On the Hearing Ally video blog today we're going to discuss tinnitus; and much
like hearing loss,
there's a lot of misinformation and conflicting information out there in the
medical community and online about what actually causes tinnintus, what it is, and
the best ways to treat it. Now there's a lot we don't know about tinnitus still and
I'm not going to sit here and claim that I know everything that is available to
know about it but my goal today is to give you a bit of a framework for
understanding what it is so that you can actually work with your healthcare
providers to problem solve this issue and how it uniquely affects you and how
your unique life plays into what might make it better or what might make it
worse. So let's dive right in.
First off, what is tinnitus? Tinnitus is a sound that's generated inside of a
person. It is not coming from an external source, ninety-nine percent of the time
it is a sound that can't be heard by anyone else, it's not actually a pressure
wave that's being generated in the outside world by the person. In one
percent of cases that actually happens. You can actually put your ear up next to
someone can hear their tinnitus. That's called "objective" tinnitus, we are not going
to talk about that today,
very rare very uncommon. We're really going to focus on the most common types
of tinnitus today.
Now you may not fall in that category, and I don't want to leave you behind,
we'll add some other resources and information about the other types of
tinnitus later on so what we're focusing on today is the type of tinnitus that's
caused by the inner ear or a sensory neural hearing loss, basically the
neural and sensory part of the auditory system. We're not talking about tinnitus
that's caused by a blockage of earwax or middle ear fluid or congestion,
anything that's going on in the outer and middle ear and that's something that
fortunately can be medically managed usually. So that's why I 100% encourage
you to see a physician, get a hearing test, have somebody looking your ear, and
make sure that there isn't something that can be easily medically managed
first. So those things were not really going to touch on today but it's
important to understand that there are a variety of different things that cause
tinnitus so when you Google it, you may come across different kinds of
treatments that actually have no mechanistic relationship to what causes
your tinnitus. So, if you see something that says it's some kind of magic cure-all
for tinnitus,
it's probably not because anyone who really understands it knows that they have to
rule out so many other pieces of information about what may or may not be
causing it before they can even begin to give you a recommendation about what
might make it better for you.
So number one if you have bothersome tinnitus, especially if it's worse or only
in one ear, especially if it occurred suddenly, you definitely want to seek
medical attention you want to go see an ear nose and throat physician and get a
hearing test. And yes, I say hearing test.
It's very important; about ninety percent of people who have tinnitus also have some
kind of hearing loss. So you know getting the test itself is not some thing where
you have to get hearing aids or you have to do something about the hearing loss
part of things, but it's important to understand what type of hearing loss may
be associated so that we can actually look at how to treat the tinnitus.
So, number one,
get a medical evaluation and then we can move forward with what might actually be
a helpful treatment paradigm for you. So let's assume it's not ear wax, you
didn't have an ear infection or anything that could be medically managed, and
(including a tumor so they can be very serious) so I will jump to let's say
for example you are like the most common
Vet going to the VA, the number-one disability at the Veterans
Administration in the US is tinnitus and that is presumably from noise exposure
in the military. so noise exposure causes hearing loss and subsequently in many
cases causes tinnitus so again in this case if you've got a lot of noise
exposure and you have tinnitus is highly likely that you have a hearing loss
alongside of it.
So in this case let's look at what actually causing the tinnitus; sure the
noise exposure caused damage to the auditory system, to the inner ear, but the
tinnuts itself we understand is not actually coming from the inner ear it's
coming from what we would say is "higher up" in the auditory system, so farther
along that auditory pathway from where the ear senses the sound and turns it
into an neural signal, or a basically an electrical signal, and goes up to the
brain so that process of going up to the processing centers of the brain that's
what i'm referring to when I say "higher up". And one of the reasons that we know
this is that if we look back at some of the research that's been done in cases
where tinnitus was extremely bothersome for people and surgeons and
researchers were looking at what could possibly be done to help. This is
quite a while ago you can look at cutting the auditory nerve, cutting that
connection between the inner ear or the cochlea and the brain and you would
assume that this would make the tinnitus go away, as well as the person's
hearing, of course and in many cases it didn't, some cases it actually
made it worse.
so why is this happening? how is this something that's coming from the inner
ear but then really coming from the brain?
Well, one of the theories, working theories, includes kind of two mechanisms:
One is that our brain and our auditory system is used to getting input
pretty much baseline sound input all the time, even when it's quiet.
