Symptoms of tinnitus
Many people experience an occasional ringing in the ears or you may hear a sound such as roaring, buzzing, hissing, or whizzing noise. This constant internal sound that does not improve is referred to as tinnitus.

What is tinnitus?

Tinnitus is a conscious awareness of a sound in the ears or head that is not due to an external noise. Every individual has their own very personal tinnitus tone. It can be a high or low frequency sound and its volume can vary over time. An estimated 300 000 people in the Canada have experienced tinnitus at one time or another. 

A significant number of people who experience tinnitus symptoms do become severely distressed by the sounds.

Tinnitus is generally divided into two types:
•    Subjective tinnitus – noises that can only be heard by the patient
•    Objective tinnitus – noises that can be heard by somebody examining the patient

Subjective tinnitus
This is by far the most common type of tinnitus. Everyone, if sitting in a soundproof room, hears noises in their heads. Usually these noises are masked in everyday life by all the noise going on in the world around us. If you cannot hear sounds in the outside world so well, you tend to notice the natural noises inside your head much more because they are not being masked by the environmental noises. 

Tinnitus is often, but not always, linked to a hearing loss. If the tiny hair cells of the cochlea are damaged, for example through certain drugs, noise exposure or as part of the aging process, the cochlea becomes less good at discriminating sounds, and your hearing is affected.

Objective tinnitus
This type of tinnitus is uncommon. Ringing noises in the ears may be caused by spasms of small muscles in the middle ear (often heard as a clicking sound) or by abnormalities of the blood vessels in and around the ear. 

It is the turbulent bloodflow that is heard directly by the inner ear, and it usually occurs in time with the heart beat (pulsatile tinnitus). Pulsatile tinnitus can occur when there is an increased bloodflow to the ear, such as during an infection and inflammation, but also because of anatomical abnormalities of the blood vessels

Causes of Tinnitus
What causes tinnitus?

Tinnitus can be caused by the following:
•    exposure to loud noise
•    a side effect of medication
•    ear or head injuries
•    diseases of the ear
•    ear infections
•    emotional stress

Tinnitus often occurs in conjunction with an auditory impairment, for instance after an acute loss of hearing.

Why doesn’t the tinnitus sound go away?
For individuals with long-term tinnitus, one or more of the causes above have, at some point, led to an auditory malfunction. The brain’s attempt to compensate for this malfunction is the start of a vicious cycle. 

The auditory cortex is the part of the brain that is responsible for hearing. Every stimulus perceived by the ear is transmitted to and processed by the auditory cortex. The nerve cell assemblies in a specific area of the auditory cortex are ‘tuned’ to a certain frequency, similar to the arrangement of keys on a piano. 

No matter what triggers may be responsible for the tinnitus – noise, medication, stress – they all lead to an interruption of the signal transmission from the ear to the auditory cortex. This means that some of your nerve cell assemblies no longer receive any signals. To stay with the piano image: some of the piano’s keys no longer work and cannot be struck by the pianist. 

However, these nerve cell assemblies do not react to the lack of stimulus by simply remaining ‘silent’. Instead the nerve cells begin to ‘chatter’ spontaneously and become synchronously attuned to one another. 

Once they have become hyperactive and synchronous in this way, the nerve cells simulate a tone that the brain ‘hears’ – the tinnitus tone. Coming back to the piano; the broken keys have created their own permanent tone even without the keys being struck by the pianist. 

Over time, this pattern strengthens and the tinnitus becomes permanently anchored – the brain has learnt a phantom sound. 
Tinnitus treatment is aimed at unlearning the tinnitus tone.

A Recent Study about Treatments for Tinnitus
Metro Hearing and Tinnitus Treatment Clinic knows that tinnitus affects millions of people. For those who are not familiar with exactly what tinnitus is, it is a disease that affects the ears. It causes a nonstop high pitched ringing or buzzing noise, which is extremely annoying and to many people suffering with it, maddening. Unfortunately, there is no cure, though researchers have been taking huge steps into the understanding of what causes tinnitus and how we could potentially put the ringing to rest!

Neuroscientists at the University of California, Berkeley recently published their findings on tinnitus and have a few new suggestions for treatment. One of the new treatment ideas was retraining the brain. Loud noises damages to the hair cells in the inner ear which in return leave a gap in frequencies that these hair cells send to the brain. More or less, ringing doesn’t originate in the ear, but in the brain, in areas such as the auditory cortex, which is receiving input from the ear. One theory is that the ringing is a phantom noise made by neurons that have lost their sensory input from the ear, therefore they start firing off spontaneously. By retraining the brain, researchers hope that they could reduce spontaneous firing by giving the cells a new form of input. Through reorganizing the cortical map, researchers believe that this would resolve tinnitus.

