Tinnitus (ringing in the ears)

Tinnitus is an umbrella term for all forms of ear or head noises, without a more precise definition of their causes. Patients with tinnitus hear sounds or tones that are perceived exclusively by the patients themselves and do not exist outside the head. Other people can therefore not hear the sounds. Colloquially, it is referred to as ringing in the ears.

According to statistics, approximately ten million people in Germany have already suffered from tinnitus at least once over a longer period of time. Of these, about three million required treatment by a doctor. It is estimated that 340,000 people in Germany suffer from tinnitus every year.

Due to the increasing exposure to noise in adolescence (for example at concerts or in discotheques), the frequency of tinnitus in adolescents and young adults is steadily increasing.

Tinnitus can be caused by numerous health disorders. For example, the ringing in the ears can be caused by damage to the auditory nerve or the inner ear. In many cases, the fine hair cells of the inner ear are also damaged by noise or viral infections.

The development of tinnitus is promoted by the following factors:

• Stress and noise: these factors are thought to be the cause in about half of tinnitus cases.
• Inner ear hearing loss
• Hearing loss: about 70 percent of patients suffer from tinnitus after a hearing loss.
• Certain ear diseases: for example, middle ear infections, eardrum perforation (injuries to the eardrum), otosclerosis (decreasing mobility of the ossicles in the middle ear) or functional disorders of the eustachian tube.
• Tumours: in the case of a proliferation of the auditory and vestibular nerves, ringing in the ears is often the first symptom.
• Certain underlying diseases outside the ear: for example metabolic diseases (hypercholesterolemia: increased cholesterol level), circulatory disorders of the blood vessels in the head area as a result of arteriosclerosis, hypertension (high blood pressure), malocclusions, diseases of the cervical spine (for example whiplash)
• Certain medications / intoxications: for example antibiotics, painkillers (such as acetylsalicylic acid) or antidepressants.
• Tension in the area of the spinal column or temporomandibular joint musculature
• Psychological factors: for example, strong emotions such as anxiety or psychological overstimulation.

More precisely, tinnitus is not a disease, but rather a symptom as a result of certain physical or psychological problems. The severity of the symptoms can vary greatly depending on the patient. The most commonly perceived symptoms are unilateral or bilateral noises that may resemble whistling, buzzing, hissing, buzzing, cracking or hissing. If the sounds occur synchronously with the pulse, this may indicate malformations or constrictions of blood vessels in the head and neck area. Often there is also a simultaneous reduction in hearing, in some cases additionally a rotary vertigo.

Tinnitus can be divided into the following types depending on its individual severity:

• Compensated tinnitus: In this case, the affected person is aware of noises, but is able to cope well with the constant exposure to noise. The suffering pressure of this form of tinnitus is low or non-existent.
• Decompensated tinnitus: This has a massive impact on all areas of life and leads to pronounced suffering. As a result of the tinnitus, sleep disturbances, concentration disorders, depression or anxiety can occur.

Depending on the duration of the clinical picture, a distinction is made between the following types:

• Acute tinnitus: complaints lasting up to three months
• Chronic tinnitus: The complaints last longer than three months.

Depending on whether the ringing in the ears can also be perceived by outsiders, a distinction is made between the following types of tinnitus:

• Subjective tinnitus: The tinnitus can only be perceived by the person affected.
• Objective tinnitus: In the case of objective tinnitus, the ringing in the ears is based on an endogenous sound source that can also be perceived or measured from the outside, such as flow noises due to constricted vessels in the head and neck area. However, objective tinnitus is extremely rare compared to subjective tinnitus.

A further distinction of tinnitus can be made on the basis of hearing:

• Tinnitus with hearing loss: Here, in addition to the tinnitus, there is a restriction of the hearing ability.
• Tinnitus without hearing loss: The hearing ability remains fully intact.

Since tinnitus can be caused by other underlying diseases that require acute treatment, the first step is to try to identify them. For this purpose, certain examinations are carried out, such as anamnesis (taking the medical history), a detailed examination of the ear, nose and throat area, an ear microscopy, balance testing, hearing tests, nasopharyngoscopy (mirroring of the nasopharynx) and, in certain cases, brainstem audiometry.

In addition, the sound threshold above which the tinnitus is no longer perceived (masking level) is determined. For this purpose, various tones are played to the patient through headphones until the volume is reached at which the tinnitus is masked.

