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May 27, 2017

Phantom of the Ear

Remember that saying “You don’t know what you have until its gone”? I’m not sure who is credited with this quote but how right they were. For me I remember when my husband and I and our two growing children lived in a two-bedroom loft. We were so ready to get out and into a place where we could spread out. But, now as I spend all day cleaning our dream place I think back longingly on our small loft.  Or I remember when I could eat pizza and ice cream and not have to work out the next day. Or better yet when I could work out without having knee pain or hamstring injuries. But for those haunted by the Phantom of the Ear they long for the days of silence. When they could sit in their favorite chair reading a book or crawl into bed knowing sleep was seconds away. But now in these serene environments the Phantom of the Ear sneaks up without warning and many times without mercy.

Tinnitus, that phantom sound only you can hear, actually affects 45 million Americans according to the American Tinnitus Association. About 90 percent of those experiencing tinnitus also have an underlying hearing loss. This hearing loss is most commonly related to noise exposure which is why musicians today wear hearing protection when performing. But that was not always the case. Pete Townshend from The Who believes his tinnitus is the result of a concert at Charlton FC in London, which according to the Guinness Book of Records was the loudest concert ever. Neil Young also suffers from hearing loss and tinnitus as does William Shatner. Shatner feels his tinnitus resulted from an on-set accident during the filming of Star Trek.

Tinnitus has been around for many years and people have been trying to cure it for just as long. Pliny the Elder, a Roman writer, recommended earthworms boiled in goose grease be put in the ear to cure tinnitus. As disgusting as that seems it might be preferable to the treatment administered by early physicians. They believed tinnitus was due to air trapped in the ear that was swirling around constantly. To release this air they would drill a hole into the bones around the ear.

These ancient remedies assumed that tinnitus was resulting from the ear, however since the mid-1990s the theories on where and how tinnitus is generated shifted from the ear to the brain mainly because people who were deaf or had their hearing nerve cut would still report tinnitus. Today researchers around the world are trying to pinpoint how and where tinnitus is generated and find a treatment or cure for it. I love reading about the research underway, however I know that some of you would just prefer to know what can be done now. If that’s you, skip down to “Managing your tinnitus”, however if you’re like me and enjoy learning about medical research, read on.

With the numerous research projects currently underway I can’t possibly go into all of them, so I picked my favorite two. The first one is focused on finding where and how tinnitus is generated. It is a global research effort that involves the University of Buffalo’s Center for Hearing and Deafness, Southeast University in Nanjing, China, and Dalhousie University in Nova Scotia, Canada. The study is using functional MRIs, which show how one part of the brain interacts with another, to see what parts of the brain are active when tinnitus is introduced. Some areas that became active were predictable like the sound processing and emotional centers in the brain while others were unexpected such as the fight or flight center, the memory region, and the motor planning center. These researchers are now working to understand how all these centers work together in generating tinnitus. For more on this research go to https://elifesciences.org/content/4/e06576.

The other research project is focused on a possible treatment for tinnitus. This is a joint effort between Oregon Health and Science University (OHSU) and the Veterans Affairs Portland Medical Center, who together are running clinical trials on tinnitus patients using transcranial magnetic stimulation (TMS). This is a non-invasive procedure where a magnetic field is used to penetrate the skull deeply enough to affect the neuron activity of the brain. In the clinical trials for treatment of tinnitus 18 of the 32 patients treated reported considerable relief of their symptoms for 6 months with no adverse side effects. To read more go to http://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2388777.

I could go on and on about the research as there is an abundance of it but then this blog would be about 10 pages long. So, instead if you have the time and are interested I’ve included a few for you to look up on your own. The Hearing Restoration Project (HRP) is working with STEM cells to regrow inner-ear hair cells with the hope that fixing the hearing loss will cure the tinnitus. To learn more, go to http://hearinghealthfoundation.org/our_research_plan. Or if you like you can read about scientist in Sweden that may have found a gene in mice that is related to tinnitus:  http://www.hearingreview.com/2016/09/scientists-focus-gene-silence-tinnitus/. Or an article looking at how Cochlear Implants may decrease tinnitus: http://www.tinnitusjournal.com/articles/can-cochlear-implants-decrease-tinnitus.pdf.

Managing Your Tinnitus

Before we start I want to point out that there is no clinically proven way to eliminate or cure tinnitus, and the FDA has not approved any medication for the treatment of tinnitus. That being said, what I will be giving you here are things that can be done to reduce the perceived intensity of the tinnitus.

Remember tinnitus is a symptom, not a diagnosis. Prior to treating your tinnitus, we need to find the origin of it. As I mentioned earlier 90 percent of people experiencing tinnitus have an underlying hearing loss so a logical first step would be to see your audiologist. A comprehensive hearing evaluation will look to see if the ear is clear of wax, if the middle ear is working without obstructions, and whether there is hearing loss.

For the other 10% whose tinnitus is not related to hearing loss an appointment with your primary care doctor may shed light on what is causing it. Many medications can have the side effect of tinnitus, however there are also non-ear related conditions that have been linked to tinnitus such as trauma to the head or neck, Temporomandibular Joint Disorder (TMJ), sinus pressure or congestion, autoimmune disorders, metabolic disorders, high blood pressure, and psychiatric ailments such as depression or anxiety disorders.

