BHI Guide to Tinnitus

7/29/2019 BHI Guide to Tinnitus

http://slidepdf.com/reader/full/bhi-guide-to-tinnitus 1/14

TinniTus (Ringing in the Ears)

Your Guide To



CONENSDenitions 3

Causes 3

Classications 4

Theimpactoftinnitus 4

Treatmentoftinnitus 6

Medicationsanddietarysupplements 6

Surgery 7

Alternativetreatments 7

Counselingandsoundtherapy 7

Hearingaids 8

Otherwearabledevices 9

Thingsyoucandotohelpyourself 9Managingtinnitus 9

Sleep 10

Concentration 10

Self-helpbooks 10

Seekingprofessionalhelp 10

Hope 11

SomeInterestingdirections 12

Conclusion 12

References 12

AbouttheAuthor 13



Yor Gide to Tinnits (Ringing in the Ears)

Richard Tyler, PhD

The University of Iowa, Iowa City, IA

Denitions

innitus is the perception o a sound that has no external source. Some o the more common soundsreported are: ringing, humming, buzzing, and cricket-like.

It can also be a combination o sounds, and or many, the sound o their tinnitus actually changes. It canbe constant or intermittent and is heard in one ear, both ears or in the head. innitus can originate in the

middle ear (behind the eardrum) or in the sensorineural auditory system.Occasionally people with tinnitus hear music or singing. Tis is dierentrom someone who has a mental illness and is experiencing hallucinations.innitus is not a ‘phantom sound’. Tere is real neural activity in your brainthat you are hearing as your tinnitus.

Cases

Tere are many causes o tinnitus, and oen the cause is unknown. Justabout anything that can cause hearing loss can also cause tinnitus. Te most common causes are: Noiseexposure (e.g. rom shooting or machines at work), a natural part o the aging process, head injury (e.g.rom a car accident or all), as a side eect o medications (e.g. aspirin).

innitus is almost always accompanied by hearing loss. I you have tinnitus, you should have your hear-ing tested by a hearing health proessional. Some 30 million adults suer rom persistent tinnitus (it can

also aect children). For 12 million, the problem is severe enough that itimpacts their everyday lie. Because tinnitus can be a symptom o a moreserious disorder, it is important to have an appropriate health evaluation.

Nearly our in ten people experience tinnitus 80% o the time during atypical day; slightly more than one in our people describe their tinnitus

as loud; and about one in ve describe their tinnitus as disabling or near-ly disabling. innitus is sometimes accompanied by hyperacusis (whenmoderately loud sounds are perceived as very loud).



Classications

raditionally, many classiy tinnitus as either being: Objective (it can be heard by the examiner), or sub- jective (it can only be heard by the person with tinnitus). But this is not always helpul because in many people with tinnitus an objective sound is emitted rom the cochlea in the inner ear, which is unrelatedto tinnitus in most cases. Tereore, I have suggested that tinnitus be reerred to as either middle eartinnitus, or sensorineural tinnitus. Tis categorizes tinnitus in the same way hearing loss is categorized,

and is helpul in understanding its mechanism and treatments.

Middle ear tinnitus originates in the cavity behind your eardrum (less common). O course, we wouldlike to determine whether tinnitus originates in the cochlea, the neural pathways, or the brain. At pres-ent, this is not possible. It is likely that in most circumstances, tinnitus originates in the cochlear (witha noise induced hearing loss). But it might also originate in the brain stem or the brain (oen with a hitto the skull). Wherever the tinnitus originates, it must be interpreted by the auditory part o the brain.Some people mistakenly suggest that it is a relatively new idea that tinnitus might be coded in the brain,but in act this was suggested decades ago.

Middle ear tinnitus is either a result o abnormal blood ow or muscles twitching. Sometimes the tin-nitus might sound like a pulsing or throbbing, or like a twitching. Oen the tinnitus is only in one ear. Insome o these situations, the tinnitus can be treated surgically, and thus a visit to an otologist (a physicianspecializing in the ear) is advisable.

Sensorineural tinnitus can have many causes (e.g. noise, medications, head injury, inections, and ag-ing). Something is establishing abnormal spontaneous nerve activity. As represented in the brain, thismight be an increase in activity, synchronous activity across nerve bers, or an over-representation o some requency region (or combinations o the above three).

