(light electronic music) - [Announcer] The region's premier medical information program, Call the Doctor.

- Tinnitus or tinnitus according to Harvard Health is ringing or other constant noise in your head.

Experts there estimate that as many as 50 to 60 million people in the United States suffer from that condition.

We're gonna dig into exactly what it is and some of the issues surrounding it on this episode of Call the Doctor.

Hello.

Welcome.

We are so glad you are with us for this season and this episode of Call the Doctor.

Let's get right to tonight's panelists.

We have a really interesting discussion, I think, coming up.

I'm really happy to welcome both of you.

If you could tell people who you are and where they can find you.

- I'm Tom Zalewski.

I'm faculty and the director of the audiology program at Bloomsburg University.

I've been there, this is ending my 24th year.

I've have a PhD in audiology from NYU.

- Wonderful.

Welcome.

And what about you, sir.

- My name is Jim Ziegler.

I'm with Family Hearing Center in Forty Fort.

I'm the practice owner now and I have my clinical doctorate, my graduate degree in audiology from Bloomsburg University.

And we've been in practice for a number of years and we serve patients of all ages from birth up to a hundred and more.

- Great.

Welcome.

I think this is gonna be an interesting one because the first question I have, and I'm very willing to admit it, how on earth do you even pronounce this?

I've heard it many ways.

Tinnitus.

Tinnitus.

What are we talking about here?

- Both are correct.

So whatever you want to call it is fine.

Either tinnitus or tinnitus.

Both are acceptable.

- Both works.

- Absolutely.

Yep.

Both work.

- Well, that's all we have today and that's (laughs).

- It's time to go home.

- And that's it.

- That's a cut.

- I'd love if we could start by describing exactly what it is.

I know that's an elementary question, but for someone who doesn't experience it, what is it and and what are people hearing?

I'll start with you.

- Well, I mean there's a lot of different things.

Basically the official definition of it is any sound in your ears or head without an external stimulus.

And it can range from high pitches to hissing to humming, to buzzing, whatever, all right?

Voices and music, it's not tinnitus, that's something else.

But any other noises without an external stimulus, whatever they want to call it is tinnitus.

- So it doesn't necessarily take a particular shape or sound.

It can be a lot of different things that someone might hear?

- A lot of different things that people will hear or describe, and again, their brain wants to organize it into something.

So some people will hear it as steam or hissing or crickets or motor running or they feel like there's something outside of their house and it's really not there externally.

But it's a perception they have internally.

- I like what you said there, their brain wants to make sense of that because I'm starting to see that's a big part of this.

It's not necessarily hearing.

So could you tell me a little bit about that component?

Is it a neurological issue?

I guess I'll start there.

- Well, there's a neurological component and certainly people who suffer the most from the tinnitus.

And I'll let Dr. Zalewski address more of how that works.

But if you have a hearing loss, and by and large a majority of the people that suffer from tinnitus or tinnitus have hearing loss.

And so that area of the brain is looking for input from the ear that's no longer there because of their hearing difficulty.

And so it's very common to have hearing loss and the tinnitus at the same time because of that absence of input.

And the other thing that will happen is if you took somebody with no hearing loss and then put them in an artificial environment like an anechoic chamber where there's no external stimulus, after a period of time they will hear their own body noises and a lot of other sounds and that will be very disturbing because your brain wants to organize information into something that means something.

And when it can't, that's when the system can go wrong and people become affected by it.

- And that's, you know, an important part like Dr. Ziegler said, if you were an anechoic chamber, everyone will hear some sound.

And so basically what it's saying is we all have it.

Problem is if you have a relatively good functioning auditory system, the normal ambient sounds blend in with it, cover up, and you don't hear it.

So that's something to keep in mind.

But when we talk about tinnitus, there's actually three components to it.

One, there has to be a generator.

So somewhere along the auditory system, something has to put it into motion.

Without a generator, you don't have tinnitus.

Okay?

- Give me an example of a generator.

- It could be hearing loss, it could be a perforated tympanic membrane.

It could be fluid in the middle of the ear, it could be something more serious, a growth or a tumor on the auditory nerve.

And that's the important part, determining what, where the generator is because there are two components to it.

