Tinnitus Assessment & Therapy in Singapore

What is Tinnitus

What is tinnitus?

Tinnitus is comes from the word tinnere which means “ringing” in Latin. It is used to described hearing sounds that aren’t caused by the environment. It can sound like buzzing, ringing, roaring, clicking banging or even music.

It is usually classified into 2 types:

I. Objective tinnitus – Sound is produced by the body and can be heard by placing a stethoscope to the patient’s ear.
II. Subjective tinnitus – Sound can only be heard by the patient. This is the most common type of tinnitus.

Common types of tinnitus sounds and associated diseases

Tinnitus is not a disease but a symptom of an underlying disease, auditory or psychological annoyance. Here are some common diseases and the associated tinnitus sound.

Pulsatile tinnitus (Tinnitus beats with pulse or sounds like rushing water)
Objective tinnitus caused by increased blood flow. Commonly seen in pregnancy, cardiac murmurs, anemia, vascular tumors, atherosclerosis or hypertension.
Clicking tinnitus (Rapid clicking sound at 60-200 beats per minute)
Seen in patients with muscle spams in structures near the ear. Common causes are small vessel disease or degenerative neurological disorders.
Roaring tinnitus (Ocean or wind sounds)
Caused by abnormal eustachian tube that remains open. Patients often report that lying down will bring relief. Usually seen in patients who have experienced rapid weight loss or radiation therapy.
Crackling tinnitus (Rough, crackling intermittent sounds)
This form of tinnitus is usually exacerbated by outside sounds and occurs occasionally. Its most common cause is spasm in the stapedial muscle.
Tonal tinnitus (Singular high pitched tone)
The most common tinnitus sound is tonal. And is usually associated with hearing loss, noise exposure, ototoxic drugs, depression and meningitis.
Tonal tinnitus with increased sensitivity to breathing and heart beat
Tinnitus associated with conductive hearing loss include too much earwax, otoscleoris and ear infections.
Tonal tinnitus which changes due to head or jaw movement
Somatic form of tinnitus that is usually caused by neck muscle tension or abnormal alignment of the jaw

Do I need tinnitus therapy?

While most individuals are told by general practitioners or healthcare professionals to ignore their own tinnitus, it is recommended for you to visit an audiologist or specialist doctor if:

Your tinnitus is regular or constant
Your tinnitus is getting louder or worse
Your tinnitus affects your mood, sleep, concentration or daily activities

Your tinnitus appeared after a head injury
You experience on and off hearing loss, muscle weakness in your face or vertigo along with your tinnitus
Your tinnitus is a beating sound and has the same pattern as your pulse

Our Tinnitus Services

Treating tinnitus in Singapore usually starts with an assessment. Our tinnitus assessment will comprise of a hearing assessment (audiometry, tympanometry, acoustic reflex and loudness discomfort levels). After which, you we will conduct a few tests to try to match the sounds of your tinnitus to understand what your tinnitus sounds like, how your tinnitus impacts you and determine the best treatment approach to take.

As tinnitus assessment requires more thorough investigation than a typical hearing test, please schedule at least an hour for each assessment.

What is Hyperacusis

Hyperacusis in Singapore

Hyperacusis is the condition whereby normal everyday sounds causes distress and discomfort to a person.

In most cases, the sufferer’s cochlea or hearing organ is functioning normally however has the perception that his or her ears are permanently damaged. Instead, it is the abnormal response of the auditory pathway to sound that causes a person to be intolerant to sounds.

Hyperacusis & Mysophonia Management Services

Educational counselling

Most patients find it useful when we go through the various mechanisms of how changes in the auditory system can lead to decreased sound tolerance. We also teach patients about safe levels of sound. Usually when patients understand that not all types of uncomfortable sounds lead to damage in their hearing their symptoms are alleviated.

In some cases, patients find themselves misunderstood by family members. We do involve family in our counselling sessions as to help them understand that patients do not consciously cause their sound sensitivity. Involving the family in the treatment process is generally beneficial to both patients and family.

Positive Association & Desensitization

Desensitization should always be practiced in a controlled manner under the guidance of a trained audiologist. Forcing a patient to endure the offending sounds for as long as possible may exacerbate the condition. Desensitization is usually practiced with positive association. The offending sound is mixed in a small degree with pleasant sounds such as music and gently introduced to the patient. The goal eventually is to slowly reduce the pleasant sounds in the mixed sounds as the patient’s reactions improves.

