Tinnitus, a condition often described as a “storm in the ear,” significantly impacts quality of life and is frequently linked to underlying mental health conditions.
Dr. Eliane Ebnöther, an attending physician at Kantonsspital Olten, notes that while the term “storm in the ear” dates back to ancient Egypt around 2000 years ago, today it more accurately reflects the challenges faced in a busy medical practice.
The prevalence of tinnitus increases with age, affecting 13.7% of individuals between 45 and 64 years vintage, according to a systematic review. Among those over 64, approximately one in four experiences the condition. This rise is attributed to both psychosocial factors associated with aging and the progressive development of age-related hearing loss, the expert explained.
Tinnitus is categorized as acute or chronic after three months of persistence. It can also be subjective – experienced only by the individual – or objective, where it can be detected by a healthcare provider. Subjective tinnitus, accounting for 95% of cases, has a wide range of potential causes:
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Related to the ear (otogen)
Noise exposure
Presbycusis (age-related hearing loss)
Inflammation (otitis media)
Sudden hearing loss
Ménière’s disease
Otosclerosis -
Caused by ototoxic substances
For example, after chemotherapy with cisplatin -
Functional
Triggered by stress and psychological strain
The less common objective tinnitus can be pulsatile, synchronized with the heartbeat, or muscle-related. It’s also important to consider issues with the Eustachian tube, growths behind the cochlea, or temporomandibular joint disorders.
Ruling out serious causes of pulsatile tinnitus is crucial, including vascular malformations (AV malformations, glomus tumors) or narrowed arteries (such as carotid stenosis).
Tinnitus is also classified as compensated or uncompensated. Uncompensated tinnitus can severely affect quality of life and is associated with anxiety, sleep disturbances, depression, and even suicidal thoughts.
The severity of tinnitus can be assessed using the Tinnitus Handicap Inventory (developed by Goebel and Hiller), which evaluates:
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Emotional responses (frustration, irritability, anxiety),
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social interaction (impact on relationships with friends and family, social activities),
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cognitive function (difficulty concentrating, reading), and
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behavioral patterns (sleep disturbances, difficulty with daily life).
The Tinnitus Handicap Inventory helps determine the severity of the condition and track progress during treatment.
Initial assessment should focus on identifying “red flags,” Dr. Ebnöther explained. This includes checking blood pressure and pulse, and listening for a pulsatile sound in the neck.
A Doppler ultrasound of the arteries supplying the brain can be performed if an AV fistula or glomus tumor is suspected. To rule out a craniomandibular dysfunction, questions about jaw pain and teeth grinding (bruxism) are important, and dental expertise may be needed.
If hearing loss accompanies the tinnitus, a referral to an otolaryngologist (ENT specialist) is recommended. Examination of the ear canal can identify chronic infections, such as a cholesteatoma. Transnasal fiberendoscopy can visualize the inner ear canal and assess Eustachian tube function.
A comprehensive hearing test typically includes:
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Pure-tone audiometry,
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Tinnitus Matching (a method to determine the individual pitch and loudness of a tinnitus sound),
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Speech audiometry,
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Tympanometry,
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Stapedius reflex testing, and
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otoacoustic emissions.
Further investigations may include brainstem audiometry, vestibular testing (if experiencing dizziness), MRI of the cerebellopontine angle in cases of asymmetrical hearing loss (particularly to rule out vestibular schwannoma), and CT angiography or MR angiography for pulsatile tinnitus.
Once organic or dangerous causes are ruled out, explaining the condition to the patient and reassuring them of its generally benign nature is key. “There are no universal treatment recommendations for tinnitus. Treatment usually involves an individually tailored approach based on severity, distress, expectations, co-existing conditions, and background,” Dr. Ebnöther emphasized.
The focus is on developing coping strategies with the patient. If hearing loss is present, hearing rehabilitation (hearing aids, potentially a cochlear implant) is important to stimulate the hair cells and reduce deprivation. This is most effective when the hearing loss frequency matches the tinnitus frequency. The effectiveness of noise generators, devices that produce background noise to mask tinnitus, is not established.
The S3 guideline “Chronic Tinnitus” recommends against using medications to treat chronic tinnitus due to insufficient evidence of their effectiveness. This includes corticosteroids. The exception is the acute stage, when tinnitus occurs in conjunction with sudden hearing loss.
A Cochrane review examining the effects of Ginkgo biloba in approximately 2000 tinnitus patients found no consistent conclusion regarding its employ for tinnitus. However, Dr. Ebnöther noted that Ginkgo biloba may be considered in patients with dementia and tinnitus.
Melatonin does not directly affect tinnitus but may be helpful in addressing sleep disturbances often associated with the condition. Betahistine, cannabinoids, and dietary supplements are not recommended due to a lack of evidence.
Cognitive behavioral therapy (CBT) is the most studied and evaluated treatment for tinnitus. A Cochrane review demonstrated positive effects on both the perceived loudness of tinnitus and on depressive symptoms and quality of life.
Tinnitus apps can also help patients develop habituation. “They are certainly a quality option that you can recommend to your patients,” the expert said, noting they are somewhat less effective than CBT.
Finally, Dr. Ebnöther emphasized the importance of recognizing and treating psychiatric comorbidities, such as anxiety, adjustment disorders, sleep disturbances, and depression. In severe cases, such as acute suicidal ideation, she noted that their hospital offers a six-week inpatient tinnitus program providing a range of therapies, including acupuncture, breathing exercises, relaxation techniques, physiotherapy, psychotherapy, and hearing aid fitting, if needed.
