The Tinnitus Website of Robert Aaron Levine, MD

“All that glitters is not gold …. All that rings is not from the ear

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Overview

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This site's purpose is to share what Dr. Levine and colleagues have learned over the past 35 years in trying to help people with their tinnitus.

Key Points

The two major causes of tinnitus are:

(1) A disorder of the muscles, tendons and joints

of the upper neck and jaw

(2) A disorder of the hearing system

(a) outer ear

(b) middle ear

(c) inner ear (cochlea)

(d) hearing nerve (auditory, VIIIth)

(e) hearing system of the brain


(3) Tinnitus may be Multifactorial

-- for example, hearing loss

can combine with a disorder

of the muscles or tendons

of the upper neck or jaw

to cause tinnitus

whereas, either one alone

would not cause tinnitus

Who is Dr. Levine

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Robert Aaron Levine, MD has spent the last 35 years providing tinnitus care to patients at the Tel Aviv Medical Center (Ichilov) and Massachusetts Eye and Ear Infirmary, a Harvard Medical School teaching hospital. For 40 years, Dr. Levine had been in the Department of Neurology of the Massachusetts General Hospital, where he did his neurology training, and the Eaton-Peabody Laboratory of the Massachusetts Eye and Ear Infirmary and Harvard Medical School, where he has been involved in hearing research.


He relocated to Israel 10 years ago where he continues his work.

FACTS about Tinnitus

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  1. About 10% of all adults report having constant tinnitus

    1. In dead silence 90% of people hear something

    1. Of all adults, in 1 of every 200 feels tinnitus interferes with their ability to lead a normal life

In other words, 1 out of 20 adults with tinnitus finds that it is very disturbing

  1. Tinnitus is often multiFACTORial

    1. Known FACTORs for ONE EAR tinnitus include

i. Same side Hearing Loss

ii. Tight sore muscles of head and neck on the same side

1. bruxism (grinding teeth)

2. neck strain

iii. Dental factors (e.g. abnormal bite)

iv. Trauma

v. Compression of same side auditory nerve

vi. Factor(s) X (unknown factors)

    1. Known FACTORs for BOTH EARS tinnitus include

i. Symmetric Hearing Loss

ii. Tight sore muscles of head and neck

1. bruxism (grinding teeth)

2. neck strain

iii. Dental factors (e.g. abnormal bite)

iv. Trauma

v. Medications

vi. Emotional trauma

vii. Factor(s) X (unknown factors)

  1. The single most important factor contributing to tinnitus is probably hearing loss

    1. The greater the hearing loss the greater the chance of having tinnitus BUT

i. 10% of normal hearing people have tinnitus

ii. 80% of deaf people have tinnitus

1. 20% of deaf people do NOT have tinnitus

  1. 80% of people with tinnitus can change their tinnitus with strong contractions or compressions of the neck or jaw muscles (somatic testing)

    1. Deaf people with tinnitus can similarly change their tinnitus

i. 6 of 11 subjects tested

  1. 50% of people without tinnitus will hear a high-pitched sound with strong contractions or compressions of the neck and jaw muscles (somatic testing)

        1. Deaf people without tinnitus can hear a sound with somatic testing

i. 2 of 3 subjects tested

  1. Hyperacusis (decreased tolerance for loud sounds)

    1. 40% of tinnitus clinic patients have hyperacusis

    2. 86% of patients with hyperacusis have tinnitus

More about tinnitus --

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WHAT IS IT?

Tinnitus is a subjective experience where one hears a sound when no external physical sound is present. Some call it "head noises,' "ear-ringing," or use similar terms to describe it.

WHAT DOES THE WORD "TINNITUS" MEAN? The word is of Latin origin and it means 'to tinkle or to ring like a bell.' It I has two pronunciations, both correct: "ti-night-us' or "tin-ni-tus."

WHAT CAUSES IT?

