Bill Klaproth (Host): This is The Healing Podcast, brought to you by MarinHealth. I'm Bill Klaproth. With me is Jo Powner, a clinical audiologist at MarinHealth, ENT Head and Neck Surgery, a UCSF Health Clinic as we talk about tinnitus. Jo, welcome.

Jo Powner: Hey, Bill. Thanks for having me.

Host: Of course. This is a big topic. I know a lot of people suffer from this. Some people call it tih-NYE-tus. We're going to call it TIN-uh-tus on this podcast, because that is the proper way to say it, right?

Jo Powner: Yes, because it is not an actual disease. It's not an inflammation. Tinnitus is pronounced with that second I short. But if you say tinnitus, don't worry. No audiologist will kick you out of the booth for that.

Host: Okay. Love it. Well, thank you for explaining that to us. So to start off, what exactly is tinnitus and how common is it?

Jo Powner: Well, tinnitus is really defined as a sound that doesn't have an identifiable source. So, the most common type of tinnitus is subjective tinnitus, and it can only be measured by the person who is experiencing it. So, you can't just come in and say, "Hey, I've got a problem in my ear. Can you look in there?" Or as one of my mother's old bosses used to say, "Can you come up close to me and can you hear it?" No. Unfortunately, we can't hear tinnitus that someone else is experiencing, but that's what makes this such a pervasive issue. Almost 50 million people in America deal with tinnitus every day. It's the number one complaint amongst us veterans. And that's an interesting statistic by itself, because people who come back from combat, who complain of issues with their ears, they're more likely to report ringing in the ears than hearing loss, even though tinnitus is closely related to hearing loss, which is what we'll be talking about today. And that's usually because tinnitus is more noticeable than mild hearing issues. And that's often why we hear people coming in complaining of tinnitus, but they insist that their hearing is fine.

Host: Yeah, that's really interesting and good stats there-- 50 million people suffer from this. So, people often describe this as a ringing in their ears, as you call it, a sound that doesn't have an identifiable source. Are there other sounds or sensations that patients report other than the ringing that we always hear about?

Jo Powner: Absolutely. Ringing is just an easy way for us to categorize tinnitus. But it can be a hissing, a buzzing, chirping. Some people say it's cicadas or frogs. I've even had people say that they hear voices somewhat like Charlie Brown's teacher in the background. And many people actually have an amalgamation of several different sounds. So, sometimes they'll hear a couple of different pitches or several pitches together, which is really where we get those hissing-type tinnitus sounds.

Occasionally, you'll have someone coming in who complains of a pulsatile tinnitus, which really beats with the heartbeat. This is a type of tinnitus that's different from your standard ringing type tinnitus. And we'll talk a little bit more about that as we go along. Generally, we think about tinnitus, like we do a candle in a well-lit room. So if you're in a well-lit place and you turn off all the lights, the candle's going to look really bright because it doesn't have something to compete with. But if we turn the lights off, the candle doesn't change. It just looks brighter because it doesn't have something to knock out all that brightness. So, most people will complain of their tinnitus at night when they're trying to wind down for bed or if they're otherwise not distracted with things. So even if people say that they're hearing these many different types of sounds, most people will complain of it in the same sense of It really only bothers me when it's quiet.

Host: Right. So, the day-to-day noises or sounds kind of mask the tinnitus. But yeah, as it gets quieter at night, that's when it gets more pronounced. It sounds like that's what you're saying.

Jo Powner: Exactly. Because masking is the perfect way to say it. Actually, that's how we define it. Because all we're looking for is what sort of things in your everyday environment are more important to your brain? So, a lot of tinnitus therapy and what we do for treating tinnitus is bringing that brain power to something else. Because if we hyperfocus on tinnitus itself and all of those bothersome sounds, that hyperfocus actually makes those sounds even worse. Even if we could physically measure them, they would be relatively mild. But the social, the psychological impact of it can make it more intense.

Host: Yeah, that absolutely makes sense. So, you said earlier this is common among veterans, which makes me think loud noises cause this. I could be wrong on that, I don't know. But what are the most common causes of tinnitus? And then, at what point should someone be concerned enough to seek care?

Jo Powner: Well, you're absolutely right that loud noise plays a big part in tinnitus. We are not sure why people who have hearing loss as a result of loud noise are more likely to experience tinnitus, but we do know that is true. So, hearing loss in general is probably the biggest confounding factor when it comes to tinnitus, which is why most people who have tinnitus are often referred to have a hearing test.