Is it, you know, an information carrier, meaning it's being produced by some type of pathology that needs to be taken care of.

And so they're using that sound to monitor it so it doesn't get bigger and track what's happening.

The other one is just unwanted noise.

And so it's just like any other noise.

HVAC, computers, your refrigerator running.

It's just there and it's not really necessary to hear it or not hear it.

So there's the generator, right?

Then there's have to be awareness to it.

Just because you have it doesn't mean you're aware of it.

Right?

So that's a whole other component to it.

You know, I have tinnitus.

I've had it since I've been a kid and I remember going to bed at night and I'd hear the, "shh."

I thought it was room noise.

Well, 20 some years later or I know what it is.

So just because you're not aware of it doesn't mean it's not there.

It's always there, it's just that you're not aware of it.

- Is someone more likely to be aware of it or is someone more likely to, you're saying everybody has it to a certain extent.

- Correct.

Correct.

- Who's more likely to be aware of it?

- Well, that's when the third component kicks in.

- I cut you off without-- - That's okay.

And that is emotionality.

And when people get emotional and that's when the anxiety and the stress, because subconsciously they start thinking that, "Oh, this is due to something more serious than what it really is."

And it's just a natural instinct that, "Oh, if I don't know what it is, and it could be something serious," subconsciously, subconsciously the brain's gonna say, "Oh, I need to watch this because this could hurt me."

And so, and the more you you hear it, the more the stress and anxiety gets kicked up, the more emotionally you get out of it, the more you're aware of it, the more the tinnit and there is the vicious cycle.

- And you're not sleeping and it just kicks over and over and over again and becomes a more serious problem for the person.

- I was actually gonna ask you that next, which was, we had talked about anxiety being a component of this, but it was unclear to me whether the anxiety was causing it or it was causing the anxiety, but now I see it's sort of just a big old wheel.

- The chicken and egg.

- Yep.

- Yep.

- Yeah.

- Exactly right.

- And our job is to get people off the wheel.

And so we work very closely with our ear, nose, and throat colleagues.

So when somebody comes to the office and they have complaints of tinnitus or hearing difficulty, we do a battery of tests and we're looking for certain patterns and certain indications by history and test results that could indicate a more serious problem.

And if that's the case, definitely we want them to follow up with ear, nose, and throat and do the imaging, do the things that need to be done to rule out an information carrier.

And something that's causing a serious problem that needs to be addressed.

And unfortunately, people have already looked some of this stuff up and even though it's a low percentage, that seed has been planted.

And so you gotta reel that back in a bit of let's figure out each step and then we'll figure out when we need to worry and help them try to break up that cycle.

- So you used the term information carrier, do you mean that that possibly could be telling you that there is a bigger problem to explore?

- Correct.

It's I always I like to say it's like pain.

You know, you can have pain in your knee for a lot of reason, I overworked it, I twisted it, I have a torn cartilage.

You still feel pain, okay?

But you gotta figure out what's causing that pain.

And that's the same thing here.

So yes, it can be, you know, heart problems, viruses, you know, retrocochlear pathologies, things along the central pathway of the auditory system, other disease processes.

So you need to have those things worked out first because we never want to work with it's an information carrier because that's there for a specific reason.

You know, I often liken it to, again, I'm gonna say how old I am, the old days with sports, you know, someone got hurt, what did they do?

They carried 'em off, they took them into the locker room, and they shot 'em up and 10 minutes later they were out running around and they did more damage because they couldn't feel it.

So that pain as well as tinnitus is there for a reason or can be there for a reason.

So you need to rule out that it's not an information carrier.

And like Dr. Ziegler said, it's so important to have that medical evaluation to rule out all of those possibilities.

And then once those are ruled out, then we can do things to help people control it and understand it.

- I don't wanna get too hung up on the numbers, but this is fairly common?

Do you see this in your office all the time?

- Routinely it's very common and people will present with it.

And one of the big causes of tinnitus or tinnitus, is noise exposure.

So people who have been exposed to louder noise through work or recreation may have a small hearing change, but they'll also have a component of that ringing that will persist.

And a lot of people have had the experience of going to a concert or a show and that you walk out and for the first two hours your ears ring and then it goes away.

