Answers to some frequently asked questions on tinnitus.
by Dr. Anirban Biswas.  DISCLAIMER:- The answers are the personal opinion of Dr Anirban Biswas and the patient should go by what the treating doctor advices and all issues discussed here should be double checked by the reader before accepting / acting on the information provided here.

Can my tinnitus be completely cured?
Not exactly! There is at present no definite treatment method available anywhere in the world that is known to cure tinnitus completely in all patients. By “cure” I mean that the abnormal sound that you feel you are hearing in the ear will completely stop. Medical science till today does NOT have any specific treatment that can permanently stop your perception of the sound that you claim to hear. Though quite a few patients do report that they stop hearing the tinnitus for a period of time after therapy, this does not happen in all patients. The objective of therapy in tinnitus is to reduce the perception of tinnitus, make it less bothersome and adapt your brain into accepting the noise just as any other noise. This is definitely possible in most patients and if medically managed well most patients have a much better quality of life.

Why do you say “your perception of the sound that you claim to hear”, I actually do hear the sound continuously, and I am not lying.
I do not dispute that you hear the sound. But to put it in a over-simplified way, this sound that you are hearing actually has no real existence and hence it is also called as an ‘unreal, virtual or phantom sound’.  it cannot be measured by any physical means and cannot be recorded or documented. Even if I put a very sensitive microphone connected to a very powerful amplifier in your ear / head,others will not be able to hear the continuous sound that you are hearing. The “ringing” or “buzzing” or the “sawing” sound that you are hearing is actually a sensation of sound perceived by you in the absence of any physical sound. In medical parlance, it is called a “Phantom sound” or TINNITUS and it is defined as a hallucination of sound in the absence of any actual sound.This of course refers to the comon type of tinnitus which is called SUBJECTIVE TINNITUS and more than 95% patients have this subjective tinnitus. The other dorm of tinnitus called OBJECTIVE tinnitus is not a virtual or a phantom sound and objective tinnitus is actually a sound that can be heard by others too. Objective tinnitus is caused by bruits or by the passage of blood through some blood vessels having structural abnormalities.Objective tinnitus can be actually stopped in most but definitely not in all cases provided the offending  / causative structure is identified. CT angiography , digital subtraction angiography, MR angiography of the head neck vessels usually help to identify and localise the causative area if it is  a abnormality in the blood vessel.

Where then is this sound coming from?
Only God knows. We do not know exactly where this sound is coming from. Had this been known, medical scientists could probably have been able to evolve a “cure” for it by medical / surgical means. A lot of research has been done (and is still being done) on this vexing issue and what we now know from years of research is that the perception of this sound comes from the hearing area of the brain (called “auditory cortex”) and not from the ears though it may appear to you to be coming from the ears. Experiments have shown that even cutting off the hearing nerve (that connects the ear to the brain) does NOT stop the tinnitus in most cases. Tinnitus is generated by an obscure neural firing in the auditory (hearing) pathways in the brain and this neuronal firing spreads to involve areas of the brain that are outside the hearing system especially the areas connected with our psychic systems. The result of this is the feeling of hearing an abnormal sound in the ears which is not only annoying and disturbing but also prevents you from concentrating at work and from sleeping. This sound upsets you and traumatizes you mentally. You are also hearing many other sounds constantly like the sound of the fan, the air conditioner etc. but they do not disturb you (even if they may be louder than the tinnitus), whereas this faint sound of tinnitus really drives you mad and annoys you so much.Some authorities believe that the perception of  this sound is originating from the psychic system and that is why when you are very euphoric or involved deeply in something that you enjoy e.g.,  an interseting football match you may not perceive the sound at all but when you are alone or you are feeling depressed the sound is so very much annoying and distressing to you.

What tests are there for tinnitus that a tinnitus patient should undergo?
Tinnitus can be the only sign of some sinister disorders like multiple sclerosis, acoustic neuroma which is a tumour in the brain  or of disorders of the ear like Meniere’s disease , labyrinthitis etc. All tinnitus patients must undergo a complete auditory evaluation that includes a pure tone audiometry with localising tests, a tympanometry and a BERA test, If the tinnitus is unilateral then an MRI of the brain with contrast is indicated. Complete tinnitus evaluation that includes tinnitus matching, tinnitus masking tinnitus suprresibility recording of tinnitus in the Tinnitus Handical Inventory to gauge the effect of tinnitus on daily life must also be done. A very sophoisticated sound proof setup with special audiometers that can test hearing at 1dB steps and at 1Hs frequency steps are required for this.The tests are a must in all patients of tinnitus. Facilities for complete tinnitus assessment are available at VERTIGO and DEAFNESS CLINIC at BJ 252 Salt Lake, India.

If there is no definite “cure” what is the point in trying to get treatment?
Even if we cannot totally stop the sound in your ears / head,medical science can very definitely give you a much better quality of life by substantially reducing your perception of the tinnitus, lowering the intensity of the tinnitus, reducing very significantly the annoyance caused by the tinnitus and habituating you to this abnormal sound sensation so that your brain accepts this just as it accepts the sound of the fan or the air conditioner without disturbing you. Most patients do get a much better quality of life after therapy.For this of course the patient must be positively thinking and not be obsessed with the sound mentally.

