Sound Advice: Tinnitusa constant ringing, hissing, or buzzing in the earscan be excruciating. Acoustic therapy and counseling can provide relief.

Dolan, Darrach

doi: 10.1097/01.NNN.0000511241.42939.a1
Departments: Eye on Therapy

Tinnitus can be excruciating, but treatments can help.

WEB EXTRA For research about tinnitus, visit http://bit.ly/NN-TinnitusResearch. To learn about drugs that can cause hearing loss, visit http://bit.ly/NN-MedicationHearingLoss. For more about tinnitus, visit the American Tinnitus Association at http://ata.org.

Article Outline

Laura Del Rosso, a 58-year-old travel writer in San Francisco, was running errands one day three years ago when a steam whistle began blasting inside her head. The sound was shrill, continuous, and overwhelming.

The shriek seemed to worsen over the next few days. She couldn't sleep or read or even watch TV. By the time she got an appointment with her family practitioner, Del Rosso was in full panic mode. After examining Del Rosso's ears and listening to her symptoms, the doctor diagnosed her with tinnitus and told her there was nothing she could do to treat it. Instead, she prescribed anti-anxiety medication for the panic attacks and to help Del Rosso sleep, and referred her to an audiologist.

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DYSFUNCTIONAL HEARING

Del Rosso's diagnosis puts her in the company of roughly 10 percent of American adults who experience tinnitus—the perception of sound in the absence of an external sound source for three months or longer, according to the National Institute on Deafness and Other Communication Disorders (NIDCD). Tinnitus is often described as a ringing in the ears, but the sounds can vary—buzzing, roaring, or hissing—and can affect one ear, both ears equally, or one ear more than the other, says Timothy C. Hain, MD, professor emeritus at Northwestern University Medical School in Chicago.

Tinnitus is not a disease but a symptom of dysfunction in the auditory system, explains Terry D. Fife, MD, FAAN, FANS, director of neuro-otology and balance disorders at the Barrow Neurological Institute and professor of neurology at the University of Arizona College of Medicine in Tucson. There are two types: subjective and objective. In objective tinnitus, the doctor can hear, through a stethoscope, the sounds the patient hears. This condition is rare. In subjective tinnitus, which is far more common, the sound is perceived only by the patient, says Dr. Hain. Very rarely, the sounds of subjective tinnitus can pulse in and out, typically in sync with the heartbeat. This condition, called pulsatile tinnitus, can indicate vascular dysfunction or another problem, such as a tumor, which should be investigated further. In the vast majority of cases, Dr. Fife says, tinnitus has no obvious cause other than associated hearing loss.

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NEURONS MISFIRING

Tinnitus occurs when neurons in the auditory system become hypersensitive and begin firing spontaneously in the absence of sound, says Richard S. Tyler, PhD, an audiologist and professor of otolaryngology at the University of Iowa. It may begin in the cochlea, the organ of hearing, or somewhere along the auditory nerve. The brain interprets these firing neurons as sound, so the noise appears real to the patient and seems to be coming from one or both ears. But in fact the sound is generated somewhere between the middle ear and the brain, says Dr. Fife.

Tinnitus is strongly associated with hearing loss, but because experts don't know the precise mechanism that causes auditory neurons to fire inappropriately, they also do not know why hearing loss may lead to tinnitus in one person and not in another. However, hearing loss caused by exposure to loud noise in the workplace or on the battlefield or from listening to loud music is still the leading type associated with tinnitus. Age-related hearing loss is a close second, but anything that can cause hearing loss or damage to the inner ear can lead to tinnitus. Even the excessive buildup of earwax, if it causes an infection or permanent damage to the eardrum, can lead to hearing loss. Additionally, more than 200 medications are associated with hearing damage.

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LOUD NOISES TO BLAME

Dale Blosser has had tinnitus for 44 years. He attributes it to damage he sustained after exposure to deafening noises while in the US Army and serving in Vietnam. While in Phu Bai, a town that was close to the border with North Vietnam, Blosser guarded a firebase from attack. For several hours a day, artillery would fire continuously. The artillerymen wore heavy ear protection, but the infantrymen guarding them only had plastic earplugs. Blosser was often as close as 20 feet from these powerful weapons for days on end.

