Ringing in the Ear (Tinnitus)

What tinnitus sounds like

People describe ringing, buzzing, hissing, whistling, roaring, clicking or humming. It may be constant or come and go, in one ear, both ears or "in the head." It is usually most noticeable in quiet rooms and at night.

Tinnitus comes in two main forms:

• Subjective tinnitus: only you can hear it. This is by far the most common type and is linked to changes in the hearing system and brain.
• Objective tinnitus: a real sound from the body, such as blood flow or muscle spasm, that a doctor can sometimes hear with a stethoscope. It is rare.

When hearing cells in the inner ear are damaged, the brain receives less input and turns up its own activity to compensate. That extra activity is perceived as sound, much like phantom limb pain.

Common causes of ringing in the ears

Age-related hearing loss

Presbycusis, gradual hearing loss with age, is the most common cause. It usually affects both ears and high-pitched sounds first. Many people do not realize their hearing has changed until tested.

Noise exposure

Loud concerts, power tools, firearms, factory work and headphones at high volume damage inner ear hair cells. Temporary ringing after a loud event is a warning sign. Repeated exposure leads to permanent hearing loss and tinnitus.

Earwax and ear infections

Impacted earwax, ear infections, fluid behind the eardrum and Eustachian tube dysfunction can all cause tinnitus with muffled hearing. These are often easily treated.

Medicines

High-dose aspirin, some antibiotics (aminoglycosides), loop diuretics, certain chemotherapy drugs (cisplatin), quinine and some antidepressants can cause or worsen tinnitus. Do not stop a prescribed medicine without talking to your doctor.

Other causes

• stress, anxiety and poor sleep, which make tinnitus louder and more noticeable
• TMJ disorders and neck problems, which can change the sound when you clench or move the jaw or neck
• head and neck injuries
• caffeine, alcohol and nicotine in some people

Less common but important causes

• Ménière's disease: attacks of vertigo lasting 20 minutes to hours, low-pitched roaring tinnitus, ear fullness and fluctuating hearing loss in one ear.
• Acoustic neuroma: a slow-growing, noncancerous tumor on the hearing and balance nerve. It causes one-sided tinnitus and hearing loss, sometimes imbalance.
• Sudden sensorineural hearing loss: rapid hearing loss in one ear, often noticed on waking, with tinnitus. It needs treatment within days.
• Otosclerosis: abnormal bone growth in the middle ear, often in young adults, with gradual hearing loss.

Pulsatile tinnitus

Pulsatile tinnitus is a rhythmic whooshing or thumping in time with your heartbeat. It is often caused by turbulent blood flow and should always be investigated. Causes include:

• high blood pressure, anemia, an overactive thyroid and pregnancy, which increase blood flow
• narrowing of the carotid artery
• raised pressure in the brain fluid (idiopathic intracranial hypertension), usually with headaches and vision changes in younger women
• abnormal connections between arteries and veins near the ear
• vascular tumors in the middle ear

Ringing in one ear

Tinnitus in only one ear is more likely to have a specific cause, such as earwax, an infection, Ménière's disease, sudden hearing loss or, rarely, an acoustic neuroma. Persistent one-sided tinnitus, especially with hearing loss in the same ear, needs a hearing test and often an MRI.

How tinnitus is diagnosed

A doctor will ask about the sound, which ear, whether it pulses, noise exposure, medicines, hearing changes, dizziness and how much it affects you. They will look in your ears and examine the head, neck and jaw.

Tests may include:

• Audiogram (hearing test): recommended for all people with persistent or one-sided tinnitus
• Tympanometry: checks middle ear pressure and eardrum movement
• MRI for one-sided tinnitus or asymmetric hearing loss, to look for an acoustic neuroma
• CT or MR angiography and blood tests for pulsatile tinnitus

Treatment for ringing in the ears

There is no pill that cures most tinnitus, but several approaches reduce how loud and bothersome it feels:

• Treat the cause: wax removal, treating infections, changing medicines, managing blood pressure.
• Hearing aids: for people with hearing loss, they restore sound input and often reduce tinnitus significantly.
• Sound therapy: background noise, white noise machines, fans or apps, especially at bedtime, make tinnitus less noticeable.
• Cognitive behavioral therapy (CBT): has the strongest evidence for reducing tinnitus distress, sleep problems and anxiety.
• Tinnitus retraining therapy: combines counseling and sound therapy to help the brain filter out the sound.
• Treat anxiety, depression and insomnia, which amplify tinnitus.

Supplements such as ginkgo biloba, zinc and melatonin are not recommended for tinnitus by the American Academy of Otolaryngology because evidence of benefit is lacking.

Preventing tinnitus

• Use earplugs or earmuffs around loud noise, including concerts and power tools.
• Follow the 60/60 rule with headphones: no more than 60% volume for 60 minutes at a time.
• Do not clean ears with cotton swabs.
• Get a hearing test if you notice hearing changes.

Frequently asked questions

What causes ringing in the ears?

The most common causes are age-related hearing loss, exposure to loud noise and earwax buildup. Ear infections, certain medicines, stress, jaw problems, Ménière's disease and, rarely, an acoustic neuroma can also cause it. Many people with tinnitus have some hearing loss.

Is ringing in one ear serious?

Usually not, but it is more likely to have a specific cause than tinnitus in both ears. See a doctor if it lasts more than a week, especially with hearing loss, dizziness or fullness in the same ear. Sudden hearing loss in one ear needs urgent treatment.

What is pulsatile tinnitus?

Pulsatile tinnitus is a rhythmic whooshing or thumping sound in time with your heartbeat. It is usually caused by changes in blood flow near the ear, from high blood pressure, anemia, thyroid disease or a blood vessel problem. It should always be checked by a doctor.

Does tinnitus go away?

Tinnitus from a loud concert or an ear infection often goes away within days to weeks. Chronic tinnitus may not disappear completely, but most people find it becomes much less noticeable over months as the brain learns to tune it out, especially with sound therapy and CBT.

How can I stop the ringing in my ears?

Treat any cause such as earwax, use background sound at night, protect your ears from noise, and manage stress and sleep. Hearing aids help if you have hearing loss. Cognitive behavioral therapy is the most effective treatment for reducing how much tinnitus bothers you.