Tinnitus & Hearing Health: The Functional Approach

The Sound That Isn’t There

Tinnitus is perception without stimulus — a phantom sound that exists only in the brain. Ringing, buzzing, hissing, roaring, clicking, pulsing, whooshing. It affects 15-20% of the population, roughly 50 million Americans. For most, it is a mild annoyance. For 2-3 million, it is debilitating — disrupting sleep, concentration, emotional stability, and quality of life to the point of despair.

Conventional medicine often tells tinnitus patients there is nothing to be done. Learn to live with it. This is both incomplete and unnecessarily hopeless. While there is no pill that silences tinnitus, a systematic approach addressing root causes, neuroplasticity, nutritional support, and psychological reframing produces meaningful improvement in the majority of patients willing to engage with a multi-modal protocol.

Understanding the Mechanism

Tinnitus is not an ear problem. It is a brain problem triggered by an ear event.

The central gain theory, now the dominant model, works like this: damage to the cochlea (from noise, ototoxic medications, aging, infection) reduces auditory input to the brain. The auditory cortex, deprived of its expected signal, compensates by turning up its own gain — amplifying neural activity to fill the gap. This is the same process that produces phantom limb pain after amputation. The brain generates sensation to replace missing input.

The limbic system (amygdala, hippocampus) and the autonomic nervous system become involved through classical conditioning. If the brain tags the tinnitus signal as threatening, the amygdala activates a stress response every time the signal is detected. Cortisol rises. Attention narrows onto the sound. The tinnitus becomes louder, more distressing, harder to ignore — which increases the stress response, which increases attention, which increases perceived volume. A vicious feedback loop.

This is why tinnitus severity correlates more strongly with psychological distress than with audiometric measures. Two people with identical hearing loss can have dramatically different tinnitus experiences based on how their limbic system processes the signal.

Root Cause Mapping: The IFM Lens

Noise Damage

The most common cause. Cumulative exposure to sounds above 85 dB damages outer hair cells in the cochlea — the delicate sensory cells that amplify and tune incoming sound. Once destroyed, they do not regenerate in humans. A single gunshot (140-170 dB), concert (100-115 dB), or years of occupational noise exposure (construction, manufacturing, military) can trigger permanent tinnitus. Noise-induced hearing loss and tinnitus are two expressions of the same cochlear injury.

Ototoxic Medications

Medications that damage cochlear hair cells or the auditory nerve:

• Aspirin/salicylates: High-dose aspirin (>4g/day) classically produces reversible tinnitus
• Aminoglycoside antibiotics (gentamicin, tobramycin, streptomycin): Cause irreversible cochlear damage. Risk increases with duration, dose, and renal impairment
• Cisplatin and carboplatin: Chemotherapy agents with well-known ototoxicity — up to 80% incidence with cisplatin
• Loop diuretics (furosemide, bumetanide): Usually reversible; risk increases with IV bolus dosing and renal impairment
• Quinine: Reversible ototoxicity (cinchonism)
• NSAIDs: Chronic high-dose use associated with increased tinnitus risk

TMJ Dysfunction

The temporomandibular joint shares innervation with the middle ear via the trigeminal and facial nerves. TMJ dysfunction — clicking, popping, pain, bruxism — can generate or exacerbate tinnitus through somatosensory input to the dorsal cochlear nucleus. Clenching the jaw, moving the jaw forward, or pressing on the TMJ often modulates the tinnitus sound in these patients. If jaw involvement is suspected: dental evaluation, splint therapy, addressing bruxism (night guard), manual therapy to the masseter and pterygoids.

Cervical Spine

The dorsal cochlear nucleus receives somatosensory input from C1-C3 nerve roots. Cervical dysfunction — muscle tension, facet arthropathy, disc degeneration, poor posture (forward head posture from screen use) — can drive tinnitus through this pathway. Clue: the tinnitus modulates with neck movement, is unilateral, and correlates with neck pain or stiffness. Treatment: manual therapy (chiropractic, osteopathic, physical therapy), postural correction, ergonomic workstation setup.

