Hearing Library2016-12-21T17:24:10-06:00
What is Tinnitus?2014-10-08T09:39:33-05:00

Tinnitus is an abnormal perception of a sound reported by a patient. This “head noise” is unrelated to an external source of stimulation. Tinnitus is a common disorder affecting over 50 million people in the United States. It may be intermittent, constant, or fluctuant, mild or severe, and tinnitus may vary from a low roaring sensation to a high-pitched type of sound. The location of the tinnitus may be in one or both ears, or it could also involve the head.

Classifications of Tinnitus
Tinnitus may or may not be associated with a hearing loss. It is classified as:
-Subjective tinnitus – A noise perceived by the patient alone, which is quite common. With this type of tinnitus, the patient has problems with the auditory (hearing) nerves or a deficit in the auditory pathway, which is the part of the brain that interprets nerve signals as sounds
-Objective tinnitus – A noise perceived by the patient as well as by another listener, which is relatively uncommon. With this form of tinnitus, the patient and the doctor can hear the head noise. This is usually due to a vascular issue, a muscle contraction, or an inner ear condition.

Symptoms of Tinnitus
The bothersome sound of tinnitus is described differently by different patients. The head noise may be of a low pitch to a high squeal, and it can affect one or both ears. Typical symptoms of these phantom noises are described as:
-Ocean waves

Causes of Tinnitus
Tinnitus is the term for the perception of noise when no external sound is present. It is often referred to as “ringing in the ears,” although some people hear hissing, roaring, whistling, chirping, or clicking. Tinnitus (often called head noise) is not a disease, but a symptom of another underlying condition – of the ear, the auditory nerve, or elsewhere. Tinnitus can be intermittent or constant, with single or multiple tones. Its perceived volume can range from very soft to extremely loud.

Factors that Contribute to Tinnitus
The exact cause (or causes) of tinnitus is not known in every case. There are, however, several likely factors which may cause tinnitus or make existing head noise worse. These include:
-Noise-induced hearing loss
-Wax build-up in the ear canal
-Certain medications
-Ear or sinus infections
-Age-related hearing loss
-Ear diseases and disorders
-Jaw misalignment
-Cardiovascular disease
-Certain types of tumors
-Thyroid disorders
-Head and neck trauma

Of the many factors that contribute to tinnitus, exposure to loud noises and hearing loss are the most common causes of tinnitus. Treating a hearing loss, either by medical management or with hearing aids can help. Modern digital hearing aids also provide tuned noise maskers, which may alleviate the tinnitus. Other new and effective tinnitus treatments are also available. If you have tinnitus, a comprehensive hearing evaluation by an audiologist and a medical evaluation by an otologist are recommended.

Tinnitus Treatment and Management
Tinnitus will not cause you to go deaf. Statistically, 50 percent of patients may express that their tinnitus decreases with time or is hardly perceptible. Generally, most patients will not need any medical treatment for tinnitus. There are several treatments and measures to help with the management of tinnitus.
Listening to a Fan or Radio
The external noise will mask some of the head noise. In addition, other sound source generators can be obtained and be adjusted to sound like environmental noises, and this is also effective in masking tinnitus. Generally, this is more advantageous if one is attempting to go to sleep.
Tinnitus Masker Device
A tinnitus masker is utilized for some patients. It is a small electronic instrument built into a hearing aid case. This device generates a sound which prevents the wearer from hearing his own head noise. The technology of a tinnitus masker is based on the principle that most individuals with tinnitus can better tolerate outside noise than they can their own inner head noise.
Biofeedback Training
This is effective in reducing the tinnitus in some patients. Biofeedback training consists of exercises in which the patient learns to control various parts of the body and relax the muscles. When a patient is able to accomplish this type of relaxation, tinnitus generally subsides. Most patients have expressed that the biofeedback offers them better coping skills.
Avoidance Measures
Other measures to control tinnitus include making every attempt to avoid anxiety, as anxiety will increase tinnitus. You should attempt to obtain adequate rest and avoid over-fatigue as patients who are tired seem to notice their tinnitus more. The use of nerve stimulants is to be avoided, as are excessive amounts of caffeine and smoking. Stimulating agents tend to make tinnitus worse.
Avoiding Certain Medications
There are some drugs which will also cause tinnitus. If you have tinnitus and are on medication, you should discuss the symptom of tinnitus with your physician. In many instances, once the drug is discontinued, the tinnitus will no longer be present. These medications include:
-Certain antibiotics (gentamicin, neomycin, and streptomycin)
-Antidepressants (amitriptyline and nortriptyline)
-Anti-inflammatory drugs (aspirin, ibuprofen, and naproxen)
-Antihypertensives (captoprin and ramipril)
-Heart medicines (propranolol and verapamil)
-Parkinson’s drugs (levadopa)
-Diuretics (furosemide and bumetanide)
-Supplements (vitamin A and niacin)

There are several medications which have been utilized to suppress tinnitus. Some patients benefit with these drugs and others do not. Each patient has an individual response to medication, and what works for one patient may not work for another. Some of these medications have been proven, however, to decrease the intensity of the tinnitus and make it much less noticeable. There is, however, no drug anywhere which will eliminate tinnitus completely and forever.
For tinnitus management, visit the American Tinnitus Association website for more information, ideas, and strategies at www.ata.org

Cause of Tinnitus2014-10-06T21:26:12-05:00

Tinnitus is the term for the perception of sound when no external sound is present. It is often referred to as “ringing in the ears,” although some people hear hissing, roaring, whistling, chirping, or clicking. Tinnitus is not a disease but a symptom of another underlying condition – of the ear, the auditory nerve, or elsewhere. Tinnitus can be intermittent or constant, with single or multiple tones. Its perceived volume can range from very soft to extremely loud. 50 million Americans experience tinnitus to some degree. Of these, about 12 million have tinnitus which is severe enough to seek medical attention. Of those, about two million patients are so seriously debilitated by their tinnitus, that their day to day functioning is affected.

The exact cause (or causes) of tinnitus is not known in every case. There are, however, several likely factors which may cause tinnitus or make existing tinnitus worse: noise-induced hearing loss, wax build-up in the ear canal, certain medications, ear or sinus infections, age-related hearing loss, ear diseases and disorders, jaw misalignment, cardiovascular disease, certain types of tumors, thyroid disorders, head and neck trauma and many others. Of these factors, exposure to loud noises and hearing loss are the most common causes of tinnitus. Treating a hearing loss, either by medical management, if indicated, or with hearing aids, may offer relief of tinnitus. Modern digital hearing aids also provide tuned noise maskers which may alleviate the tinnitus Other new and effective tinnitus treatments are also available. If you have tinnitus, a comprehensive hearing evaluation by an audiologist, and a medical evaluation by an otologist is recommended.

The Prevalence of Tinnitus2014-10-06T21:25:32-05:00

What is Tinnitus and How Many People Have It?

Tinnitus is the term for the perception of sound when no external sound is present. It is often referred to as “ringing in the ears,” although some people hear hissing, roaring, whistling, chirping, or clicking. Tinnitus can be intermittent or constant, with single or multiple tones. Its’ perceived volume can range from very soft to extremely loud.


50 million Americans experience tinnitus to some degree. Of these, about 12 million have tinnitus which is severe enough to seek medical attention. Of those, about two million patients are so seriously debilitated by their tinnitus, they cannot function on a “normal,” day-to-day basis.

Tinnitus Treatment and Management2014-10-06T21:27:19-05:00

Generally, most patients will not need any medical treatment for their tinnitus. For patients who are greatly bothered by tinnitus, they may use some masking techniques such as listening to a fan or radio which would mask some of their tinnitus. In addition, other sound source generators can be obtained and be adjusted to sound-like environmental sounds and this is also effective in masking tinnitus. This generally is more advantageous if one is attempting to go to sleep. A tinnitus masker is utilized in some patients. It is a small electronic instrument built into a hearing aid case. It generates a noise which prevents the wearer from hearing his own head noise. It is based on the principle that most individuals with tinnitus can better tolerate outside noise than they can their own inner head noise.

Biofeedback training is effective in reducing the tinnitus in some patients. It consists of exercises in which the patient learns to control the various parts of the body and relax the muscles. When a patient is able to accomplish this type of relaxation, tinnitus generally subsides. Most patients have expressed that the biofeedback offers them better coping skills.

Other measures to control tinnitus include making every attempt to avoid anxiety, as this will increase your tinnitus. You should attempt to obtain adequate rest and avoid overfatigue because generally patients who are tired seem to notice their tinnitus more. The use of nerve stimulants is to be avoided. Therefore, excessive amounts of caffeine and smoking should be avoided. Tinnitus will not cause you to go deaf and statistically, 50 percent of patients may express that their tinnitus with time decreases or is hardly perceptible.

There are other medications which have been utilized to suppress tinnitus. Some patients benefit with these drugs and others do not. Each patient has an individual response to medication, and what may work for one patient may not work for another. Some of these medications have been proven, however, to decrease the intensity of the tinnitus and make it much less noticeable to the patient. There is, however, no drug anywhere which will remove tinnitus completely and forever. There are some drugs which will also cause tinnitus. If you have tinnitus and are on medication, you should discuss the symptom of tinnitus with your physician. In many instances, once the drug is discontinued the tinnitus will no longer be present.

Visit the American Tinnitus Association website for more information, ideas and strategies at www.ata.org

A Patient’s Guide to Tinnitus2014-10-06T22:15:42-05:00

What is tinnitus?

Tinnitus, often described as ringing, buzzing or hissing sounds in the ears, is a symptom that can be related to almost every known hearing problem. Tinnitus can be temporary (acute) or permanent (chronic). It can also be constant or intermittent. Temporary tinnitus can be caused by exposure to loud sounds, middle or inner ear infections, and even wax on the eardrum. Because tinnitus can sometimes be treated medically, all patients who develop the symptom should first consult with an ear, nose and throat physician (otolaryngologist).

Tinnitus and hearing loss

Chronic tinnitus is usually associated with some degree of hearing loss. 90% of the patients who come to our Tinnitus Clinic have at least some hearing loss. Below are questions commonly asked by tinnitus patients:

Q: Does tinnitus cause hearing loss?
A: No. In fact, the reverse is true: whatever caused a person to have hearing loss (including noise exposure, infections, aging or genetic factors) is also responsible for the generation of tinnitus.

Q: Does tinnitus interfere with hearing?
A: No, tinnitus does not interfere with hearing, although it may affect ones attention span and concentration. On the other hand, tinnitus might seem louder if hearing loss increases (or if you wear ear plugs or ear muffs) because outside sounds will no longer reduce the perception of tinnitus.

Q: Does cutting the hearing nerve cure tinnitus?
A: Unfortunately, cutting the nerve does not relieve tinnitus often enough to recommend it as a treatment. It does, however, produce total deafness in the operated ear, may cause balance problems, and in some cases can make tinnitus worse.

How many people have chronic tinnitus?

According to Seidman & Jacobson,1 Approximately 40 million Americans have chronic tinnitus. For 10 million of these people, tinnitus can be a severely debilitating condition. However, for 30 million Americans with tinnitus, it is not bothersome. Tinnitus does not interfere with the enjoyment of life for the majority of people who experience it.

What can be done to help people who are bothered by chronic tinnitus?

I agree with Duckro et al2 who wrote: “As with chronic pain, the treatment of chronic tinnitus is more accurately described in terms of management rather than cure.” The goal of tinnitus management is not necessarily to mask or remove the patients physical perception of tinnitus sounds. Instead, we help patients learn to pay less attention to their tinnitus so that it bothers them less of the time. The realistic goal of an effective tinnitus management program is to help patients understand and gain control over their tinnitus, rather than it having control over them. Ultimately we hope to help patients progress to the point where tinnitus is no longer a negative factor in their lives. We want them to move from the “severely debilitated” group of tinnitus sufferers to the “not bothered by tinnitus” group and to enjoy their lives as much as possible.

There is usually no cure for chronic tinnitus that has been present for a year or more. One day, medical science will probably develop a way to eliminate the symptom. In the meantime, there are several effective management strategies that provide relief for most tinnitus patients.

Elements of an effective tinnitus management program

It is preferable for the program to have a Tinnitus Management Team rather than just one clinician. Depending on the clinical expertise required to help a particular patient, a Tinnitus Management Team could be composed of an otolaryngologist, an audiologist, a neurologist, a psychologist, a psychiatrist, and sleep or pain specialists.

The Tinnitus Management Team members should be willing and able to spend a substantial amount of time with each patient.

As much information as possible should be gathered about each patients medical, hearing, tinnitus, and psychosocial histories and conditions. Because each tinnitus patient is unique, therapeutic interventions should be individualized. The most successful treatment programs employ multimodal strategies that are designed to address the specific needs of each patient.

Patients should meet with Tinnitus Management Team members for an in-depth interview and review of their histories and conditions.

Patients should receive education about possible causes of tinnitus as well as reassurance and counseling regarding factors that could exacerbate or improve their condition.

Patients should receive the following:

  • Thorough otolaryngological and neurological examinations.
  • Comprehensive audiological evaluations.
  • Tinnitus evaluations that include matching tinnitus to sounds played through headphones.

Evaluations of acoustic therapies: based on the patients audiological evaluations, various devices should be described and demonstrated. These could include hearing aids, in-the-ear sound generators, tinnitus instruments (combinations of hearing aids + sound generators), tabletop sound generation machines, Sound Pillows, tapes or CDs.

For patients with significant hearing loss, hearing aids will not only improve their hearing ability, the devices will also reduce their perception of tinnitus. For patients with normal hearing, in-the-ear sound generators usually provide relief from tinnitus.

The Tinnitus Management Team should review the results of evaluations and explain them to the patient.

Recommendations can then be formulated and explained to the patient. Referral and contact information regarding physical or psychiatric evaluations, psychological counseling, and other recommended services or products should be provided.

