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What You Can Do


John Wooden, the "Wizard of Westwood" and arguably the finest basketball coach in the history of the game, once said, "Do not let what you cannot do interfere with what you can do."  Stephen Nagler, arguably the worst athlete in the history of the game, once said, "Tinnitus may be viewed as a sign to conduct one's life prudently, but not prudishly."  I would like to take a few moments to examine these two aphorisms - that of the coach and that of the uncoachable - in light of what might be considered reasonable tinnitus patient management.

A few years ago I treated a very interesting gentleman in my clinic.  Upon first seeing this fellow, a professional wrestling announcer might refer to him as "Six Foot Seven Inches of Rompin' Stompin' Dynamite."  To us at the clinic, however, he came across as living somewhat of a larval existence, surrounded by a cocoon of concern and paralyzed by the fear that he might - just might - do something that would make his tinnitus worse.

"Mr. Smith, what exactly is it that makes your tinnitus worse?"

"Everything, just everything makes it worse.  Getting up, moving around, exercising, soft music, stress, going to a mall, sleeping, eating, just everything."

"Well, what seems to make it better?"

"Doc, nothing makes it better."

"Nothing?"

"Nothing at all."

"It only gets worse, right?"

"Right."

"Well, how bad is it right now?"

"It's horrible now - I don't see how it could get much louder or annoy me more.  I'm at my wit's end."

By the conclusion of this first day visit - a day of intensive audiological, medical, otological, and psychosocial evaluation - I had already decided that Mr. Smith would be an excellent candidate for Tinnitus Retraining Therapy, but I had to be certain to include elements of Cognitive Behavioral Therapy to begin to modify some of the obvious distorted "all-or-nothing thinking," which had resulted in his self-imposed incarceration.  That meeting, however, would not be held until the next day.  I decided to make the best use of the evening ahead.  Mr. and Mrs. Smith had traveled a considerable distance to Atlanta to come to the clinic, and I suggested that they have dinner out at a restaurant I knew to be not very noisy, one with an excellent wine list and a chocolate dessert menu that had clearly already exacted its toll on my own belt size.

"But we don't really eat out anymore.  And red wine and chocolate are bad for tinnitus."

I suggested that since according to him his tinnitus was already as bad as it could get, wine and chocolate were unlikely to make it worse.  I told them to have a nice evening out - in fact I insisted on it - and I told them to enjoy a glass or two of wine ... and to be sure to try the chocolate dessert sampler.

The smiles on Mr. and Mrs. Smith's faces the following morning upon their return to the clinic told it all!  Of course Mr. Smith's tinnitus was no worse; by his own admission it was already as bad as it could possibly be.  Actually, things seemed a bit better - and he and his wife had enjoyed a pleasant evening out.

We spent the next few hours reviewing the principles of Tinnitus Retraining Therapy and also began to work on examining some of Mr. Smith's cognitive distortions.  We additionally talked for quite some time about how Mr. Smith might go about not letting what he cannot do interfere with what he can do.

Some basic guidelines then -

  1. A person affected by tinnitus cannot afford to be exposed to excessively loud noise for any appreciable amount of time.  How loud is too loud?  It seems to me a bit compulsive to carry around a decibel meter everywhere, so I would simply offer Dr. Jack Vernon's guideline:  If the sound in a room is so loud that a person affected by tinnitus must raise his or her voice in order to be heard, then that person should either leave the room or use ear protection.

  2. A person affected by tinnitus cannot afford to take medications known to potentially cause damage to the auditory system, unless the situation is life-threatening and no acceptable alternative can be found.  These ototoxic medications include the aminoglycoside antibiotics when given by vein or by injection (e.g., gentamicin, streptomycin, amikacin, neomycin, tobramycin); the quinine-based antimalarials (e.g., chloroquine) and quinine-based antiarrhythmics (e.g., quinidine); and the platinum-based chemotherapeutic agents (e.g., cisplatin).  Additionally, for compelling anecdotal reasons I personally do not believe that tinnitus patients should take the antibiotic Zithromax (azithromycin) or the non-steroidal anti-inflammatory agent Relafen (nabumetone).

