Official Guidelines for Tinnitus Management

Tinnitus Retraining Therapy (TRT) is an approach to managing problematic tinnitus. Many people have tinnitus, but only a very small percentage of those find that the sound affects their quality of life. This management approach is based on Dr. Pawel Jastreboff’s Neurophysiological Model of Tinnitus (Jastreboff, 2004). This model was initially proposed as a theory for why only a very small percentage of people that have tinnitus are bothered by it, while most people are not.  We know from research that those with problematic tinnitus and other sound sensitivities develop an abnormal neural connection between the auditory pathway from the ears to the brain and the limbic system, which is the seat of our emotions. The limbic system is our survival centre and gets us ready to fight a predator or flee from the situation. To prepare our body to jump into action, stress hormones are released into the bloodstream, causing changes in our body to prepare for a fight to keep us safe. It is the meaning or interpretation that we give the situation that determines whether the limbic system will become activated. For example, if you were walking down an alley at night, and a dog jumped out at you and began barking, you would likely feel scared, anxious, upset and possibly other emotions such as anger towards the owner who didn’t have their dog on a leash. Your heart might start pounding, you might be breathing more shallowly, and your pupils might dilate. Now imagine that the loud barking dog was wagging his tail, excited to see you. Your initial reaction may be one of surprise, but after seeing that the dog was friendly, you would likely become calm almost immediately. Now let’s think about this. The loud barking was identical in both scenarios. The volume and other characteristics of the barking in both examples were identical. Why was your reaction different in these two examples? The answer is that the meaning you gave to each situation was different. When you believed the loud barking to indicate that the first dog was dangerous and may cause you harm, your body immediately went into protective mode, preparing to fight the dog, run away from it, or freeze, hoping that the dog would lose interest in you and leave. On the other hand, when you interpreted the loud barking as a sign of excitement, you might feel excited or happy to have encountered a friendly dog on your evening stroll, one who is hoping that you’ll throw him a ball or stick. The important lesson in this example is that the sound of the barking itself is not what caused you to react differently to the potentially menacing dog and the friendly dog. Instead, it was the meaning you attributed to the barking that caused the distinctly different emotional reactions. Tinnitus is just a sound, plain and simple. It is not going to do you harm. Most people that have tinnitus do not experience any disruption in their quality of life. If you talk about your tinnitus negatively out loud or in your thoughts and dwell on all the ways that you believe the tinnitus has negatively affected your life and your happiness, you are giving it power. Your brain will begin to believe that this sound is dangerous and needs to be monitored. When you give the tinnitus power in this way, your brain will react as if the sound is truly a threat to your life, and the continual activation of your fight or flight centre, forcing you to keep listening and waiting for the sound to cause you harm. Your brain has been trained to believe the sound means danger. TRT changes the way that the brain thinks about the tinnitus, which changes the negative impact it has on your emotions and on your life. Reference: Jastreboff, P.J. (2004). The Neurophysiological Model of Tinnitus. In Snow, J.B Tinnitus: Theory and Management (pp.96-107). BC Decker Inc.

You have likely heard of sound therapy as a common approach to reduce the awareness of tinnitus. Sound therapy refers to adding sound to your environment or through ear worn devices so that you are less aware of the tinnitus. Many people find that the tinnitus is less bothersome during the day when there are other sounds present in the environment. Adding sound to our environment can be an effective way to reduce the awareness of tinnitus and push it into the background, which can be helpful when in bed or when focusing on a task in quiet surroundings. When we have tinnitus, we are understandably ear-focused, and management strategies have also focused on the ears. While using sound to distract the brain from the tinnitus can be an effective component of tinnitus management, we may not consider that we have four other senses that we can use to our advantage! Engage your other senses for a more effective way to refocus away from the tinnitus. Add fragrances to your environment, stroke your pet, squeeze a stress ball, play with a fidget spinner, rub a smooth stone, enjoy a hard candy, place visually appealing or stimulating objects in your environment, or have a framed photo of people or events nearby that make you smile. Paying attention to input from more than one of our senses will give the brain less opportunity and energy to focus on the tinnitus. Sound therapy uses only the sense of hearing to distract from the tinnitus, and while this can be helpful, bi-modal stimulation is now being put into practice. Bi-modal stimulation for tinnitus management refers to using more than one ‘mode’ or sense to take the focus off the tinnitus. There is now a bimodal device, The Lenire (pronounced len-EAR), that pairs tongue and sound stimulation to help you pay less attention to the tinnitus. A tongue tip stimulator sits on the surface of the tongue, with your mouth closed, and delivers mild pulses to the tongue while the handheld controller adjusts the pulsing signal. Wireless headphones play calming music that is coordinated to the tongue stimulation. This device is currently only available in the United States. If you are interested in learning more, click this link https://www.lenire.com/  The choice of sound you use depends on the situation, and on your activities and goals. For example, if the goal is to help you fall asleep or allow you to focus your attention away from the tinnitus to another task, choose sounds that are boring, monotonous, meaningless, steady, non-repetitive, and uninteresting. Repetitive soundtracks such as thunder or waves will alert the brain to anticipate the next crash of thunder of waves. When the brain is anticipating a sound, it is actively listening, which is not conducive to sleep and focus. We want your brain is passively listening, meaning that the sound is there but not grabbing your attention. If hearing loss is present, wearing hearing aids will often reduce the awareness of the tinnitus. Hearing aids can also produce various masking sounds, for example white noise or other coloured sound. If hearing is normal, masking devices can be used without any amplification.

