Tinnitus is defined as the perception of sound(s) in the ears or head when no external sound is present. While it is often referred to as “ringing in the ears,” tinnitus can present as different sounds, including buzzing, hissing, whistling, swooshing, and clicking. Tinnitus is also described as a “phantom sound” or “phantom auditory sensation” that shares many similarities with chronic pain disorders.
There are two types of tinnitus: subjective and objective tinnitus.
Subjective tinnitus is generated by the brain (auditory cortex) in response to disturbances within the auditory system. Subjective tinnitus is only audible to the patient. Objective tinnitus is rare and is defined as the perception of sound(s) generated by sound sources in the body that are transmitted to the ear such as a blood vessel adjacent to the middle ear (pulsatile tinnitus). Objective tinnitus can be audible to others such as in the case of rapid muscle spasms of the soft palate (myoclonus).
Tinnitus is not considered a disease but rather a condition resulting from a wide range of health issues. Tinnitus is most commonly caused by noise exposure, age-related changes, whiplash and head injury, acoustic neuroma, side-effect of some prescription medications (e.g., high dose of aspirin, some antibiotics, antidepressants and chemotherapy agents), Ménière’s disease, otosclerosis, ear infection, severe cold and flu, Eustachian tube dysfunction and aerotitis, temporomandibular joint dysfunction, diabetes, high blood pressure, hyperthyroidism, arthritis, stress, anxiety and depression.
Tinnitus is almost always accompanied by hearing loss. It is estimated that 90% of tinnitus patients present with some degree of hearing loss. Patients with tinnitus may also experience decreased sound tolerance. The most common form of decreased sound tolerance is hyperacusis which is characterized by the experience of discomfort and sometimes ear pain with everyday sounds such as dishes clanking, babies crying, dogs barking, cars honking and sirens of emergency vehicles. It is estimated that 40% of tinnitus patients present with hyperacusis.
Tinnitus is a prevalent condition. It is estimated that 15% to 20% of the general population experiences tinnitus at some point in their lives. The condition interferes with daily activity in about 3% to 5% of the affected population.
Tinnitus becomes a problem when it affects quality of life. The impact of a problematic tinnitus ranges from a mild annoyance to a completely debilitating condition with significant social and economic consequences. The most common tinnitus-related complaints are:
difficulty understanding speech and television, poor appreciation of music, and trouble using the phone;
interference with work duties, social activities, and family responsibilities;
effects on general health including sleep disturbances, fatigue, headaches and ear pain;
emotional and cognitive problems including annoyance, irritation, inability to relax, anxiety, depression, suicide ideation and difficulty concentrating.
A problematic tinnitus has both auditory and non-auditory (emotional) components. The auditory component involves the perception of the sound of tinnitus generated by the brain (auditory cortex) in response to disturbances within the auditory system. When hearing loss is present, the brain receives reduced information from the ears. The brain adapts to this change by compensating for the lack of information. In an effort to fill in the blanks, the auditory cortex augments its processing activity. The tinnitus or phantom sound heard is essentially the perception of this increased activity.
Even with normal hearing ears, the brain can receive incomplete information. Scientists have observed abnormalities with the delicate structures of the cochlea (inner ear) such as the outer hair cells and auditory nerve fibres that don’t always show up on a clinical audiogram. This phenomenon is referred to as hidden hearing loss or cochlear synaptopathy.
The non-auditory component involves the emotional reaction to the sound of tinnitus. The annoyance experienced with tinnitus is the result of negative thoughts, fears, and worries associated with the experience of tinnitus. Is my tinnitus going to get worse? Will I be able to go back to work? Will I be able to enjoy silence again? What if I lose all hearing in my good ear? An emotional response is triggered when the brain starts focusing a significant amount of attention onto the tinnitus. The negative thoughts associated with tinnitus lead to distress, which increases attention and monitoring of tinnitus resulting ultimately in a more noticeable and intrusive tinnitus. This is what is referred to as the vicious cycle of problematic tinnitus. The brain temporarily loses its ability to filter out the harmless sound of tinnitus before it reaches consciousness. Tinnitus becomes problematic when natural habituation mechanisms are held back by the negative experience and fears associated with tinnitus.