Many times despite an exhaustive evaluation no cause can be identified. Hearing loss is a risk factor for tinnitus. Even with a total hearing loss 20% of people have no tinnitus. Often problems having nothing to do with the ear can cause tinnitus such as painful disorders of the head or upper neck [such as the temporomandibular joint (TMJ) syndrome or whiplash]. On the other hand, almost everything that can go wrong with the ear may be associated with tinnitus. Problems ranging in severity from ear blockage from wax to ear infections to acoustic neuromas (benign tumors) can produce tinnitus. Pulsatile tinnitus can be caused by abnormal blood vessels or even upper neck or jaw muscles. Tinnitus can sometimes even be a side effect of medications (herbal, prescription or non-prescription).

HOW COMMON IS TINNITUS? VERY COMMON. It is currently estimated that about one out of every ten American adults have chronic tinnitus to some degree. For the vast majority of people, their tinnitus is little more than a minor nuisance. Yet, it has been estimated that 1 of every 200 adults in this country consider their tinnitus as interfering with their ability to lead a normal life.

WHAT IS IT LIKE TO HAVE TINNITUS? People with the recent onset of tinnitus can have a very difficult time for the first couple of months before they become adapted to this new experience. Fortunately, for most people their tinnitus eventually becomes no more than a nuisance. In its severe form, however, tinnitus can be a chronic condition causing loss of concentration, sleep problems, and psychological distress. It can also make a deteriorating hearing condition or balance disorder appear worse. Tinnitus can fluctuate from day to day, and even from hour to hour. Tinnitus can be perceived as being in the ears or in or around the head, and can have one or a variety of different sounds such as ringing, hissing or roaring.

DO WE KNOW WHAT TINNITUS IS? The DCN (dorsal cochlear nucleus) hypothesis can account for the most common types of tinnitus. Other theories account for rarer types of tinnitus. There is more than one way tinnitus can develop and tinnitus can develop from a combination of factors. See –

BASICS [English] https://www.youtube.com/watch?v=Oxw6NzlH9_Y&list=PLwSMnU-eOumdt-iq_Qg98lMW_Rm8ofkOf

יסודות [עִברִית] https://www.youtube.com/watch?v=f9imX9U7V0E&index=3&list=PLwSMnU-eOumdt-iq_Qg98lMW_Rm8ofkOf

IS IT ASSOCIATED WITH HEARING LOSS? SOMETIMES. Tinnitus does not necessarily cause hearing loss, and hearing loss does not necessarily cause tinnitus, although the two often co-exist. In many cases tinnitus is present where there is no loss of hearing. In others there can be hearing loss and yet no tinnitus. In some cases, tinnitus is associated with hearing loss. For example, some of those who have been exposed to excessively loud sounds will develop a high frequency hearing loss and high-pitched tinnitus.

DOES TINNITUS MEAN THAT ONE IS GOING DEAF? NO. The development of tinnitus is an indication that there has been some kind of change in the overall balance of activity in the hearing parts of the brain, but in no way does it mean the patient will become deaf.

WHAT IS SENSITIVITY TO SOUND? A minority of tinnitus patients also experience more than the usual sensitivity to sound. This tolerance problem can occur in individuals with or without a hearing loss. Although this problem is difficult to manage, some relief can occur through a habituation program.

WHAT MAKES TINNITUS WORSE? In general there is a wide variation amongst tinnitus patients. What might worsen one person's tinnitus will have no effect on another person's tinnitus. Worsening is nearly always temporary. 1. Psychological factors. Nearly everyone notices that their tinnitus is worse during times of stress, anxiety or depression. These are virtually the only things that worsen nearly everyone's tinnitus. 2. Loud Noise. Some find their tinnitus worsens when they are exposed to loud sounds. Like all people, tinnitus patients should protect their ears from loud sounds: power tools, guns, motorcycles, noisy vacuum cleaners, etc. should be used only with ear protection - ear plugs and/or ear muffs. 3. Various jaw, head and neck postures or muscle contractions can alter tinnitus, but usually only temporarily. 4. Aspirin and quinine in high dosages can cause a temporary tinnitus. Caffeine almost never affects tinnitus. In some alcohol changes their tinnitus but always temporarily.