But if you do that over and over again, eventually the ringing doesn't go away.

So a lot of our testing and things will look for those problems and by case history we can talk about prevention and try to manage it so it doesn't get to that point.

Or when we're working with teenagers, how do you manage the sound and music and things you're listening to so you don't get to that point where you have tinnitus that doesn't go away.

- Approximately about a third of the people in the United States have tinnitus.

Right?

And if you look at it worldwide, it's about 15%.

So that, I mean if you look at the numbers, people say, "Oh, it's only a third."

But that's a of people and that doesn't mean, I always like to say, I like to say it's a spectrum from, yes I have it.

Oh well, not crazy about it.

To all the way at the other end to where people are suicidal.

And you have to find out where they are on that spectrum to determine what you're going to do to help that person.

- Well let's get into what you can do to help that person if it can be taken care of at all or what steps you might start with someone, you know, what are some of the first questions you might ask or things you might try with the a patient?

Either one of you can take it.

- Well we would certainly look into their history and talk about some lifestyle things.

So if they have been traditionally around a lot of noise, talk about using more consistent hearing protection to try to, it may not make the ringing go away, but we can at least keep things from getting worse.

Then if they do have a hearing loss, certainly hearing aids will help with that because now you're going to pick up the normal sounds in addition to conversation and hearing your children and parents and everybody around you better.

But you're also going to hear the other sounds that everyone else hears and that will mask your tinnitus.

So a lot of new hearing aid patients don't like hearing paper rustling, refrigerators, water running in the sink.

But those are actually good things.

So once you kind of get re-acclimated to hearing those sounds again, then the tinnitus subsides and the newer generations of hearing aids actually have a program that we can put in and that's a sound therapy component.

So if somebody has a sound that they don't like that they can't control, we can give them another sound that they can listen to, that they can control.

And so they can listen to wind, ocean, water, rain, a variety of things or just plain white noise.

And if they have that going in the background, then their own noise subsides.

And I find a lot of patients will start off with that sound generator program in the beginning and when they come in for their follow ups with their hearing aids, they'll look and they're only using that sound generator 10% of the time.

And it's like, well in the first six months they had it 90% of the time, but once they kind of got used to things and their tinnitus subsided, then just the normal amplification and hearing the sounds around them brought their tinnitus under control.

So a lot of things that people come to us with a lot of anxiety, the main thing is it's not going to continue to get worse.

There will be a point where it kind of cress and it becomes manageable.

And so we can't make it go away, but we can make it manageable.

- Just so I'm clear, would you recommend hearing aids for someone without hearing loss who has this or you would only recommend those for someone who also has hearing loss?

- The hearing aids would be recommended for someone who also has hearing loss and we can decide to activate it or not, activate the sound generator program.

But for the person who doesn't have a hearing problem, then we would there, fortunately, there's a multitude of apps and smartphone things that are available that can play those sounds either through a set of wireless earbuds or just through the speaker in their phones.

So if they're working quietly at home and their tinnitus is bothering them, they can put on music or ocean noise or rainfall through their app.

And there are apps designed specifically for tinnitus sufferers that will go through some of the mind relaxation techniques and things like that to help overcome some of those aspects of it.

- Yeah.

And and that's where a lot of confusion comes in.

Yes, we know that a lot of people who have tinnitus also have hearing loss, but not everyone who has tinnitus has hearing loss.

So yes, there's a close correlation between the two, but it's not a cause and effect cause if that was a cause and effect then everyone who has hearing loss would have tinnitus.

So there's a fair amount of people who have normal hearing and who has tinnitus.

So now it's just trying to figure out, okay, is it misfiring hair cells or are there some hair cells that are damaged or not functioning as well as it should be?

Or has the baseline changed somewhere else in the system?

Or is it due to lifestyle things?

You know, alcohol, nicotine, caffeine, diets, you know, so, so it takes a, you know, when you work with tinnitus people, it takes a long time to get a good history to find out, you know, so are there any external factors causing it?

You know, such as I said the caffeine, alcohol, you know, diets, are they using spices on their foods?

Cause there's tons of sodium in spices, so you have to figure out all of those things.

Is there medications that are contributing to it?

