Q&A: Understanding Tinnitus, Ringing in the Ears

May is Better Hearing & Speech Month (BHSM), which aims to raise awareness about communication disorders, including speech, hearing, voice and language. At the University’s Pennsylvania Ear Institute (PEI), faculty and students are committed to hearing loss prevention, offering a comprehensive array of services related to evaluation and rehabilitation.

According to the Centers for Disease Control and Prevention (CDC), more than 40 million adults in the U.S. report hearing trouble, and the most common cause of hearing loss is noise exposure.

Rebecca Blaha, AuD, answered questions on one of the most common health conditions in the country — tinnitus. In this Q&A, Dr. Blaha, assistant professor in the University’s Osborne College of Audiology (OCA) and lead audiologist at PEI, explains that people who hear a ringing, buzzing, hissing, music or even voices — might want to listen a little closer.

Q: How do you pronounce tinnitus?

A: To be correct, it's tinnitus (ringing in the ears). A lot of people pronounce it as tinnitis, but an -itis, in medical terminology, means that you have inflammation within your body like arthritis, tendinitis or something that would cause your body to produce swelling, heat or a pain sensation, for example, which isn't what's happening in the auditory system with tinnitus. 

Q: What is tinnitus?

A: Right now, the theory is that it is an increase in spontaneous neural activity. Science currently believes that when hearing loss sets in, there are less sensory receptors that are sending signals up to the brain. So, the brain receives less input, increasing spontaneous activity within the neural circuits that are not responding. The brain reacts to decreased sensory stimulation by producing the sound to even the scales because it wants to maintain a certain level of balance. The brain expects a certain level of information. If the level of activity decreases, the brain tries to recreate it in some way, which is spontaneous change in the system. 

Q: What can cause tinnitus, generally?

A: Most of the time it will be exposure to loud noise without hearing protection, like a concert or loud hobbies such as hunting, woodworking, motocross or similar. Most people will tolerate loud sounds if they find it enjoyable, forgetting about hearing protection. We don't see that every patient with hearing loss reports experiencing tinnitus-related sounds. Science really hasn't figured out the light switch moment. Some people can have profound hearing loss and still report hearing a ringing sound while others we would define as clinically normal who don’t have hearing loss can still report tinnitus. So, it doesn't always follow a very typical pattern with testing.

Q: Are all tinnitus-related sounds the same among individuals?

A: It doesn't have to be ringing. It can be another sound like humming, rushing or chirping. Some people even report hearing music or voices, like a repetitive phrase or familiar song from childhood.  

Q: We know there isn't a cure for tinnitus, but what are some ways to manage it and provide some relief? 

A: Because we're trying to change neural activity, there are some experiments going on now that look at how to stimulate the brain in a way that would cause it to reduce its activity or make it go away completely. But there hasn't been anything studied that is able to be replicated well and show universal benefit. 

Usually, we're trying to relieve the emotional side of tinnitus. Right now, the majority of people suffer because of the anxiety it produces. Other people often don't understand why it is so debilitating, so they feel isolated and depressed. We focus a lot on counseling and how to use low level background noise to reduce the stress and anxiety tinnitus causes.

We also use sound therapy. Typically, not by itself. We try to couple sound therapy with a counseling aspect so that we can develop the right mindset, promoting relaxation. A lot of times the therapy used for sound therapy is whatever the patient wants as long as it helps them relax. 

Q: Does tinnitus occur more in a quieter environment?

A: That’s when it’s noticeable. Tinnitus is typically constant, so it's always going on. However, the room has to be quiet enough for a person to actually hear it. But hearing tinnitus is a good thing because it actually needs to happen for the brain to begin the process of recognizing that it's constant, not threatening and it shouldn't involve the individual’s attention. Since patients find their tinnitus to be exceedingly annoying, their perception of it is very loud. If we were to measure it, however, usually with a test, tinnitus is just above the hearing threshold. So, it's not very loud, but patients fixate on tinnitus sounds and it becomes louder than it actually is. Going through the mental process helps kind of deprogram the brain, basically. 

Q: How can people prevent tinnitus?

A: People need to be very careful about their noise exposure. In loud environments, hearing protection is essential. There are some apps now that are free for most smartphones that are fairly accurate as sound level meters. Right now, government guidelines for Occupational Safety and Health Administration (OSHA) and the National Institute of Occupational Safety and Health (NIOSH) start monitoring for hearing loss if the decibel level is 85 or higher. So, based on the guidelines, a person can be exposed to a sound level of 85 decibels for eight hours before it would damage the majority of hearing. If the sound level increases by five decibels to 90, guidelines recommend cutting exposure time in half to four hours. The recommended exposure limit decreases exposure time by half for every five-decibel increase, meaning listening to a sound level of 95 decibels is safe for two hours and 100 decibels for one hour. People just have to know the sound level of a noise and how long they will be listening. In addition, properly inserted hearing protection, like the little yellow foam ear plugs that cost about 50 cents, are very good. They're going to attenuate about 20 decibels, which is pretty significant, as long as the seal is maintained. 

Q: What is the test for tinnitus?

A: It’s basically a hearing test. We just need to see if there's been any change to a patient’s sensitivity. The first place we check is how well do you hear vowels, consonants, things like that. If those are normal, then there are ultra-high frequencies because human hearing goes up to 20,000 Hz. Patients can have hearing loss developing in those ultra-high frequencies that has not affected their communication. Then, we would adjust our test procedure to look at those areas to see where it might be starting.

Q: Do you find that a lot of people come to the Pennsylvania Ear Institute (PEI) with tinnitus already?

A: Yes. It’s a common symptom. It used to be reported that it was the primary symptom that gets people in the door before they acknowledge hearing loss. A lot of people will take between seven to 10 years to admit that they have a hearing problem. So, another symptom is usually what brings them to PEI. 

It does take work to manage tinnitus effectively. Most of it is about reducing stress AND adopting a healthy lifestyle. Exercise, eating better, quitting smoking and anything that's going to help you feel better in general will also improve a person’s tinnitus.