What is tinnitus?

Dr. Harun Ar Rashid, MD - Arthritis, Bones, Joints Pain, Trauma, and Internal Medicine Specialist Dr. Harun Ar Rashid, MD - Arthritis, Bones, Joints Pain, Trauma, and Internal Medicine Specialist
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Tinnitus is commonly described as a ringing in the ears, but it also can sound like roaring, clicking, hissing, or buzzing. It may be soft or loud, high-pitched or low-pitched. You might hear it in either one or both ears. Roughly 10 percent of the adult population of the United States has experienced tinnitus lasting at least five minutes in the past year. This amounts to nearly 25 million Americans.

Tinnitus is defined as a sound a person hears that is generated by the body, rather than by an outside source. Most tinnitus is subjective. This means the examiner cannot hear it, and there are no tools to measure or hear that sound. Objective tinnitus can arise from an aneurysm. This can be objectified and heard by the examiner. Other objective tinnitus investigation includes temporomandibular joint disease (TMJD) and tensor tympani muscle spasm.

Types

Based on the outcomes of the doctor’s examination, he or she will determine which type of tinnitus you have. Doctors distinguish between the following types of tinnitus:

  • Subjective and objective tinnitus: Subjective tinnitus can only be heard or perceived by the person who has it. Possible causes include problems with the auditory (hearing) system or the nerves that belong to it. In objective tinnitus, which is very rare, the doctor can hear the sounds too or detect the nerve signals causing the sounds. This is the case with tinnitus that is caused by blood-vessel-related problems, for instance. Here the doctor can hear a pulsing noise in the carotid artery in the neck with the help of a stethoscope.
  • Primary and secondary tinnitus: If no clear cause can be found, it is referred to as primary tinnitus or idiopathic tinnitus. If there is an identifiable cause, it is known as secondary tinnitus. Possible causes include a perforated eardrum or a vascular (blood vessel) disease.
  • Acute and chronic tinnitus: If the sounds last longer than three months, it is considered to be chronic tinnitus.
  • Various levels of severity: Tinnitus can be mild and hardly affect your everyday life, or only occur from time to time but then be distressing when it does. Sounds that are constantly and clearly heard are more serious: They can have a big impact on your daily life and work, for instance because it is hard to sleep and concentrate properly.

What causes tinnitus?

Tinnitus (pronounced tin-NY-tus or TIN-u-tus) is not a disease. It is a symptom that something is wrong in the auditory system, which includes the ear, the auditory nerve that connects the inner ear to the brain, and the parts of the brain that process sound. Something as simple as a piece of earwax blocking the ear canal can cause tinnitus. But it can also be the result of a number of health conditions, such as:

  • Noise-induced hearing loss
  • Ear and sinus infections
  • Diseases of the heart or blood vessels
  • Ménière’s disease
  • Brain tumors
  • Hormonal changes in women
  • Thyroid abnormalities

Tinnitus is sometimes the first sign of hearing loss in older people. It also can be a side effect of medications. More than 200 drugs are known to cause tinnitus when you start or stop taking them.

People who work in noisy environments—such as factory or construction workers, road crews, or even musicians—can develop tinnitus over time when ongoing exposure to noise damages tiny sensory hair cells in the inner ear that help transmit sound to the brain. This is called noise-induced hearing loss.

Service members exposed to bomb blasts can develop tinnitus if the shock wave of the explosion squeezes the skull and damages brain tissue in areas that help process sound. In fact, tinnitus is one of the most common service-related disabilities among veterans returning from Iraq and Afghanistan.

Pulsatile tinnitus is a rare type of tinnitus that sounds like a rhythmic pulsing in the ear, usually in time with your heartbeat. A doctor may be able to hear it by pressing a stethoscope against your neck or by placing a tiny microphone inside the ear canal. This kind of tinnitus is most often caused by problems with blood flow in the head or neck. Pulsatile tinnitus also may be caused by brain tumors or abnormalities in brain structure.

