What is tinnitus? Learn The Causes of Ringing in The Ears and Possible Treatments

Do you hear sounds no one else can hear? It’s called tinnitus, and it’s more common than you think. Colloquially described as a “ringing in the ears,” tinnitus can also manifest as a continuous clicking, buzzing or humming sound in one or both ears.

One in 10 adults in the United States has had a bout of tinnitus lasting five minutes or longer in the past year. It’s typically associated with hearing loss, but 20 percent of persons with tinnitus have normal hearing.

Types of Tinnitus

Tinnitus is broken down into two broad tinnitus types or categories: subjective and objective.

Subjective tinnitus	Subjective tinnitus accounts for the vast majority of cases. This means a person is hearing sounds that no one else can hear. The symptoms can’t be externally measured, so audiologists rely on self-reporting for diagnosis.
Objective tinnitus	Objective tinnitus is when sounds originating in a person’s ear or head can be measured using equipment or otherwise observed by someone else. This type of tinnitus is much rarer, and it’s rooted in some physiological phenomenon occurring close to the auditory system. For example, a muscular spasm in the jaw might produce a clicking audible to the tinnitus sufferer and an outside observer.
Pulsatile tinnitus	Pulsatile tinnitus is a subcategory defined by the type of sound a person hears. It’s a rhythmic whooshing that syncs with a person’s heartbeat.  Pulsatile tinnitus is almost always objective. A common type of objective pulsatile tinnitus is a throbbing noise in the inner ear produced by irregular cardiovascular activity in nearby blood vessels.

Tinnitus Characteristics

Tinnitus comes from the Latin word tinnire, which means “to ring,” but “ringing in the ears” hardly captures people’s broad range of experiences. It can be a minor nuisance or a loud noise that makes it hard to function.

People with tinnitus have variously likened it to crickets, a breeze, grinding steel, or a running engine. Tinnitus patients have reported hearing the tune of a well-known song or voices with no accompanying speech. The diversity of documented experience suggests complex mechanisms at play.

Associated Symptoms

The agitation caused by tinnitus contributes to a host of related symptoms, such as problems concentrating, insomnia, and a decreased ability to understand speech.

Tinnitus can also take a toll on your mental health, causing or aggravating conditions like anxiety and depression. This is primarily due to a loss of sleep and reduced quality of life associated with tinnitus.

Causes of Tinnitus

It could be the temporary result of exposure to loud sounds or a sign of a severe health problem. Sometimes, it’s a combination of two or more medical conditions. Here are a few common causes of tinnitus:  

Hearing Loss and Ear Damage

A common cause of tinnitus is damage to the inner ear from loud noise exposure. Soldiers are constantly exposed to loud sounds like explosions and gunfire, so they have high rates of tinnitus.

Factory workers, musicians, and other occupations where people are surrounded by loud noises experience noise-induced hearing loss that can cause tinnitus.

Tinnitus can be a byproduct of age-related hearing loss, too. As people age, their ability to hear high-frequency sounds diminishes, so lower sounds seem more pronounced, leading to tinnitus.

It can also stem from hearing loss rooted in conditions affecting the inner and middle ear, like ear infection, otosclerosis, wax blockage, sinus infections and Meniere’s disease.

Diseases and Disorders

Tinnitus is a symptom of various neurological disorders, autoimmune disorders, metabolic conditions, and severe viral and bacterial infections. Some common examples:

• Brain tumors
• Multiple sclerosis
• Syphilis
• Lyme disease
• Hypothyroidism or hyperthyroidism
• Fibromyalgia
• Rheumatoid arthritis

Traumatic Injuries

Whiplash, concussions, and other head or neck trauma are known to cause tinnitus. Injuries to that area can affect the auditory nerve and blood vessels around the ear or damage the parts of your brain that process sound.

The temporomandibular joint shares many nerves and ligaments with the ear, so trauma to the jaw or infections of the teeth and gums can produce a ringing in the ears.

Snorkeling, deep-sea diving, flying and other activities subject the body to changes in pressure. This sometimes causes barotrauma to your sinuses, which can lead to tinnitus.

Cardiovascular Disease

Pulsatile tinnitus is often a symptom of a circulatory problem like a damaged blood vessel near the ear or a heart condition. People experience it as a rhythmic pulsing in time with the heartbeat.

