Tinnitus

from Wikipedia, the free encyclopedia
Classification according to ICD-10
H93.1 Tinnitus aurium
ICD-10 online (WHO version 2019)

Tinnitus ( Latin "ringing of the ears" of tinnire, "ringing" auris "ear"), shortly tinnitus and ringing in the ears called, refers to a symptom in which the person listens for sound, which no external sound sources can be assigned. An alternative name is the phantom noise ( English phantom noise ).

definition

Tinnitus is a hearing experience that no one on the ear striking sound on or is experienced on both sides. It is based on a hearing impairment. The auditory impression of tinnitus usually has no relation to the sound in the patient's environment. The nature of the apparent noises is very diverse: The auditory impressions are described as humming, whistling, hissing, hissing, cracking or knocking. The noise can be constant in its intensity, but it can also have a fluctuating or even rhythmically pulsating character. However, it does not always have a resemblance to a noise from the real acoustic environment. Tinnitus must also be clearly differentiated from auditory hallucinations , so-called acoasms .

Tinnitus can also be created artificially in the majority of people with healthy hearing, and indeed by just a few minutes in a silent, soundproofed cabin. Possible explanations for this were discussed as an unfamiliar influence on the normal volume control in the auditory brain or the detection of a previously existing weak tinnitus that was hidden by the normal ambient noise.

Tinnitus is often divided into different degrees of severity. Biesinger defines four degrees of severity:

  • Grade I: The tinnitus hardly affects the person affected. Despite the ringing in the ears, there is no pressure of suffering.
  • Grade II: those affected can cope with their everyday lives without major negative consequences. However, tinnitus is experienced as stressful in certain situations or under stress.
  • Grade III: There are permanent impairments of the quality of life and the professional performance. Disturbances in the emotional, physical and cognitive areas are to be expected. The people concerned are still able to work.
  • Grade IV: Complete decompensation: those affected are severely impaired, both professionally and privately; Inability to work, suicide.

From grade III one speaks of decompensated tinnitus.

Pulsatile tinnitus

Pulse-synchronous noises in the ears are a symptom caused by various causes that must be differentiated from idiopathic tinnitus. They are mostly unilateral and are often based on an intracerebral (located in the brain) blood vessel-related cause, e.g. B. dissection of the internal carotid artery . Imaging methods therefore play an important role in diagnosis .

distribution

Tinnitus affects more than 25% of residents in developed countries at some point in their lives. In Germany, over 15% of people over the age of 65 perceive ear noises continuously and for a long time. Due to different recording methods, almost all comparisons of studies on the spread of tinnitus by region, gender, age, etc. so far (as of 2017) are of very little value. In addition, every seventh person in Germany , Austria and Switzerland suffers at least once in their life from long-lasting ear tones.

causes

Tinnitus can occur in connection with a variety of other diseases of the ear or the auditory pathway . A distinction is made between the usual “subjective tinnitus” and the rare “objective tinnitus”. The latter is based on a sound source present in the body, usually in the inner ear , whose acoustic emissions (emissions ) can be measured in the ear canal as spontaneous otoacoustic emissions (SOAE) .

The subjective tinnitus can only be heard by the person concerned and cannot be measured acoustically, as it is not based on sound waves, but on incorrectly controlled nerve activity in auditory and other parts of the brain. However, correspondingly deviating brain activity can be shown with imaging methods - which so far (as of 2017) has only been done for research purposes and not yet to support diagnoses.

Studies on tumor patients whose auditory nerve was severed as part of a tumor operation showed that these operations usually brought little or no relief from the symptoms of tinnitus. This is explained by the fact that the cause of chronic tinnitus is usually not in the inner ear (see above).

Warning signs against noise-induced hearing loss

Possible causes of subjective tinnitus

Pathophysiology

The functional imaging enables the representation of circumscribed neuronal activation.

For a long time it was thought that subjective tinnitus develops in the inner ear. However, this theory could not be upheld because tinnitus usually persists after the auditory nerve is transected.

With the help of imaging procedures it could be shown that the neuronal activity in different brain areas is changed in patients with tinnitus. It is believed that tinnitus - when it is a result of hearing impairment - develops in a similar way to phantom perception and phantom pain . Tinnitus is usually aggravated by repeated conscious attention, namely through nervous learning processes of sensitization . In this respect too, tinnitus behaves similarly to pain.

Acoustic or other stress increases the risk of triggering tinnitus. Brain areas that are involved here, such as the almond kernels , also influence the activity in the auditory pathway and thus the possible tendency to perceive tinnitus.

