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What causes tinnitus?
We don't yet know what technically causes tinnitus. We do know, however, what is associated with the onset of tinnitus. Most commonly, tinnitus is associated with exposure to loud noise-either long-term loud noise or sudden loud noise such as a gunshot or explosion. Hearing loss does not "cause" tinnitus, but a positive correlation exists between the degree of hearing loss and the prevalence of tinnitus-that is, the likelihood of incurring tinnitus increases with increasing hearing loss. The onset of tinnitus can also be the result of head and neck trauma or pathology, drugs or medications, and other medical conditions (e.g., acoustic neuroma, cardiovascular and cerebrovascular disease, hyper- and hypothyroidism, a period of intense stress).
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What is a sound tolerance condition?
Sound tolerance conditions are varied and nuanced. Without distinguishing between the different types, people often refer to any sound tolerance condition as "hyperacusis," although many different terminologies have been used. Hyperacusis is indeed the most common type; others include "misophonia" [pronounced mee-so-fonia] and "noise sensitivity." "Phonophobia" is a related condition.
To briefly summarize: Hyperacusis is physical discomfort or pain when any sound reaches a certain loudness. Misophonia refers to emotional reactions only to certain sounds (often sounds made by the mouth or nose), regardless of their loudness. Noise sensitivity refers to feeling annoyed or overwhelmed due to a perceived noisy environment. Phonophobia is fear that sound will be uncomfortable for any reason. (Note: Not everyone agrees with these categories of sound tolerance problems.)
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What is cognitive behavioral therapy (CBT) for tinnitus?
Treatment with CBT can be thought of as a buffet of different self-help techniques. As its name indicates, there are cognitive and behavioral components to the therapy. The purpose of the cognitive component is to identify negative thoughts and beliefs and replace them with thoughts and beliefs that are more helpful in managing reactions to tinnitus. The intent of the behavioral component is to learn specific coping skills for self-managing the effects of tinnitus. Therapy is divided up into different areas of focus, including changing thoughts about tinnitus (cognitive restructuring), distraction activities, relaxation techniques, and education about the auditory system, improving sleep, and general health. There is no agreement as to which of these areas of focus might provide the most benefit for tinnitus management.
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What are your overall tinnitus recommendations?
My overall recommendations are (a) become informed with accurate and realistic information about tinnitus; (b) do everything possible to protect your ears from harmful sounds; (c) have your hearing evaluated-ideally by an audiologist who specializes in tinnitus management; (d) receive a medical examination by an otolaryngologist to rule out any serious underlying medical condition that might be responsible for the tinnitus; (e) consider treatment from a psychologist or other behavioral health provider who specializes in anxiety, depression, and/or insomnia that might be associated with tinnitus; (f) don't invest in expensive products or therapies unless you are certain that free or low-cost solutions will not work for you, and there is solid science to support making such an investment; and (g) remain open-minded but skeptical regarding any claims for products or treatments, especially those that require a significant investment on your part.
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Are there standards for tinnitus clinical management?
There are no official standards for how to evaluate or treat tinnitus. Different organizations have published recommendations, which are of course helpful.1,2 Recommendations in these guidelines are inconsistently adhered to by clinicians who provide tinnitus services. They often aren't even aware that the guidelines exist. Ask your clinician, "Do you follow any published tinnitus practice guidelines? If not, why not?"
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Are clinicians certified or credentialed to provide tinnitus services?
Any clinician can, in fact, claim to be a tinnitus expert. Other than receiving certain knowledge-based training that is available, clinicians are not credentialed in tinnitus management as for many healthcare specialties. We rely on credentialing to verify that a clinician has received the proper education and training and demonstrated competency. This is not possible in the domain of tinnitus practitioners. It is therefore hit-or-miss when looking for professional help.
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How is "tinnitus" pronounced?
Tinnitus is pronounced two different ways. It can be pronounced tinn-EYE-tiss or TINN-uh-tiss. Either is acceptable. Most people in the general public say tinn-EYE-tiss, while most researchers and healthcare professionals say TINN-uh-tiss. Take your pick!
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Are there different kinds of tinnitus?