Tinnitus is typically more bothersome when you are in a quiet environment, such as in bed trying to fall asleep, or upon waking in the night or in the morning. If there is no competing sound in the room, you will automatically be drawn to the noise in your head and ears. The trick is to give your brain another sound to focus on. You have likely been told to put sound into your environment to reduce the awareness of the bothersome sound. What you may not know is that certain sounds are preferred to others for this purpose. The general recommendation is to choose sounds that are steady, uninteresting, monotonous, and non-repetitive; sounds that aren’t going to grab your attention or alert you. Many people will mention that they fall asleep listening to a podcast or the television turned on to low volume, or music, often on a timer. The potential problem with this strategy is that as you are drifting off, your brain is still listening. If a topic, word, or familiar piece of music is heard, your brain will be activated. Familiar information that has been coded in your auditory cortex, the part of your brain that gives meaning to information that you have acquired through your hearing, is coded in your brain as important, and you will be alerted. If you have a cell phone, you have access to thousands of soundtracks that can be streamed through a speaker from your phone. People often find water tracks soothing, even if they do not have tinnitus. Rainfall, stream, or waterfall are popular options. Ocean wave tracks are not advised, as the crash of the waves occurs at a regular interval. The brain will begin to anticipate the next crash of the wave, and in doing so, it will be actively listening, which not conducive to sleep. The same occurs when listening to thunder tracks. White noise like what your fan would produce, consists of all the pitches of the range of human hearing being produced at the same volume. Pink noise is white noise filtered to better match the natural ear acoustics and has greater low-frequency energy than white noise, making it sound lower in pitch. There are other colours of noise out there, but brown noise is one that has become popular for studying, focus, and sleep. It is a lower pitched sound than pink noise, which many find more soothing and relaxing, sound like surf or a waterfall in the distance. Some people even combine white, pink and brown noise to create ‘neopolitan’ noise!  Whichever sound you choose, whether rain, waterfall, or filtered noise, the volume should be set so that you can hear both the tinnitus and your sound choice. We want to allow the brain to hear the tinnitus with less impact, so that over time our brain learns to tune the tinnitus out rather than to go looking for it. If you would like help managing tinnitus, book an appointment with us and we can get started on finding the best sound for you.