IS MY TINNITUS GOING TO GET EVEN WORSE? VERY UNLIKELY. The general pattern of tinnitus severity usually decreases gradually from the time of its first occurrence. Sometimes the tinnitus even disappears altogether: it does not often get markedly worse.

DOES TINNITUS GO AWAY? SOMETIMES. Yes, but it is difficult to predict for any individual.

WHAT SHOULD A TINNITUS PATIENT DO? Initially each patient should be examined by a physician with expertise in tinnitus. The purpose of the examination is to determine the cause of the tinnitus and whether there are SPECIFIC ways to correct or control the underlying condition. For example, treatment of ear conditions (such as Meniere's syndrome or otosclerosis) can sometimes result in the tinnitus disappearing. Treatments for head, neck or temporomandibular jaw joint (TMJ) problems associated with tinnitus have been effective for some who suffer from both conditions.

WHAT NONSPECIFIC TREATMENTS ARE AVAILABLE FOR TINNITUS?

Several nonspecific treatments are currently available and several other experimental approaches hold promise for the future. These include:

1. Medications Many medications have been investigated as possible relief agents for tinnitus. These medications have included anticonvulsant medications, tranquilizers, antianxiety medications, and antihistamines. For some patients, these medications are effective in helping them cope with the tinnitus. For example, depressed patients with chronic tinnitus often perceived treatable disability due to depression as untreatable disability due to chronic tinnitus. It is also well established that Lidocaine administered intravenously can often stop the tinnitus, but its effect is not long lasting [less than 30 minutes]. Research continues in an attempt to identify a medication that can be administered orally and have a long lasting, comparable effect to Lidocaine. Anecdotes abound regarding suppression of tinnitus with medications. Only oral benzodiazepines [e.g. clonazepam] have been convincingly shown to quiet tinnitus. Antidepressants have been shown to improve the overall well-being of people with tinnitus; in fact people with chronic tinnitus often perceive their disability due to depression as untreatable disability due to chronic tinnitus. A relatively rare form of tinnitus [“typewriter tinnitus”] is suppressed by carbamazepine.

2. Masking. Masking refers to using an external sound to mask or cover up the tinnitus. With a masker the patient hears the masking sound and not her/his tinnitus. Anything that generates a sound can be used as a masker. Commonly used items are fans, air conditioning units, radios or televisions. Effective masking can be produced by apps on a smartphone. Also available are “maskers,” devices resembling hearing aids (and worn in the ear) that present a selected band of noise to the patient's ear. Masking seems to work for only a few patients, but [like most treatments] it is presently not possible to predict in advance which patients can be helped with this treatment. Masking does not seem to damage hearing when used over long periods of time.

3. Shifting Of Attention. The fundamental problem with troublesome tinnitus is that the patient is unable to ignore (that is shift her/his attention away from) the tinnitus. Techniques that have reported success with shifting attention away from the tinnitus include hypnosis, "self-hypnosis," and sound based therapies such as (a) "tinnitus retraining therapy (TRT)" (using a hissing sound) and (b) Neuromonics (using music). Their goal is to 'retrain' the brain to ignore the tinnitus. They use either a device resembling a hearing aid (TRT) or an mp3 player (Neuromonics). The level of the sounds are relatively low so that often the tinnitus can still be heard. Counseling is a key part of the treatment. Benefits can occur within a few weeks to a year or more.

4. Relaxation Techniques. Relaxation aids in coping with psychological distress. Since stress seems to worsen tinnitus, being able to control stress and tension can be very helpful in coping with tinnitus. All relaxation techniques, when well done, are probably equally effective: they include biofeedback and meditation.

5. Counseling, cognitive behavioral therapy, and patient education have all been shown to be useful for many patients who are having trouble coping with tinnitus.