In addition, studies have shown that the nerve cells of those affected are more active at almost all stations on the auditory pathway than in people without tinnitus. According to this, the neurons of these people fire spontaneously more often and also react more sensitively to external stimuli.

Possible consequential damage

Tinnitus can be accompanied by the following psychological side effects:

However, many tinnitus sufferers do not develop any of the symptoms mentioned above.

The often discussed suicide as a result of tinnitus is controversial. On the one hand, there are patients who reported that they thought of a suicide attempt because of the enormous stress caused by tinnitus. However, retrospective studies showed no causal link between tinnitus and suicide. According to the conclusions of these authors, tinnitus patients who committed suicide had a variety of other reasons for suicide ( comorbidity ). It should be noted that retrospective studies are associated with statistical uncertainties. However, since experimental prospective studies on such a topic are prohibited for ethical reasons, a complete clarification of the facts is not possible.

The majority of patients affected by tinnitus can compensate for the noises in the ears in the long run and suffer from little or no impairment of quality of life ( habituation ). Nevertheless, about 2 to 3% of the population remain impaired in their quality of life by the tinnitus.

to form

After the period of perception of tinnitus, two phases are usually distinguished in German-speaking countries :

  • Acute tinnitus (up to three months)
  • Chronic tinnitus (over three months)

In the past, tinnitus that lasted between three and six months was also referred to as subacute . So far there is no scientific basis for the division into two or three phases, it is only based on empirical values. This explains the different information. In the acute and subacute phase there is comparatively often a spontaneous healing or improvement of the symptoms. However, the longer the tinnitus persists, the more likely it is that it will persist.

More recent research now assumes that there are a larger number of subtypes of tinnitus, each with different developmental complexes. There is evidence that changes in the brain structure of tinnitus patients lead to an amplification of auditory signals. Brain regions that are considered are the ventro-medial prefrontal cortex and the nucleus accumbens . Both regions are involved in the development of chronic pain.

Further research deals with the phenomenon of "somatosensory tinnitus", sometimes also called "somatic tinnitus". This is a form of tinnitus in which the person concerned triggers the tinnitus through physical movements (e.g. by shifting the chin, pressing or touching nerves, muscles or skin on the head) or influences its intensity or tone can. The hyperactivity of nerve cells in the nucleus cochlearis , a region of the brain stem that is responsible, among other things, for the modulation of movements and acoustic signals is assumed here .

This makes it possible to further subdivide tinnitus into acute and chronic phases according to causes:

  • Damage to hair cells in the ear
  • Neurological changes in the brain stem region
  • Neurological changes in the prefrontal cortex

The heterogeneity of the causes can explain why different therapeutic approaches work for some patients and not for others, because different causes require different therapies. A further subtyping of the tinnitus forms is therefore necessary in order to (further) develop specific forms of therapy.

Audiometric examination (tinnitus matching)

The prerequisite for tinnitus matching is the collection of a tone audiogram , i.e. the determination of the hearing threshold . Tinnitus is almost always associated with a hearing disorder.

The characteristics of an ear noise are recorded by audiometric examinations:

  • Determination of the pitch of the noise in the ear (comparison measurement with sine tones or narrowband noise ).
  • Masking measurement with sine tones or narrow band noises. Typically, a ringing in the ear caused by the inner ear can be masked by sinus tones or narrow band noises 5–10  dB (up to 20 dB) above the threshold.
  • Measurement of residual inhibition . Typical of inner ear-related noises in the ears is that the noises in the ears are suppressed for a few seconds after concealment with sinus tones or narrow-band noises and only then reappears.

Therapies

Because of the many possible causes of tinnitus, the exact diagnosis in tinnitus patients is of crucial importance, since in some cases a causal treatment is possible. Various treatments are used to relieve tinnitus. These include different forms of acoustic stimulation, behavioral therapeutic approaches, combined therapeutic approaches that include acoustic stimulation and behavioral therapeutic elements ( e.g. tinnitus retraining therapy ), drug therapy methods, physiotherapy , magnetic and electrical brain stimulation methods. For most of the therapies offered, there is no proof of effectiveness from sufficiently large placebo-controlled studies.

An increase in knowledge about the mechanisms of tinnitus development has nonetheless led to the development of a variety of new therapeutic approaches that have been and are being investigated in pilot studies in recent times.

