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When we think of our ears, we often think only of their ability to help us hear the sounds around us. While this is one of their functions, the inner ear is also responsible for our balance. Our balance system keeps us upright to remain focused on an object when our head is moving and to inform us if we are accelerating or slowing down horizontally and vertically, such as when we are in a vehicle or riding an elevator. Our brain uses these signals along with input from our eyes and from our muscles and joints to allow us to move our bodies with coordination and little effort. When a person experiences a concussion or traumatic brain injury (TBI), the inner ear can be affected. The auditory (hearing) and vestibular (balance) organs of the inner ear send information to the brain through electrical impulses transmitted along a nerve pathway. Injury to the auditory-vestibular system can result in symptoms of hearing loss, tinnitus, imbalance (feeling off-balance, light-headed, spaced out, or foggy in the head) and vertigo (spinning). Other symptoms may include memory issues, word-finding problems, sensitivity to auditory and visual stimulation such as light and movement, headache, fogginess, and fatigue. Symptoms may vary between individuals, depending on several factors, including the age and gender of the patient, pre-existing medical conditions, and length of time between concussions. Patients may not be aware of hearing loss and tinnitus immediately after head injury because symptoms of vertigo, nausea, and headaches are often more debilitating. As the patient begins to recover, these ear-related symptoms are noted. As hearing, tinnitus, and balance issues are closely related, a multidisciplinary approach for assessing and managing these symptoms is advantageous. Assessing the patient as a whole person with input from professionals of various disciplines gives a more complete understanding of the patient’s challenges, and a management plan can be developed based on priorities developed by the multidisciplinary team. Not only does the patient experience a more comprehensive assessment and management plan, but professionals working in multidisciplinary settings become aware of considerations from the perspective of other professionals. This improves their ability to develop management plans in the context of the whole patient, not just within their area of specialization. At the Calgary Ear Centre, we offer full auditory assessments, tinnitus management strategies, and referral for assessment and management of balance disorders. If you have had a concussion or other head injury, please call us to make an appointment for consultation.

Our hearing deteriorates as we age. This is a normal part of aging and typically not something we need to have checked by an Ear, Nose, and Throat (ENT) specialist. Think of gradual hearing loss from aging being like other changes that occur over time, such as vision decline or physical changes to your appearance. These are changes that are to be expected and do not signal that medical consultation is necessary. With age, our high frequency hearing gradually deteriorates, and we slowly lose the clarity to sounds. We may not be aware of a significant decrease in volume, but you may feel that your understanding of speech has worsened, especially if you are in background noise, such as a family gathering or restaurant, or if you cannot see the speaker’s face. Tinnitus, the buzzing, hissing, or other sounds that might occur in the ears, is often a symptom of hearing loss, especially if it is constant or lasts for hours. The first step is to have your hearing tested by an audiologist. Brief episodes of tinnitus lasting seconds to a couple of minutes are normal and do not need to be investigated unless they are accompanied by dizziness. There are instances where a medical referral is appropriate. A referral to an ENT may be warranted if any of the following are present: If there is a significant difference in hearing between the ears with or without tinnitus. If you experience an unexplained and sudden loss of hearing, typically occurring in one ear, and possibly accompanied by dizziness or vertigo. If you are experiencing chronic middle ear infections, with or without discharge. If you experience a head injury resulting in hearing loss, tinnitus and/or balance problems. In all the above instances, a complete auditory evaluation or hearing test is recommended to determine whether a referral to a medical specialist is warranted. A complete hearing test includes a detailed hearing history obtained by your audiologist, followed by an evaluation of your hearing, which includes listening to the individual tones that make up the sounds of speech and speech clarity testing. Speech clarity scores are crucial in determining how clearly you hear words when they are presented at a comfortable listening level. Two people can have the same graph for the tones, but one may person may hear much better for speech testing than another which will give your audiologist more information when they provide recommendations. If you have a straightforward hearing loss, equal in both ears, and no asymmetrical symptoms such as tinnitus, there is no need to see an ENT. Your audiologist will explain your results and will typically offer you the option to try hearing aids for 60 days if you have a hearing loss. The trial period will allow you to try the hearing aids in situations that you find challenging to see if they help you hear better and if they reduce your awareness of the tinnitus.

