Ringing in Your Ears? It's All in Your Head. An Interview with Dr. Craig Kasper.

Ringing in the ears, aka tinnitus, already extremely common, is now being linked to COVID. (Just what we don't need – another bizarre symptom.) But COVID or not, many of us will experience tinnitus at some point in our lives. It can range from unnoticed to annoying to maddening. And you probably don't know that it's coming from your brain, not your ears. Dr. Craig Kasper, a New York audiologist and world-renowned tinnitus expert, has generously agreed to tell us all about the condition. So, perk up your ears. This information may very well apply to you now or as you age.

JB: Dr. Kasper, thanks very much for your time. Can you give our readers a description of how tinnitus may manifest itself? What do people who have this condition "hear?"

CK: The accepted definition of tinnitus is the awareness of a sound without the presence of an external sound source. Tinnitus can come in the form of subjective tinnitus as well as objective tinnitus. In the case of subjective tinnitus, only the person affected can hear the sound somewhere in the head or ears (ringing, buzzing, hissing sounds are most common). With objective tinnitus (which is not quite as common), the affected person as well as others (an inquisitive audiologist, for instance) can hear the sound, which often presents as a clicking from the jaw joint (TMJ) or the heartbeat.

The accepted definition of tinnitus is the awareness of a sound without the presence of an external sound source.

JB: How common is tinnitus? Is it possible to have it without knowing it?

CK: According to recent statistics, tinnitus impacts approximately 45 million people in the US, with nearly 20 million people reporting that their tinnitus is a burden on a daily basis. So, it is one of the most common symptoms (yes, it is a symptom of a number of conditions, not a disease) we experience.

One of the most interesting aspects of tinnitus is that almost everyone experiences some form of ringing or buzzing in the ears/ head at some point in life. But for most of us, it doesn’t mean anything, and our brain pushes that phantom sound into the background of awareness. One example I provide to patients: if you’re sitting right now, think about the pressure your bottom is feeling on the chair. Until I made you aware of that pressure, it simply didn’t exist. The same thing happens with all of our senses. If our brain does not perceive something as a threat or interesting enough to pay attention to, it pushes that input to the background of our awareness (think about a fan running in the corner of your room).

One example I provide to patients: if you’re sitting right now, think about the pressure your bottom is feeling on the chair. Until I made you aware of that pressure, it simply didn’t exist. The same thing happens with all of our senses

For some reason, for those bothered by their tinnitus, the brain believes it needs to pay attention to it. It is perceived as bad or wrong. There is an emotional response to the sounds. It is that constant training of the brain to pay attention to the tinnitus that ultimately does not allow our brain to simply push the sound into the background; it becomes a learned response. So, is it possible to have tinnitus without knowing? Sure. But if you don’t perceive a symptom, does that symptom actually exist?

JB: Is tinnitus an inevitable consequence of aging?

CK: One of the most common disorders that cause tinnitus is hearing loss. But while hearing loss becomes more likely as we age, not everyone with hearing loss experiences tinnitus. The reality is that tinnitus can surface at any age. Throughout the years, I have seen children bothered by tinnitus, and I’ve cared for 100-year old patients who didn’t perceive tinnitus at all. Ultimately, in many cases, tinnitus is a consequence of some form of hearing loss in addition to changes in other parts of the brain, which are triggered by some form of emotional stressor.

JB: From what I've read, tinnitus involves the ears but also the brain. Let's start with the ears. What happens to and why? Is there some kind of damage? Aging Both?

CK: Inside our skull, behind the ear, there is a protrusion. Within that space is our inner ear, which houses tens of thousands of microscopic sensory hair cells. Those hair cells are organized very much like the keys on a piano. Sound from the environment enters the ears, and those hair cells convert the sound into electrical impulses, which are transmitted to the hearing centers in the brain. It is in the brain where we ‘hear’ those sounds of the world.

(Left) Normal hair cells. (Right) Damaged hair cells. The damage is irreversible. Credit: Baylor College of Medicine

As we just learned, it is hearing loss (often caused by damage to those hair cells) that serves as the catalyst for tinnitus to occur. Hearing loss can result from a variety of insults to the system. While aging of the system is a nice blanket concept, it really includes genetics, noise exposure, various illness, medications, and physical trauma to the hearing structures we might sustain throughout a lifetime. Also, keep in mind, chronic health conditions such as diabetes can also negatively impact our hearing system.

JB: Can you explain how the brain reacts to the loss of hearing?

It is usually when we experience hearing loss (one of the most common causes is the damage that occurs to those hair cells) that the electrical impulses do not reach the brain as robustly as they once did. The brain perceives this void, or reduction, in sound and will physically change its organization. This is called brain plasticity. When those changes occur, the brain will literally turn up its internal amplifiers in search of the sound it once perceived so beautifully. That, in essence, is what we know as tinnitus. But it is not until our limbic system (the brain's emotional center) becomes involved do we perceive tinnitus as a persistent nuisance.

The brain will literally turn up its internal amplifiers in search of the sound it once perceived so beautifully. That, in essence, is what we know as tinnitus.

JB: I have not seen any evidence that any intervention, pharmacological or otherwise, makes any difference. Is there anything that can be done for tinnitus sufferers?

CK: The most important concept for anyone experiencing tinnitus to understand is that there is always something that can be done to reduce this, sometimes debilitating, symptom. For many people, the awareness of tinnitus will simply disappear over time. For others, when tinnitus is more persistent, it is helpful to keep the following in mind: tinnitus often requires 1) medical assessment to rule out any serious contributing medical conditions, and 2) audiological assessment to understand if hearing loss is present and potential causes of that hearing loss.

Ultimately, there is no magic pill that can eliminate tinnitus from our world, but there are management strategies that have many years of science to support them. For example, clinician-directed sound therapy partnered with cognitive behavioral therapy is widely accepted as one of the best methods to manage tinnitus. For someone with hearing loss, working with a licensed audiologist who can appropriately dispense hearing aids has been shown to be highly effective. Finally, incorporating mindfulness meditation, yoga, and breathwork has been wonderful for many people negatively impacted by tinnitus. Again, the most important concept: while tinnitus can vary from person to person, there is always something that can be done, and finding a knowledgeable clinician is the first step on the path to moving beyond tinnitus.

While tinnitus can vary from person to person, there is always something that can be done

JB: Dr. Kasper, thanks very much for your time and expertise. If there are tinnitus sufferers in or near the New York area that need help, would it be OK for them to ring you up? (Apologies)

CK: Sure. No extra charge for bad puns.