What are the treatment modalities available and how effective are they?
The ancient Egyptians used to treat tinnitus by pouring hot oil into the ears. We do not do it today but results of treatment are practically the same. Jokes apart, there is practically nothing that has not been tried for tinnitus but a “cure” in the literal sense of the word is yet to be evolved. Of all the treatment modalities that have been tried till now, TINNITUS RETRAINING THERAPY has been found to be the most effective. The other modalities are, e.g. use of tinnitus maskers, use of noise generators, use of some drugs, music therapy, etc. etc. but none of them (even TRT) have been found to be as effective as “chloroquin” in “malaria”. There is no true EVIDENCE BASED treatment for Tinnitus. Nonconventional treatment modalities like low intensity lasers etc, phase inversion of the tinnitus sound, electromagnetic wave stimulation etc have been tried, some patients are partially helped but definitely not all. Moreover since thre is a large psychic component in tinnitus actual results are hard to ascertain.

What is Tinnitus Retraining Therapy and how is it done?
It is form of specialized form of psychotherapy which involves the services of an expert and well-trained psychotherapist and the use of a noise generator (which you will have to purchase and wear for several hours daily). The process is time-consuming and usually takes 1½ to 2 years of regular therapy. Moreover it requires you to constantly wear the noise generator, which looks like a hearing aid (something that may be more traumatizing to you due to the stigma people have on hearing aids). The major draw-back of TRT is the long duration of therapy (even then, the results are not 100% guaranteed), the difficulty in getting an effective and qualified psychotherapist especially tuned to tinnitus management, and the cost of the noise-generator. Moreover, what many centers carry out in the name of TRT is a hoax. Unscrupulous and untrained persons abound who do not have any infrastructure at all and carryout a lot of nonsense in the name of TRT and basically dupe the hapless and naive tinnitus suffers. But if the TRT is carried out properly (with special emphasis on the word ‘properly’) about 70 to 75% patients are said to (rather, claimed to)  benefit from the therapy.

What do you mean by “benefit” from TRT therapy ? Will my tinnitus stop totally?
As already explained, the answer is “No !”. The tinnitus is not expected to stop totally, but the annoyance caused by it will definitely lessen, you will be habituated to the tinnitus and your quality of life will improve in a big way, provided the TRT is carried out by a knowledgeable and ethical person which is not always the case. You will also have to be patient, as, TRT is a very time-consuming therapy and the success of the program depends a lot on your perseverance, involvement and uninterrupted continuation of therapy. There is no “magic cure “for tinnitus and you should not expect on overnight miracle.

Is Tinnitus a very common disorder?
Yes! Very common. One in seven of the general population 0f USA and one in ten of the general population of UK suffer from tinnitus. One in thirty of USA and one in twenty of UK suffer from very severe bothersome tinnitus. So you are not the only one. The exact incidence of tinnitus in our country is not known but should be something similar to that of UK and USA.

Is Tinnitus Retraining Therapy the latest and best treatment for tinnitus or has anything newer, more simpler and more affordable and more effective been introduced?
Yes, the latest treatment modality for the management of tinnitus is the TINNITUS PHASE OUT THERAPY (TPOT). This is a very simple and adequately effective treatment modality that does not require the patient to buy and wear a device permanently as is required in TRT. Moreover, the duration of treatment is also much lesser. The TPOT treatment is approved by FDA in USA and a number of clinical trials have been done in several parts of the world all of which have proved its efficacy. The treatment is non-invasive and just requires the patient to hear a customized sound through headphones connected to an instrument for about half an hour every alternate day or twice weekly for a month or so. However, TPOT is effective only in cases of “tonal” tinnitus, i.e. if you have a tinnitus of a fixed tone i.e., of a fixed frequency. The clinician can find it out for you. The success rate in different studies have to shown to be more or less the same as that with TRT and in some studies the results have been found to be better than TRT. The patient compliance is also much higher as it does not have any of the drawbacks of TRT. However the initail success as was claimed for tinnitus phase out therapy is not valid today as the instruments fot the phase out therapy are not easily available.

How is the TINNITUS PHASE OUT THERAPY administered?
As explained, you will have to come to our clinic after taking an appointment though my secretary (tel no.- 09836725371) where your ears will be examined and routine investigations done first to ensure that your tinnitus is not being caused by any harmful or dangerous cause like a tumor in the brain, and second to find out if your tinnitus is being caused by some treatable disorder like Meniere’s Syndrome, Otitis Media etc. which are treatable diseases that may cause tinnitus. The TPOT will be administered only after we have investigated you thoroughly and are convinced that treatable causes and life-threatening causes of tinnitus have been ruled out. If any of them are found we will first treat you and try to cure the cause of the tinnitus if possible. Tinnitus due to these causes often is cured totally if the causative disease is properly treated. The problem is that most patients are not so lucky and tinnitus in the majority of patients is of idiopathic origin. After the routine investigations are done, we will ascertain the pitch (frequency in Hz) and intensity (loudness in dB) of your tinnitus. This is done by matching your tinnitus with different types of sounds that will be presented to you through headphones. We have a special a instrument for that, This process takes about half an hour and is a subjective test dependent upon your responses. If we find that the pitch and intensity of the tinnitus has been identified accurately, then we start the Tinnitus Phase Out Therapy. The success of the therapy depends upon accurate matching of the pitch and loudness of your tinnitus. The therapy consists of making you hear through headphones a customized sound that is based on the pitch and loudness of your tinnitus for half an hour every alternate day for 5 to 6 sessions. This we do in our clinic, so you will have to come over to us every alternate day. If we find that you have benefited from these sessions then we continue the treatment further for a few more sessions. There is also an option of our customizing the sound, and handing over a small portable machine to you for sessions at home but till now we are not doing so. Until the treatment is more popularized and more accepted, we are offering the service only from our clinic at Bell Vue and have not yet started the home treatment.