If you have tinnitus, you may have noticed that when there are other sounds in the environment, you do not hear the tinnitus as much. Or perhaps you find that when you are taking a shower, the tinnitus is less obvious. Many people with hearing loss have tinnitus, which is typically a symptom of damage to the ear, most commonly from ageing or noise exposure. Some people have tinnitus even with normal hearing. The goal of tinnitus management is to reduce your awareness of the tinnitus so that it does not affect your quality of life. When you have a hearing loss , you are not hearing all the sounds around you, even though you may be functioning well. Correcting for the hearing loss with hearing aids often reduces the volume of the tinnitus. In addition, all hearing aids have a built-in sound generator, which allows the clinician to program the devices to play a soft masking sound helpful for reducing the awareness of the tinnitus, whether you have a hearing loss. Even if hearing loss is not your major concern, the first step is to have a complete auditory evaluation and discussion about the tinnitus with your audiologist. They will make recommendations for tinnitus management based on the results and the impact that the tinnitus has on your life. You are welcome to try devices in the office to see if the tinnitus becomes quieter when wearing them. If you feel that the devices might be of benefit, we can order some for you to try for 60 days so that you can take them home and try them in your own surroundings. Your clinician can suggest which devices you might like to try, based on your budget and lifestyle. You have nothing to lose by trying! Let us help.

Everyone wants a quick-fix or a pill that can cure all ailments. Life has become fast paced and even waiting for a short time becomes frustrating. My audiometer, the equipment that I use to test hearing, is slow to start. Slow these days would have been considered lightning speed years ago. That I must wait up to twenty seconds for it to load the necessary programs makes me feel impatient and irritated as I sit waiting for it to come alive so that I can start my day. This is the way of the world: We want things done, fixed, and resolved pronto so that we are not inconvenienced by the wait. Wanting a quick fix is true with chronic medical conditions as well. In our urgency to fix tinnitus, we can work ourselves into a state of panic and desperation. If you were told that there is nothing that I could do you to help you and you would have to learn to live with it, the panic and desperation accelerate until the tinnitus consumes you and it is all you can think about. The good news is that while there may be no way to immediately eliminate the sound, that is a far cry from saying that there is no help. Tinnitus, like other chronic conditions, requires management, and that requires time and some effort on your part. There are many chronic conditions that are managed effectively, despite having no cure or remedy. Tinnitus is one of those. There are many tools including sound therapy and hearing aids that can reduce your awareness of the head noise to a point that it has no impact on your quality of life. You may already have periods of time when you are busy and are unaware of the tinnitus, or perhaps you do not hear it when you are in the shower or in background noise. Tinnitus management typically includes a sound therapy component, which is just a fancy way of saying that if we add other sounds into our environment so that the tinnitus is partially or completely masked and not as obvious. The goal of sound therapy is not to completely cover the tinnitus with other sounds. We want to allow the brain to hear it, but with less impact, so we mix it with other sounds. The brain gradually integrates the tinnitus, and it becomes meaningless, just as other new sounds do after the novelty wears off. Ask yourself: “If I could enjoy doing my life and activities as I did before I had tinnitus, would that improve my quality of life?” What is important to understand is that the tinnitus does not need to be eliminated for this to happen. Your brain is fixating on the sound, and it is the hyper-focus on the sound rather than the sound itself that is the problem. We do not need to get rid of the tinnitus for your quality of life to improve. The key is to retrain your brain to stop fixating on the tinnitus. Once the brain looks elsewhere for stimulation, the tinnitus will settle and no longer trigger you. That process is referred to as ‘habituation’. Once the brain takes its focus of the tinnitus, it will no longer have the hold on your that it presently has and there will be room to enjoy life as you previously did.

