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Scientifically formulated and clinically tested nutritional supplements

Gary Jacobson, Ph.D.
May 22, 2002

The title of my talk is "What is Tinnitus, Why Do I Have It, and What Does it Mean?" And that's sort of a loose guide to what I'm going to be talking about tonight. First of all, how many of you have tinnitus? [Most of the audience raises their hands.] I could feel the air—it almost knocked me over. So everybody in the room has it. And so I don't need to tell you that tinnitus is the perception of sound when none exists in the environment. There is another kind of tinnitus called objective tinnitus, which is when other people can hear the sound sensation that you have. Then there's another entity called hyperacusis. How many of you have sound sensitivity—sounds that for other people would be fine but for you are painful? Okay, that's hyperacusis, an abnormally strong reaction to sounds of moderate to normal loudness. It's estimated that somewhere between 3 and 40 percent of tinnitus patients have hyperacusis and 10 percent of tinnitus patients are more bothered by their hyperacusis than by their tinnitus.

Tinnitus is not a disease. It's a symptom of an ear problem, like dizziness or hearing loss. So it's not a disease, it doesn't change anything, but it is a symptom that something is wrong in the auditory system. Now how does the ear work? I'm now going to give you the Freshmen-level anatomy-of-the-ear lecture. There are four divisions of the ear: the outer ear, the middle ear, the inner ear, and then there are the brain pathways of hearing.

The outer ear ends at the eardrum, and this membrane vibrates back and forth when sound waves bounce up against it. There are three bones back of the eardrum—one of which connects to the eardrum—and they're set into motion by vibrations of the eardrum. These vibrations are then funneled into the snail shell here, which is called the cochlea. Inside the cochlea, there's this little tiny device that does a lot of the work, in fact, most of the work that helps us hear, and that's called the Organ of Corti. You don't have to remember it, there's not going to be a quiz later on. The Organ of Corti changes sound into electricity. That's what it's doing right now. This [pointing to Organ of Corti in diagram of ear] is taking my voice. I'm vibrating the eardrum, and the vibrations are being converted into an electrical signal, which goes down this cable into an amplifier, which is transmitted to the speakers. The inner ear takes sound waves and converts them into an electrical code that then travels through the nerve of hearing, through the brain pathways, up to the hearing part of the brain, which is located in the temporal lobes.

These signals are transmitted through a cable, which is the hearing nerve, processed through the auditory pathway, and converted into meaning once it gets to the cortex. Damage to the inner ear results in a loss of sensitivity to sound for part of or all of the hearing range. We call that a hearing loss. If your ear is less sensitive than it should be to sound, that's another way of saying that you have hearing loss. Hearing loss affects your ability to hear speech sounds. It may also affect your ability to appreciate music. For communication purposes, for example, if you are unable to hear high tones or treble sounds, then you don't hear f's and s's and t's and th sounds as well as you should, and speech is unclear. It's not that it's not loud enough; it's just that it's not clear because the damaged inner ear is distorting the spectrum of sound that's getting to your brain.

The same damage that causes hearing loss also causes the inner ear and/or brain pathways or centers to create electrical signals where no sound exists in the environment, and that is tinnitus. So the damage that results in one symptom, hearing loss, also causes the inner ear or brain pathways to generate more electricity than it normally would when there's no sound, and that electrical pattern, once it gets to the cortex, you then hear sound. That is tinnitus.

Now, how big is the tinnitus problem? It's estimated, depending upon whom you read, give or take a couple of million, that 30 to 40 million Americans have tinnitus. Eight to 10 million have sought medical help because of tinnitus, two to four million are handicapped or disabled by their tinnitus, and even people with normal audiometric tests, normal hearing tests, can experience it. I'll raise my hand and I'll be one of the 12 to 14 percent of normal hearing people in this room who have a symptom of an ear problem.

Now, age distribution: it's not surprising that we start seeing people with tinnitus once they reach 40, 50, 60 years of age. As soon as you start wearing bifocals, everything starts falling apart. So the distribution, the percentage of patients presenting to a clinic, men and women, tends to be above 40. Of patients we see in our clinic, most have had their tinnitus for longer than one year. Again, these are percentages of patients in this figure who have tinnitus who present to a clinic. About 29 percent feel that their tinnitus was caused by trauma, either noise trauma or head injury. Fourteen to 15 percent have medical conditions, diseases, or treatments for diseases, and about 43 percent have no idea—it just came on, and we'll probably never know exactly why. For about 51 percent of the group, tinnitus came on gradually. For about 39 percent, tinnitus came on suddenly—sudden is less than a week.

