Tinnitus

This information is not a substitute for medical advice. You should always see your GP / ENT Consultant.

July 2005 © British Tinnitus Association

What is Tinnitus?

Tinnitus is the term for noises heard ‘in the ear or ears’ or ‘in the head’ when no obvious source of sound is apparent. The noises are usually described as ringing, whistling, hissing, buzzing or humming. Tinnitus is not a disease or an illness, it is a non-specific symptom, that can be brought on by a mental or physical ‘change’, not necessarily related to hearing. In a mild form, tinnitus is extremely common. Almost everyone gets the occasional ringing in the ears, either without any clear trigger or after exposure to loud sounds, be it at work or socially. About 10% of us experience tinnitus frequently and approximately 5% of the adult population in the UK experience persistent or troublesome tinnitus.

Occasionally people have tinnitus that takes the form of recognisable musical sounds or even complete tunes rather than the more common ringing, hissing, buzzing sounds. This is referred to as musical imagery tinnitus or auditory imagery tinnitus. It usually occurs in older people who also have a hearing loss and quite often these people have a strong musical interest. The exact mechanism by which this form of tinnitus occurs is unknown but probably involves the auditory memory parts of the brain. Unfortunately, this form of tinnitus is sometimes initially mistaken for mental illness. However, once it has been recognised as tinnitus rather than a psychiatric condition it can be treated in the same way as other forms of tinnitus. Helping hearing loss with appropriate hearing aids is particularly important with musical imagery tinnitus.

What causes it?

Tinnitus may start suddenly or have a more gradual onset. Due to the non-specificity of the symptom the start may be related to mental or physical changes in relation to retirement, being made redundant, having concerns about your own health, or that of a close relative. It may be related to the discomfort of having your ears syringed or attending noisy night clubs or pop concerts. Tinnitus could also be related to perceived changes in hearing. Most sufferers become aware of the tinnitus in a quiet environment. Fortunately, tinnitus is rarely an indication of a serious disorder and a doctor will be able to check against this possibility. Some medicines can have tinnitus as a temporary side-effect, the most common being aspirin, but usually only when taken in high doses. The low dosage prescribed for heart problems is unlikely to have any effect. If you think a prescribed medication may be causing or aggravating your tinnitus, ask your doctor about it. As it is the brain we hear with, it is not surprising that the brain is central to both the perception of and our reaction to the tinnitus signal. So the brain is also central to the successful management of tinnitus.

What should you do?

If you think you have tinnitus, go and see your GP. You may need to be referred to an Ear Nose and Throat Specialist or an Audio Vestibular Physician, who will take a full medical history and provide a thorough examination. Based on this, medical conditions related to the tinnitus can be confirmed or ruled out, and thereby provide a basis for more specific tinnitus management.

Do not worry about your tinnitus, and do not try to do things to get rid of it, as this only becomes tinnitus related activity, and could actually makes tinnitus worse. Based on the medical investigations as indicated above, and information about how tinnitus is generated, the emotions related to the tinnitus perception can be changed. As the attitude to the tinnitus changes, the brain reverts to its usual activity of filtering out ‘predictable’ signals from the different sensory systems (hearing, smell, touch, vision etc.), thereby filtering out the tinnitus signal from your conscious mind. This is how we learn to live without our tinnitus.

Problems with sleep and concentration?

Tinnitus is the random signal for silence and therefore becomes more noticeable in a quiet environment, like the bedroom. It may interfere with your sleep, either by preventing you from falling asleep, or giving you the impression that it wakes you up, and then prevents you from going back to sleep. Some sufferers also have a feeling that they never get ‘a good night’s sleep’ and therefore feel tired with poor concentration and lack of energy the next day. A simple way of preventing this chain of thought is to look at sleep as a reward for what you have done instead of a preparation for tomorrow. (Like the emotions related to going away, job interviews, exams etc. or tinnitus - which prevent you from relaxing and falling asleep). It may also be helpful to understand that if you go to bed with a problem, your brain will be active instead of relaxed, trying to deal with the problem. It is this process that prevents you from sleeping. When we are aware of tinnitus at bed-time, the brain treats it like a ‘problem’, maintaining an active emotional thought process, and it is this activity that prevents the relaxed brain activity need to fall asleep. Sleeping pills may help for a short time, but they may have side-effects and their usefulness may wear off over time. We also often overestimate the amount of sleep we need – between five and nine hours is normal for adults – and often this decreases with age. From what is explained above, you can see that your general wellbeing will probably influence the way you react to tinnitus – when you feel content and happy, you forget about it. At other times, if you feel burdened by your problems, anxious and stressed, it becomes more difficult to ignore the tinnitus. Therefore it is important, based in factual information, to change your attitude to the tinnitus signal.

