Timothy C. Hain, MD. • Page last modified: August 10, 2019
|Typical tinnitus masker. This particular one is sold by Sharper image, but there are many alternatives (about $100)||Another machine sold by Target to produce white noise. (about $50)||Neuromonics device ($2000+). See comments below about alternatives using "apps".|
Tinnitus masking is carried out by providing an external sound that reduces the annoyance of the tinnitus through either disguising it, suppressing it, or making it more pleasant. When masking suppresses tinnitus, it makes it controllable. This is extremely important for psychological well being !
Controlled studies of maskers have shown small effects (Dobie, 1999), and a recent Cochran review (Hobson et al, 2012), suggested that there was limited data, poor studies, and lack of strong evidence of an effect. Henry et al (2016) reported in a small number of veterans, that masking, TRT and tinnitus education all decreased tinnitus compared to no treatment. The lack of a specific effect of one approach vs. another suggests that one's choice of treatment might best be chosen by expediency. Of these three, masking is clearly the fastest and cheapest.
Additionally, although unsupported by the data reviewed above, from our own clinical experience with treating tinnitus, we think that masking is the most effective treatment of tinnitus. Masking has been advancing recently, while TRT and tinnitus education has shown no changes. While masking is not a cure-all, it is much more likely to work than any medication, or any device. Of course, surgery is generally not a treatment option for tinnitus. Manipulation of one's emotional reaction to tinnitus (medication or psychotherapy of various kinds such as TRT, CBT, or tinnitus education), should ideally be combined with masking.
Masking is most likely to occur if it the masking sound is similar in frequency to the tinnitus to be masked. Reduction of annoyance is important. Annoying and uncontrollable sounds can create a positive feedback look where there is even more annoyance and hypervigilance. If one's primitive brain can be fooled into thinking that tinnitus is "normal", or even pleasant, it is much easier for the person to ignore the sound.
The purpose of testing for tinnitus is to assess hearing, and tinnitus matching -- to quantify the tinnitus. There is no objective test for tinnitus as yet. In our practice at Chicago Dizziness and Hearing, our "basic" assessment for tinnitus is
- audiometry with LDL
- sweep OAE
- Tinnitus Matching
During the tinnitus matching, we determine how maskable the tinnitus is. There are a couple of definitions to consider here:
The minimal masking level (MML) is the intensity of a sound required to mask tinnitus. The stimulus is raised in 5 db steps and patients are asked whether their tinnitus is still audible.
Residual inhibition (RI) means that the tinnitus remains inaudible after the masking sound is stopped (Feldman, 1971). It is good to have lots of residual inhibition. More than a minute of RI is unusual.
The most effective way to do masking is to find out what type of noise suppresses your tinnitus (if any), and then make arrangements to expose yourself to this noise.
Most masking is implemented by trial and error. One tries out the fan, the TV, the clock-radio, apps on one's cell phone, and sees what works. Hearing aids of any type can be very effective maskers, but generally it is not prudent to purchase one of these strangely expensive little pieces of personal electronics unless you have a significant hearing loss.
At this writing in 2015, in our opinion, the most effective method of masking is probably to combine an "app" from your smartphone with knowledge about your tinnitus from an audiogram and "tinnitus matching".
Apps suggested for tinnitus include:
Despande and Shimunova reviewed tinnitus Apps in 2019. They reprted "The Google Android platform revealed the most number of tinnitus apps. The "tinnitus management" category consistently outperformed the other categories-containing the most number of apps and the most number of features. A small proportion of misinformation apps were detected across platforms. There were no significant differences in the total number of features between free and paid apps (except on the Windows platform). A cost-feature analysis revealed that more expensive apps did not necessarily offer more number of features. "
Listening to the interstation static on the FM radio, tapes of ocean surf may be helpful. Pillow speakers sold by Radio Shack may be helpful in order to avoid disturbing others. This is a very cheap method.
CD's are available that contain masking sounds, for example, the "DTM-6B" system sold by Petroff Audio Research. This is a collection of 6 CD's found by Mike Petroff, an individual with tinnitus, to be helpful for him, and marketed for this purpose. They are endorsed by Jack Vernon, a tinnitus practitioner associated with the ATA. Our thought is that these CD's are probably good masking sounds, but we wonder if they are worth $139+$6 S/H. We suspect that there are much less expensive alternatives.
One may also go about this in a formal way -- measure your tinnitus, determine if a hearing aid is needed, determine the masking sound that works, and implement a masking stimulus using some sort of personal sound playback system. This is probably a little more effective than trial/error, but requires the cooperation of a clinician who is willing to treat tinnitus.
We have experimented in our practice with customized masking. After matching the patient's tinnitus, we check for maskability using white noise. For those who are maskable -- i.e. tinnitus is reduced by white noise -- using a program called Matlab, we produce a sound file that is customized to the frequency of the tinnitus. This sound is mixed in with music provided by the patient. The idea is similar to the "Neuromonics" device and the "S-tone" method described below, but the implementation is much simpler and less expensive. It is still rather labor intensive though as it requires tinnitus matching, creating a customized sound file, and mixing in the sound file with background music. We stopped doing this after the rise of Tinnitus "apps" on smartphones.
The main way that this approach differs from conventional masking is that the sound is filtered, and customized to the tinnitus frequency. This makes the masking sound less disturbing as it does not contain useless frequencies (Paglialonga et al, 2011). This method can be delivered using the "trial and error" method, downloading filtered sounds through "apps", at very low cost.
Nevertheless, this is very labor intensive -- in 2019, we think that the best way to go about customized masking is the "do it yourself" technique -- combine a knowledge of your tinnitus (from tinnitus matching) with one of the numerous apps that are available through the Apple or Android platforms.
Tyler et al recently reported that a particular type of customized masking -- "S-tones" consisting of a carrier frequency amplitude modulated at 40 hz, matched to the tinnitus pitch, was more effective than broadband noise (2014). We are dubious - -it is of course impossible to placebo control two different audible interventions. We do think though that matching the masking to the tinnitus is very logical.
Strauss et al (2015) reported another type of masking, using a notch filter that removes sound at the tinnitus frequency from hearing aids might be helpful. This is of course the opposite of providing sound around the frequency of the tinnitus. We are dubious that this method is any better than a hearing aid alone.