Cardiovascular conditions and blood disorders affect blood flow, leading to pulsatile tinnitus. Some examples include:

• High blood pressure
• Atherosclerosis
• Anemia

Psychiatric Causes

Depression, anxiety and stress can cause tinnitus. As we’ve already mentioned, the reverse is also true. Due to the link between psychiatric conditions and tinnitus, antidepressants and other psychoactive medications have proven effective at treating tinnitus.

Drug Side Effects

Certain drugs can produce a toxic reaction in the inner ear, and tinnitus is one of the earliest signs.

Some of these medications are essential and have few effective alternatives, so doctors will wait to see if the tinnitus passes and only discontinue them if the symptoms are persistent and debilitating.

Drugs that might cause tinnitus include:

• Loop diuretics like ethacrynic acid, acetazolamide,
• Antibiotics like aminoglycosides
• Painkillers like nonsteroidal anti-inflammatory drugs (NSAIDs), salicylates, or aspirin
• Cancer drugs like vincristine and platins
• Quinine-based drugs

Diagnosing Tinnitus

Because tinnitus has so many potential causes, medical professionals must rule them out by process of elimination, systematically moving from the most likely to the least.

The process can be time-consuming and may not yield a clear answer. Many tinnitus cases are idiopathic, meaning the source of the symptoms cannot be definitively determined.

Ear Exam and Hearing Tests

The majority of tinnitus cases originate within the ear itself, so that’s where medical professionals look first.

Diagnosis starts with a thorough ear exam to check the middle and inner ear for common causes of conductive hearing loss, such as foreign bodies, impacted ear wax and other obstructions in the ear canal.

Next, an audiologist will administer various hearing tests to look for signs of sensorineural hearing loss. These might include:

Pure-tone audiometry	A subjective measurement of the patient’s hearing sensitivity that involves tones played at different frequencies through the air and via bone conduction
Tympanogram	A test measuring the response of the hearing mechanism in the middle ear, including the eardrum and conduction bones
Acoustic reflex test	An observation of how middle ear muscles contract in response to loud sounds
Speech recognition test	A subjective hearing test of the patient’s ability to hear and repeat words

Supplemental Tests

Audiologists may administer some additional tinnitus tests to better understand a patient’s subjective experience of their tinnitus symptoms, which can help identify underlying pathologies and determine if treatments like sound therapy and masking might be effective.

Sound matching	A technician estimates the intensity and type of symptoms by playing common tinnitus sounds, and the patient confirms which ones match their experience.
Minimum masking	The loudness of a patient’s perceived sounds is approximated by playing narrow-band noises at different volumes to determine the lowest level at which the tinnitus symptoms are covered up or masked.
Loudness discomfort	An audiologist will expose the patient to increasingly loud sounds to establish the volume level at which the patient starts to feel discomfort or pain.

Imaging Scans

Depending on the results of initial exams, a doctor may recommend some additional testing to weed out possible causes and zero in on underlying medical conditions. Imaging scans are sometimes used to rule out abnormalities in the nervous system.

Asymmetrical hearing loss is a possible sign of neurological disorder.

Here are some standard diagnostic scans:

• Computerized tomography (CT) or computerized tomographic angiography (CTA) of the brain or temporal bone
• Magnetic resonance imaging (MRI) of the brain or internal auditory canals

Burden Testing

The American Academy of Otolaryngology has called on doctors to evaluate the burden of tinnitus symptoms during the diagnostic process. Exploring the impact of tinnitus on a patient’s everyday life can inform treatment options.

This includes surveys and questionnaires probing the effect of tinnitus on:

• Sleep
• Emotional state
• Ability to perform work and daily tasks
• General quality of life

Treating Tinnitus

There are also effective therapies to mitigate symptoms and make living with tinnitus easier.

Hearing Aids

If hearing loss is the cause of your tinnitus, hearing aids might help. A hearing aid can boost ambient sounds across the spectrum, helping to mask annoying tinnitus sounds. Increasing the external sound you hear can take your mind off the buzzing and ringing in your ears.

Antidepressants

Antidepressants like alprazolam, clonazepam, and oxazepam are effective at reducing the intensity of tinnitus. Studies found that when people stopped taking these medications, their tinnitus returned to its previous levels.

