Tinnitus: Dr Sedley at NTDF 1/2

as dr. will sadly who's going to give the presentation today so we welcome with just prior so that yeah kevin has doin speech the text in the corner and you see billion Jim at the back they fill him in the event to do if you don't want to be in the finished product of the film just let us know I'll let the guys know that and it won't appear anywhere and I won't appear anywhere without anybody's where they were just seeing it and content first yep we all okay with that yeah and I'm our hand you two well I thought I don't have enough things on my belt I should I should add some more I have my watch on there this morning it fell off while I was walking down the corridor that's right well thank you for thank you for having me here it's it's my pleasure really I'm I'm hoping that you'll come away having learned something about tinnitus I can't explain everything to you I've come out to come on to my my background and training and everything in detail but I've spent three hours recently trying to explain my new theories of tinnitus to ER to a world expert and it took the full three hours to just about just about and get us to see eye to eye and check we were talking about the same thing so I'm not going to be able to explain everything but I'm hoping I can educate you a bit and also I'd like to be educated because as our thinking and understanding of tinnitus is moving on I'm thinking all the time about how how we might as as doctors as health professionals best organize our tinnitus services to meet the needs of yourselves and after all you and other people with tinnitus are who it's all about not us sort of before I launch into the talk I suppose I'll tell you a bit about my background so I'm I'm a doctor I graduated from Medical School in 2007 and I I've come in I will hold my hands up and say I've come into working with tinnitus by complete accident I was always fascinated by the brain and how the brain creates our sense of reality and what we experienced and thought I should probably do something that captures that down the line I was lucky enough to get a post funded me to start conducting research straight out of medical school in with research on the brain and nervous system and I've crossed paths with a very able chap called Tim Griffiths over at Newcastle University and we've been conducting research together since and he works in the auditory system I thought well the auditory system that's part of the brain I'd like to study that why not give it a go and quite quickly came across tinnitus and my first reaction was why would anybody want to study that it sounds really boring and the first you know the first thing to say and it's not the most important thing about it is that when you get into it it's it's fascinating we you know we are anyone who experiences this I myself get a bit it's being tricked we're all being fooled by our brains into experiencing as you know as clear as daylight as real as anything else that there is you know a sound a thing that's there that is not in the outside environment you know this this is happening no one else can see it so I can see why people might not be excited about it but listen you know this is real and this is happening to one in seven people or more and that's perhaps the most important thing this is this is huge this is more common than you know asthma diabetes epilepsy you know as on this you know on a scale of prevalence up with cancer heart disease and things that shitty this should you know this is affecting people of all ages doesn't have a solution and once you start to get into that you think why why is why is more not not being done why why are and I'm sure you're all we are wondering this yourself why why isn't this a bigger priority why you know why isn't why isn't there more talk about this this is just being allowed to happen now thankfully actually I've as I've learned there is a tremendous amount of research going on into tinnitus worldwide it's a very active research community there's a lot of big figures prominent being a fantastic people working on it world you know in the UK and worldwide but we're still not there and still you know being in the clinic in the doctors surgeries wouldn't you wouldn't know it was all going on because we're still we're still not cracked it and we're not we're not there so I've worked on on tinnitus on and off for seven over seven years now I've just been lucky enough to get funding from the Medical Research Council to undertake three years full time research into tinnitus which I've just finished including in part thanks to thanks to some members of this group I shan't name any names confidentiality and that and this this is my third time being here I came as a junior researcher who knew nothing about tinnitus and wanted to meet people and get volunteered and I'm hoping as times gone on I'll be able to give a little bit more back and it'd be a less one-way street of me coming from my own knowledge we'll see I don't want to promise promise too much anyway so I'll launch I'll launch into a lot of computers now we're now doing that I'll tell you what I'm gonna talk to you about anyway this is this is a whistle-stop tour and then a number of questions I'd like your opinion on so I'm gonna define tinnitus give a little bit of background you you're not going to need to know this this stuff and I'm gonna focus a little bit less on what what we know from tinnitus research and what tinnitus research can explain and I'm actually going to focus a bit on what what it still can't explain I'm then going to talk about some of my own research and that of some of my colleagues that we've performed locally and in collaboration with some other research groups talk a bit about treatments not too much because as you'll know generally there are not good widely effective treatments but on less some of these and why why they don't work and then lay out what in my mind are some of the perhaps potentially potentially fruitful avenues for research and