Vincent Cumberworth BSc FRCS Consultant Ear, Nose and Throat Surgeon

Clementine Churchill Hospital Sudbury Hill Harrow Middlesex HA1 3RX
Private Secretary: Tel: 020 8872 3866 Fax: 0208872 3861

Information is supplied only upon the condition that the viewer will make their own determination as to the suitability of the information for its purposes prior to use. There will be no responsibility for information that is misused or misinterpreted and the information should not be used as a substitute for consultation with a health care professional. It is not possible to answer questions regarding individual cases or to enter into individual correspondence.

TINNITUS

How we hear

Our conscious awareness of sound takes place near the surface of the brain when a pattern of electrical activity travelling up the nerve of hearing from the ear reaches a point just below the auditory cortex. The hearing nerve has about 10,000 different fibres, and patterns of activity in these fibres are matched with other patterns, which are held in the auditory or hearing memory.

Most of what we hear is a sequence of sounds, like speech or music. There is a continuous process of matching one familiar pattern with the one coming from the ear. Each time a pattern from the ears is matched with a pattern in the auditory memory we have the experience of hearing a sound.

Putting together these matched patterns starts a process of evaluation. Another part of the brain close to the hearing centre is involved in the meaning of what we hear and in interpreting the language. If it’s a foreign language, we can hear the sound but may not understand the meaning.

Sound

Sound is of enormous importance. Hearing evolved in animals who were constantly in fear of their lives because of attacks from predators. The ability of animals to develop extremely acute hearing by which they could detect the very small sounds of an attacker a long way off, contributed to the survival of that species.

Warning signals produce acute anxiety in an animal, prompting appropriate action to avoid attack, the so called survival reflex. Some sounds can be identified as warning signals, while others can evoke a feeling of security or pleasure. We have this experience every day with sounds that alarm us such as traffic horns and sounds that soothe us such as music, or the sounds of nature.

The auditory cortex in our brain has a large number of connections with the limbic system which is concerned with emotion and learning. Each sound that we hear and learn the meaning of, has an “emotional label” attached to it, which may change from time to time according to how we feel in ourselves and the context we hear them in. For example the sound of a neighbour’s television may be acceptable or unpleasant and intrusive, depending on whether it belongs to a well loved friend or relation or somebody else who for various reasons we dislike.

What is tinnitus?

Tinnitus is the word for noises which some people hear ‘in the ears’ or ‘in the head’ – buzzing, ringing, whistling, hissing and other sounds which do not come from an external source. Tinnitus is very common and is experienced by up to one in 10 adults. It occurs more often in people over 40 years of age than in younger people. Tinnitus signals come from the natural background activity of the hearing nerve. This background activity is present in nearly everyone.

It can happen to people with normal hearing as well as to deaf or hard of hearing people. It is also possible to have a considerable hearing loss without any tinnitus at all. Nearly everyone has experienced tinnitus temporarily – for example, for a few hours after going to a disco or when listening carefully in a very quiet room.

What causes tinnitus?

It is important to distinguish between emergence of tinnitus lasting a short time, and persistent tinnitus, which causes distress. Persistent tinnitus is often triggered or made worse by emotional events; bereavement, work and family stress, accident and injury (not necessarily to the ear) or retirement, or moving to a much quieter environment. It may start during a period of unrelated depression or anxiety. Persistence of tinnitus usually involves the development of feelings of hopelessness and despair that nothing can be done. In mild cases this may be reflected as a feeling of annoyance or disquiet. The traditional teaching on tinnitus was that it was caused by damage to the ear, which cannot be corrected. This ignores the fact that many cases of hearing loss are not associated with tinnitus. Tinnitus is certainly twice as common in hearing impaired people, but may not be because the inner ear is below par! If you are hard of hearing, communication is often a strain. This ‘straining to hear’ focuses the subconscious brain to pick up anything coming from the inner ear. So everyone has background noise in the hearing system just like a tape recorder with a blank tape playing. The perception and loudness of tinnitus depends on whether the brain suppresses these sounds or whether it amplifies them because of their importance as a real or potential threat.


Many things can cause tinnitus to emerge but it is mainly related to two factors: hearing disorders associated with ageing and exposure to loud noise. Distressing tinnitus most commonly begins to persist after an emotional upset or an illness, injury or infection which may or may not be related to the hearing mechanism. It can also appear as a reaction to or side effect of a drug. Often a combination of such factors over a period of time will trigger tinnitus.