Hearing loss is kind of the low-hanging fruit in the tinnitus world. And loud noise exposure directly relates to hearing loss in really how the structures of the inner part of the cochlea get damaged. So if we think about our cochlea as a big water balloon. And in the bottom of that water balloon, we have little hair cells that wave back and forth. They're kind of like seaweed. When you have a loud sound, it actually creates a really a physical tidal wave in the cochlea that crashes along the first bend of our pretty snail shell of that structure. And that creates an Identifiable and recognizable signature on a hearing test. And right where that first bend of the cochlea is, where that sound crashes up against that area, that's where most people with loud noise exposure will report their tinnitus. So, we absolutely look at loud noise as something that is preventable for tinnitus sufferers. And that's also why it's so important to protect your hearing against loud sound.

Host: I would imagine people like construction workers who are near loud sounds all the time, or maybe people that have gone to one too many rock concerts, they're more at-risk for tinnitus, I should say.

Jo Powner: Absolutely. And not just people who go to those concerts, but the musicians themselves. That's actually what I specialize in, is working with musicians, especially those who have tinnitus. So, I see this an awful lot in my practice. But you don't have to have loud noise exposure with your hearing loss in order to have tinnitus related to it. So, most people who come in with a tinnitus and a mild hearing loss will actually report that their tinnitus causes them to have a hearing loss. So, they might say something like, "I could hear very well if I didn't have this ringing that just blocks everything out." And the reality is it's kind of reverse of that.

When you have a hearing loss, your brain is aware of something that is missing. So, it says, "Hey, something used to be here. It used to sound like this." So, it kind of sings to itself all day long. And that's because your temporal lobe of your brain really wants a hundred percent of input all of the time. So if it's missing something, it's going to do what it can to make it up. We think of this like a phantom sound in the same sense that you would have a sensation of your hand if you were to lose your hand in a traumatic event. So if you have phantom limb syndrome or the part of your brain that's responsible for feeling that appendage is still there, it's going to have the sensation of that appendage, even if it's no longer physically present. And the same is true for sound hearing loss and tinnitus.

Host: Wow, that's really interesting. There is lot more to this than you would think.

Jo Powner: Ears are fascinating.

Host: It is fascinating. So, you were mentioning earlier, people can go through their normal day and won't be bothered by it too much. But when it gets quiet and gets more pronounced, that's when it's problematic. Are there other ways that it can affect daily life, including sleep or concentration at work or even mental health? If it's really like, "I can't stop this ringing in my ears," can you talk about that, Jo?

Jo Powner: Yeah, absolutely. So like you said, tinnitus has a potential to be super minor, right? It's only noticeable in a quiet situation with the listener focusing on the sound that's really when you're going to notice it the most. So, most people will notice it, especially if they're listening to this right now, "Wow. I'm really noticing my tinnitus because we're talking about it, right?" It's where your attention is. So, it's somewhat of a self-fulfilling prophecy. So if the issues snowball, that inevitably makes the tinnitus worse. So, we call this hypermonitoring. So really, our goal in tinnitus treatment is to break out hypermonitoring, and that's because it has these other secondary effects.

So when a patient struggling with tinnitus has a high stress response, it creates this cyclical pattern where they notice the tinnitus, they get upset by it. Then, the tinnitus gets louder or more bothersome, and that causes more stress, and it goes on and on and on. So, it just gets worse and worse and *worse.

Sleep is probably the biggest piece here. I'm glad that you mentioned sleep, because I'd argue most people who come in with tinnitus, if they report they're not getting quality sleep, they are more likely to report their tinnitus as being very disruptive. That it will also impact their concentration, their ability to do things in quiet, like reading or getting tasks done for their jobs. It also has a huge impact on their mental health. In my practice, sleep is the first behavioral aspect that I will start to address with tinnitus. Because once we get sleep under control, tinnitus tends to alleviate itself. So, sleep hygiene is huge in this piece. I would argue that if most physicians would report that the best thing you can do for your body is drink more water, I would say the second thing on that list is get more sleep. Tinnitus in particular has a direct one-to-one correlation with sleep and severity.

Host: So Jo, can you then explain the two types of tinnitus, starting with autogenic or ear and hearing related?

Jo Powner: Absolutely. So, autogenic tinnitus is the number one thing that I see in my practice, because it's related directly to ears and hearing specifically. So if you have a hearing loss and that's causing a deficit in what the temporal lobe is receiving day-to-day, it's trying to fill in the blank, like we said before. So, that's an autogenic tinnitus. Autogenic tinnitus is probably the easiest to take care of from an audiological perspective. So while this is a disappointing thing for some people to hear, autogenic tinnitus is treated by treating the hearing loss.

