The Neuroscience of Tinnitus
We now know that tinnitus is not a disease of the auditory system alone. It has already been postulated by Jastreboff more than 20 years ago that the difficulty to ignore tinnitus, the annoyance of tinnitus, the anxiety that tinnitus becomes worse, the irritability and the concentration difficulties are related to functional changes in non-auditory brain systems.
Neuroimaging studies in tinnitus patients have helped to identify the involved networks in detail. Thus altered activity in the central auditory pathways is not sufficient for tinnitus perception. This explains that many patients with hearing loss (and consequent increased activity in the central auditory pathways) do not perceive tinnitus. Only when the auditory activity is connected to activity in the “attentional network” the tinnitus is consciously perceived. If this activity is further accompanied by activation in a “distress network” the patient perceives tinnitus distress. Imaging studies have also demonstrated that the hippocampal area, which plays an important role for memory, is involved in chronic tinnitus.
This finding indicates that there may be a “tinnitus memory”, which perpetuates tinnitus perception. Whether the tinnitus signal is perceived as important and whether the attention focus is kept on the tinnitus, depends on activation of the salience network. A high salience of the tinnitus signal in turn may increase the perceived loudness of tinnitus by causing increased amplification of the signal in auditory pathways. This principally useful mechanism of the brain to amplify important information results in case of tinnitus in a vicious circle that contributes to the perpetuation of tinnitus.
Noteably it is important that the different brain networks involved in tinnitus may differ from patient to patient, depending on the specific clinical characteristics. Thus for example in people that are distressed by their tinnitus, the brain activity that is relevant for tinnitus perception is connected to increased activity in the distress network. Moreover earlier findings that the brain activation patterns changes with increasing tinnitus duration have been confirmed. This indicates the importance to differentiate between different forms of tinnitus.
Many individuals with tinnitus have abnormal oscillatory brain activity. We have found that by using techniques which contribute to the normalization of such pathological activity (e.g. by neurofeedback, relaxation, hypnosis and counselling techniques) we obtain a significant reduction in tinnitus intensity and other factors as measured against the Tinnitus Handicap Questionnaire (THQ) and Tinnitus Functional Index (TFI).
Ten Important Tinnitus Management Strategies
1. Maintain a rich sound environment. This helps to stimulate the auditory pathways and retrain your brain to defocus away from the tinnitus. \if you have significant hearing loss, consider the fitment of hearing aid(as) as appropriate.
2. Use ear protection when sound exposure is likely to cause hearing damage (e.g. loud concerts, occupational noise, movie theatre, prolonged dental work, etc). Ear protection should be selected depending on the situation (e.g. Musician’s ear plugs for concerts and movie theatre; ear muffs for industrial situations; noise cancelling headphones for long haul flights).
3. Avoid very quiet environments or blocking your ears or using ear plugs in normal sound level situations. This is particularly relevant in the early stages of tinnitus. Once you have habituated to your tinnitus and hardly ever notice it and are no longer distressed by your tinnitus, you will be able to enjoy very quiet situations again.
4. Do not be overly concerned about temporary spikes in your tinnitus which can occur from time-to-time as a result of reactive tinnitus to certain triggers such as car cabin noise when on a long trip, certain foods and drinks, medications, stress, dental treatment, neck and jaw problems, neuralgia, etc. For most people, the peak intensity eases over time.
5. Discuss your medications with your GP and/or treating specialist. Some medications or combinations of medications have been reported to trigger or exacerbate tinnitus or can cause damage to your hearing - ototoxic (e.g. Aspirin and certain antibiotics).
6. Remember that tinnitus perception is strongly correlated to your degree of stress and anxiety about tinnitus. Fear of tinnitus will enhance your attention to the tinnitus and contribute to distress and anxiety and this will increase your perception of tinnitus. As a consequence, what is a small tinnitus signal can be perceived as overwhelmingly loud as your auditory neural pathways amplify the internal sound.
7. Utilise any technique that reduces your anxiety levels such as relaxation, meditation, mindfulness, hypnosis, neurofeedback, yoga, tai chi, etc. It is important that you receive reassurance, understanding and support from a suitably qualified tinnitus counsellor.
8. The use of appropriately prescribed medication in the early stages of tinnitus is understandable and acceptable. If medication is of the benzodiazapine family, then possible addition and withdrawal is a consideration. Short-term and infrequent use is best. Slow withdrawal is important to minimise the chances of tinnitus spikes.
9. Remember that invariably tinnitus improves over time and in many people they become completely unaware of their tinnitus for most of the time. For some people, being aware of head or ear-sounds is a normal phenomenon. The most realistic goal is therefore to only be aware of your tinnitus when you listen for it or in very quiet situations.
10. Tinnitus perception and intensity invariably eases over time. However, if you become extremely distressed or affected by your tinnitus it is important to talk to someone about it. If you are in an emergency, or at immediate risk of harm to yourself or others, please contact emergency services and talk to someone now.