There's just this kind of low-level activity that's happening from healthy
cells in the ear so when you damaged one specific part of the ear, like from a
noise exposure is one little frequency window that tends to be affected most,
you're going to reduce or eliminate that baseline activity, that baseline input up
to the auditory system, and then when there is outside sound coming in at that
particular pitch it's not going to be as loud as it normally would. So what does our
brain do? Our brain is detecting a difference in its norm. Its norm is to
get a little bit of information all the time and so as a compensation strategy
we think that the brain actually fills in that missing information at that
particular pitch. So this is interesting, that's often where people hear let's say
high-pitched ringing is, where they'll have the most hearing loss and in this
model that makes a lot of sense.
So our brain is actually creating the sound to fill in that missing
information in some people because we want to fill in that information,
potentially with something meaningful the sound can actually start to sound
like music or it can mimic some of the sounds in the environment, like birds.
This is a little bit more uncommon but it's just to kind of illustrate that
this is actually what's happening
The other mechanism that plays a role tinnitus, is one that actually
suppresses information that isn't important.
so kind of like background noise. Tinnitus in a lot of ways is similar to pain and
our brain can respond by suppressing tinnitus
similarly to the way we suppress pain. If you think about it if you've ever
watched your thumb, you know hammering something, of course initially really
hurts but after a few minutes or even after 30 seconds
the pain is not as acute, even though the damage to your thumb is the same as
it was when you first hit it.
so the brain is able to say this is a constant input, I'm no longer in danger
from this, let's ignore that information.
Same thing goes for if you said can you feel your shirt before I asked that
question you probably didn't feel your shirt on your skin but once you ask the
question then you can notice it so our brain is able to ignore information that
isn't important now that mechanism works for a lot of people they know that the
tinnitus is there if they ask if they can hear it or if they focus on it but most
of the time they can ignore it if this is true for you that means you're you
know that's the lucky group of people with tinnitus, they can usually
ignore it and that's the goal for a lot of people to get to with tinnitus so not
that tinnitus is completely goes away, but that were able to use the mechanism
to suppress it much more effectively.
Now what might interfere with this mechanism to suppress background noise?
Well there's a lot of different things and I again don't claim to be an expert
in this area but what I understand about tinnitus specifically and how the brain
suppresses it, is that it has a lot to do with kind of like the
fight-or-flight system, or the activation of our nervous system. So things that
overexcite or stress our nervous system are likely to stress this suppression
mechanism. so when I ask my patients have you had trouble sleeping lately?
have you had more stress in your life? a big project going on or a relationship
issue? have you been drinking more caffeine? are you aware of food allergies
or do you have seasonal allergies? all of those things can increase that baseline
activity of our nervous system. They cause stress or inflammation and it puts
a harder toll on the body's ability to ignore background noise (like tinnitus).
Ironically and unfortunately, tinniuts for a lot of people makes it challenging
for them to fall asleep, so this can perpetuate the problem. But looking at
those areas of your life, areas where sleep and your overall health and your
diet impact how loud or how bothersome the tinnitus is really important. So if you
can take an inventory of when the tinniuts is getting worse or if it's changing
quality or if it's bothering you more,
what's going on at that time or what's going on during the day, that can help
lead you to maybe the source specifically for you. Now again, everyone
is so unique and certain things maybe more of a stressor for one person than
another.
So you can really help yourself and help your healthcare providers troubleshoot
this problem by looking at what really affects your tinnitus specifically and
how it affects it. so that's one really important thing to look at. I also
train healthcare providers on how to use their specific specialty or how they
approach things, to help patients address this. For example, acupuncture can be
very helpful for some people with tinnitus and not really help other people at all.
When we look at research as a whole for treatments, acupuncture doesn't seem to
come up as something that robustly and significantly helps the majority or
enough people in the test group. But I've clinically seen this help small groups
of people. So you may be one of those people you may not be. Acupuncture maybe
something that you want to try but my point is is that the acupuncturist may
need to understand exactly what's inflaming or exacerbating your nervous
system and not really look at potentially trying to get rid of the
generating of the sound, but look at your body's ability to suppress it.
So, Important differentiation there. The next thing i want to discuss is how
over-the-counter or kind
of one pill type prescription of tinnitus plays a role here. Unfortunately there
are a number of over-the-counter medications or supplements that make
high claims about the ability to get rid of tinnitus completely. Now like I said
before,
anytime you see something that's acts like it's a one-stop shop for tinnitus,
it's probably not. In my experience these things have not worked for people. I also
am not aware of any real, you know high quality, research that shows that
any of those supplements work. But if you're aware of some feel free to send
that my way, happy to read it.
Among those medications, a good percentage of them actually have things
in them that can make tinnitus worse like quinine. so make sure you read the label
if you are going to explore this area and and don't take anything that has
something in it that causes tinnitus or you know is a problem for you.
