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Alex88

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 #1 
I have had tinnitus for roughly five years after excessive noise exposure at a night club. I have seen an ENT and audiologist and they have concluded that there is nothing physically wrong with me, and that I have no NIHL. I have been told that I need to learn to live with the tinnitus and up until a few months ago I was largely habituated to it.

Roughly three months ago, I started experiencing frequent spikes, for no apparent reason. I have had a few spikes in the past, but they would come and go quickly, and I wouldn't have another one for several months. Now I'm having spikes way more frequently, and they're lasting significantly longer. I'm having a tough time dealing with it and I'm not sure what to do.

Are these spikes something that I will eventually habituate to, the same way I did with the original tone? Or is this something I ought to consider seeking treatment for? Do you have any advice on coping with these spiked in the interim?

Thanks in advance for you input, Dr. Nagler. And thanks for creating this forum.
Dr. Nagler

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 #2 
Hello Alex88 ... and welcome.

So first, allow me to re-interpret your ENT and audiological evaluation. What they determined is (1) whatever is causing your tinnitus, it is nothing that can be corrected with the expectation that your tinnitus will be cured, and (2) whatever is causing your tinnitus, it is not one of the exceedingly rare causes of tinnitus that represent a threat to your health.

But as far as your not having any hearing loss goes, well everybody has some degree of hearing loss - even those with normal audiograms. The hearing loss might not be severe enough to cause a noticeable threshold shift on an audiogram, but for sure it is there. And that is because we lose 0.5% of our hair cells for every year of our adult life through natural attrition. [The medical term for that phenomenon is presbycusis.] Moreover, since nobody has ever found a correlation between the degree of one's hearing loss and the loudness of one's tinnitus, even somebody with a normal audiogram can have screaming tinnitus merely by virtue of the brain's response to a mismatch between one's outer hair cells and inner hair cells (or some similar mechanism). And by the same token, there are profoundly deaf individuals who to the best of their knowledge have never experienced tinnitus at all.

Now that was a mouthful. Are you with me so far?

Stephen M. Nagler, M.D.

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The best way to find yourself is to lose yourself in the service of others.
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No bird ever soared in a calm. Adversity is what lifts us.
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Alex88

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 #3 
Dr Nagler,

I appreciate the clarification with regards to my ent and audilogical evals. The way you have stated things makes perfect sense to me.

And I believe I'm with you so far. Basically, the fact that my audiogram came back normal doesn't mean that I have zero hearing loss. And, whether or not I have hearing loss is largely irrelevant to the level of tinnitus I experience?
Dr. Nagler

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Quote:
I appreciate the clarification with regards to my ent and audilogical evals. The way you have stated things makes perfect sense to me. 

Excellent. I confess that it took a while for this stuff to make sense to me back in the mid-1990s - so you are ahead of the game already!

Quote:
And I believe I'm with you so far. Basically, the fact that my audiogram came back normal doesn't mean that I have zero hearing loss. And, whether or not I have hearing loss is largely irrelevant to the level of tinnitus I experience?

Close, very close. Since everybody has hearing loss, it is the degree of hearing loss that is irrelevant to the level of tinnitus that you experience. More hearing loss does not mean louder tinnitus, and louder tinnitus does not mean more hearing loss.

Next, you mentioned NIHL (Noise-Induced Hearing Loss). Do you happen to know the mechanism by which excessive exposure to loud noise can result in hearing loss? [Yes, it's important with respect to your spikes. We'll get there.]

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
Alex88

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 #5 
I think we are on the same page now. I could edit my previous statement to instead say "my level of hearing loss is largely irrelevant to the level of tinnitus I experience".

And I have a very elementary understanding of the mechanism by which sound damages hearing. My understanding is that the ear drum sends sound waves to the three bones in the middle ear, which assist the cochlea in converting the sound waves to fluid waves. The fluid waves travel from the cochlea through the basilar membrane, which is covered in cilia. The cilia convert the fluid wave into an electrical impulse which travels through the auditory nerve to the brain. NIHL typically occurs when the fluid waves entering the basilar membrane are too intense (which happens when an individual is exposed to sustained sounds over 85db), resulting in death of the cilia.