future for how we might start to really make more progress in tackling tinnitus and then I'll finish finish with some questions for you and that's where I'm hoping to hoping to continue to learn myself so I don't need to define tinnitus for you it's you hear sound where there is not sound in the environment it's generally persistent and it's usually a simple sound some people get music and very rarely even voices although that unusual in this context may be musical lyrics but we're talking about some you know basic tinnitus whether it's ringing or whistling and hissing a banging or buzzing these sorts of things and that are generally an isolated phenomenon it can occur due to parts of a wider wider neurological disorder but it's generally something that occurs in in and of its own right in in isolation as I mentioned before so the the best evidence about the prevalence of this we have it's from us studies it but I think a is about the same about one in seven people will seek medical attention in there in their lifetime for ongoing troublesome you know tinnitus enough to bother them and two percent of the whole population claims to have a significantly impaired quality of life long term on account of ongoing tinnitus so this is this is massive and don't need me to tell you it's massive but it's it's massive and it's very very common it becomes more common with increasing age but it can start anytime from childhood and it's not a not a rarity any anywhere from there onwards and a big the big risk factor is hearing loss I'll come a bit uh come on to that a little bit more just now in fact in a minute actually so what my this is my impression of what happens when somebody gets tennis and goes to the doctor so if you start at the top here you you go oh I've got this noise in my ear this isn't very nice you go to the doctor if they don't think well I can hear so much that's going on the doctors bound to be able to see or hear something because why am i hearing all this the doctor looks in your ear and goes yeah I can't see anything at all they'll say you've got wax or something like that but we'll basically say mmm not sure let's do a hearing test maybe let's do an MRI scan anyone here to had an MRI scan yep and whether or not there's anything on either of those I mean this person here at this example person has some high-frequency hearing loss which most people with tinnitus have some people won't and regardless of the result of that and regardless of the results of the MRI scan you come back to the doctor who goes don't know and you go one of these two ways you are either like the other like this more stoical woman at the bottom here who goes oh well if there's nothing else wrong I can live with this alright or you go well that's no good this is awful I can't live with this and you get driven totally mad and and that you know this this is and this is that anyone had enough anyone had an experience with doctors that doesn't fall into this category oh yeah okay so you've got that you've got the shrug without even the initial test all that okay so you have an even more limited journey than that and that's many anyone can anyone relate to cancer this answer this Julia I can see I'm seeing a lot of nominee I'll come back I'll come back to this at the end what we'll go on with the body of the tongue so a lot of one of you know one of the big questions in early tinnitus research but it's actually still not a solved question although it's often treated as solved where is the tinnitus is it coming from the ear or is it coming from the brain so we started out thinking well the sounds in the air surely it's coming you know it kinda kurz old mainly if the air is damaged surely it's coming from the air Julie the eight years angry and damaged and the little hair cells are sending off nerve impulses and we're hearing them right but and so on this sort of right hand edge of the scales there's some factors in favor of tinnitus being generated in the air if you have a major source that you know noise induced hearing loss for a sudden noise trauma or even if you just go to a really now at loud my club concert or anything and get ringing in your ears afterwards even temporarily the tinnitus often starts straightaway so you might think when the brain hasn't had time to catch up and cause anything so that suggests maybe it's from the air and in in the gung-ho glory days of surgery they used to go around cutting peoples in the auditory nerve from the ear to try and treat tinnitus and it did sometimes work you'll notice I'll come back to this procedure as you can tell me it features on the other side as well and actually more recently they've shown that in animal models where you use noise trauma to cause what we think is tinnitus the activity higher up in the brain that you record is correlated to the activity in the ear they fire and peak at the same time so that does seem to be a connection between them and there's a anyone here take fruisé amide as a water tablet common water tablets but I learned recently attacks on the ear as well it doesn't act on the brain at all that it acts on the ear and suppresses active in the cochlear a little bit and they've found that giving this drug to animals with senators acute tinnitus that just cause seems to help and they tried it in people and it maybe helps a bit but it just doesn't while you're giving it no real lasting benefit he's a big injected doses so again you can do something to tinnitus just by working on the air but we also know if factors in favor of it having a brain origin on this or the left side of the scales what people who have hearing loss and tinnitus have reduced firing in the auditory nerve so the brain is getting at overall it's getting less input from the ear but when you measure activity in the hearing pathways in the brain it's elevated so somehow the brain is going from reduced input to increased activity higher up we think it's turning up the volume dial turning up the gains somewhere in the pathway and you some