  3. A person affected by tinnitus can and should be exposed to all kinds of sound that is not excessively loud.  The auditory system flourishes in the presence of environmental sound, and it starves in the presence of prolonged environmental silence.  Moreover, in the absence of environmental sound, the auditory system will do what it is meant to do -seek sound - and in so doing, tinnitus will be unnecessarily magnified.

  4. A person affected by tinnitus can and should consider taking medications (with the exception of those ototoxic agents mentioned above) from that long list of medications reported to occasionally cause or exacerbate tinnitus as a side-effect if the use of the medication is medically indicated.  Since these drugs do not cause damage to the auditory system, any tinnitus exacerbation due exclusively to their use should resolve within a few days.  In my mind there is no need to deprive oneself of medically indicated treatment (in the absence of an acceptable alternative) for fear of the remote possibility of temporary aggravation of tinnitus.  Even aspirin, the classic offender, may be taken safely - especially in the kind of small doses recommended by cardiologists.  High doses of aspirin will cause tinnitus in anyone, but it is very rare that one aspirin a day will have an adverse effect.  In the unlikely event that it does, the person affected by tinnitus must then decide if the cardiac benefit is worth the slight increase in tinnitus.  If not, then simply stop the aspirin!

  5. In moderation a person affected by tinnitus can and should feel comfortable about participating prudently as he or she may wish in life's activities, as long as those activities are legal, ethical, and not unhealthy.  It is a source of constant wonder to me how many people affected by tinnitus have given up that morning cup of coffee, that once a week (or more than once a week my waistline says) chocolate dessert, or that glass of red wine they used to so enjoy with dinner.  If you enjoy coffee, then have a cup.  If you enjoy wine, then have a glass.  If wine were damaging to the auditory system, then it would be prudent not to have wine.  But wine does not damage the cochlea.  So it would be prudish to avoid a glass or two if you really enjoy wine with dinner.  On the other hand, it would be prudent not to drink any wine with dinner if you were an alcoholic.  It would be prudent not to drink any wine with dinner if you were taking Xanax or a similar medication.  It would be prudent not to drink any wine with dinner if you did not prefer wine or if you simply did not wish to drink any that night.  And it most certainly would be prudent not to drink eight glasses of wine with dinner, but that suggestion has nothing to do with tinnitus.  Most importantly, if that glass or two of wine with dinner did, indeed, exacerbate your tinnitus, then it would be prudent todecide whether or not you would want to have a glass occasionally anyway, basing that decision on the knowledge that no harm was being done to the cochlea and not on the unfounded fear that a little wine, a little coffee, a little chocolate might do some irreparable damage.

  6. It is prudent for a person affected by tinnitus to look forward to the knowledge the future may bring - especially the possibility of a true cure - but it is prudish for a person affected by tinnitus to be paralyzed by fear of the knowledge the future may bring.  There are in all probability numerous environmental and dietary influences that currently wreak havoc upon our auditory systems, but about which we are completely unaware.  Imagine conversations in the otological and audiological communities twenty years from now:  "Do you believe it?  Those folks back in '98 actually ate salad!  Everybody knows salad damages the cochlea and causes tinnitus.  How could they be so foolish and irresponsible?"  Well, today it is not foolish and irresponsible to eat salad, to drink Coke, to take ibuprofen, to chew a Hershey bar, to live up in the Rockies at altitude, and to put spices in foods.  If we constantly ruminate about the future, we will be unable to take full advantage of the present - not only to exist, but to live.


So listen to the coach and listen to the uncoachable.  Do not let what you cannot do interfere with what you can do; in so doing consider conducting your life in a prudent manner, not a prudish one.  Tinnitus is a bad enough deal as it is; do not let it take an additional toll unnecessarily.

..........