People complaining of tinnitus usually have primary tinnitus, which is phantom sound in the head or ears that is generated within, and perceived within, the brain. It is a stream of abnormal brain activity that gives rise to the phantom sound. The exact cause of primary tinnitus is not currently known (research is ongoing), but its onset can often be associated with certain factors (referred to as "exposures"). Primary tinnitus is most often associated with exposure to loud noise, but it can be caused by chemicals that are toxic to the auditory system or by one of many medical conditions. It can even be triggered by stress.
Secondary tinnitus, which is relatively rare, is an actual sound that is produced somewhere in the head or neck because of some mechanical irregularity that generates the sound. The sound is detected by the inner ear and processed by the brain as for any external sound. The most common type of secondary tinnitus is pulsatile, which is typically perceived as a "whooshing" sound that pulses with the heartbeat. Although pulsatile tinnitus is usually diagnosed as harmless, serious conditions may underly it. Non-pulsatile secondary tinnitus can include middle-ear (behind the eardrum) muscle spasms and eustachian tube dysfunction. Middle-ear muscle spasms can cause buzzing, clicking, or crackling sounds, or the sound of a beating drum. Eustachian tube dysfunction typically produces clicking or popping sounds, along with a feeling of fullness/pressure in the ears and muffled hearing. If any of these symptoms of secondary tinnitus are experienced, it is essential to visit a physician who specializes in the ear (usually an otolaryngologist, also known as an ear, nose, and throat - ENT - doctor).
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Is any ear or head noise considered "tinnitus"?
(Note that we are just referring to primary tinnitus to answer this question-see "Are there different kinds of tinnitus?")
One definition of tinnitus that has been in the scientific literature for many years is "sound in the ears or head that lasts at least 5 minutes and occurs at least two times a week." But wait, what if the sound lasts less than five minutes? Or what if the sound lasts at least five minutes but occurs less than twice a week? What about short-term tinnitus following exposure to loud noise?
There are five possible categories with respect to the experience of phantom sounds in the ears or head.
Brief Ear Noise. It is a rare person who has not experienced brief ear noise. This refers to a tonal sound (like a piccolo or flute) that is heard suddenly in one ear and then dies down (or decays) after a minute or so. Along with the sudden tone is a sense of hearing loss and "fullness" in the same ear. All of these symptoms decay together as the tonal sound decays. Brief ear noise is a completely normal occurrence and no cause for concern. It is often called transient ear noise. It has also been called spontaneous tinnitus.
Temporary Ear Noise. Ears are normally sensitive to an extremely wide range of intensity levels, from the soft sound of someone breathing to the noise of a jet engine. It is such a wide range, in fact, that a special scale had to be developed, called the decibel (or dB) scale. Above a certain point on the dB scale, sound is intense enough to cause damage to the ears. The point here is that intense sound can result in ear or head noise that lasts a short while-usually up to a week or so. This temporary ear noise is a red flag that damage has been done, and continued exposure to intense sound can lead to permanent hearing loss and tinnitus.
Occasional Ear Noise. We are now in the gray area of when ear or head noise qualifies to be categorized as tinnitus. It might seem like we're asking the nonsensical question, "When does tinnitus become tinnitus?" We are obviously dealing with a terminology problem. It is unfortunate that the word tinnitus has been used to refer to any phantom sound that comes from inside the head or ears. So we are being careful here to distinguish ear or head noise from tinnitus.
The definition of occasional ear noise is "ear or head sound that lasts at least five minutes and occurs less than weekly." The sound must last at least five minutes to distinguish it from "brief ear noise," which almost always lasts less than five minutes. The sound also must occur less than weekly to distinguish occasional ear noise from intermittent tinnitus, as described next.
Intermittent Tinnitus. When ear or head noise lasts at least five minutes and occurs at least weekly, then the noise is called intermittent tinnitus. The regular (at least weekly) occurrence of the noise is what distinguishes intermittent tinnitus from occasional ear noise. It may seem like an arbitrary distinction, but it serves as a useful benchmark to distinguish tinnitus from other phantom ear and head noises.
We might say that brief ear noise, temporary ear noise, and occasional ear noise do not rise to the level of being considered health conditions. Individuals who experience these phantom sounds should be aware of what they are and whether they might be precursors of tinnitus. Protecting the ears from loud sound is always a critical concern, and especially if a person experiences temporary or occasional ear noise. Intermittent tinnitus meets the criteria to be considered a health condition.