Origins of tinnitus (Neurophysiologic Model)

The development of the neurophysiologic model of tinnitus was proposed in the 1980s by Jastreboff. The model proposed that tinnitus results from the abnormal processing of a signal generated in the auditory system. And the limbic system is responsible for the emotional response towards tinnitus. Negative reinforcement (feelings of stress, frustration, fear) enhances the perception of tinnitus and increases the duration in which it is perceived.

Figure 1. Graphic representation of the Jastreboff Neurophysiological Model of Tinnitus 1990

This lead to the development of Tinnitus Retraining Therapy, a successful tinnitus management that focuses on retraining and relearning. Once the tinnitus loses its negative meaning, however loud or intrusive it is, it will lessen, and in many cases, the tinnitus may not be heard for long periods of time.

Interesting research on tinnitus

An interesting study done in 1953 revealed that up to 93% of individuals with no tinnitus experience temporary tinnitus when asked to sit in a sound proofed room for a short period of time. Most reported hearing buzzing, ringing sounds like what tinnitus suffers hear. This experiment suggests that tinnitus may be the body’s natural response to changes in our sound environment (silence). The change in sound environment could be due to environmental factors such as sitting in a quiet room or due to physiological changes in our ears, such as hearing loss due to ageing or noise exposure.

Another interesting research shows that only 15% of tinnitus sufferers find tinnitus disturbing and affects their quality of life. The other 85% are not bothered by tinnitus. While the most popular explanation would be that every suffers from varying degrees of tinnitus loudness and duration, the study shows that it actually an individual’s perception of tinnitus that determines whether he or she will find it unpleasant or something of little importance. In fact, some individuals have reported liking their tinnitus, associating the sounds with crickets in a calm forest.

The reason behind the high success rate of tinnitus management in our centre is because we tackle tinnitus using sound therapy and educational counselling. We also believe in using a multi-disciplinary approach and work with our partner ENT doctors and psychologists to effectively treat tinnitus symptoms.

Sound therapy

Sound therapy can be used in a variety of ways to reduce the perception of the tinnitus. The most successful outcomes we notice among our patients is the use of “Habituation” whereby the brain successful classifies tinnitus as an important sound to ignore (see Figure 1). This involves retraining the brain into only hearing on a “important to hear” basis. For example, if you sit in a busy restaurant for a long time, your brain habituates to background sounds. You become unaware of the nearby chatting and only “hear” important” sounds such as your loved one talking to you. Sound therapy habituation aims to achieve the same result via a combination of sound generations such as hearing aids, headphones or phone apps.

Educational Counselling

In educational counselling, we reduce the patient’s emotional reaction to the tinnitus. We find that once patients understand the mechanisms behind tinnitus, the negative impacts of tinnitus tend to decrease in patients over time. However note some patients take months and maybe years to alter their perceptions. These patients may have co-existing anxiety or depression and it may take longer to change their feelings towards the tinnitus.

More on hyperacusis

The way our auditory pathways process sounds is complex. Some sound can be loud but ignored whereas some sounds which may be softer in volume but “loud” enough to get our attention. For example, if a person is sitting in a busy restaurant with loud chatter around, he or she will usually be able to hear someone calling his or her name from across the room even if spoken softly. The subconscious part of our nervous system can enhance or suppress sound signals based on learnt experience form what we perceive to be important. Changes in our auditory pathway or brain can cause abnormal perceptions of sounds, common causes include: noise exposure, Lyme’s disease, Meniere’s or Temporomandibular Joint Syndrome.

Mysophobia and phonophobia

Another common condition where a person suffers from decreased sound tolerance is mysophobia. Individuals suffering from mysophobia develop an intense dislike of a certain sounds known as “trigger sounds” such as food chewing, breathing or pen clicking. Instead of feeling distress of discomfort, common reactions include irritation followed by disgust or anger. Sometimes the individual experiences physical symptoms such as pressure in the chest. Phonophobia on the other hand is a stronger reaction where by the individual fears the specific sound. It is a rare phobia whereby the sufferer suffers from anxiety, panic attack and even headaches upon hearing the sound.

Interestingly, the mechanism behind mysophobia is does involve an abnormal auditory pathway response. Rather it is theorized to be the result of enhanced connectivity between the within the brain between the auditory and emotional regions. As mysophobia is only limited to selective “trigger sounds”. Also, a study published in 2013 revealed that while mysophobia sufferers disliked hearing certain sounds, they do not have the same reaction when the same sound was self-produced. Another study revealed that over half of mysophobia sufferers have family members to have similar dislike to the sounds suggesting that mysophobia. This suggests that mysophobia is probably not due to a change in the auditory pathway but a condition which may involve learned behaviour.