The key to tinnitus relief is to first address the underlying hearing loss with hearing aids, regardless how minor it may seem on the audiogram and/or whether the patient perceives their loss. We addressed this on the margins six years ago in Frustration With So-Called “Minimal” Hearing Loss;1, 2 and again in Uh Oh! Here Comes Noise-Induced Cochlear Synaptopathy …And It Just May Up-End Everything We Know About Hearing Conservation; but since the tinnitus issue keeps popping up, it’s worth a look from the experts.
Doug Beck AuD wrote in June 2017:3
Quite often, for the patient suffering from chronic, annoying, or debilitating tinnitus, hearing loss is a major concern. The “80/80 Rule”4 states approximately 80% of all people with sensorineural hearing loss (SNHL) have tinnitus and approximately 80% of all people with tinnitus have SNHL. People who complain of bothersome tinnitus perceive something which is distressing and uncomfortable most (or all) of their waking hours. Interestingly, this is somewhat in direct contrast to people with (only) hearing loss, the majority of whom do not perceive a particularly audible or blatant sensory cue indicative of hearing loss.
As such, many people with tinnitus are unaware of their hearing loss, because their hearing loss is “relatively silent” as compared to their perceived tinnitus. Therefore, although hearing loss and tinnitus are most often present in the same person, tinnitus may be the overwhelming symptom from which the patient seeks relief.
Subjective tinnitus can be quite annoying, with the Centers for Disease Control estimating as many as one in six, about 50 million Americans, suffer from this condition; and more troubling, that as many as 20% of teens and young adults have hearing loss. This NBC News report5 provides a nice demonstration of what many tinnitus sufferers experience:
Subjective tinnitus can be any combination of ringing, screeching, roaring, hissing, rushing, and/or whistling6 noises generated due to random synapse firing in the auditory cortex, similar to the “phantom limb syndrome” experienced by amputees. In addition, tinnitus can also take the form of musical noises, or random unintelligible speech, [There is also the relatively rare objective tinnitus, which is caused by actual fluid turbulence noise produced in the vascular structures near the ear;7 and also voices with clear speech due to psychiatric conditions; but these topics are beyond the scope of this article.]
Various tinnitus treatments exist such as notched sound therapy,8,9 cognitive behavioral therapy (CBT), which is sometimes combined with antidepressants; and sadly, desperate sufferers fall for “herbal” treatments, which is no more than snake oil.
Up until about 15 years ago, before analog hearing aids went out of fashion, these older hearing aids also output white noise (generated in the solid state devices in the amplifier circuit due to thermal activity), and in fact one of the specifications on the data sheet was “equivalent input noise,” which was measured in the Frye test boxes, and was typically in the neighborhood of 26 dB. Oftentimes, the combination of the amplified environmental sounds along with this gentle white noise was adequate to suppress the wearer’s tinnitus.
However, with the advent of hearing aid digital signal processing combined with very low noise digital-to-analog converters (DAC’s), hearing aids actually became pretty quiet, so many hearing aid manufacturers now include digital noise generators in their devices (but not in the hearing aids sold at Costco). These noise generators fall into three broad categories:
- White noise, now often with high and low pass shaping filters to generate so-called brown, pink, or blue noise;
- Other sounds, such as Widex Zen chimes, and Starkey Tinnitus Technology products, for more advanced cases of tinnitus, for use by tinnitus specialists;
- Mobile phone apps, such as the free ReSound Relief app (App Store — Google Play) (Relief reference guide). These work with any hearing aid capable of receiving Bluetooth or other streamed audio.
Caution Flag #1: When using a tinnitus relief app, watch out for the additional hearing aid battery consumption of about 2.5mA when direct UHF (900 mHz or 2.45 gHz) streaming is used, whether Bluetooth 4.0/Low Energy (BLE), or the similar ReSound/Cochlear Unite and Phonak Roger protocols; and this is why we have an ironclad rule of a minimum #13 battery size — regardless of loss — for any 2.45 gHz–capable hearing aid for streaming robustness, especially in this new era of Thimerosal-free cells. Starkey’s engineers correctly foresaw this issue in their Halo devices; however GN’s ReSound and Beltone divisions still sell #312–fueled devices, despite the numerous problems experienced in all five generations of devices since 2011 [wink wink JW!].
Generally, when enabling shaped noise in hearing aids, you’ll want the level to be as low as possible, i.e. barely audible, and shaped as narrowly as possible, to avoid interfering with speech perception. The way this author fits these instruments is to first dial in the gain to address the underlying hearing loss; and only then add the noise, in 1 dB increments, until tinnitus suppression is largely successful.
Caution Flag #2: Although the (re!)discovery of open RIC and thin tube fittings over the last decade has greatly contributed to improved user acceptance, this author had a case of a social worker with a moderate–severe loss, where the tinnitus suppression blue noise was audible to others, and generated complaints during one–on–counseling sessions.
- The “80/80 Rule” states approximately 80% of all people with sensorineural hearing loss (SNHL) have tinnitus and approximately 80% of all people with tinnitus have SNHL;
- Hearing aids almost always will work well to address the underlying hearing loss triggering the tinnitus, whether the the patient admits to the loss or not;
- Many hearing aids — but not the ones sold at Costco — also have shaped masking noise generators;
- ReSound and third party tinnitus masking apps work well, but hearing aid battery consumption is an issue if UHF (900 mHz or 2.45 gHz) streaming is used;
- Open fit hearing aids can “leak” the masking noise, making it audible to others.
- Frustration With So-Called “Minimal” Hearing Loss. February 7, 2012, The Hearing Blog
- Doug Beck: Hearing aid amplification and tinnitus: 2011 overview. The Hearing Journal. 2011;64(6):12-14.
- Annette Mazevski, Doug Beck, & Colin Paxton: Tinnitus Issues and Management: 2017. The Hearing Review. 2017;24(7):30-36.
- Doug Beck: Issues in tinnitus and tinnitus management: 2012. Paper presented at: British Academy of Audiology (BAA) Podium Presentation, Manchester, England;
- What ear ringing or tinnitus sounds like. NBC News, October 7, 2017;
- Guest Article: What Are The Most Common Tinnitus Frequencies? Peter Phua, MD The Hearing Blog, June 26, 2015;
- Tinnitus — Ear, Nose, and Throat Disorders. By Debara L Tucci, MD, MS, MBA, Professor, Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Merck Manuals;
- Guest Article: Notched Sound Therapy As A Treatment For Tinnitus: A Guide For Hearing Professionals. Peter Phua, MD, The Hearing Blog, August 13, 2013;
- Guest Article: A Critical Review Of The Evidence For Notched Sound Therapy As A Treatment For Tinnitus: A Summary. Peter Phua, MD, The Hearing Blog, September 25, 2013;
- What motivates hearing aid use. Jason Galster PhD, Starkey Research & Clinical Blog;
- Sergei Kochkin’s response to What motivates hearing aid use, January 29, 2012;
- Tinnitus: Symptoms and Causes. Mayo Clinic.