• TINNITUS phase out therapy
• Phasing out the nightmare of TINNITUS

Introduction :-
Tinnitus is the perception of sound (s) in the ear (s) / head in the absence of any external or internal auditory stimulation, i.e., without any corresponding mechanical activity in the cochlea. It is now believed to result exclusively from some neural activity within the CNS. This abnormal neural activity in the brain causing the sensation of sound in the absence of any peripheral auditory stimulation, i.e. without any detectable physical sound may be induced by decreased / absent input from the auditory periphery (tinnitus with deafness) or may occur solely due to disorders in the higher auditory pathways without any dysfunction of the peripheral auditory system (tinnitus without deafness). The current consentious on the pathophysiology of tinnitus is that this abnormal perception of sound is caused by some obscure abnormality in the higher auditory pathways in the brain and is intimately linked with stress / anxiety / psychological trauma and various involvements of the limbic system. Tinnitus is now conceptualized as a phantom auditory perception caused by dysfunctional neuronal firing in large neuronal circuits in the brain that also include regions located outside the primary auditory cortex (area 41) particularly in the attentional and limbic systems of the brain. This is why psychic and psychological factors are intimately related to tinnitus. In tinnitus, the auditory cortex picks up signals within its own auditory circuits creating an endless loop of signaling. This results is a vicious cycle of perpetual firing of neurons in the higher auditory pathways and this firing spreads to involve the limbic system also. Breaking this perpetual loop of signaling is the objective of therapy in tinnitus.


Incidence
The incidence of tinnitus is very high. I in 7 of the general population of USA suffer from tinnitus and 1 in 30 are very severely affected. In UK, 1 in 10 of the general population suffers from tinnitus, and 1 in 30 are very severely affected.

MANAGEMENT :-
Numerous treatment options are available but results of treatment are not very effective. The currently advocated modalities are, e.g. Tinnitus Retraining Therapy (TRT), Tinnitus Maskers, Noise Generators, Psychotherapy, Behavioral Therapy, and of course drugs like Ginkgobiloba, Caroverene, Lidocaine, Alprazolam. Tocanide etc. A lot of many other procedures and drugs like neurotropic Vitamins have also been tried but have been proved to be totally ineffective. Of all the modalities of treatment used for tinnitus, Tinnitus Retraining Therapy has been found to be the most rational and beneficial, provided it is done properly, but it too has been several shortcomings viz.- a minimum period of 1½ to is 2 years of therapy which is rather too long for any patient to continue treatment, the involvement of a professional psychotherapist and the constant use of a noise generator which is a wearable device that looks very much like a hearing-aid. This makes the treatment costly and cumbersome and causes the drop-out-rate to be very high. Moreover, TRT is very improperly done in most clinics and what is done in the guise of TRT without a noise generator and without the services of an experienced and trained psychotherapist is basically a hoax and is a slur on our profession. Most ENTs are too ignorant on the methodology of the treatment of TRT and are incapable of monitoring the outcome of any tinnitus therapy. Quite a few unscrupulous persons offering TRT services capitalize on this ignorance of the ENTs and fraudulently earn money from the naive and hapless tinnitus suffers most of whom are prepared to go to any length for a cure. TRT though effective in many patients and currently one of the best options for tinnitus managementyet is a rampantly abused modality and with its many shortcomings, is not always a very practical and viable solution.

Tinnitus Phase Out Therapy (TPOT) is a new treatment modality, which is much less cumbersome and requires lesser time and is less exposed to malpractice, unlike TRT. It works by disrupting the continuous loop of signaling in the central auditory nervous system. This form of therapy introduces a sound opposite in phase to the tinnitus sound that counteracts the tinnitus by playing the sound at the same pitch but shifting the sound wave in time. It is like a pendulum (i.e. the tinnitus) being knocked out of phase by a second pendulum (the therapeutic sound) swinging at the same speed but shifted in time. The first pendulum will be disrupted, i.e. the loop of signaling in the brain causing the tinnitus will be cancelled. If this process of disrupting the loop is repeated several times, then the additive effect of this disruption produces some degree of inhibition of the tinnitus. In tinnitus phase out therapy the patient has to identify the pitch and loudness of the tinnitus himself by matching the pitch and loudness of the tinnitus. A special instrument capable of generating sounds that can be varied in loudness (intensity) from 5dB to 110dB in 1dB steps and in pitch (frequency) from 100Hz to 15,000Hz in 10 to 20Hz steps is used to match the patient’s tinnitus very accurately in loudness and pitch. Once the pitch and loudness of the patient’s tinnitus has been accurately identified, a customized sound is generated from the TPOT machine, which is fed into the patient’s ears for brief periods of time (say) for 30 minutes every alternate day. After 5 to 6 sessions the patient is assessed and the effectiveness of the therapy is evaluated. If any significant improvement in the patient’s tinnitus is obtained, then the treatment is continued for a few more sessions. If required, the sound customized for the particular patient may be stored is a portable machine and handed over to the patient for twice weekly sessions at home. However, we are not offering the option of domiciliary treatment now, until the efficacy is more established, as it is a very costly instrument. The patients are scheduled to visit the treatment centre twice a year for re-assessment. If the characters of the tinnitus are found to have changed then another spell of a few sessions are offered after customizing the treatment sound according to the parameters of the new tinnitus sound. The Tinnitus phase out therapy definitely does NOT cure the tinnitus and does not guarantee a benefit in each and every patient of tinnitus. Efficacy of the treatment is judged by different parameters and about 60 to 80% of patients in different studies have been found to have significantly benefited from this therapy. This therapy is scientifically supported and is an FDA approved, patented treatment modality. This primary research work had been done in Columbia University and clinical trials have been done in different parts of the world. This treatment is meant only for tonal tinnitus, i.e. those patients who have a puretone tinnitus only are expected to benefit from this therapy. If the patient cannot match the tinnitus properly (which is a totally subjective procedure), this treatment is not effective as the phase shifted treatment sound is customized according to the precise pitch and loudness of the patient’s tinnitus. If the patient incorrectly identifies the pitch and loudness of the tinnitus, the treatment sound will also be improper and the therapy ineffective. The tinnitus phase out therapy is a convenient safe and simple way to alleviate tinnitus and is worth a try in most cases of tinnitus. It requires much lesser time than TRT, is much less costlier and does not require extensive sessions with the psychotherapist or the constant use of a wearable devise.