Even with all of these associated conditions and causes, some people develop tinnitus for no obvious reason. Most of the time, tinnitus isn’t a sign of a serious health problem, although if it’s loud or doesn’t go away, it can cause fatigue, depression, anxiety, and problems with memory and concentration. For some, tinnitus can be a source of real mental and emotional anguish.

Common causes of tinnitus

In many people, tinnitus is caused by one of the following:

  • Hearing loss. There are tiny, delicate hair cells in your inner ear (cochlea) that move when your ear receives sound waves. This movement triggers electrical signals along the nerve from your ear to your brain (auditory nerve). Your brain interprets these signals as sound. If the hairs inside your inner ear are bent or broken — this happens as you age or when you are regularly exposed to loud sounds — they can “leak” random electrical impulses to your brain, causing tinnitus. The most common cause of subjective tinnitus is noise trauma. For example, an employee who works in a noisy industry loses hearing at the 4000 Hz tone. Now the employee hears a sound that is similar to the 4000 tones.
  • Metabolic diseases: Heart, hypertension, and diabetes are associated with an onset of tinnitus. Various drugs are ototoxic to some individuals or at sufficient doses. For example, high doses of aspirin cause tinnitus, and the issue resolves when aspirin is stopped.  Ear diseases cause tinnitus including Meniere disease or lesions affecting the eighth cranial nerve.
  • Ear infection or ear canal blockage. Your ear canals can become blocked with a buildup of fluid (ear infection), earwax, dirt or other foreign materials. A blockage can change the pressure in your ear, causing tinnitus.
  • Head or neck injuries. Head or neck trauma can affect the inner ear, hearing nerves or brain function linked to hearing. Such injuries usually cause tinnitus in only one ear.
  • Medications. A number of medications may cause or worsen tinnitus. Generally, the higher the dose of these medications, the worse tinnitus becomes. Often the unwanted noise disappears when you stop using these drugs. Medications known to cause tinnitus include nonsteroidal anti-inflammatory drugs (NSAIDs) and certain antibiotics, cancer drugs, water pills (diuretics), antimalarial drugs and antidepressants.

Other causes of tinnitus

Less common causes of tinnitus include other ear problems, chronic health conditions, and injuries or conditions that affect the nerves in your ear or the hearing center in your brain.

  • Meniere’s disease. Tinnitus can be an early indicator of Meniere’s disease, an inner ear disorder that may be caused by abnormal inner ear fluid pressure.
  • Eustachian tube dysfunction. In this condition, the tube in your ear connecting the middle ear to your upper throat remains expanded all the time, which can make your ear feel full.
  • Ear bone changes. Stiffening of the bones in your middle ear (otosclerosis) may affect your hearing and cause tinnitus. This condition, caused by abnormal bone growth, tends to run in families.
  • Muscle spasms in the inner ear. Muscles in the inner ear can tense up (spasm), which can result in tinnitus, hearing loss and a feeling of fullness in the ear. This sometimes happens for no explainable reason, but can also be caused by neurologic diseases, including multiple sclerosis.
  • Temporomandibular joint (TMJ) disorders. Problems with the TMJ, the joint on each side of your head in front of your ears, where your lower jawbone meets your skull, can cause tinnitus.
  • Acoustic neuroma or other head and neck tumors. Acoustic neuroma is a noncancerous (benign) tumor that develops on the cranial nerve that runs from your brain to your inner ear and controls balance and hearing. Other head, neck or brain tumors can also cause tinnitus.
  • Blood vessel disorders. Conditions that affect your blood vessels — such as atherosclerosis, high blood pressure, or kinked or malformed blood vessels — can cause blood to move through your veins and arteries with more force. These blood flow changes can cause tinnitus or make tinnitus more noticeable.
  • Other chronic conditions. Conditions including diabetes, thyroid problems, migraines, anemia, and autoimmune disorders such as rheumatoid arthritis and lupus have all been associated with tinnitus.