Habituation is a simple form of learning in which we progressively stop paying attention to annoying sensory information. Habituation happens all the time. For example, the loud ticking of a grandfather clock in a quiet room doesn’t seem as resounding after a while and starts fading in the background. We forget about the humming noise coming from the ventilation system until it stops working. Habituation is also why some people can live near a train station, the highway or an airport. In time, the brain ceases to respond to these sounds as they are perceived as non- threatening, familiar and meaningless.
The good news is that there are evidence-based treatments designed to assist habituation of a problematic tinnitus. It is possible to retrain the brain to no longer react to tinnitus and bothersome environmental sounds.
Most tinnitus patients seen in today’s audiology clinic present with a subjective tinnitus, some form of decreased sound tolerance and hearing loss. There are comprehensive management programs currently dispensed by audiologists specialized in these hearing-related disorders that facilitate tinnitus habituation and desensitization of the auditory system to bothersome environmental sound(s). The most commonly used are Tinnitus Retraining Therapy, Progressive Tinnitus Management, and Cognitive Behavioral Therapy.
As an audiologist at the Canadian Hearing Society providing services to patients with tinnitus and decreased sound tolerance, I am often asked what methods of treatment I use in my practice. I am a firm believer in the Tinnitus Retraining Therapy (TRT) approach. Most of the counselling material and assessment and management protocols I use come from TRT. More specifically, TRT is based upon the idea that structures in the brain other than the auditory system are involved in the development of a problematic tinnitus. The limbic and autonomic nervous systems are believed to be the primary and dominant non-auditory brain systems responsible for tinnitus annoyance and distress while the auditory system plays a secondary role.
TRT was developed by Dr. Pawel Jastreboff (Research Neuroscientist), Dr. Jonathan Hazell (ENT Specialist) and Jacqui Sheldrake (Clinical Audiologist) in the 1990s. TRT combines the use of directive counselling sessions and fitting of sound therapy devices such as ear-level sound generators and hearing aids. The counselling component aims at demystifying tinnitus/ hyperacusis and creating a new frame of reference for thinking about the troublesome condition. The sound therapy component is designed to provide enrichment of the auditory background noise, reduce the audibility of tinnitus and improved audibility of sounds difficult to hear for patients with hearing loss.
A comprehensive audiological assessment is essential for the success of TRT. The assessment includes a detailed case history designed to investigate causes, characteristics and progression of tinnitus and general physical and emotional health. A thorough hearing examination is also performed to assess patient’s hearing health and associated hearing loss and decreased sound tolerance. It is crucial to consider the entire person as many internal and external factors can not only cause tinnitus but also aggravate its perception and experience.
If you are struggling with a problematic tinnitus, inquire about comprehensive management programs offered by your community Audiology and Psychology clinics. Let a professional help you live a life free of tinnitus burden.
Dany Pineault completed his Doctor of Audiology (Au.D.) at A.T. Still University. He has been an audiologist for 25 years and has extensive clinical experience in the assessment and management of problematic tinnitus and decreased sound tolerance. He currently practices as a clinical audiologist at the Canadian Hearing Society, the largest non-profit hearing healthcare organization of its kind in North America and is also a research advisor for Statistics Canada. He recently co-authored the Tinnitus in Canada paper (Ramage-Morin P, Banks R, Pineault D and Atrach M, 2019).
Dany is an assistant adjunct professor at A.T. Still University. He teaches the Tinnitus and Hyperacusis course to students enrolled in the Post-Professional Doctor of Audiology program and is an off-campus preceptor supporting Canadian University Audiology Programs (e.g.: University of British Columbia, Western University, Dalhousie University and l’Université d’Ottawa).