Constant Tinnitus. Constant tinnitus is ear or head noise that is always there. It never stops. People like me know without a doubt that their tinnitus is constant. If a person is unsure whether the tinnitus is constant or intermittent, this question can help: Can you always hear your tinnitus when you are in a quiet room? If the answer is "yes," then the tinnitus is constant. If the answer is "no" or "not sure," then any of the other categories are possible.
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What is "fluctuating tinnitus"?
Fluctuating tinnitus is usually noticed as the loudness of tinnitus increasing and decreasing but can also include changes in pitch or changes in quality (which refers to the complexity, or the spectrum, of the sound-also referred to as timbre, pronounced TAM-ber). Tinnitus fluctuations might be pronounced, or they can be subtle. They may occur often or only occasionally.
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Does tinnitus "phase shift"?
Every real sound (not tinnitus) is composed of sound waves. The waves can be in phase or out of phase, and they can gradually shift from one to the other. This is an audio effect that was used in popular music starting in the 1960s, so it's something that most people have at least heard. It sounds like an ethereal "sweeping" as the phase shifts between "in" and "out."
Tinnitus can fluctuate in such a manner as to sound like phase shifting. This perception might be common for people who hear their tinnitus distinctly in each ear. The tinnitus may sound essentially the same in each ear, but it also may sound like phase shifting is occurring continuously between ears. It needs to be emphasized that tinnitus is not composed of sound waves, so there is no actual phase shifting going on with the tinnitus neural signal. It just may sound like phase shifting.
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Does tinnitus sound different for different people?
Tinnitus is typically referred to as "ringing in the ears." Some people have concluded that, since their head noise does not sound like "ringing," they must not have tinnitus. In reality, tinnitus can sound like just about anything. Besides "ringing," it is most often described as "hissing" or "clear tone." Other common descriptions are "buzzing," "hum," "high tension wire," "ocean roar," "whistle," and "crickets" or "insects." These are actual descriptions from over 1,000 patients who visited the OHSU Tinnitus Clinic (www.tinnitusarchive.org). Many patients chose "other" because none of the sounds listed described the sound of their tinnitus. For example, one patient's tinnitus was described as sounding like "dragging chains."
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Are "musical hallucinations" a type of tinnitus?
Musical hallucinations are a complex form of tinnitus. They are not to be confused with "earworms." An earworm is a song that is stuck in your head. It is a form of auditory imagery and often results from hearing a certain song and then imagining that song over and over again. Sometimes just mentioning a certain song will trigger an earworm. With distraction, intentional or unintentional, the imagined song usually disappears. That is what distinguishes earworms from musical hallucinations-earworms can be controlled, while musical hallucinations cannot. A musical hallucination is just like tinnitus-it is a phantom auditory perception that persists and cannot be turned off at will.
Musical hallucinations may not be recognizable as familiar songs, whereas earworms are repetitive songs that are familiar from previous listening (unless the person is imagining original music, which is what songwriters do when they compose). Musical hallucinations are less likely to contain words (lyrics) than are earworms. Also, people who are musically skilled are less likely to report musical hallucinations than people who are not.
All forms of auditory hallucinations, which are usually perceived as voices or music (and sometimes as environmental sounds-for example, a barking dog), have been studied primarily in the context of mental health. The presence of auditory hallucinations, however, does not mean a person has a mental illness. Because of this potential stigma, auditory hallucinations tend not to be discussed or reported by people who experience them.
Musical hallucinations without mental illness are more common in women (70–80% of cases) than men and tend to increase with age, hearing loss, and social isolation. Sometimes they can be caused by medications, primarily antihypertensives (drugs that control blood pressure). The take-home message is that musical hallucinations are more common than most people realize, and they are not an indication of a mental disorder.
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What can make tinnitus seem louder?
Some people have what is often referred to as reactive tinnitus. That means that certain sounds in the environment tend to make the tinnitus seem louder. The tinnitus "reacts" to those sounds by increasing in its perceived intensity.