Another suggestion to help cure tinnitus was to find a drug that would be able to inhibit the random firing by neurons in the auditory cortex. Through a study done on rats with tinnitus, when the inhibitory neurotransmitter GABA was increased, the rat’s tinnitus was cured. Though, there is still much work that must be done before any of this treatment could be used in people, as the side effects of increased GABA currently prohibit its human use. These steps are huge in finding a treatment for tinnitus and a cure could mean peace for so many people. If you suffer from tinnitus, Metro Hearing and Tinnitus Treatment Clinic offer several tinnitus treatments options.

Non-Medical Management:
Although there are many non-medical treatment modalities, only a few have received widespread acceptance The three most common, and most promising, non-medical methods of treatment are masking, tinnitus retraining therapy (also known as habituation therapy) and cognitive therapy. Alternative non-medical treatements include; biofeedback, psychological counseling, nutritional controls, acupuncture, gingko biloba, and Vitamin B 12. For an overview and comprehensive listing of herbs and vitamins purported to assist in the management of tinnitus, the reader is referred to the March 2000 issue of Tinnitus Today, published by the American Tinnitus Association (ATA). It should be noted that gingko biloba, despite its enthusiastic cohort of supporters, has been rather clearly shown to have no more benefit than a placebo (Drew & Davies, 1999). For a more comprehensive overview of treatment, the reader is referred to the book by Vernon (1998), Tinnitus – Treatment and Relief, available from the ATA (published by Allyn and Bacon).

Maskers and Combination Devices:
Masker use, as described by Dr. Jack Vernon, (1977, 1978, 1979, 1981) has proven to be effective for some, but not for all. Masking involves using an external signal (i.e., masking noise) sufficient to mask or ‘cover’ the ongoing tinnitus. The rationale is that an external acoustic stimulus is easier for the patient to ignore than the constant, ongoing tinnitus. Johnson (1998) reported the use of masker devices was effective about 35 to 40% of the time for those who investigated their use. Although not an impressive number in isolation, tinnitus sufferers who were in the 35 to 40% group find masker devices to be a godsend. A combination device, an instrument containing both a hearing aid and a noise generating circuit, increased success rates to about 70%. That is, for those tinnitus patients having tinnitus and hearing loss sufficient to interfere with speech understanding, the combination device provided more relief than a masker device alone. The combination device also provided more relief than a hearing aid alone. Maskers and combination devices continue to be used by tinnitus patients, suggesting that these instruments continue to be a valuable therapeutic modality, which provides relief and reduces the high stress level often associated with tinnitus.

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Tinnitus Retraining Therapy
Dr. Pawel Jastreboff (www.tinnitus-pjj.com/) is recognized as the person who conceived and popularized the use of Tinnitus Retraining Therapy. In essence, Dr. Jastreboff postulated that acoustic, or acoustic-like perceptions, could be habituated to if they were not considered to be a harbinger of disease, danger or mental stress. For example, grandfather clocks ticks day in and day out. Yet those who live in a house with a grandfather clock have habituated to its ticking. Literally, they do not perceive it. Similarly, the refrigerator motor goes on and off many times during the day, yet one is not consciously aware of it. If you are sitting in front of a computer as you read this, you are probably not aware of its cooling fan. This ability to habituate to a number of sensory experiences is an integral part of human behavior.

Jastreboff’s (1987, 1994a, 1994b, 1990) account of the model goes something like this:
First, there is the perception of the stimulus. At the cortical level, a decision is made as to whether overt action of any kind is mandatory. If the conscious brain deems the stimulus does not demand some purposeful behavior, it can be habituated to (i.e., dismissed) if there are frequent occurrences of the same stimulus. Suppose, however, that tinnitus serves as the stimulus? The conscious brain attempts to make some rational decision. ‘Have I heard this before? What causes it? Is it some sort of precursor indicating I am going deaf? Do I have a serious disease? I haven’t heard this sound before and I must attend to it until I understand its cause.’ The cortex, failing to find an answer for the tinnitus’ presence, labels the sound a threat. The limbic system (the brain’s emotional control system) is thus alerted and activated to the tinnitus, and the tinnitus becomes a more significant problem for the patient.

