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Everything You Should Know About Tinnitus

Many are familiar with the phenomenon of buzzing ears. A tinnitus as hissing, whistling, hissing or humming know most. Almost every fifth German had once a chronic tinnitus, so was affected for more than 3 months at a time. Especially between the 40th and the 50th year of life the symptoms begin. With us you will learn everything about tinnitus: causes, forms, symptoms and methods of treatment.

Forms of tinnitus

How tinnitus is perceived by the patient varies greatly. The buzzing in your ears can be either rhythmic or constant. As a sufferer, you experience these symptoms at different volumes. There may be other secondary symptoms besides these as concomitant symptoms. Associated symptoms include:

  • Disturbance of concentration
  • Headaches
  • Sleep problems

Basically, tinnitus can be distinguished in its duration and its type. One considers the period from the first appearance of the ear noises, until the symptoms subside. A duration of up to 3 months is called acute tinnitus, everything beyond that as chronic tinnitus.

Beyond that, there are two types.

  • Objective tinnitus: Objective tinnitus is based on an actual measurable sound source (e.g., vascular, muscular, or respiratory) near the inner ear. This occurs very rarely.
  • subjective tinnitus: Subjective tinnitus (tinnitus aurium) has no sound source inside the body, yet a sound or noise is perceived by the affected person due to faulty information processing of the auditory system. This form of tinnitus occurs much more frequently.


The reasons for tinnitus are very diverse. However, in many patients, no clear cause can be identified.

The objective tinnitus

The objective tinnitus can be heard by other people or measured with very sensitive microphones. It involves flow sounds of blood vessels through constrictions (pulsatile sound) or clicking sounds caused by involuntary twitching movements of the muscles in the middle ear or palate. Other causes may include valvular heart disease, anemia, an open tube (the connection between the middle ear and the nasopharynx), or a benign tumor in the cephalic region (glomus tumor)

The subjective tinnitus

The subjective tinnitus is heard only by the affected person and is not measurable with microphones. Its origin is not yet fully explainable. Experts assume that damaged hair cells or malfunctioning nerve pathways transmit false signals to the brain. Another source of interference may have originated directly in the auditory center, so that the transmitted information from the auditory nerve arrives correctly but is processed incorrectly.

Possible causes and associated disorders

  • Ossification in the junction between the third auditory ossicle (stapes) and the inner ear (Otosclerosis)
  • Middle ear inflammation
  • Internal ear infections
  • Tubal dysfunction
    • Tube is the term used to describe the connection between the middle ear and the nasopharynx
  • Inadequate blood flow to the inner ear
  • Drum defect
  • Closure of the ear canal due to earwax or foreign body
  • Perilymph fistula

Other possible causes:

Hearing loss

Hereditary, acquired, or age-related hearing loss may be accompanied by tinnitus

Acoustic neuroma

This benign tumor squeezes the auditory nerve. It can cause dizziness and diminished hearing in addition to tinnitus.

Morbus Menière

Morbus Meniere is a spinning vertigo that occurs in attacks. During an attack, the affected person usually suffers from a low-pitched sound as well as hearing loss.

Dysfunction of the cervical spine

Changes or blockages, particularly in the three uppermost joints of the cervical spine, are possible but are critically discussed as a cause.

Tooth and jaw area

Patients with pain and dysfunction of the masticatory muscles, temporomandibular joints, and teeth are significantly more likely to suffer from tinnitus than patients without these so-called craniomandibular dysfunctions (CMD). Patients with tinnitus due to CMD usually have normal hearing. This form of tinnitus predominantly affects women, usually of younger age.

Emotional/Psychological Distress

Psychological disorders such as depression or anxiety disorders are risk factors for developing ringing in the ears. About half of those suffering from chronic tinnitus are or have been under increased stress.