We are not talking here about tinnitus reacting to sounds that are so loud they can cause damage to the ears. Once sound in the environment reaches a certain level of loudness, it can damage or destroy the sensitive hair cells in the inner ear. It would be expected that anyone's tinnitus would get louder when exposed to such high levels of sound. That is not reactive tinnitus. Rather, reactive tinnitus refers to tinnitus becoming louder when a person is exposed to sound that is not so loud as to cause damage. The types of sounds that cause tinnitus to "react" are different for everyone who has this condition.
Other things can make tinnitus seem louder, such as stress, anxiety, insomnia, some medications or drugs, drug interactions, and things we eat and drink. Tinnitus becoming louder as a result of any of these things would not be considered reactive tinnitus.
People with tinnitus often report that certain events, experiences, feelings, or things they eat or drink cause their tinnitus to become louder. These kinds of things are specific to individuals and would not apply to all people who have tinnitus. For instance, people often claim that beer, wine, coffee, chocolate, salty foods, tobacco, etc. makes their tinnitus louder. For most people this would not be the case, but it does occur for some people. It's the same thing with emotional distress, insomnia, and drugs. It is often claimed that these make a person's tinnitus louder, but these are exceptions rather than the rule.
In general, it is important for people with tinnitus to determine if anything causes their tinnitus to become louder. If so, then such things should be avoided. Also, tinnitus can fluctuate on its own. It might therefore seem that something causes tinnitus to become louder when really it was just a natural fluctuation.
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Can tinnitus be more than one sound?
At the OHSU Tinnitus Clinic, about half of the patients reported that their tinnitus consisted of just one sound (www.tinnitusarchive.org). The other half reported two, three, or even more sounds. Some said they heard multiple sounds, but they were unsure how many.
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Is tinnitus a disease?
People often ask this question. There are different answers, depending on the definition of "disease." Tinnitus is a symptom of a causal or underlying mechanism of action somewhere within the auditory nervous system. Tinnitus is a health condition, but it is not a disease in the contemporary sense.
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What is somatosensory tinnitus?
Somatosensory tinnitus is also referred to as somatic tinnitus or somatically modulated tinnitus. A surprising number of people can change (modulate) the sound of their tinnitus. The modulation is caused by some kind of physical contact or movement involving the head, neck, jaw, eyes, or even the arms and hands. The phenomenon is caused by complex interactions between the auditory system and other neural systems.
Somatosensory tinnitus is not a form of secondary tinnitus. It is a subtype of primary tinnitus that can be modified by different physical (somatic) maneuvers. When this occurs, the sound of the tinnitus can become louder, softer, higher in pitch, lower in pitch, or even different with respect to its quality (timbre). It is fairly common and does not normally pose any medical concerns, unless an associated skeletal or muscular disorder requires treatment. Some physicians and audiologists specialize in evaluating somatosensory tinnitus. Clinical approaches to evaluating and treating somatosensory tinnitus are varied because of the lack of evidence-based guidelines.
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Is my tinnitus permanent?
Tinnitus may be temporary or long-term. The longer a person has had it, the more likely it is to persist. That is not to say that long-term tinnitus cannot become reduced in intensity or disappear altogether. It is impossible to predict how a person's tinnitus might change over time.
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When does tinnitus become "chronic"?
In their "Clinical Practice Guideline: Tinnitus," the American Academy of Otolaryngology-Head & Neck Surgery Foundation (AAO-HNSF) made a distinction between short-term and long-term tinnitus. They noted that people whose tinnitus was still bothersome after six months were more likely to require therapy for their tinnitus than people whose tinnitus had been bothersome for less than six months. They further noted that most research studies of different therapies for tinnitus required that their participants had experienced tinnitus for at least six months (to ensure that the tinnitus was relatively stable). For these reasons the AAO-HNSF referred to tinnitus of less than six months' duration as "recent-onset," and tinnitus of at least six months' duration as "persistent."
In the medical literature, a short-term condition is generally considered acute, while a long-term condition is called chronic. It really doesn't matter if we refer to tinnitus of less than six months duration as acute or recent-onset, or if we refer to tinnitus of at least six months duration as chronic or persistent. In the interest of promoting standardization consistent with the AAO-HNSF recommendations, however, the preferred terms are recent-onset and persistent.