Emotional involvement with tinnitus can produce psychological and physiological behaviors. Sleep disturbance, irritability, anger, loss of concentration and anti-social consequences are often reported. If these negative behaviors produced by the limbic system persist over time, then the autonomic nervous system may also become involved. A self-perpetuating cycle of events takes place in the brain. The subconscious brain continues to maintain the conscious brain’s awareness of the tinnitus. The conscious brain continues to involve the subconscious brain, including the limbic and autonomic nervous systems, as it seeks a resolution that is not forthcoming. This cycle, in turn, serves to increase the subjective loudness and importance of the perceived sound.

Jastreboff suggests two things that are important in the control of the tinnitus:

1- The patient must habituate to the tinnitus itself, and
2- The patient must habituate to the emotional consequences of the tinnitus.

To habituate to the tinnitus, it is necessary to reduce the contrast between the ambient noise level and the subjective level of the ongoing tinnitus. To accomplish this task, bilateral noise generators are used These are acoustically similar to, but much quieter than, tinnitus maskers. Depending on the individual patient requirements and categorization, the level of the noise produced by the generators may be increased equal to the loudness of the tinnitus. This makes it more difficult for the conscious brain to concentrate on the ongoing tinnitus.

To habituate to the emotional consequences, directive counseling is used. The essence of this directive counseling, according to Jastreboff, is to make certain the patient understands what tinnitus is, demystifies it as much as possible, and realizes that it not an indicator of a serious physical or psychological problem. To achieve this change of thinking, it is necessary to reinforce one’s understanding of the disorder. To do so, the patient must be adequately counseled. This is accomplished through a prearranged and individually scheduled series of follow-up appointments wherein the clinician and the patient review the patient’s current status. Jastreboff maintains that the Tinnitus Retraining Program treatment program typically achieves its greatest success within 18 to 24 months. Importantly, this does not mean that nothing positive happens until then. Rather, it indicates that it probably will take 18 to 24 months to achieve maximal results. Clinics throughout the world, our own included, report success rates in the 80-90% range with tinnitus retraining therapy. Success is determined by the following criteria:

Cognitive Therapy
One of the common threads found in therapeutic approaches to tinnitus treatment is the effective use of counseling intervention. One such counseling intervention process is Cognitive Therapy. ‘Cognition’ refers to thought processes. ‘Therapy’ refers to some form of management intended to create change in the thinking process. Therefore, the purpose of cognitive therapy is to alter the negative thinking of the patient and bring about a more realistic assessment and understanding of the problem. Sweetow (1986) reports on management of the tinnitus patient using cognitive therapy as a therapeutic base. Dr. David Burns (1980) is to be given much of the credit in the development of Cognitive Therapy. Cognitive Therapy is a form of behavioral modification. The practitioner attempts to modify the ways in which the patient may react to his or her tinnitus. Dr. Burns coined the phrase ‘cognitive distortions.’ These distortions are defined in the following ways:

1. All or nothing thinking: If performance falls short of perfect, you see yourself as a total failure.
2. Overgeneralization: You see a single negative event as a never-ending pattern of defeat.
3. Mental Filter: You see a single negative detail and dwell on it exclusively.
4. Disqualifying the positive: You reject positive experiences by insisting that for some reason or another, they don’t count.
5. Jumping to conclusions: You make a negative interpretation of a particular event,although there is no evidence to support the negative conclusion.
6. Magnification: You exaggerate the importance of things or events.
7. Emotional reasoning: You think your negative emotions reflect the way things really are.
8. Should statements: You try to motivate yourself with should or shouldn’t statements.
The emotional consequence is guilt.
9. Labeling and mislabeling: Instead of describing your action as an error, you attach a negative label, such as ‘I’m no good,’ to yourself
10. Personalization: You see yourself as the cause of some negative event, even though you were not.

It is evident that these distortions of thinking tend to perpetuate the patient’s negative behaviors. Failure to modify cognitive distortions can have undesirable consequences and lead to destructive behaviors. Although Cognitive Therapy was not intended primarily for tinnitus patients, it has been useful in their counseling process. Whether, and to what extent, audiologists should be involved in cognitive therapy with tinnitus patients is a controversial topic. There are strong arguments both for and against. On the one hand, audiologists, more than anyone else, understand the auditory system, and provide hearing system rehabilitation. Furthermore, audiologists engage in counseling routinely. All aural rehabilitation beyond the provision of hearing aids is by definition counseling. The hearing aid fitting process itself involves counseling. On the other hand, audiologists generally do not have explicit training in emotionally centered counseling, and need to work within their scope of practice and licensure.

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