In the 1600’s, a man by the name of Pliny the Elder coined a term to describe a sound that had plagued some humans for centuries; tinnitus. From the Latin word Tinnire (to ring), it describes the ability to hear an internal sound, with no external source.
There are two main types of tinnitus, objective and subjective. Objective tinnitus is relatively rare and explains approximately 5% of cases. Its defining features are that it can usually be localised to a physical source, and sometimes seen (as with muscular spasms of the ear drum) or heard (e.g. vascular changes in or around the the ear). It is commonly referred to as pulsatile, as many types have a rhythmic quality, pulsing either in time with the persons heart-beat (pulse-synchronous), or out of time (asynchronous). What we’re here for, however, is subjective tinnitus. This type is far more common, affecting roughly 16% of the worlds population on a constant basis, and 3% distressingly so. It is also the type linked to ageing ears, hearing loss or those over exposed ears to sound – which is where musicians and industry workers come in.
Tinnitus is a symptom of systemic changes within our body, and not a disease. Research indicates musicians are four times more likely to experience it due alterations in their auditory pathway, often linked back to their sound-related exposure. For some, tinnitus can cause a great deal of stress and concern, especially in the initial stages of discovery. Here we attempt to simplify some of the latest research into why and how it occurs, so a layer of ambiguity can slowly be lifted, replaced with understanding hope.
In Search of Balance
Our bodies operate in a way that loves to maintain equilibrium, known in science as homeostasis. A seesaw analogy is often used to describe the way the hearing pathway works to maintain it’s own homeostasis. Imagining one end of a seesaw outside our head, and the other end inside our mind, if one end goes down – the other must go up. In much the same way, if we lose the ability to hear as much as we were previously used to, our brain’s very natural response is to increase activity of the hearing centre internally as compensation. While that might sound good on paper, this increased internal stimulation can also lead to something that might one day become tinnitus. For this reason, hearing loss is often seen in tandem with tinnitus and vice-versa.
You might be thinking, however, I hear tinnitus and I don’t have a hearing loss, so what’s that to do with me? But the truth is, no one hears as well as they did the day that they were born and we’ve all experienced hearing change.
Over time, we all accumulate a degree of wear and tear in our ears and auditory system, whether we attend a metal concert weekly or not. And while this wear and tear may not be enough to become a diagnosed hearing loss, it is enough for our hearing center to notice a change, and with any change comes a pushing down on the external seesaw of sound, and a raising of that internal noise in our mind. The more it happens, the greater the chances of audibility of that signal as the system becomes out of balance. For science buffs out there, this is known as increased central gain of the auditory pathway, a neuroplastic response of the human mind trying to compensate the best it knows how for a lifetime of change.
Having a change in hearing, however, isn’t enough to cause tinnitus on it’s own. While they often go hand in hand, many thousands of people experience hearing loss without also having tinnitus. The reason as to why many researchers believe this is so, is due to another key component, the Fronto-Striatal Gating System (*pauses for breathe*). This incredibly long name is exactly what is sounds like – a gate! It works in part, to decide which internal sounds reach consciousness or not, much like a bouncer out the front of any nightclub choosing who to, and not to, let in. When working properly, a tinnitus like sound simply isn’t let through, it doesn’t pass the check. However, if this system (or bouncer) makes a mistake and decides it is worth hearing – even just once – it can become almost impossible to remove, remaining in conscious awareness, leading to a whole new cascade of events.
So why and how does this sound get past our protective gating system? Think back to the last time you made a mistake, we’ve all made at least one. If you’re like us and have made many more than one, you might start to notice a pattern – they’re much more likely to happen when you’re sick, tired, stressed or run down. Why? Mental load. Each of these periods in time place extra stress on our mental faculty and reduces our capacity to function normally. We can only sustain so much duress before we start to make errors, misfire or miscalculate the situation. The gating system is just like us, when our minds are run-down or under pressure, the chances of making an error, such as letting tinnitus through, become greater. This is one reason we believe many individuals begin to hear tinnitus at or around periods of stress and/or illness.
