Tinnitus

Synonym

noises in the ears, tinnitus

Definition

Tinnitus is a sudden and constant, mostly unilateral painless ear noise of varying frequency and volume.

EpidemiologyResources

In Germany about 3 million people suffer from tinnitus. 800,000 of them suffer from ear noises with extreme impairment of everyday life. Approximately 270,000 new cases are diagnosed every year.

According to a recent survey, 10% of adults often describe suffering from tinnitus, but it disappears within 5 minutes. Only 7% of them consult a doctor for this reason. Tinnitus in children is particularly common if the affected persons already suffer from a disease of the ears with accompanying hearing loss.

2.7% of hearing impaired children between 12 and 18 years of age report permanent tinnitus sounds. There are no gender differences among adults. The main age of onset of the disease has been described as 60-80 years of age. However, in recent years a shift to younger years can be observed.

Symptoms

The initial symptoms of tinnitus are usually a sudden ear noise in one ear of different frequency. The ringing in the ears can be described as a wadding and by the affected patients as an “unreal” hearing experience. Due to the mostly unilateral hearing loss, dizziness is not uncommon, but it usually subsides within a few hours while the ringing in the ears remains.

Noises of very different types, frequencies and volumes are described. The sounds can be whistling, humming, hissing, muffled or clear, can be so quiet that they can only be heard in a very quiet environment (e.g. when sleeping) or so loud that they cause massive impairment of daily life. In extreme forms of the disease, the accompanying symptoms described above occur.

Causes

Among the causes of tinnitus that are discussed, a distinction is made between the causes of subjective and objective tinnitus. The subjective tinnitus is based on subjective sensations. The sounds are therefore only perceived by the person affected.

Possible causes of subjective tinnitus include, for example, a blockage, dislocation or obstruction of the external auditory canal, which can cause “ringing in the ear”. These so-called obstructions of the external auditory canal can be caused, for example, by tumors or foreign bodies in the ear that interfere with the transmission of sound. If ear noises occur in this context, one speaks of a conductive tinnitus.

Another possible cause of a subjective tinnitus can be damage to the cochlea, which can be triggered, for example, by a sound trauma. The resulting ear noises are described as sensoneurinal tinnitus. It is assumed that this is the most common cause of subjective tinnitus.

Damage to the central auditory pathway, i.e. damage to the brain, is also discussed as a possible cause. In this case one speaks of central tinnitus. For all the groups of causes mentioned, it is assumed that various psychological factors and stress have an influence on the symptoms of subjective tinnitus, or that stress itself can be the cause.

Objective tinnitus can be detected with the help of aids. With objective tinnitus, a distinction is made between “vascular” and “muscle” causes. Abnormal connections between an artery and a vein, so-called arteriovenous fistulas, can cause tinnitus.

Here and in other vascular malformations that cause ringing in the ears, we speak of vascular tinnitus. An objective tinnitus, which is caused by violent, rhythmic movements of the internal muscles in the ear, the soft palate or the temporomandibular joint, is called myogenic tinnitus. Some scientists describe the above-mentioned causes rather as triggers of the tinnitus and see the actual main cause in the brain.

They assume that due to the above mentioned “triggers” there are alterations in the auditory cortex in the brain and consequently to the tormenting ear noises. If the hair cells in the inner ear are destroyed, e.g. due to a sound trauma, they cannot pass on information to the nerve cells in the auditory cortex. These nerve cells are then virtually unemployed and do nothing.

The frequencies they are responsible for cannot be offered to the brain.Just like in real life: where less work is done in one place, more must be done in another. In this case, this means that the neighboring nerve cells are more industrious and offer the brain a frequency in excess. This could result in ear noises.

According to some researchers, it could also be that the unemployed nerve cells overreact and this could lead to the ear noises. Since the ear noises are often perceived in the frequency range in which the greatest hearing loss can be detected, this theory could be correct. In addition, certain researchers had observed that in some patients, a certain area of the brain, the so-called prefrontal cortex, was often reduced in size.

The function of the prefrontal cortex is to suppress noise, such as tinnitus. It was also found that in some patients, the anterior cingulum in the brain was damaged. The anterior cingulum has the task to pay more or less attention to certain stimuli.

If the anterior cingulum considers the noise in the ear to be significant, it can be all the more difficult for the affected person to listen away. Whether the tinnitus is perceived as negative, positive or neutral may depend on the amygdala, another part of the brain in the limbic system. In the case of chronic tinnitus, it is also assumed that a so-called tinnitus memory develops in the hippocampus.

Some authors assume that the ear noises leave a kind of trace in the brain, inviting the nerve cells to take the “tinnitus route” again. The triggers, causes and theories of tinnitus continue to be discussed very controversially. In various studies a connection between stress and tinnitus has been found.

However, stress does not necessarily lead to tinnitus. Only when the stress is perceived as stressful can it cause unpleasant noises in the ear. This type of stress is called distress.

Stress factors, also called stressors, are all stimuli that cause stress and prompt the body to adapt. Tinnitus can be one such stress factor. Often, the tinnitus is more intense and louder when the person is under stress.