So at this point, I really like to emphasize that tinnitus by itself is not a disease. So remember, that's why we don't call it ti-NYE-tus. Tinnitus is a symptom. It just happens to most commonly be a symptom of a hearing loss. So, autogenic tinnitus is what we are looking for in the audiology clinic.

When we're looking at other types of tinnitus, so I'm going to go ahead and bleed into that second type already, non-autogenic tinnitus would be everything else. So if you have a tinnitus that isn't related to your ears, it's easy to identify because it isn't consistent. If you have a tinnitus that tends to change in either pitch or loudness or quality, when you move your head or neck in different positions, well, that means it's probably physiologic, it's probably related to something else going on in your head, your neck, your teeth, even your jaw.

So if you notice that your tinnitus has this manipulatable quality to it, and it does shift, that tells me it's probably not going on in your ears because we don't have enough power to adjust things in our cochlea. Whatever the cochlea is doing, it's going to stay static. So if you can change your tinnitus, chances are we could probably change it for you by doing things like sending you to the dentist or even going to the physical therapist.

Host: Wow, that's fascinating. Okay. Interesting. So, you talked about the non-autogenic, that is where hearing is fine-- not a hearing problem, as you said-- but it's still present due to some other physiological issue.

Jo Powner: Correct. And they can coincide. You might have more than one. So if you notice, if you move your head or neck around, that one of the pitches or tones in your head does change, but the other doesn't. Well, congratulations, you've got both. So, we might want to try to deal with the non-autogenic type first.

The only other piece here that I do want to mention, if you have a tinnitus that is pulsatile, that's the one that I talked about earlier, and it pulses with your heartbeat, that is something that's worth bringing up with your general physician, because pulsatile tinnitus can absolutely relate to something vascular. So, you want to make sure there's nothing going on in your carotid artery or your jugular vein. Your jugular vein runs right behind your eardrum. So, it's not uncommon for those structures to touch each other so you can hear your heartbeat, especially if you're laying down in bed. But if it's sudden or if that's a change that you've never noticed before that's worth addressing, because we want to make sure there's nothing going on in the vascular realm.

Host: Right. So if someone suspects they have tinnitus. What does the evaluation process typically look like?

Jo Powner: Well, we usually start with an ear exam and a hearing test. Again, that's our low-hanging fruit. I take a lot of time at the first visit though to determine if the tinnitus changes in that quality, the pitch or loudness, and we do our little exercise where people will kind of shift their head in a circle. I have them open and close their jaw. I really had to get into the habit of asking patient's about their dental history.

I had a patient who came in, was absolutely adamant that his ears were just screaming. He was really in a lot of distress. which I would like to say is an uncommon thing with tinnitus patients, but it's really not. Coming in and being really distressed is a common site in an audiologist's day-to-day practice. But this patient, put him in the booth, did his hearing test-- absolutely perfect. He could hear a flea pee in the snow. It was totally perfect. But he really was concerned about this tinnitus. So, I asked him if anything else had changed in the last week since it cropped up. And he said, you know, "Funny you mention it. This really happened because I bit down on something and it broke my tooth." I kind of looked at him a little funny. And I said, "Well, did you go to the dentist yet?" And he said, "No, my ear is screaming." So, he was much more concerned about his ears than he was his tooth. So, I shushed him out of the office, told him to call his dentist. And he called me about two days later and said, "You were right. Got my tooth fixed, and now my ear has calmed down." So, don't take for granted that if you have especially a very loud sudden change in your tinnitus, that tells us that it's probably something else.

So, all of our evaluation, it doesn't just encompass a hearing test, we're really looking at you as a whole person, not just a set of ears with legs, though that would be fascinating. Ears are incredibly tied to the entirety of your being. So, sound is very emotional. Tinnitus is one of those things. So we want to look at you as a whole person. And all the other structures in the head and neck, your facial nerve comes down the side of your face almost like a hand. So, it stands to reason if you have something going on in your jaw or in your teeth or in your neck. If it causes some extra stimulation of your facial nerve, well, believe it or not, your facial nerve runs kitten caboodle right next to your eighth nerve in your skull. And that eighth nerve runs everything up to the temporal lobe. So if some electrical stimulation of that facial nerve crosses over into your eighth nerve, it will go up to that temporal lobe, which interprets everything as a sound, which is why if you have a problem in these other extraneous parts of the face, neck and jaw, it's going to result in hearing something, even if it's not really coming from your ears.