Another way in which the likelihood of first hearing tinnitus can be raised, is by reducing the ability to hear sounds around us. The truth is, almost any individual in a completely soundproof booth will hear some internal noise or tinnitus, yet entering back into the real world, find it inaudible as it becomes masked over by everything around them. If we, however, reduce sounds coming into our ears, either through temporary hearing injury, ample wax blockage in our ears, or hearing loss, we are like a tide pulling further and further away from shore, creating more and more chance of new shells being uncovered. The more sound is pulled back from entering your ears, the more chance your own tinnitus can be uncovered.
Irrespective of pathway, hearing tinnitus for lack of a better word, remains to be somewhat chance, and we wholeheartedly disagree with placing blame on oneself if it is heard. We do not yet fully understand why some do, and some don’t experience tinnitus when exposed to the very same experiences. What we do understand slightly more so, however, is how and why some people cope, and others seem to fight an uphill battle.
The Emotional Slide
Once tinnitus has become audible, here’s where people divide. On one hand, you have the majority who hear it, acknowledge it, and let it drift to the background. For some, however, it becomes louder, more intrusive and even terrifying for them to hear, driving a downward spiral of emotion and fear. The difference between these two responses is complex, relating to our past, our mental health, even our personality traits, but in the moment of subconscious truth, it comes down to one thing, how our minds label it.
How we label things is incredibly important. If something is important, it gets more attention. If something is a threat – even more so! For the individual comfortable with tinnitus, it appears they have successfully labelled the sound as a neutral, uninteresting piece of information not worth focusing on. For some, however, a very rapid decision is made that places great import on the tinnitus, labeling it as a warning, threat or danger that activates our flight-fight response. If this is the case, running away from tinnitus becomes as seemingly logical as running away from any threat. In response, our emotions are engaged, from worry to depression, as we search for an answer to something we feel is impacting our lives.
The difficult thing with this threat response, is it can lead to a self-perpetuating, negative cycle. We hear the tinnitus – we label it a threat – worry and distress – our body responds, and most importantly – the tinnitus becomes louder, more intrusive in our head. In this way, the cycle can not only lead to an emotional downward spiral, but worsens the very thing we’re trying to escape. It is here where some can get stuck, and help may be needed to break this process and begin in unraveling the response and turning the signal back down.
Does it get louder forever?
Gladly, no! One of the main fears heard in a tinnitus clinic is that it will increase and get louder forever, especially if the individual has just heard it. It can be a huge contrast, when comparing it to the silence the individual was used to before, however, over time they’ll come to learn that tinnitus instead moves up and down like a wave. At times in our lives there will be moments or days when the tinnitus feels loud and overwhelming. However, the reverse is also true, with it dipping back down into our mental background, audible, but forgotten about for weeks on end. The key to successful tinnitus management is about embracing the changes and fluctuating nature of tinnitus, empowering the listener to tune into what turns their tinnitus up, and what turns it down, so they too can place it where it should be; behind them.
So, What to Do?
Management strategies for tinnitus show the greatest success when achieved in a team. If you are curious, or struggling with adjusting to tinnitus, finding professionals to create a web of support around you is a great first step. There is only so much work we can do alone, before we realise it is healthy and right to accept the help of others. Here is what we recommend:
- See your GP: This is for two reasons, firstly, to check the health of your outer ear, and especially keep an eye our for ear wax. Wax blockage in the ear has been known to cause temporary tinnitus for some, or trigger it in others. If getting it removed, we recommend the manual removal method (not syringing), which can be done through a specialist center, your audiologist, and at times your GP (see wax management). If you haven’t seen a medical professional in a while, it can be a great idea to touch base with them and get a standard blood test performed. Common deficiencies, such as vitamin D and Iron, are known to cause symptoms that can make the journey of wellness more laborious than it needs to be. While they don’t directly reduce tinnitus, if they help improve mood or sleep, they help support a healthier you, more able to combat tinnitus.
