Tinnitus: In the Brain of the Beholder

Marc_Fagelson    Baguley_PTINN    David_Baguley


By: Marc Fagelson, BA, MS, PhD and David M. Baguley, BSc, MSc, MBA, PhD

Co-editors of Tinnitus: Clinical and Research Perspectives

Most audiologists and patients understand tinnitus to be the perception of a sound that is not connected in any way to an environmental event. For some patients, the sound produces minimal discomfort and is noticeable only a fraction of the time. Other patients are not so fortunate, and their tinnitus may persist and prove distracting when they are in the presence of other sounds or when they try to communicate. A relatively small proportion of patients with tinnitus, still probably more than 10 million people worldwide, have bothersome tinnitus that consistently reduces their quality of life and affects most routine activities. Such patients often respond to tinnitus as though its presence merits the attention and concern consistent with that demanded by a sound that is recognized as a threat. These patients illustrate some of the more confounding elements of tinnitus: it is a sound experience that may produce, or be associated with, powerful emotions and physiologic responses consistent with those demonstrated in fear-avoidance research.

A person’s experience with tinnitus may be complex and multi-faceted. Some patients link tinnitus to traumatic events, perhaps those that triggered the tinnitus onset. Other patients report psychological conditions such as anxiety and depression appear to exacerbate tinnitus and may be reinforced by tinnitus-related negative associations. Often, tinnitus severity is dictated not by the sound, but by the patient’s interpretation of and response to the sound. In this regard, the power of tinnitus to exert influence over a person’s life is in the eye, or ear, of the beholder.

Tinnitus interventions, then, may be viewed as proceeding along parallel tracks: abolishing or attenuating the sound may be the target of a treatment strategy, or the patient’s response to tinnitus may be the target of a management strategy. Both approaches are considered in detail, and with many examples, in Tinnitus: Clinical and Research Perspectives.

Tinnitus management and treatment approaches must be evaluated and employed with respect to the unique complaints and experiences reported by patients with bothersome tinnitus. Additionally, the effects of tinnitus, as referenced by artists and writers, or in historical passages, suggest that tinnitus is a global concern whose occurrence transcends exposure to industrial sounds, toxins, or presumed contemporary causes. Tinnitus is part of the human condition, and as such has pervaded for centuries many aspects of life, medicine, and art. Illustrating this point, the so-called “tinnitus trope” is a mechanism used in films such as “Hunger Games” or “Dallas Buyers’ Club” to suggest, respectively, the after-effects of an explosion at close range, or the sensation that one experiences of a piercing sound immediately preceding a blackout. The ubiquity of the tinnitus experience in society makes its use in film effective and relatable to much of the viewing public. Such references to tinnitus, and the often-related sound tolerance problems, or hyperacusis, are often found in secular and religious literature, from Thomas Hardy to J.K. Rowling. Many readers recall the mention of buzzing in Harry Potter’s ears when he is agitated; the tendency of stress to exacerbate tinnitus is well-known to patients.

Indeed, physical and psychological stress is often more closely linked to tinnitus severity than hearing loss. Auditory pathway connections to other neural systems, such as those related to arousal and emotions, produce vastly different effects that depend upon diverse factors such as the conditions under which tinnitus started, its relation to traumatic exposures, or the sound itself reminding the patient of past experiences or events. While these effects may complicate intervention strategies, they also provide the rationale for interprofessional patient care and consideration of co-occurring physical and psychological conditions that may exacerbate tinnitus severity.

Characterization of the tinnitus sound and effects does not lend itself standard psychophysical measurement. For example, the audiogram is a notoriously poor predictor of tinnitus severity, and when tinnitus loudness is matched to external tones, the match often occurs at a sensation level akin to a whisper or quiet voice. Modeling of tinnitus mechanisms is accordingly difficult. Findings from animal studies are being linked to measures of human neural function to establish potential targets of interventions. The lack of a consensus regarding mechanisms and interventions reminds us that the tinnitus experience of each patient is unique, and in many cases requires careful consideration of the disturbances and emotional responses to tinnitus. Clearly, no simple intervention can manage the diverse needs of all patients with tinnitus.

In addition to cases of bothersome subjective tinnitus, many patients experience tinnitus that is either objective (that is, audible to other people), or that changes in response to tactile pressure or movements of the head, neck, or body. Objective, or somatosensory tinnitus often requires medical attention prior to, or as an element of, the management of their tinnitus. In particular, pulsatile tinnitus merits medical intervention. Because pulsatile tinnitus may be a symptom of vascular disorder, special care must be taken with its assessment and medical care. A variety of non-vascular medical conditions also may be related to objective tinnitus and include middle ear myoclonus or involuntary muscle contraction in the middle ear space. Tonic tensor tympani syndrome is another potential cause of such somatosounds; these conditions of the peripheral auditory system may be amenable to surgical or drug intervention. In other cases, tinnitus reportedly changes in association with jaw movements, neck manipulations, and other physical activities. It is often reported that such somatic modulations are triggered by muscular problems that can be managed with exercises and relaxation strategies.