Host: So, those would be examples of non-autogenic, would that be correct?

Jo Powner: Correct. So, the hearing test is the easy one. Everything else is where we have to ask a lot of extra questions.

Host: All right. So then, for somebody that has autogenic, if you will, tinnitus, is it always permanent then? I mean, with the non-autogenic, like you said, you just gave the example, the person cracked their tooth and all of a sudden the ear started acting up. They fixed the tooth and the sound went away. For someone that has autogenic tinnitus, is it always permanent then or can it improve over time? And what does recovery or management of it usually involve?

Jo Powner: Well, this is the part where people tend not to like me so much because, unfortunately, I do have to give the bad news that because tinnitus is a symptom, if it is a symptom of hearing loss, generally there is no magic cure for hearing loss. We can treat it, but that doesn't mean that it's going to go away without some extra help from amplification or some other treatments like surgery if you have a surgically-indicated hearing loss, which most people don't.

So generally, yes, the answer is tinnitus is permanent, but that does not mean that it can't be treated. So, I have a little bit of a pet theory, which is that most physicians who tell their patient's that tinnitus is permanent and there's nothing we can do about it. Chances are those people probably have some other symptoms of hearing loss and they don't want to see me. So, they don't like to refer people to the audiologist if they don't have to. I think because it means that they'll have to do it themselves at some point.

But the great thing is, because we can treat hearing loss relatively simply through amplification and by increasing those extra sounds in your environment called sound enrichment. So, remember at the beginning where we said that tinnitus is kind of like a candle in a well-lit room, if we turn up the lights or we turn up the sound or increase your sound enrichment by improving your hearing, tinnitus, it stands to reason, will become less severe.

So, most of my patient's who come in with a truly autogenic tinnitus if they come in for a hearing aid evaluation. I'll put a demonstrating device on them, and I'll put in what we call a first fit, which is where we do the prescription of their hearing test into a hearing aid. Just real basic, no fine tuning. If they report that their tinnitus changes, whether it gets less intense or if it changes in pitch, or if it goes away entirely, that's kind of diagnostic. So if we can manipulate the tinnitus through sound-- so not through your head and neck movement, but just through sound-- that tells us that it not only is autogenic, but it is responsive. So, we can treat that tinnitus, we can do something about it.

I would say that some people will also note that their tinnitus changes with things like caffeine stimulants, and there's that sleep piece that we talked about before. But the number one thing that helps impact tinnitus is stress reduction. So, we do know that stress has, again, a one-to-one relationship with tinnitus, just like sleep does. But the tricky thing about stress is your body doesn't know the difference between positive and negative stress. So if we think of it like, "Oh, I'm so stressed out. I've got a new job interview coming up and I've got my sister's wedding I have to plan for, and I've got to travel out there. And, oh, I'm moving, so I've got to deal with all the packing. And oh, it's just so stressful." So, these folks are going to come in and say, "Oh, I can't sleep. I'm so stressed out. Uh-oh. And it turns out my ringing is crazy too." Well, let's tip that on its head. Let's say, "Oh, I'm so excited. I'm going to do a new job interview, and now my sister's getting married and I can't wait. I'm going to help her. And oh, I'm going to move to this new house and I can't wait to get there. Well, the truth is your body doesn't know the difference between those two scenarios. It's still stress. So, trying to keep an even keel will also help with your tinnitus reduction. So, I tell everybody, "Calm down. Taking a chill pill will really help with your tinnitus."

Host: Even keel, as you say. Steatotic Eddie is what we're looking for.

Jo Powner: Yes.

Host: And that's kind of the coping strategy that you would recommend. As you said, stress and fatigue make tinnitus worse for many people.

Jo Powner: Yes, absolutely. It is almost a cruel joke that if you're stressed out, that your tinnitus gets worse, because you're already dealing with it. But that's absolutely true. And so, anything you can do to help reduce your stress, whether that's improving your sleep hygiene. So, that's turning your phone off, leaving it away from you for about an hour before you go to sleep. Listening to things like this podcast before you go to sleep would be a great way to reduce your stress and improve your sleep hygiene. Things like getting into a nice routine of exercise, stress reduction also involves things like meditation and mindfulness practice, improving your diet, reducing those extra stimulants like caffeine, alcohol. And even salt intake can be related not just to stress, but to tinnitus. And also, other autogenic symptoms like dizziness can be impacted by salt intake.