Emergence of tinnitus usually lasting for a short period is extremely common, e.g. after going to a disco, or listening carefully in a quiet room. This is a natural phenomenon experienced by 90% or more of the population and goes away after a short time (even though loud music can damage your hearing). Persistent tinnitus occurs in about 10% of the population and is probably mostly due to parts of the brain concerned with analysing sound signals focusing on weak messages, which are part of normal ear function in most cases. Some people, who experience quite normal tinnitus emergence, can easily get the idea that something dreadful has happened e.g. damage to the ear, or brain, or that they are going to be stuck with the problem for life. We now know that it is the kind of negative and inaccurate thinking that is frequently responsible for the focusing of the subconscious part of the brain on the small tinnitus signals coming from the ear. In some people a fear or phobia may develop for the perceived sound, creating feelings of annoyance, apprehension or even anxiety and depression. These emotions are generated in other areas of the brain outside the hearing mechanisms.

This need not be a problem. Many people have permanent tinnitus but carry on life as before, untroubled by their internal noises. Other factors usually determine whether tinnitus persists and causes annoyance: it is the effects of tinnitus which can make it an unpleasant condition. These may include difficultly in sleeping and the tiredness and irritability that follow; lack of concentration; anxiety and depression; withdrawal from social activities; and fear of tinnitus and of the future.

Is there a cure?

Occasionally, when underlying ear conditions are treated, tinnitus is reduced. For example, antibiotics can clear up an infection of the middle ear; wax can be removed from a blocked ear; changing or ending a course of medication may put an end to the noise.

When tinnitus persists, there is no drug or operation which will immediately get rid of it, at present. There are, however, a number of ways to get significant relief from tinnitus, and it is nearly always possible with appropriate treatment to reduce the distress that tinnitus can cause and quite often virtually abolish it.

In all cases of tinnitus the right counselling, often combined with relaxation techniques, is essential to relieve the worries that people may have about their tinnitus. The fear that tinnitus may indicate a serious disease (this is very, very rarely the case), or advancing deafness can usually be met with the reassurance that tinnitus is harmless. Normally people get used to it so that, in time, it becomes much less noticeable and intrusive.

Where tinnitus continues to cause distress, it often creates feelings of annoyance, apprehension, anxiety or depression. Research with tinnitus patients over a number of years has helped us understand how the emotional and perceptual areas of the brain can magnify and maintain the awareness and stress of tinnitus. Tinnitus Retraining Therapy aims to overcome these reactions to tinnitus, and to reduce perception of the tinnitus sounds.

Retraining Therapy

The discoveries of the mechanisms responsible for tinnitus and tinnitus distress have lead to a programme called ‘Retraining Therapy’. This technique has been developed in conjunction with the RNID team and is now being used successfully in several centres around the world.

Tinnitus retraining first involves learning about what is actually causing the tinnitus. This begins with proper examination by an ear specialist followed by a full explanation of what is going on in the ear and the brain to produce the tinnitus sound. We need to learn that the sounds of tinnitus, which we may interpret as distressing affecting life quality and seemingly unending, are, in reality, the sounds of nature coming from the ear, but wrongly identified as threats. With appropriate counselling (or “retraining”) from professionals, we can change even strongly held views that tinnitus is a threatening and unpleasant experience, which cannot be altered.

In the subconscious part of the brain concerned with hearing, beyond the inner ear, but before the act of conscious perception of sound takes place, networks of nerve cells (neuronal networks) are programmed to pick up signals on a “need to hear” basis. Think of the way we invariably detect the sound of our own name or a distant car horn, whereas we may be unaware of the sound of rain pounding on the roof or surf beating on the seashore. Retraining therapy involves reprogramming or resetting the networks, which are selectively picking up inner ear “nature sounds” because they have been identified as a threat, either to life, or life quality.

The presence of any continuous stimulus usually results in a process called habituation, whereby the individual responds less and less to the stimulus as long as it does not have any special negative meaning. The final stage in this process is when the signal is no longer detected. With tinnitus this means that it is no longer heard, even if it is listened for. Retraining therapy can achieve this and achieve much benefit, even when there is not complete habituation. Although the process takes a long time (often 2 years or so in the initial stages, tinnitus becomes gradually less unpleasant but may still be loud), then becomes quieter for longer periods of time and eventually disappears or becomes a natural part of the background “sound of silence”. After retraining, it is usually possible for people to hear some internal sound when listening in a silent place, but this is normal and not distressing.

