“Normal Hearing” and Tinnitus
There is a growing body of literature showing individuals that have tinnitus with a “normal” hearing evaluation, without any other obvious cause for the tinnitus. There have been recent theories for why this might occur, with one of them being called synaptopathy or “hidden hearing loss”.12,15 This theory proposes that the neural synapse, or communication point between the hair cell and the auditory nerve, can become damaged. This damage at the level of the synapse is enough to cause the individual to perceive tinnitus and likely have some degree of hearing difficulty, but not enough to cause the audiogram to be abnormal.12,15 At the time of writing this there is no gold standard for the assessment for “hidden hearing loss”.
Management of Tinnitus
There is no treatment to silence one’s tinnitus. This is due to tinnitus most often being related to sensorineural hearing loss, which at present, can only be managed with hearing aids or cochlear implantation dependent on the amount of hearing loss. The hair cells damaged within the inner ear in sensorineural hearing loss cannot be regenerated currently in humans. Neither hearing aids nor cochlear implantation truly treats the damaged inner ear; these devices simply provide greater access to sounds through amplification. Also, the generation of tinnitus appears to be complex and multi-faceted, involving changes in the central auditory pathway neural firing patterns, making it unlikely that this would immediately silence one’s tinnitus, even if the hair cells could be regenerated.8
That is not to say that nothing can be done to help manage tinnitus. It has long been a recommendation to “mask” or cover one’s tinnitus sound with another, less bothersome noise. The use of background noise to mask bothersome tinnitus dates back to French physician Jean Marc Gaspard Itard, who recommended his patients utilize a roaring fire to mask out their tinnitus in the 1800’s. The use of a tinnitus masker is still recommended by most practitioners today for those with bothersome tinnitus. Most individuals nowadays utilize either smart phone applications or stand alone masking devices to achieve these masking effects.
Most practitioners agree that hearing aids are useful in managing tinnitus, especially for those who also have sensorineural hearing loss.16 By amplifying soft sounds as in the case of hearing aids, the hearing aids works as a tinnitus masker of sorts. There are also hearing aid programming protocols to maximize the benefit of hearing aids for tinnitus management.17 Many modern hearing aids have a tinnitus masker option, allowing for further masking with the hearing aids.
One’s own subjective evaluation of their tinnitus can have a large impact on how bothersome it is to them.10 That is to say that ones self-evaluation of the tinnitus can evoke strong emotional responses from within the brain.10 If one evaluates their tinnitus as a vengeful spirit, which is sure to mean their impending demise as was common in Babylonian times, then their tinnitus may be evaluated as a sound of extreme importance, associated with negativity and fear. Thus, one’s evaluation of the tinnitus sound can evoke extreme conditioned emotional responses dependent solely upon how it is assessed, which has a direct relationship to how bothersome it is to the individual. This bi-directionality of tinnitus is of extreme importance in the management of tinnitus and it is imperative that there be at least some degree of counseling that aims to promote a correct evaluation of ones tinnitus. Strategies that may be usefully implemented in tinnitus management along with hearing aids and masking options include cognitive behavioral therapy9 and mindfulness training.14
There is currently a recommendation against the use of dietary supplements and/or the use of antidepressant medications for routine management of tinnitus. Other treatments, like transcranial magnetic stimulation are also not recommended. There is currently not a professional consensus on the use of acupuncture for tinnitus management.19