Follow-up: patients should be encouraged contact the clinic anytime if they have questions and also to inform clinicians of their progressSome tinnitus patients also experience insomnia,3 anxiety4 or depression.5 These symptoms can form a vicious circle and exacerbate each other as illustrated in the diagram below:

Tinnitus does not always start this cycle. Some patients experienced depression, insomnia, or anxiety before their tinnitus began. Tinnitus can, however, make each of these problems seem worse. Also, patients who continue to experience depression, insomnia, or anxiety report that these factors can cause their tinnitus to seem more severe. In these cases, effective treatment of depression, insomnia, and anxiety is necessary. A combination of medication and/or psychotherapy should reduce the severity of all of these conditions including tinnitus.

Things to Avoid

  1. Harmful Sounds — Wear ear plugs or ear muffs as protection against loud sounds such as gunfire, gas lawn mowers, leaf blowers, chain saws, circular saws, other power tools and heavy machinery. Exposure to loud sounds can make tinnitus worse and can also cause additional hearing loss.
  2. Excessive use of alcohol, caffeine, or aspirin — However, moderate use of these products is usually O.K.
  3. False claims about tinnitus “cures” or herbal “remedies.” These do not exist for most cases of chronic tinnitus.

Even though a true “cure” for most cases of chronic tinnitus is not yet available, patients can obtain relief from the symptom with assistance from qualified and experienced clinicians.


1. Seidman MD, Jacobson GP. Update on tinnitus. Otolaryngol Clin North Am 1996 Jun;29(3):455-465.

2. Duckro PN, Pollard CA, Bray HD, Scheiter L. Comprehensive behavioral management of complex tinnitus: a case illustration. Biofeedback Self Regul 1984 Dec;9(4):459-469.

3. Folmer RL, Griest SE, Martin WH. Chronic tinnitus as phantom auditory pain. Otolaryngol Head Neck Surg 2001 Apr;124(4):394-400.

4. Folmer RL, Griest SE. Tinnitus and insomnia. Am J Otolaryngol 2000 Sept-Oct;21(5):287-93.

5. Folmer RL, Griest SE, Meikle MB, Martin WH. Tinnitus severity, loudness, and depression. Otolaryngol Head Neck Surg 1999 Jul;121(1):48-51.

For More Information

American Tinnitus Association
P.O. Box 5
Portland, OR 97207-0005
telephone: (800) 634-8978
email: tinnitus@ata.org
web: www.ata.org

OHSU Tinnitus Clinic
Mail Code NRC04
Oregon Health & Science University
3181 SW Sam Jackson Park Road
Portland, OR 97201-3098
telephone: (503) 494-7954
email: ohrc@ohsu.edu
web: https://www.ohsu.edu/ohrc/tinnitusclinic.

Author: Robert L. Folmer, Ph.D. This article was originally published on Healthy Hearing (www.healthyhearing.com) on 1/14/02 and is reprinted here, based on popular request.

Tinnitus: It Has a Certain Ring to It2014-10-06T22:17:08-05:00

Tinnitus: It Has a Certain Ring to It.

Robert E. Sandlin, Ph. D., Adjunct Professor of Audiology, Private Practice, San Diego, CA & Robert J. Olsson, M. A.

Robert E. Sandlin, Ph.D.
Adjunct Professor of Audiology
San Diego State University
San Diego, California


Robert J. Olsson, M.A.
Clinical Director
California Tinnitus & Hyperacusis Therapy Center
San Diego, California


Fifty million Americans experience some form of tinnitus. Twelve million have sought professional intervention. Tinnitus is a significant and common problem across the USA. For individuals with tinnitus, something is occurring within the auditory system, or elsewhere in the neural pathways, which gives rise to the perception of an acoustic-like sensation, for which there is no known external cause. There are two types of tinnitus; objective tinnitus, wherein the patient and the practitioner can hear the ongoing tinnitus, and, subjective tinnitus, heard only by the patient. By far, the most prevalent of the two is subjective tinnitus. Some estimates indicate that 95 percent of all tinnitus is subjective.

Since the audiologist has interest in conditions and anomalies that affect the auditory system, and since tinnitus is such a condition, it seems logical that our scope of training should provide differential diagnostic and therapeutic intervention management for tinnitus. However, many audiologists do not have an extensive background in the clinical management of tinnitus. This is not an indictment of audiologists as a professional body. Audiologists have strong clinical backgrounds in the assessment of hearing loss with regards to the type and degree of hearing loss, diagnostic testing and interpretation, prevention of hearing loss and in the provision of rehabilitative practices and devices for the hearing impaired. Tinnitus management is a relatively new arena for the audiologist and therefore, this paper serves to explore some of the issues associated with tinnitus management by the audiologist. Based on a thorough understanding of tinnitus, a definitive and defensible audiologic diagnosis can be made and a plan of rehabilitation formulated. It is not the purpose of this article to encourage audiologists to consider clinical involvement with tinnitus patients. Rather, our purpose is to offer an overview of major therapeutic approaches used in the treatment of this disorder.

At this time, there is no single therapeutic approach to the treatment of tinnitus that is sufficiently compelling to warrant its exclusive use above all others. There are no test batteries for tinnitus that provide reliable, clinical predictors of cause or treatment. Perhaps this uncertainty keeps many audiologists from being involved in treating the tinnitus patient. For others, the obstacle may be the depth of the psychic involvement of tinnitus sufferers with their condition, for tinnitus is as much an emotional issue as it is a ‘hearing’ issue.

Three Realities in Tinnitus Treatment:

There are three realities that one must be aware of in the treatment of tinnitus. First, there is no consensus as to what causes the problem. This is not to suggest that a rational answer for the mechanisms of tinnitus is not of interest, but rather that is not germane to our discussion of tinnitus treatment. Second, there is no known cure. Third, all present forms of therapeutic intervention treat the symptoms of the disorder, not the cause of the disorder.

Given these clinical limitations, what are the current therapeutic practices used by those who treat the tinnitus patient? Rather than offering an exhaustive analysis of each modality, we will discuss specific approaches related to both medical and non-medical intervention processes. Parenthetically, it has been our observation that the therapeutic modality chosen is most often determined by the professional and clinical backgrounds of the practitioner. Medical models seem to be supported by physicians. Non-medical models appear to be supported by other non-physician professionals. For example, psychologists rely on counseling, whereas audiologists generally employ some form of sound/auditory therapy.

Medical Management:

Medical models typically include the use of drugs to attempt to control the subjective loudness of the ongoing tinnitus, or (more commonly) to reduce the intensity of the patient’s response to it. For the most part, specific drugs seem to be the medical treatment of choice. Anti-anxiety and anti-depression medications reduce negative behaviors brought on by the presence of tinnitus. Other drugs used in the treatment process may include lidocaine, tocanide (oral cognate of lidocaine), Lasix, Misolene, Tegratol and others. Sandlin and Olsson (1999) reviewed the value of drug use and the risks assumed by the patient.

To date, there is no large body of evidence that warrants adapting one particular form of drug therapy. Each of the drugs mentioned above has proven beneficial to some. The general wisdom suggests that drugs constitute an ongoing process that permit the patient to derive some prolonged benefit. Brummet (1997) cautions the practitioner about possible consequences of drug use to control tinnitus. Most patients are treated with non-medical approaches.

Surgical Management:

Some, but very few, physicians have previously elected to perform surgery to eliminate or reduce or control tinnitus. Surgical management of tinnitus has not produced consistent, acceptable results. Surgically sectioning the auditory nerve of the offending ear, more often than not, does not solve the problem. For some, the subjective loudness of the tinnitus, as perceived in the post-operative period, is the same. For others, the tinnitus is exacerbated. Another form of surgical control of tinnitus involves microvascular surgery to eliminate or reduce vascular compression (i.e.‘vascular loops’) in the area of the VIII cranial nerve, theorized by some to be a frequent cause of tinnitus (Vernon, 1998). Another surgical approach involves direct electrical stimulation of structures deep in the brain (Shi & Martin, 1999).

Non-Medical Management:

Although there are many non-medical treatment modalities, only a few have received widespread acceptance The three most common, and most promising, non-medical methods of treatment are masking, tinnitus retraining therapy (also known as habituation therapy) and cognitive therapy. Alternative non-medical treatements include; biofeedback, psychological counseling, nutritional controls, acupuncture, gingko biloba, and Vitamin B 12. For an overview and comprehensive listing of herbs and vitamins purported to assist in the management of tinnitus, the reader is referred to the March 2000 issue of Tinnitus Today, published by the American Tinnitus Association (ATA). It should be noted that gingko biloba, despite its enthusiastic cohort of supporters, has been rather clearly shown to have no more benefit than a placebo (Drew & Davies, 1999). For a more comprehensive overview of treatment, the reader is referred to the book by Vernon (1998), Tinnitus – Treatment and Relief, available from the ATA (published by Allyn and Bacon).

Maskers and Combination Devices:

Masker use, as described by Dr. Jack Vernon, (1977, 1978, 1979, 1981) has proven to be effective for some, but not for all. Masking involves using an external signal (i.e., masking noise) sufficient to mask or ‘cover’ the ongoing tinnitus. The rationale is that an external acoustic stimulus is easier for the patient to ignore than the constant, ongoing tinnitus. Johnson (1998) reported the use of masker devices was effective about 35 to 40% of the time for those who investigated their use. Although not an impressive number in isolation, tinnitus sufferers who were in the 35 to 40% group find masker devices to be a godsend.

A combination device, an instrument containing both a hearing aid and a noise generating circuit, increased success rates to about 70%. That is, for those tinnitus patients having tinnitus and hearing loss sufficient to interfere with speech understanding, the combination device provided more relief than a masker device alone. The combination device also provided more relief than a hearing aid alone.

Maskers and combination devices continue to be used by tinnitus patients, suggesting that these instruments continue to be a valuable therapeutic modality, which provides relief and reduces the high stress level often associated with tinnitus.

Tinnitus Retraining Therapy

Dr. Pawel Jastreboff (www.tinnitus-pjj.com/) is recognized as the person who conceived and popularized the use of Tinnitus Retraining Therapy. In essence, Dr. Jastreboff postulated that acoustic, or acoustic-like perceptions, could be habituated to if they were not considered to be a harbinger of disease, danger or mental stress. For example, grandfather clocks ticks day in and day out. Yet those who live in a house with a grandfather clock have habituated to its ticking. Literally, they do not perceive it. Similarly, the refrigerator motor goes on and off many times during the day, yet one is not consciously aware of it. If you are sitting in front of a computer as you read this, you are probably not aware of its cooling fan. This ability to habituate to a number of sensory experiences is an integral part of human behavior.

Jastreboff’s (1987, 1994a, 1994b, 1990) account of the model goes something like this:
First, there is the perception of the stimulus. At the cortical level, a decision is made as to whether overt action of any kind is mandatory. If the conscious brain deems the stimulus does not demand some purposeful behavior, it can be habituated to (i.e., dismissed) if there are frequent occurrences of the same stimulus. Suppose, however, that tinnitus serves as the stimulus? The conscious brain attempts to make some rational decision. ‘Have I heard this before? What causes it? Is it some sort of precursor indicating I am going deaf? Do I have a serious disease? I haven’t heard this sound before and I must attend to it until I understand its cause.’ The cortex, failing to find an answer for the tinnitus’ presence, labels the sound a threat. The limbic system (the brain’s emotional control system) is thus alerted and activated to the tinnitus, and the tinnitus becomes a more significant problem for the patient.

Emotional involvement with tinnitus can produce psychological and physiological behaviors. Sleep disturbance, irritability, anger, loss of concentration and anti-social consequences are often reported. If these negative behaviors produced by the limbic system persist over time, then the autonomic nervous system may also become involved.

A self-perpetuating cycle of events takes place in the brain. The subconscious brain continues to maintain the conscious brain’s awareness of the tinnitus. The conscious brain continues to involve the subconscious brain, including the limbic and autonomic nervous systems, as it seeks a resolution that is not forthcoming. This cycle, in turn, serves to increase the subjective loudness and importance of the perceived sound.

Jastreboff suggests two things that are important in the control of the tinnitus:

1- The patient must habituate to the tinnitus itself, and
2- The patient must habituate to the emotional consequences of the tinnitus.

To habituate to the tinnitus, it is necessary to reduce the contrast between the ambient noise level and the subjective level of the ongoing tinnitus. To accomplish this task, bilateral noise generators are used These are acoustically similar to, but much quieter than, tinnitus maskers. Depending on the individual patient requirements and categorization, the level of the noise produced by the generators may be increased equal to the loudness of the tinnitus. This makes it more difficult for the conscious brain to concentrate on the ongoing tinnitus.

To habituate to the emotional consequences, directive counseling is used. The essence of this directive counseling, according to Jastreboff, is to make certain the patient understands what tinnitus is, demystifies it as much as possible, and realizes that it not an indicator of a serious physical or psychological problem. To achieve this change of thinking, it is necessary to reinforce one’s understanding of the disorder. To do so, the patient must be adequately counseled. This is accomplished through a prearranged and individually scheduled series of follow-up appointments wherein the clinician and the patient review the patient’s current status.

Jastreboff maintains that the Tinnitus Retraining Program treatment program typically achieves its greatest success within 18 to 24 months. Importantly, this does not mean that nothing positive happens until then. Rather, it indicates that it probably will take 18 to 24 months to achieve maximal results.

Clinics throughout the world, our own included, report success rates in the 80-90% range with tinnitus retraining therapy. Success is determined by the following criteria:

1. Tinnitus awareness is reduced by 20%.
2. The impact of tinnitus on the quality of life is reduced 20%.
3. Tinnitus annoyance is decreased by 20%.

The success criteria listed above represent minimal levels of improvement. The majority of patients exceed the 20% level of change.

Cognitive Therapy

One of the common threads found in therapeutic approaches to tinnitus treatment is the effective use of counseling intervention. One such counseling intervention process is Cognitive Therapy. ‘Cognition’ refers to thought processes. ‘Therapy’ refers to some form of management intended to create change in the thinking process. Therefore, the purpose of cognitive therapy is to alter the negative thinking of the patient and bring about a more realistic assessment and understanding of the problem. Sweetow (1986) reports on management of the tinnitus patient using cognitive therapy as a therapeutic base.