The Impact of Tinnitus

When tinnitus rst begins, most o us would be concerned and seek inormation. Not knowing thecause, wondering whether it is a sign o something worse, and not having control over it, could lead todistress or anyone. Discovering there is no cure can make that initial reaction even worse.

But there is help. You can do something about it. People coming to our clinic with tinnitus typically areeither: Curious, concerned, or distressed. Te curious patients have some basic concerns and enquire abouttherapies. Concerned patients are bothered by their tinnitus, and want detailed inormation and strategies orreducing the impact o their tinnitus. Distressed patients are very bothered. Tey require proessional help toreduce their stress and improve their coping abilities. None o these responses are wrong. Everyone’s tinnitusis a bit diferent, and we are all diferent people with diferent lie experiences, weaknesses and strengths.Some people do not appear to be too bothered by their tinnitus, but most would wish it would go away.

innitus can have a direct inuence on: Toughts and emotions, hearing, sleep, and concentration.

Thoughts and emotions

How do you think about your tinnitus?

n Do you think it will ruin your lie?n Do you think you will never be able to get to sleep?n Do you think no one else really understands tinnitus?n Do you think nothing can be done?



The Impact of Tinnitus

Te way you think about your tinnitus will inuence your emotional reaction to it. Toughts like thismight naturally lead to eelings o annoyance, depression, anxiety or anger. innitus does not have tointerere with your enjoyment o lie. Tere are many proessionals that understand tinnitus and canhelp you. Several counseling-based approaches, such as Cognitive Behavior Terapy and Mindulness

Terapy, have been helpul to many with tinnitus. You can change the way you think about and reactto your tinnitus.

Hearing

Some people with tinnitus (39%) say that the sound o the tinnitus competes with or masks things they are trying to hear. Most people with tinnitus also have a hearing loss, and it is not always easy to tellwhether hearing difculties are due to the hearing loss or to the tinnitus. I believe that tinnitus can in-terere with hearing in some people. Oen a patient will report that their tinnitus makes it difcult orthem to hear a phone or a bird, that they have to listen through their tinnitus, or that they have to hear

people talking above the noise o their tinnitus. Tere are many things you can do to improve yourlistening strategies, and hearing aids oen improve hearing and tinnitus!

Sleep

It should be easy or everyone to appreciate lying in bed at night, in a quietroom, thinking about the day. But there is a constant ringing in the back-ground. Many tinnitus suerers (20%) report that when they are in their quietbedroom, their tinnitus intereres with them getting to sleep. It can also makeit more difcult to get back to sleep when we wake up in the middle o thenight. Some even report that their tinnitus is worse aer waking up in the

morning, or even aer a brie aernoon nap. Tere are many things you cando to nurture your sleep experience, and most individuals with tinnitus

beneft rom sound therapy while alling asleep.

Concentration

Some types o tinnitus can be quite distracting. A number o people (26%) with tinnitus report that they have difculty ocusing on a task because o their tinnitus. Tis might include reading a book or thenewspaper. Tere are many opportunities to improve your concentration habits.

Effects on the activities of our lives

Tese direct eects on our thoughts and emotions, hearing, sleep and concentration can lead to second-ary problems in the activities o our daily lives. In particular, problems in any o these areas can lead todifculties at work, socialization with amily or riends, and enjoying leisure activities. Oen people

with tinnitus are surprised to learn that many o their riends have tinnitus. Most have learned tomake their tinnitus less important in their lives. You can too!



Treatment of Tinnitus

Tere are many things you can do to help with your tinnitus. First, it is important to understandand accept, that, at least presently, there is no cure. Tere is no pill or surgery that has been shown to

eliminate tinnitus in replicated scientic studies with adequatecontrol and good measurement tools. Counseling and soundtherapy, including the use o hearing aids, can be very helpul.

Tere are many things that you can do to help yoursel.

In all treatments, it is important to distinguish three approach-es. Tey might be interrelated, but it is important to appreciatethe main ocus.

1) Eliminating your tinnitus. Presently, there are no ap-proaches to eliminate your tinnitus. Several approaches are be-ing explored.

