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Health-Tech / October 1st 2020

How we designed an app that reduces the constant ringing in the ears

Roberto González's profile picture
byRoberto González

Lullaby creates personalized treatments for Tinnitus, all you need is a pair of headphones

Some years ago I started suffering from Tinnitus, a condition that makes you hear a constant high-pitched buzzing sound. How does it feel? Imagine being exposed for a long time to very loud music, like at a bowling alley or a recital, and when you come home and rest your head on the pillow you feel a kind of constant ringing in your ear. 

That same sound is experienced by those of us who suffer from Tinnitus. But we don't hear it for just a few hours, in our case it is constant, every day, all the time. Not only does it make it very difficult for me to sleep in a quiet room, but in my case it also prevented me from having conversations with people because the sound was louder —and infinitely more irritating— than any tone of voice.

There began the nightmare of the eternal sound that led me desperately to a medical consultation. Then a second, a third, a fourth and at the fifth… I gave up. All the doctors examined me and basically sent me back home with no solution beyond "turning on a fan at night to cover the sound", which in addition to being extremely condescending was useless.

What I found odd about this condition is that it is estimated that 3% of the world's population suffers from severe Tinnitus, the response I received from professionals was quite amateurish for such a common disease.

Although some doctors claim that tinnitus affects older people and it is almost reasonable to say "it is an age-related problem" without paying much attention to it, in 2015 the World Health Organization estimated that “1.1 billion teenagers and young adults are at risk of hearing loss" that can lead to ringing in the ears. This would no longer be a problem for a small segment of the population.

Frustrated by the lack of answers, I decided to try to solve my problem the same way we do at Aerolab: by empathizing with the user —in this case the patient— and creating a user-friendly solution, without having to resort to experts.

After many weeks investigating the condition and the state of the art in treatments for Tinnitus we arrived at a final result that is not only a treatment based on the most promising scientific studies of the last decades, but above all it works better than many of the commercial treatments on the market.

After several months of treatment, I managed to drastically reduce the volume of this sound, and this year we decided to make it public, free and open source for other patients.

But before we could start working on a treatment we had to be able to answer a very basic question:

What is Tinnitus?

According to the doctors I consulted with, Tinnitus is not a disease, but a symptom of an ear problem, which can range from a wax plug to hearing damage from listening to loud music. The most recurrent explanation is that the inner ear has microscopic cilia that shake to detect sound waves.

When damaged, some of them get stuck in the "on" position making us hear a beep permanently, even when we are in absolute silence.

This sounds quite reasonable, and since the ear and those cilia are a microscopic structure, the chances of any kind of surgical treatment are essentially null. As in every condition without a clear treatment, we also find bizarre proposals to the extreme, such as "sticking a laser in your ear" or "getting a stem cell injection in Thailand that costs you 100 thousand dollars", added to hundreds of placebos made just to extract money from patients desperate for a cure.

And it is in this desperation that an idea occurred to me, which with my lack of sleep almost seemed revolutionary: If the problem is in the ear, what if I cut my ear off? 

As brutal as it sounds, it made some sense: if I cut the auditory nerve to disconnect my ear from my brain, I should stop hearing on that side, eliminating both the sounds that exist and those that do not. In my desperation, going deaf in one ear in exchange for no longer hearing that beep seemed like a tough but fair exchange. And who knows, maybe I would become a great painter in the process ;)

But strangely enough, I was not the first person to have this idea. In the early 1900's, when medicine was more art than science and such innovative treatments as sticking a stick in your eye when someone was irritable, several doctors tried to go down this road to solve serious cases of Tinnitus. And they had all come to the same conclusion: Cutting off your ear doesn't work.

Beyond the fact that these doctors had found a way to leave their deaf and Tinnitus patients for life (which frankly seems like an extra sadistic version of hell), this Tinnitus thing had become interesting. Because if cutting the auditory nerve doesn't work, it means that the problem is not in the ear as everyone thinks, and this leaves us with an even bigger question mark.


What is the real cause of Tinnitus?

Seeing that the popular explanation was at least partially incorrect, I decided to fully investigate the condition. Unfortunately, one of the first obstacles encountered in incurable conditions is that it is full of opportunists who sell colored mirrors at unaffordable prices. This led me to limit the search among people who know how to work scientifically, and after eliminating tons of junk information, I found two writings that were fundamental.

The first one was the book Tinnitus Retraining Therapy (TRT) from Emory University, which not only includes a very well structured treatment to get used to sound based on Cognitive Therapy, but also contains a general overview of all the treatments available up to that moment, with a good scientific eye. Although it is a rather dense and technical book, it was my starting point to design a treatment that improves the quality of life of most patients without the need to resort to a professional.

But the most important was a paper from the University of Parma, where they started from the premise that Tinnitus is not so much about hearing, but is mainly a neurological problem. According to them (and several other researchers), Tinnitus arises when the brain, trying to adapt to a hearing loss, makes a mistake and ends up imagining a very high-pitched sound where there should be silence.