Answers to some frequently asked questions on tinnitus.
Dr. Anirban Biswas.

Can you completely cure my tinnitus ?
No ! There is at present no definite treatment method available anywhere in the world that is known to cure tinnitus completely in all patients. By "cure" I mean that the abnormal sound that you feel you are hearing in the ear will completely stop. Medical science till today does NOT have any specific treatment that can permanently stop your perception of the sound that you claim to hear. Though quite a few patients do report that they stop hearing the tinnitus for a period of time after therapy, this does not happen in all patients. The objective of therapy in tinnitus is to reduce the perception of tinnitus, make it less bothersome and adapt your brain into accepting the noise just as any other noise. 

Why do you say "your perception of the sound that you claim to hear", I actually do hear the sound continuously, and I am not lying.
I do not dispute that you hear the sound. But this sound has no real existence and it cannot be measured by any physical means and cannot be recorded or documented. Even if I put a very sensitive microphone connected to a very powerful amplifier in your ear / head, I will not be able to hear the continuous sound that you are hearing. The "ringing" or "buzzing" or the "sawing" sound that you are hearing is actually a sensation of sound perceived by you in the absence of any physical sound. In medical parlance, it is called a "Phantom sound" or TINNITUS and it is defined as a hallucination of sound in the absence of any actual sound.

Where then is this sound coming from?
Only God knows. We do not know exactly where this sound is coming from. Had this been known, medical scientists could probably have been able to evolve a "cure" for it by medical / surgical means. A lot of research has been done (and is still being done) on this vexing issue and what we now know from years of research is that the perception of this sound comes from the hearing area of the brain (called "auditory cortex") and not from the ears though it may appear to you to be coming from the ears. Experiments have shown that even cutting off the hearing nerve (that connects the ear to the brain) does NOT stop the tinnitus in most cases. Tinnitus is generated by an obscure neural firing in the auditory (hearing) pathways in the brain and this neuronal firing spreads to involve areas of the brain that are outside the hearing system especially the areas connected with our psychic systems. The result of this is the feeling of hearing an abnormal sound in the ears which is not only annoying and disturbing but also prevents you from concentrating at work and from sleeping. This sound upsets you and traumatizes you mentally. You are also hearing many other sounds constantly like the sound of the fan, the air conditioner etc. but they do not disturb you (even if they may be louder than the tinnitus), whereas this faint sound of tinnitus really drives you mad and annoys you so much.

If there is no definite "cure" what is the point in trying to get treatment ?
Even if we cannot totally stop the sound in your ears / head, we can very definitely give you a much better quality of life by substantially reducing your perception of the tinnitus, lowering the intensity of the tinnitus, reducing very significantly the annoyance caused by the tinnitus and habituating you to this abnormal sound sensation so that your brain accepts this just as it accepts the sound of the fan or the air conditioner without disturbing you. Most patients do get a much better quality of life after therapy.

What are the treatment modalities available and how effective are they?
The ancient Egyptians used to treat tinnitus by pouring hot oil into the ears. We do not do it today but results of treatment are practically the same. Jokes apart, there is practically nothing that has not been tried for tinnitus but a "cure" in the literal sense of the word is yet to be evolved. Of all the treatment modalities that have been tried till now, TINNITUS RETRAINING THERAPY has been found to be the most effective. The other modalities are, e.g. use of tinnitus maskers, use of noise generators, use of some drugs, music therapy, etc. etc. but none of them (even TRT) have been found to be as effective as "chloroquin" in "malaria".