At some point, he noticed a ringing in his ears. At first it came and went, and the combat environment was so loud that he didn't pay too much attention to it. But when he returned home after his tour of duty, the ringing became continuous and muted normal sounds and speech. Still, compared to his other medical problems—a broken back, posttraumatic stress disorder, and Dupuytren's contracture, a condition that causes the fingers to stiffen and curl—the tinnitus seemed bearable.

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PUTTING TINNITUS IN PERSPECTIVE

No cure exists, but several strategies and therapies can help people manage the condition, says Dr. Hains. “You're not going to find a pill or an eardrop that will get rid of your tinnitus. But if your tinnitus makes you anxious, for example, you can take a drug to control your anxiety,” he says. Guidelines from the American Academy of Otolaryngology include recommendations to see an audiologist for a hearing test and having a hearing aid fitted, if necessary. Sound therapy and cognitive behavioral therapy (CBT)—a form of talk therapy that helps people recognize and challenge negative beliefs and replace them with more positive ones—may also help if the tinnitus is persistent and bothersome.

Dr. Hain reassures patients that tinnitus doesn't harm the brain or the nervous system. He also discourages them from trying every remedy on the internet or “thinking they can find a way to crack this if they try.” For many, this reassurance is enough. Del Rosso's audiologist told her that although it might take one to two years, most people will become “habituated” to the tinnitus sound, and it will fade into the background. However, for about 10 percent of those with tinnitus, the condition can be debilitating and can require additional treatment, according to the American Tinnitus Association. “It can be a very disturbing thing to have in your head,” Dr. Hain says. “This is not a minor thing. It's important for me to be compassionate and to convey to my patients that I understand what's going on and how terrible this is.”

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SOUND THERAPY CAN HELP

Devices that emit sounds—anything from continuous white noise to soft music—may help occupy the auditory cortex and distract it from the tinnitus, says Dr. Tyler. After some trial and error, Del Rosso settled on an acoustic device that plays soothing sounds and background noise, which her audiologist adjusted to fit her particular hearing frequency.

Del Rosso also bought a tabletop sound generator, a device that can produce white noise or a variety of nature sounds, to use while she sleeps. This is crucial for those who become overly conscious of their tinnitus in the quiet of the night and can't fall asleep, says Dr. Fife. Something as simple as a whirring fan may be as effective as a sound generator, he says. Del Rosso says playing the acoustic device six to eight hours a day and keeping the sound generator on at night provides relief.

People with tinnitus can also download masking apps on their smartphones, says Dr. Hain, who usually recommends them to his patients. “I don't think these are placebos. I really think they help people,” he says. He recommends typing “tinnitus” and “masking” into a search engine and experimenting with free apps. Beltone, a hearing aid company, and Neuromonics, a company specializing in tinnitus treatments, carry such apps, he says.

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TRY COGNITIVE BEHAVIORAL THERAPY

To help Del Rosso keep tinnitus from dominating her life, her audiologist also suggested CBT. With the help of a therapist who himself had tinnitus for 20 years, Del Rosso learned how to reframe her thoughts about her condition. These sessions allowed her to work around the tinnitus, while a low-dose anti-anxiety drug helped her sleep and reduced her anxiety. Gradually, Del Rosso found she could ignore the tinnitus to a greater extent. She began to experience days and, more recently, whole weeks where she didn't notice the steam whistle in her head.

Blosser has also successfully managed his tinnitus, although largely on his own, and he admits there are still times when the noise is so bad he wants to “rip his head off.” On most days, though, he says staying mentally active—focusing on a good book or an absorbing project—allows him to push the tinnitus out of his mind.

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A HOLISTIC APPROACH

Although everyone with tinnitus experiences and manages it differently, many people report similar challenges, says Dr. Tyler. The four most common are worry, anxiety, or depression; difficulty hearing because of the noise or because of actual hearing loss; trouble sleeping; and an inability to concentrate. He and his colleagues at the University of Iowa have developed an approach to manage all four called Tinnitus Activities Treatment (TAT). The approach incorporates counseling, acoustic therapy, hearing loss correction, if possible or necessary, and referrals to psychologists or psychiatrists if the patient's emotional state seems to require it. The goal, Dr. Tyler says, is to help people see beyond tinnitus and adapt to the noise so that it recedes into the background.

