Whistling, humming, squealing, thumping and hissing - all unpleasant noises that one would like to avoid. But escape is not possible when the agonizing sounds come not from outside at all, but from within.
The feeling of being at the mercy of the noise, not knowing whether it will ever stop, is often the worst thing for those affected.
Tinnitus (literally "ringing") is the name given to the phenomenon when the hearing itself seems to produce sounds that can distress a person day and night. 40% of all people suffer from the complaints in the course of their lives. 10-20 % are permanently affected.
Tinnitus is not a disease, but a symptom, similar to headaches or toothaches, and can have numerous causes. Tinnitus is not pathological in every case. In an anechoic room, virtually all people hear some whistling or hissing.
Even though tinnitus subsides without consequence in most people, others are very persistently affected. Medication does little to no good, and at some point the phrase, "You'll have to put up with it." comes up.
Is this true? What is behind tinnitus? And what can be done?
Tinnitus does not usually come out of the blue. Typical triggers are persistent stress, infections, inflammations or a loud noise, such as the explosion of a firecracker. Often, several causes come together.
Hearing loss, a sudden onset of hearing loss, is also common. But there are many more clinical pictures that can lead to tinnitus:
- Bang trauma
- Hearing loss
- Noise-induced hearing loss
- Age-related hearing loss
- Otosclerosis (calcification of the ossicles)
- Metabolic diseases
- Diseases of the cervical spine
- Kidney diseases
- Stress and tension
Tinnitus is common. About one in four people suffer from it for a long time at least once in their lives.
Approximately 1 million people with tinnitus in Germany require therapy, with around 250-350,000 new cases every year.
Women are affected slightly more often than men.
Acute and chronic tinnitus
Short-term tinnitus is largely normal. Suddenly there is a beeping in the ear. Such events are not rare and usually disappear after a few minutes. Depending on the duration, one distinguishes between different forms:
- up to three months duration: acute tinnitus
- three to 6 (or 12) months duration: subacute tinnitus
- above that: chronic tinnitus
Tonal and non-tonal tinnitus
About half of those affected suffer from tonal tinnitus, the other half from non-tonal tinnitus.
Tonal means a whistling, ringing, buzzing, chirping, etc. The tones are usually very high in the range of 3000 Hz.
Non-tonal means a hiss, hum, buzz, crackle, pop, rumble, etc.
Objective or subjective tinnitus
A distinction is generally made between objective and subjective tinnitus. In the case of objective tinnitus, sounds are actually produced, e.g., by flowing blood, cracking when swallowing, or muscle activity. Such sounds can be registered by an examiner e.g. with a stethoscope or microphone from the outside.
In the case of subjective tinnitus, there is simply nothing at all. It hisses and whistles for no apparent reason. The noise is caused by disturbed stimulus processing.
Another classification concerns the degree of severity:
- Grade 1: compensated tinnitus without suffering,
- Grade 2: compensated tinnitus, which is perceived as disturbing in the case of stress and psychological strain,
- Grade 3: decompensated tinnitus with permanent impairment in private and professional life,
- Grade 4: tinnitus with complete decompensation in the private sphere or occupational disability.
Innocent inner ear
What happens in tinnitus at the neurophysiological level is not yet fully understood. For a long time, the main attention was focused on the ear itself. It was assumed that there was local damage to the ear. In desperate cases, therefore, the auditory nerve was cut in order to help the patients achieve the peace they longed for. The severely affected would rather be deaf than continue to endure the unbearable whistling.
But the successes failed to materialize. The noise persisted despite deafness. This made it clear that the problem was not in the inner ear, but in the subsequent processing of stimuli.
"Fibromyalgia of the Hearing."
In more recent times, theories on the origin of tinnitus have changed. They are very similar to the explanation of chronic pain. Similar to pain, hearing is only made possible by a mixture of excitation and inhibition. Impulses go from the ear toward the brain. Other signals go from the brain toward the ear and cause insignificant things to be inhibited.
The path from acoustic event to perception proceeds through three stages. First, a sound event is converted into an electric current in the inner ear.