When we think of our ears, we often think only of their ability to help us hear the sounds around us. While this is one of their functions, the inner ear is also responsible for our balance. Our balance system keeps us upright to remain focused on an object when our head is moving and to inform us if we are accelerating or slowing down horizontally and vertically, such as when we are in a vehicle or riding an elevator. Our brain uses these signals along with input from our eyes and from our muscles and joints to allow us to move our bodies with coordination and little effort. When a person experiences a concussion or traumatic brain injury (TBI), the inner ear can be affected. The auditory (hearing) and vestibular (balance) organs of the inner ear send information to the brain through electrical impulses transmitted along a nerve pathway. Injury to the auditory-vestibular system can result in symptoms of hearing loss, tinnitus, imbalance (feeling off-balance, light-headed, spaced out, or foggy in the head) and vertigo (spinning). Other symptoms may include memory issues, word-finding problems, sensitivity to auditory and visual stimulation such as light and movement, headache, fogginess, and fatigue. Symptoms may vary between individuals, depending on several factors, including the age and gender of the patient, pre-existing medical conditions, and length of time between concussions. Patients may not be aware of hearing loss and tinnitus immediately after head injury because symptoms of vertigo, nausea, and headaches are often more debilitating. As the patient begins to recover, these ear-related symptoms are noted. As hearing, tinnitus, and balance issues are closely related, a multidisciplinary approach for assessing and managing these symptoms is advantageous. Assessing the patient as a whole person with input from professionals of various disciplines gives a more complete understanding of the patient’s challenges, and a management plan can be developed based on priorities developed by the multidisciplinary team. Not only does the patient experience a more comprehensive assessment and management plan, but professionals working in multidisciplinary settings become aware of considerations from the perspective of other professionals. This improves their ability to develop management plans in the context of the whole patient, not just within their area of specialization. At the Calgary Ear Centre, we offer full auditory assessments, tinnitus management strategies, and referral for assessment and management of balance disorders. If you have had a concussion or other head injury, please call us to make an appointment for consultation.

Our hearing deteriorates as we age. This is a normal part of aging and typically not something we need to have checked by an Ear, Nose, and Throat (ENT) specialist. Think of gradual hearing loss from aging being like other changes that occur over time, such as vision decline or physical changes to your appearance. These are changes that are to be expected and do not signal that medical consultation is necessary. With age, our high frequency hearing gradually deteriorates, and we slowly lose the clarity to sounds. We may not be aware of a significant decrease in volume, but you may feel that your understanding of speech has worsened, especially if you are in background noise, such as a family gathering or restaurant, or if you cannot see the speaker’s face. Tinnitus, the buzzing, hissing, or other sounds that might occur in the ears, is often a symptom of hearing loss, especially if it is constant or lasts for hours. The first step is to have your hearing tested by an audiologist. Brief episodes of tinnitus lasting seconds to a couple of minutes are normal and do not need to be investigated unless they are accompanied by dizziness. There are instances where a medical referral is appropriate. A referral to an ENT may be warranted if any of the following are present: If there is a significant difference in hearing between the ears with or without tinnitus. If you experience an unexplained and sudden loss of hearing, typically occurring in one ear, and possibly accompanied by dizziness or vertigo. If you are experiencing chronic middle ear infections, with or without discharge. If you experience a head injury resulting in hearing loss, tinnitus and/or balance problems. In all the above instances, a complete auditory evaluation or hearing test is recommended to determine whether a referral to a medical specialist is warranted. A complete hearing test includes a detailed hearing history obtained by your audiologist, followed by an evaluation of your hearing, which includes listening to the individual tones that make up the sounds of speech and speech clarity testing. Speech clarity scores are crucial in determining how clearly you hear words when they are presented at a comfortable listening level. Two people can have the same graph for the tones, but one may person may hear much better for speech testing than another which will give your audiologist more information when they provide recommendations. If you have a straightforward hearing loss, equal in both ears, and no asymmetrical symptoms such as tinnitus, there is no need to see an ENT. Your audiologist will explain your results and will typically offer you the option to try hearing aids for 60 days if you have a hearing loss. The trial period will allow you to try the hearing aids in situations that you find challenging to see if they help you hear better and if they reduce your awareness of the tinnitus.

If you have tinnitus, you may have noticed that when there are other sounds in the environment, you do not hear the tinnitus as much. Or perhaps you find that when you are taking a shower, the tinnitus is less obvious. Many people with hearing loss have tinnitus, which is typically a symptom of damage to the ear, most commonly from ageing or noise exposure. Some people have tinnitus even with normal hearing. The goal of tinnitus management is to reduce your awareness of the tinnitus so that it does not affect your quality of life. When you have a hearing loss , you are not hearing all the sounds around you, even though you may be functioning well. Correcting for the hearing loss with hearing aids often reduces the volume of the tinnitus. In addition, all hearing aids have a built-in sound generator, which allows the clinician to program the devices to play a soft masking sound helpful for reducing the awareness of the tinnitus, whether you have a hearing loss. Even if hearing loss is not your major concern, the first step is to have a complete auditory evaluation and discussion about the tinnitus with your audiologist. They will make recommendations for tinnitus management based on the results and the impact that the tinnitus has on your life. You are welcome to try devices in the office to see if the tinnitus becomes quieter when wearing them. If you feel that the devices might be of benefit, we can order some for you to try for 60 days so that you can take them home and try them in your own surroundings. Your clinician can suggest which devices you might like to try, based on your budget and lifestyle. You have nothing to lose by trying! Let us help.