It helps to talk

People around you, your family and friends, may either have the wrong information about tinnitus or difficulties in understanding your problem, which in the initial phase may actually make your tinnitus worse. It may therefore help to talk over the troubles your tinnitus is causing you with someone who has personal experience of the condition and has appropriate information concerning tinnitus generation and its management, to the extent that they have ‘learned to live without it’. Contact the BTA for details of a local group, just to have a chat, or share experiences at a meeting. You can also talk in confidence to one of the friendly, experienced staff on our free telephone helpline – 0800 018 0527.

It does get better

Studies have indicated that, even without any ‘treatment’, the noises disappear in 11% of cases, and in another 13% their severity diminishes, as the brain loses interest in and stops surveying the signal. This process is called ‘habituation’ and it can take several months or years. Tinnitus can become emotionally distressing in the initial period. This is commonly due to misconceptions as to the cause, prognosis and management of tinnitus. There is also a general feeling of not being taken seriously by the medical profession. Many are told: ‘It is not serious, there is no cure, and you have to learn to live with it’. It can be argued that this is, to a certain extent true. In most cases there is not a serious underlying medical condition and you will gradually learn to stop paying attention to the tinnitus noises, in the same way that you ignore all the other ‘predictable’ noises of daily life. But, it is important to have a thorough medical examination as explained above, in order to put your mind at rest. Remember that tinnitus is a real random signal, which the brain has previously learned to ignore. It has now remerged for reasons that you, as a sufferer, may or may not know. The ‘cure’ consists of a relearning process that will again take away your awareness of the tinnitus signal, i.e. ‘to learn to live without it’. The important message is not to do anything because of your tinnitus, just to avoid silence and the brain will do the rest. Remember, tinnitus is like any sound, it is not the source of the sound that is important, but your interpretation of it (speech, music, alarms, background noise, etc.). Your reaction to these sounds are more dependent on your frame of mind and reaction, than the actual sound itself.

Medical treatment

If you do have a problem, don’t hesitate to contact the professionals for help. Many ENT and audiology departments now offer treatment for tinnitus, based on the individual patient’s needs. The treatment may include medication for any medical condition, adjustment to current medication, or an explanation of the condition and its relation to tinnitus. It may include counselling, relaxation therapy and stress management and advice on the use of hearing aids, white noise generators (WNG) and environmental sound enrichment. There are two main parts to treatment: the first, and most important, is educational. It is made up of a detailed explanation of the mechanisms of hearing and our current understanding of tinnitus generation, its inherent unimportance and the fact that it is amplified by anxiety and over-attention to it. The second part is sound therapy to reduce the contrast between tinnitus and silence and may involve the use of a wearable noise generator (WNG) – a device similar to a hearing aid. The noise generator should be set to produce a constant, wide-band ‘sshh’ noise at a comfortable level. The device is worn for as many hours as possible, especially during quieter times. Most people find the sound quite soothing. It can also help those with hyperacusis (over-sensitivity to sounds) which sometimes accompanies tinnitus, and can cause distress. There is currently ‘no tablet for tinnitus’.

