The noise that never goes away

Shortly after my 70th birthday, a high-pitched hum began in my left ear. I noticed it only during quiet times but soon realised that it never went away.An ear, nose and throat specialist (otolaryngologist) examined my ears and took a thorough medical history that included questions about noise exposure and the drugs I take. An audiologist checked my hearing. Diagnosis: tinnitus, with mild hearing loss in the upper range that closely matched the pitch of the hum.

Although the hum was not particularly disturbing, I asked what might be done if it should get loud enough to interfere with my life and ability to hear speech clearly (about 85 per cent of tinnitus cases are accompanied by hearing loss). The answer was that I could be fitted with a hearing aid. But since my tinnitus is still mild, no mention was made of anything that might relieve the constant noise in my head.

Tinnitus is a chronic noise of varying intensity, loudness and pitch that has no external source. Rather, it seems to come from within a person’s head. It is most apparent to the sufferer when all is quiet, and may not be noticed when the person is otherwise distracted – while participating in physical activity, for example, or listening to music.

There is currently no cure for tinnitus, a potentially life-disrupting condition that affects about 10 per cent to 20 per cent of people, mostly those aged over 65, but also many veterans of the wars in Iraq and Afghanistan. Among possible causes are head and neck injuries, drugs that damage the ear, blood vessel disease, autoimmune disorders, ear conditions and disorders of the temporomandibular joint. Until recently, no treatment had been shown to have lasting effectiveness in controlled clinical trials, despite a host of remedies variously endorsed by hearing specialists and commercial interests.

In addition to a hearing aid, the most commonly prescribed remedy is a so-called masking device: a white-noise machine that introduces natural or artificial sound into the sufferer’s ears in an attempt to suppress the perceived ringing. But eventually the noise of the masker can become as disruptive as the tinnitus. ‘‘When patients respond poorly to the masking device, they are often told they haven’t used it long or consistently enough,’’ a psychologist and researcher in the Netherlands, Rilana F.F. Cima, says.

Fear and anxiety

Cima says that, like me, most people with tinnitus function fairly well. But for about 3 per cent of people with the condition, it is extremely disabling, causing intense distress, fear and anxiety, and leaving them unable to function.  Cima  says patients would do almost anything to avoid hearing the sound in their heads and the feelings of fear and anxiety that result. Recently, Cima’s team demonstrated the effectiveness of a multidisciplinary, psychology-based approach to this problem. The technique, published last spring in The Lancet, does not make the ringing go away but does show that now there is real hope of relief for people whose tinnitus impairs their ability to work, sleep and enjoy life.

In an accompanying editorial, Dr Berthold Langguth of the University of Regensburg in Germany, an international authority on tinnitus, says the team’s findings ‘‘overcome the idea that nothing can be done to treat tinnitus’’ and provide ‘‘a clear statement against therapeutic nihilism.’’James Henry, a specialist in auditory rehabilitation at the Veterans Administration Medical Centre in Portland, Oregon, where many veterans with traumatic brain injuries are treated for tinnitus, says Cima has done ‘‘probably the best study to date, a good job that is advancing the field.’’  

An improved approach

The three-month treatment developed and carefully tested by the Dutch team is based on cognitive behavioral therapy and relies on principles of exposure therapy long proven effective to treat phobias. While the use of cognitive behavioral therapy for tinnitus is not new, the team’s demonstration of a scientifically validated, comprehensive approach to the problem offers a therapeutic blueprint others can use.

Unlike the use of a tinnitus masker, the treatment is simple, relatively brief and does not require patients to purchase or use devices to gain relief. If necessary, patients who ‘‘relapse’’ can return for a brief therapeutic brush-up.

Cima’s team enrolled 492 patients with varying degrees of tinnitus and randomly assigned them to receive either usual care or ‘‘specialised’’ care. Usual care, in the Netherlands as well as in the US, involves a medical exam and hearing test, typically followed by a prescription for a hearing aid, a masking device, or both.

Patients may also be given antidepressants, anti-anxiety drugs, sleep aids or other medication to relieve emotional distress and other disabling symptoms. The Dutch treatment relies solely on psychological techniques. Following an education session about tinnitus and lessons in deep relaxation, patients are gradually exposed to an external source of the very ringing they hear in their heads. After 10 or 12 sessions, they become habituated to it and no longer find it threatening.

It is not the noise itself but ‘‘patients’ extremely negative reaction to it that creates daily life impairment,’’ Cima says.

She likened the approach to helping people overcome their fear of spiders by inducing deep relaxation and gradually introducing them to increasingly realistic objects of their fear. ‘‘They may never learn to love spiders, but they can live with them more comfortably,’’ Cima says.

Henry, who has been involved in tinnitus research for a quarter of a century, says his team uses a similar approach with five treatment sessions, which ‘‘takes care of about 95 per cent of cases.’’

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