Conventional medicine

Drug treatments for acute tinnitus

In new-onset tinnitus occurred in German-speaking sometimes a drug treatment with vitamin E -products, magnesium , glucocorticoids (eg. As cortisone ) intravenously given local anesthetics such as procaine and circulation-promoting agents (eg, pentoxifylline , HES or plant Ginkgo -Präparate) . The drugs were administered either as tablets or intravenously (as infusions) depending on the severity and suspected cause of the tinnitus. There are no high-quality comparative studies that could unequivocally prove the superiority of a certain drug over another. Likewise, no evidence could be provided that any of the drugs had a greater effect than the administration of a placebo . Rather, it was used based on empirical values ​​and theoretical considerations that have since become obsolete. In view of the unproven effect, high costs and possible side effects , this procedure is no longer relevant. So-called infusion therapy for acute tinnitus was unusual in countries such as the USA and Great Britain, as well as in Scandinavia . The European multidisciplinary guideline for tinnitus published in 2019 makes a recommendation against the drug treatment of tinnitus, as there is no evidence of its effectiveness, but side effects are likely.

Drug treatments for chronic tinnitus

Drug treatments for chronic tinnitus are controversial. Doctors particularly criticize the long-term use of drugs that stimulate blood circulation. According to an extrapolation from 1999, costs of at least DM 100 million annually  (= approx. 51 million euros) are to be expected here, “although the effectiveness of such substances has not been scientifically proven and the symptoms usually persist despite taking medication ". In addition, the risk of possible side effects is emphasized.

No less controversial are tinnitus therapies with substances that interfere with the neurotransmitter balance. These include u. a. Caroverine , flupirtine , glutamic acid , Glutamic acid , memantine , whose efficacy could not be provided in controlled studies and neramexane. The attempt to specifically administer appropriate drugs in a placebo-controlled study using a catheter in the inner ear was also unsuccessful.

Studies in which patients were given tablets containing the active substances tocainide , carbamazepine or gabapentin remained unsuccessful . Only the local anesthetic lidocaine was able to achieve results in high doses when administered intravenously, which were significantly superior to placebo treatment. However, the effects only lasted for a very short time in the relevant studies. In addition, a high rate of side effects was observed, so that long-term therapy with lidocaine is not an option.

The benefit of antidepressants has only been shown in tinnitus patients who suffered from tinnitus and depression .

Cognitive behavioral therapy

There is evidence of the effectiveness of cognitive behavioral therapy for patients with tinnitus. Although no reduction in the perceived loudness of the tinnitus was achieved (six studies), the signs of depression decreased (six studies) and the general quality of life improved by making the tinnitus less distressing (five studies).

Tinnitus retraining therapy

Tinnitus retraining therapy (TRT) is a combination therapy consisting of counseling (like cognitive behavioral therapy ) and acoustic stimulation. Because the effectiveness is no better than that of cognitive behavioral therapy alone, only the latter has been recommended by the relevant medical societies since 2010.

Experimental therapy attempts

Since 2008, transcranial magnetic stimulation has been explored as a way to alleviate tinnitus. In doing so, those areas of the brain that are changed in activity in tinnitus patients are specifically influenced (modulated) by magnetic stimulation. Several studies indicate that this method can partially alleviate the perception and stress of tinnitus.

Electrical neurostimulation has been used experimentally since 2006 to research possible therapeutic suitability depending on the type of tinnitus and patient group.

Acoustic stimulation (masking by noises, patient-specific filtered music applications (“notched music”), “coordinated reset” neuromodulation) have so far - as of 2017 - achieved no results that would justify a recommendation for general therapeutic use.

Alternative treatments

There are a number of alternative treatments available, but most of them are highly controversial. Among other things, the stellatum blockade is used to widen the blood vessels in the head and neck, the hyperbaric oxygen therapy or the lineis method . Patients usually have to pay for these treatments themselves, as their effects have not been proven. It should be noted that tinnitus in the acute phase can become quieter or heal without treatment.

A study from 2006 indicates an important role played by the expectations of tinnitus patients with regard to the supposed therapeutic success. Tinnitus sufferers who had a positive attitude towards hyperbaric oxygen therapy before the start of treatment reported improvements significantly more often than those with a neutral or negative attitude.

In hypnotherapy , tinnitus is treated in a methodologically comparable way to hypnotic anesthesia, using suggestions to block out disturbing stimuli. The goal of treatment is habituation . The results achieved in trance are reinforced by post-hypnotic suggestions. To date, there are no randomized controlled studies in tinnitus patients on this treatment.