Anything you can do to reduce that hypermonitoring, that cyclical focus of, "There's the tinnitus. There it is, because I can hear it now. I'm really hearing it." We want to bring us to a different scenario. I've got a funny little anecdote if you don't mind me sharing.

Host: Absolutely.

Jo Powner: So if we imagine hypermonitoring as an active situation, this is a little story I like to tell patient's. So, let's imagine you're going through a hike through the woods. You're up at Armstrong Woods up by Greenville, which is a beautiful place, and let's pretend that you're there and it's starting to rain. And you're wandering through the forest and you end up finding a little bed and breakfast, and you've got to get some shelter from the rain, right? So, you go in and you meet with the guy who runs the whole place. And he looks a little bit like Norman Bates. He's a little creepy. So, he's going to tell you, "Well, I'm going to take you up to this nice little house on the top of the hill." And he decides that he likes you. So, he's going to put you in this nice little duplex and he says, "Just so you know, there's a steam heater in this room. The steam heater's broken. So, it's going to hiss at you all night. But don't worry about it, it's just the steam heater. You can listen to the rain outside and you'll forget about it." So, you thank old Norman and you go in and you're going to be on your merry way.

Let's pretend somebody comes up to the same bed and breakfast after you. And they also notice that he looks a little bit like Norman Bates, but they tease him. And he decides instantly he does not like them. So, he takes them up to the same little duplex that you're in and he puts them on the other side. But before he lets them in for the night, he says, "Oh, by the way, I think there's a snake loose in your room. So good luck with that." And he walks away.

Now, we know, of course, that it's just a steam heater, right? We know it's not a snake, but do you think the people who think that there's a snake loose in their room are going to get a lot of sleep? Probably not. So, the idea is the same. They have the same coping strategies, right? They still have the rain outside to mask that noise, which is something you can easily do at home. You can listen to rain sounds, a noise generator. Even a fan can help reduce that tinnitus at night when you're trying to sleep.

But if we think of it psychologically as something that's going to hurt us. Those coping strategies are less likely to work, so that's why stress reduction is so important. We want to tell our brains it's just a steam heater, not a snake loose in the room.

Host: The power of the mind can help manage it.

Jo Powner: Absolutely. It can't be understated that the power of your mental state as it surrounds tinnitus has a big impact. So, you don't need to know the cause of your tinnitus for it to be either impactful or not, but it certainly helps if you know that it isn't nefarious, it's not going to hurt you. It's probably just static sound that's in the background and it's the brain's way of telling you, "Hey, you know, your body is like a big cookie, and sometimes that cookie starts to crumble. So if you have problems in your ears, you'll have problems with tinnitus. But that's okay. It's not the end of the world."

Host: Right. So, for listeners, Jo, experiencing tinnitus right now, what's the most important first step they should take?

Jo Powner: First step should be get a hearing test. We've got to know what's going on in that system. So even if your doctor tells you that there's nothing that can be done, fight to get a hearing test. A baseline hearing exam can not only tell us what's happening in your hearing system, but it can help safeguard you against problems in the future, just in case your hearing or your tinnitus changes.

We want to make sure we can monitor those things. I would also say the first thing that you should do or maybe shouldn't do in this case is don't believe all those snake oil ads that you'll read about. So, there are a number of different ads online that will say that, "Oh, take this magic pill and it will get rid of your tinnitus," or "Watch this ad and we'll tell you all the secrets that doctors don't want you to know." I'm going to let you all in on a not so little secret. Fifty million people in America struggle with tinnitus. If there was a secret magical cure, we wouldn't be keeping it a secret. So, it's not as simple as taking a pill. There is no magic cure. Instead, we want to find out what's actually happening in that system. Because tinnitus, again, is not a disease, it's a symptom. So, our job is to look for where is it coming from?

Host: Jo, this has been fascinating. And like you said, 50 million people suffer from this. So, I know this is a very important topic. Thank you so much for your time. We really appreciate it.

Jo Powner: Of course, happy to be here and excited to see what happens next with your podcast.

Host: Well, thank you, Jo. I appreciate that. And once again, that is Jo Powner. And for more information you can go to mymarinhealth.org. And if you enjoyed this podcast, please share it on your social channels and check out the entire podcast library. For topics of interest to you, I'm Bill Klaproth. This is The Healing Podcast, brought to you by MarinHealth. Thanks for listening.