we stimulate auditory regions of the brain we perceive sound, even if no external sound was played. With hearing loss, there is damage to those sensory receptors (we call hair cells) and thus we begin to lose some of the input to the auditory region of our brain that was normally present. The auditory regions of our brain and brainstem want stimulation; when it stops receiving input, it adjusts so that it does get some input. So after the hearing loss our brain tries to compensate changing. This is called neural plasticity. The side effect of these neural changes is tinnitus. Due to the damaged hair cells or peripheral neural damage, our auditory brain region tries to compensate and begins picking up on a neural signal due to the change (i.e. plasticity), which is the tinnitus you hear.
FMRI studies showed more than just the auditory region of the brain activated when a person is experiencing tinnitus. They also showed other parts of the brain, particularly the limbic system which its primary role is in processing and memory of emotional reactions. If the tinnitus comes out of nowhere or even slowly builds up, our first thought can be: is something wrong, am I going crazy, am I going deaf, do I have some disease, or just what the heck is this ringing! Since we don’t know and can’t stop it, we are stressed and our brain sees it as something negative and we attend to it. This is why when you are stressed your tinnitus may seem worse.
Steps to treat the tinnitus
How we treat the tinnitus is using methods to train your brain to recognize the tinnitus signal is not conveying important information, it is not a sign of danger and your brain does not need to focus on it anymore!
- The first step to this process is to understand what tinnitus is and what it is not. We will also request you see an otolaryngologist (ENT) to help rule out any medical causes. We can train our brain to ignore tinnitus. This process is called habituation.
- Understanding habituation is the second step in treating tinnitus. If you brain had to attend to every signal coming in at all times it would be very overwhelmed. This is what we will do with the tinnitus, we will train your brain to realize it is not a true sound and that it is not an important signal, it is simply a normal and common side effect of hearing loss.
- The third step for tinnitus treatment is applications of sound therapy. The basic idea behind sound therapy is to play a soothing sound (via earphones, speakers in room, hearing aids with combo sound generator) at a level that does not mask the tinnitus (does not cover up completely), but at a level that reduces perception of tinnitus and provides relief. The idea is the tinnitus
- is a constant sound that is perceived as aversive, to habituate, we must show the brain that a constant sound can be perceived as meaningless or even soothing. In addition, the stimulation provides a real external sound for the brain to disrupt attention to the tinnitus.
- The fourth component of tinnitus treatment is distraction Sometimes there is the feeling you can’t escape the tinnitus. In particular during times of stress and lack of stimulation we can become even more focused on the tinnitus. One way to help break that attention is through step 3, sound therapy. In addition, distraction can be very helpful. If you are having a rough episode with your tinnitus, don’t just sit there and listen to it. Put on the sound therapy and distract yourself and do something you enjoy.
- Finally step is diet, exercise, lifestyle, and mental health. Poor general health, sedentary lifestyle, poor diet, and inadequate sleep can all exacerbate tinnitus. Many medications used to treat effects of unhealthy lifestyles can actually cause tinnitus. Let tinnitus be an alarm, maybe even a wake-up call to take care of you and get healthy! Getting into shape may not cure your tinnitus, but it can reduce stress, improve sleep, allow you to stop taking certain medications that do significantly influence tinnitus. If you have significant stress in your life, anxiety, depression either related to the tinnitus or not, therapy can be helpful. As we discussed stress can exacerbate tinnitus.
Cognitive behavioral therapy (CBT) is a therapeutic approach that helps a patient identify maladaptive thoughts and behaviors and learn stress reduction techniques. CBT can be very beneficial for tinnitus patients and should be considered all patients.
Before starting any diet or exercise program consult your primary care provider for tinnitus management.