This is my understanding at least. I'm sure it's way more complicated than I'm making it seem.
Dr. Nagler

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 #6 
Quote:
I think we are on the same page now. I could edit my previous statement to instead say "my level of hearing loss is largely irrelevant to the level of tinnitus I experience".

100% correct.

Now I'll add one other piece, one that may be hard to buy, but it's true. The severity of your tinnitus (i.e., the degree to which your tinnitus affects your life) is largely independent of its loudness. More to the point of your initial inquiry - just because you have a spike, that does not in-and-of-itself make your tinnitus more severe. It makes it louder, but it does not make it more severe.


Quote:
And I have a very elementary understanding of the mechanism by which sound damages hearing. My understanding is that the ear drum sends sound waves to the three bones in the middle ear, which assist the cochlea in converting the sound waves to fluid waves. The fluid waves travel from the cochlea through the basilar membrane, which is covered in cilia. The cilia convert the fluid wave into an electrical impulse which travels through the auditory nerve to the brain. NIHL typically occurs when the fluid waves entering the basilar membrane are too intense (which happens when an individual is exposed to sustained sounds over 85db), resulting in death of the cilia. 

This is my understanding at least. I'm sure it's way more complicated than I'm making it seem.

So even though I might quibble about the 85dB figure, I'll give you a solid A on that one. As you correctly state, it is the sound waves rather than the sound itself that cause the damage. The louder the sound, the greater the amplitude of the sound waves producing it, and the greater damage those sound waves can potentially cause.

Here's the important takeaway: Since tinnitus is not associated with a sound wave, no matter how loud your tinnitus sounds, it cannot possibly cause physical damage to any part of your auditory system. And that is true even with a spike!

Now to the crux of my response. [And let me add that you've been a very good sport about it!] Recall above when I wrote, "The severity of your tinnitus (i.e., the degree to which your tinnitus affects your life) is largely independent of its loudness." So if loudness plays a relatively minor role, what would you say it the primary determinant of tinnitus severity?

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
Alex88

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 #7 
That's an interesting point. I never really thought of it that way. I can certainly see what you mean though. An individual with extremely loud tinnitus that genuinely doesn't care about it at all, would probably describe their tinnitus as being mild. On the flip side, and individual with very quiet tinnitus that becomes fixated on it and is very anxious and depressed about it would probably describe their tinnitus as being relatively severe. So it's basically the impact of the tinnitus that dictates its severity, not the volume. In my situation, the spike is making my tinnitus more severe not because its making my tinnitus louder, but becasue it's having a greater impact now that it did before. Am I understanding correctly here?


As far as what determines tinnitus severity, I'm not really sure. I'm thinking it may all just come down to state of mind and how an individual views their tinnitus?

Dr. Nagler

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 #8 
Quote:
An individual with extremely loud tinnitus that genuinely doesn't care about it at all, would probably describe their tinnitus as being mild. On the flip side, and individual with very quiet tinnitus that becomes fixated on it and is very anxious and depressed about it would probably describe their tinnitus as being relatively severe. So it's basically the impact of the tinnitus that dictates its severity, not the volume. In my situation, the spike is making my tinnitus more severe not because its making my tinnitus louder, but becasue it's having a greater impact now that it did before. Am I understanding correctly here? 

Yes. Perfect!

Quote:
As far as what determines tinnitus severity, I'm not really sure.

The primary determinant of tinnitus severity is reaction. So, as I see it, the key to solving your particular problem (as stated in your first post) lies not in doing anything about your spikes, but rather in understanding how and why you react to your tinnitus (along with the spikes) the way you do and in taking steps to mitigate that reaction. The problem is that you cannot make yourself not react to your tinnitus; your reaction to your tinnitus is largely beyond conscious control. The good news is that there are a number of strategies for indirectly mitigating your reaction to your tinnitus. Perhaps you might start with applying the principles outlined in my Letter to a Tinnitus Sufferer.

I sincerely hope this discussion has at least gotten you started.

All the best -

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
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