2) Improving your overall well being. I your general well being is in good shape, that will likely makeit easier to cope with your tinnitus. General approaches to accomplish that, such as relaxation, healthy

oods and exercise are always a good thing. In appropriate cases, treating severe depression and anxiety with medications can also be helpul. Psychological counseling can also be very helpul or some.

3) Te reaction to your tinnitus. Although you might not be able to eliminate your tinnitus, there areseveral approaches to modiying your reactions. I will discuss several o these below.

Medications and Dietary Supplements

I want to be clear that in my opinion, despite many advertising claims, no medication or herbal supple-ment has been shown in well-designed studies to cure tinnitus.

Although there are no medications to treat the tinnitus, sometimes a medication can cause tinnitus, and

stopping or changing that medication can eliminate the tinnitus. It can even be the interactions o takingtwo or more medications that can be causing the tinnitus. O course,you should check with whomever prescribed the medication(s) beorestopping them. But i you think this might be a actor in your tinnitus,it might be worth pursuing.

Medications can also be used to treat reactions to tinnitus, specically anxiety and depression, and to acilitate sleep. Tese medications arenot treating the tinnitus directly, but or some they can be very helpul.

In some people, tinnitus might be caused by some deciency o some

nutrient in the body. A ew researchers over the years have thought they ound a dietary supplement that might cure tinnitus, in at least some patients. But these have yet to bereplicated in well-designed controlled investigations. You should be aware that an excess o some supple-ments can be harmul.




Surgery

Tere are some very rare orms o middle-ear tinnitus that can be treated surgically. Middle ear musclesthat are twitching can sometimes be severed, and occasionally there is abnormal blood ow in the mid-dle ear where an operation can be helpul. Tis condition is usually in one ear only and the abnormalblood ow sometimes sounds like a pulsing or throbbing sound. Tis condition is rare, but representsa good reason to have a thorough medical work up.

Some people have asked to have their hearing nerve cut so that they can eliminate their tinnitus, eventhough they will lose their hearing in that ear. Unortunately, the operation is rarely successul. Peoplelose their hearing but still have their tinnitus. Te operation is rarely done today.

Alternative treatments

I will not attempt to review the hundreds o treatments that have been proposed and are oen aggres-

sively marketed. Some might have merit, but I choose to emphasize only general procedures that havescientic support and/or are widely accepted by experienced clinicians. For example, I do not believethere is sufcient evidence to recommend acupuncture or dental treatment to treat tinnitus.

Because there is no cure or tinnitus, and because so many are bothered by it, there is the potential ormany exaggerated claims regarding possible new treatments. Surng the internet produces hundreds o hits that claim, or indirectly claim, to help tinnitus. Caution is warranted, o course.

ypically, to be accepted as a viable treatment by healthcare proessionals, studies need to have:

n a control condition,n a good measurement tool,n be studied by a group that does not benet rom a positive outcome, andn be replicated by at least one other research team.

It is unlikely that you will be able to judge the appropriateness o a study you read about on the internetor in the press. Tereore always check with your hearing health proessional, clinical psychologist orotologist about a ‘new’ ‘treatment’ you learn about.

Counseling and Sound Therapy

Tere are several dierent counseling approaches to help people with tinnitus. Some provide basicinormation about hearing loss and tinnitus, and some engage the patient in collaborative activities toassist in coping, accepting, thinking and reacting to tinnitus in dier-ent ways. I have used innitus Activities reatment, which includesindividualized collaborative counseling in our areas, depending on in-dividual needs:

n thoughts and emotions,n hearing,n sleep andn concentration.




Many tinnitus suerers report that the presence o background sound reduces the prominence or theloudness o their tinnitus. Te background sound can be present in the environment (e.g. an noise).Tere are non-wearable devices that produce pleasant background sound (e.g. raindrops). Additionally,wearable maskers or sound generators are available that produce a ‘shhh’ noise (these can also be com-

bined with hearing aids). Te use o hearing aids improves communication, reduces the stress associ-ated with intensive listening, and also can partially mask the tinnitus. Modulated tones and so musiccan also be very eective in non-wearable and wearable devices.

