Peer Reviewed
Roger Daltrey, co-founder and lead singer of The Who, had this to say of bandmate Pete Townshend’s famous penchant for bludgeoning Fender Stratocasters:
“Pete wasn’t just smashing his guitar. He used to stick the neck of it right up into the amps and through the speakers to make all kinds of surreal noises… The guitar used to scream, and it used to go on for about five minutes until it was wrecked.”1
After decades of antics–including a record-shattering 126-decibel concert in 1976–Townshend joined the ranks of Neil Young, Eric Clapton, and Ozzy Osbourne in developing both hearing loss and tinnitus.
With an estimated national prevalence of at least 10%, tinnitus afflicts millions of adults beyond famous guitarists.2 A 2016 epidemiologic review by Bhatt and colleagues revealed that 36% of those with tinnitus experience continuous symptoms; 27% report symptoms lasting longer than 15 years. Not surprisingly, tinnitus rates are higher in those with sustained occupational or recreational noise exposure (although the difference might be murky in Townshend’s case), with odds ratios of 3.3 and 2.6, respectively. Complicating the matter, however, is a subgroup of patients with neither a history of severe noise exposure nor a measurable hearing impairment.3 Indeed, exposure to loud environments is also associated with tinnitus, underscoring urban noise as a harmful environmental pollutant.4
The growing prevalence of tinnitus, coupled with the rise in associated factors like urban noise, poses an increasingly common problem. For millions of patients, the unrelenting ringing, hissing, or buzzing can be debilitating; while seemingly innocuous, the long-term perception of phantom sound is associated with increased depression and anxiety symptoms and poor sleep quality.5
Unsurprisingly, initial theories of tinnitus pathophysiology localized the problem to the cochlea. Given the relationship between cochlear hair cell damage and sensorineural hearing loss–and the abundance of data linking both hearing loss and tinnitus incidence to noise exposure–it seemed logical to attribute other sensory aberrations to a common underlying structural cause.6 The notion of a purely peripheral origin, however, lost traction with reports that not all patients with treatment-resistant tinnitus achieved relief with cochlear nerve sectioning.7
More recent theories evoke a model of neuroplasticity–a change in central auditory processing as a result of altered peripheral inputs. In cases of exposure to intense sound, cochlear hair cell lesions predictably result in an initial drop in neural output. However, as time progresses, neurons in the cochlear nucleus–particularly those representing damaged hair cells–increase their rate of spontaneous activity, possibly as a compensatory response to sensory deprivation.8 Similar plastic changes occur farther along the auditory pathway, including cortical reorganization in the primary auditory cortex, with functional studies even implicating frontal areas involved in attention and memory.9 Tinnitus, then, may not always require peripheral damage; rather, it could reflect network-level changes throughout the auditory pathway that ultimately result in altered perception of sound.10
And then, the ultimate question: what does any of this mean for the patient in your clinic reporting months of nagging ringing in her ears? Understanding tinnitus as a central neurologic disorder, rather than a structural hearing problem, may have important clinical implications for a notoriously frustrating-to-treat condition. Indeed, most of the literature-reported successful treatments focus on neurobehavioral rather than cochlear interventions. Cognitive behavioral therapy has been shown to both reduce tinnitus severity and, consequently, improve tinnitus-related psychiatric complaints.11 In a similar vein, biofeedback therapy–a self-regulation technique to modulate involuntary responses to perceived stimuli–has shown modest success in reducing tinnitus-related distress.12
More tailored therapies employ sound stimuli to modulate awareness of aberrant perceptions. Tinnitus retraining therapy is one such technique, in which patients are exposed to a low-level external sound source (e.g., white noise) that partially masks the underlying tinnitus to facilitate habituation to both. Although up to 80% of trial participants have reported significant symptomatic improvement, this can take up to two years to achieve and may not be permanent.13
A newly FDA-approved approach takes advantage of the additional sensory inputs that influence the cochlear nucleus. In theory, modulating the concurrent somatosensory and auditory inputs to the same structure might induce plastic changes, much in the same manner as other forms of learning. A 2023 randomized clinical trial in JAMA Network examined this concept by employing synchronized auditory and somatosensory stimulation in 99 patients with tinnitus.14 Participants received 30 minutes daily of either bisensory or auditory-only treatment for six weeks, followed by a washout phase, and then 30 minutes daily of the other treatment. Primary endpoints were changes in tinnitus functional index (TFI) scores–an aggregate of symptom severity ratings–and reported tinnitus loudness level. Bisensory treatment yielded significant improvements in TFI scores (intention-to-treat population: –12.0 [95% CI, –16.9 to –7.9] points; P < .001; per protocol population: –13.2 [95% CI, –16.0 to –10.5] points; P < .001) after six weeks. Subjective tinnitus loudness levels likewise improved by roughly 6 dB in the bisensory group (intention-to-treat population: –5.8 [95% CI, –9.5 to –2.2] dB; P = .08; per protocol population: –7.2 [95% CI, –11.4 to –3.1] dB; P = .03). Interestingly, both effects persisted into the washout phase, with follow-up surveys demonstrating TFI score improvements up to 36 weeks following treatment. And while the daily process of cleaning, donning, and sitting quietly with the device proved tedious for many participants, the bisensory therapy was otherwise well tolerated. Coupled with existing retraining techniques, this result supports the efficacy of leveraging neuroplasticity to tackle tinnitus.