Masking and Sound Therapy

Audiologists and ENTs have had tremendous success using sounds or music to relieve tinnitus symptoms. All forms of sound therapy are developed based on the same principle, but there are subtle differences in methodology:

Tinnitus masking therapy (TMT)	Gentle noise at the right volume and frequency can drown out tinnitus in some patients.
Tinnitus retraining therapy (TRT)	This therapy utilizes wearable sound generators to retrain the brain to ignore tinnitus sounds via the psychological process of habituation.
Music therapy	This desensitization technique employs spectrally manipulated music tailored to the tinnitus characteristics of each individual to mask tinnitus.

Electrical Suppression

If your tinnitus is rooted in a dysfunction of the inner ear, it might be possible to treat it through a barrage of tiny electrical pulses to the cochlea. In some cases, this therapy has successfully suppressed tinnitus or rendered it virtually unnoticeable.

Transcutaneous electrical nerve stimulation of the skin by the ear can also negate tinnitus, depending on the cause.

Massaging and Stretching

Counseling and Behavioral Therapy

As we’ve already mentioned, there’s a strong association between mental health issues like stress, anxiety and depression. Counseling, talk therapy, and other forms of psychological treatment can help you manage these conditions and alleviate tinnitus.

In particular, cognitive-behavioral therapy (CBT) is a valuable tool for addressing tinnitus. A meta-analysis of 18 studies found that CBT is more effective than behavioral treatment alone. Weekly sessions of one or two hours yielded improvements in symptoms lasting a year or longer.

Managing Tinnitus

Tinnitus symptoms can be reduced by simple changes to your diet, habits, and behavior. The American Tinnitus Association has produced a guide to managing tinnitus, including some helpful tips for relieving discomfort and treatment options if symptoms persist.

Here are a few measures the American Tinnitus Association recommends to relieve tinnitus:

Reduce Stress

Cutting down on stress is good for your overall health, and it will address some of the underlying conditions that cause you to develop tinnitus. Some stress management techniques include:

• Biofeedback
• Relaxation techniques
• Mindfulness
• Deep breathing exercises

Get Enough Sleep

Tinnitus can cause a miserable feedback loop. Your symptoms affect your sleep, increasing stress levels and making your tinnitus worse. To break this vicious cycle, the American Tinnitus Association suggests taking steps to improve sleep hygiene.

Try to keep a regular bedtime and avoid drugs that affect your sleep, such as alcohol, caffeine and cigarettes.

Tinnitus Prevention

To spare yourself the annoyance and discomfort of living with tinnitus — not to mention the hassle and expense of treating it — it’s best to take some measures to avoid developing the condition in the first place.

Here are a few things you can do to prevent tinnitus:

Protect Your Hearing

Earmuffs and fitted earplugs prevent damage to your inner ear, reducing your risk of developing permanent sensorineural hearing loss, a leading cause of tinnitus.

Keep Your Ears Clean and Healthy

In addition to protecting yourself from harsh noise, you need to adopt some good habits to maintain your ears’ overall health and hygiene. Clean your ears regularly with medicated ear drops to flush out ear wax, a common cause of conductive hearing loss.

Treat every ear infection as soon as it appears. Waiting for it to go away increases the risk of harm. Schedule a hearing test and ear exam annually. This is especially vital as you age.

Exercise and Eat Well

Tinnitus is often a sign of general ill health, so an overall healthy lifestyle is your best defense. Aerobic exercise improves the blood flow to your ears and prevents high blood pressure and cardiovascular disease, one of the many risk factors for tinnitus.

Nutritional deficiencies have been linked to tinnitus, so improving your diet can help. For example, research shows that people are more likely to develop tinnitus if they don’t get enough B12, a vitamin your body uses to produce the outer covering that shields the auditory nerve.

Conclusion

Tinnitus can be a minor annoyance or serious disability that makes everyday life a challenge. While more studies are still needed to understand the precise causes and pathology, medical science is making progress, offering hope to tinnitus sufferers.

Advances in research have yielded effective tinnitus treatments and strategies for managing symptoms that can reduce the impact of living with the condition. Of course, prevention is essential. Protect your hearing and live a healthy lifestyle to address the root causes of tinnitus.    

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