Ginkgo , which has been intensively investigated in several series of tests, achieved the same results as a placebo preparation for chronic tinnitus. The effect on acute noises in the ear cannot be supported by qualitatively sufficient clinical studies either. The effectiveness of ginkgo therapy must therefore be seriously questioned.

With regard to jaw correction therapy, there are neither qualitatively sufficient studies that prove a causal relationship between disorders in the chewing apparatus or jaw (craniomandibular dysfunction) and tinnitus, nor those that prove the effectiveness of such a therapy in tinnitus.

For the application of low-level laser therapy , in which the inner ear is irradiated from the outside with a laser, there are neither scientifically founded concepts nor meaningful studies in the specialist secondary literature .

So far, there are neither scientifically based concepts nor meaningful studies on sound therapy , which is supposed to restore the function of the ear with music. The same applies to the controversial Tomatis therapy , in which specially distorted pieces of music (mostly by Mozart ) are heard through headphones.

General rules for dealing with tinnitus

The patient should expose himself to as little stress as possible and not to excessive acoustic stress. In order not to concentrate on the noise in the ear, acoustic distraction could be used, for example soft rhythmic music. This is a great way to help alleviate the problems falling asleep often associated with severe tinnitus. In general, it should be prevented that the entire thinking and feeling of the patient revolves more and more around the perception of the noise, as experience shows that this increases the level of suffering. Absolute silence easily leads to concentration on the noise in the ear and subjectively reinforces it.

After six to twelve months, one speaks of chronic tinnitus. Then it is especially important that the person concerned learns to deal with the noise in the ear. Often, after a long period of time, people get used to the noise and the patient no longer perceives it as being as annoying as it was at the beginning. Psychological help and self-help groups can support the patient here (see above: cognitive behavioral therapy ).

There is no scientific basis for the recommendation, which is still often made, to avoid drinks containing caffeine in the case of tinnitus . Avoiding other foods is also usually unnecessary.

prevention

Anyone who is exposed to a noise level of 70 dB or more for a long period of time has an increased risk of developing tinnitus. Appropriate hearing protection helps to prevent this. There are also drugs that can damage the ear. Avoiding these preparations or taking them in low doses can also help prevent tinnitus.

Composed tinnitus in classical music

There is a composed tinnitus in the string quartet No. 1 in E minor “From my life” by the Czech composer Bedřich Smetana . About two and a half minutes before the end of the last movement (according to today's performance practice), the lively music suddenly breaks off, and above a threatening-sounding deep tremolo of 2nd  violin , viola and cello , the first violin continues for about ten seconds with a drawn out four-bowed bow E one, which, in contrast to the other instruments, has an annoying whistle due to its extremely high register. This E is supposed to represent the tinnitus that plagued the composer.

literature

Guidelines

  • S3- Tinnitus guideline of the German Society for Ear, Nose and Throat Medicine, Head and Neck Surgery. In: AWMF online (as of 2015)
  • DE Tunkel, CA Bauer, GH Sun, RM Rosenfeld, SS Chandrasekhar, ER Cunningham, SM Archer, BW Blakley, JM Carter, EC Granieri, JA Henry, D. Hollingsworth, FA Khan, S. Mitchell, A. Monfared, CW Newman , FS Omole, CD Phillips, SK Robinson, MB Taw, RS Tyler, R. Waguespack, EJ Whamond: Clinical practice guideline: tinnitus. In: Otolaryngology - Head and Neck Surgery. Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. Volume 151, number 2 Suppl, October 2014, pp. S1 – S40, doi: 10.1177 / 0194599814545325 , PMID 25273878 (free full text).

science

counselor

  • Eberhard Biesinger (Ed.): Tinnitus. Springer, Heidelberg 2005, ISBN 3-540-22720-2 .
  • Eberhard Biesinger: Tinnitus. Finally peace in the ear. 2nd edition, Georg Thieme Verlag, Stuttgart 2012, ISBN 978-3-8304-6482-2 .
  • Bernhard Kellerhals, Regula Zogg: Tinnitus Help. A workbook for patients and their medical and non-medical assistants. 5th edition. Karger, Basel 2004, ISBN 3-8055-7718-4 .
  • Helmut Schaaf u. a .: Psychotherapy for tinnitus. Schattauer Verlag, Stuttgart 2001, ISBN 3-7945-2155-2 .

Web links

Wiktionary: Tinnitus  - explanations of meanings, word origins, synonyms, translations
Wiktionary: Ringing in the ears  - explanations of meanings, word origins, synonyms, translations
Commons : Tinnitus  - Collection of pictures, videos and audio files

Individual evidence

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