These approaches attempt to mitigate tinnitus-related distress using psychotherapy and, recently, neuromodulatory strategies. But what options exist for those with debilitating, intractable symptoms? One encouraging new salvage therapy involves basal ganglia deep brain stimulation to interrupt the altered network activity previously implicated in tinnitus. A 2019 phase I trial demonstrated a treatment response rate of 60-80% in patients with severe, refractory tinnitus, opening the possibility that invasive therapy may become a viable option with additional research.15
Despite its prevalence, tinnitus has historically lacked efficacious, evidence-based therapies. Recent advancements in understanding its neurologic underpinnings, however, have informed the development of increasingly sophisticated treatments, including a newly approved bimodal neuromodulation device. And while addressing potential causes–particularly widespread noise pollution–remains a challenging public health problem, newer treatments at least offer patients a chance to return to sensory normal (and perhaps, with some degree of caution, to the recording studio).
Carolyn Akers is a Class of 2025 medical student at NYU Grossman School of Medicine
Reviewed by Michael Tanner, MD, Associate Editor, Clinical Correlations
Image courtesy of Wikimedia Commons –Tinnitus Attack Rock & Metal Day’z 2024 09.jpg
References
1. Ivie D. Roger Daltrey Is Calling Bullshit on Pete Townshend’s Guitar-Smashing Passion. Vulture. Published October 23, 2018. Accessed August 9, 2023. https://www.vulture.com/2018/10/roger-daltrey-never-liked-pete-townshends-guitar-smashing.html
2. Bhatt JM, Lin HW, Bhattacharyya N. Tinnitus Epidemiology: Prevalence, Severity, Exposures and Treatment Patterns in the United States. JAMA Otolaryngol Head Neck Surg. 2016;142(10):959-965. doi:10.1001/jamaoto.2016.1700
3. Vielsmeier V, Lehner A, Strutz J, et al. The Relevance of the High Frequency Audiometry in Tinnitus Patients with Normal Hearing in Conventional Pure-Tone Audiometry. Biomed Res Int. 2015;2015:302515. doi:10.1155/2015/302515
4. Cantuaria ML, Pedersen ER, Poulsen AH, et al. Transportation Noise and Risk of Tinnitus: A Nationwide Cohort Study from Denmark. Environ Health Perspect. 2023;131(2):027001. doi:10.1289/EHP11248 https://ehp.niehs.nih.gov/doi/10.1289/EHP11248
5. Oosterloo BC, de Feijter M, Croll PH, Baatenburg de Jong RJ, Luik AI, Goedegebure A. Cross-sectional and Longitudinal Associations Between Tinnitus and Mental Health in a Population-Based Sample of Middle-aged and Elderly Persons. JAMA Otolaryngol Head Neck Surg. 2021;147(8):708-716. doi:10.1001/jamaoto.2021.1049 https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2781095
6. Henry JA, Roberts LE, Caspary DM, Theodoroff SM, Salvi RJ. Underlying Mechanisms of Tinnitus: Review and Clinical Implications. J Am Acad Audiol. 2014;25(1):5-126. doi:10.3766/jaaa.25.1.2
7. Wigand ME, Hellweg FC, Berg M. Tinnitus after microsurgical interventions at the internal auditory canal. Laryngol Rhinol Otol (Stuttg). 1982;61(3):132-134. https://pubmed.ncbi.nlm.nih.gov/7098703/
8. Kaltenbach JA, Godfrey DA, Neumann JB, McCaslin DL, Afman CE, Zhang J. Changes in spontaneous neural activity in the dorsal cochlear nucleus following exposure to intense sound: relation to threshold shift. Hear Res. 1998;124(1-2):78-84. doi:10.1016/s0378-5955(98)00119-1
9. Rauschecker JP, Leaver AM, Mühlau M. Tuning out the noise: Limbic-auditory interactions in tinnitus. Neuron. 2010;66(6):819. doi:10.1016/j.neuron.2010.04.032
10. Rauschecker JP, May ES, Maudoux A, Ploner M. Frontostriatal Gating of Tinnitus and Chronic Pain. Trends Cogn Sci. 2015;19(10):567-578. doi:10.1016/j.tics.2015.08.002 https://pubmed.ncbi.nlm.nih.gov/26412095/
11. Cima RFF, Maes IH, Joore MA, et al. Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: a randomised controlled trial. Lancet. 2012;379(9830):1951-1959. doi:10.1016/S0140-6736(12)60469-3
12. Weise C, Heinecke K, Rief W. Biofeedback-based behavioral treatment for chronic tinnitus: results of a randomized controlled trial. J Consult Clin Psychol. 2008;76(6):1046-1057. doi:10.1037/a0013811
13. Jastreboff PJ, Jastreboff MM. Tinnitus retraining therapy for patients with tinnitus and decreased sound tolerance. Otolaryngol Clin North Am. 2003;36(2):321-336. doi:10.1016/s0030-6665(02)00172-x https://pubmed.ncbi.nlm.nih.gov/12856300/
14. Jones GR, Martel DT, Riffle TL, et al. Reversing Synchronized Brain Circuits Using Targeted Auditory-Somatosensory Stimulation to Treat Phantom Percepts. JAMA Netw Open. 2023;6(6):e2315914. doi:10.1001/jamanetworkopen.2023.15914
15. Cheung SW, Racine CA, Henderson-Sabes J, et al. Phase I trial of caudate deep brain stimulation for treatment-resistant tinnitus. J Neurosurg. 2019;133(4):992-1001. doi:10.3171/2019.4.JNS19347