Did you ever wonder how our brain sorts all the information that comes at us every second of the day? Like a good manager, the brain prioritizes incoming information and deals with what it believes to be the most urgent tasks, putting others on the back burner until the most pressing task is dealt with. Our brain’s sole purpose is to keep us safe. If there is a change to our environment, our senses alert the brain to that change, and we are compelled to pay attention to the change to see if there is a threat to our safety and survival. Any change in the status quo will set off alarm bells and we will be put on alert until we either determine that the change is non-threatening, or we deal with the threat by fighting it or running from it. In the case of sound, it is not just the awareness of new or unfamiliar sounds that triggers us to investigate, it is the change in the sound environment that is alerting to our brain. That means even the removal of an expected sound can catch our attention and cause us to focus on that change. Someone who lives in an urban setting where there may be traffic noise throughout the night, or perhaps trains pass at regular intervals, may become unaware of these sounds. Their brains habituate to the expected sounds so that other information can be attended to. If that person was to go camping or visit a friend in a rural setting, they may have problems falling asleep because it is too quiet. Their brains would alert them to the change in the sound environment so that the change can be investigated. The phrase ‘deafening silence’ comes to mind. For those who are used to a certain amount of environmental noise, the change to an environment of little or no sound can be alerting and can even cause anxiety or a feeling of unease. There have been a handful of times in history when Niagara Falls has nearly completely frozen over. Those who lived close to the falls were woken by the eerie silence or had problems falling asleep. Their brains had accommodated to the steady roar of the falls. When that roar was reduced to a trickle, they were alerted to the absence of the familiar sound. Quiet sounds can be as alerting as loud sounds if they carry emotional weight. A new parent can be woken from a sound sleep if their new baby starts to whimper in a room down the hall. Although the physical volume of the sound is very quiet, the impact of sound is significant as it triggers an emotional response tied to the meaning given to the sound - thoughts of love and protection, or possibly aggravation and frustration. It is the thought about the sound that results in the emotional response to the situation. If the parent is sleep-deprived and must get up to go to work in the morning, the thoughts about being woken in the night will be different than if the parent is able to sleep in the following morning. The sound of the baby is not what determines the mood of the parent, bur rather the meaning and thoughts around the baby whimpering. Our own names have strong emotional weight for us and those who know us. If you are at a large gathering where everyone is talking, you may barely be able to hear the person standing directly in front of you, yet when someone across the room mentions your name, you may hear it clearly above all the chatter. The reason for this is that your name has significant emotional weight. You have heard your name being spoken since infancy and it has been imprinted in your brain. Your name was not being spoken louder than the rest of the conversation in the room, but it popped out above the rest because it has been assigned importance and therefore your brain will be alerted and will hear it above sounds in the room that are as loud or louder.  These examples demonstrate that the measured volume of a given sound is not as important as the meaning that we give the sound, whether positive or negative. We can measure the volume of a person’s tinnitus in the sound booth by increasing the volume of a tone or hiss that approximates the frequency of the tinnitus, and asking the person to indicate when the volume of the tinnitus is equal to the volume of the sound we are delivering through the earphones. While those with bothersome tinnitus often describe the tinnitus as being as loud as a siren or jet engine, they match the volume of their tinnitus to a sound that is very quiet, often not much louder than the quietest sound that person can detect at the same pitch. Why is this? Our distress from the tinnitus is related to the thoughts we have about the tinnitus, the meaning we give it and the focus we place on it. A quiet sound can have a big impact. Our brain has been trained to be on high alert to monitor this intruder we call tinnitus, and we are bothered by it because we focus on it over everything else. You may claim that you are unable to turn your focus away from the tinnitus, but there are techniques to retrain your brain to put the tinnitus in its place so that it has no impact on your quality of life. Most people that have tinnitus experience no impact from it. They have habituated, and you can too. Find an audiologist who can help you retrain your brain to filter out the tinnitus so that it has little to no impact on your quality of life.

I have been asked many questions about tinnitus over the years. Here are some more answers to the most common questions I have been asked. Q: What is the correct pronunciation of tinnitus? I sometimes hear it called ‘TIN-it-tis’ and other times ‘Tin-EYE-tis’; which is correct? A: Both pronunciations are correct. What is not correct is ‘Tinn-in-EYE-tis’. That’s just goofy. Q: Should I see and Ear, Nose and Throat doctor about my tinnitus? A: That depends. ENTs deal with medical issues pertaining to the Ear, Nose, and Throat. In other words, conditions of the ear that need to be medically monitored or possibly surgically addressed. If you have a hearing or ear issue that is not typical, these are referred to as “red flags for referral”, and you should be referred to an ENT for consultation. Q: What do you mean by “red flags”? A: Red flags are atypical findings on your hearing test results. Your audiologist has been educated about the auditory system and auditory pathway from the ear (where sound is collected) to the brain (where the sound is given meaning). Based on your age, your history of noise exposure, and other medical conditions, the audiologist will anticipate certain results on your hearing test. If your results are unexpected, this could warrant a referral to see an ENT. Q: Can you give me some examples of what might be unexpected on a hearing test? A: Sure! Unlike our eyes, both of our ears should deteriorate at the same rate. If there is a significant difference between the hearing of the right and left ear, this would not be typical and should be checked out. In audiology it is all about symmetry. Not only should the hearing be equal for the right and left ear, symptoms should also be the same for the right and left ear. If you have tinnitus in only one ear, or if it is significantly louder in one ear, this is also not typical and should be investigated. Another type of tinnitus that would warrant investigation is tinnitus that pulses in time with your heartbeat. This is called “Pulsatile tinnitus” and is typically related to the blood flow through the vessels in your head and neck, and should be checked by an ENT. Q: I sometimes get a plugged feeling in one ear, and a high-pitched tone that lasts a few seconds, then it goes away. Does that mean I have damage to my hair cells?  A: Brief tinnitus, like what you just described, is called “transient’ tinnitus” and is something that many of us experience. It is normal and does not indicate damage.

