Ringing in the Ears : The Tinnitus Menace

Being a doctor for Hearing and Balance, one of the most common complaints that I see in my practice is that of buzzing in the ears, known in medical lingo as tinnitus. Of course, what we English speaking doctors call Medical Lingo is chiefly words originating from Latin. In this case Tinnitus takes origin from the latin word Tinnire, which translates to "Tinkle or Ringing".

Our body is used to all sorts of sound, from those noisy tube-light chokes to background buzzing of refrigerators, motor sounds from pumps, jet engines flying over head and sundry. Almost everybody adapts to those sounds. Why then, do the same individuals present as patients when they hear an internal ringing or buzz in their ears, even if the volume is significantly lower than outside ambient noise?

To answer this, a lot of research has been undertaken into the field, and the answers that we now have are astonishing.

Fact #1 : There is little correlation between the loudness of tinnitus sound and its effects.

Patients with softer tinnitus can be greatly disturbed by it and people with really loud tinnitus can sometimes not be bothered about it at all. Researchers didn't expect to find this info. In the past, the sole criteria of documenting severity of tinnitus used to be a loudness match (try to figure out how loud a patient hears his tinnitus), but since loudness did not always mean severity, this attempt therefore does not give as much clinical information to the doctor as he/she had expected it to.

Fact #2 : The Symptoms Tinnitus causes aren't truly auditory

Tinnitus does not cause decline in hearing. A patient who has tinnitus isn't more likely to develop a hearing problem than somebody without tinnitus and in fact, most often than not, tinnitus is not a marker for a disease.

Fact #3 : The Limbic System has more to do with Tinnitus than the Auditory Cortex

I like using latin words. I am sorry. Part of the medical training. Anyway, this is the most exciting point about tinnitus, and the most important one when we plan treatment.

Here's the backstory for Fact #3 : Long time ago, evolution was shaping the mind to be what it is today.  The common point in many higher life forms (us included) is the Limbic System, or the emotional system. All senses that we have (eyes, ears, touch, etc) have connections to the Emotional System and the Rational System. We evolved to take all decisions based on emotions, and use the rational mind only after it has been trained. In a nutshell, often when people can't decide between the heart and the mind, the limbic system is the heart, and the rational brain is the mind.

In the case of tinnitus, at the onset the sufferer is curious. He/she wants to know what this sound is and why are they hearing it. The rational brain tries, but can't explain, because it is unlike anything else that the rational mind has experienced. So there's a blank. The patient then asks the emotional brain, and since the emotional brain is trained to save the animal from predators and risks, it thinks the tinnitus sound to be a threat, a warning or a disease. Once the patient establishes the sound as a threat, it is difficult to let go of that sound, and there are all sorts of negative emotions that cloud the patient's mind, such as anxiety, stress and occasionally depression.

Often this forms a two way reaction, with tinnitus increasing stress, and stress (from office/home/anywhere else) increasing tinnitus.

Source: wikimedia commons : Blausen.com staff.

Treatment:

There are treatments aimed at reducing the sound, and there are treatments aimed at reducing the emotional upsets that tinnitus causes. We have had very little success in the first, but amazingly the second treatment has had as high success rates as 80% in multi-centric trials in India and abroad.

Tinnitus Re-training Therapy is based on the Neuro-physiological Model of tinnitus, the one with the limbic system. The principle is to re-train the brain into taking tinnitus as just another sensation, much like touch. Just as one doesn't feel one's footwear, or the clothes on one's body unless their mind goes to that, the tinnitus sufferer doesn't feel the tinnitus unless they want to. This is possible when the patient stops taking tinnitus as a threat and takes it only as another sensation. To help in this, a specific treatment plan is followed which uses counselling, sound therapy and brain pasticity to make the tinnitus sufferer let go of their tinnitus.

For more information on the program and how it can help somebody you know, write an email to me at contact@primehearing.com

VOR-Y Good Image Stabilizer

Most of today's youth has had early exposure to photography, thanks to people having a camera on their person almost all the time. This has brought about a change in the collective consciousness and the youth now realizes the importance of  ̶r̶e̶s̶p̶e̶c̶t̶i̶n̶g̶ ̶o̶t̶h̶e̶r̶ ̶p̶e̶o̶p̶l̶e̶'̶s̶ ̶p̶r̶i̶v̶a̶c̶y̶  a steady hand while taking a picture. It's an easily understood concept. The Camera Lens is focusing at the subject, and any movement of the lens while capturing an image changes the relative position of the subject on the Lens, thus blurring everything. There is an easy remedy to prevent this from happening. This post is not about that remedy.

Example :  

 (Source: http://www.ulearn.photography.com )

This post is really about how what happens with the Camera does not happen with the Eye. The Eye works just like a camera (or the other way around as some evolutionists would lead us to believe; bloody quacks), however the images remain in sharp focus no matter how we move our head while looking at the subject. There is something in the human system that keeps the gaze stabilized no matter what the rest of the body is doing, be it walking, running or riding a roller coaster. Something, that moves the eye in the opposite direction of head movement at an acutely exact speed, so the lens continues looking at the subject without displacing so much as half a degree despite the rest of the camera moving about in almost any plane. Had this not been so, our vision would have been a long and continuous movie shot with an incredibly shaky camera.

The question is, what is it that makes sure the shaky camera stabilizes?

