Tinnitus

This page is for those suffering from a particular type of tinnitus. Sometimes called "A Million Crickets" tinnitus: it is bilateral (heard in both ears); pretty much constant (though varying in intensity); has a main frequency at about 10kHz (a very high-pitched whistle or ringing); and is not associated with significant hearing loss. Other types of tinnitus (unilateral, pulsatile, low-frequency, associated with significant hearing-loss, caused by drug therapy - eg NSAIDS) are not covered here.

Why am I writing this?

I am a doctor in the UK (consultant anaesthetist), so have a medical background, ready access to specialist advice, and am able to assess medical information professionally. One day in January 2013 I woke up with loud tinnitus in both ears. I had no prior history of this, and had had no recent exposure to loud noise. I expected this tinnitus to settle - it didn't. This page contains the story of my tinnitus and its management - some wrong turns, and what eventually helped significantly. Some tinnitus information on the internet is inaccurate and even misleading. This page contains the information I would have liked to have had when my tinnitus started. Hopefully it can save some of you some time, and maybe even some money.

Miracles, secrets, books, DVDs and merchandise

You will not find these here. The information on this page is free, and presented without sensational claims and language. You will find plenty of persuasive people willing to take your money for promises of dramatic improvements / cures. All I'll say is that I know how medical science works - if there was a secret/magic cure we medics would soon get to know about it and would use it. Doctors are perfectly happy to embrace effective treatments even when we don't fully understand them (this includes my own specialty, Anaesthesia).

Things which DON'T cause tinnitus

This form of tinnitus is a neurological condition and the cause is unknown. It is therefore reasonable to try treatments appropriate to neurological conditions. I will get to the treatment side later, but what about other potential causes: middle-ear pathology, TMJ (temporomandibular joint) pathology, infection (viral, fungal, prion), dietary deficiency (vitamins, trace elements), external radiation (EMF), allergy, cancer, or cerebrovascular disease?

Medical science is familiar with this form of tinnitus. Some things can be fairly confidently ruled out. Being bilateral it cannot be local middle-ear nor TMJ pathology. It occurs with approximately the same incidence in India, as in the UK, USA etc - ruling out sunlight, dietary deficiencies, etc. Repeated investigations have never revealed any viruses and anti-viral treatments are not successful. Steroids (powerful anti-inflammatory agents) are not effective. Initial triggers seem to vary widely and include: a single very loud noise (eg an explosion), repeated exposure to uncomfortably loud noises (some musicians), or no apparent trigger at all. It is largely (but not exclusively) a disease of middle-aged to older people. The time-course is typically a sudden onset, with characteristic exacerbating conditions, and unpleasantly long lasting "spikes" where a stimulus would cause worsening of the tinnitus for many hours. MRI scanning does not reveal a structural cause. There are no EEG changes.

So what is happening?

The following concept has been in the medical domain for over 20 years, is generally accepted, and corresponds with my understanding of my own tinnitus. The brain is a noisy organ. The neuronal circuits in your brain are able to recognise this internal noise, and suppress it so effectively that you never hear it - even if you sit in a quiet room and try very hard. Part of your internal noise is a high-pitched whistle which you may have heard it a few times through your life if you ever banged your head hard, were slapped across the face, or had large amounts of alcohol to drink.

The noise-damping mechanism can be rendered ineffective in two ways: an increase in brain-noise that exceeds what your damping mechanisms can cope with, or a loss of the effectiveness of the damping mechanism. Either (or both) will result in an awareness of a high-pitched noise that appears to affect both ears simultaneously and sounds like a million crickets chirping. You become aware of the noise of your own brain.

Confusion

Why so much confusion surrounding tinnitus? There are a large number of sensory stimuli that affect the neuronal circuits where the tinnitus is occuring. Most of these make the tinnitus worse and it is the easiest thing in the world to think of these sensory inputs as somehow causing the tinnitus. They include: the taste of salt, hot drinks of any sort, protruding your jaw and therefore moving your TM joints, high-pitched hair-drier type fan noise, a sudden loud cough close to your ear, music with many harmonics eg piano, and car wheels driving on rainy roads. Stress and tension cause multiple changes in the sensitivity of neurons and consistently make tinnitus worse. These are all unpleasant - but should not be thought of as causes. Other sensory stimuli tend to distract your attention or improve the damping mechanism: gentle white noise like a fan or shower, the hubbub of soft converation, or a gentle breeze blowing across your ears. These are comforting and therefore useful in managing the distress of the tinnitus.

My early attempts at treatment

Frustratingly, most of what I tried did not seem to help, and my experiments sometimes made my tinnitus temporarily worse. It was hard to know when it was worth persisting with treatments despite my attempts to follow some sort of logical principles. However, once I starting experiencing persisting success (tinnitus is one of those symptoms that can seem worse / better on a daily or even hourly basis) it really was exhilarating. But always the worry that any improvement would be short-lived.