Medication side effects

A number of medications, called ototoxic drugs, cause side effects that affect the ear. This not only damages hearing, but can also trigger tinnitus. A selection of these medications include:

  • Diarrheal medications (diuretics)
  • special antibiotics
  • Chemotherapeutics in the context of cancer treatments
  • Anti-malarial agents
  • Acetylsalicylic acid in higher doses
  • Certain psychotropic drugs

Other causes

  • Cardiovascular disease, e.g., arrhythmias, high or low blood pressure
  • Metabolic disorders, e.g., diabetes or renal dysfunction
  • Disorders in hormone balance, e.g., during menopause
  • Skull-brain traumas
  • Diseases of the central nervous system (e.g., multiple sclerosis), brain tumors, meningitis
  • Narcoses, especially via the spinal cord (spinal anesthesia)
  • Changed pressure conditions in the ear, e.g., due to diving or air travel (barotrauma in case of negative pressure, caisson disease in case of positive pressure in the ear)
  • Alcohol abuse


Tinnitus can cause a wide variety of sounds, which can also vary throughout the day: A whistling, hissing, hammering, buzzing, ringing, knocking or creaking. They occur singly or mixed, persistent or variable, waxing and waning, with a constant tone or oscillating, in one or both ears. Most commonly, patients describe high-pitched beeps or a monotonous, lower-pitched murmur. In cases of severe hearing loss, it may even be a melody. If there is objective tinnitus due to vascular processes, the sounds are heard in time with the pulse.

Ear sounds are perceived by the patient in one ear, both ears, or in the center of the head. Measured objectively, they are no louder than the rustling of dry leaves, just above the so-called threshold of hearing. This is the limit above which someone can individually hear a sound.

Stress, physical overstrain or alcohol consumption can have an amplifying effect. Some people perceive their sound especially at night because of the silence and therefore fall asleep poorly.

In connection with hearing loss, tinnitus is perceived as louder because the sounds from the environment are no longer distracting.

Dizziness and hearing loss can accompany acute tinnitus - especially in the course of a hearing loss.

Especially in the acute phase of tinnitus, about half of those affected are overly sensitive to loud sounds in the environment (hyperacusis). Quiet music, murmuring voices or car traffic, on the other hand, have a pleasant effect, as they push the inner noise into the background.

Division into degrees

Whether and how much the affected person suffers from it varies greatly. Important are the form of the day, how one deals with the tinnitus and in what way the sound is perceived. For a comparability between the many individual cases, medical experts have formulated 4 degrees of severity:

Division according to Biesinger et al.

Grade 1: The tinnitus is well compensated, i.e., there is no suffering

Grade 2: The tinnitus occurs mainly in silence and is disturbing under stress and strain

From grade 3, one speaks of decompensated tinnitus

Grade 3: The tinnitus leads to a permanent impairment in the private and professional sphere. Disturbances in the emotional, cognitive and physical areas occur.

Grade 4: The tinnitus leads to complete decompensation in the private sphere. Affected persons are considered incapacitated by the stress.

Examination / Diagnosis

The anamnesis, the patient's medical history is the first step. Based on this, the ENT can already give an initial assessment of the severity. A description of the ringing in the ears and the accompanying symptoms that is as precise as possible allows conclusions to be drawn about possible causes of the tinnitus. How long the tinnitus occurs, how it is perceived and with which everyday noises it can possibly be compared. A description as exact as possible is important for the diagnosis. Have there been accidents, operations on the head, diseases of the ears or has the patient been permanently exposed to noise? This is all discussed via a questionnaire or in a conversation with the ENT physician.

The anamnesis interview is followed by a comprehensive ENT medical examination. These usually include an otoscopy or also called ear examination, examination of the paranasal sinuses and pharynx. If the ear noise is described as synchronous with the pulse, the carotid artery is also listened to and thus an objective tinnitus can be detected.

If objective tinnitus is ruled out, various hearing tests can be used to check the patient's loudness, frequency, and speech hearing. Furthermore, various measurement methods are used to check the ear pressure, the vibration behavior of the eardrum field (reflex measurement), the functional capacity of the auditory ossicles (impedance measurement/tympanometry), and the auditory nerve (measurement of the auditory nerve conduction velocity using brainstem audiometry, ABR).

