Tinnitus Refresher: What Is It?
Tinnitus is the perception of sound in the absence of external auditory input from the environment. It’s a difficult term to pin down because tinnitus can sometimes be described as a symptom or as a disease (or rather, a collection of diseases). People are often confused by this.
For example, an acoustic neuroma is a tumor that grows on the auditory nerve, and tinnitus can be described as a symptom that results from that. Alternatively, tinnitus is often described as a distinct disease that can have multiple possible causes, such as hearing loss. For this article, we’ll categorize tinnitus as a disease with several possible causes.
The most common type of tinnitus is something called sensorineural tinnitus, which is the result of hearing loss (the most common issue for DJs and musicians). Hearing loss can result from age, noise exposure, or other causes. As a result, the sensory input that feeds into the auditory nerve can be partially (or completely) cut off, resulting in sensorineural tinnitus, which manifests as perceiving sound in the absence of any sound from the environment.
a ringing sound in the ears, most often described as a high pitched “eeee” sound
For most people with hearing loss and sensorineural tinnitus, this results in a ringing sound in the ears, most often described as a high-pitched “eeee” sound. Tinnitus sounds may be constant, or they may be pulsatile (repetitive, as if playing on loop). Click here to listen to a sample of tinnitus sounds that patients have reported. Hyperacusis, a sensitivity to sound, also often co-exists with sensorineural tinnitus, and may be due to the same underlying cause.
Tinnitus can be acute (for example, in the hours after going to a loud concert), or chronic (lasting indefinitely). Because noise exposure is a risk factor for hearing loss, and because hearing loss can cause tinnitus, DJs are particularly at risk for developing this condition.
Generally, when you read about tinnitus online, usually people are referring to chronic sensorineural tinnitus — persistent tinnitus which has resulted from hearing loss.
If you experience tinnitus, it’s important to speak to your doctor. In some cases, tinnitus requires specific medical investigations and treatment. For example, pulsatile tinnitus — a rhythmic whooshing sound that repeats on loop — may be due to high blood pressure. By treating the high blood pressure with a medication, the tinnitus may be eliminated entirely.
If you have tinnitus, and want determining your tinnitus frequency, a free tinnitus tuner (a frequency matcher) is available here.
Why Does Tinnitus Suck?
Some of you may be thinking — why does this matter at all? The answer is simple: if you have tinnitus, it can be terrible.
Imagine a sound that never goes away, like a fire alarm that’s perpetually going off inside your head.
Imagine a sound that never goes away, like a fire alarm that’s perpetually going off inside your head. For some people, tinnitus can be a maddening experience. For people with chronic sensorineural tinnitus, they can go decades without a moment of silence. It’s not the tinnitus tone itself that causes harm, but your brain’s reaction to the tone that causes harm. In addition to being annoying, tinnitus has been linked to psychological distress, depression, anxiety, an inability to concentrate, and in some cases, even suicide. For example, abnormalities in the amygdala (the fear center of the brain) may be associated with tinnitus.
Further amplifying this misery: no one except you can see or hear the thing that’s causing you all this distress. Sometimes people will callously tell you to just get used to it, betraying a lack of empathy for your suffering. They can’t quite understand why a simple sound can cause so much harm, and it can feel quite isolating when others don’t understand your pain. That’s why I recommend joining the excellent Tinnitus Talk forum – it’s a great resource and community for those who are suffering.
Some people with chronic sensorineural tinnitus will habituate to the tone over time. Habituation means a person will unconsciously learn to ignore the sound over time such that it no longer causes them any significant distress. Some people habituate gradually, others quickly, and some never at all. Those who do not habituate can suffer greatly. The principle of Tinnitus Retraining Therapy, one of the oldest treatments for tinnitus, is to induce a habituation response.
Why Is Tinnitus So Hard To Treat?
The first thing you have to understand about tinnitus treatment is that for the most common hearing loss tinnitus, there is no definitively proven treatment or cure. If you read anything about a “cure” online, make no mistake: you are being sold snake oil.
Even though sensorineural tinnitus results from hearing loss, it’s actually a disorder of the brain. Once input at certain hearing frequencies is lost, the brain reorganizes its connections through a process called neuroplasticity. Our current models of tinnitus suggest that tinnitus is a result of this process of reorganization.
A helpful analogy is to think of a guitar amp: as you increase the volume of the amplifier (the gain), it becomes more sensitive to input from the instrument (ear), and as many of you have noticed, the amplifier will produce a low humming sound (tinnitus). Such a model accounts for why people with tinnitus from hearing loss often paradoxically experience hyperacusis, which is the increased sensitivity to sound.