About 40 percent of patients will say they hear it in the left ear primarily. About 32 percent hear it in the right ear, 17 percent in both ears, and about eight percent in the head, not the ears.

How about irritability and nervousness caused by tinnitus? Does that sound familiar? Forty-three percent says sometimes, 48 percent say often, and only 18 percent are not irritated or nervous about their tinnitus. How about sleep interference? Probably the number one disability caused by tinnitus, 45 percent say yes, sometimes, 25 percent say yes, often. So we've got about 70 percent of patients with this problem.

Now, how in the world do you measure a phantom, something that you can't see? The way we do it is we put a sound in the ear, usually opposite the ear with tinnitus. So if the tinnitus is in my right ear, we put a tone in my left ear, and we say, "Tell me how loud to make that tone until it matches the loudness of your tinnitus." So you say, "Make it louder or softer until it's about the same." When we do that we find some surprising things. We find that 40 percent of patients who come to a center with a complaint of tinnitus say that their tinnitus is 0 to 3 decibels (dB) loud. Another 29 percent say it's 4 to 6 dB loud. Another 15 percentsay 7 to 9 dB loud. And actually when you add it all up, about 95 percent of patients with tinnitus will say the loudness of their tinnitus is no louder than about 15 dB. A whisper is about 35 dB, to give you a frame of reference. Yet if you take the same group of people and you say, "I want you to give me a number between 0 and 10 about how loud your tinnitus is to you," you find that about 55 percent of patients, a little over half, will choose a number above 6. So even though 95 percent of patients with tinnitus will match the loudness of their tinnitus to a tone that is no louder than 15 decibels, on a scale of 0 to 10, they will choose a number above 6 for how loud it is.

Most tinnitus is high in pitch, not surprising since most people have a loss of treble (high pitch) hearing. And it doesn't take very much noise to cover up the tinnitus, which is a good thing. It takes generally less than 20 dB of noise in order to cover it up, and remember again about 35 dB is a whisper. So how does this low level, low loudness, continuous-but-internal sound create a disabling and handicapping condition? This is what we think happens. First, there's an injury somewhere, usually to the inner ear. The electrical responses from the inner ear or brain centers of hearing increase. That's an increase in electricity that's produced. The hearing part of the brain interprets that electrical pattern as hissing, ringing, buzzing, electrical sound, wind, crickets, whatever you call it. You become aware of the signal, that tinnitus, and identify it as being inside instead of outside and then you begin to listen to it, and the more you listen to it, what happens? It's louder and then you worry about it and you start listening more to it, and it gets louder and louder, and then you start thinking things like "Gee, I wonder if it's going to get louder? Is it out of my control?" This constant awareness of tinnitus makes it possible for you to develop the ability to detect your tinnitus even when there's noise.

If you have a baby, you can sleep through trucks going by and jets going overhead, but if you have a baby monitor on and you hear your baby cry, you wake up because that sound has significance. So somewhere the brain is able to detect this internally generated signal even when there's background noise. Your stress levels increase. Your ability to cope with tinnitus decreases. And then it becomes the thing that you listen to most—you tune in to the All Tinnitus Network. It becomes difficult or impossible to ignore it. So now you're listening to it, it's getting louder. You start worrying about it, you listen to it more, it becomes louder yet. And then you become anxious, and then, in the extreme, you may become depressed, and depression is probably the most common psychological condition for patients who have tinnitus.

So what treatments are guaranteed to make tinnitus disappear? Robert Dobie is an M.D., a medical doctor, an otologist, or ear specialist, and a neuro-otologist, and he's the head of the National Institutes of Health Division of Hearing and Balance. Dr. Dobie attempted to do what's called a meta-analysis. He looked for common threads running through the literature for treatments for tinnitus to see if there were any treatments that showed, in a consistent manner, positive outcomes. So he reviewed Medline articles from 1966 to 1988. He found during this 32-year period only 69 randomized clinical trials having to do with tinnitus. These are some of the drug treatments that he reviewed. This is a list of all the medications that had been tried offering no benefit over, essentially, a sugar pill. And these are the non-medical treatments—we're even throwing in now psychotherapy, electrical and magnetic stimulation, acupuncture, masking, biofeedback, hypnosis, ultrasound, miscellaneous drugs. And the summary of the paper was: no treatment can yet be considered well-established in terms of impact and absence of placebo effects. So what does that mean...does that mean that there is no hope? No, it doesn't mean that there's no hope, it means that we need more research. We need more well-conducted scientific research to understand this problem better.

What are some non-medical methods that show promise for helping me cope with tinnitus? Now I think Dr. Seidman is talking about medical and complimentary medicine treatments. I'm going to mention some non-medical ones.