In the masking o tinnitus. Tere are two kinds o masking:

n otal Masking is when the masking sound (oen noise) completely covers the tinnitus. It is likesubstituting the masking sound (e.g. a whooshing noise) or the tinnitus. Many people preer thisto their tinnitus, and they can control when they listen to their tinnitus and when they listen to themasking sound.

n Partial masking is when the masking sound only partly covers the tinnitus. Both the tinnitus and

the masking sound are heard together. Many people preer this to their tinnitus, because the prom-inence o the tinnitus is reduced, and some also report its loudness is decreased. Dierent types o sound therapies recommend dierent levels o maskers in partial masking.

Hearing aids

Most people with tinnitus also have a hearing loss, and most o you will improve your hearing abilitieswith hearing aids. Hearing aids can also help tinnitus. Tey can help in many dierent ways. Hearingaids improve hearing. Tis reduces the stress associated with the need to careully listen. Te reductionin stress makes it easier to accommodate to the tinnitus. Hearing aids ampliy background sounds, and

or many people this partial masking reduces the loudness or prominence o the tinnitus. In a recentstudy by the Better Hearing Institute we determined the ollowing with respect to the use o hearing aidsin mitigating the eects o tinnitus:

n 27.8% o hearing aid users reported receiving moderate to substantialreduction in their tinnitus when using their hearing aids.

n wo out o three people experienced tinnitus relie most o the time toall o the time, while three out o ten (29%) reported the use o hear-ing aids alleviated their tinnitus all o the time

n Subjects who had their hearing aids t by hearing health proession-

als, who used a more comprehensive hearing aid tting protocol, arenearly twice as likely to experience tinnitus relie than people t by hearing health proessionals who used a minimalist hearing aid ttingprotocol.

I you think you need hearing aids in addition to the concerns about your tinnitus, you should see ahearing health proessional. By all means ask i they are skilled in the management o tinnitus. Tere areadjustments to a hearing aid that can be made to maximize the benet provided someone with tinnitus.For example, some report that loud sounds make their tinnitus worse. Hearing aids can be adjusted toreduce the chances o this happening.



Other wearable devices, including tinnitus maskers

Wearable devices are available specically designed to treat tinnitus. Most resemble hearing aids, and tbehind or in the ear canal. Tey typically either produce a broadband noise (a whooshing sound) (andare called tinnitus maskers), a processed sound designed to be easy to listen to and to aect the tinnitus,or they produce music or processed music (or some combination o this).

When noise is used, people set the noise level at dierent levels. For years I have advocated that the noisebe chosen or individuals. Some benet rom total masking o their tinnitus or trying to adjust the levelto where they just hear the tinnitus through the noise. My experience is that a lower partial masking levelis suitable and preerable or most people.

Non-wearable sound generating devices

Additionally, there are non-wearable sound generating devices aimed at helping tinnitus. Some soundsare environmental sounds, specially selected or processed music, or combinations o these. For example,some include waves lapping against a shore, raindrops on leaves, or easy-listening classical music. Other

sounds are specially designed just or tinnitus suerers.

Things you can do to help yourself

Managing tinnitus

Tere are many things you can do to help yoursel manage your tinnitus.

n How you think about your tinnitus will inuence your emotional reactions.n I you have tinnitus, you likely have a hearing loss as well. Te poorer your hearing, the more di-

culty you will have communicating. In addition to your hearing loss, your tinnitus can also inter-ere with your hearing. All o us can appreciate the difculty hearing while a loud whistle or cricketnoise is going on in the background. Te strategies you would normally use to help with you hear-ing are likely to also help with you tinnitus. Some examples are:

ry to distance yoursel or someone you are talking with rom any noise source. ry to watch the ace o the person who is talking

n Go to the BHI web site to learn more about aural rehabilitation strategies.n I you have a hearing loss and tinnitus, see a hearing health proessional to determine how much

hearing aids will help your hearing and your tinnitus.


http://www.betterhearing.org/aural_education_and_counseling/

http://www.betterhearing.org/aural_education_and_counseling/



1


Sleep

Tere are several things we can all do to acilitate getting to sleep at night. Tese include:

n Not eating large meals beore sleeping,n Not drinking coee beore sleeping,n Reducing bright light and distractions (e.g. television) rom the bedroom,n Only going to bed when you are tired.n Additionally, you can use sound therapy when you are trying to get to sleep. Tis might include: A

so easy listening music that will play until you have allen asleep, steady state noise, pre-recordedrelaxation sounds, recordings designed or those with tinnitus. Some sound generators producea sound rom a pillow loudspeaker, so that another person sleeping in the room will not hear thesound. Some preer to leave the sound on all night so that it will be present when you wake up dur-ing the night or in the morning.