Environmental sound therapy

Alternatively, or at other times such as during the night, environmental sound could be added, for example an electric fan, a ticking clock, a radio off-station or a special freestanding, natural sound generator. The added sound takes the brain’s focus away from the signal for silence (tinnitus) by reducing the contrast between the background sound and tinnitus. Tinnitus is thus less easy to identify, the brain learns to ignore the other sounds and the tinnitus (habituation) as both are audible. Those who may be hard of hearing should be provided with hearing aids. The same principles apply: the brain has to relearn to hear as the signal that comes through the hearing aid is different to the one without amplification (previous auditory memory). By building up a ‘new’ auditory memory via the use of hearing aids, the brain will initially focus on sounds that are ‘new’, like the renewed awareness of bird song, rustling of paper and toilets flushing etc. As the brain reclassifies these sounds, it decides on their relative importance and the habituation process takes place. It is the same process that takes tinnitus away, as it is not as audible and not standing out as much in contrast to silence as it did. It is important that all hearing aid users start using the aids in relative silence and in situations where they are not ‘listening’. It is no good only using the aids for social events were you feel you need the aids, as the brain has no auditory memory of all the sounds present, and would therefore struggle to decide which one to focus on. The result is poor benefit and ‘useless aids’ that ends up in a drawer instead of the ears. Remember that the brain needs time and practice to relearn the importance of different sounds in different settings. As the new memory is built up, habituation takes place and the person using the aid gradually regains confidence in their ability to hear.

Relaxation

Most people report a worsening of their tinnitus when they are anxious or tired. Learning to relax is probably one of the most useful things you can do to help yourself. Those who practise relaxation say it reduces the loudness of their tinnitus and helps them become indifferent to their tinnitus. If your mind is occupied with absorbing activities, it will in fact block awareness of other sensations such as tinnitus, in other words the tinnitus is not audible. Activity, both mental and physical is therefore helping to block the tinnitus signal from your conscious mind. Some people deliberately keep busy, but remember do not keep active because of tinnitus, as it then becomes tinnitus related activity, and may actually make your tinnitus worse! Do things because you have to or want to, for whatever reason, as long as it is not because of your tinnitus. Also remember that excessive activity may result in stress, which could then worsen your tinnitus, so make time for relaxation and don’t overdo anything.

Are everyday sounds a problem?

People with tinnitus can usually tolerate moderately noisy surroundings, but others (with hyperacusis) may be disturbed by everyday noises. Hyperacusis, like tinnitus, can be counteracted by gradual retraining of your sound tolerance, as indicated above.

Take care of your hearing

Frequent, prolonged exposure to loud noise increases the risk of getting tinnitus, or of making it worse, so take care to avoid very loud sounds, or protect your ears against them. Wear proper ear protectors (not cotton wool) when hammering metal, using power tools and when you are near any noisy motor. Ear plugs can also help cut out the harmful effects or discomfort of very loud music. But, don’t wear them if you feel sensitive to ‘ordinary’ sound as this may be part of hyperacusis, actually making the hyperacusis worse.

What’s being done

A large and increasing volume of research is being undertaken worldwide and there has been substantial progress over the last two decades. Over the last 15 years great improvements have been made in both professional and lay counselling, relaxation training and applications of sound therapy. Specialised treatment for tinnitus is now available at many local hospitals.

More Information

The British Tinnitus Association is the only national charity dedicated to helping those affected by tinnitus. We operate a Freephone confidential support line on 0800 018 0527 and our services are free to all. If you want to keep up to date with progress in research, learn about the latest developments in treatment and read about other people’s experiences, why not become a member and receive our quarterly journal, Quiet?

There is a wide range of information sheets on tinnitus and associated subjects which can also be downloaded from the following website – www.tinnitus.org.uk

British Tinnitus Association Registered charity no: 1011145 Freephone: 0800 018 0527 Website: www.tinnitus.org.uk

Patron: The Duchess of Devonshire DL President: The Rt Hon Sir Stephen Sedley
Vice Presidents: Jack Shapiro Stephanie Beacham Geoffrey Bates OBE

Click here to find out more about tinnitus.

[Information supplied by the British Tinnitus Association].

Laurence McKenna PhD

February 2005 © British Tinnitus Association

This information is not a substitute for medical advice. You should always see your GP / ENT Consultant

Insomnia is defined, amongst other things, as difficulty in falling and/or staying asleep. Mild sleep disturbances are very common, to be classified as ‘insomnia’ the delay in going to sleep or going back to sleep needs to be considerable, occurring at least three or four times a week and persisting for six months or more.

Sleep disturbance affects most people at some stage of our lives. It is common not only in adults but also in children, and is particularly prevalent amongst the elderly.