Some treatments seemed to help initially but after honest self-assessment I concluded that they had no effect. I cut caffeine out of my diet. Caffeine is a neuronal stimulant, and it is perfectly plausible that it might make tinnitus worse, however I was aware that at least one medical study had failed to show any effect. A year caffeine-free did not reduce my tinnitus. I started coffee again, but not in the evenings.

I had several hours low-dose IV lidocaine infusion - a local anaesthetic that had been positively linked with improved tinnitus. The neurological effects were striking, it felt like I'd had about 3 pints of beer. I had high hopes for this - if my tinnitus dramatically reduced I planned to try trans-cutaneous patches. Sadly, the effect on the tinnitus was minimal, transient and disappointing. I was offered a repeat trial but did not think it worthwhile.

I inflicted on myself a high-volume copy of my tinnitus, hoping that it would make my tinnitus initially worse, but that the subsequent "improvement" would continue on down past the starting level hopefully to a new low point. Ouch - very bad move, my tinnitus was much worse for hours after that, and only very slowly subsided to the original levels. My advice ... don't!

I considered, but did not try, notch filters. These electronic devices remove the tinnitus frequencies from your hearing. I liked the concept, but notch filters run directly counter to established habituation therapies - hmmm.

I bought a pair of noise-cancelling headphones. These were very pleasant to wear, and when I used them protected me from noise-induced spikes. The background tinnitus itself persisted. (Obviously the "noise-cancelling" mechanism cannot directly improve the tinnitus which is internal).

After 18 months of tinnitus I was resigned to living with it for the foreseeable future, I am glad I did not give up. I looked again at the principles used in CBT. I did not expect much, I had initially rejected this approach because CBT subjects typically report being happier after a course of treatment, but with the volume of their tinnitus unchanged. Like many sufferers I wanted a "just make it go away" therapy, not a "learn to love your tinnitus". I decided to give it a go - recognising that a significant length of time would be required before I could draw any firm conclusions.

Treatment

It took me a while to come to terms with this, because at first it seemed a bit of a cop-out, but I am now certain that successful treatment needs to be based on habituation. This has a sound neurological basis, neurones are plastic which means that they can adjust their behaviour and thresholds over a period of time leading to long-term alterations in brain function. Habituation effectively restores (or enhances) the original neural damping system, producing a lasting reduction in the perception of tinnitus without side effects.

I am aware of medically supervised programmes of CBT (cognitive based therapy) which use a multimodal approach to managing tinnitus. The meat of these - the bit that makes the difference - is the habituation. Unfortunately tinnitus is common, and access to time-consuming management programs can't be made available to all sufferers. There are several companies willing to sell you devices (with fancy scientific-sounding names) to cure your tinnitus - all of these work in a similar way. However with little outlay, no risk, and following some simple guidelines I think it is possible to successfully treat your own tinnitus using habituation to the tinnitus frequencies.

Habituation

After experimenting with sound sources (a few days of each), I settled - rather arbitrarily - on one called violet (or purple) noise (click for 10 hours of this). This is a hiss like white or pink noise but tipped towards the high frequencies including significant energy around the offending 10kHz. For habituation one suggested regime is to play it into both ears, 8 hours a day for a period of a year. The pink noise volume should be approximately equal to your tinnitus - which for me varied a lot, because my tinnitus often got louder while listening to the habituuation noise. I used open-backed hifi headphones (Grado SR125), because I wanted to be able to hear room noise etc while I was playing the noise. I managed a few hours at a time, but would often miss days (life can't just stop).

The idea is to train your brain that a particular noise - in this case your tinnitus - is non-threatening background noise, and your brain will gradually learn to ignore it. This is a physical process involving resetting the neuronal circuits involved. Once trained your tinnitus will seem to disappear for long periods - though you may be aware of it if you try to hear it in a quiet environment.

To my surprise, I began to see definite, reproducable, and lasting improvement. I tried not to get too excited, telling myself that I would wake up one day and find myself back to square one, but several months on that has not happened. For me the success has been startling, and I am enjoying my music once again. If you try this treatment give it a decent shot - there is no quick fix, training the neural circuits in your brain is a slow process.

Tweaking the treatment

I got some white noise, and equalised the sound myself to ensure that the energy peak was exactly on 10kHz, with a reasonable spread into both higher and lower frequencies. I recorded 1 hour's worth to a FLAC file (a high quality audio file). So I now have a sound-file I can carry around with me and play from my phone or laptop as well as on my PC.

So, it's now mid 2016. Most days, from getting up until I go to bed, I am completely unaware of my tinnitus. If the topic comes up in conversation I become aware of it - a bit like talking about the pressure of the ground on the soles of your feet. It is still there and I become aware of it in the following circumstances: lying in bed in a quiet room; hearing a hairdryer - even if it is in another room; driving on a wet road on a rainy day; — basically all the things that I originally noticed producing spikes. I now don't worry about it because it is there but does not seem to be getting worse. Is that a cure? Well, it feels like one because I no longer worry about it, am rarely aware of it, and I now have the music-enjoying side of my life fully back!




Alan Hope