And the obvious response to that is, that since the question was cleverly inserted by the Ear Doctor to make his specialty sound more important, the answer must be The Ear. *Ooh the joys of narcissism.* 

One of the major tasks of the Inner Ear, which houses the Vestibule, is Gaze Stabilization. The ear has five pairs of organs that detect acceleration : 3 of them detect Angular Acceleration in X, Y and the Z axis, and 2 detect linear acceleration in horizontal, and vertical planes respectively. Let me break down the balance organ for you, not literally of course, else what sort of a maniac will that make me. But the concept of this all.


Angular and Linear Acceleration Explained:

a) When you move your head up and down, like when saying Yes.  (Pitch Plane : Angular)

b) When you move your head left to right, like when saying No. (Yaw Plane, Angular)

c) When you tilt your head to one side and then to the other, like saying "Okay". Universally this is called the Indian Headshake, and leaves westerners uber confused over what we mean. Legend has it that it was deviced as a ploy to confuse the British and had a role in India attaining Independence in 1947. (Roll Plane, Angular)

d) Linear Motion, forward, when accelerating in a car (or reversing the car) (Linear Horizontal)

e) Linear Motion, upward, when moving in the elevator (or down :) ) (Linear Vertical)

Note: If you did try the neck movements while reading this blog, and the words remained in sharp focus despite your head moving in various directions, then that means your Ears are performing the job wonderfully well, and you have my deepest congratulations for that. 

All 5 of these organs are attached to eye muscles, and move the eyes in the opposite direction of head movement at the precise speed so the eye can keep its gaze right where it needs to, and images don't move, change or blur.

Clearly this was of paramount importance to our ancestors when they went hunting. They needed to have their vision locked on the pray to hunt while they ran behind it jumping over all sorts of obstacles, else humanity would have died out of starvation. The same system over time improved tremendously so it can now help Virat Kohli keep his eyes fixed on the ball, and eventually catch it while taking all sort of tumbles, and he can get to become the man of the match.

The Gaze Stabilization System medically is abbreviated as the VOR and dead folks don't have it. This forms the basis of the Doll's Eye Test. If one has had a head injury, and to make things worse, fails this test, his/her organs are given to someone who deserves them more than s/he. Hence if you want to keep your organs, remember to pass this test, under all circumstances. This makes the Doll's Eye Test the most important test that one will ever take in his/her life. Luckily, one doesn't need to prepare too much to pass this test.

That sums up Image Stabilization Network, and how it separates our lives from a Ram Gopal Varma movie with incredibly poor camera angles and stability. Will discuss what happens when there are problems in the Vestibule, and VOR is partially compromised, in another post.

Below are some images that may help understand the concept of the ear organs, the vestibule, the planes of motion and the VOR test.

image : http://taichi-ireland.com/2015/04/15/gyroscope/

VOR on Roll Plane

Various Eye Muscles that the Vestibular System moves to attain Vestibulo-Ocular Reflex

The 3 Semicircular Canals and the Utricle and Saccule, the five organs 

that are responsible for the vestibulo-ocular reflex

Vestibular Medicine in India

Vestibular Medicine is the science of the Balance system. The organs vital to maintain balance are collectively grouped as the Vestibular Organs, or simply the Vestibule.  Unlike the big organ systems like the CardioVascular System (CVS) or the Central Nervous System (CNS), the Vestibule is small, kind of works in the background without drawing too much attention to it and is relatively low key. Hence the Medical Councils all over the world did not find it worth their time to allocate a separate specialisation to the science of balance, so you rarely find a doctor who tells you he/she specialises in Balance or Vestibular System unlike a plethora of specialists in Cardiology and Neurology. This forms part of the problem we have.

Since there are multiple causes of vertigo (dizziness), and the Vestibule is closely related to the hearing organ or the cochlea, Vestibular medicine is in a way clubbed with ENT, though not at an advanced level. Thence, those ENT Doctors who have a generic interest in the balance system have taken a step forward and claimed Vestibule as their specialisation. Of course, since all nerves ultimately reach the Brain, and dizziness as a symptom can have its roots at the CNS the Neurologists too have a stake in the game.  But the significant problem here is that Vertigo is not THE DISEASE the ENT.S and Neurologists bargained for during their training as doctors.

The glamour of being an ENT Surgeon is right there in the name of the specialisation, that is Surgery. Most cases of Vertigo do not require surgery,  and so during the days of training, most of which are spent anticipating a stint in the Operation theatre, Vertigo as a disease is at the far end of the mind of the budding surgeon.  More often than not it continues to snooze there unless vigorously shaken up by the surgeon's conscience or, more frequently,  the Head of Department.

Likewise, the budding Neurologist is busy dealing with life threatening diseases such as Stroke, Brainstem disease or siezures. Vertigo therefore is left without being anyone's priority and by the time practicing doctors realise the sheer volume of the problem in their patients, its too late to go back to the text book so most patients would end up taking generic antivertigo medicines which have little effect at the root of the problem, or running around different set of ENTs and Neurologists who themselves would be busy dodging the patient elsewhere.

If Vertigo as a symptom needs to be managed rationally, it will need to be integrated early on in the medical curriculum. Most Undergraduate Medical Students spend immense time learning the intricacies of managing complex surgeries when more often than not the big chunk of patients they see will come with symptoms of  back pain and vertigo, and time spent on the latter two is little, if any at all.

The author, Dr Kshitij Malik is an Audiovestibular Physician, a Post Graduate from University College London and specilises in Hearing & Vertigo disorders. He can be connected at dr.kshitij@primehearing.com