Vascular (Pulsatile Tinnitus)

Tinnitus that pulses in time with the heartbeat — “whoosh, whoosh, whoosh” — is a distinct entity. It is not neural phantom perception but actual sound generated by turbulent blood flow near the cochlea. Causes include: atherosclerotic carotid disease, dural arteriovenous fistula, glomus tumor (paraganglioma), benign intracranial hypertension (pseudotumor cerebri), high-output states (anemia, thyrotoxicosis). Pulsatile tinnitus requires imaging (CT angiogram, MRA, or MRI with vascular sequences) to rule out treatable and occasionally dangerous vascular lesions.

Metabolic Causes

• Insulin resistance: Cochlear blood supply is exquisitely sensitive to metabolic dysfunction. Hyperinsulinemia impairs cochlear microcirculation. Kraft (1998) found hyperinsulinemia in a significant proportion of tinnitus patients
• Thyroid dysfunction: Both hypothyroidism and hyperthyroidism associated with hearing changes and tinnitus
• Vitamin B12 deficiency: The auditory nerve requires adequate myelination; B12 deficiency impairs nerve conduction
• Zinc deficiency: The cochlea has one of the highest zinc concentrations of any tissue in the body

Stress and Anxiety Amplification

Stress does not cause tinnitus, but it amplifies it dramatically. Chronic stress elevates cortisol, which increases auditory cortex excitability and limbic reactivity. It also disrupts sleep, which independently worsens tinnitus. The relationship is bidirectional: tinnitus causes stress, stress worsens tinnitus.

Mold and Environmental Toxins

Mycotoxins (particularly trichothecenes and ochratoxin A) are neurotoxic and can damage the auditory system. Patients with mold-related illness (CIRS) frequently report tinnitus as a prominent symptom. Heavy metals (mercury, lead) are also ototoxic at chronic low-level exposure.

Testing

• Audiogram: Baseline hearing assessment. Most tinnitus patients have some degree of hearing loss, even if subjectively unaware
• Tympanometry: Middle ear function
• MRI with gadolinium: Rule out acoustic neuroma (vestibular schwannoma) — a benign tumor of the vestibulocochlear nerve. This is essential if tinnitus is unilateral or asymmetric
• Metabolic panel: Fasting glucose, fasting insulin, HbA1c, lipid panel
• Thyroid: TSH, free T4, free T3
• Nutrient levels: B12 (plus methylmalonic acid), zinc, magnesium, vitamin D, ferritin
• Inflammatory markers: CRP, ESR
• If pulsatile: CT angiogram or MRA of head and neck

Supplement Protocol

Supplement	Dose	Evidence	Mechanism
Zinc picolinate	50mg	Arda 2003 — subjective tinnitus improvement in zinc-deficient patients	Cochlear has highest zinc concentration in body
Magnesium glycinate	400-600mg	Cevette 2011 — protection against noise-induced hearing loss	Glutamate antagonist, reduces excitotoxicity
Ginkgo biloba	240mg (EGb 761 extract)	von Boetticher 2011, Morgenstern 2002 — mixed but positive trend	Improves cochlear blood flow, neuroprotective
Vitamin B12	1000-5000 mcg methylcobalamin	Shemesh 1993 — B12 deficiency more common in tinnitus patients	Auditory nerve myelination
NAC	600-1200mg	Protection against noise-induced damage (Kramer 2006 military study)	Glutathione precursor, cochlear antioxidant
Melatonin	3mg at bedtime	Hurtuk 2011 — improved tinnitus severity, especially nighttime	Antioxidant + sleep support (tinnitus worst at night)
Alpha-lipoic acid	300-600mg	Neuroprotective, improves cochlear blood flow	Mitochondrial antioxidant
CoQ10	100-200mg	Supports cochlear mitochondrial function	Hair cells are energy-intensive
Vitamin D3	Target 50-70 ng/mL	Deficiency associated with sensorineural hearing loss	Anti-inflammatory, neuroprotective

Sound Therapy

The auditory cortex is plastic — it can be retrained. Sound therapy works by providing external auditory input that reduces the contrast between the tinnitus signal and the auditory background, promoting habituation.