To what extent the tinnitus or the experienced stress is perceived as a burden varies from person to person. Studies have found connections between psychological instability, stress management and tinnitus. A healthy lifestyle in combination with stress management strategies showed a positive influence on the tinnitus.

It could be observed that in physically and mentally healthy people, where tinnitus was triggered by stress, it also disappeared again after the stress phase was over. Some authors assume that tinnitus can also be caused by oxidative and nitrosative stress. This means that it is assumed that free oxygen radicals and nitrogen compounds in the body lead to cell damage and can, among other things, trigger tinnitus.

Whether this type of stress contributes to the development of tinnitus is controversially discussed. However, since the above-mentioned distress can trigger or aggravate tinnitus, individual stress management for tinnitus seems to be helpful and sensible in any case. It is still unclear to what extent and actual frequency the cervical spine and jaw joint are associated with tinnitus.

Three mechanisms are described that can cause tinnitus based on a cervical spine disease: starting from the nerve, starting from the muscle or through circulatory disorders. Causes of tinnitus originating from the cervical spine include blockages, malpositions, whiplash injuries and incorrect or too rough chiropractic treatment. If the tinnitus is caused by cervical spine disease, it usually occurs on one side.

It is often heard as a deep humming or hissing sound when the head is turned. In addition, tinnitus caused by damage to the cervical spine can cause dizziness and hearing disorders. It is then important that the spinal column is specifically diagnosed by an orthopaedic specialist and that there is cooperation between the person affected, the ENT physician and the orthopaedic specialist.

The connection between tinnitus and alcohol consumption has not yet been fully scientifically researched. It is recommended to avoid alcohol in case of acute tinnitus. There are studies in which it has been observed that alcohol consumption can intensify the tinnitus and even trigger it.A connection is suspected, since alcohol has a direct effect on the brain and the brain also plays a role in the development of subjective central tinnitus.

Some sufferers reported a short-term reduction in ear noise after alcohol consumption. It is suspected that this could be due to short-term relaxation. However, since the longer-term toxic effects of alcohol are known, it is strongly discouraged to consume it regularly or in larger quantities.

An important part of the diagnostic process is the patient interview (anamnesis), which should include how long the symptoms have persisted (differentiation between acute, sub-acute and chronic), whether the noise in the ear is so quiet that it can be masked by environmental noise, whether there is additional hearing loss in the affected ear or in the other ear, whether the noise in the ear is influenced by psychological influences or physical stress, whether the noise changes with different body or head positions, whether the type of tinnitus can be changed by certain drinks or food and whether there are accompanying illnesses such as cardiovascular disease, arteriosclerosis, metabolic disorders. Furthermore, the patient should be asked which medication he or she is taking. There are different medicines, which have an ear-damaging effect and can also lead to tinnitus-like complaints.

Under these aspects, the frequent tinnitus of unknown cause can be distinguished from tinnitus caused by medication, metabolic diseases and diseases of the circulatory system. After questioning the patient, one should then carry out appropriate examinations on the patient individually and not according to a strict scheme. There is a choice of ENT medical examination of the ear including the eardrum and nasopharyngoscopy (examination and reflection of the nasopharynx) and examination of the tube patency.

From an internal medicine point of view, the carotid artery should be listened to with a stethoscope (auscultated) or a so-called Doppler sonography should be carried out to rule out atherosclerotic changes and associated circulatory disorders. A sound audiometry with detection of the discomfort threshold (the point at which hearing a normal sound is painful), determination of the loudness of the tinnitus sound as well as determination of the type of sound and frequency, determination of the so-called masking level (which sound must be applied from the outside so that the patient no longer perceives his tinnitus sound), examination of the eardrum and the stapedius reflex in relation to respiratory activity, Brainstem audiometry, neuronal examination of the vestibular nerve, examination of posture and the spine (to see whether spinal postural deformities may affect a vessel or nerve in such a way that the ear is undersupplied) and examination of the dentition and masticatory apparatus should be performed in every patient with tinnitus. These examination elements, which are part of the basic diagnostics, can be followed by further examinations in individual cases.

If a tumor is suspected, which leads to an impairment of the auditory nerve with a resulting tinnitus, a computer tomography (CT) or a magnetic resonance imaging (MRI) can be performed. In order to exclude certain autoimmune diseases or infections, a corresponding blood count of the patient can be performed. The blood should be examined for: Lyme disease, HIV/AIDS, syphilis, rheumatoid factors, tissue-specific antibodies, blood sugar, blood lipids, liver enzymes and thyroid hormones.

In case of suspected involvement of the central nervous system, CSF diagnostics (cerebrospinal fluid analysis) should be performed. In addition to the internal examination of the vessels, a psychological component of the tinnitus should also be considered and a corresponding psychosomatic diagnosis should be made by a psychiatrist. A tinnitus diagnosis is a multidisciplinary task that can employ ENT specialists, internists, dentists, neurologists and psychologists.

A frequently used questionnaire was developed by Goebel and Hiller. It contains 51 questions that are asked of the patient and which are subsequently evaluated. The questions asked are divided into scales named as follows: emotional impairment, cognitive impairment, penetrance of tinnitus, hearing problems, sleep disorders, somatic physical disorders.Depending on the answers to the questions, a classification of the tinnitus can be made.