Dr. David Burns (1980) is to be given much of the credit in the development of Cognitive Therapy. Cognitive Therapy is a form of behavioral modification. The practitioner attempts to modify the ways in which the patient may react to his or her tinnitus. Dr. Burns coined the phrase ‘cognitive distortions.’ These distortions are defined in the following ways:

1. All or nothing thinking: If performance falls short of perfect, you see yourself as a total failure.
2. Overgeneralization: You see a single negative event as a never-ending pattern of defeat.
3. Mental Filter: You see a single negative detail and dwell on it exclusively.
4. Disqualifying the positive: You reject positive experiences by insisting that for some reason or another, they don’t count.
5. Jumping to conclusions: You make a negative interpretation of a particular event,although there is no evidence to support the negative conclusion.
6. Magnification: You exaggerate the importance of things or events.
7. Emotional reasoning: You think your negative emotions reflect the way things really are.
8. Should statements: You try to motivate yourself with should or shouldn’t statements.
The emotional consequence is guilt.
9. Labeling and mislabeling: Instead of describing your action as an error, you attach a negative label, such as ‘I’m no good,’ to yourself
10. Personalization: You see yourself as the cause of some negative event, even though you were not.

It is evident that these distortions of thinking tend to perpetuate the patient’s negative behaviors. Failure to modify cognitive distortions can have undesirable consequences and lead to destructive behaviors. Although Cognitive Therapy was not intended primarily for tinnitus patients, it has been useful in their counseling process.

Whether, and to what extent, audiologists should be involved in cognitive therapy with tinnitus patients is a controversial topic. There are strong arguments both for and against. On the one hand, audiologists, more than anyone else, understand the auditory system, and provide hearing system rehabilitation. Furthermore, audiologists engage in counseling routinely. All aural rehabilitation beyond the provision of hearing aids is by definition counseling. The hearing aid fitting process itself involves counseling. On the other hand, audiologists generally do not have explicit training in emotionally centered counseling, and need to work within their scope of practice and licensure.


The incidence of tinnitus is rather high. Early on, there was little interest in the clinical management of this disorder. That is changing. Increased awareness and interest, spurred on by the American Tinnitus Association, have contributed greatly to the number of clinicians, audiologists included, providing therapeutic programs.

Although the cause, or causes, of tinnitus is unknown, treating the symptoms of the disorder has been beneficial. Even though there is no one absolute therapeutic approach or treatment modality, there are medical and non-medical intervention programs, which have proven to be of significant value. It is no longer defensible to tell a patient to ‘go home and learn to live with it.’

We are convinced that audiologists will find clinical and research challenges in working with the tinnitus patient. However, if the audiologist is to diagnose and manage those with tinnitus, we strongly recommend that he or she seek sufficient academic and clinical training prior to the provision of service. Reading a few articles is a wholly inadequate preparation. In particular, attempting to implement tinnitus retraining therapy without proper instruction can leave the patient in a worse condition.

We feel that at some future date a cure will be found for tinnitus. It is quite possible that the cure will come in the form of specific drugs, which are effective in altering neurochemical behaviors that reduce or eliminate the onset or awareness of tinnitus without the serious side effects of the medications now sometimes employed. We also believe that a compelling therapeutic approach will emerge.

Regardless of what the future holds, there is a current need to provide treatment for those who suffer from this disorder and seek relief. As individuals who have worked with the tinnitus patient for
several decades, the authors can say without fear of contradiction that providing tinnitus management therapy is a demanding challenge that can stimulate your clinical and intellectual abilities and can greatly impact and improve the quality of life of your patients.

Direct correspondence or inquiries to:

Robert J. Olsson, M.S. Ed., M. A., Au.D. Candidate, FAAA
California Tinnitus & Hyperacusis Therapy Center
6505 Alvarado Road, Suite 103
San Diego, California 92120
(619) 583 6612


Brummelt, R.E. (1997). Are there safe and effective drugs available to treat mv tinnitus? In J. Vernon (Ed). Tinnitus: Treatment and Relief Allyn & Bacon, Needham Heights, MA. Pp, 34-42.

Burns, D. (1980). Feeling Good: The new mood therapy. Avon Books, New York pp.4243.

Drew, S.J. Davies, W.E. (1999). Gingko biloba in the treatment of timutus. Preliminar,~ results of a matched pair. double blinded placebo controlled trial involnug 1115. In the proceedings of the 6~internateional tinnitus seminasr. CD ROM. Tinnitus & Hyperacusis Centre, London

Johnson, R. (1998), The masking of tinnitus. In J~ Vernon (Ed). Tinnitus: Treatment and relief Allyn & Bacon, Needham Heigths, MA. Pp.164-173

Jastreboff, P.J.., Brennan, F.F., Sasaki, C.T. (1987). Behavioral and electrophhysiological animal model of tinnitus. In H. Feldman ~d). Proceedings of the III International Tinnitus Seminar, Muenster, Karlsruhe, Karsch Verllag. Pp.95-99

Jastreboff, P.J., (1990). Phantom limbs: Scientific American 266, pp: 120-126

Jastreboff P.J., Sasaki, C.T. (1 994a). An animal model of tinnitus: a decade of development. Am J Cto: 15:19: pp 19-27

Jastreboff, P.J., Hazell, J.P.W., Graham R.L.(1994 b). Neurophysiological model of tinnitus: Dependence of the minnimal masking level on treatment outcome. Hear Res: 80: pp.216-232

Sandilin, R.E., Olsson, R. J. (1999). Evaluation and selection of maskers and other devices used in Treatment of Tinnitus and Hyperacusis. Trends in Amplifiction, 4(1).

Shiy, Y.B., Martin, W.H. (1999). Deep brain stimulation – a new treatment of tnniitus? In proceedings of the 6~ international tinnitus seminar. CD ROM, Tinnitus & H,~peracusis Centre, London.

Sweetow, R. (1986). Cognitive aspects of tinnitus patient management. Ear Hear 7(6): 390-396. Sweetow, R. (1989). Adjunctive approches to tinnitus-patient management. Ear Hear. 42:11; pp.3843

Vernon, J. (1979). The use of masking in relief of tinnitus. In H. Silverstein, H Norell (Eds). Neurological Surgery of the Ear. Birinnigham, AL: Aesculapius.

Vernon, J. (1981). The history of masking as applied to tinnitus, In Tinnitus Proceedings of the First International Tinnitus Seminr. New York. The Jour Laryn and Cto, Ashford, Kent, UK: Invicta Press: Suppl 4, pp 76-79)

Vernon, J. (1982). Relief of tinnitus by masking treatment. In G.M. English ~d). Ctola~ngology. Philadelphia: Harper & Rowe: pp.1-21.

Vernon, J.( 1998). Tinnitus: Treatment and relief Allyn & Bacon, Needham Heights. MA.

Managing Chronic Tinnitus As Phantom Auditory Pain2014-10-06T22:16:25-05:00

Managing Chronic Tinnitus As Phantom Auditory Pain

Robert L. Folmer, Ph. D., Assistant Professor of Otolaryngology, Oregon Health Sciences University, Portland, OR

Robert L. Folmer Ph.D.
Tinnitus Clinic, Oregon Hearing Research Center, Department of Otolaryngology, Oregon Health Sciences University, Portland

Correspondence to:
Robert L. Folmer, Ph.D.
Oregon Hearing Research Center
Mail Code NRC04
3181 SW Sam Jackson Park Road
Portland, OR 97201-3098

Telephone: (503) 494-8032
Fax: (503) 494-5656
email: folmerr@ohsu.edu
Web address: www.ohsu.edu/ohrc/tinnitusclinic

Patients experiencing severe chronic tinnitus have many characteristics in common with chronic pain patients. This study explored these similarities in order to formulate treatment strategies that are likely to be effective for patients experiencing phantom auditory pain. Answers to questionnaires filled out by 160 patients who visited our Tinnitus Clinic were analyzed. Patients rated the severity and loudness of their tinnitus; completed the State-Trait Anxiety Inventory (STAI) and an abbreviated version of the Beck Depression Inventory (aBDI). Patients received counseling, audiometric testing, and matched the loudness of their tinnitus to sounds played through headphones. Tinnitus severity was highly correlated with patients degree of sleep disturbance, STAI and aBDI scores. The reported (on a 1-to-10 scale) — but not the matched — loudness of tinnitus was correlated with tinnitus severity, sleep disturbance, STAI, and aBDI scores. Treatment recommendations are discussed in reference to these results.

Tinnitus is the sensation of sound without external stimulation. Jastreboff1 referred to tinnitus as phantom auditory perception. Outside of the auditory system, the most infamous example of phantom perception is reported by some patients who have lost a finger, hand, arm, toe, foot or leg. These patients continue to perceive the presence of — and sometimes pain from — appendages that have been amputated. Missing appendages that continue to generate sensations are known as phantom limbs; painful sensations attributed to them are referred to as phantom limb pains.

Similarities between the perception of chronic tinnitus and the perception of chronic pain were listed by Tonndorf2: both tinnitus and pain are subjective sensations; both are continuous events that may change in quality and/or character over time; both have the potential to be masked/reduced by appropriate sensory stimulation or medications; both the auditory and somatosensory systems possess a well-developed network of efferent fibers that appear to exercise some control over afferent activity; de-afferentation (that is, a disruption in the balance between afferent and efferent activity) might explain both perceptions; both perceptions are under the control of the central nervous system; efforts to treat both sensations peripherally have met with limited success.

To this list of similarities Moller3 added: chronic pain and some forms of tinnitus are characterized by hypersensitivity to sensory stimulation; the anatomic locations of the neural structure(s) generating the sensations of chronic pain or tinnitus are different from the locations of the structures to which these symptoms are referred (the ears for tinnitus or the peripheral location of injury for pain); the strong psychological component that often accompanies chronic pain or tinnitus supports the hypothesis that brain areas (limbic/sympathetic) other than those responsible for sensory perception are involved; pain and tinnitus are both heterogenous, multimodal disorders that can have different causes and pathophysiologies; consequently, multimodal approaches should be used to treat these disorders.

Muhlnickel et al4 used magnetoencephalography to compare the organization of auditory cortex in 10 chronic tinnitus patients with that of 15 non-tinnitus control subjects. Results of their study demonstrated that the organization of auditory cortex in tinnitus patients was significantly different from the control subjects, especially in brain areas corresponding to perceived tinnitus frequencies. Muhlnickel et al4 concluded that similarities between these data and the previous demonstrations that phantom limb pain is highly correlated with cortical reorganization suggest that tinnitus may be an auditory phantom phenomenon.

Jeanmonod et al5 hypothesized that positive neurological symptoms (including neurogenic pain and tinnitus) might be attributable to abnormal neuronal activity in the thalamus (specifically, low threshold calcium spike bursts that are related to thalamic cell hyperpolarization). A subsequent magnetoencephalographic study by Llinas et al6 demonstrated that neurogenic pain and tinnitus are both characterized by thalamocortical dysrhythmia resulting from inhibitory asymmetry between high- and low-frequency thalamocortical modules at the cortical level. These findings support the assertions of Jastreboff1, Tonndorf2, Moller3 and others who contend that abnormal asymmetries of neuronal activity are responsible for tinnitus generation.

It is clear that the perception of chronic tinnitus has many physiological characteristics in common with the perception of chronic pain. In his behavioral nosology, Briner7 used the phrase phantom auditory pain to describe severe chronic tinnitus. The present study will explore similarities in psychological characteristics, reactions, and coincidental disturbances exhibited by patients who experience chronic tinnitus or pain. The goal is to contribute to the development of treatment strategies that are likely to be effective for patients experiencing phantom auditory pain.

Detailed questionnaires were mailed to patients prior to their initial appointment at the Oregon Health Sciences University Tinnitus Clinic. These questionnaires requested information about patients medical, hearing, and tinnitus histories. Appendix 1 contains twelve questions that constitute the Tinnitus Severity Index8 which is an efficient indicator of the negative impacts of tinnitus upon patients. The State-Trait Anxiety Inventory (STAI)9 and an abbreviated version of the Beck Depression Inventory (aBDI)10 were also included.

Data relating to patient demographics, audiometric thresholds, matched and reported (according to the 1-to-10 scale in Appendix 1) tinnitus loudness, tinnitus severity, sleep difficulties, aBDI and STAI scores were analyzed.

RESULTS: Data from the last 160 patients (112 males, 48 females; mean age 50.912.8 years; age range 17-87 years) who visited our clinic were analyzed. Table 1 contains the grand averaged pure tone air conduction thresholds for these patients. This pattern of high-frequency sensorineural hearing loss is typical for our patient population.

Table 2 contains mean STAI, aBDI, tinnitus severity scores, matched and reported tinnitus loudness values for three groups of patients based on their response to question 12: Does your tinnitus interfere with sleep? Note that mean values for all of these measures tend to increase with greater sleep interference. Statistically significant differences exist between the No and Often sleep interference groups on all measures except the matched loudness of tinnitus. Statistically significant differences exist between the Sometimes and Often sleep interference groups on all measures except the matched and reported loudness of tinnitus. Statistically significant differences exist between the No and Sometimes sleep interference groups on two measures: severity and reported loudness of tinnitus.

Table 3 contains mean STAI, aBDI, tinnitus severity scores, matched and reported tinnitus loudness values for all of the patients in the study. Because there were no significant differences between male and female patients in any of these measures, correlation analyses were performed on mean values derived from the group as a whole. Fifty patients (31%; 30 males, 20 females) reported that they had current depression. Fifty nine patients (37%; 35 males, 24 females) reported a history of depression. Scores on the aBDI ranged from 0 to 28 (maximum possible score = 39). Thirty four patients (21%) scored 8 or higher on the aBDI which, according to Dobie & Sullivan,10 can indicate that a patient is experiencing major depression.