Since hearing loss is the leading cause of tinnitus let’s start there. Tinnitus related to hearing loss is thought to be due to neuro-plastic changes in the brain. A survey of hearing professionals found that 60% of their patients with both tinnitus and hearing loss found relief from the tinnitus when wearing hearing instruments. Isn’t it funny how sometimes the most direct and obvious route is the best. By having amplification, the listener’s attention is diverted to other sounds in the environment and away from their tinnitus. The American Tinnitus Association used the visual below to illustrate how hearing instruments can help to mask or reduce the effects of tinnitus through hearing instruments.  Picture A represents a person with untreated hearing loss and tinnitus. The environmental sounds are indistinct making the tinnitus, represented by the cricket, more pronounced. Picture B represent the same person wearing a hearing instrument. Now even though the tinnitus (cricket) is still there the clarity of the other environmental sounds makes it less noticeable.

If your tinnitus is related to hypertension, depression, anxiety, or Meniere’s Disease making some lifestyle changes with diet and exercise can help. Some people feel that caffeine, alcohol, or salty foods exasperate their tinnitus so keeping a food diary could help find a trigger if there is one. Also, making healthier choices when it comes to food can reduce hypertension, increase blood flow, heighten your energy level and just improve your overall well-being which in turn could alter your emotional response to the tinnitus.

Likewise, exercise not only can reduce weight and stress levels but also can create a diversion away from the tinnitus. What exercise is best depends on you. Practicing yoga or other exercises that involve relaxation or meditation can help to reduce stress and possibly the perception of tinnitus; whereas some say the wind noise while biking helps to mask the tinnitus and give at least temporary relief from it. But, keep in mind noise exposure leads to hearing loss and tinnitus. So, no matter what exercise you choose be cautious of the music volume while you are working out so you do not end up exasperating the tinnitus.

Tinnitus maskers are a common go to for treating tinnitus as they are easy and can be inexpensive. Hearing instruments today typically come with a tinnitus masker built-in which can easily be turned on by your audiologist.  If you do not wear hearing instruments just adding sound into your environment will help to mask the tinnitus. This can be done by downloading a tinnitus masking app on your smartphone or turning on a CD with soothing music or environmental sounds.  For more severe tinnitus a better but more expensive option would be a notched-music or pitch matching device. These devices customize the sounds around the frequency of your tinnitus in an attempt to disrupt the abnormal neural firing in the auditory cortex. Reported results on these devices can vary but several studies show patients that follow the program report less perceived tinnitus at the end of the program.

If the above treatments do not offer you enough relief then you may want to consider behavioral therapy. Behavioral therapy focuses on someone’s emotional reaction to their tinnitus and helps them develop coping mechanisms to reduce the internal attention given to the tinnitus. This is accomplished by learning relaxation techniques and completing cognitive training to find more positive ways of thinking about the tinnitus. Behavioral therapy has consistently been shown to reduce individuals perceived severity of tinnitus as well as reduce tinnitus-related anxiety and depression.

Tinnitus thought to be related to psychological conditions such as anxiety, depression, or obsessive compulsive disorder can occasionally be treated with antidepressants or antianxiety medications. However, I want to again be clear that there are currently no FDA approved drugs for the treatment of tinnitus. That being said if your tinnitus is severe and related to a psychological ailment your doctor may prescribe one of these medications. The hope is that these medications would reduce the negative emotions or the psychological burden of the tinnitus.

If you have trauma or tension in the muscle or tendons near the ear a visit to a physical therapist or chiropractor may help. Whereas a dentist could assist with tinnitus stemming from Temporomandibular Joint (TMJ) dysfunction.

For those who prefer a more holistic approach there are a few options. One I am not enthusiastic about would be herbal remedies such as gingko balboa, zinc supplements or melatonin. My hesitation is due to a lack of evidence that these work, so I question if it may be more a placebo effect. The holistic option I am intrigued by is acupuncture, which helps to promote good circulation and blood flow. It has gotten mixed reviews with some reporting it to be successful in treating tinnitus related to poor circulation while other articles claim it is not effective. Truth be told I have never tried acupuncture but I am fascinated by it and have it on my bucket list. Even if acupuncture does not help your tinnitus it is said to help boost your immune system, alleviate pain, lower blood pressure, and maybe even help you sleep better. So if it does some or all of those things plus reduces your tinnitus it is worth considering. The most you have to lose is a little time and money.

With so many options and such mixed reviews it’s hard to know which is best. My advice would be to first pursue hearing instrument if you have a hearing loss, and perhaps utilize the tinnitus masker in it. If you are still bothered by your tinnitus evaluate when your tinnitus occurs or what triggers it. Is it when you’re in quiet or all day? Due to stress? Related to other health problems or medications? Once you feel you have found the trigger pick the best treatment for that cause. Sometimes finding the right treatment means you and your audiologist have to take on the role of researchers, and through trial and error find what works for you.