ConcentrationI your tinnitus intereres with your ability to concentrate, there are a ew things some people have oundhelpul. Tey include:

n Separating long, complex tasks into shorter onesn aking requent breaks during tasksn Eliminating distractions

Additionally, the use o sound therapy also makes it easier to concentrate on tasks or many people withtinnitus.

Self-help Books

Tere are also some excellent sel-help books available. I have ound the ollowing to be the most helpul:

n Davis, P. Living with tinnitus. Rushcutters Bay, N.S.W.: Gore & Osment; 1995.

n Hallam R S. (1989). Living with tinnitus: Dealing with the ringing in your ears. Wellingborough,Northamptonshire, Torsons; 1989.

n Henry JL, Wilson PH. innitus: A self-management guide for the ringing in your ears. Boston:Allyn and Bacon; 2002.

n yler RS.(Ed). Te Consumer Handbook on innitus. Auricle Ink Publishers., Sedona; 2008.

Seeking Professional help

While I hope this discussion o tinnitus is helpul, you could very well benet rom even more help by seeing a hearing health professional trained in tinnitus management, a clinical psychologist, an otologist,otolaryngologist or a psychiatrist. It should be understood regardless o which proessional you visit,that they may vary dramatically in their training and ability to help you manage your tinnitus. Some willeven tell you “Nothing can be done”. While it is true there is currently no cure or tinnitus there are many

http://www.betterhearing.org/hearing_loss_treatment/hearing_loss_treatment_professionals/index.cfm

http://www.betterhearing.org/hearing_loss_treatment/hearing_loss_treatment_professionals/index.cfm



1


things that can be done to manage or alleviate the impact tinnitus has on your lie. And research showsthat some people report complete cessation o tinnitus aer counseling and sound therapy or being twith hearing aids.

As you seek proessional help ask them to tell you in detail their training in tinnitus management. I, in

your opinion, they have the credentials to treat or help you manage their tinnitus, then ask them how eective their treatments have been in managing or mitigating the eects o tinnitus in their patients.

Since most people with tinnitus have hearing loss the main tool to alleviate your tinnitus with hear-ing loss will be with sound therapy or hearing aids in conjunction with counseling. In our experience,people who are very good in tting hearing aids, that is those who use best practices in tting hearingaids, will be able to help more o their patients manage their tinnitus. For a discussion on best practicessee the Better Hearing Institute’s Guide to Buying Hearing Aids.

Most o us can benet rom the training and experience o proessionals who have helped others withsimilar problems to ours. Do not hesitate to seek proessional help i you eel you might benet.

Hope

Much has changed in the understanding and treatment o tinnitus inthe last 5 years. Tere is good reason to be hopeul that you can re-duce the problems that you relate to your tinnitus. And, there is goodreason to believe that a treatment will be available soon that turns thetinnitus o, at least in some people. Here is why I am hopeul:

n A variety o counseling and sound therapy options are becom-

ing more widely available by experienced clinicians.n Device companies and pharmaceutical companies are eagerly

pursuing new approaches, many with some preliminary success.

n Animal models are being developed in an attempt to link neural activity and behavior linked totinnitus.

n Research money or tinnitus is increasing, with the direct eect that more researchers are now involved in tinnitus than ever were beore.

Another reason or hope is that researchers and clinicians are now appreciating that it should be pos-sible to identiy dierent subgroups o people with tinnitus. Dierent subgroups o tinnitus will likely

respond to dierent orms o treatments. One way you can help is to complete a survey on our website .

http://www.betterhearing.org/hearing_loss_treatment/hearing_aids/buying_hearing_aids/index.cfm


http://www.uihealthcare.com/depts/med/otolaryngology/clinics/tinnitus/index.html






1

Some Interesting Directions

Tere are a ew areas o study that I think deserve some mention.