Rule Number One: Be Skeptical
The current scientific consensus is that there is no definitively proven treatment or cure for chronic sensorineural tinnitus. Yet, at the same time, there’s a surfeit of available therapies online.
Why? The reason is simple: when there’s demand for something, people find a way to supply it. That doesn’t mean you should believe them. I won’t link to them here, but there’s a multitude of ebooks available online that claim to hold “secret cures” for tinnitus. They have absolutely no scientific basis at all — they’re just marketing gimmicks.
In addition to outright deception, the other important thing to understand is that not all scientific evidence is created equal. Just because there’s a small study that appears to prove that a particular treatment works, that doesn’t necessarily mean that it actually works.
Because of common errors in the statistical analysis of medical studies, most published research findings are false. Research findings are more likely to be true if they:
- Have many participants
- Demonstrate large, not incremental, therapeutic benefits
- Contain randomized controlled trials (they have an experimental and a placebo group)
- Have findings that are replicated by other experimenters several times
The majority of studies with tinnitus contain few participants and have not been replicated successfully. The best studies aggregate results of multiple randomized controlled trials that each have large numbers of participants. This is called a meta-analysis.
Treatment or Coping Enhancement?
There’s two therapeutic approaches to tinnitus: lowering the volume of the tinnitus tone, and reducing the psychological distress caused by the tinnitus tone.
Earlier therapies, such as tinnitus retraining therapy, focused on reducing the psychological distress caused by the tinnitus tone. Newer therapies are focused primarily on directly eliminating or lowering the tinnitus tone itself.
Medications
Presently, there is no standardized medication medication regimen that is recognized by clinicians as being effective for the treatment of tinnitus. It is rare for a physician to prescribe a medication for tinnitus, and side effects have been a particularly vexing problem.
Small experiments have been conducted which initially showed some promise but then encountered substantial barriers to widespread use. Here’s some medicines that have been tried:
- a local anesthetic, lidocaine, was found to suppress tinnitus when injected intravenously. However, because of the impractical nature of using an intravenous medication for the treatment of tinnitus, an oral variant was tested for the treatment of tinnitus. Unfortunately, it didn’t work well and came with significant side effects.
- A recent study appeared to demonstrate that clonazepam may decrease tinnitus loudness. Unfortunately, other studies seem to show that clonazepam isn’t useful unless combined with an antidepressant. Antidepressants alone do not appear to alleviate tinnitus, but may help with depression that might be associated with tinnitus (if you have tinnitus-related depression / anxiety, speak to your doctor. These conditions have their own independent treatments).
- Some anticonvulsants may have a small effect in lowering the volume of tinnitus, but not enough to warrant the side effects.
- Supplements like zinc and omega-3 fatty acids failed to show any help in randomized controlled trials.
- Lots of people try gingko, but it’s completely ineffective.
- Many people try homeopathic remedies, but it’s just water, and is ineffective for the treatment of any medical condition.
- A drug being developed by Otonomy, an American pharmaceutical company, is being tested as a treatment for tinnitus. As of the writing of this article, it’s proceeding to a phase II clinical trial. The drug is an NMDA receptor antagonist, which affects the transmission of signals between neurons.
The Old Generation of Sound Therapies
Previous sound therapies were focused on reducing the psychological distress of tinnitus itself. Tinnitus Masking was a therapeutic treatment meant to “hide” the tinnitus tone by flooding the auditory system with a distracting background noise that effectively drowns out the tinnitus tone. The intent is to reduce awareness of one’s tinnitus tone. Unfortunately, a meta-analysis of tinnitus masking did find evidence that it is ineffective in reducing tinnitus severity or loudness.
Tinnitus Retraining Therapy (TRT) is a combination of sound masking and counseling, and is meant to induce habituation to a patient’s tinnitus tone. It can be accessed via audiologists. By retraining the brain to essentially “ignore” the tinnitus tone, the psychological distress (in terms of anxiety, etc.) can be reduced. A meta-analysis demonstrated that this approach is much more effective than Tinnitus Masking alone. TRT has been a staple of tinnitus treatment for years but unfortunately does not directly lower the volume of one’s tinnitus. TRT may produce improvement over the long term in 80% of patients who are treated.
Therapy + Meditation
Multiple randomized controlled trials have been performed to evaluate the effectiveness of Cognitive Behavioural Therapy (CBT) for reducing the psychological distress caused by tinnitus. Most appear to have moderate levels of evidence, but because CBT requires a fair amount of time, patients would often drop out of receiving the therapy.
