Tinnitus

Tinnitus is the term used to describe hearing any sounds which are not present externally. Tinnitus is most commonly heard as ringing, hissing, buzzing or clicking, and can be a single sound or a number of different sounds.

What is tinnitus?

Tinnitus is most commonly a subjective neurological phenomenon triggered by a hearing loss or a change in hearing. Tinnitus can develop with normal hearing.

Objective tinnitus or “somatosounds” have a physical source generated in or near the ear and may be audible to others. Somatosound sources can include the TMJ (jaw joint), patulous eustachian tube, palatal and middle ear muscles (particularly tensor tympani syndrome (TTS), dehiscent semicircular canal, intracranial pulsations and vascular flow murmurs.

Tinnitus can be enhanced by periods of high stress and fatigue. The effect on the surrounding musculature from stress-related jaw clenching, night time bruxism and TMJ dysfunction can cause or aggravate tinnitus at both a somatic and neurological level. TTS symptoms can develop in people with tinnitus, most commonly resulting in an unexplained sensation of blockage in the ear.

Research has shown that almost everyone develops temporary tinnitus in an abnormally quiet environment (such as a soundproof booth).

An increased awareness of tinnitus can occur if it changes in some way and becomes louder, or more frequently present.

Tinnitus becomes significant when:

it becomes perceived as intrusive, irritating or distressing
it frequently fluctuates or spikes
it affects sleep
there is an increase in active tinnitus monitoring
people doubt their ability to cope with their tinnitus
high levels of tinnitus-related anxiety/distress develop.

DWM Audiologist, Myriam Westcott, and a leading neuroscientist were interviewed for the ABC Radio National Health Report on tinnitus. This interview includes a discussion with person who suffers from tinnitus and her experiences in obtaining help.

Myriam Westcott was also interviewed for The Saturday Paper on the increased level of people suffering from tinnitus and the impact of Covid on tinnitus.

Habituation

Most people will spontaneously habituate or adapt to their tinnitus over time. This means, while it may be heard, attention is rarely given to it and an emotional acceptance of it is achieved. This process involves a gradual increase in the periods of time where the tinnitus is not noticed, as well as a gradual reduction in the annoyance or distress it may cause.

People can become stuck in this process and are unable to habituate to their tinnitus as fully as they would like. For a satisfactory level of habituation to be achieved, some degree of acceptance of the tinnitus is needed. Tinnitus acceptance is based on an integration of the tinnitus into the concept of a normally functioning sense of ‘self’, both physiologically and psychologically.

In a two-way process, tinnitus awareness, volume and prominence are typically influenced by anxiety, depression and stress. The onset and/or aggravation of tinnitus can be a highly distressing or even traumatic experience, tapping into the primeval parts of the brain where sounds (including tinnitus) are evaluated to identify potential threats to one’s safety, wellbeing and survival. If this is the case, an intense tinnitus reaction can be involuntarily maintained or become enhanced, so the process of tinnitus habituation is impeded.

Tinnitus therapy assesses and treats each person’s individual barriers towards habituation, aiming to help them achieve a more comfortable coexistence with their tinnitus.

Our Program

Myriam Westcott and Kate Moore provide an individualised program to assist you in management of your tinnitus reaction and guide you to achieve a satisfactory level of tinnitus habituation.

Any questions you may have will be addressed to ensure you have an understanding of what this process involves.

Our program involves:

an evaluation of the emotional impact of your tinnitus
a thorough investigation of your history with regards to your tinnitus and barriers to habituation
a hearing assessment (if not already carried out)
providing detailed information about your tinnitus – including an opinion about the possible cause and the factors that affect your tinnitus onset, persistence and reactivity
information on the neurophysiological basis of tinnitus and tinnitus-related distress and annoyance
a detailed and personalised explanation of your hearing test results, the peripheral and central auditory system and associated somatic and psychological pathways
a personalised therapy program to support habituation.

Therapy – Tinnitus Treatment

We will provide you with practical, self-managed evidence-based strategies known to lead to tinnitus habituation. These strategies will be developed with you and personalised to suit your individual coping style.

This may involve:

the use of hearing aids
sound enrichment strategies
counselling in cognitive management strategies
training in stress management and relaxation
specific techniques to cope with periods of heightened tinnitus awareness and/or volume.

For many people, the information and guidance provided in one appointment may be sufficient to move towards tinnitus habituation. For this reason, our initial appointment time is one and a half hours.

However, the time involved in a program will vary, depending on the level of your reaction to your tinnitus and the ongoing guidance and support that you require.

Myriam Westcott is the only clinician in Australia invited to contribute to “The Multidisciplinary European Guideline for Tinnitus: diagnosis assessment and treatment” Cima et al, 2019. Prominent neuroscientists and clinicians in the tinnitus field, as well as tinnitus patients with the condition, contributed to this guideline. This guideline was designed to set worldwide standards for the provision of tinnitus treatment.

Tinnitus and Hearing loss

A hearing assessment is an essential component of a tinnitus evaluation. A hearing loss that develops gradually is often unrecognised. It is not uncommon for a diagnosis of a hearing loss to come as a surprise when tinnitus is being investigated.

Straining to hear a conversation results in communication difficulties. This causes frustration, fatigue and stress. A hearing loss creates a “cognitive load or burden”. These are known tinnitus-aggravating factors, adding to tinnitus-related stress.

People with a hearing loss may blame their tinnitus for their hearing difficulties – particularly when communicating in groups or in background noise. They may feel they would hear better if they didn’t have tinnitus. This is not the case – tinnitus is a symptom of a hearing loss, not the cause.