Twenty percent of persons visiting tinnitus clinics have normal hearing. Some have somatosensory tinnitus. Here, stimulation from cervical or TMJD has activated the dorsal cochlear nucleus and sends impulses to the auditory center. Evidence for this is that stimulation similar to whiplash or TMJD has been shown to cause anatomical changes in the dorsal cochlear nucleus.

A rare cause of tinnitus is the Chiari malformation. Tinnitus occurs when low-lying cerebellar tonsils cause auditory nerve tension and can be unilateral or bilateral.

Symptoms

The symptoms of tinnitus include ringing, buzzing, roaring, hissing, or whistling in the ears. The noise may be intermittent or continuous. Most of the time, only the person who has tinnitus can hear it.

Tinnitus is most often described as a ringing in the ears, even though no external sound is present. However, tinnitus can also cause other types of phantom noises in your ears, including:

  • Buzzing
  • Roaring
  • Clicking
  • Hissing
  • Humming

Most people who have tinnitus have subjective tinnitus, or tinnitus that only you can hear. The noises of tinnitus may vary in pitch from a low roar to a high squeal, and you may hear it in one or both ears. In some cases, the sound can be so loud it interferes with your ability to concentrate or hear external sound. Tinnitus may be present all the time, or it may come and go.

In rare cases, tinnitus can occur as a rhythmic pulsing or whooshing sound, often in time with your heartbeat. This is called pulsatile tinnitus. If you have pulsatile tinnitus, your doctor may be able to hear your tinnitus when he or she does an examination (objective tinnitus).

Diagnosis

A physical exam should focus on the ear and the nervous system. The ear canal should be inspected for discharge, foreign body, and cerumen. The tympanic membrane should be inspected for signs of infection and tumor (red or bluish mass). A bedside hearing test should be done. Cranial nerves, particularly vestibular function, are tested along with peripheral strength, sensation, and reflexes. A stethoscope should be used to listen for vascular noise over the course of the carotid arteries and jugular veins and over and adjacent to the ear.

  • Hearing (audiological) exam. During the test, you’ll sit in a soundproof room wearing earphones that transmit specific sounds into one ear at a time. You’ll indicate when you can hear the sound, and your results will be compared with results considered normal for your age. This can help rule out or identify possible causes of tinnitus.
  • Movement. Your doctor may ask you to move your eyes, clench your jaw, or move your neck, arms and legs. If your tinnitus changes or worsens, it may help identify an underlying disorder that needs treatment.
  • Imaging tests. Depending on the suspected cause of your tinnitus, you may need imaging tests such as CT or MRI scans.
  • Lab tests. Your doctor may draw blood to check for anemia, thyroid problems, heart disease or vitamin deficiencies.

Do your best to describe for your doctor what kind of tinnitus noises you hear. The sounds you hear can help your doctor identify a possible underlying cause.

  • Clicking. This type of sound suggests that muscle contractions in and around your ear might be the cause of your tinnitus.
  • Pulsing, rushing or humming. These sounds usually stem from blood vessel (vascular) causes, such as high blood pressure, and you may notice them when you exercise or change positions, such as when you lie down or stand up.
  • Low-pitched ringing. This type of sound may point to ear canal blockages, Meniere’s disease or stiff inner ear bones (otosclerosis).
  • High-pitched ringing. This is the most commonly heard tinnitus sound. Likely causes include loud noise exposure, hearing loss or medications. Acoustic neuroma can cause continuous, high-pitched ringing in one ear.

X-rays and MRI are not usually done for tinnitus unless there is an unexplained difference in hearing and balance in the ears.

An audiogram is a hearing test measuring hearing levels to determine hearing loss. The patient is asked to match which of the tones matches their tinnitus. The audiologist introduces that sound as to volume, and the patient estimates how loud they hear their tinnitus. Hearing via the bone of the ear is tested and compared with hearing via the earphone called an air-bone test. If the patient hears better with the bone test, this suggests a condition called otosclerosis which is treatable. Patients with otosclerosis, in whom the stapes fail to move well, can have surgery that corrects the otosclerosis and restores air conduction. In some patients, tinnitus is relieved. In others, tinnitus remains or becomes worse.