people think you know quite rightly so this this increased gain or amplification might have something to do with with tinnitus there and also cutting the auditory nerve can cause tinnitus and it can exacerbate tinnitus so sometimes it helps sometimes it makes it worse so it's quite clear that whatever the link with the ear is the brain is quite capable of generating tinnitus by itself so it seems watch this space for the further debate anyway but there's as well as this ongoing debate this there are some things there are some things that still don't add up despite all the international research effort in tinnitus so one these are some hot you know these are some of the selected oddities it's not all of them that we haven't explained one of these is tinnitus is normal the majority of people have tinnitus I'll try and convince you of this not to the same extent but but do so this got a picture of a soundproof booth here 60 percent of utterly well healthy normal hearing adults if you put them in a soundproof booth and tell them to concentrate 60 percent of them quite quickly will say oh yeah actually I hear and they'll describe a sound that is just like the tinnitus that you or I would experience it's much quieter it doesn't it can't get itself above background noise but it's there and it's the same thing and when you quantify it when you measure the pitch it's the same thing that we experience but it's it's much much less so every or the majority of people have a bit of tinnitus and even those who don't if you get them to do forced contractions and movements of their head neck and jaw the majority of them can cause tinnitus while doing these maneuvers in fact I didn't used to have tinnitus I was so interested by this I practiced with all kinds of maneuvers lots I used have a lot of train journeys and I'd sit there trying this and that and I was I cause tinnitus it didn't go away it's not that bad but it's not gone so tinnitus is is the norm now you might say well no maybe everybody's got damaged hearing but you know it's it's it's more unusual not to have a bit of tinnitus so that's one thing we're trying to explain something that is a normal phenomena but is grossly exaggerated in some people now we all that we all know hearing loss is a big risk and put the major risk factor for tinnitus but even when tinnitus is caused by hearing loss it doesn't have to start at the same time it can start as soon as something the thing that causes the hearing loss it can start you can have the hearing loss which has gone on and on and on and on no problem for months years and one day bang the tinnitus starts why is that what's what's this second process why you know how can this have been there the whole time that you only get the tinnitus there much later and we you know anecdotally this can begin out-of-the-blue or during a time of physiological or psychological stress sort of high alert modes and things are we are we on that are we and threat detection mode are we picking up on things that slip under the radar because we're hyperstimulated there's there's theories on this it's not a straightforward relationship anyway and also hearing loss can occur without tinnitus and many people have hearing loss and never get tinnitus so why do they not why do they not get it and some people do and then why do some people without hearing loss get tinnitus so it's not a consistent relationship in any in any respect now coming into it I don't want to go into too much of the fine detail of brain recordings but there I'll tell you there's been a lot of interest of measuring ongoing brainwaves this is with electrodes on your scalp or magnetic sensors around the brain picking up a lot the the auditory part of your brain is doing just at rest and then about from about 2005 onwards there was a lot of interest in this because he research groups were they were taking a group of people with tinnitus and comparing them to well okay they were taking middle aged people with hearing loss and tinnitus and measuring their brain activity and they were taking University students with no hearing loss and no tinnitus and getting them to sit at rest in the scanner and comparing their brain activity and lo and behold there were lots of differences in the hearing parts of the brain through these abnormal patterns of activity and lots of theories have been built on this careers have been made on this but when people have gone back and done the same study but not used young normal hearing University students and used people of the same age and the same hearing level as the people with sinesses there are no differences so hearing loss and a predisposition towards tinnitus has has correlates in terms of brain activity it changes your ongoing brain activity but the brain activity doesn't seem to care who actually goes on to get tinnitus so we may be measuring a precursor but then there's something there's something a bit less defined this second hit you know that the bit that why you suddenly wake up with tinnitus one day when you never had it before even though you had ripped hearing loss for 10 years we're not getting at that in terms of brain imaging but if you suppress tinnitus temporarily or if then you cause reliable changes in brain activity there are reliable brain correlates of how loud the tinnitus is and if you successfully treat it bit controversial that treatment in question here then again you get brain activity changes so there are brain correlates of the severity of tinnitus but not of not that actually distinguish people from with tinnitus to those who are just predisposed with it so we're still missing a trick so in terms of the research I've been doing so I've been working full-time on tinnitus research the last three years but I've done patent periods of tears this research off and on over for several years before that and I've been very fortunate in terms of getting research funders interested so I've been supported a lot by the National Institute of Health Research in the medical