The first is understanding the beast that's got you. The more you understand about tinnitus, the easier it is to understand the problem. And just like any problem that you have, before you go see a doctor, you worry about it. You wonder if it's some dreadful thing. And then the physician sits down and explains to you. You know that it isn't the brain tumor that you thought it was. Instead, you have something very simple, and you feel so much better when you leave, it almost feels like you did receive some type of cure for the problem. So the purpose is to demystify tinnitus, to give it dimension, and to help you put your tinnitus experience into context. Through counseling and education, your emotional response to tinnitus decreases, the degree that you worry about it decreases. Knowledge is power, the more that you understand, the less you feel that it has a hold of you.

This results in a decrease of importance of that tinnitus sound—and the brain has this wonderful ability to not listen to sounds that are not important. Think about where you work, where you live, and the continuous sounds that are in your environment—you don't listen to them, because if you paid attention to every sensory stimulus in your environment, you couldn't survive. The brain recognizes immediately when you walk into a room the sounds that are meaningless and sounds that are meaningful. Meaningless sounds are still processed by the inner ear; they're still made into electricity. They still are sent through the nerve, up the cable, through the brain pathways. But the brain does not permit you to perceive those sounds. They're still there and you could listen to the ventilation system up in the ceiling, if you chose, but you choose not to, so you don't hear it. And that's the fan in your home, that's the air conditioning coming on and off. The goal is to get to the point where the brain does the same thing with internally generated sound as opposed to the externally generated sound. Sound is sound; the brain doesn't know the difference. Sound is sound, whether it's internal or external. We give it the significance that makes the brain perceive it. We worry about it, we feel threatened by it, and that gives that sound, that tinnitus, the significance that makes it impossible for the brain not to make you hear it.

What we're talking about is a concept called habituation. Habituation is a lesser and lesser reaction by the brain to some sensory stimulus, whether it's visual, auditory, or tactile, that's repeated over and over again. We want people to habituate not only their reaction to tinnitus, but also their perception of tinnitus. There are a couple of different sound therapies. There's masking, which is using an external sound to cover up an internal sound. That's a term you've probably read about. And there's something called tinnitus retraining therapy. Using noise a little differently, instead of covering up tinnitus, you turn it up to a point where it interferes with your perception of it. The devices look like hearing aids, either in the ear or over the ear, they have volume controls on them and this is sort of a schematic idea of what we try to accomplish when we use noise. If this spike here is the loudness of your tinnitus and if we poured this much noise on top of it, you wouldn't hear your tinnitus any more. But remember what I said before: if your brain is very good at detecting tinnitus, sometimes you have to turn this noise up quite a bit to get that relief where you don't hear your tinnitus at all, and by that time, the noise is so loud, you say, "Well, my gosh, this is worse than my tinnitus." How many people have tried masking and found that? [A dozen or so hands raise.] Yes, that's a pretty common experience.

The idea is to use noise in a slightly different way. You turn up the generators to the point where you're just barely able to hear your tinnitus, so you can still hear your tinnitus if you listen for it. The fact that it's still audible means that the brain is still processing the tinnitus, and since you don't hear your tinnitus as well, you learn to ignore it. So only part of the tinnitus is audible to you—you only hear that point that's just above the noise. As you wear these noise generators over a period of time, weeks, months for some people, you get to a point where you get a string of days, maybe a week or two weeks, where you realize at the end of the day when you take them out that you weren't aware of the tinnitus during the day. At which point you turn down the volume control, and then slightly more of your tinnitus is audible to you, and you get used to that level for weeks or months. As you reach the same point where you're not aware of your tinnitus for a period of time, you gradually work down the loudness of the noise. The objective of tinnitus retraining therapy is to eventually not use the generators—as opposed to maskers, which are use for a long time, sometimes as long and as often as you want to cover it up.

We advocate people use the generators a minimum of 8 hours a day; otherwise the brain can't learn to ignore the sound—it can't ignore a sound that it cannot hear. We also don't like people to be in a completely quiet environment because, again, what happens when it's quiet? You hear your tinnitus louder. The worst time is at night, when everything is quiet and there are no sounds or distractions in the environment. And so patients are advised to create continuous sound wherever you are to interfere with your ability to hear the tinnitus. Now for patients who have hearing loss and tinnitus, you've got this additional problem of not being able to hear speech well. In those situations, patients are fit with combination noise generator devices and hearing aids. And there are now companies that make digital hearing aids with noise generators built into them. Which is kind of a paradox. We'd been hoping for years and years for the manufacturers to make absolutely clean, clear sounding hearing aids and now we're pouring noise on top of them for patients who have tinnitus as a problem, as an additional problem.

And that is where I stop.
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