Everyone wants a quick-fix or a pill that can cure all ailments. Life has become fast paced and even waiting for a short time becomes frustrating. My audiometer, the equipment that I use to test hearing, is slow to start. Slow these days would have been considered lightning speed years ago. That I must wait up to twenty seconds for it to load the necessary programs makes me feel impatient and irritated as I sit waiting for it to come alive so that I can start my day. This is the way of the world: We want things done, fixed, and resolved pronto so that we are not inconvenienced by the wait. Wanting a quick fix is true with chronic medical conditions as well. In our urgency to fix tinnitus, we can work ourselves into a state of panic and desperation. If you were told that there is nothing that I could do you to help you and you would have to learn to live with it, the panic and desperation accelerate until the tinnitus consumes you and it is all you can think about. The good news is that while there may be no way to immediately eliminate the sound, that is a far cry from saying that there is no help. Tinnitus, like other chronic conditions, requires management, and that requires time and some effort on your part. There are many chronic conditions that are managed effectively, despite having no cure or remedy. Tinnitus is one of those. There are many tools including sound therapy and hearing aids that can reduce your awareness of the head noise to a point that it has no impact on your quality of life. You may already have periods of time when you are busy and are unaware of the tinnitus, or perhaps you do not hear it when you are in the shower or in background noise. Tinnitus management typically includes a sound therapy component, which is just a fancy way of saying that if we add other sounds into our environment so that the tinnitus is partially or completely masked and not as obvious. The goal of sound therapy is not to completely cover the tinnitus with other sounds. We want to allow the brain to hear it, but with less impact, so we mix it with other sounds. The brain gradually integrates the tinnitus, and it becomes meaningless, just as other new sounds do after the novelty wears off. Ask yourself: “If I could enjoy doing my life and activities as I did before I had tinnitus, would that improve my quality of life?” What is important to understand is that the tinnitus does not need to be eliminated for this to happen. Your brain is fixating on the sound, and it is the hyper-focus on the sound rather than the sound itself that is the problem. We do not need to get rid of the tinnitus for your quality of life to improve. The key is to retrain your brain to stop fixating on the tinnitus. Once the brain looks elsewhere for stimulation, the tinnitus will settle and no longer trigger you. That process is referred to as ‘habituation’. Once the brain takes its focus of the tinnitus, it will no longer have the hold on your that it presently has and there will be room to enjoy life as you previously did.