research council who've funded me for the last three years and all the research I've been doing and and the things I'd like to talk to you about our own brain activity and and brain chemistry as well which is a more emerging area in tinnitus and you know once again I've always received very great support from members of members of this group I'm not I'm not touting for business here unfortunately there's no there's no project just now on the horizon I do plan to continue this research down the line but you know another another note of thanks to everybody who's you know even those who volunteered and not being suitable it's all all very appreciated so just just to bring you through a couple of these studies this is this is one that's just being accepted for publication actually in a very in the Journal of Neuroscience which they're very well respected venue for it to appear I look looked at 14 people with with chronic tinnitus and 14 people who are really well matched for age hearing sex everything else and a split the groups half normal hearing normal ish hearing half with significant hearing loss and again the control healthy bond with volunteers without tinnitus were were matched in every respect about the tinnitus and these are just I don't know if anyone's familiar with looking at audio grounds here but the left to right us the different frequencies from low to high we've got left here a right here and the worse the hearing is so we're seeing a drop-off a worsening hearing into the higher frequencies and the the DAT the solid line is the control group the dashed line is the tinnitus group and you can see I was very proud of this that matches that good just never never happened really so so I got very lucky there but they were very nicely matched group and there's a table I won't take you through everything just showing that all the other measures we got matched as well if everyone's gone through an MRI scanner so of using special techniques to look at the brain chemistry in the auditory cortex they're higher higher hearing center of the brain so an example here this is this is one individuals brain image and this square is this is the area we got the study measured the chemical signals from it's quite a large area but it covers the whole the whole auditory cortex and what we get out is this nice chemical spectrum if anyone's in familiar with mass spectrometry or other kinds of spectrometry we get these nice chemical Peaks and as a blown-up one of here this is what we're interested in this is this is gaba anyone's come across gaba it's the main it's the main inhibitory chemical in the brain that dampens down excessive activity lots and lots of well-known medications work on gaba the benzodiazepines many epilepsy drugs some some others as well and there's reason to think that there might be there might be deficiencies in gaba localized to the auditory parts of the brain and tinnitus so an inability to inhibit what should normally be inhibited perhaps to the point where it doesn't get perceived it's that's there that's the thought and what what we found particularly look at the right we've got a better signal from the right side of the brain for technical reasons but the control group has this amount of gaba and the tinnitus group had significantly less which can't be accounted for by hearing age any of these other factors it seems like there is a primary deficiency of chemical inhibition related to tinnitus so this is this the full implications of what this means are yet to be established that it's a need for further work but this is this is really the first time that this has been conclusively demonstrated to tell you a bit about another study this that this one actually did down in London I'm using an M eg scanner if anyone's ever had an EEG will you stick all their little electrodes on your scalp this is if anyone's a physics anyway if anyone's a physics nerd you'll know that any source of an electrical field is also a source of a magnetic of electrical potential is also a source of a magnetic field at right angles and so instead of putting electric sensors on the brain you can use magnetic ones and there's a few technical around I won't won't bore you with but we have a scanner that down there we we can get access to so I've dragged 16 people with tinnitus and another another well-matched group of of controls master aged Nexen hearing loss and done resting it so as I mentioned before this kind of research has been done but not not generally with well matched groups only once so this is the second bone we started using well matched groups and I've looked at a few things that the first study and study didn't to focus on activity in the auditory cortex and hearing parts of the brain and compared these groups this is an M eg scanner so there's a nice array of magnetic sensors buried deep in here just on just so over the surface of the brain the whole rest of this is a massive tank of liquid helium because these are superconductors and they only work when they're about at Absolute Zero so it's perfectly safe as long as nobody punctures the tank it's well armoured they've never been any M eg accidents it's very safe quiet machine this is not one of my volunteers but this is the same scanner this is exactly what would have looked like and I made them sit there and look at a white cross on a black screen it was very boring but what did we find there were no differences between the tinnitus group and the control group as before I've worked very hard on using the most sensitive techniques to find any subtle differences there might be so again we're not differentiating between those with tinnitus and those simply with the predisposition with the here with the hearing loss and all the changes that go with the hearing loss all the compensator II Pro says extra amplification in the brain but what we did find and again these are some these yellow boxes for just my areas of interest in these hearing related or tinnitus related parts of the brain there were there were