Table 4 contains Pearson Correlation coefficients and 2-tailed p values that resulted from statistical analyses of these measures. Note that tinnitus severity is highly correlated with STAI and aBDI scores. The reported — but not the matched — loudness of tinnitus is correlated with tinnitus severity, STAI, and aBDI. Both anxiety indices were highly correlated with each other and also with the aBDI.

Results from this and other studies demonstrated that the severity of chronic tinnitus is often correlated with insomnia11, anxiety12, and depression.13 As illustrated in Figure 1, these symptoms can form a vicious circle and exacerbate each other. Insomnia, anxiety, and depression are also common co-symptoms for patients with chronic pain. In fact, the word pain can be substituted for the word tinnitus in Figure 1 and the relationships among these symptoms will remain the same.

What other characteristics do pain patients have in common with tinnitus patients? Numerous studies contributed to the following list: hypochondriasis; obsessive-compulsive tendencies; high degrees of self-focus/attention; perceived lack of control over symptoms/life events; catastrophic thinking; focusing/dwelling on symptoms; maladaptive coping strategies; reluctance to admit to problems other than immediate physical symptoms; the patients perceived severity of their condition is not necessarily related to objective measures of stimulus intensity; severity of symptoms can be related to patients perceptions of attitudes or reactions of others to their condition. Of course, every patient does not necessarily possess any or all of these characteristics. However, these traits are more likely to occur in pain or tinnitus patients who perceive their symptoms to be severe or debilitating.

Did the onset of chronic tinnitus cause these behaviors or co-symptoms to occur? Dobie & Sullivan10 reported that approximately 50% of their tinnitus patients with depression had at least one bout of major depression before the onset of their tinnitus. Rizzardo et al14 reported that 50% of their patients exhibited psychological symptoms before the onset of tinnitus; 71% of these patients experienced greater than normal levels of depression, anxiety, hypochondriasis, and/or neuroticism after tinnitus began.

Rizzardo et al14 stated that there appears to be a link between psychological distress and tinnitus in a potential somatopsychological and psychosomatic vicious circle (a psychological predisposition to react emotionally to events, tinnitus as a source of distress that reinforces the symptom, accentuating hypochondriac fears). Dobie & Sullivan10 agree that some people are more predisposed to depression than others and that tinnitus is one of many internal and external triggers that can precipitate major depression in susceptible individuals. Perhaps the most logical conclusion was stated by Halford & Anderson12: It is considered that the causal relationship between these psychological variables and tinnitus severity is likely to be bi-directional.

How can this information be used to help patients with severe chronic tinnitus? Because tinnitus patients share many similarities with chronic pain patients, otolaryngology clinicians can use some of the same techniques and strategies in tinnitus treatment that are employed in pain management. These include the following15:
1. Treatment of depression using medications and/or psychotherapy. Sullivan et al16 demonstrated that successful treatment of depression can reduce the severity of tinnitus for patients experiencing both maladies. Some antidepressant medications will also improve sleep patterns and reduce anxiety. Identification of tinnitus patients who are also experiencing depression can be accomplished by using the complete Beck Depression Inventory17 or other appropriate instruments (such as the aBDI10).
2. Treatment of insomnia using medications, relaxation therapy, and/or acoustic therapy (this includes pleasant sounds generated in the bedroom by tabletop devices, tapes, CDs, pillow speakers, fans, or small fountains).
3. Treatment of anxiety using medications, relaxation therapy, psychotherapy, biofeedback, hypnosis, massage, or any other appropriate stress management techniques.
4. Any neuroses, psychoses, or other maladaptive behaviors need to be assessed and addressed during a series of psychotherapy/counseling sessions. Many experts agree with House18 who wrote that most tinnitus patients can often be helped by psychological intervention. If the physician, nurse, or audiologist does not feel that they have the time or training to provide the counseling personally, the clinician should refer the patient to an appropriate mental health professional.

Acoustic therapy is one way to give patients some control over — and relief from — their tinnitus. This can include the devices mentioned above as well as in-the-ear sound generators, hearing aids, or combination instruments (hearing aids + sound generators).

Because patients with severe tinnitus often have negative affectivity (characterized by tendencies to be distressed, worried, anxious, and self-critical), their counseling should be as positive and productive as possible. Jakes et al19 admonished clinicians: instead of advising patients that they must learn to live with it with no advice as to how this is to be achieved, one could rather advise them that distress about tinnitus is not determined by having tinnitus, and that an intrusive, subjectively loud tinnitus will not necessarily produce a strong effect on the patient’s social, domestic, or economic functioning. After appropriate tests have ruled out acoustic neuroma or other retrocochlear etiologies for a patient’s tinnitus, clinicians should reassure the patient that tinnitus is usually related to hearing loss20 and that it is a harmless perception of sound generated by the auditory system. Tinnitus will not necessarily become worse with time and it does not portend additional hearing loss nor the manifestation or exacerbation of any other medical condition.

Because each tinnitus patient has a unique medical, psychological and social history, therapeutic interventions should be individualized. In fact, the most successful treatment programs employ multimodal strategies that are designed to address the specific needs of each patient. Hawthorne et al21 concluded that psychiatric intervention significantly reduced the emotional distress in a population of tinnitus patients. This was achieved by not only dealing with the somatic disease but also by psychiatric management of the coincidental mental distress. This was very time-consuming. Many of the patients had complex difficulties; although they all had tinnitus and most had mood disturbance, no history was typical. The problems were protean and the psychotherapeutic interventions had to be tailored for each person.

How effective are individualized, multimodal treatment programs at reducing the severity of chronic tinnitus? We conducted a long-term follow-up study of 174 patients (130 males, 44 females; mean age 55.9 years) who were evaluated and treated in our clinic between 1994-1997. 22 One to four years after their initial clinic appointment (mean = 2.3 years), these patients reported no significant change in self-rated loudness of tinnitus. However, there was statistically significant improvement in nine of the twelve measures of tinnitus severity (including feeling irritable or nervous; feeling tired or stressed; difficulty relaxing; difficulty concentrating; interference with their required activities; interference with their overall enjoyment of life; interference with sleep; the amount of effort to ignore tinnitus; and the amount of discomfort usually experienced when tinnitus is present) for the entire patient population. A subset of 40 patients who purchased and used in-the-ear devices (hearing aids, maskers, or combination instruments) reported significant improvement in all twelve measures of tinnitus severity.

If a clinician has assessed and treated every reasonable medical cause for a patient’s tinnitus, and the patient reports little improvement in tinnitus severity, the clinician should do one of two things: 1) spend the time necessary to effectively treat the patient according to procedures described here and elsewhere23; or 2) refer the patient to a comprehensive treatment center with experienced personnel who are willing and able to spend a substantial amount of time with each patient. For a certain number of patients with phantom auditory pain, only a specialized treatment program of this type can help them to improve their condition. Telling patients that since nothing can be done for tinnitus they just have to learn to live with it is both erroneous and counterproductive.

1. Jastreboff PJ. Phantom auditory perception (tinnitus): mechanisms of generation and perception. Neurosci Res 1990;8:221-254.
2. Tonndorf J. The analogy between tinnitus and pain: a suggestion for a physiological basis of chronic tinnitus. Hear Res 1987;28:271-275.
3. Moller AR. Similarities between chronic pain and tinnitus. Am J Otol 1997;18:577-585.
4. Muhlnickel W, Elbert T, Taub E, Flor H. Reorganization of auditory cortex in tinnitus. PNAS 1998;95:10340-10343.
5. Jeanmonod D, Magnin M, Morel A. Low-threshold calcium spike bursts in the human thalamus: common physiopathology for sensory, motor and limbic positive symptoms. Brain 1996;119:363-375.
6. Llinas RR, Ribary U, Jeanmonod D, et al. Thalamocortical dysrhythmia: a neurological and neuropsychiatric syndrome characterized by magnetoencephalography. PNAS 1999;96(26):15222-15227.
7. Briner W. A behavioral nosology for tinnitus. Psychol Rep 1995;77:27-34.
8. Meikle MB. Methods for evaluation of tinnitus relief procedures. In: Aran JM, Dauman R, editors. Tinnitus 91: proceedings of the fourth international tinnitus seminar. Amsterdam: Kugler Publications;1992. p. 555-562.
9. Spielberger CD. State-Trait Anxiety Inventory for adults (Form Y). Palo Alto, California: Mind Garden, 1998.
10. Dobie RA, Sullivan MD. Antidepressant drugs and tinnitus. In: Vernon JA, editor. Tinnitus treatment and relief. Boston: Allyn and Bacon;1998. p. 43-51.
11. Folmer RL, Griest SE. Tinnitus and insomnia. Am J of Otolaryngology 2000;21(5):287-293.
12. Halford JBS, Anderson SD. Anxiety and depression in tinnitus sufferers. J Psychosomatic Res 1991;35:383-390.
13. Folmer RL, Griest SE, Meikle MB, Martin WH. Tinnitus severity, loudness and depression. Otolaryngology – Head and Neck Surgery 1999; 121:48-51.
14. Rizzardo R, Savastano M, Bona Maron M, et al. Psychological distress in patients with tinnitus. J Otolaryngol 1998;27(1):21-25.
15. Irving GA, Wallace MS. Pain management for the practicing physician. New York: Churchill Livingstone; 1997.
16. Sullivan M, Katon W, Russo J, et al. A randomized trial of nortriptyline for severe chronic tinnitus. Arch Intern Med 1993;153:2251-2259.
17. Beck AT, Steer RA. Beck Depression Inventory manual. San Antonio Texas: Psychological Corp.;1987.
18. House PR. Personality of the tinnitus patient. J Laryngol Otol 1984; Suppl 9:233.
19. Jakes SC, Hallam RS, Chambers C, Hinchcliffe R. A factor analytical study of tinnitus complaint behavior. Audiol 1985;24:195-206.
20. Schleuning A. Medical aspects of tinnitus. In: Vernon JA, editor. Tinnitus treatment and relief. Boston: Allyn and Bacon;1998. p. 20-27.
21. Hawthorne MR, Britten SR, OConnor S, Webber P. The management of a population of tinnitus sufferers in a specialized clinic: Part III. The evaluation of psychiatric intervention. J Laryngol Otol 1987;101:795-799.
22. Folmer RL, Griest SE. Improvements in tinnitus severity: a follow-up study. In Hazell J (ed): Proceedings of the Sixth International Tinnitus Seminar. London: The Tinnitus and Hyperacusis Centre, 1999;546-549.
23. Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol 2000;11(3):162-177.

There IS something you can do about tinnitus!2014-10-06T22:13:58-05:00

Barbara Tabachnick Sanders, American Tinnitus Association (ATA), Director of Education


Nearly 50 million people in the U.S.A. have tinnitus. Tinnitus may be described as a ringing, hissing or other noise heard in the ears or head when there is no outside source for the sound. Tinnitus is not a disease but a symptom of an underlying condition in some part of the body – the ear, the auditory nerve, the brain, or elsewhere.

Fortunately, the majority of people who experience tinnitus are able to ignore or dismiss the internal noise they hear as nothing more than a nuisance. But for about 12 million Americans, the noises are unrelenting and distressing. When tinnitus is that severe, it can interfere with one’s ability to sleep, concentrate, hold a job, and interact socially.

Since 1979, the American Tinnitus Association (ATA) has been an advocate and resource for millions of people who have troubling tinnitus and who need answers. ATA is a donation-supported organization that leads the nation in funding tinnitus research. ATA educates patients, adults and children alike;  their families, doctors, and all hearing health professionals regarding the causes of tinnitus and the many ways to relieve it. ATA produces clear and helpful informational brochures for tinnitus patients on coping strategies, treatments, the effects of loud noise on hearing, and the first steps to take.

ATA’s Web site (www.ata.org) is a current and ready resource for anyone seeking tinnitus answers and information today. ATA provides local self-help group and professional resource lists, elementary school hearing conservation programs, the quarterly journal Tinnitus Today, and, perhaps most importantly, hope to thousands of Americans with tinnitus.


 For millions of people, the cause (or etiology) of their tinnitus is unknown. The most common known cause of tinnitus is exposure to loud noise — usually either a single intense blast (like from a shotgun blast) or a long-term noise exposure (such as from working in a factory for many years).

Tinnitus can also be caused by:

  • ear infections

  • ear wax (cerumen) buildup

  • use of aspirin, quinine, alcohol, certain antibiotics, and other drugs

  • underactive thyroid gland

  • allergies

  • middle ear disorders (such as otosclerosis)

  • Meniere’s disease

  • disorders of the temporomandibular joint (TMJ)

  • injury involving the neck or head, like whiplash

  • acoustic neuroma, a tumor on the auditory nerve

  • Certain prescription drugs (such as “mycin” antibiotics) and non-prescription drugs (such as aspirin) can cause tinnitus in susceptible people. Tinnitus-causing drugs might also make existing tinnitus louder. Ask your doctor or pharmacist, or look on the PDR side effects list for tinnitus-causing drugs. If you are prescribed one of those drugs, ask about a substitute medication.


    Many people ask, “Do I have tinnitus?” The simple answer is, “If you hear it, you have it.” The not-so-simple answer is, “Tinnitus is a symptom of something that has gone wrong somewhere in the body – maybe in the ear, or along the auditory pathway to the brain, or in the brain, or elsewhere.” In the majority of cases, the source of the tinnitus is idiopathic – that is, without a known source. Nevertheless, many physical disorders do include tinnitus as a primary or secondary symptom, and these physical disorders can only be addressed and “ruled out” by professionals.


    If you have tinnitus, get a thorough medical and audiological examination. These examinations may uncover a treatable cause and point you to the most appropriate treatment. ATA can give you the names and phone numbers of ENT physicians, audiologists, and other health professionals in your area who are versed in tinnitus management.

