Ask the Audiologist

Tinnitus

Tinnitus is a very common complaint. It is usually described by the patient as a "noise" located in the ears or head, specifically as ringing, hissing, wind blowing, ocean roaring, or even the sound of crickets. Practically everyone can hear some kind of noise if they sit quietly in a very quiet place for awhile, like in a hearing test sound booth. However, tinnitus can be very loud for some people, sometimes sounding like a jet engine inside their head. Most people don't pay any attention to their tinnitus, just like they don't pay any attention to the refrigerator sound in their kitchen, but for some it can be a devastating, overwhelming, distraction.

What causes tinnitus?
The most common causes of hearing loss producing tinnitus are:

  • Obstruction of the ear canal from wax, a foreign body, or infection
  • Middle ear pathology such as middle ear infections, allergies, traumatic injuries, scar tissue, or impaired motion of the three middle ear bones
  • Conditions which disturb the fluid balance of the inner ear
  • Conditions which cause deterioration of the inner ear or auditory nerve
  • Tumors of the auditory pathway

Tinnitus may be caused by conditions unrelated to the ear, such as:

  • Temporomandibular joint syndrome (TMJ)
  • Muscle spasms
  • Vascular problems
  • Side effect of some medications

How is tinnitus treated?
If your tinnitus doesn't bother you, don't worry about treating it. You haven't built a sound proof box to put your refrigerator in, have you? But some tinnitus is very bothersome, and in those cases treatment should be sought out.

The first step in treating tinnitus is to treat any problems that may be contributing to the tinnitus. This includes:

  • Removal of wax or foreign body from the ear canal
  • Treatment of infections of ear canal and middle ear
  • Surgical treatment of middle ear disease or conditions affecting the function of middle ear bones
  • Dental treatment of temporomandibular joint (TMJ) pathology
  • Medical or surgical treatment for vascular disorders
  • Treatment of the causes of sensorineural hearing loss (drugs, noise exposure, metabolic disorders)
  • Surgical treatment of inner ear tumors

Hearing Loss
If tinnitus is due to a permanent hearing loss, as is the case for most people, then there are several options available to try to alleviate it. These include:

  • Vasodilators which have provided limited relief for some people
  • A tinnitus masker which is a small electronic instrument that fits like a hearing aid and generates a noise which prevents the wearer from hearing his own ringing
  • Biofeedback which trains the patient to control circulation to various parts of the body and to relax muscles attached to the head
  • Medical or surgical treatment which may be recommended to eliminate tinnitus
  • Hearing Aids sometimes help reduce the annoyance of tinnitus by bringing environmental sounds into the picture. Often, when tinnitus is accompanied by hearing loss, the normal sounds of everyday life are missing, leaving only the tinnitus for the patient to hear. Once the patient can hear background sounds better, the tinnitus may be much less bothersome.

Tinnitus Retraining Therapy (TRT)
If it turns out that your tinnitus doesn't have a medical solution, then there is a very successful treatment, called "Tinnitus Retraining Therapy", developed by Dr. Pawel J. Jastreboff and colleagues.

The goal of TRT is habituation of tinnitus. That means that after the retraining therapy, you will still be able to hear the tinnitus, but it won't bother you. Do you remember when you first moved into your present home, how much noise the refrigerator made, and how much it bothered you? Does it bother you now? No, of course not. You got used to it.

Some people who live near subways or airports get so used to the noise, that they are disturbed if the noise stops for some reason. "Something sounds funny". Lots of people have that experience with interstate highway noise.

The path to success with TRT is a long one. First you have to be sure that there is no treatable cause of your tinnitus. So the first thing that a TRT clinic does is send you off for a zillion medical tests. If there is a physical cause, a medical doctor treats you for it, and that's that. However, if all the medical and audiological experts are convinced that there is no treatable cause for your tinnitus, and you yourself are convinced that there is no dangerous condition that is causing the tinnitus, then the TRT program can get started.

According to Dr. Jastreboff's theories, tinnitus can have a threatening meaning to some people, like a car's horn when you are crossing a street, or a bear's roar when you are out camping. That's the reason for all the medical testing: You have to be convinced that your tinnitus is not a threat; that it's just another noise in our noisy world. TRT uses "directive counseling", intensive, interactive, individualized educational sessions, to convince your subconscious that your tinnitus is not a threat. These directive counseling sessions take place over months or even years.

The second part of TRT is to convert the tinnitus from a loud sound to a soft sound, so that it can be naturally habituated. Dr. Jastreboff uses the example of a candle on a birthday cake. In a dark room, one small candle can seem very bright, while the same candle, once the lights are turned on, doesn't seem very bright at all.

In TRT, a masking sound is introduced into the ear at a level just quieter than the tinnitus. You can still hear the tinnitus, but just barely. The masking device may be a fan in the room, a white noise generator, or perhaps a special hearing aid with noise built in. The special hearing aid is obviously more convenient, as it can move around with you, and it is what most TRT patients choose. After the Tinnitus Retraining Therapy program is complete, there is no more need to wear the noise generators, as the tinnitus has be habituated, just like traffic noise is habituated by a taxi driver.

TRT is not a cure. The tinnitus is still there. However, it no longer bothers you.

TRT programs are offered at many clinics around the world. Dr. Jastreboff's original collaborators have a clinic in London. For the last 10 years, Dr. Jastreboff operated a clinic at the University of Maryland at Baltimore, and that clinic is still there. Dr. Jastreboff, himself, has moved to Atlanta and opened a TRT clinic at Emory University. The Baltimore clinic has been teaching others how to perform TRT. However, remember that a necessary part of TRT is a lot of medical testing, so the clinics that are associated with medical facilities may prove to be more satisfactory.

The directive counseling part of the program requires an extremely skilled therapist. Dr. Jastreboff recommends a year or more of active TRT practice under the supervision of a major clinic before starting up a separate clinic. So, ask about your potential TRT therapist's experience before signing up to the program.

Another factor is cost. TRT programs are not generally covered by insurance. Even some of the medical testing may not be covered, since it is designed to prove there is no medical problem. "No diagnosis" means "no pay" for many insurance plans. To make this very clear, many of the TRT centers do not belong to any insurance plans. If you go there, you must pay yourself.

So, after all of these cautions, should you begin TRT? Well, the success rate is very high. With thousands of patients through the various programs, the success rate is about 80% or higher. You just must decide how much does your tinnitus bother you. Tinnitus is overwhelming to some people; you'll know it, if yours bothers you. At least check out the medical solutions. Your tinnitus may have a medical cure.