Hearing loss and tinnitus

One way in which the ear itself does contribute to tinnitus is if there is a hearing loss. This may be quite slight, or just in the high frequencies. Any tendency to “straining to hear” can increase amplification of sound signals in the subconscious part of the brain, and increase the ease by which tinnitus signals can be picked up from the cochlea. This is why it is important to correct any hearing loss however slight, with appropriate hearing aids, as part of overall tinnitus management.

Masking and White noise generators

White noise generators (previously called “maskers”) have a different role to play. Tinnitus masking was at one time thought to be useful in that it simply made tinnitus inaudible, but these “masking” instruments are now being used in a quite different way in the process of retraining. Much better long-term results can be obtained if white noise is used at very low intensities which the tinnitus can be heard at the same time. White noise contains all frequencies and therefore very gently stimulates all the nerve cells in these subconscious networks, allowing them to be more easily programmed, or reset, so that tinnitus signals are no longer detected.

Masking and retraining (habituation) therapies are diametrically different and in retraining, the device is of secondary importance. Maskers emit white or wide band noise (like surf); their aim is to try and make tinnitus inaudible. When used in retraining therapy, they are called ‘noise generators’. They are used at a low level, not to make tinnitus inaudible, but to help bring about changes in the subconscious hearing system. They also reduce the contrast between complete silence (when tinnitus can naturally ‘emerge’ in anyone) and also distract slightly from the sound of the tinnitus.

Masking or suppression of tinnitus by white noise can provide symptom relief, sometimes persisting after the use of the masking device has stopped for a variable time. Generally it cannot produce full habituation and disappearance of the tinnitus.

What help is available from ENT departments and Tinnitus Clinics?

Many people will find a consultation, examination and diagnosis from a specialist reassuring. This specialist may propose treatment which could include:

• A hearing aid – even if there is only a slight hearing loss, the use of a hearing aid may reduce or ‘mask’ tinnitus. It may also help take the strain out of listening – straining to hear can also focus the subconscious brain to pick up tinnitus noises more easily.
• A noise generator (previously known as a tinnitus masker) – a device, which looks like a hearing aid and generates a quiet, gentle ‘shush’ noise of its own. This gives the ear something else to listen to, and diverts the attention of the listener, so that the tinnitus moves into the background. Noise generators are often available through the NHS and are also sold by hearing aid dispensers and suppliers.
• Noise generators may also be used as part of the Tinnitus Retraining Therapy (TRT). This aims to reduce the brain’s perception of tinnitus so that it becomes much less of a problem. TRT involves directive counselling and challenging negative beliefs, long-term low-level noise therapy using noise generators, the appropriate use of hearing aids and their earmoulds, relaxation therapy, and the treatment of any stress, anxiety or depression. Noise therapy as part of a tinnitus retraining programme produces subtle changes in the subconscious part of the brain which then permanently filters out the tinnitus.
• Relaxation therapy using stress management and relaxation techniques and tapes.
• Counselling – an essential part of any successful programme of tinnitus management.
• Medication for the effects of tinnitus such as anxiety, sleeping problems, or depression or for an ear infection or to improve the blood supply.

What about coping strategies?

These are an important part of traditional tinnitus management, and can still help sufferers, although they cannot on their own get rid of tinnitus. Reducing overall anxiety levels, for instance by relaxation techniques, can sometimes quieten tinnitus and make sleep easier. The goal of coping strategies is to learn to tolerate or ‘live with’ something that will be ever-present. The goal of retraining therapy is to habituate or remove first the emotional response and then the perception of tinnitus itself, so that it is no longer distressing.

What can I do to help myself?

If you have tinnitus, it is important not to feel it is a threat. Often the best thing to do is to talk to someone who really knows about tinnitus – like the advisers or counsellors who work for the RNID tinnitus Helpline, the British Tinnitus Association or a local tinnitus support group. Anxiety and tension can make tinnitus much worse so learning how to relax is important. You may like to join a relaxation class and teach yourself relaxation techniques.

Try to avoid silence. A very silent environment is not natural, although many people find the idea of silence attractive. In silence, tinnitus sounds are much more likely to emerge and become troublesome. Always make sure that there is a pleasant and unintrusive low level of background noise. This could come, for example, from an open window, a fan or a radio tuned off station, or it could be music. However, do not use these sounds to mask the tinnitus (unless the tinnitus is very quiet).