Tinnitus Retraining Therapy (TRT — Jastreboff): The gold standard. Combines sound generators (worn like hearing aids, delivering broadband noise just below tinnitus level) with directive counseling to reclassify the tinnitus from “threat” to “irrelevant.” Based on the neurophysiological model — the goal is not to mask the tinnitus but to habituate to it. Treatment takes 12-24 months. Success rates of 80% for significant improvement in multiple studies.

Notched music therapy: Custom-filtered music removes the frequency corresponding to the patient’s tinnitus pitch. This promotes lateral inhibition in the auditory cortex at the tinnitus frequency — essentially training the brain to reduce activity at that frequency. Emerging evidence (Okamoto 2010).

White noise generators: Simple background noise (white, pink, or brown noise) reduces tinnitus contrast. Bedside sound machines are particularly helpful for sleep — tinnitus is perceived as loudest in quiet environments because there is no competing input.

Hearing aids: If hearing loss is present (as it usually is), amplifying external sounds reduces the central gain that drives tinnitus. Modern hearing aids can include built-in tinnitus sound generators. This is the single most effective intervention for tinnitus patients with measurable hearing loss.

Cognitive Behavioral Therapy (CBT)

Cima (2012), published in The Lancet, demonstrated that specialized CBT for tinnitus was significantly more effective than usual care for reducing tinnitus-related distress. CBT does not reduce the volume of the tinnitus — it changes the brain’s emotional and cognitive response to it. By breaking the catastrophizing-attention-distress cycle, CBT reduces the limbic system’s involvement. The tinnitus signal becomes less salient. Patients report that the tinnitus “fades into the background” even though the audiometric signal has not changed.

CBT techniques include: cognitive restructuring (challenging catastrophic beliefs like “this will never get better” or “I will go insane”), attention redirection, relaxation training, sleep hygiene, and graded exposure to quiet environments.

Photobiomodulation (LLLT)

Low-level laser therapy applied to the mastoid process or external ear — typically 808nm near-infrared, 5-10 minutes per session, 3-5 times weekly. The proposed mechanism: photobiomodulation of cochlear hair cells and auditory neurons, improving mitochondrial function and reducing inflammation. Evidence is conflicting — some studies show modest benefit, others show no effect. A reasonable adjunctive option for patients who have not responded to other interventions, with minimal risk.

Hearing Preservation

Tinnitus prevention is hearing preservation. The functional medicine approach to lifelong auditory health:

• Noise protection: Earplugs at concerts, sporting events, when using power tools. Custom-molded musician’s earplugs attenuate evenly across frequencies. Keep earphone volume below 60% of maximum; follow the 60/60 rule (60% volume, maximum 60 minutes continuous use)
• Ototoxic medication awareness: Request hearing monitoring (baseline and serial audiograms) during cisplatin, aminoglycoside, or chronic high-dose NSAID therapy
• Cardiovascular health: The cochlea depends on a single end-artery (labyrinthine artery) with no collateral circulation. Atherosclerosis, hypertension, diabetes — anything that impairs microvascular function impairs cochlear blood supply. Exercise, omega-3s, blood pressure control, glycemic management — all protect hearing
• Anti-inflammatory diet: Chronic systemic inflammation damages the stria vascularis (the cochlear structure responsible for maintaining endolymph ion composition). An anti-inflammatory diet protects cochlear function
• Exercise: Regular cardiovascular exercise improves cochlear blood flow. The cochlea benefits from every systemic cardiovascular improvement

The silence that healthy ears produce is itself a form of sound — the sound of a system in balance. Tinnitus is what the brain generates when that balance is lost.

If your brain is turning up the volume to compensate for something missing, what else in your life might benefit from that same question?