Dr. Hain uses a similar approach. “I give my patients a flow chart that divides treatment into three areas: medical, masking, and psychological. I usually tell them that evidence for medical treatments such as diuretics or nerve stabilizers are no better than placebo.” Instead, he encourages his patients to try masking the tinnitus and to treat their psychological reactions to the condition. “The more tinnitus bothers you, the angrier your brain gets, which isn't helpful.” Dr. Hain encourage his patients to learn how to ignore tinnitus rather than obsess about it.

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REFRAME YOUR RESPONSE

As part of TAT, Dr. Tyler encourages his patients to change their emotional response to the tinnitus. He uses a doorbell analogy: Normally, when you hear a doorbell ring, you think someone is at the door. But if every time the doorbell rings something disastrous happens—a car crash outside, a fire next door, a child crying—you begin to associate the sound with disaster and become anxious when you hear it. If, on the other hand, every time the doorbell rings something good happens—you get flowers, a friend visits, a neighbor brings dessert—you associate the sound with pleasure. In each case the sound is the same, but your reaction is different. He asks his patients to consider tinnitus as just a sound, neither good nor bad. If they can do that, they are one step closer to adjusting to it.

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BLOCK IT OUT

Humans are capable of shutting out sound, says Dr. Fife, who reminds his patients that if they woke every time they heard a sound they'd never sleep. “We can get used to the ticking of clocks, traffic noises, and bird songs, so humans can ignore sounds and not be bothered by them.” CBT can teach people to block out tinnitus, he says.

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DON'T IGNORE HEARING LOSS

Experts agree: If you can hear better, you are less likely to be bothered by your tinnitus. Be sure to get your hearing evaluated and assessed by an audiologist, and, if necessary, get fitted for an appropriately calibrated hearing aid.

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ADDRESS THE STRESS

The stress of tinnitus can cause anxiety, depression, and sleep disruption for some people. Dr. Hain encourages his patients to see a psychologist or psychiatrist to help them manage the stress. “I usually tell my patients that if they can hang in there for a couple of years, they'll get much better at blocking it,” he says. “Above all else, don't give up quickly.”

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How Acoustic Therapy Works

For people with tinnitus, most audiologists prescribe some form of acoustic therapy to help nudge the buzz into the background. How this happens is not fully understood, but several theories exist.

One theory holds that the background noise simply masks the tinnitus, and eventually the patient learns to disregard it. Another argues that certain therapies may actually change the arrangement of neurons, and over time the ones that fire spontaneously, causing the ringing sound, shift their attention away from the tinnitus frequencies. This reduces the number of neurons firing inappropriately and lessens the tinnitus.

And some argue that acoustic therapy can do both. Since the scientific evidence is not complete and the mechanisms that cause tinnitus are unknown, it's impossible to say that any specific acoustic therapy can actually reverse tinnitus.

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AVAILABLE DEVICES

Don't give up on acoustic therapy until you find what works for you, urges Richard S. Tyler, PhD, audiologist and professor of otolaryngology at the University of Iowa. He emphasizes that no two tinnitus patients are the same, so no single therapy will work for everyone.

Dr. Tyler suggests discussing the options with your audiologist. Some devices simply play white noise, others play nature sounds or music, and still others combine soothing sounds with white noise. Some can be tailored to patients' specific needs and require an audiologist or other medical professional to set the frequencies, while more basic models just play background sounds. And there are many combination hearing aids and white noise generators with a range of functions.

The scientific evidence for one device being superior to another is still being debated, but choice is important, Dr. Tyler believes, because one patient may benefit from one type of sound while another may benefit from a device whose sounds are tailored by an audiologist.

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How to Avoid Hearing Loss

Hearing loss is strongly associated with tinnitus. To lower your risk, follow this advice.

* Limit exposure to loud sounds.

* Wear appropriate ear protection in the presence of loud noise.

* Treat persistent ear infections before they do permanent damage.

* Avoid a buildup of earwax or other obstructions in the ear that could lead to infection or damage to the eardrum.

* Check all medications with your doctor. Some are associated with tinnitus and hearing difficulties.

© 2016 American Academy of Neurology