n Electrical stimulation of the cochlea : It has been known or some time that recipients o cochlearimplants who have tinnitus oen report that their tinnitus is decreased by the electrical stimulationCochlear implants stimulate the hearing nerve electrically or those who obtain limited beneft rom

hearing aids. A small minority o implant recipients get tinnitus aer receiving a cochlear implantNot everyone will be helped with a cochlear implant, but many groups are studying this eect, and believe there will be a wearable, implantable device within 5 years. Not everyone will be helped, bumany will be.

n Electrical Stimulation o the brain: Another approach is to provide electrical activation o the brainAs I mentioned, the representation o tinnitus must be in the auditory cortex. Studies have begun toprovide electrical stimulation within the skull but outside o the sheath that contains the brain. Otherapproaches go beneath the surace o the brain. Tese approaches are experimental, and they involve ahigher risk.

n Magnetic Stimulation o the brain: Electrical current can also be produced by a changing magnetic

eld. Investigators have placed magnets on the surace o the skull (without any operation), and havebeen able to inuence the perception o tinnitus (and hearing). Any reduction in tinnitus, when it is ob-served, is short-lived. Investigations are underway to develop a treatment protocol that produced morelong-term eects, and minimizes side eects.

Conclusion

Tis overview provides some background to help you understand tinnitus, what options you have nowand what options you might have in the uture. Tere are many things you can do to help yoursel to adjustand accommodate to your tinnitus. And, there are many proessionals prepared and motivated to help you

References

Davis, P. Living with tinnitus. Rushcutters Bay, N.S.W.: Gore & Osment; 1995.

Hallam R S. (1989). Living with tinnitus: Dealing with the ringing in your ears. Wellingborough,Northamptonshire, Torsons; 1989.

Henry JL, Wilson PH. innitus: A self-management guide for the ringing in your ears. Boston: Allyn andBacon; 2002.

Kochkin, S., yler RS. (2008) innitus reatment and the Eectiveness o Hearing Aids: Hearing CareProessional Perceptions. Te Hearing Review; 15(13): 14, 16, 17, & 18.

Kochkin, S., yler, RS, and Born, J. Te prevalence o tinnitus and efcacy o various treatments, Hearing Review, November 2011.

Searcheld, G. D. (2006). Hearing aids and tinnitus. In yler RS (Ed) innitus treatment: clinical protocols. Tieme, New York. p 161-175



1

References

Stouer JL, yler RS. (1990). Characterization o tinnitus by tinnitus patients. Journal of Speech and Hearing Disorders, 55: 439 453.

yler, R. (2006). Neurophysiological models, psychological models, and treatments or tinnitus. In R. S.

yler (Ed.), innitus treatment: Clinical protocols (pp. 1-22). New York: Tieme Publishers.yler, R. S. and Erlandsson, S. (2003). Management o the tinnitus patient. In: L.M. Luxon, J.M. Furman,

A. Martini, and D. Stephens. (Eds.), extbook of Audiological Medicine (pp. 571-578). London,England: aylor & Francis Group.

yler, R.S.(Ed). (2008). Te Consumer Handbook on innitus. Auricle Ink Publishers., Sedona, AZ.

yler, R.S., Chang, S.A., Gehringer, A.K., Gogel, S.A. (2008). innitus: How you can help yoursel! Audiological Medicine, 6: 85-91.

yler, R.S., Haskell, G., Gogel, S., and Gehringer, A. (2008) Establishing a innitus Clinic in YourPractice. American Journal of Audiology ; 17: 25-37.

Abot the Athor

Richard yler, Ph.D. is Proessor in both the Department o Otolaryngology - Head & Neck Surgery and inthe Department o Communication Sciences and Disorders at the University o Iowa. He has edited threebooks and authored numerous articles on the subject o tinnitus. Te two most recent are:

n or clinicians - innitus reatments; Clinical Protocols, Teime, 2006

n or the general public - Consumer Handbook on innitus, Auricle Ink Publishers, Sedona, AZ, 2008

Acknowledgement

Te center photo on the cover o this Guide is reprinted with the permission o Auricle Ink PublishersSedona, AZ.



1

WWW.BETTERHEARING.ORG

1444 I STREET, NW | SuITE 700 | WASHINGTON, DC 20005 | 202-449-1100

http://www.betterhearing.org/

http://www.betterhearing.org/

BHI Guide to Tinnitus

Documents

Transcript of BHI Guide to Tinnitus