Epilogue (11/99) -

The above piece was written in the spring of 1998.  I subsequently had the opportunity to see Mr. Smith in follow-up at eighteen months.  He had, indeed, participated in the outlined protocol - willingly, but clearly somewhat skeptically ... at least at first.  The Tinnitus Retraining Therapy component of treatment was undertaken and completed precisely as recommended by Jastreboff for Category I tinnitus patients.  Mr. Smith had undergone three intensive directive counseling sessions with application of the Neurophysiological Model tailored to his individual circumstances - an initial session in person, a follow-up session in person six months later, and another follow-up session by telephone six months after that.  Moreover he had been in contact with us by telephone on several occasions as additional issues arose.  And he had been wearing white noise generators in each ear set at a very comfortable level just below the "mixing point" to decrease sensory contrast - all precisely according to TRT Category I methodology.  With respect to the Cognitive Behavioral Therapy element of his treatment, numerous classical cognitive distortions had been identified including "all-or-nothing thinking," "overgeneralization," "mental filter," and "disqualifying the positive."  A series of "homework exercises" and challenges were devised (and revised in telephone follow-up) with an eye towards Mr. Smith changing his distorted thoughts about his tinnitus, thereby changing the distorted feelings that those distorted thoughts evoked, and ultimately impacting the entire tinnitus experience in a clearly positive manner.

"Doc, my tinnitus is there, but I'm not aware of it most of the time ... and it doesn't stop me from doing anything ... anything except playing the piano."

"Why can't you play the piano now, Mr. Smith?"

"Because I never learned!!!"

This man, who had been for all intents and purposes paralyzed by his tinnitus, was "back" - sense of humor and all.

His score on the Oregon Hearing Research Center Tinnitus Severity Index had dropped by 75%.  The intrusiveness of his tinnitus had dropped from 10/10 to 2/10.  He still had tinnitus - he could hear it anytime he listened for it.  But throughout an average day in his life, he was not aware of it much at all ... and when he was aware of it, he was not annoyed by it.  This from a man who had by his own account at his intake interview been aware of his tinnitus 100% of his waking hours, and for whom tinnitus had essentially dictated his every move.

As we arrive at the turn of the millennium, there is no universal cure for tinnitus.  Someday there will be one, but not today.  And as we look to tomorrow for the cure, I find it very reassuring to know that today - even though a person might have tinnitus, the person need not suffer from tinnitus ... indeed, that person need not even hear it!

Let me tell you about a man, a man who was so religious and devout that he prayed three times a day - every day - with his heart and soul.  Not only that, he was constantly helping others - he was generous with charities, he assisted in soup kitchens, he visited the sick in hospitals, he gave shelter to the homeless.  Joe was just wonderful.  He was a real "good guy," and everybody in the town knew him, liked him, and respected him.

One day, a huge storm arose, bringing rains and floods so bad that one would think they'd never cease.

As the floodwaters rose, Joe had to leave the bottom level of his home and go upstairs, so he wouldn't drown.  Someone going by on a raft looked in the window of the house, noticed Joe's dire straits, and offered him a life preserver.  Joe politely refused, claiming that since he was such a religious and charitable man, God would surely perform a miracle, cause the rains to stop, cause the floodwaters to recede, and save him.

Joe then had to go up on the roof of his home as the waters continued to rise.  Another fellow came by in a boat, and said, Joe, jump in - let me help you."  Joe steadfastly refused, claiming that God would surely perform a miracle, cause the rains to stop, cause the floodwaters to recede, and save him.

He then crawled to the top of the chimney, as the waters rose even more.  A helicopter came by and dropped down a rope ladder.  Joe wouldn't climb up, knowing for sure that God would perform a miracle, cause the rains to stop, cause the floodwaters to recede, and save him any minute.

Well, the story is obvious, isn't it?  Joe of course drowns, and he meets up with God in Heaven.  God says, "Joe, good to see you.  How ya doin'?"  Joe says, "Well it's a real nice place you have here, God, but - to tell you the truth - I'm a little upset ... I wasn't ready to die.  Why didn't you stop the rain ... why didn't you cause the floodwaters to recede ... why did you let me die?"  And God responds, "Joe, Joe, what do you want?  I did cause the rain and the floods - that's true.  But I also sent you a life preserver, I sent you a boat, I sent you a helicopter.  What'd you expect?  A miracle, maybe?"

Tinnitus is a bad deal - it's an incredible test of the human spirit.  But there is legitimate hope.  There are effective treatments now - masking, cognitive therapy, TRT, many more.  We have the life preserver, the boat, and the helicopter.  We have them now.  I would suggest that we not ignore the life preserver, the boat, and the helicopter today - while waiting for the miracle of the cure tomorrow.

Stephen M. Nagler, MD, FACS



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