    There are many treatments that help people manage their tinnitus. Some common treatment protocols are outlined below:

    Masking is the introduction of an external, pleasant, low-volume sound that reduces the perception of the tinnitus. Maskers (or sound generators) are as small as hearing aids and can be worn the same way. New digital and programmable masking devices are available. These are specialty devices manufactured by hearing aid manufacturers, and can be “tuned” to help mask the sounds of your tinnitus. Masking can also be achieved with environmental tabletop sound machines and special tinnitus masking recordings. Some patients use creative homemade maskers, such as fans, or radios “de-tuned” between stations, or soft music, or even CDs (or cassettes), which play the sounds of a rain forest or a waterfall.

    “Tinnitus retraining therapy (TRT) is a treatment that combines the introduction of sound (usually with masker-like sound generators set to a non-masking level) with specialized and highly beneficial patient education and directive counseling. The goal of TRT is to reduce the patient’s awareness of his or her tinnitus. TRT is available through many audiology offices.”

    with hearing aids helps to bring back environmental sounds that can naturally mask tinnitus. Since many people with tinnitus have hearing loss, there is often a double benefit for those patients. For example, patients with hearing loss and tinnitus may discover hearing aids help them hear more easily, which can — in and of itself — reduce stress and make the tinnitus more tolerable. In some cases, the amplified sounds heard through hearing aids mask the tinnitus.

    Several medications have shown limited, but positive effects on tinnitus. Xanax, Neurontin, Pamelor, Klonopin, and dozens of other prescription drugs are helping people cope more effectively with their tinnitus. All medications have the potential for unwanted side effects. These side effects need to be weighed against the possible benefit they might deliver. Of course, all medical options should be reviewed with your physician.

    Some herbs have been reported to help manage or reduce tinnitus. While there is little scientific evidence of these successes, there are many anecdotal and individual reports of success. Herbs can behave like medicines in the body and interact with other medicines being taken. As a precaution, always talk with your doctor before trying herbal preparations.

    Acupuncture, biofeedback, and hypnosis have also been used with anecdotal success. Relaxation and stress-reduction exercises (such as progressive relaxation) can help make tinnitus more tolerable. It is well known by professionals that stress and anxiety can exacerbate (or worsen) tinnitus.

    Although not exactly a tinnitus treatment, the use of hearing protection is an important part of any tinnitus treatment plan. Existing tinnitus is often made worse by exposure to loud noise. The ATA suggests that earplugs, protective earmuffs, or a combination of the two be worn in very noisy situations. Foam earplugs are relatively inexpensive (less than two dollars a pair at most pharmacies) and, if properly situated in the ear, can cut out 15 to 20 decibels of sound. “Musicians’s Earplugs” are customized earplugs that can cut out 15 decibels across all frequencies, which enables the wearer to hear music and conversations, just at a quieter level. Customized earplugs are more expensive, but they are made to comfortably and exactly fit the wearer’s ears. .

    Since a combination of treatments is often what a patient needs to obtain relief, it usually takes persistence and patience to find the right tinnitus management therapy for each individual.

    Tinnitus Research

    There are dozens of tinnitus-specific research studies in progress around the world. The American Tinnitus Association, the Tinnitus Research Consortium, the National Institute of Deafness and Other Communication Disorders, and various universities have funded these studies. Some of the research projects are examining the benefits of cochlear implants, electrical stimulation, and experimental drug therapies for tinnitus patients, and at brain scanning to see which parts of the brain “light up” when tinnitus is present.

    Education and Support for Patients

    While the search for a cure continues, ATA’s educational programs and support networks help fill in the gaps for tinnitus patients. ATA sponsors a national network of health professionals – ENTs, audiologists, mental health professionals, and hearing aid specialists- all who treat tinnitus patients. ATA also sponsors a national self-help network. Lists of local support groups and tinnitus health professionals are available from ATA. Many audiologists assist or become tinnitus support group leaders.

    ATA reaches out to children with our Hear for a Lifetime program. Hear for a Lifetime helps 1st through 3rd graders understand that they can walk away from loud noise, turn it down, or cover their ears to conserve their good hearing.

    Educating Health Professionals about Tinnitus

    Tinnitus sufferers usually seek medical attention when their tinnitus first appears. Unfortunately, the majority of patients are told by their doctors that “nothing can be done” and that they need to “learn to live with it.” But most are not told how to live with it, or about the many treatment options available (see above).

    The impact that unremitting tinnitus has cannot always be measured or understood. Consequently, many doctors dismiss tinnitus, to the great (and sometimes tragic) dismay of the patient. ATA is committed to educating health professionals about current tinnitus treatments, the value of one-on-one support, the benefits of counseling and the unnecessary havoc created when they tell patients to live with it.

    Today, more professionals than ever are taking the time to explore the myriad of tinnitus treatment options with their patients. Many understand that the solution to a particular patient’s tinnitus might lie outside their professional domain. And importantly, more are willing to work in concert with other health professionals for the benefit of the patient.

    When healthcare professionals, family members, and patients learn about tinnitus – its treatments, causes, and breakthroughs in research, ATA accomplishes the best part of its mission: to help tinnitus patients find the answers and help they seek.

    Frequently Asked Questions about Tinnitus

    What is tinnitus?

     Tinnitus is the perception of sound when no external sound is present. The noise can be ringing, screeching, hissing, humming, clicking, chirping, buzzing, even music; constant or intermittent; subtle or perceived as incredibly loud.

    Now that I have tinnitus, what is the first thing I should do?

    See an ear, nose, and throat doctor (otolaryngologist) and an audiologist to rule out any serious medical problem. Next, learn about your options and get involved in choosing your treatments. Use earplugs or other hearing protection in noisy environments to possibly avoid worsening the tinnitus. Join the American Tinnitus Association to keep current on new tinnitus treatments and to support research.

    Can tinnitus be prevented?

    Yes, some tinnitus can be prevented. Protect your ears with earplugs and/or protective earmuffs in all loud environments! Since many drugs can cause tinnitus, ask your doctor or pharmacist about the possible side effects of medications (and herbs) before you take them.

    Does having tinnitus meant I am going deaf?

    No. While an estimated 80% of people with tinnitus have some hearing loss, a significant number of people with tinnitus have normal hearing. Hearing loss may often help reveal or worsen existing tinnitus since the background sounds that had previously been heard, and were helping to “mask” the tinnitus, are no longer being heard.

    Is there a nutritional approach to treating tinnitus?

     There is no research on this subject. However, some patients report anecdotally that their tinnitus is made worse by consuming certain foods, such as cheese, salt, caffeinated foods (coffee, tea, chocolate), red wine, and aspartame (Nutrasweet).

    How can I join the American Tinnitus Association?

    You can write, call, or go online to join ATA.
    American Tinnitus Association
    P.O. Box 5
    Portland, OR 97207-0005
    Annual membership is $25 in the U.S., $40 outside of the U.S.

    All ATA members receive the quarterly journal, Tinnitus Today, featuring research updates, Jack Vernon’s Q & A column and articles of special interest to tinnitus patients and their families. Members also receive six educational brochures on treatments, coping, noise, and more; lists of local tinnitus support groups and health care providers; discounts on tinnitus-related books and videos; and access to the Member’s Only section on ATA’s Web site (www.ata.org).


    Tinnitus can be a debilitating problem. But fortunately there are many successful treatment programs. If you have tinnitus, see an audiologist and a physician for a complete examination before starting a treatment plan. It might take a combination of treatments (for example, TRT and medication, or masking and biofeedback) and possibly some lifestyle changes (avoiding certain foods, alcohol, caffeine, or tobacco) to best manage your tinnitus.

    Additionally, if a health care professional has told you to “go home and learn to live with it” without telling you HOW to live with it, seek other professional advice. And please, visit ATA?s Web site (www.ata.org) or call 800-634-8978 for the latest tinnitus information and self-help resources.

    The American Tinnitus Association: A Resource for Enhancing Tinnitus Patient2014-10-06T22:22:37-05:00

    The American Tinnitus Association: A Resource for Enhancing Tinnitus Patient Services

    Cheryl McGinnis, MBA, Executive Director of the American Tinnitus Association.

    Introduction and History:

    The American Tinnitus Association (ATA) assists healthcare providers in serving patients who have, or are learning to cope with, tinnitus. An estimated 40-50 million people in the United States experience tinnitus, 10-12 million of these individuals have sought help for their tinnitus and 2.5 million people report their tinnitus is debilitating (AAA, 2001).

    Hearing healthcare services in general, and audiologic services in particular, are in demand as these patients seek answers and relief from the ringing, hissing, roaring, or other sounds that are perceived, but cannot be attributed to an external sound source.

    Charles Unice, MD, and Jack Vernon, PhD, founded the American Tinnitus Association (ATA) in 1971 for the purpose of providing financial support for tinnitus research. During the early years, the University of Oregon Medical School (now known as the Oregon Health Sciences University) sponsored ATA as an affiliate nonprofit association. Advisors to the ATA were scientists, academicians, clinicians, businessmen, and public officials. Volunteers completed all activities of the association until 1979 when a small full-time staff was hired and the ATA was incorporated as a 501©(3) organization. Robert Hocks, a Portland businessman, was the first Board of Directors Chairman and Gloria Reich, PhD, was the first Executive Director.

    The ATA currently has a 13 member Board of Directors and a 22 member Scientific Advisory Committee (SAC). The Board of Directors is responsible for the governance issues of the association including setting policies. The Scientific Advisory Committee members are physicians, audiologists, and other researchers who review research grant applications and advise the Board and staff on scientific matters.

    ATA’s research grant program funds tinnitus research projects at the nation’s top institutions. Many ATA funded projects have gone on to receive support from the National Institutes of Health. Please visit our Web site (www.ata.org) for a listing of research projects funded. To date, ATA’s support for tinnitus research exceeds $1.3 million. Our goal is to fund $500,000 in research projects for each of the next three years. Musicians including Styx and Barbara Streisand, as well as others, have donated money for tinnitus research.

    Importantly, funding research was not (and is not) the only function of the ATA. People with tinnitus and tinnitus treatment specialists requested many things of the ATA. Callers asked for information about the condition and for techniques that would provide relief. In 1978, ATA initiated workshops, regional meetings, and seminars for professionals and patients to learn about tinnitus.

    Public Service Announcements (PSAs) to raise public awareness featured such celebrities as Lou Ferrigno (actor in Incredible Hulk TV series), William Christopher (actor in M*A*S*H series), Tony Randall (actor in Odd Couple series), and Al Unser (auto racing driver).

    Tinnitus Diagnosis and Management:

    The diagnosis and management of tinnitus has become highly specialized. The long wait to obtain appointments in tinnitus clinics across the U.S. gives testimony to the need for this focused, specialized care. A person troubled by tinnitus will usually seek services from a family physician, an ENT, or an audiologist. This is where appropriate diagnosis must begin. ATA staff encourage tinnitus patients to seek diagnosis and treatment from physicians and audiologists. A multidisciplinary team approach is recommended (AAA, 2001). Interestingly, hearing loss is a co-existing condition for 90% of individuals who have tinnitus.

    The most common cause of tinnitus is exposure to excessively loud noise – either a single intense event (acoustic trauma), or long-term noise exposure. Other causes of tinnitus might include; physical trauma to the head or neck, acoustic trauma, conditions such as hypertension, acoustic neuroma, ear infection, impacted cerumen, ototoxic drugs, thyroid disease, vascular disorders, TMJ disorder, nutritional deficiency, aneurysm, multiple sclerosis, and many others. Prescription and over-the-counter drugs can exacerbate tinnitus. In some cases, tinnitus will lessen or completely disappear when the offending drug is discontinued.

    The physician’s role in tinnitus diagnosis and treatment is typically to rule out, counsel or treat physical or medical causes of tinnitus. In some cases, successful treatment of a medical condition can relieve tinnitus. Most patients who seek medical help for their tinnitus learn there is no serious medical problem causing their condition. This knowledge is sometimes enough to allow some patients to adapt to their tinnitus. Other people, however, experience tinnitus as disruptive and stress inducing, and need help learning how to cope with and manage the sounds.

    The audiologist’s role is multifaceted and relates to comprehensive testing (including; diagnostic audiometric evaluations, loudness discomfort levels, tinnitus pitch and loudness matching, minimal masking level, questionnaire administration and interpretation), hearing protection, hearing aids, tinnitus maskers, assistive listening devices, tinnitus management therapies, counseling and tinnitus support group participation and facilitation.

    Sometimes referral to a professional counselor or other specialists experienced in managing tinnitus patients, is particularly beneficial when stress, depression or obsession with tinnitus is noted by the audiologist or the physician.

    Tinnitus Treatment Strategies:

    Among the vast treatments for tinnitus, the most common treatments include:

    *Hearing aids are often used to help ‘cover-up’ tinnitus by increasing the sounds of the environment. Multiple memory (multiple program) hearing aids are sometimes useful as they provide alternative sounds to listen to, depending on the tinnitus and the acoustic environment.

    *Specialized tinnitus maskers which produce low-level sound to reduce or eliminate the perception of tinnitus. Masking can cause ‘residual inhibition,’ the reduction or elimination of tinnitus that continues for a short time after the masker is removed.

    *Combined hearing aid/tinnitus maskers, in one unit. These units allow the patient to select which circuit to listen to, either the masker or the traditional hearing aid circuit.

    *Tinnitus retraining therapy (often referred to as TRT) involves directive counseling to de-mystify tinnitus. Tinnitus retraining therapy also uses maskers to help a person learn to be less aware of, or to habituate to, the sounds of their tinnitus.

    *Biofeedback is essentially a method of relaxation, sought as a stress-reduction technique to help control heart rate, blood pressure, breathing, and muscle tension.

    • Drugs can help ease stress, depression, and sleep difficulties. Many of these drugs are available by prescription only, and most have met with minimal, although highly variable success.

    *Counseling services can assist with stress, depression or anxiety that may accompany tinnitus. Cognitive therapy helps patients alter the way they react to tinnitus by identifying and eliminating negative thought and behavior patterns.

    *Alternative treatments sought include naturopathy, hypnosis, massage therapy, and acupuncture.

    Professional advice is beneficial to best match the patient with an appropriate treatment strategy. Referring patients to the ATA will further enhance the services provided directly. For people seeking tinnitus information, often the local healthcare professionals are the best first step. Secondarily, ATA can provide additional patient support though our education, advocacy, research and support services.