I have been asked many questions about tinnitus over the years. Here are some answers to the most common questions I have been asked. Q: What causes tinnitus? A: Tinnitus is typically a symptom of permanent damage to the hair cells in the inner ear. The two most common causes of hair cell damage are aging and noise exposure; however, head injuries and certain medications that are toxic to the ear may cause tinnitus. Q: Are there different types of tinnitus, and why do they call it “ringing” in the ear? Mine sounds more like a hiss. Is that still tinnitus? A: Good question! Any sound that you hear in your ears or in your head when there is no external source for that sound is called tinnitus. Some people hear more of a tone, others may hear hissing or even music! Q: How many people have tinnitus? A: Stats Canada (2019) reports that up to 30% of Canadians have tinnitus. Most people are bothered by it at first, but then they adapt or ‘habituate’ to the sound over a period of weeks to months. A small portion of the 30% find that it affects their sleep and daily functioning, leading them to seek professional help. Q: Is there a cure for tinnitus? A: Many chronic medical conditions can be managed effectively and have little to no impact on quality of life. Tinnitus is one of these conditions. Whether or not something can be cured is not as important as how it impacts our sleep, relationships, and daily activities. Focusing on a cure can often close our minds to available options for management in the here and now, preventing us from enjoying our lives. Many of us feel the need to find the right doctor or a magic pill that will take away the tinnitus, leading us to believe that there is no hope without a distinct cure. I can tell you for a fact that this is not true. There are many medical and physical challenges that people live with. Despite these conditions, they can still have a wonderful quality of life. By focusing on what is not yet available while waiting and hoping for a cure, can lead us to feel hopeless, angry, anxious, and victimized. Q: So, I don’t need to get rid of the tinnitus - I just need to learn skills and tools to help me function and sleep better? This will improve my quality of life? A: Exactly! Our bodies change in various ways throughout our lives, and we adapt. Our brain may just need a little help to switch gears and get used to the new normal. We learn to do things differently rather than stopping them altogether. Rather than focusing on how it used to be, I recommend focusing on the here and now. Learn to adapt to the current reality and move forward. Appreciate the things that you value in life, such as family, friends, activities, your career, or anything else! Reference: Ramage-Morin, P., Banks, R., Pineault,D., & Atrach.M. (2019). Health Reports: Tinnitus in Canada. Stats Canada. Retrieved from https://www150.statcan.gc.ca/n1/pub/82-003-x/2019003/article/00001-eng.htm

These terms are sound sensitivity conditions that we help people manage. You have likely heard of tinnitus (pronounced tin-EYE-tus OR TIN-i-tis), the annoying sounds people hear in their head or ears. Tinnitus and other sound sensitivities can have an impact on sleep, work, relationships, and overall quality of life. Hyperacusis is a sensitivity to medium to loud sounds, often those that are higher in pitch. These are generally sounds that the average person would not find bothersome. One in three people who have tinnitus will also experience hyperacusis. Sounds that are typically cited as bothersome are plates and cutlery clattering, dogs barking and children squealing. These sounds may cause discomfort or pain. The fear of encountering a loud or painful sound can result in those with hyperacusis becoming fearful about leaving their homes or attending events where they have no control of the sound environment. Changes in behavior and lifestyle in an effort to avoid these sounds is called phonophobia , and can significantly impact quality of life. Misophonia is a sensitivity to quiet sounds, typically ‘face noises’ such as chewing, swallowing, lip-smacking, and nasal whistles. This condition can impact mealtimes, as the person with the condition may not be able to eat at the table with their partner or family. Repetitive sounds, such as a pen clicking, or keyboard clicks can also cause emotional distress. The sounds that cause the distress are called ‘triggers’, and typically cause an exaggerated emotional response such as rage and/or anxiety. Visual triggers can also be experienced even when the sound of the trigger can not be heard. If you or someone you know is experiencing sound sensitivity challenges, call to book an appointment with us. We can help you manage the impact of these conditions so that you can enjoy an improved quality of life. References: Jastreboff, P. (2019). Thirty Years of The Neurophysiological Model of Tinnitus and Tinnitus Retraining Therapy (TRT). Cited in Canadian Audiologist. Vol 6, Issue 4. https://canadianaudiologist.ca/neurophysiological-model-tinnitus-retraining-therapy-feature/ Katzenell, U. , Segal, S. (2021) Hyperacusis: Review and Clinical Guidelines. (2021). Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 22(3):321-6; discussion 326-7. www.researchgate.net/publication/11989158_Hyperacusis_Review_and_Clinical_Guidelines