correlates of factors related to tinnitus perhaps most interestingly the degree of hearing loss particularly within the tinnitus group but in both did correlate very strongly with with ongoing activities so again it's the predisposition not the tinnitus that's causing these brain changes but the loudness this the perceived loudness of the tinnitus did also correlate with time for brain activity and also the current loudness on a day-to-day basis in a slightly different part of the brain this is a more high level area so it may be that there are correlates in the hearing part of the brain about how loud your tempters tinnitus is and then in these higher centers the signal gets fed through on the days more so on the days where the tinnitus is is bad again the service needs this needs more work but it echos what we were suspecting before that we've we've been missing a trick we're not getting at V what is the brain corylus of tinnitus as opposed to just all the surrounding confounding predisposing factors and what one one last study I'll tell you about before trying to bring any of some of this together the the people up here who I did the brain MRI scans on to get the chemical measurements they also had an EEG study well I made them watch The Lion King without the sound on and played lots of very loud repetitive annoying sounds to them to see how the brains responded to the sounds kudos to anyone who went through this by the end of the day it's the last thing you feel like doing most people tolerated it well one person couldn't hack the sound it wasn't anyone from here it was one of the control volunteers in fact so we measured their brain activity one using some special sounds and I used ones in the tinnitus range and ones below the Telesis range and what what it what it found these are so again the group the greys of the control group the whites of the tinnitus group and the height of the bar is just the strength of the brain response here the the the sounds at one kilohertz below the tinnitus frequency that's really below everyone's Genesis range we're exactly the same between the groups but at 4 kilohertz which fell within everyone's tinnitus range tinnitus group has significantly greater amplification of these and this was after accounting for the hearing loss and even after accounting for hyperacusis so there is there are things going on there is abnormal brain chemistry there is excessive sound amplification but there isn't a there isn't a tinnitus sure it seems in the ongoing brain activity this is something we're still failing to failing to spot yeah so what you know what I've been helping to demonstrators Genesis isn't associated with changes and ongoing brain activity over and above a predisposition to tinnitus but it does it is associated with deficient chemical messengers that normally inhibit brain activity and it is associated with increased amplification of set of sounds and sound signals coming up from the ear I'll talk a bit about treatments and then maybe even a bit about why they don't work so if anyone's heard of this though the Cochrane Library is one of our sort of hallowed institutions of research evidence so whenever there's been randomized double-blind controlled trials of treatments the Cochrane Library come along and invite people to review these in a systematic manner and bring a vet bring together in a formal way all the evidence that exists on a subject and then publish a report about what works what doesn't what might work and what they've found have been a lot of there's I don't know I don't know why they managed to have enough evidence to review a number of studies on ginkgo biloba fit in it's just anyone taking ginkgo biloba so they concluded that there were there wasn't evidence to support I mean I would never encourage if anyone perceive as a ban of takes it and perceives the benefit I always say carry on but they concluded ginkgo biloba and various drugs antidepressants benzodiazepines and anti-epileptics there's no evidence to support their use they no one's to convincingly done better with their tinnitus than those given placebo intermediate so no you know here I may well be challenged on this because these are in really widespread use but hearing aids and masking devices are used a lot for people with tinnitus who have significant hearing loss who experience a benefit from them the conclusion was there isn't the evidence to support their use but there's just not very much evidence at all and what does work are psychological therapies not to make the tinnitus quieter but to allow people to habituate and react more positively on neutrally to their tinnitus so the one with the best evidence is cognitive behavioral therapy has also tinnitus retraining therapy so those those definitely work is very good evidence for it and then there's a all other you know approaches to doing the same thing that just haven't had the formal evidence so we're at a state where people going back to that earlier pathway and you know the two the two example patients one who is very bothered one who wasn't treatment really aims to get people from that bothered category more towards the less valid category tonight I suspect a lot you know a lot of what goes on here is very much with this this aim in mind but we're missing a trick for actually making the tinnitus get quieter or go away that's the that's the million dollar question still and a lot of other treatments have been tried people have injected Botox around the ears and into the scalp people and this is just alphabetical order they've used brain implants that electrically stimulate different bits of it either the auditory cortex or the deep structures in the brain there are acoustic treatments using little iPod like devices that they customize sounds to try and to try and suppress the tinnitus as EEG neurofeedback where you learn to control your brainwaves these ones that we correlate with the severity of the tinnitus there's transcranial ultrasound I'm not even sure how that's meant