Now this signal reaches the brainstem and thalamus and is analyzed there. It is compared with stored sounds and subjected to a kind of pattern recognition. At the same time, fibers go to the limbic system and the amygdala (tonsil nucleus), which cause emotional coloring. This emotional significance is very essential to perception. Insignificant things are blanked out, threatening, dangerous and unpleasant signals always have priority as warning signals. Only after that, in a third step, the conscious perception takes place.
So if you slumber gently, your hearing does register the sounds of the street or the wind in the trees. The impulses are picked up and directed to the thalamus. Upon analysis, the upstream brain nuclei conclude that the signals have long been known, and the limbic system also shows no increased emotional interest. As a result, no arousal stimulus is sent to the conscious mind. Sleep is not disturbed. Not only at night, the vast majority of noises are thus constantly actively blocked out.
The situation is different with a quiet squeak, e.g. the opening of the bedroom door. This is also immediately identified and interpreted as threatening. With a jolt, the sleeper is awake and senses from the palpitations how much adrenaline has already been released. Similarly, young mothers are startled when their child whimpers softly.
Tinnitus is understood as a misperception or "phantom perception", similar to phantom pain. When it develops, causes in the inner ear, thalamus and consciousness are mixed.
In addition to loud signals (e.g., after an explosion), the emotional coloring of the signal is crucial. Threatening or frightening sounds are perceived much more intensely than soothing music. Attention is also essential. Those who pay attention to tinnitus involuntarily amplify it
Thus, tinnitus can be understood as a vicious circle. In the beginning, there is often an external cause that triggers the temporary whistling or humming. Anxiety and tension then intensify the problem. The more stress this causes a person, the more he pays attention to it, the less favorable the course.
This representation is certainly simplified. But recently it has become clear that tinnitus also belongs to the circle of central sensitization disorders, likefibromyalgia and otherfunctional disorders.
We have seen in recent years that breathing disorders are very common in tinnitus.
First the good news. Tinnitus and even hearing loss have a basically good prognosis. Even if no therapy is carried out, the symptoms disappear completely in almost 70% of cases and to a greater extent in almost 90%.
The suffering caused by the annoying noise thus affects only about one in ten. But they are often extremely persistently affected. A great deal has been tried in the way of medication. Most of them proved ineffective.
In contrast, non-drug therapy - usually in the form of more comprehensive treatment - has proven promising.
Avoiding nonsensical measures
Here is the - incomplete - list of proven ineffective methods or procedures without clear evidence of efficacy:
- Antiepileptic drugs (drugs to treat epilepsy)
- Nicotinic acid preparations
- Hyperbaric chamber
- Soft laser
Most of these methods assume "impaired circulation" or other damage to the ear, but this is usually not true.
Only antidepressants show a small effectiveness. However, the potency is not great. An attenuation of the tinnitus volume by a few decibels has been described. Whether sedatives help is not entirely certain.
Infusion of the local anesthetic lidocaine causes a significant improvement of the tinnitus. However, relatively high dosages must be given for this purpose, at which side effects are difficult to prevent. In addition, the effect lasts only a short time. Thus, this therapy is out of the question in everyday life.
Clarity about the causes
So what works against the "man in the ear". The central point of attack is stimulus processing in the brain. If it is possible to change the meaning of the sound, then the chance increases that a signal will be sorted out as insignificant by the thalamus and will not reach the consciousness.
However, as long as the whistling sound is interpreted as threatening, it is difficult to succeed. On the contrary, it is absolutely impossible not to perceive a noise voluntarily. So, as in other cases, the problem arises of wanting to achieve something consciously, which is actually only possible unconsciously. So once again a case of yellow elephants, which are quite difficultnotto think about.
In the first place of an effective therapy is the education about the connections that have been presented above. Especially important is the fact that the hearing itself is fine. It has only become hypersensitive. Once the diagnosis "tinnitus without organic cause" has been established with certainty, it is not useful to carry out extensive further diagnostics, since the examinations only fixate more strongly on the symptom.
A first proven way is to avoid complete silence. In an anechoic room, as mentioned, all people hear some noise. In contrast, the splashing of an indoor fountain, soft music or other soothing sounds have proven very effective as a simple therapy against tinnitus.
The next principle lies in enjoyment. One cannot be afraid and enjoy at the same time. So if you listen to your favorite music with pleasure, you will suffer much less from the disturbing noises. Many sufferers therefore wear headphones as often as they can in order to perceive pleasant acoustic impressions in place of the agonizing noise.