With the help of a blood test, possible inflammations or an increased cholesterol level can be determined. By measuring the blood pressure, hypertension (high blood pressure) can be diagnosed. An examination of the masticatory system can reveal possible malocclusions or temporomandibular joint disorders. An orthopedic examination can rule out involvement of the cervical spine.

In some cases, imaging procedures are also performed. In particular, magnetic resonance imaging (MRI) is used to exclude certain tumors (for example, acoustic neuroma, paraganglion) or Doppler sonography (ultrasound examination) of the neck vessels.

An important therapy option is to identify and eliminate the causes of tinnitus. Often, however, these cannot be determined exactly. Depending on whether the tinnitus is acute or chronic, there are clear treatment guidelines, which are based on the time course and the severity of the disease.

Acute tinnitus

In the case of acute tinnitus, it is particularly important to start treatment as early as possible - ideally within the first few days after the onset of the ringing in the ears. The following measures, among others, can be carried out:

• Infusion therapy: in this case, the patient is administered blood circulation-promoting drugs via an infusion, whereby an improved supply of blood and oxygen to the inner ear is to be achieved.
• Cortisone: If it is suspected that the tinnitus has an inflammatory cause, an infusion of cortisone is administered.
• Pressure chamber therapy (hyperbaric oxygen therapy): If the above-mentioned therapies do not achieve any improvement, a pressure chamber therapy can be performed.
• Physical-medical or physiotherapeutic treatment: These procedures can be used if injuries or misalignments of the cervical spine are the cause of the tinnitus.
• Orthodontic treatment: This is performed if misalignments of the dentition or the temporomandibular joint trigger the tinnitus.

Chronic tinnitus

If the patient suffers from chronic tinnitus, intensive medical care is of particular importance. It is important that the patient learns to cope with his constant ringing in the ears in everyday life. Stress reduction and special relaxation methods such as autogenic training or yoga can also promote the healing process.

With the help of psychotherapeutic approaches, those patients can be helped who are insecure, depressed or anxious due to the tinnitus. Among other things, cognitive behavioural therapy has proven to be effective in this context.

By using special hearing aids such as tinnitus masks or noise generators, the perception of the tinnitus can be suppressed. They have a visual resemblance to hearing aids and continuously produce a noise that distracts from the tinnitus sounds or covers them up completely. In some cases, tinnitus retraining therapy (TRT) is also performed. TRT involves the fitting of hearing aids. In addition, several counselling sessions, in which education and advice (counselling) and psychotherapeutic support are offered, are completed over a period of about 18 months. Good treatment results can be achieved by using these special hearing systems in conjunction with tinnitus retraining therapy.

If, in addition to the tinnitus, there is a reduction in hearing, the use of hearing aids can be useful. In the case of severe sensorineural hearing loss, this can be treated with an inner ear electrode (cochlear implant). In many cases, the tinnitus disappears completely when hearing is restored, or at least the symptoms improve.

In the case of acute tinnitus, a so-called spontaneous healing occurs in about 60 to 80 percent of cases. This is understood to mean a sudden complete disappearance of the ringing in the ears. Chronic tinnitus only heals spontaneously in exceptional cases.

However, the symptoms of chronic tinnitus often improve over time. In most cases, after about 18 months, sufferers perceive the ringing in the ears to be much quieter than at the beginning of the disease. Rarely, however, the complaints can also increase in intensity over time.

Prognosis with therapy

In general, the prognosis is better the earlier treatment of acute tinnitus is started. In the case of acute tinnitus, the best result can be achieved with the help of cortisone infusion therapy. The goal of treatment is to completely eliminate the ringing in the ears.

In the case of chronic tinnitus, the complete elimination of the ringing in the ears can only rarely be achieved. In this case, the best therapeutic results can be achieved by learning certain processing strategies - the patient learns, for example, to no longer perceive the tinnitus by specifically listening to it.

Complications of tinnitus

If the affected person does not succeed in getting used to the tinnitus, the following complaints can also occur:

• Depression
• Sleep disturbances
• Headaches
• stomach pain
• Anxiety

In exceptional cases, these secondary complaints can even lead to incapacity to work. With the help of a medical-psychological combination therapy, the burden of the tinnitus can be significantly reduced in the early phase and possibly even a chronification of the disease can be prevented.