    ATA Services and Resources:

    The American Tinnitus Association’s many programs are organized under the acronym E.A.R.S. – Education, Advocacy, Research, and Support.

    The education program includes ‘Hear For a Lifetime,’ which teaches 1st through 3rd grade students how to avoid tinnitus. Additionally, we offer outreach programs to doctors, audiologists, and hearing aid specialists regarding tinnitus and treatment as part of our education program.

    Our two most visible and popular means of providing information are through our quarterly journal, Tinnitus Today, which is sent to all ATA members, and the ATA Web site www.ata.org.

    ATA offers books, videos, audiotapes, informational brochures, and posters. Our bibliography service includes over 4,000 article titles related to tinnitus. ATA’s six educational brochures answer the most common questions about tinnitus and are available in English and in Spanish.

    Brochures are sold for 25 cents each to members and $1.00 each to non-members. Information covered is described by the titles:


  • Coping with the Stress of Tinnitus; Information about Tinnitus;

  • Noise and Its Effects on Hearing and Tinnitus;

  • If You Have Tinnitus: the First Steps to Take;

  • Tinnitus Treatments: What’s New, What Works; and

  • Understanding Tinnitus: Advice for Family and Friends.

    ATA sponsors several public forums around the U.S. annually. Our public forums feature panels of audiologists, physicians, and researchers with expertise in tinnitus. Equal time is given for attendees to ask questions of the experts.

    Our advocacy department researches public policy issues, supports hearing conservation activities, and provides resources for people needing specific assistance on such things as pursuing insurance claims. Our national media campaign aims to raise awareness, generate support for research, and educate people on ways to prevent tinnitus.

    The support program includes self-help groups, help network volunteers, and provider listings – all resources to help people cope with tinnitus. Self-help groups meet regularly to share coping strategies, offer a supportive environment, and emphasize positive change. ATA has a network of 50 self-help groups. Group leaders receive information and organizational support from the ATA. Frequently, leaders schedule guest speakers – audiologists, biofeedback specialists, medical doctors, psychologists, and others who actively treat tinnitus patients.

    Help Network Volunteers are friendly telephone, e-mail, and letter contacts that listen and respond to callers needing understanding, comfort, and information. In this way, support and comfort is given while engaging in a healthy dialogue about ways to successfully manage tinnitus.

    Our Tinnitus Provider Listing includes the names and contact information of physicians, audiologists, and other healthcare providers who have an active interest in treating tinnitus. The listed professionals self-report their specialties and services and are listed by region for distribution to interested patients.

    Tinnitus is often as frustrating for the clinician to treat as it is for the patient to resolve. The ATA is a resource available to tinnitus patients and healthcare professionals. We invite you to become involved in the ATA as a member yourself.

    You can contact us by calling (800) 634-8978, writing to us at PO Box 5, Portland, OR 97207, or e-mailing tinnitus@ata.org.

    Recommended Resources and References:

    AAA (2001). American Academy of Audiology Position Statement on ‘Audiologic Guidelines for the Diagnosis and Management of Tinnitus Patients.’ Audiology Today, Vol 13, No 2, March/April 2001.

    Tyler, R. S., (Ed.). (2000). Tinnitus Handbook. San Diego, CA: Singular Thomson Learning.

    Vernon, J. A. & Tabachnick Sanders, B. (2001). Tinnitus questions and answers. Needham Heights, MA: Allyn & Bacon.

    To view all Healthy Hearing Articles on Tinnitus, please click here.

    Why Arent Hearing Conservation Practices Taught in Schools?2014-10-06T22:12:26-05:00

    Robert L. Folmer, Ph.D., Oregon Hearing Research Center, Oregon Health & Science University, Portland, OR
    Robert L. Folmer, Ph.D.
    Oregon Hearing Research Center
    Mail Code NRC04
    Oregon Health & Science University
    3181 SW Sam Jackson Park Road
    Portland, OR 97201-3098

    Telephone: (503) 494-8032
    Fax: (503) 494-5656
    email: folmerr@ohsu.edu
    web: www.dangerousdecibels.org

    According to the OSHA’s Occupational Noise Exposure Standard and Hearing Conservation Amendment (published in the Federal Register on March 8, 1983), if workers are exposed to excessive sound levels, “the employer shall administer a continuing, effective hearing conservation program.”

    Children are often exposed to excessive levels of sound

    At some time in their young lives, 97% of 273 third graders surveyed by Blair et al (1996) had been exposed to hazardous sound levels. Chermak & Peters-McCarthy (1991) reported that 43% of the elementary school students in their study routinely listened to a personal stereo system or television at a loud volume. Thirty percent of the students said they sometimes participated in other noisy activities (such as shooting firearms or attending auto races); however, only 5.5% of the students ever used hearing protection while engaged in these activities. Sources of excessive sound exposure for children include loud music (Lipscomb, 1972; Meyer-Bisch, 1996), real or toy firearms (Woodford, 1973; Lipscomb, 1974), power tools (Roeser, 1980; Plakke, 1985), fireworks (Ward & Glorig, 1961; Gupta & Vishwakarma, 1989), loud toys (Axelsson & Jerson, 1985; Hellstrom et al, 1992); snowmobiles or other loud engines such as jet skis or motorcycles (Bess & Poynor, 1972).

    Noise-Induced Hearing Loss (NIHL) in children

    When humans of any age are repeatedly exposed to hazardous sound levels without using adequate hearing protection, the common result is noise-induced hearing loss (NIHL). Several studies have demonstrated that the prevalence of NIHL among children is increasing (Woodford & O’Farrell, 1983; Chermak & Peters-McCarthy, 1991; Montgomery & Fujikawa, 1992). Anderson (1967) reported a surprisingly high prevalence of NIHL in school-aged children more than 30 years ago. Blair et al (1996) claimed that 1% of the school age population has some degree of NIHL. Niskar et al (2001) estimated that 12.5% of all children in the United States aged 6 to 19 years have noise-induced hearing threshold shifts (NITS) in one or both ears. Studies by Weber et al (1967), Cozad et al (1974) and Hull et al (1975) all found relatively large numbers of school boys who failed hearing screenings at 4000 Hz — an indicator of NIHL. Evidence of NIHL was also observed in Swedish (Costa et al, 1988), Chinese (Morioka et al, 1996) and French (Meyer-Bisch, 1996) children.

    What are the consequences of NIHL in children?

    Even though the degree of high frequency hearing loss detected in these studies was generally mild and usually not even noticed by the children involved, Lass et al (1986) warned: “the significance of the problem lies in the insidious nature of noise-induced hearing loss (NIHL) as well as the cumulative interaction between this type of loss and sociocusis. It follows then that a mild high-frequency hearing loss in a 16-year-old high school student may well deteriorate to a debilitating degree in later life. Additionally, there is another factor that could indicate that damage to the auditory system in this population is more prevalent and/or significant than might be believed from results of hearing tests.” Prasher (1998) reiterated the assertion that audiometric thresholds may be normal despite substantial loss of outer and inner hair cells.

    Children with high frequency hearing loss in Anderson’s (1967) study had more learning difficulties and behavioral problems than their classmates who had normal hearing. Bess et al (1998) reported that, compared to their classmates with normal hearing, children with minimal sensorineural hearing loss (MSHL) scored significantly lower on the Comprehensive Test of Basic Skills; they also exhibited more behavioral problems and lower self-esteem. Thirty-seven percent of children in the study with MSHL failed at least one grade compared to the school district average of eight percent or less.

    What should be done?

    In response to this trend of increasing NIHL among children, numerous experts have recommended the implementation of hearing conservation education programs in schools:

    “Educating students to the possible consequences of future vocational and avocational noise exposure, as well as instructing them in how to protect their hearing when exposed to noxious noise levels, may prevent further hearing loss and perhaps extensive communication problems later in life.” (Cozad et al, 1974)

    “The findings from this survey certainly suggest the need for some form of hearing conservation program at the high school level.” (Roeser, 1980)

    “Hearing-conservation programs are needed to provide students with the proper information about hearing and hearing loss, and about the protective measures to prevent hearing loss at home, in school (e.g., in industrial art classes), and at social/recreational events.” (Lass et al, 1987a)

    “Education on the hazards of noise is needed at all levels, and early education is particularly important.” (Florentine, 1990)

    “Strategies to prevent damage from sound exposure should include the use of individual hearing protection devices, education programs beginning with school-age children, consumer guidance, increased product noise labeling, and hearing conservation programs for occupational settings.” (National Institutes of Health Consensus Development Conference Statement, 1990)

    “Due to the rising numbers of children acquiring noise-induced hearing loss (increasingly in the elementary school years), education about the impact of excessive noise on hearing would be a worthwhile addition to the health curriculum of any school district. It is only through early and repeated education that we may reach these young people so that they may responsibly prevent permanent hearing loss.” (Anderson, 1991)

    “Hearing conservation programming should begin no later than third or fourth grade in order to prevent noise-induced hearing loss.” (Chermak & Peters-McCarthy, 1991)

    “Education regarding the potential dangers of high decibel levels for students should begin in the elementary grades.” (Montgomery & Fujikawa, 1992)

    “Comprehensive, age-appropriate educational programs must be developed for elementary and secondary students and their parents to acquaint them with potentially hazardous noise sources in their environment.” (Brookhouser et al, 1992)

    “Otolaryngologists should support efforts to provide information about NIHL as part of health education in our schools.” (Dobie, 1995)

    “The percentage of high-frequency hearing losses is greater in the upper grades, suggesting that hearing conservation programs should be introduced in the elementary grades.” (Blair et al, 1996)

    “Educate the public and especially children to practice lifetime hearing health with regular audiograms and ear protection against toxic noise.” (Wheeler, 2000)

    Even though children are often exposed to excessive sound levels, there are no policies requiring hearing conservation practices to be taught in our nation’s classrooms. In spite of mounting evidence that the prevalence of NIHL is increasing among children — and contrary to the recommendations of countless audiologists and other experts in the field — basic hearing conservation information (that could prevent many cases of NIHL) remains conspicuously absent from most school curricula.

    Why aren’t hearing conservation practices taught in most schools?

    • Lack of public awareness about how excessive sound exposure damages hearing and the consequences of hearing loss. In general, people tend to take hearing for granted until their own hearing loss becomes so severe that it interferes with communication. Because most teachers, school administrators, and parents are not aware of the problem, hearing conservation and the preventability of NIHL are given a low priority if they are considered at all.
    • Lack of effective dissemination of existing hearing conservation programs, curricula, and materials.

    Berger & Royster (1987) made the following statement about occupational hearing conservation programs: “In large part, what is needed is not the development of new solutions, but rather the broad dissemination of existing techniques plus the education and motivation of management and labor alike to speed the implementation of effective programs.” If we substitute the words “administrators, teachers, parents, and students” for “management and labor,” this statement would also apply to school hearing conservation programs.

    The problem is not a lack of hearing conservation education materials and resources. The problem is not a lack of agreement among experts about what should be done. Given the paucity of hearing conservation instruction that is offered in our nation’s schools, the problem is a lack of dissemination of this important information to our children.

    • Lack of perpetuation of hearing conservation instruction. A relatively small number of teachers, audiologists, nurses, or trained volunteers have presented hearing conservation curricula in selected classrooms across the country. However, if the person who implemented the program retires, moves, or stops making such efforts for other reasons, hearing conservation education in those schools usually diminishes or ceases completely.

    What can be done to address these problems?

    • Raise public awareness about hearing; how hearing can be damaged by excessive sound exposure; the consequences and permanent nature of sensorineural hearing loss; how NIHL can and should be prevented.
    • Inform teachers and school administrators about existing hearing conservation programs, curricula, and materials that can be used in classrooms.
    • Persuade teachers and school administrators to integrate hearing conservation messages into existing lesson plans on hearing, sound, music, science, math, and health.
    • Seek a mandate from state and local school boards, and state or federal legislatures to implement and perpetuate hearing conservation instruction to each new 1st, 4th, 7th, and 10th grade class of students in all of the nation’s schools on a continuing basis.

    What elements should be included in a hearing conservation education program for children?

    Lass et al (1987a) recommended the following: Instruction about 1) normal auditory mechanisms; 2) types of hearing loss and their causes; 3) noise and its effect on hearing; 4) warning signs of noise-induced hearing loss; and 5) specific recommendations for preventing noise-induced hearing loss. Anderson (1991) added the following topics to the list: Instruction about consequences of hearing loss and how it can affect life quality; what kinds of noises or noisy activities are most dangerous to hearing?

    It is not necessary to spend exorbitant amounts of class time to cover the basics of hearing, hearing loss and hearing conservation. Teachers should be encouraged to integrate the information into existing lesson plans on hearing, sound, music, science, math, and health.

    Chermak et al (1996) reported that students who received the hearing conservation message through an interactive style of instruction exhibited greater improvement on post-instruction tests than students who heard it in a more traditional lecture format. Results from a study by Bennett & English (1999) agree with this conclusion. Therefore, a hearing conservation program for children should be as interactive as possible and utilize a variety of media and activities.

    What resources are available to facilitate hearing conservation instruction in classrooms?

    Table 1 lists twelve organizations that produce or use a variety of materials in a comprehensive hearing conservation curriculum for school-age children.

    To view Table 1 please Click Here. (Requires Adobe Acrobat)

    The Crank It Down! curriculum includes construction of a sound thermometer, spaghetti and Play-doh model of stereocilia, and demonstrations of proper usage of hearing protection. The “Know Noise” video and “Unfair Hearing Test” audiocassette — a list of 10 common words with high frequencies filtered out to simulate hearing loss — (both available from the Sight and Hearing Association) also are used. Crank It Down! has been presented by trained guest speakers to students in second, third, fourth, and fifth grades. Presentations to students in second and third grades can be shortened and simplified by leaving out the sound thermometer and “Unfair Hearing Test” activities. Crank It Down! materials are available from the National Hearing Conservation Association.

