Treatment eases tormenting ringing in the ears

Barbara Cooke says the phantom noise she hears is "like when you put a conch shell to your ear."

She is not talking about a sunny, sandy, soothing surf sound. What the busy Center City grandmother experiences is more like a tidal wave - an inescapable roar that drowns out everything else.

Cooke, 71, has tinnitus, the perception of sound in the absence of an environmental source.

An estimated 50 million Americans have this spooky, incurable problem, which is growing, especially among veterans and aging baby boomers. Most people adapt and stop noticing it. But Cooke is among the hapless 10 million or so who are tormented and exhausted by it.

"It was so sudden," she recalled of the onset of her tinnitus late last year. "It drove me crazy. I was probably close to suicidal. I just sat and cried."

The good news is that helpful therapies are available. Cooke is getting relief from one of the newest, developed by Neuromonics Inc. of Bethlehem, Pa. A portable, customized audio player, combined with counseling and monitoring by an audiologist, aims to retrain the brain to filter out the noxious stimulation.

"I can still hear it, but it doesn't bother me anymore," Cooke said last month at Thomas Jefferson University Hospital's Balance and Hearing Center.

Audiologist Elizabeth Gray smiled and said, "Your brain is changing its perception."

Tinnitus - from the Latin word tinnire, meaning "to ring" - plagued Van Gogh, Beethoven, Oscar Wilde, and more recently Rosalynn Carter, David Letterman, and William Shatner, to name a few.

In many cases, including Cooke's, tinnitus accompanies hearing loss, a fairly inescapable part of aging. But it can also be triggered by head injury, ear infections, jaw dysfunction, medicines ranging from chemotherapy to aspirin, and a bane of modern society: loud noise.

Tinnitus has become an active area of research over the last 20 years, yet scientists cannot completely explain the phenomenon. One theory is that the inner ear's sound-receiving cells become injured, so they can't properly send signals to the auditory nerves.

In any case, tinnitus - like pain - is highly subjective. The pitch, loudness, frequency, and type of sound vary from patient to patient.

Many treatments have been tried, including certain drugs, herbal supplements, lasers, electromagnetic waves, hyperbaric oxygen, acupuncture, biofeedback, hypnosis, hearing aids, relaxation exercises, and sound-masking devices.

Because the evidence of effectiveness is sketchy, health insurers generally will not cover treatment - and quack remedies abound.

"I went into Google and searched 'tinnitus treatment' and got a billion hits," said Tom Willcox, an ear, nose, and throat doctor and director of the Jefferson hearing center.

One time-honored area of research exploits the brain's amazing ability to focus on new or significant sounds, while ignoring unimportant ones.

Initially, this led to portable or bedside devices that basically "blotted out tinnitus with another sound," said fellow otolaryngologist William H. Martin, who heads the renowned tinnitus research program at Oregon Health & Science University.

"Sometimes you can introduce sound in one ear and treat tinnitus in the other ear. Go figure that," said Martin, who previously directed Temple University's Garfield Auditory Research Laboratory. "And you can use low-frequency sound, like an ocean sound, to mask high-frequency tinnitus."

Masking therapy has evolved to use low-level, broadband sound that competes with - rather than overrides - the tinnitus. The goal is to retrain the brain to ignore the disruptive noise, the same way it stops noticing highway traffic or the neighbor's barking dog.

For some patients, this is as simple as putting on a TV, a stereo, a fan, or a machine that plays "white noise" such as a gurgling brook.

For others, this process, called habituation, can be stymied by the brain's limbic system, which is involved in emotional response.

"If you hate dogs or hate your neighbor, that barking sound is not going to fade into the background," Martin explained.

And someone who is anxious, tense, sleep-deprived, and depressed because of a phantom noise is not going to stop obsessing about it.

Pawel J. Jastreboff, now director of Emory University's tinnitus center, was among the first to theorize that the limbic system plays a big role in severe, intractable tinnitus. In the 1980s, he invented tinnitus retraining therapy, which combines sound-masking with counseling.

Neuromonics, which grew out of the doctoral dissertation of Australian tinnitus researcher Paul Davis, also has a two-pronged strategy.

The patient uses a device similar to an MP3 player to listen to a low-level hissing that is embedded in soothing music (a choice of classical or New Age). The hiss is custom-calibrated to periodically mask the patient's tinnitus, encouraging habituation, while the music "positively engages the brain's limbic system," to quote the brochure.

The patient listens at least two hours a day for several months, then the music is unmasked - replaced with a hiss-free version - and the daily listening continues.

The six- to nine-month treatment, including audiology sessions, costs $3,500 to $5,000. That puts Neuromonics - introduced about three years ago and now available at 250 clinics - at the audible-gasp end of the price range for tinnitus therapies.

Neuromonics' advertising says its treatment is a "global breakthrough," but that's, well, advertising. The company told the Food and Drug Administration that its system was substantially the same as the Dynamic Tinnitus Mitigation System made by Petroff Audio Technologies and the Custom TCI Instrument made by Siemens.

How effective is Neuromonics?

In clinical trials, 90 percent of suitable patients reported success, defined as at least a 40 percent reduction in tinnitus severity and frequency, said Rick Giancola, Neuromonics' chief executive officer.

He said Neuromonics was among treatments being tested by the Department of Veterans Affairs. Hearing loss with tinnitus is the leading reason for disability awards among troops who served in Iran and Afghanistan. By 2011, the ranks of hearing-disabled veterans are expected to hit 800,000, more than double the number in 2005.

But Neuromonics isn't for everyone. In studies, it did not work as well for unsuitable patients, such as those with serious psychological problems or severe hearing loss.

And Davis, Neuromonics' inventor, pointed out in a 2008 study that patients' self-reported improvement "may have been influenced" by their desire to get what they paid (a lot) for.

Cooke, for one, feels it has been a good investment. Late last month, audiology tests showed that she perceives her tinnitus to be half as loud as when she began treatment, and her sensitivity to external sound is back to normal. She can tolerate up to 100 decibels - equivalent to a rock concert - whereas even loud conversation bothered her four months ago.

Still, she hasn't completely conquered her aural demon.

"I haven't even thought of it for weeks," she marveled, "but now that we're talking about it, it's all I can hear!"