A normal night's sleep has several stages, from light to deep sleep, including several awakenings, the first after just a couple of hours sleep. Natural awakenings are usually forgotten by the morning, but if a person worries about his or her tinnitus during them, they will last much longer. It seems most likely that tinnitus does not actually wake people, but of course, it can be the first thing they notice when a natural awakening occurs.

As people grow older they experience less very deep sleep and more awakenings. Sleep becomes lighter and more fragmented and there is a tendency to nap during the day. Most people get about seven or eight hours sleep, but normal sleep times vary enormously.

Why sleep?

Surprisingly, the exact reason for sleep is unclear. Possibly it conserves or restores energy, but the evidence for this is not completely clear. People do tend to feel bad if they have not slept well, but no known changes in the body's biochemical or metabolic mechanisms result from sleep loss. Long term or ‘chronic’ sleep loss should be distinguished from short term loss.

People who have been deliberately deprived of sleep in the laboratory tend to do less well on psychological and other tests. The effects of ‘jet lag’ are also well known to many; however, it is not clear whether this is a result of sleep loss, or more to do with disruption of the body clock.

The pattern is different, however, amongst those who have chronic poor sleep. There are large individual differences in how well or how badly they do in tests. Many people perform very well on little sleep. Clearly, people need to act sensibly and be aware of their limitations, but for many people a loss of sleep may not have the devastating consequences that most of us fear. Worrying about sleep loss is one of the things most likely to keep it going. As far as we know, no-one has ever died just from lack of sleep.

Some do's and don'ts

It is worth talking to your doctor if you suffer from insomnia. Sleep loss may be related to some other medical condition which may be treatable. Many GPs offer medication to help people sleep. Such medications have had a bad press in recent years, but should not be rejected out of hand. With medical guidance in the selection of the right medicine and its proper use, a short term crisis can be greatly relieved. Sleep is very much a matter of habit or routine. More often than not, poor sleep results from poor routines, and often people's attempts to solve their sleep problems actually make them worse.

Avoid using alcohol to induce sleep it may send you to sleep but, apart from the obvious problems associated with alcohol abuse, it will disrupt the normal sleep pattern. You may wake sooner and have trouble getting back to sleep.

Avoid using ‘over the counter’ medicines to help you sleep many have a similar effect to alcohol. Herbal remedies and "natural" products may help some people.

Limit the amount of caffeine (tea, coffee, cola, etc.) & nicotine you take both are stimulants and will keep you awake.

Fit people tend to sleep better but get fit carefully. Avoid exercise near bedtime. It may tire you out but it also disrupts the normal sleep cycle.

A busy mind makes it more difficult to sleep if you have worries, spend a set amount of time (say half an hour) each evening, considering how to resolve them. Write your ideas down.

Try to unwind for at least an hour before bedtime. Draw a curfew between daytime and night or bed activities. Relegate worrying thoughts to the next day's "worry session".

Go to bed when you feel sleepy not just because it's a certain time on the clock.

Relaxation can be enormously helpful classes and tapes are widely available. Practise relaxation exercise during the day and find some short form of relaxation to try at night.

Avoid using the bedroom for things apart from sleep don't watch television, do crosswords, write reports etc. in bed.

When you get into bed turn the light off straight away tell yourself that sleep will come when it is ready. Don't try to go to sleep, resting in bed can be just as helpful. If you are not asleep in 20 to 30 minutes, get up and go to another room and do something relaxing like reading. Go back to bed when you feel sleepy again. Repeat the process if you are not asleep in another 30 minutes.

Don't eat if you wake at night you may train your body to expect food at that time.

Get up at the same time each day even at weekends. Don't sleep beyond a set point in the morning even if you have only had a small amount of sleep. Getting up at the same time each day is one of the most important things to do to try and improve your sleep.

Try not to sleep in the day or catch up on lost sleep cat napping is not helpful in improving sleep, but some elderly people might find this difficult.

Stick to a routine.

There is a wide range of information sheets on tinnitus and associated subjects which can also be downloaded from the following website – www.tinnitus.org.uk

British Tinnitus Association Registered charity no: 1011145 Freephone: 0800 018 0527 Website: www.tinnitus.org.uk

Patron: The Duchess of Devonshire DL President: The Rt Hon Sir Stephen Sedley
Vice Presidents: Jack Shapiro Stephanie Beacham Geoffrey Bates OBE