    Dangerous DecibelsTM is a hearing health education program being developed by the Oregon Hearing Research Center and the Oregon Museum of Science and Industry. Program goals are to raise public awareness about mechanisms of hearing and hearing loss, and to educate people about sources of, effects of, and how to protect themselves from hazardous levels of sound. When completed, the program will include 11 permanent museum exhibits; classroom curricula and activities for all school-age children; training and materials for teachers; epidemiological and educational research components.

    HIP Talk was developed by the House Ear Institute in Los Angeles. The curriculum, originally designed for fifth- and sixth-graders, includes information about ear anatomy (illustrations are provided), environmental noise, hazardous sounds, and ways to protect hearing. Also included are separate quizzes for elementary, middle school, and high school students; the “HIP Talk” video (produced in 1992, 34 minutes); 400 pairs of foam ear plugs to distribute to students; and a form that solicits comments about the curriculum from teachers. The video is a significant component of the curriculum. Because much of the video consists of a panel discussion among musicians and a moderator, it will not hold the attention of most students. However, a brief segment of the video contains an effective simulation of hearing loss: the audio portion of a Flintstones cartoon is filtered to demonstrate mild, moderate, and severe high frequency hearing loss.

    Know Noise is distributed by the Sight and Hearing Association of St. Paul, Minn. The Know Noise program includes lesson plans, activities, illustrations, and transparencies for grades three through six. Also included are the “Know Noise” video (produced in 1993, 14 minutes), the “Unfair Hearing Test” audiocassette, supplemental articles, and teacher comment forms. The main weakness of this program is the video. Although it conveys some useful information, the “Know Noise” video, like many hearing conservation videos, is dated. This problem is recognized by producers of educational materials: videos are expensive to make and they tend to go out of date quickly. If the fashions, music, and dialogue seem antiquated or “corny” to an audience of children (especially older children), these distractions tend to dilute any educational message contained in the video. However, carefully selected portions of videos that are less susceptible to this aging process (and still convey pertinent information) may be used indefinitely.

    Wise Ears, one of the most complete hearing conservation curricula for children available on the Internet, is provided by the National Institute on Deafness and Other Communicative Disorders (NIDCD). Their web site includes lesson plans and activities for grades three through six, questions and answers about hearing, an interactive sound ruler, and three videos. NIDCD also distributes the video “I Love What I Hear” (produced in 1992, 8 minutes) to be used in the classroom.

    Table 2 lists seventeen organizations that produce one or a few types of material (e.g., a video or printed material) designed for children or which could be adapted for use in a classroom.

    To view Table 2 please Click Here. (Requires Adobe Acrobat)

    Perry Hanavan’s “Virtual Tour of the Ear” web site provides a comprehensive list of links to dozens of web sites that contain a variety of illustrations, photographs, micrographs, and animations of the outer, middle, and inner ear as well as auditory structures in the brain.

    To encourage people to protect their ears from hazardous noise, most hearing conservation programs include some information about how the ear works and how excessive sound exposure causes permanent damage to inner ear structures. One of the fastest and most entertaining ways to convey this information is to use animations such as those in “The Hearing Video” produced by the Workers’ Compensation Board of British Columbia, Canada. Portions of this fast-paced, informative, and entertaining video can be used with students of all ages. One negative aspect of “The Hearing Video” is its relatively high purchase price. A less expensive video that illustrates auditory system function and damage is “Quieting the Skies” (available from N.A.S.A. Central Operation of Resources for Educators). A much more technical, anatomically accurate and expensive video series, “Human Hearing,” is being produced in four volumes by Caldwell Publishing Co., in Redmond, Wash.

    Most of the other resources listed in Table 2 provide basic information (booklets, pamphlets, posters, or web sites) about hearing and the consequences of excessive sound exposure. For example, Howard Leight Industries produces posters and leaflets with photomicrographs of a normal cochlea with the caption “This is your inner ear,” and a cochlea damaged by excessive sound exposure with the caption “This is your inner ear without plugs. Any questions?”

    How effective are hearing conservation programs for children?

    Numerous studies evaluated the effectiveness of hearing conservation programs administered in elementary schools (Chermak & Peters-McCarthy, 1991; Blair et al, 1996; Chermak et al, 1996; Bennett & English, 1999), middle schools (Lass et al, 1987b; Knobloch & Broste, 1998), and high schools (Lewis, 1989; Lerman et al, 1998; Lukes & Johnson, 1998). All these studies concluded that, compared to preinstruction responses, students’ performance on hearing knowledge and noise awareness questionnaires improved significantly after they participated in hearing conservation programs.

    It is much more difficult to assess potential changes in behavior that might occur as results of these programs. Knobloch and Broste (1998) reported that 87.5% of students who received hearing conservation instruction used hearing protection devices in noisy environments at least some of the time. Only 45% of students in control groups who did not receive such training reported using hearing protection in similarly noisy conditions. Studies by Lass et al (1987b), Lewis (1989), and Chermak et al (1996) all reported postinstruction increases, compared to preinstruction responses, in student intentions to protect their ears from excessive sounds.

    The ultimate goal of hearing conservation education programs is to reduce the prevalence of noise-induced hearing loss among children and adults. Even if hearing conservation instruction began immediately in all of the nation’s classrooms, it would take years to determine if such instruction had any effect on the prevalence of NIHL in the United States. However, every person who can be spared the debilitating consequences of NIHL (including communication difficulties, isolation, frustration, depression, or chronic tinnitus) is worth the effort.


    Hearing conservation should receive attention and resources similar to those allocated for anti-smoking, anti-drug, teen pregnancy, and sexually transmitted disease education programs that are now presented routinely in public schools. The time is now to wage a public health campaign against NIHL, a potentially debilitating condition that, according to Dobie (1995), “is almost entirely preventable.”

    This article was adapted from Folmer RL, Griest SE, Martin WH. Hearing conservation education programs for children: a review. Journal of School Health 2002;72(2):51-57.


    Anderson KL. Hearing conservation in the public schools revisited. Seminars in Hearing 1991;12(4):340-364.

    Anderson UM. The incidence and significance of high-frequency deafness in children. Am J Dis Child 1967;113:560-565.

    Axelsson A, Jerson T. Noisy toys: a possible source of sensorineural hearing loss. Pediatrics 1985;76(4):574-578.

    Bennett JA, English K. Teaching hearing conservation to school children: comparing the outcomes and efficacy of two pedagogical approaches. J of Educational Audiology 1999;7:29-33.

    Berger EH, Royster JD. The development of a national noise strategy. Sound and Vibration 1987;21(1):40-44.

    Bess FH, Dodd-Murphy J, Parker RA. Children with minimal sensorineural hearing loss: prevalence, educational performance, and functional status. Ear and Hearing 1998;19(5):339-354.

    Bess FH, Poynor RE. Snowmobile engine noise and hearing. Arch Otolaryngol 1972;95:164-168.

    Blair JC, Hardegree D, Benson PV. Necessity and effectiveness of a hearing conservation program for elementary students. J of Educational Audiology 1996;4:12-16.

    Brookhouser PE, Worthington DW, Kelly WJ. Noise-induced hearing loss in children. Laryngoscope 1992;102:645-655.

    Chermak GD, Curtis L, Seikel JA. The effectiveness of an interactive hearing conservation program for elementary school children. Lang Speech Hearing Services in Schools 1996;27:29-39.
    Chermak GD, Peters-McCarthy E. The effectiveness of an educational hearing conservation program for elementary school children. Lang Speech Hearing Services in Schools 1991;22:308-312.

    Costa OA, Axelsson A, Aniansson G. Hearing loss at age 7, 10 and 13 – an audiometric follow-up study. Scand Audiol 1988;Suppl 30:25-32.

    Cozad RL, Marston L, Joseph D. Some implications regarding high frequency hearing loss in school-age children. J of School Health 1974;44(2):92-96.

    Dobie RA. Prevention of noise-induced hearing loss. Arch Otolaryngol Head Neck Surg 1995;121:385-391.

    Florentine M. Education as a tool to prevent noise-induced hearing loss. Hearing Instruments 1990;41(10):33-34.

    Folmer RL, Griest SE, Martin WH. Hearing conservation education programs for children: a review. J of School Health 2002;72(2):51-57.

    Gupta D, Vishwakarma SK. Toy weapons and firecrackers: a source of hearing loss. Laryngoscope 1989;99:330-334.

    Hellstrom PA, Dengerink HA, Axelsson A. Noise levels from toys and recreational articles for children and teenagers. Br J of Audiology 1992;26:267-270.

    Holland HH. Attenuation provided by fingers, palms, tragi, and V51R ear plugs. JASA 1967;41(6):1545.

    Hull FM, Meilke PW, Timmons RJ, Willeford JS. The national speech and hearing survey: preliminary results. ASHA 1975;13:501-509.

    Knobloch MJ, Broste SK. A hearing conservation program for Wisconsin youth working in agriculture. J of School Health 1998;68(8):313-318.

    Lass NJ, Woodford CM, Lundeen C, et al. The prevention of noise-induced hearing loss in the school-aged population: a school educational hearing conservation program. J of Auditory Res 1986;26:247-254.

    Lass NJ, Woodford CM, Lundeen C, et al. A survey of high school students’ knowledge and awareness of hearing, hearing loss, and hearing health. Hearing J 1987a;15-19.

    Lass NJ, Woodford CM, Lundeen C, et al. A hearing-conservation program for a junior high school. Hearing J 1987b;32-40.

    Lerman Y, Feldman Y Shnaps R, et al. Evaluation of an occupational health educational program among 11th grade students. Am J of Industrial Med 1998;34:607-613.

    Lewis DA. A hearing conservation program for high-school-level students. Hearing J 1989;42(3):19-24.

    Lipscomb DM. The increase in prevalence of high frequency hearing impairment among college students. Audiology 1972;11:231-237.

    Lipscomb DM. Dangerous playthings. Noise: The Unwanted Sounds. Chicago: Nelson- Hall; 1974.

    Lukes E, Johnson M. Hearing conservation: community outreach programs for high school students. AAOHN J 1998;46(7):340-343.

    Meyer-Bisch C. Epidemiological evaluation of hearing damage related to strongly amplified music (personal cassette players, discotheques, rock concerts) — high- definition audiometric survey on 1364 subjects. Audiology 1996;35:121-142.

    Montgomery JK, Fujikawa S. Hearing thresholds of students in the second, eighth, and twelfth grades. Language, Speech, and Hearing Services in Schools 1992;23:61-63.

    Morioka I, Luo WZ, Miyashita K, et al. Hearing impairment among young Chinese in a rural area. Public Health 1996;110:293-297.

    Niskar AS, Kieszak SM, Holmes AE, et al. Estimated prevalence of noise-induced hearing threshold shifts among children 6 to 19 years of age: the Third National Health and Nutrition Examination Survey, 1988-1994, United States. Pediatrics. 2001;108(1):40-43.

    Noise and Hearing Loss. NIH Consensus Statement 1990;8(1):1-24.

    Occupational Safety and Health Administration. Occupational noise exposure; hearing conservation amendment; final rule. 29CFR1910.95 Federal Register 1983;48(46):9738-9785.

    Plakke BL. Hearing conservation in secondary industrial arts classes: a challenge for school audiologists. Language, Speech, and Hearing Services in Schools 1985;16:75-79.

    Prasher D. New strategies for prevention and treatment of noise-induced hearing loss. Lancet 1998;352:1240-1242.

    Roeser RJ. Industrial hearing conservation programs in the high schools (protect the ear before the 12th year). Ear and Hearing 1980;1(3):119-120.

    Ward WD, Glorig A. A case of firecracker-induced hearing loss. Laryngoscope 1961;71:1590-1596.

    Weber HJ, McGovern FJ, Zink P. An evaluation of 1000 children with hearing loss. J Speech Hearing Dis 1967;32:343-354.

    Wheeler J. Hear US: let’s talk about conquering deafness. Hearing Health 2000:10-11.

    Woodford CM. A perspective on hearing loss and hearing assessment in school children. J School Health 1973;43:572-576.

    Woodford CM, O’Farrell ML. High-frequency loss of hearing in secondary school students: an investigation of possible etiologic factors. Language, Speech, and Hearing Services in Schools 1983;14:22-28.

    Hearing Aids: Reasonable Expectations for the Consumer2014-10-06T22:11:41-05:00

    Rose L. Allen, Ph.D., CCC-SLP/A, Assistant Professor of Audiology, East Carolina University, Dept. of Communication Sciences & Disorders

    Editor’s Note: This article was the winning submission for the Audiology Online (www.audiologyonline.com) contest sponsored by Rayovac Ultra Pro Line, for the best new article written for consumers and patients, titled “Hearing Aids: Reasonable Expectations for the Consumer.” We offer Dr. Allen our congratulations for her excellent work, and we invite the readers to download (in its entirety) and distribute this article to their patients for educational purposes. —-Editor


    Since you are considering the purchase of hearing aids, it’s important for you to establish reasonable expectations from these highly sophisticated, miniature devices. Acquiring hearing aids is not merely a simple act of going to a store and purchasing a product.

    Rather, it is a complex process – one that evolves over time and begins with the hearing-impaired individual accepting the realization that hearing impairment has detrimental effects on interpersonal relationships and safety. The hearing impaired person’s motivation to hear well is the single most important factor in determining the success of the hearing aid fitting. It is important to realize that you will not experience the exact same benefits from your hearing aids as your neighbor does. This individuality is a critical component, and I want to emphasize that your expectations should be based on you, your type and degree of hearing loss, your past experiences, and the improvements you personally receive from amplification.

    The title of this article implies there are “reasonable expectations” for the consumer. Therefore, there must also be “unreasonable expectations”. For the most part, there is only one totally unreasonable expectation – do not expect normal or perfect hearing.

    It is my hope that this point-by-point tutorial will help guide you in establishing realistic and reasonable expectations from hearing aids, from the professionals you interact with, through the process of acquiring hearing aids, using them effectively, maintaining them, and living the fullest life possible.