Meditation via Mindfulness Based Stress Reduction has been shown to have efficacy in reducing tinnitus distress. Mindfulness also has general benefits that cut across your experience of daily life, so it’s a good habit to pick up. More resources are available here.
Newer Sound Therapies
Multiple newer sound therapies have been developed in recent years, typically with an intent to commercialize them. Since profit can be a motivator that sways the results of scientific studies, it’s important to retain a healthy skepticism with respect to individual newer sound therapy options (there are quite a few). Most of the studies in this space have a limited sample size and haven’t been replicated by independent groups of researchers.
Unsurprisingly, independent academics that have evaluated the newer sound therapy options have come to the following conclusion:
“Overall there is currently insufficient evidence to support or refute the routine use of individual sound therapy options. It is likely, however, that sound therapy combined with education and counseling is generally helpful to patients.”
Newer sound therapies generally involve the administration of specially processed audio that is customized to the patient’s particular tinnitus frequency. In general, they are thought to work through the process of neuroplasticity — the brain’s ability to reorganize its own connections.
- One of the original sound therapy companies in this space is Neuromonics Sound Therapy. Initially, they offered sound therapy via a proprietary medical device, but have since transitioned to offering a mobile app. They’ve published clinical trials of their therapy which they state has produced “rapid and profound results.” However, an independent review found that these clinical trials had “limitations” with respect to the Consolidated Standards of Reporting Trials (CONSORT), and they concluded that the “lack of methodological transparency, and the proprietary nature of NTT limits the ability of independent investigators to evaluate the merits of this clinical approach.”
- Another sound therapy option is Acoustic Coordinated Reset Neuromodulation. A randomized controlled trial with 63 patients demonstrated a mean reduction in Tinnitus Questionnaire scores of 50% among those who responded to the sound therapy (the Tinnitus Questionnaire is a measure of the distress caused by tinnitus). However, independent review similarly states that the evidence is still lacking to make any substantial claims about its efficacy.
- Listening to a computer-generated tone that matches your tinnitus tone may result in Residual Inhibition. After listening to this tone and stopping the tone, your tinnitus may be suppressed for up to a minute. You can experiment with this process with a computer-generated tinnitus tone.
- Notched Sound Therapy involves identifying a user’s tinnitus frequency, and then processing audio by removing the sound energy at and around their tinnitus frequency. White noise or music can be “notched,” resulted in Notched White Noise or Notched Music. Sustained listening to these sounds is thought to reduce tinnitus tone volume via lateral inhibition of the tinnitus-producing auditory neurons. It was developed by independent groups of Italian and German researchers, which initially produced a 75% and 26% volume reduction respectively. A larger subsequent clinical trial revealed a smaller volume reduction with Notched Music than that observed in the initial Notched Music experiments. A critical review of Notched Sound Therapy concluded that there is still insufficient evidence to recommend it for standard clinical use. Additional research is available here.
Medical Devices
If you have hearing loss, tinnitus can be improved with the installation of hearing aids, which can be fitted by your local audiologist. Unfortunately, it’s possible to have tinnitus with a normal audiogram, possibly because of hearing loss that is not detectable with a traditional hearing test. If you suspect you have hearing loss, speak to your doctor, who may send you for a hearing test (an audiogram).
- Repetitive Transcranial Magnetic Stimulation (rTMS) has been tested as a means for reducing tinnitus volume. Small experiments have shown that it may transiently reduce tinnitus volume. Older studies appeared to show promise that this might be a useful long term therapy for tinnitus, but a newer randomized controlled trial appeared to show that it doesn’t work.
- Transcranial Direct Current Stimulation (applying a weak electrical current to the head) has been used in combination with Notched Sound Therapy, but was not found to improve the effectiveness of Notched Sound Therapy alone.
- Vagal Nerve Stimulation (stimulation of the Vagal nerve with a medical implant) was paired with tones that excluded the tinnitus tone (in a manner analogous to Notched Sound Therapy). A preliminary experiment showed promise, but this device has not yet been approved.
Conclusions
Tinnitus is a complex neurological phenomenon that has been resistant to the development of a clinically validated “cure” or universally acknowledged effective treatment. Experimental treatments show promise, but must be evaluated skeptically. Many treatments are marketed far beyond their evidence and some are outright scams (e.g. e-books, homeopathy, etc.).
It can be overwhelming to research all the available treatments that exist, but being educated is the first step in finding an effective way to cope with this condition.