Concrete tinnitus diagnostics also include measurement of tinnitus intensity (intensity in dB) in relation to the respective hearing threshold and frequency characteristics (pitch of the ear noise in kHz)*. The various examinations attempt to localize and characterize the tinnitus in more detail in order to initiate appropriate treatment procedures.

If necessary, the otolaryngologist will cooperate diagnostically with colleagues from other fields in order to clarify, for example, dental causes, malpositions of the cervical spine, underlying internal diseases (e.g. cardiovascular diseases) or psychological problems.


Treatment of acute tinnitus

Acute tinnitus, which often occurs with a sudden hearing loss, should be treated like a hearing loss, usually by cortisone treatment. In addition, damage to the auditory nerve should be ruled out as a possible cause of tinnitus.

Treatment of chronic tinnitus

Comprehensive education and counseling (counseling)

In the case of (chronic) tinnitus that has persisted for several months (> 3 months), therapy is oriented toward the severity of the distress and possibly existing concomitant diseases (comorbidities). The treatment goal is primarily to improve the patient's quality of life and to compensate for the distressing condition as best as possible.

Comprehensive education and counseling form the basis for this. The focus here is on changing thought and behavior patterns, if necessary in combination with psychotherapeutic therapy. Tinnitus habituation, i.e. the acceptance and thus the possible "forgetting" of the tinnitus as well as the learning of distraction strategies, the promotion of well-being, stress management, are the goal.

Background is a tinnitus management therapy (TBT). TBT assumes an altered hearing perception, triggered by a change process of auditory pathway areas in the brain.

Psychotherapeutic intervention

For chronic tinnitus, scientific research has shown that psychotherapeutic or behavioral intervention is the best-studied and therefore scientifically recommended method of therapy.

Stress management/relaxation techniques

A sufficient relaxation is very important for tinnitus patients in every phase of the disease. In this way, the great concentration on the agonizing noise can be reduced. With a number of different techniques, relaxation skills are learned or supported. These include: Autogenic training, biofeedback, as well as progressive muscle relaxation according to Jacobson.

Hearing aids and hearing training

If there is a hearing loss, a hearing aid fitting is important, which usually also has a beneficial effect on tinnitus. In the case of profound hearing loss, the use of a cochlear implant is recommended. This can be supplemented by hearing therapy, in which inhibitory parts of auditory perception are promoted and trained in relation to the tinnitus.

Tinnitus noiser and tinnitus masker

The benefits of a noise device, also called a noiser, or a masker have not been sufficiently scientifically proven. The tinnitus noiser produces a quiet noise, virtually as a counter tone to the tinnitus. As a result, the brain classifies the tinnitus noise as unimportant after some time and the affected person no longer perceives it or perceives it less. With the masker, tinnitus noises are drowned out and can be alleviated in this way. The functions are partly integrated into hearing aids.

Music therapy

In music therapy in the context of a tinnitus disorder, the hearing is retrained, for example, with conscious listening to sounds. Familiar and beloved pieces evoke positive memories. The auditory training is intensified by variations of these melodies. The selected music should be tuned to the tinnitus frequency. The method has not been conclusively proven scientifically, but it has a relaxing effect in any case and is suitable as a supportive treatment. According to a study by the German Center for Music Therapy, it was shown that in tinnitus patients treated with music therapy, the ringing in the ears had become quieter after one year and was perceived as less bothersome.

Medications, Supplements & Acupuncture

Medications and dietary supplements cannot improve chronic tinnitus, according to the current 2021 patient guideline. There is also no evidence for acupuncture, but this can relieve pain and tension responses.

Treatment of objective tinnitus

When objective tinnitus is diagnosed, the disease that triggers it is treated. Vascular disorders or vasoconstrictions, for example, are surgically removed. Muscle twitches are suppressed, for example, with medications used to treat epileptic seizures (anticonvulsia or antiepileptic drugs). Blockages in the cervical spine or jaw are corrected. These treatments usually cause the ringing in the ears to subside.