    1. Expect others to notice your hearing loss before you do! A common complaint of hearing-impaired individuals is that other people mumble – and if they would just speak up, it would be easier to hear them! This is placing the “blame” externally, rather than accepting the reality that your ears are not as good as they used to be. Realize that it is your hearing. Take that step to have your hearing tested before you blast your loving spouse out of the den with the blaring sound of the TV set. Seek the advice of your local hearing instrument specialist (HIS), who you will find listed in the yellow pages under “hearing  aid specialist” or “hearing aids”. Of course, another option is to go to the Healthy Hearing website (www.healthyhearing.com), and if you enter your city and state, or just your zip code, a list of professionals will be created for you.

    2. Expect your Hearing Instrument Specialist (HIS) to be knowledgeable, courteous, and accommodating. Your HIS will take a thorough case history. He/She is searching for information about your hearing loss, it’s probable cause, and whether your offspring may be affected. It is important to establish the presence of any medical condition associated with your hearing loss as this will trigger a medical referral. Comprehensive hearing and hearing aid evaluations will be conducted. These evaluations will provide information about the degree and nature of your hearing loss, as well as your ability to process and discriminate the fine sounds of speech. Comfortable listening levels will be defined, as well as a determination about how well you tolerate loud, intense speech and other sounds. These findings are very important as they allow the professional to pre-set some of the characteristics of the hearing aid’s circuitry. You will have time to talk with the HIS about the differing styles of hearing aids (in-the-ear, in-the-canal, completely-in-the-canal, behind-the-ear), the advantages and disadvantages of each style, and maintenance issues and costs involved. Approximately 80% of all hearing aids sold fit in the ear1. After you and your hearing professional determine the best style of hearing aid for your needs, an ear impression will be obtained. The ear impression is a plastic cast of your ear which reveals the exact shape of your ear, so the laboratory can place circuitry in a hearing aid shell that will fit your ear(s) only.

    3. Expect differing opinions. If you choose to seek the advice of two or more HISs, you may get differing opinions about the “best aid” for you. Everyone in the hearing aid industry acknowledges the fact that there is not a single “best” hearing aid. Rather, there are many excellent hearing aid brands available, and there are many different types of circuitry that may benefit you. Your HIS uses the case history information and the evaluation results to make the best recommendation for you and your lifestyle. Expect a recommendation to purchase two hearing aids if both of your ears are hearing impaired and are “aidable.” There are many benefits to binaural (two ear) hearing, including being better able to understand speech in noise, and being better able to localize sound. Your HIS will explain the advantages of a binaural fitting versus a monaural fitting in more detail2. Nonetheless, it is very important to understand that if you have two ears with hearing loss, and you only wear a hearing aid on one ear, you will still have significant hearing problems, even under the best of circumstances. A reasonably good analogy is to consider wearing a single eye glass (monocle) for a two-eye vision problem, such as being near-sighted or far-sighted ? it simply will not work well for very long!

    4. Expect your Hearing Instrument Specialist (HIS) to assess your hearing difficulties in several environments and define individual goals for you. Although there are many self-assessment scales available, a popular one is the Abbreviated Profile of Hearing Aid Benefit (APHAB) developed by Cox and Alexander3. It may be administered to you prior to and following the hearing aid fitting to identify the benefits you receive from the hearing aids and to measure the reduction of any disabling effects of your hearing loss. The COSI (pronounced “cozy”) is the Client Oriented Scale of Improvement which was developed by Dr. Dillon and colleagues at the National Acoustics Laboratory in Australia 4. As you will remember from my earlier comments, I emphasized that benefits from hearing aids are highly individualized. The COSI allows the HIS to determine, based on your input, five major goals or changes you want to occur as a result of wearing hearing aids. These goals may include hearing your spouse better in the car, hearing your friends better on the phone, or any others that relate to you and your hearing difficulties. These assessments are not like the hearing evaluation given by the HIS. These are tools that allow us to measure your self-perception of how your hearing loss affects your activities of daily living and how amplification can improve your quality of life.

    5. Expect to be offered a 30 day trial period. Although not always required by law, many audiologists/HISs offer a trial or rental period of 30 days for you to adapt to amplification. You may be asked to pay a non-returnable fee during this time. Ask about this trial period, and if not offered, seek a second opinion. Use this 30 day period to test the hearing aids in the environments that are typical of your lifestyle – not only at home, but also at your friends and relatives homes, your favorite restaurant, shopping center, grocery store, or place of worship.

    6. Expect a referral to a physician to rule out any medical condition that may contribute to your hearing loss. All hearing aids are medical devices and, as such, are governed by regulations of the Food and Drug Administration (FDA). The FDA requires that all users of hearing aids be examined by a physician, preferably one who specializes in diseases of the ear. If you are over the age of 18 years, you may be given the opportunity to sign a medical evaluation waiver that will allow the HIS to proceed with your hearing aid fitting. It is in your best interest to be evaluated by a physician prior to the hearing aid fitting, but particularly so if you have a history of ear problems or hearing loss of unknown origin.

    7. Expect the hearing aids to cost more than you think they should. There are three categories of hearing aid technology – analog, digitally programmable, and digital. Analog technology has been around for many years. Aids utilizing this technology are also called “conventional” hearing aids and they are the least expensive. According to the most recent dispenser survey published in the Hearing Review in June of 2001, the average price of a hearing aid with analog technology will cost approximately $900 to $1500 per aid, depending on the size of the aid – the smaller the aid, the larger the price1. Digital hearing aids use digital signal processing – the newest form of technology on the market. Digital hearing aids are indeed complete computers, similar to the PC on your desktop, but they are the size of a pencil eraser! These aids cost approximately $2500 per aid, similar to your PC. Digitally programmable hearing aids will probably cost somewhere between the conventional price and the digital price. You may benefit from any of the three types of technology. Speak with your HIS about the types of circuitry and which would be best for you. Importantly, in 2002, some basic digital hearing aids are available at a lower price than in previous years. Many of the manufacturers have switched the focus of their product lines to completely digital offerings, as digital products are more efficient and have broader application. Consequently, as the demand and sales have increased, the price has gone down a little. The bottom line is that there are many more digital hearing aids on the market in 2002 than there was in 1999, and the prices vary tremendously, as do the products.

    8. Expect an initial orientation session with your Hearing Aid Specialist (HIS) in which you will learn how to handle and care for your new aids. You should invite your spouse or significant other to attend this first critical session in getting oriented to your new aids. During this session, you will be taught how to operate the hearing aids, how to clean them, and how to change the batteries. You will receive written information about your aids – a booklet called a “User Instructional Brochure” which is a requirement of the FDA. Please note, batteries are particularly important. Please be sure to store them and use them exactly as your hearing healthcare professional advises. Please be sure to keep all batteries way from pets and children. It may be difficult for you to remember all the things the HIS tells you during this first session, so don’t leave the office without your instructional brochure! It will be very valuable to you, particularly during the first weeks of owning your new hearing aids.

    9. Expect a period of adjustment. Remember the 30-day trial or rental period mentioned earlier (see point 5 above)- Once you get your new hearing aids, expect an adjustment period of several days to many weeks to get used to the daily care and maintenance of the hearing aids.

    You?ll need time to learn how to; insert and remove the hearing aids from your ears, learn to adjust the volume control (some hearing aids have volume controls, other are automatic), learn how to clean them, learn how to open and close the battery door, learn to change the battery, get accustomed to placing the hearing aids in a dry-aid kit for the times when they are not in your ears. As you can see, there is a lot to learn, and people learn at different speeds. I recommend that you go slowly, learn one thing at a time, practice, and stay in contact with your hearing healthcare professional.

    Many times, a spouse (or significant other) is very useful in helping you adjust to the new responsibilities of ownership of hearing aids. The largest adjustment you will go through is, of course, listening with your new hearing aids. You will hear sounds that you have not heard for a long, long time. Some of these will be “good sounds”, like the songs of the birds or high-pitched voices of children. Other sounds, the “obnoxious ones”, are sounds we need to hear for our safety and/or general knowledge of what is happening around us. These are sounds like the refrigerator or air conditioning units humming and buzzing, the sound of our footsteps, or a “knock” in the sound of the car engine. Research in this area has shown that this adaptation or adjustment period may last a few months. It takes time for the brain to re-learn all these sounds. Be patient!

    10. Expect your voice to sound different. For many reasons, your voice will sound strange to you at first – like being in a barrel. This is a normal early perception and it is often called the “occlusion effect”. If you don’t adjust to this after a few days, discuss this with your HIS. Many times, this feeling can be alleviated through changing the vent size in your hearing aids or changing the amount of amplification you are getting for low-pitched tones. Your HIS deals with this issue regularly, and they will be able to solve this with you, over a short period of time.

    11. Expect a good, comfortable fit. Initially, it will take a while to get used to having the hearing aids in your ears. You may experience a little soreness or irritation at first, but after a few days or a week or so, you should be able to wear the aids for several hours per day without any pain or discomfort. I always find it reassuring when patients tell me they often forget that they are wearing their aids. Remember – even though the HIS will make your ear impressions so your hearing aids will be custom fit, many things can happen in the manufacturing process and any discomfort should be reported to your HIS immediately. If your aids are not comfortable, you will not get the maximum benefit from them, and you should not wear them. Report all discomfort or irritations to your hearing healthcare professional, and do not wear the hearing aids until he/she advises you as to how to best address the problem.

    12. Expect multiple follow-up appointments. The greatest advantage of digital hearing aid technology is the flexibility in programming the sound quality, as well as many other electro-acoustic characteristics of your hearing aids. These hearing aids are highly sophisticated instruments with many features. The computer software that is used to program your hearing aids allows the HIS to make a multitude of adjustments while the aids are in your ears. You can actually hear many of the changes as the HIS is adjusting different features or characteristics. Other features will only be noticeable in other environments. So, be sure to tell your HIS as much as you can about your listening experiences in many environments. If you are a new user, you may get an initial setting of about two-thirds of the amplification that will be ideal for you. As you get used to your aids, the HIS will increase the amount amplification over several visits. This will help in your adjustment period and lessen the chances of rejection due to over-amplification.

    13. Expect your audiologist/HIS to evaluate the benefits provided by your hearing aids. This is normally done in at least two ways. First, electronic measurements of “real ear” performance give the HIS an idea of how the aids are functioning when the hearing aids are in your ears. Your HIS may make measurements in which a small microphone is placed in your ear to measure what is happening in your ear canal with and without the hearing aids in place. This is an objective measure and a starting point for successive changes in the performance of your aids. Secondly, the APHAB, COSI, or other assessment scales may be repeated so the HIS can help you evaluate pre- and post-fitting hearing difficulties. These two evaluation methods are important in establishing the benefits you personally receive from amplification. If there are no significant changes in these measures, your HIS will need to make additional changes in your hearing aid fitting.

    14. Expect to be able to hear well, but not perfectly, in quiet one-to-one situations and most small group settings. In order for you to hear well, we must make sound audible, then comfortably loud. Your hearing aids will amplify sound so speech will become comfortably loud. You should be able to hear most of what is said without having to watch a person’s lips all the time. However, even people with normal hearing watch the person speaking in order to gain more information! Even when wearing the hearing aids, you should combine your vision and your hearing to maximize your benefits from the hearing aids. When sound is comfortably loud, it will be easier for you to listen and the stress of straining to hear rapidly diminishes. Therefore, listening in social situations becomes pleasurable again. If everyday sounds are uncomfortably loud, report this to your a HIS immediately.

    15. Expect an optimal “distance for hearing”. The best distance for hearing with your aids will be dependent on the type of microphones in your hearing aids, and other factors. The hearing aids may be directional or omni-directional. Find out from your audiologist/HIS which type of microphones you have, and the effective listening range or effective “distance for hearing”. People within this distance will be the most audible to you. Once you increase the distance from the source you want to listen to, it will get increasingly difficult to hear – just like without the hearing aids.

    16. Expect to have difficulty hearing in noisy situations. You may say that you can hear fine in quiet and that the noisy situations are the ones in which you need the most help. This is a common statement made by individuals who have presbycusis (hearing loss due to aging), noise-induced hearing loss, or any hearing loss where the
    high-pitched tones are affected the most. Eventually though, as your hearing loss progresses, your ability to hear in quiet settings is also affected. Background noise is a nuisance for everyone, even normal hearing individuals. As sophisticated as today’s technology is, hearing aids still cannot eliminate background noise for you. Some of the more sophisticated digital circuitry can effectively reduce (although not eliminate) background noise. If you are in a lot of noisy environments, it is important to discuss this with your audiologist/HIS when discussing your case history and setting your goals for improvement.

    17. Your hearing aids may squeal (also called “whistle,” or “feedback”) under some circumstances. If a hearing aid is somewhat functioning and has a good battery in it, this squeal (acoustic feedback) will occur when the hearing aid is cupped in the hand. Most users find that this helps determine the status of the battery and it is a good sign! However, you should be able to wear your hearing aids at a comfortable loudness level and not experience this squeal. If you do not have a volume control on your aids, they will squeal when you place them in your ears – until you get them placed comfortably. Sometimes, your aids will squeal if you press the phone too tightly to your ear. Report these events to your audiologist/HIS and determine what is normal, what is abnormal, and what can be done to reduce unnecessary acoustic feedback.

    18. Expect repairs. You should realize that hearing aids are incredibly sophisticated devices being inserted in the ear canal where moisture and cerumen (ear wax) is waiting to attack any foreign object! Hearing aids are also prone to being dropped if our fine motor dexterity is a little compromised. Microscopic solder joints that connect the tiny wires of the microphone and receiver to the computer chip in the hearing aid can be jarred loose. All repairs cannot be avoided, but the majority of repairs can be avoided with regular and careful maintenance! Being careful and establishing and maintaining a good preventive maintenance schedule, at home and at your audiologist?s/HIS?s office, can significantly reduce the number of repairs on hearing aids. Your aids will probably come with a standard one year warranty, and after that, you can purchase hearin