That being said, there may be certain herbs and supplements or
minerals, vitamins that acually do help your tinnitus there's definitely some
research that suggests that certain mineral deficiencies can exacerbate
tinnitus. So lack of magnesium, vitamin b12 and other essential nutrients can
definitely cause inflammation or exacerbate it or in the nervous system,
affect our mood and just affect the whole person and their ability to use
that suppression mechanism. If you think that that's something that might
be true for you, I would definitely ask your healthcare provider to let you know
what kind of supplements are the best for you to try. Now there are other
interventions that have more to do with an actual, physical intervention
device or therapy. So these are actually the areas that research has shown help a
significant number of people with tinnitus. Let's go through a couple of those.
Number one are ear-level masking devices. So what I mean by that is that is a
little device that fits behind-the-ear, can look very much like
a hearing aid and in fact, this feature can be embedded into a real hearing aid.
What a masker does is it brings in a sound, whether it's an ocean like sound
or fan, white noise like sound. It delivers a frequency specific volume
specific sound that helps the person ignore or mask out their underlying
tinnitus. Now, the goal is not necessarily for this sound to be louder than the
tinnitus, but make it so that the person can more easily ignore their own tinnitus.
This requires someone actually fitting you with the device, making appropriate
settings and sometimes giving you multiple settings to choose from
throughout the day and depending on what's going on. And sometimes these
things can change you need ongoing follow-up but they are highly effective
for a lot of people. I mentioned hearing aids, hearing aids are actually
very helpful for people who have both tinnitus and hearing loss, I should say
most people, so around seventy percent. Typical example let's say there's a
veteran who has ringing in their ears, they notice a little bit of hearing loss
but it's not their primary motivation for coming into my office. They turn out
to have a moderate to severe hearing loss now this person just based on that,
is a hearing aid candidate, but their primary motivation is is there tinnitus so
what I say in that situation is, 'hey you've got a 30-day trial period with
hearing aids, you may be one of the seventy percent of people who has a
significant benefit from hearing aids to suppress that tinnitus, so let's just see.'
We fit that person person with hearing aids. I don't expect them to
know on the first day if this is going to be something that helps their tinnitus
enough or not, we have to send them home and try different settings and them to
be in different environments, but the vast majority of the time they're going
to come back after two weeks and say 'you know, this really does help my tinnitus.' and
on top of that, it really helps them get more clarity when they are
talking with people. They can hear their spouse much more effectively,
they're more engaged in social situations, are not avoiding them, they're
no longer bluffing when they say that they've heard something, and you know we
know that there's a lot of other factors and that improve quality of life and
job satisfaction and income from hearing aids, but we'll talk about that
another time. For this person they're really most concerned about their tinnitus
and the hearing aids, just at their normal setting, seem to be doing the
trick. Some people, that other thirty percent it doesn't help them enough and
in that case we can try a tinnitus masker that's built into the hearing aid.
Basically, I can give that person a separate program or I can have it
playing all the time,
a low-level background noise that we've determined is helpful for them to ignore
their tinnitus and that like I said, can be really helpful for the other group of
people. Now this is not to say that hearing aids and maskers help everyone
in some form or enough, there are a lot of people that it doesn't seem to help
at all.
Cognitive-behavioral therapy or "CBT", is another option. This option helps people
learn how to ignore the sound and there's no masking device
necessarily involved, there's another treatment, Tinnitus Retraining Therapy or
"TRT," which I understand uses a kind of like a combination between CBT and
masking device. There's also things that are still in research like
Transcranial Magnetic Stimulation or "TMS." It's not approved by the FDA yet for
treatment of tinnitus, but currently it looks like it has a lot of promise.
Like I said, I'll include links to all these different resources to see if you
can find people in your area that can help you with these methods or just your
own healthcare provider do a little bit of problem solving or detective work
about what might be triggers for your tinnitus and ways to manage it more
effectively.
Basically, make sure that you're crossing your T's and dotting your i's getting
medical intervention as needed and doing your research and really coming into
this with an open mind about how you may be able to be helped.
There's just a lot more available out there that most people are aware of and
it is not hopeless case to treat your tinnitus there's there's a lot of success
that I see in my work all the time. So go ahead and take care of this. If you need
help with more information or getting a better understanding of what's going on
for you specifically or a family member,
please feel free to contact me and we can see how we can work together.
I'm also going to have some continuing education available for healthcare
providers, so feel free to refer them to my website if they're interested in
learning more of the mechanisms behind things like tinnitus and hearing loss.
Alright thanks for watching, have a good one!
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