to work for us there's research going into that there's frozen midol this saying acts on the ear not just music therapy listen to your favorite music three hours a day or however long but the tinnitus frequencies taken out the evidence of be a bit iffy some people seem to get benefit from it not really cracking the tinnitus making it go away but and then there's this tDCS that's putting an electrical current through the brain as our TMS repetitive magnetic stimulation firing sequences of magnetic pulses there and all you know these variably do a bit but they're not really nailing it in the long term and then there's this vagus nerve stimulators people have the vagus nervous there is that it's a big player in the autonomic system it's what makes your body relax so this stimulates it and induce relaxation while playing you tones match to your tinnitus and that's meant to undo the tinnitus networks the trials are ongoing in humans it worked it worked in rats but as I'll come on to what works in rats and guinea pigs and mice doesn't always work in people people well there's a number of differences which brings me on to what and you know that it's not there's been a great number of treatments that look really promising in the animal studies but then when you get them into people they either don't work as well or don't work and why why is why is this so the to to sort of popular arguments for why why this might be the case one one would be to say that what we're measuring in the animals is not really tinnitus so I think the question everyone always ask me is well how do you tell if an animal has tinnitus at all and that there's two there's two broad ways of doing this one is you train the animal to do a certain behavior or not do it when it hears a tone that resembles tinnitus – high-pitched ongoing ongoing todor sound like that and then you do something to its ear you damage it or something and then if the animal starts doing that behavior that it learned to do when the sound is there then you think hey I've got tinnitus now it seems quite reliable it's very laborious it takes months and months and months and then there's these high throughput methods where if you play anyone really if if any anyone who's suddenly exposed to a very loud sound will jump and startle and animals rodents have this great startle reflex but you can make something less startling by playing a smaller sound before it and in fact you can make the startling thing less startling if you have an ongoing tone if you just put a little gap in that tone just before the big sound that elicits the startle you've had that warning and you're not as startled so the little gap before suppresses the startle response but what they've found is animals thought to have tinnitus with the right conditions to get it if you put this little gap in the noise in the tone before they're there weren't any less startled it was like they couldn't hear the gap so there's a lot of excitement about this because you don't need to train the animals you can do you can use this model and dozens of animals really quickly and loads of research groups have started using it unfortunately it's heavily confounded and it's turned that they've actually done the same things in people and it turns out the tinnitus doesn't fill in the gap at all there are just difficulties in gap perception due to the hearing damage and different and exaggerations or changes in the startle response so it's all there's been it's been a bit of a disappointment that so one of the reasons is we're not maybe weren't really measuring tinnitus when we thought we were another one is that animals tend they tend to cause tinnitus in an animal demonstrate the presence of tennis discs oh yeah it's there give the treatment and then measure them straight after the treatment and then assess them a week three weeks down the line and that that's great but Pete most people with tinnitus don't seek medical attention or do you know don't enter up enter a drug trial or a trial of any treatment when they've had tinnitus for a week they then to end up hurting at Sinister's for the six months two years five years ten years so it is not reasonable to assume that the brain and the pathways in the from the brain of someone who's just developed tinnitus are anywhere like the same as someone who's had it for years things things change over time and become up can become much more stubborn and that's there's research on this so what to bring some things go I don't want to get too bogged down in detail but what I think is happening in tinnitus I think that a lot of people have a predisposition to tinnitus if you have hearing loss your brain will turn up the gain to compensate for it and there's always noise in the system there's always cells that randomly fire that's just that's just life and that noise gets amplified that gets fed through but so that it's a tinnitus precursor anyone with hearing loss I would argue how's this certain people with a given chemical makeup in their brain lots of people have this but usually or in that state the brain Tunes it out our brains are very very good at tuning out things that are irrelevant we've got a lovely clean targeted view of the world we just perceive the things that are relevant and all lots and lots of signals just never make it into our radar the brain has ways it just says all this signals to low quality or it doesn't mean anything and if you think about this noisy poor quality spontaneous signal from the ear that's ongoing and never Changez it doesn't relate to anything in the environment it's only natural our brain would would attempt to tune this out but for whatever reason at some point some temporary factors conspire to get the brain to pay attention to this and as a single comes onto our conscious threshold and I would say at that point where there might be a window to intervene and get it back below the radar and it goes away again but if it's there for long enough then we learn to expect it we give it a name we pay attention