Because sometimes if it's one of these external things, it's as simple as well reducing it.

You know, years ago I had a patient came in and I asked him, "Are you drinking caffeine?"

And he said, "Oh yeah."

"How much do you drink?"

And the patient says, "Oh, I drink 10 pots a day."

And I'm like, "You mean 10 cups?"

"No, 10 pots."

I said, "Well that might be the problem."

And so had him cut back and came back a couple weeks later said, "It's fine."

So that's the thing, trying to find out as you go back to what's the generator?

- And it sounds like it could be a number of things that are, it really takes a long investigation.

- Yeah.

Yeah.

- For lack of a better term.

- Do you find that people come to you and think it's in their head or think that perhaps, I mean it it's an actual medical condition, but a lot of what you're recommending is mindfulness and noise machines or things of that nature.

Do people kind of look at you and say, "Well that's not what I wanted?"

- Well everybody wants the instant fix and they have all the, so once they've searched for tinnitus once on the website, now they have suddenly a hundred different ads showing them, if you take this pill, it'll go away.

And by the way, now all that stuff is junk and it's incredibly spammy and you send in your money and you can never get off the list.

And it goes on and on from there.

So a good source is the American Tinnitus Association, atta.org, and they will have a list of things that do and don't work and some things that are plausible.

And so there can be multiple generators.

So some people do find some help with a supplement Lipo-Flavonoid.

So one of the ENTs I work with, that's one of his first lines of, let's try this and you try it for a month and if it helps, great.

If it didn't make a difference in a month, don't buy any more of it, cause that's not what it's being generated by in your system.

But some people find relief from it and so it's, you know, worth a try.

But a lot of people, yes, they want the magic pill and when it's no, it's these other things, then we need to start to work with them to have realistic expectations on how to break up their process.

Also, it's not something that's just going to go away the next day, like taking medication for a headache, unfortunately.

It is a process, but on the other hand, it does work.

You will be able to sleep, you will get to the point where it's less disturbing to you.

And if it's so disturbing that as Tom said, or Dr. Zalewski said, there are people on the spectrum where they are very distraught and they really need to be referred to somebody who can help manage those destructive thoughts and reel it back in and that will work.

It will get better.

- Does it happen in both years or one or who knows?

- Yes.

- Correct.

- Yeah.

- Yeah.

Yes.

- Yes all of that, yes.

- Yeah it is.

And the reason why we talk so much about, you know, these mindfulness is because you gotta understand how the auditory system works.

Sound comes in and the auditory cortex wants to identify it.

So when a sound comes in, it wants to say, "Oh, this is my computer running, this is my turn signal on, this is whatever."

And so if that can't identify it, it sends it off to another part of the brain called the hippocampus, and here's auditory memory in there and it does the same thing.

And if it identifies it, done, moves on.

Right?

If it doesn't, it throws it to the next one.

The amygdala, same thing.

However, if the amygdala can identify it, it's tied to the adrenal glands.

Right?

So then your adren, you get pumped up, and what has strong ties to your autonomic and your limbic system.

So now your fight or flight and your emotions, you get upset about it.

Why can't I, you know, what is the sound?

What's going on?

(sighs) I'm angry, I, ugh, I can't take.

And all of that is the fight or flight and the emotion.

So you need to get people to realize, this is why we said it's, you know, it's just unwanted noise because that's all it is.

Once we rule out it being an information carrier, it's unwanted noise.

And so getting them to realize, breaking those negative ties of tied to the emotions and your fight or flight, you know, to realize this is nothing more than my air condition, than my refrigerator, than people can deal with it and live with it.

So it's just getting them to understand this is just a byproduct of the system, depending what's going on.

Whether a damage system or a system that has some subtle damage or that's just misfiring for some reason.

- I liked your example too of it's not the noise, it is your reaction to the noise.

It is what is happening in your brain that's trying to figure out that noise.

That's typically where you see the problem?

- Sure.

Yeah.

- So the reaction is for the people who are suffering, truly suffering, it's their reaction.

So the vast majority of people with tinnitus from whatever reason, manage it, live with it.

It's annoying, but it's there.

But I can carry on my daily life.

But for the small group, it's a very significant problem and it's that reaction to it that is the issue.