Aging and noise exposure are the two most common causes of permanent hearing loss. We all lose our hearing as we age, starting to lose hair cells in our inner ear from the age of 12. The frequencies that are affected are much higher than we need to hear for speech, so we are unaware of these changes (Arvin, 2013). Aging is unavoidable; however, the second most common cause of hearing loss is noise exposure, which is something we can prevent. Noise exposure at work and recreationally can lead to permanent hearing loss. Hearing loss from aging and noise exposure begins in the high frequencies and affects the clarity of speech, with less effect on the perceived volume. With current scientific research suggesting that uncorrected hearing loss is associated with cognitive decline and dementia (Burry, 2020), protecting our hearing is not only for important for communication, but also crucial for your brain health. The Alberta Occupational Health and Safety Act regulates noise levels that employers must follow to keep their workers’ safe from damage to their ears. Sound levels are measured in decibels (dB). There are different dB scales used for different purposes, but for the sake of simplicity, we will refer to sound levels here only as ‘dB’. Employers in Alberta are required to monitor noise levels in work areas and if levels exceed 85 dB, workers are required to wear hearing protection and have their hearing monitored regularly. As an aside, every 3dB increase in volume results in a doubling of the sound pressure against the eardrum, meaning the safe exposure time for workers is cut in half. For example, a worker who is in a noisy environment of 85dB can work safely for eight hours, while a worker working around 88dB is only safe in that environment for four hours. I recall a medic who transported patients by helicopter asking me if the hundreds of thousands of dollars spent on a new ‘quieter’ helicopter whose internal noise was reduced by only 3dB was worth the money spent. The answer - absolutely! While 3dB to the average person might seem like a small number, dB scales are logarithmic, meaning that small numeric changes represent large functional changes. In this case, the reduction of 3dB allowed air ambulance personnel to double their safe exposure time in the helicopter without compromising their hearing. Hearing protection tools such as foam inserts, custom earplugs, or earmuffs, are given a noise reduction rating (NRR). The challenge here is that the rating given on the packaging is determined under ideal laboratory conditions. In real life, insertion, and re-insertion of foam plugs throughout the day, perhaps with unclean hands and sometimes in a rush, may only be providing half the noise reduction than what is indicated on the package. Even a slight gap between the earplug and the wall of the ear canal can reduce the effectiveness of the protection significantly. In addition, taking off the hearing protection throughout the day, even for brief periods, significantly reduces the overall protection when averaged over the worker’s shift. For example, even if a worker wears his hearing protection for 80% of his shift, the overall hearing protection of an earplug that is rated to have 33dB of protection will effectively be reduced to only 7dB of protection, which is likely inadequate (IHSA, n.d.). The combination of less than ideal insertion of foam plugs and wearing of these plugs less than 100 % of the worker’s shift can result in negligible hearing protection overall. To get the full benefit of hearing protection, it must be worn 100 % of the time and inserted properly. One final piece of information: if you have a hearing loss, it is difficult to judge how loud is ‘too loud’. Those with noise induced hearing loss often tolerate louder sounds than someone with normal hearing, and for that reason, may feel that hearing protection is not necessary. It is not recommended to rely on your own perception of noise volume. Ensure that noise levels are taken in your workplace, and that hearing protection is worn when indicated. Hearing loss from noise exposure is permanent, and it not only affects interactions with your friends and family, but also impacts your brain health. While hearing loss from aging is a fact of life, hearing loss from noise exposure is 100 % preventable. Protect your hearing. References Arvin, B., Prepageran, N., Raman, R. High frequency presbycusis -Is there an earlier onset? Indian J Otolaryngol Head Neck Surg, 65 (Suppl 3), 480-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3889367/ Behar, A. (2014). The (in)famous NRR -New derating. Canadian Audiologist, 1 (4) . https://canadianaudiologist.ca/the-infamous-nrr-new-derating/ Burry, M. (2020, December 22). Understanding auditory deprivation: Why untreated hearing loss is bad for your brain. Healthy Hearing. https://www.healthyhearing.com/report/46306 Infrastructure Health and Safety Association (IHSA) (n.d). Don’t let noise steal your hearing. [Pamphlet] Vol 12 , (1). https://www.ihsa.ca/pdfs/magazine/volume_12_Issue_1/hearing_protection.pdf