Did you ever wonder how our brain sorts all the information that comes at us every second of the day? Like a good manager, the brain prioritizes incoming information and deals with what it believes to be the most urgent tasks, putting others on the back burner until the most pressing task is dealt with. Our brain’s sole purpose is to keep us safe. If there is a change to our environment, our senses alert the brain to that change, and we are compelled to pay attention to the change to see if there is a threat to our safety and survival. Any change in the status quo will set off alarm bells and we will be put on alert until we either determine that the change is non-threatening, or we deal with the threat by fighting it or running from it. In the case of sound, it is not just the awareness of new or unfamiliar sounds that triggers us to investigate, it is the change in the sound environment that is alerting to our brain. That means even the removal of an expected sound can catch our attention and cause us to focus on that change. Someone who lives in an urban setting where there may be traffic noise throughout the night, or perhaps trains pass at regular intervals, may become unaware of these sounds. Their brains habituate to the expected sounds so that other information can be attended to. If that person was to go camping or visit a friend in a rural setting, they may have problems falling asleep because it is too quiet. Their brains would alert them to the change in the sound environment so that the change can be investigated. The phrase ‘deafening silence’ comes to mind. For those who are used to a certain amount of environmental noise, the change to an environment of little or no sound can be alerting and can even cause anxiety or a feeling of unease. There have been a handful of times in history when Niagara Falls has nearly completely frozen over. Those who lived close to the falls were woken by the eerie silence or had problems falling asleep. Their brains had accommodated to the steady roar of the falls. When that roar was reduced to a trickle, they were alerted to the absence of the familiar sound. Quiet sounds can be as alerting as loud sounds if they carry emotional weight. A new parent can be woken from a sound sleep if their new baby starts to whimper in a room down the hall. Although the physical volume of the sound is very quiet, the impact of sound is significant as it triggers an emotional response tied to the meaning given to the sound - thoughts of love and protection, or possibly aggravation and frustration. It is the thought about the sound that results in the emotional response to the situation. If the parent is sleep-deprived and must get up to go to work in the morning, the thoughts about being woken in the night will be different than if the parent is able to sleep in the following morning. The sound of the baby is not what determines the mood of the parent, bur rather the meaning and thoughts around the baby whimpering. Our own names have strong emotional weight for us and those who know us. If you are at a large gathering where everyone is talking, you may barely be able to hear the person standing directly in front of you, yet when someone across the room mentions your name, you may hear it clearly above all the chatter. The reason for this is that your name has significant emotional weight. You have heard your name being spoken since infancy and it has been imprinted in your brain. Your name was not being spoken louder than the rest of the conversation in the room, but it popped out above the rest because it has been assigned importance and therefore your brain will be alerted and will hear it above sounds in the room that are as loud or louder.  These examples demonstrate that the measured volume of a given sound is not as important as the meaning that we give the sound, whether positive or negative. We can measure the volume of a person’s tinnitus in the sound booth by increasing the volume of a tone or hiss that approximates the frequency of the tinnitus, and asking the person to indicate when the volume of the tinnitus is equal to the volume of the sound we are delivering through the earphones. While those with bothersome tinnitus often describe the tinnitus as being as loud as a siren or jet engine, they match the volume of their tinnitus to a sound that is very quiet, often not much louder than the quietest sound that person can detect at the same pitch. Why is this? Our distress from the tinnitus is related to the thoughts we have about the tinnitus, the meaning we give it and the focus we place on it. A quiet sound can have a big impact. Our brain has been trained to be on high alert to monitor this intruder we call tinnitus, and we are bothered by it because we focus on it over everything else. You may claim that you are unable to turn your focus away from the tinnitus, but there are techniques to retrain your brain to put the tinnitus in its place so that it has no impact on your quality of life. Most people that have tinnitus experience no impact from it. They have habituated, and you can too. Find an audiologist who can help you retrain your brain to filter out the tinnitus so that it has little to no impact on your quality of life.

I have been asked many questions about tinnitus over the years. Here are some more answers to the most common questions I have been asked. Q: What is the correct pronunciation of tinnitus? I sometimes hear it called ‘TIN-it-tis’ and other times ‘Tin-EYE-tis’; which is correct? A: Both pronunciations are correct. What is not correct is ‘Tinn-in-EYE-tis’. That’s just goofy. Q: Should I see and Ear, Nose and Throat doctor about my tinnitus? A: That depends. ENTs deal with medical issues pertaining to the Ear, Nose, and Throat. In other words, conditions of the ear that need to be medically monitored or possibly surgically addressed. If you have a hearing or ear issue that is not typical, these are referred to as “red flags for referral”, and you should be referred to an ENT for consultation. Q: What do you mean by “red flags”? A: Red flags are atypical findings on your hearing test results. Your audiologist has been educated about the auditory system and auditory pathway from the ear (where sound is collected) to the brain (where the sound is given meaning). Based on your age, your history of noise exposure, and other medical conditions, the audiologist will anticipate certain results on your hearing test. If your results are unexpected, this could warrant a referral to see an ENT. Q: Can you give me some examples of what might be unexpected on a hearing test? A: Sure! Unlike our eyes, both of our ears should deteriorate at the same rate. If there is a significant difference between the hearing of the right and left ear, this would not be typical and should be checked out. In audiology it is all about symmetry. Not only should the hearing be equal for the right and left ear, symptoms should also be the same for the right and left ear. If you have tinnitus in only one ear, or if it is significantly louder in one ear, this is also not typical and should be investigated. Another type of tinnitus that would warrant investigation is tinnitus that pulses in time with your heartbeat. This is called “Pulsatile tinnitus” and is typically related to the blood flow through the vessels in your head and neck, and should be checked by an ENT. Q: I sometimes get a plugged feeling in one ear, and a high-pitched tone that lasts a few seconds, then it goes away. Does that mean I have damage to my hair cells?  A: Brief tinnitus, like what you just described, is called “transient’ tinnitus” and is something that many of us experience. It is normal and does not indicate damage.