And that's where, you know, people can and should get help because they don't have to live like that.

- Not just for tinnitus or tinnitus here, but we're talking about hearing in general.

You had mentioned that a lot of this is preventable, that a lot of hearing loss and hearing issues are preventable.

What are some of the things that you would tell people, tell your patients to really be careful for?

Watch out for?

- Yeah, a lot of times when I talk to people is, you know, if you're using headphones is simply just, if I have to take them out to have a conversation, if I have to turn down the volume to have a conversation, if I take them out, my ears feel full and I have some ringing or buzzing in the ears.

Way too loud.

Way too loud.

So, so that's kind of the way to do it.

And then just depending on what you're doing, your lifestyle, if I'm using power tools or whatever, if I can have a conversation at a normal level and I can hear someone at about three feet away without having to raise my voice, you're probably good for several hours.

But if you have to start raising your voice or turn it off, you gotta wear hearing protection in those situations.

So what we've gotta remember what sound is, it's not just, oh, exposure to once.

It's a time intensity thing.

So the louder it is, the safe time gets shorter.

And so it might not just be once, you know, so yes, you're exposed to a concert, 110 dB, your ears are full.

Yeah, you've probably done some damage, but for the most part, not too much.

But if you continue to do that week after week after week after week, the the inner ear, the hair cells inside are not gonna rejuvenate.

And that's where the problem begins.

- And is there a way of knowing how much you can take?

Or is it you'll know when you've had too much only?

I mean, unfortunately.

- Unfortunately, yes.

You'll find out after the fact and you won't get that function back.

So that's why there's so much emphasis with younger ages with prevention.

And so generally you can listen to your music or your MP3 player or your phone about halfway on pretty much all you want.

And that's pretty much safe according to all the measurements in some of the research.

And then if you push it more, you should limit that time to about an hour because as Dr. Zalewski said, it's not only the level of the sound, but it's the duration.

So most people will tolerate about an hour at a higher level.

So if you wanna do that to do your exercise, really feel the music and that's fine, that's okay.

But you should just be aware of that and then back it off to halfway for the rest of the time that you're going to listen.

And again, if you have to really raise your voice to carry on a conversation, that's a sign that you've really pushed it.

And then the other factor is impulse noise.

So a steady sound, like a loud amount of music that's fairly predictable, this loud, this long, this is safe, this isn't safe.

If you worked in a factory in front of a machine, there are good guidelines for this loud, this long, is okay, but impulse sounds, target shooting, things like that cause more damage faster.

And we don't have good guidelines for that.

So anything like that, cause sometimes, especially hunting culture, oh, it's only a 22, that's still going to damage your hearing, you should put on earplugs or earmuffs while you're shooting and then take it off when you're done.

- I do worry about my children watching, my kids watching their videos and, you know, that's nothing I ever did and I wonder, are we raising a generation of people who are gonna have hearing issues down the road?

- Well (laughs).

- If they crank it up all the time, yes.

But for the most part, most people I've found are fairly responsible with it.

And even among younger musicians, they don't like having their ears ring after every show.

And that's a teachable moment.

And so if you can reach people at that point and then keep them from doing that over and over and over again, and that will prevent the damage.

- What I often tell people is who don't have a background, would you stand behind a jet engine without earplugs on?

And people are like, well, no.

- Yeah, of course not.

Right.

- Well, there are some, you know, phones, their music can get up as loud as that jet engine.

- Geez.

- Yeah.

- So-- - Just be careful.

- Yeah.

and so people have this misconception, oh, it's music and I like it, it's not gonna hurt me.

Well, sound, the the ear is not selective.

If it's loud enough, it doesn't matter if you like it or don't like it, it's gonna damage it.

- [Julie] Your ear can't tell the difference.

- Right.

Correct.

- Yeah.

Right.

Well, thank you, thank you both very much.

I say this at the end of every show, but I had so many more questions I'd love to dig into, but it's been really fascinating.

I appreciate your insight very much.

That's gonna do it for this episode of Call the Doctor.

We are glad you have joined us.

And if you've missed something, you can find it at our website, wvia.org.

For all of us at WVIA, we'll see you next time.

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