- See an Audiologist: Having your hearing tested is a great next step in finding support. Your audiologist can help triage you to other professionals if needed, remove ear wax, or guide you in creating a management plan (see what to expect from a hearing test). Not all audiologist specialise in tinnitus, but if you approach your local center they will be able to let you know.
- Screen for muscular involvement: This is usually done under the guidance of an audiologist or physiotherapist, however, we will be uploading a screening tool here shortly. Somatic modulation refers to the ability some people have to alter their tinnitus by muscular movements. Muscular tension in and around the ear appears to play a role in increasing volume or intrusiveness of tinnitus for some, which can often be reversed through addressing this concern. A very common one, for example, is clenching of the jaw, or head and neck movements. If you can alter your tinnitus through jaw movements – find a dentist specialising in TMJ. However, if you can alter your tinnitus through neck and shoulder movements – find a physiotherapist who can look for any surrounding areas of compression, tension or stress.
- Meditate: This is the cheapest, most wonderful resource we could advise any to try. Meditation is a wonderful tool to help strengthen your mind and assist with aspects of mental health and well-being, however, the reason we recommend it here, is to strengthen a part of your brain that needs work; auditory attention. For individuals locked onto tinnitus, brain imaging studies have shown a weakness of the auditory attention pathway. Daily meditation has been shown to strengthen this pathway, assisting in making that subconscious decision to look away. It is by no means a promise to remove it, but a tool to help reduce it and place it where it needs to be – the background. We recommended exploring this with the use of background sounds, or using app’s like Calm as it allows for easy to use, guided meditations with soothing masking sounds.
- Psychology: At all times in life, psychology is a great tool to support us, however, for chronic tinnitus, even more so. Study after study report psychological difficulties experienced by tinnitus suffers, from depression to anxiety. While this connection is somewhat chicken and the egg, the end result is the same. In Australia, Medicare rebates are available through a Mental Health Care Plan that make accessing support much more affordable. Speak to your GP about finding one that’s right for you, or search here at www.psychology.org.au. We recommend seeking out a health psychologist, trained in Acceptance Commitment Therapy or Cognitive Behavioural Therapy.
- Manage the risk: If you’re surrounded by sounds that could be causing hearing injury, we highly recommend reading our page on hearing protection. Taking steps to reduce the chances of tinnitus, or worsening it, start by protecting what you have.
- Surround sound: Individuals struggling with the intrusiveness of tinnitus may find benefit from introducing more soothing masking sounds into their environment. This may be something as simple as a CD or phone app, or introducing a water feature to create sound atmosphere that provides relief. These tools become particularly useful on louder days, when trying to relax or sleep. It’s a cruel irony that tinnitus pervades our daily existence, most dominant in the times when we wish to rest. Using sound enrichment can help make that easier. Several free apps exist, however, you may wish to try White Noise, or look into those available by Sound Oasis.
- Hearing aids: If you do have a measurable loss, ample research indicates that use of hearing aids can bring relief and masking of the tinnitus while worn. These devices help balance out the imbalance mentioned above, driving in sounds previously inaudible so that your brain is swamped with auditory distraction. They also have the benefit of improving your ability to understand speech. If getting to the end of the day, drained by asking people repeats is you – this could be a good way forward.
- Finally, get moving: It may seem counter-productive, but physical movement supports your mental health and physical health equally. Yoga in particular has been studied alongside tinnitus with good results. It may not be the ticket to remove it, but it could be the thing to help you better manage it and turn it down.
If Pliny had anything to say about it, we’d still be using breast milk and leek juice in our ears to try and fend it away, yet as time would tell, this is not so effective. The best results for tinnitus continue to be prevention first, and management second.
If you are finding it difficult to adjust to your tinnitus, you may like to read our piece on Hearing Tinnitus, Grieving Silence. If you need immediate support, each number below is there to help.
It gets easier:
Lifeline Australia:13 11 44
Tinnitus Association Victoria: 0427 849 885, 0423 203 296 or
0400 554 046
British Tinnitus Association: For UK users: 0800 018 0527
Image by Kate Disher-Quill