to it we may worry about it once all that's happened quite quickly it's not just a meaningless irrelevant thing it's a real thing and once and you know this can happen totally outside of our voluntary control even our subconscious sensors are picking up and say no this is a you know this is a real thing and once it's there firmly is a real thing even if all these temporary factors subside and the signal driving it becomes much less strong our brain is tuned to pick up on it can you you know how do you how do you learn to forget or unremember something that has become a real thing I'd like to give her a little example of this as I hope too many of you haven't seen this picture before but anyone anyone like to tell me what's what's in this is what's in this picture is this is this more than just a random pattern of dots and any volunteers yeah it is it is a dog can anyone see the dog so yeah the dog is here and you get the impression that might be the shade underneath the tree and the trunk of a tree and a path coming down here now can anyone can everyone see the dog now so the dog's the dog's head is here if you can see its ear there it's got a leg here leg here as its body and it's a Dalmatian dog so it blends in with the speckles if you can't see it take my word for it that's written for anyone who can can you unsee the dog now if I come back off this slide for comeback can you see anything other than the dogs straightaway we'll all convent there's a lot of silence I'm assuming that's because everyone's convinced and this is a very well well-established two things so once once you've seen it you can't no matter how hard you try you will and it you could look at this picture in ten years time you'll see the dog you will see the dog straightaway and this is this is I think this is what I would argue the trouble with tinnitus is I would say this pattern of black and white dots you know at a glance you'd almost dismiss as noise you know and if your eyes just glanced over it it was just there in the background you saw it you might you'd probably net you know never necessarily give it a second look but once you picked up on it it becomes a real thing it's a vivid thing and it's something that we cannot help but look out for again and it you know and this is down to the subconscious involuntary parts of our mind once it's there we expect it you can't undo that I think a similar thing is happening in tinnitus here once that sound is there that will not sound the spontaneous activity that precursor of sound is all is there and everyone with a predisposition but once we launch upon to it once once it's become a real thing you can't you don't go back well well not naturally generally can that you know does this tell us that you know does this does this inform us does the you know do these do these theories if true help us and I can think of two ways this might help us the first is can we can we identify can we get rid of tinnitus before it crosses that point of no return where the memory is lodged it won't go away again might only have a few weeks from when it starts if if that or can we find a way to undo that memory that that notion of the tinnitus is a real thing that keeps this you know that perpetuates the vicious cycle that makes us keep on picking up on it where once upon a time it would have slipped under the radar and never gone noticed on that note I was lucky enough to study eight neurosurgical patients this is their brain this is the left-hand side of their brain and all these this person had epilepsy that was nothing to do with their tinnitus but they had tinnitus from from noise damage from firing guns and they they spent two weeks with all these every black dots as an electrode on the surface of their brain waiting for them to have seizures because they wanted to find out where it came from where the suit the Epilepsy came from and take that bit of the brain out but while he was there we did some experiments on the tinnitus we contrasted the high a low tinnitus states all these orange circles of the brain activity that corresponds to the tinnitus but what I'm showing you here in red he had a tiny tiny malformed area of his brain here that in red here it's very close to this is the back end of one of the memory centers in the brain as an orange circle they're indicating that that bit of brain changed its activity when the tennis has changed and then this darker gray area around this is the area the surgeons ended up removing from the brain now this this man had tinnitus in both his ears it had been there for a very long time one and you'll see that the area they took out just lopped off the back end of this memory center not the whole thing but a little bit of it that seemed relevant to tinnitus and after that now that the in in many respects one half of the brain controls the other half of the body or represents it or the other ear so the opposite side to which he was operated on the tinnitus went from that ear and it never came back now I'm not suggesting it you know the people go and have brain surgery but there was it had been suggested actually the targeting that structure might be a way of sort of breaking this breaking this memory of tinnitus yes and actually getting rid of it and we've talked to the person who put those theories out he's very excited about all of this that actually it does seem like so we didn't we didn't interrupt the hearing parts of the brain just there's a tiny bit of that memory center implicated in tinnitus and that and the tennis has went from it from the other ear now unfortunately he did have a few not not dramatic but he had a few cognitive problems it's you know it wasn't without side effects so this is not a widely effective treatment but it does just make us wonder is there a more rational targeting safer more low-key approach to breaking this cycle as has been done in a still rather a blunderbuss lobotomy esque fashion here so it's food for thought you

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