Hearing aid fitting offers significant benefit to people with tinnitus + hearing loss. Amplification of external sounds supports the hearing loss and reduces tinnitus awareness. Contemporary hearing aids can be programmed to produce low volume broadband sound to provide sound enrichment when the hearing aids are worn in silence. Additionally, many contemporary hearing aids direct connect via Bluetooth to mobile phone/iPad apps.

Once you have adapted to the amplification provided by your hearing aids, you can expect a significant reduction in stress and fatigue.

FAQs

What is tinnitus?

Tinnitus is the term used to describe any sounds heard in the ears or the head which are not present externally.

There are two main types of tinnitus:

Subjective tinnitus
Objective tinnitus

Subjective tinnitus is most common and can only be heard by you. Objective tinnitus is rare and, although faint, can be heard by others.

What is the main cause of tinnitus?

A hearing loss or a change in hearing is the most common cause of subjective tinnitus. However, tinnitus can develop without a measurable hearing loss. Tinnitus can be caused or aggravated by head, neck and jaw movements – this is known as somatosensory tinnitus. Certain medications, neurological conditions and head injuries can also cause tinnitus.

Pulsatile tinnitus, where the heartbeat is heard, may indicate a vascular condition and needs to be medically evaluated. Objective tinnitus usually arises as a result of muscle contractions. TTS-associated clicking tinnitus is a form of objective tinnitus and can be heard by others.

What is the most effective treatment for tinnitus?

Neuroscience research has identified most cases of tinnitus as a neurological phenomenon, arising in the first step in the central auditory pathway – the series of locations in the brain where sounds are processed.

There is, as yet, no specific treatment to stop this process. Evaluating and treating any identifiable cause for the tinnitus can help. For persistent tinnitus, treating any associated anxiety and distress, and aiming for a satisfactory level of tinnitus habituation to be achieved are the most effective treatments.

Does tinnitus go away?

Tinnitus can be a temporary result of exposure to loud noise/music and fade away overnight or after a few days.

If there is a treatable cause for the hearing loss leading to tinnitus, then treating the cause can treat the tinnitus. If the tinnitus is associated with a persistent hearing loss or has been present for more than 6 months, it is likely to remain.

For most people, the tinnitus spontaneously moves into the background of their awareness over time.

What happens if tinnitus goes untreated?

If tinnitus persists, an audiological assessment to evaluate hearing levels, ear health, possible causes and to support tinnitus related anxiety and distress is a good first step.

Tinnitus therapy aims for tinnitus habituation to be achieved, where the tinnitus is in the background most of the time and causes little annoyance when noticed.

What does tinnitus sound like?

Tinnitus is most commonly heard as ringing, hissing, buzzing or clicking, and can be a single sound or a number of different sounds.

Tinnitus can be intermittent or persistent, and often fluctuates in volume.

Can ear wax cause tinnitus?

Wax blocking the ear canal or sitting against the ear drum can affect the hearing and cause tinnitus.

Can a hearing aid stop tinnitus?

Hearing aids, by amplifying external sounds around you, will result in your internal noise, or tinnitus, becoming less noticeable.

Hearing aids can be programmed to produce a sound in quiet environments so the tinnitus is less noticeable at those times. This may be in the form of white noise or streaming via an app.

The effort of straining to hear a conversation when a hearing loss is present and the resultant communication difficulties frequently lead to frustration, fatigue and stress. These are all major aggravating factors in tinnitus awareness and annoyance.

Can ear drops help tinnitus?

Ear drops do not directly treat tinnitus.

Ear drops might be used to treat an outer ear infection or to soften ear wax, both of which can be causes of tinnitus.

Why is my tinnitus louder at night?

Tinnitus is often more noticeable in a quiet environment, particularly if there also are no sources of distraction. For this reason, many people with tinnitus are likely to be more aware of their tinnitus in a quiet bedroom at night.

The tinnitus will not be as obvious when surrounded by a constant low level neutral sound, whether you are trying to fall asleep or if you wake during the night.

We carry stress in our jaw, which can manifest as jaw clenching or tooth grinding during sleep. This can be an aggravating factor for tinnitus.

Is it bad to sit in silence with tinnitus?

Research has shown that almost everyone develops temporary tinnitus when placed in an abnormally silent environment (such as a sound proof booth) and instructed to pay attention to any sound they may hear. So we all have a very low level internal hum.

According to the neurophysiological model of tinnitus, when people with tinnitus remain in a silent environment for some time, the gain (or volume) in the central auditory pathway increases, resulting in enhancement of the tinnitus sound.

You are therefore more likely to notice or listen to your tinnitus in a quiet room. This increased awareness may lead to an increase in active monitoring of the tinnitus. This, in turn, may lead to an escalating cycle of increased irritation and distress, which will, in turn, increase the awareness and the intrusiveness of your tinnitus.

Our senses react not to the absolute value of a stimulus, but to the difference between the stimulus (ie tinnitus) and the background. The tinnitus will not stand out as sharply and will be less obvious when surrounded by another sound.

Sound enrichment involves adding sound to your environment. The aim is to surround the tinnitus sound with a low volume, neutral sound which is easily ignored.

What is the best doctor to see for tinnitus?

Start with your GP, who will oversee your tinnitus care and can provide a Medicare-rebateable referral for a hearing assessment. Patients with significant tinnitus should be referred to an audiologist for a full diagnostic hearing assessment, which includes pure tone audiometry and Tympanometry testing to assess middle ear function.

In the majority of cases, tinnitus does not require further investigation.

Referral by your GP to an ENT specialist for investigation will be recommended if a person has unilateral tinnitus (heard in one ear only), particularly with an asymmetric hearing loss in that ear.

Other reasons for further investigation or onward referral include pulsatile tinnitus, tinnitus associated with significant vertigo, tinnitus in association with significant neurological symptoms and/or signs, or tinnitus causing significant psychological distress.

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