Having something else more pleasant and interesting to listen to such as music, TV or radio, can prove a valuable distraction to tinnitus and reduce the contrast between tinnitus and silence. Many people with tinnitus will say that it isn’t there when they’re not listening to it, when their mind is on something else, and they’re not worrying about it. Tinnitus is a very real sensation, but if you’re not tuned in to it, it can be much less of a problem.

Will ‘alternative’ treatments help my tinnitus?

Some people with tinnitus have said that ‘alternative’ or ‘complementary’ therapies such as acupuncture and hypnotherapy have been of benefit. Although they probably have no direct effect on tinnitus, they may help you relax and sleep better, which can improve your tinnitus. Most such treatments are only available privately, but some are available on the NHS.

Does tinnitus affect children?

Although tinnitus occurs more in people in their middle or later years, it can affect younger people too, including children. Children tend to complain much less about symptoms and to accept them more readily. With any ear problem in children, it is important to seek specialist help – symptoms can often be effectively treated.

Does tinnitus cause deafness?

Research indicates that tinnitus does not cause deafness, although both tinnitus and deafness may have the same cause, particularly noise damage to the ears. Tinnitus may affect your ability to concentrate, so you could ‘miss’ conversation. Having a hearing loss which has not been treated (for example, with the optimum hearing aids) makes any coexistent tinnitus more troublesome.

What makes tinnitus worse?

Most people with tinnitus are not distressed but it – it is simply something which is there which does not affect their lives. Those who do become distressed generally find their tinnitus to be threatening in some way, seeing it (quite wrongly) as being caused by a serious disease, or as going on forever, getting louder, and finally driving them mad. These beliefs may lead them to monitor and magnify their tinnitus constantly.

Very loud noise can make tinnitus worse and cause hearing loss. You should wear proper ear protection when using noisy power tools (ear muffs or plugs, not cotton wool), and limit your exposure to very loud music played through speakers or headphones. It is important not to use earplugs or muffs to exclude everyday sounds, even if your hearing seems rather sensitive. This makes tinnitus and hearing sensitivity worse.

Tinnitus does vary– either spontaneously, or it may be temporarily aggravated by stress, certain drugs, and sometimes if you have too much of some foods and drinks (notably caffeine an alcohol) – but usually does not worsen with time alone.

What about drug therapies?

Current understanding of tinnitus makes it unlikely that any one drug will permanently switch off tinnitus. Tinnitus sounds are treated rather like warning signals by the brain, so instant cure would indicate a fault in the security system! However, it is likely that some drugs will speed up retraining therapy by acting on chemicals used in passing messages between brain cells. Work in this area is already underway. People who suffer extreme distress, depression or sleeplessness may need short term drugs (e.g. a course of antidepressants under medical supervision) to deal with this aspect of the problem.

What about diet?

There is no evidence that any special diet or food abstinence will help tinnitus. It may be aggravated (but sometimes helped!) by alcohol or stimulants such as caffeine. Many people follow very rigid diets, which reduce their life quality, already depleted by bad experiences tinnitus. To be sure something in your diet upsets your tinnitus you need to do careful tests of exclusion of one substance at a time. In rare cases where tinnitus is part of Menieres syndrome, salt restriction can help but seek specialist medical advice first.

Is tinnitus psychological?

The word is often used to suggest that the tinnitus sufferer is ‘at fault’, and that they should be less nervous or anxious. Persistence of tinnitus does involve parts of the brain (like the emotional centres) that are also part of psychology. This is why tinnitus often gets worse with stress. But the real fault lies in the way the brain processes information coming from the ear, treating weak signals that are part of the natural mechanism of the ear as if they were potential threats. This is how the tinnitus becomes loud and distressing. The perception of tinnitus is just as real as the perception of any external sound.

I also get discomfort with outside sounds. Why?

When the brain processes hearing information, and enhances the tinnitus signals, it may do the same thing with outside sounds, particularly those that ‘sound like’ the tinnitus. This results in oversensitive hearing, or hyperacusis. It is present in 60% of those who have troublesome tinnitus. It also occurs without tinnitus and with completely normal hearing. The mechanism is very similar to that of persistent tinnitus, and can be treated effectively within a retraining programme.