Music as therapy
An essential element of therapy is regaining control over a phenomenon to which tinnitus sufferers feel helpless. Tinnitus cannot be controlled, but other noises can. Actively playing music is therefore a very effective approach to controlling tinnitus ("perpetrator instead of victim"). We offer programs for this purpose.
Those who cannot benefit from such therapy can try to create beautiful sounds themselves with a simple instrument (e.g. gong).
Directing attention is another way to avoid constantly thinking about the tinnitus and thus intensify it. If you are watching an exciting movie, you don't have to worry about "listening away."
Unfortunately, everyday life is usually not quite so exciting. With appropriate training, however, it is possible to focus attention on other soothing sounds. How do your own footsteps on the floor, the rustling of clothes, the hitting of keys on the computer, birds outside the window, the sounds of the street, the crackling of a fire in the fireplace, etc. sound?
You can learn how to do this in a systematic way with mindfulness training. You can find it in our breathing app.
Meditation and relaxation
Another possibility is to shift the meaning. Make what was agonizing sound pleasant (or neutral). This path requires a little training, but holds great opportunities. The prerequisite is learning a relaxation program, e.g. progressive muscle relaxation.
This is followed by consideration of the context in which the noise could occur in a pleasant form. For example, the whistling can be interpreted as part of the background noise of a train. Now, in a further step, a small story is invented. For example, one remembers how one once went on vacation to the sea by night train as a child. Now we practice. In a relaxation situation, you imagine again and again the beautiful train ride, the rocking, rattling, whistling, and the happy mood that goes along with it.
If one has practiced this sufficiently often, then the association of pleasant relaxation and a trip on vacation automatically emerges at the end, as soon as the tinnitus enters the consciousness. Excellent conditions to convince the thalamus to block out the noise as insignificant.
Reduce anxiety and tension
Of fundamental importance is the reduction of anxiety. Nothing focuses attention more strongly on a perceived noise than the fear that it may never stop. If you suffer from the idea that you could go "crazy," lose your job, or never escape the agonizing whistling for the rest of your life, you animate the thalamus & co. to focus even more attention on the tinnitus. Thus the noise becomes chronic.
In recent years, we have been able to see that many patients with tinnitus have unconsciouslyaccelerated breathing. This leads via various biochemical mechanisms to an increased sensitivity of nerves in the brain.
For this reason, we carry out systematic breathing training with those affected, which the patients can then continue at home.
Raising the stimulus threshold and reducing anxiety are thus once again the central features of therapy for tinnitus. The different stimulus thresholds for cold, warmth, balance, pain, etc. are interconnected. If one succeeds in hardening in one area, this has positive consequences for other areas as well. Therefore, in pronounced and persistent cases, a multimodal therapy is a sensible option.
In most cases, those affected suffer not only from tinnitus, but also from other functional complaints.
Therefore, in cases of pronounced tinnitus and in patients who suffer from other complaints at the same time, a multimodal therapy should be carried out.
- Music therapy methods
- Physical methods (heat and cold therapy)
- Sleep hygiene
- Change of diet
- If necessary, pain therapy and other specific treatments according to individual needs
Duration of therapy
Even if a tinnitus has been present for a very long time, a therapy does not necessarily have to extend over a long period of time. In a study (H. Argstatter: Heidelberger Musiktherapiemanual, 2009) it was found that a one-week intensive daily therapy was equally successful as a 12-week treatment once a week. This is consistent with our experience.
We therefore treat tinnitus with similar long therapy sequences as other functional disorders, i.e. usually 2 weeks.
Tinnitus has very great similarities with other forms of functional disorders e.g. chronic pain disorders like fibromyalgia or chronic vertigo.
The ability to fade out certain frequencies has to be trained systematically. Inner peace and perceived security are essential for this. Body-related procedures (massages, heat, movement) are central to this.
In recent years, we have also been able to recognize the great importance of breathing for tinnitus. Therefore, breathing therapy plays an essential role in multimodal therapy.
In the end, the tinnitus is usually not completely gone. But it is such that it is simply "forgotten". "Yes, I still have tinnitus when I listen, but it doesn't bother me," is a common outcome.