What is Tinnitus Retraining Therapy and how is it done ?
It is form of specialized form of psychotherapy which involves the services of an expert and well-trained psychotherapist and the use of a noise generator (which you will have to purchase and wear for several hours daily). The process is time-consuming and usually takes 1½ to 2 years of regular therapy. Moreover it requires you to constantly wear the noise generator, which looks like a hearing aid (something that may be more traumatizing to you due to the stigma people have on hearing aids). The major draw-back of TRT is the long duration of therapy (even then, the results are not 100% guaranteed), the difficulty in getting an effective and qualified psychotherapist especially tuned to tinnitus management, and the cost of the noise-generator. Moreover, what many centers carry out in the name of TRT is a hoax. Unscrupulous and untrained persons abound who do not have any infrastructure at all and carryout a lot of nonsense in the name of TRT and basically dupe the hapless and naive tinnitus suffers. But if the TRT is carried out properly about 70 to 75% patients do benefit from the therapy.

What do you mean by "benefit" from TRT therapy ? Will my tinnitus stop totally ?
As already explained, the answer is "No !". The tinnitus is not expected to stop totally, but the annoyance caused by it will definitely lessen, you will be habituated to the tinnitus and your quality of life will improve in a big way, provided the TRT is carried out by a knowledgeable and ethical person which is not always the case. You will also have to be patient, as, TRT is a very time-consuming therapy and the success of the program depends a lot on your perseverance, involvement and uninterrupted continuation of therapy. There is no "magic cure "for tinnitus and you should not expect on overnight miracle.

Is Tinnitus a very common disorder ?
Yes ! Very common. One in seven of the general population 0f USA and one in ten of the general population of UK suffer from tinnitus. One in thirty of USA and one in twenty of UK suffer from very severe bothersome tinnitus. So you are not the only one. The exact incidence of tinnitus in our country is not known but should be something similar to that of UK and USA.

Is Tinnitus Retraining Therapy the latest and best treatment for tinnitus or has anything newer, more simpler and more affordable and more effective been introduced ?
Yes, the latest treatment modality for the management of tinnitus is the TINNITUS PHASE OUT THERAPY (TPOT). This is a very simple and adequately effective treatment modality that does not require the patient to buy and wear a device permanently as is required in TRT. Moreover, the duration of treatment is also much lesser. The TPOT treatment is approved by FDA in USA and a number of clinical trials have been done in several parts of the world all of which have proved its efficacy. The treatment is non-invasive and just requires the patient to hear a customized sound through headphones connected to an instrument for about half an hour every alternate day or twice weekly for a month or so. However, TPOT is effective only in cases of "tonal" tinnitus, i.e. if you have a tinnitus of a fixed tone i.e., of a fixed frequency. The clinician can find it out for you. The success rate in different studies have to shown to be more or less the same as that with TRT and in some studies the results have been found to be better than TRT. The patient compliance is also much higher as it does not have any of the drawbacks of TRT.

How is the TINNITUS PHASE OUT THERAPY administered ?
As explained, you will have to come to our clinic after taking an appointment though my secretary (tel no.- 09836725371) where your ears will be examined and routine investigations done first to ensure that your tinnitus is not being caused by any harmful or dangerous cause like a tumor in the brain, and second to find out if your tinnitus is being caused by some treatable disorder like Meniere’s Syndrome, Otitis Media etc. which are treatable diseases that may cause tinnitus. The TPOT will be administered only after we have investigated you thoroughly and are convinced that treatable causes and life-threatening causes of tinnitus have been ruled out. If any of them are found we will first treat you and try to cure the cause of the tinnitus if possible. Tinnitus due to these causes often is cured totally if the causative disease is properly treated. The problem is that most patients are not so lucky and tinnitus in the majority of patients is of idiopathic origin. After the routine investigations are done, we will ascertain the pitch (frequency in Hz) and intensity (loudness in dB) of your tinnitus. This is done by matching your tinnitus with different types of sounds that will be presented to you through headphones. We have a special a instrument for that, This process takes about half an hour and is a subjective test dependent upon your responses. If we find that the pitch and intensity of the tinnitus has been identified accurately, then we start the Tinnitus Phase Out Therapy. The success of the therapy depends upon accurate matching of the pitch and loudness of your tinnitus. The therapy consists of making you hear through headphones a customized sound that is based on the pitch and loudness of your tinnitus for half an hour every alternate day for 5 to 6 sessions. This we do in our clinic, so you will have to come over to us every alternate day. If we find that you have benefited from these sessions then we continue the treatment further for a few more sessions. There is also an option of our customizing the sound, and handing over a small portable machine to you for sessions at home but till now we are not doing so. Until the treatment is more popularized and more accepted, we are offering the service only from our clinic at Bell Vue and have not yet started the home treatment.