The psychological impact of tinnitus often determines its severity and effects on quality of life; consideration of  psychological state and its interactions with tinnitus is a clinical imperative. Tinnitus effects may be most effectively addressed when we acknowledge that tinnitus requires attention of clinicians and researchers willing to place tinnitus in a biopsychosocial context. In this regard, tinnitus effects may be most effectively managed by interprofessional teams that provide audiologic, psychologic, and medical interventions supporting the patient’s unique lifestyle needs and social interactions. The ability of tinnitus to influence a person’s psychological state, the way they think, and their character cannot be overstated, and it is worth considering that care provision is often most effective when it addresses patients’ thoughts and coping abilities by incorporating input from a variety of professionals.

When analyzing different tinnitus sounds and triggers, it is clear that certain patient populations will present clinicians with additional challenges. Patient’s otologic and medical histories, exposures to trauma, or co-occurring medical condition or injury often distinguish patient groups and must be considered in order to provide appropriate intervention. For patients with profound deafness, cochlear implantation has been shown in the majority of cases to reduce the intrusiveness of tinnitus; however, such patients also require extensive medical management. Regardless of hearing loss, certain patients suffer from tinnitus associated with past experiences, or stressful situations and environments that appear to exacerbate tinnitus effects. Such patients challenge clinicians because their evaluations of tinnitus may be quite different from most other patients, and their counseling may require unique elements. In addition to trauma-exposed patients, children or patients who lack independence, as well as their support groups, require adaptability and novel approaches to counseling and sound therapy when managed in a tinnitus clinic. Patient characteristics and case reports may facilitate a clinician’s ability to meet the diverse needs of different patient groups.

Sound enrichment and sound-based therapies have been employed in the care of patients with tinnitus for hundreds of years. These strategies have evolved to include hearing aids and other sound therapies that include masking with music, tones, and noise. Despite all the different management approaches, there is consensus that the priority of intervention for tinnitus accompanying hearing loss is to address the hearing loss first whether with hearing aid fitting or medical intervention. The plethora of sound therapy approaches suggests that no single strategy will provide relief for all patients. Clinicians and patients should be prepared to try different devices if necessary: for example, a bedside masker to facilitate sleep, and hearing aids for use during the day. Patients and clinicians must be open to the possibility that what works at one time may not always work. Clinging dogmatically to any single intervention strategy is most likely not the best approach; clinicians who adhere to a limited number of interventions are likely missing opportunities to provide relief to many patients.

Finally, self-help strategies for patients, as well as associated organizations charged with facilitating patient coping with tinnitus can support the efforts of patients and clinicians. While it may be years before physiologic interventions are available to a large segment of the patient population, their development and clinical trial results are essential for the clinician hoping to keep abreast of progress in this area.

Our book, Tinnitus: Research and Clinical Perspectives, provides information regarding emerging trends and future considerations for tinnitus patients, clinicians, and students of audiology, otology, psychology, and other related disciplines. Most chapters offer case studies that are intended to put human faces on the challenges associated with tinnitus management. We appreciate any and all questions or comments about our book; patients, clinicians, and students are encouraged to communicate with us at any time.

About the Editors 

Marc Fagelson, BA, MS, PhD, is director of audiology and full professor at East Tennessee State University in Johnson City, Tennessee. He completed undergraduate and master’s degrees at Columbia University in New York City and a doctorate at the University of Texas at Austin (1995). Dr. Fagelson has practiced as a clinical audiologist since 1991, and his work with military veterans suffering from tinnitus started in 2001. He has twenty-five articles and book chapters as well as more than seventy-five presentations at national and international meetings. Dr. Fagelson teaches a variety of audiology courses and focuses on research, clinical activity, and student training on patients whose tinnitus is complicated by psychological injury such as post-traumatic stress disorder.

David M. Baguley, BSc, MSc, MBA, PhD, is head of audiology and hearing implants at Cambridge University Hospitals, United Kingdom. He completed undergraduate and master’s degrees at the University of Manchester and a doctorate at the University of Cambridge (2006). Dr. Baguley has more than 140 peer-reviewed publications, is a coauthor on the books Tinnitus: A Multidisciplinary Approach, Second Edition(Wiley-Blackwell, 2013) and Hyperacusis: Mechanisms, Diagnosis, and Therapies (Plural Publishing, 2007), and coedited the latest edition ofBallantyne’s Deafness (Wiley-Blackwell, 2009). In 2010, Dr. Baguley coauthored a popular self-help book on tinnitus and hyperacusis,Living with Tinnitus and Hyperacusis (McKenna, Baguley, & McFerran; Sheldon Press). In 2006, Dr. Baguley received an International Award in Hearing from the American Academy of Audiology and has been awarded twice with the Shapiro Prize from the British Tinnitus Association for tinnitus research (2005, 2008). He is a visiting professor at Anglia Ruskin University, a fellow at Wolfson College, University of Cambridge, and is the president of the British Tinnitus Association. Dr. Baguley’s clinical and research interests focus upon tinnitus and hyperacusis, with the aim of understanding these symptoms and designing and evaluating novel and innovative interventions.



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