6. Amplification. If a patient has a hearing loss and the tinnitus is in the medium or low pitches, often a hearing aid will help. The hearing aid helps by (a) making it less of a struggle to hear and (b) from the masking provided by the ambient environmental sounds that otherwise are not heard.

7. Electrical Stimulation Patients, who have a cochlear implant to treat their profound hearing loss, find that electrical stimulation from their implant very often improves their tinnitus. Many other types of electrical stimulation are being investigated including direct and indirect brain stimulation.

8. Other. Additionally, some patients have reported finding help through various home remedies that are of unproven value as yet. It is important to remember that a natural remission can occur, perhaps coinciding with the start of a new treatment or spontaneously with no treatment at all.

SPECIFIC TREATMENTS FOR CERTAIN TYPES OF TINNITUS?

1. Typewriter Tinnitus. Carbamazepine and similar medications suppress it. This is the only type of tinnitus that is consistently treatable with medication. In rare patients, who cannot tolerate medications. surgery that relieves pressure from an artery on the hearing nerve is very successful.

2. Pulsatile tinnitus. Tinnitus that pulses with the heart beat has many different causes most of which can be treated successfully

3. Somatic Tinnitus. Sore/tender muscles, tendons and joints of the head and neck can cause tinnitus, sometimes even pulsatile. More than 50% of patients seen in our practice have a highly significant contribution to their tinnitus from sore/tender muscles, tendons and joints of the head and neck, which is treatable with physical methods directed toward them. The best treatment has been needling of the sore muscles (“trigger point injections” and “dry needling”). One of our collaborators has found that this treatment stops the tinnitus in 25% and is much improved in another 25%. Botox is showing promise for those who do not respond to needling.

IS THERE AN OPERATION FOR TINNITUS? Rarely. In cases with one ear tinnitus due to nerve compression, surgery is usually helpful. Cochlear implants have been helpful in some cases. Brain electrical stimulation has not had consistent benefit.

GENERAL RECOMMENDATIONS for shifting your attention away from the tinnitus (or "how to learn to live with it")

• Avoid the quiet. Always keep some competing sound around, such as low level background sound from a fan, music, radio etc.

• Minimize reading about tinnitus, support groups, internet, chat rooms, etc. These activities only draw your attention toward the tinnitus.

• Stay busy with things unrelated to tinnitus (e.g. family, friends, work, hobbies, religion, etc). Always have more than enough things to do. Idle time is the ally of tinnitus.

• Minimize discussion of tinnitus with family and friends. This only draws your attention to your tinnitus. Only you should bring up the subject, if you feel you must.

Local Resources for Tinnitus Treatments:

Myofascial Trigger Point Treatment:

Ynon Lerner // 052-59-66616

Relaxation Techniques:

Galit Cohen PhD // 03-6973630

TMD (TMJ) Treatments:

Larry Lockerman DDS // 052-645-9145

Counseling:

Rebecca Cox AuD // 054-357-0085

TREATMENT VIDEOS [English]

https://www.youtube.com/watch?v=dm0-hhwP3UM&index=2&list=PLwSMnU-eOumdt-iq_Qg98lMW_Rm8ofkOf

טיפולים [עִברִית]

https://www.youtube.com/watch?v=MNEEVDzYt7g&index=4&list=PLwSMnU-eOumdt-iq_Qg98lMW_Rm8ofkOf

Basics of Tinnitus {English]

בסיסי של טינטון (בעברית)

Informational Videos

Basics and Treatment (English and עִברִית)

Treatments

טיפולים (בעברית)

More ADVANCED Tutorial

What to expect from your appointment with Dr. Levine

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Dr. Levine will provide you with his opinion based upon his 35 years of experience in treating people with tinnitus and his research into tinnitus -- regarding

1. WHAT caused your tinnitus

2. HOW it caused your tinnitus

and

3. The best TREATMENT options for STOPPING your tinnitus