Tinnitus

Why tinnitus happens

Sound is detected by tiny hair cells in the cochlea (inner ear), which send signals along the hearing nerve to the brain. When hair cells are damaged by age, noise or medicines, less signal reaches the brain at certain pitches. Brain circuits respond by increasing their sensitivity, a process called central gain, and this extra activity is heard as sound. This explains why tinnitus is usually at the pitch of the hearing loss and why it can persist even if the hearing nerve is cut.

Whether tinnitus becomes bothersome depends on how the brain's attention and emotional systems react to it. When tinnitus is linked to alarm or stress, the brain keeps it in focus, which makes it seem louder. This loop is the target of cognitive behavioral therapy and sound therapy.

Subjective vs objective tinnitus

• Subjective tinnitus: heard only by you. More than 95 percent of cases.
• Objective tinnitus: a real body sound a doctor might hear with a stethoscope, such as blood flow or muscle spasms in the middle ear or palate. Usually pulsatile or clicking.

Causes and risk factors

• Age-related hearing loss (presbycusis)
• Noise exposure: occupational, military, music and recreational firearms
• Ear conditions: earwax, infections, otosclerosis, Meniere's disease, sudden hearing loss
• Acoustic neuroma: rare, causes one-sided tinnitus and hearing loss
• Ototoxic medicines: aminoglycoside antibiotics, cisplatin, high-dose aspirin, loop diuretics, quinine
• Head and neck injury, whiplash and TMJ disorders (somatic tinnitus that changes with jaw or neck movement)
• Vascular conditions for pulsatile tinnitus
• Anxiety, depression and insomnia, which amplify distress

When no cause is identified, see tinnitus of unknown cause.

Diagnosis

Guidelines recommend:

1. History and ear exam: onset, sound, laterality, pulsatile or not, hearing, vertigo, noise, medicines, mood and sleep.
2. Audiological assessment (hearing test) promptly for tinnitus that is one-sided, persistent (6 months or more) or associated with hearing difficulty.
3. Imaging only when indicated: MRI for one-sided tinnitus, asymmetric hearing loss or neurological signs. CT or MR angiography and venography for pulsatile tinnitus. Imaging is not needed for typical tinnitus in both ears.
4. Questionnaires such as the Tinnitus Handicap Inventory to measure impact and track progress.

Treatment

Hearing aids

For people with hearing loss, hearing aids amplify outside sounds, reducing the contrast with the tinnitus and lowering the brain's central gain. Many modern aids include built-in sound generators. Over-the-counter hearing aids are now available in the US for mild to moderate loss.

Sound therapy

Low-level background sound makes tinnitus less noticeable without masking it completely. Options include fans, nature sounds, apps, bedside sound machines and wearable sound generators. It is especially useful at bedtime.

Cognitive behavioral therapy (CBT)

CBT has the strongest evidence for reducing tinnitus-related distress, anxiety and sleep problems, though it does not change loudness. It is delivered by psychologists, audiologists trained in it, or through structured internet-based programs.

Tinnitus retraining therapy (TRT)

Combines directive counseling about how tinnitus works with sound therapy over 12 to 24 months to promote habituation. Evidence is moderate.

Treating related problems

• Better sleep habits and CBT for insomnia
• Treatment of anxiety and depression in their own right
• Physical therapy or dental treatment for TMJ and neck-related tinnitus
• Cochlear implants for people with severe deafness in one or both ears, which often reduce tinnitus as well

What does not work well

The AAO-HNS guideline recommends against routine use of antidepressants, anticonvulsants, anxiolytics or intratympanic medicines to treat tinnitus itself, and against dietary supplements such as ginkgo biloba, melatonin, zinc or lipoflavonoids, because evidence shows little benefit. Transcranial magnetic stimulation is not routinely recommended. A bimodal neuromodulation device that pairs sounds with tongue stimulation is available in the US for some patients, with modest evidence.

Living with tinnitus

• Most people find tinnitus less intrusive over 6 to 12 months as the brain habituates.
• Protect remaining hearing with earplugs in noise.
• Avoid complete silence.
• Limit caffeine and alcohol only if you notice they make it worse; evidence of an effect is weak.
• Exercise, relaxation and mindfulness reduce stress-driven loudness.
• Support groups and the American Tinnitus Association offer resources.

Frequently asked questions

What causes tinnitus?

Most tinnitus is caused by hearing loss from aging or noise, which leads the brain to increase its own activity, heard as sound. Other causes include earwax, ear infections, Meniere's disease, certain medicines, jaw or neck problems, and, for pulsatile tinnitus, blood vessel conditions.

Can tinnitus be cured?

Tinnitus caused by earwax, infections or medicines can disappear once treated. Chronic tinnitus from hearing loss usually cannot be cured, but hearing aids, sound therapy and CBT reduce its loudness and impact so that many people barely notice it.

What is the best treatment for tinnitus?

For people with hearing loss, hearing aids are often the most helpful first step. Cognitive behavioral therapy has the strongest evidence for reducing distress. Sound therapy helps, especially at night. Treating sleep problems, anxiety and depression also makes a big difference.

Do supplements help tinnitus?

Current guidelines do not recommend supplements such as ginkgo biloba, zinc, melatonin or lipoflavonoids for tinnitus, because studies have not shown meaningful benefit. They can also interact with medicines. Spending on proven approaches such as hearing aids and CBT is usually more effective.

Does tinnitus get worse over time?

Tinnitus often stays stable and many people become less bothered over months. It can worsen with further noise exposure, progressive hearing loss, stress or poor sleep. A sudden change in your tinnitus, especially in one ear, should be checked.