Tinnitus, after so much research, ended up being a bug in the brain. Needless to say, being a developer I loved this hypothesis, not only because I empathized with the idea, but because all bugs in one way or another can always be corrected.

The little problem with this plan is that the brain is not exactly open source, so no one has the source code. And the legend says that after writing the software in a hurry in a week, the developer disappeared and nobody knows how to contact him.


How do you fix a bug in software that no one understands?

In a normal computer, the way to solve a problem of this type is by decompiling the application and trying to access the source code in order to modify it to our liking. But the brain is not a normal computer, it is a neural network and the way to modify it is trying to train it to behave as you want.

In this sense, neural networks do not work as a traditional app. They work by strengthening and weakening links between millions of neurons, and as those links change, the brain reprograms itself and mutates its behavior to adapt to new environments and situations.

This means that, if we could design a very precise stimulus to the ear, we should be able to slowly retrain our brain to erase those links and at the same time remove the "code" that we don't want. Like the one that makes us hear a high-pitched beep that does not exist.

That's when I noticed that all recent papers on the subject executed a variation of the same idea: to eliminate Tinnitus the only thing you have to do is convince the brain that misbehaving neurons are not really working. Essentially create a sound wave that constantly reiterates to the auditory cortex "this part of the ear is not working", with the aim of disconnecting those neurons that broke off from the rest.

Not only that, but I discovered that there were companies that were already marketing this treatment for astronomical prices, for something that I was able to implement in one afternoon with some Javascript and a pair of good quality headphones

And since the solutions available were very basic, expensive or directly poorly implemented, I began to design a solution that would allow the treatment of Tinnitus without having to resort to a professional.


How does Lullaby work?

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Lullaby was designed so that anyone can treat their Tinnitus from the comfort of their home, with only a computer and a pair of headphones.

The first step of the app is the diagnostic process, which is designed to be able to determine exactly how often the Tinnitus is even without a musically trained ear. Based on which ear is the problem, what kind of frequency and its characteristics, the app generates a perfectly personalized treatment for each user.

The second part consists of generating white sound, a type of noise that stimulates the entire auditory cortex at the same time. This forces the neurons to turn on and off quickly, recognizing that they are in a uniformly noisy environment.

It is to this sound that we make a small but important modification: Exactly at the frequency of our Tinnitus, we generate a break in the signal, in which we hear absolute silence. This means that the entire auditory cortex actively notices that it is listening to noise, except for the misbehaving neurons. These receive silence, forcing the brain to take control of the situation and gradually deactivate the broken neurons to reduce the volume of the Tinnitus.

Finally, one of the worst recommendations to patients with Tinnitus is to try to block out the sound with more noise. The big problem that this generates is that the brain before a stimulus that turns out to be stressful (as a very sharp beep), generates a permanent sensation of anxiety, of which something terrible is about to happen. As a consequence, this causes stress and makes you pay even more attention to the Tinnitus making it more prominent. This in turn causes us to become more irritated, to pay more attention to it and so on, entering into an infinite loop of irritability, which means that we can never get used to Tinnitus and always have to cover it up with other noises.

That is why the treatment also consists of a cognitive part, designed to introduce the idea that you are going to listen to that sound for a long time, and a good part of Lullaby is designed to deal with this problem in a healthy way, allowing us to get used to the sound little by little so that after turning down the volume we can deal healthily with the reduced Tinnitus that we have left at the end of the treatment.

And it is based on these three components that we design the treatment, so after making a diagnosis, we only have to turn on the unique treatment for our case and wait. A lot. Because the brain can do great things, but neural networks require a lot of time to adapt and modify their internal code. And that time is usually measured in months.


How well does it work?

After spending a year documenting the volume of my Tinnitus on a daily basis with this treatment, the results were extremely positive. I managed to reduce the volume of the sound by almost 80% and, above all, I was able to go back to sleep in a room in absolute silence. From a deafening high-pitched beep capable of driving Mahatma Gandhi crazy, it became a sound like a fan running in the next room. For most patients the results are equally promising.

Following the treatment 3 hours a day, the volume of the Tinnitus is reduced by 20% after 3 months of use, and can be reduced by 80% after 12 months of use, turning down the volume of the sound to the point that it is almost undetectable, or even disappears completely.

Not only that, but the cognitive part of the treatment allows to achieve a remarkable improvement in the quality of life of patients, helping them to get used to the sound and allowing them to continue with an excellent quality of life.

And best of all, this treatment, which usually costs thousands of dollars, can now be replicated with a few lines of Javascript. That's why we decided to publish it in an open source format, so that anyone can access both the diagnosis and the treatment completely free of charge. Now the only thing needed to enjoy the silence again is a pair of headphones and a little patience.

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