The audiologist measures how long tinnitus is relieved by masking tone. The longer the tinnitus is inhibited, the better the prognosis.

Are there treatments that can help me?

Tinnitus does not have a cure yet, but treatments that help many people cope better with the condition are available. Most doctors will offer a combination of the treatments below, depending on the severity of your tinnitus and the areas of your life it affects the most.

  • Hearing aids often are helpful for people who have hearing loss along with tinnitus. Using a hearing aid adjusted to carefully control outside sound levels may make it easier for you to hear. The better you hear, the less you may notice your tinnitus. Read the NIDCD fact sheet Hearing Aids for more information.
  • Counseling helps you learn how to live with your tinnitus. Most counseling programs have an educational component to help you understand what goes on in the brain to cause tinnitus. Some counseling programs also will help you change the way you think about and react to your tinnitus. You might learn some things to do on your own to make the noise less noticeable, to help you relax during the day, or to fall asleep at night.
  • Wearable sound generators are small electronic devices that fit in the ear and use a soft, pleasant sound to help mask the tinnitus. Some people want the masking sound to totally cover up their tinnitus, but most prefer a masking level that is just a bit louder than their tinnitus. The masking sound can be a soft “shhhhhhhhhhh,” random tones, or music.
  • Tabletop sound generators are used as an aid for relaxation or sleep. Placed near your bed, you can program a generator to play pleasant sounds such as waves, waterfalls, rain, or the sounds of a summer night. If your tinnitus is mild, this might be all you need to help you fall asleep.
  • Acoustic neural stimulation is a relatively new technique for people whose tinnitus is very loud or won’t go away. It uses a palm-sized device and headphones to deliver a broadband acoustic signal embedded in music. The treatment helps stimulate change in the neural circuits in the brain, which eventually desensitizes you to the tinnitus. The device has been shown to be effective in reducing or eliminating tinnitus in a significant number of study volunteers.
  • Cochlear implants are sometimes used in people who have tinnitus along with severe hearing loss. A cochlear implant bypasses the damaged portion of the inner ear and sends electrical signals that directly stimulate the auditory nerve. The device brings in outside sounds that help mask tinnitus and stimulate change in the neural circuits. Read the NIDCD fact sheet Cochlear Implants for more information.
  • Antidepressants and antianxiety drugs might be prescribed by your doctor to improve your mood and help you sleep.
  • Other medications may be available at drugstores and on the Internet as an alternative remedy for tinnitus, but none of these preparations has been proved effective in clinical trials.

The American Academy of Otolaryngology has issued clinical practice guidelines for tinnitus. These include:

  • Stress Reduction: This includes using biofeedback, measured breathing, etc. Although stress itself is not a cause of tinnitus, as in any condition, stress and anxiety can make the condition worse.
  • Cognitive Therapy: The more the patient understands what tinnitus is and is not the less negative effect. Once the patient fully cognizes – understands that tinnitus is similar to itching, the symptoms are reduced.
  • Masking: When the body hears the same sound from the cell phone or sound device, this reduces the symptoms.  There are various forms of masking. Essentially these masking sounds take the attention away from the internal tinnitus sound and replace it with relaxing sounds.
  1. Introduction of the same sound
  2. Introduction of an altered sound
  3. Music with the tinnitus sound removed
  4. White noise or pleasant sounds
  • Sleep improvement: Tinnitus can affect normal sleep and therapy should be directed to better sleep hygiene.

The official guidelines stress that no medication cures tinnitus. However various combinations of magnesium, alpha-lipoic acid, N-acetyl cysteine, and others have been tested for protection of hearing from noise. When these are effective, it is difficult to differentiate from the placebo effect or from the impact of having a program where the patient feels they are in charge of bringing the brain into the healing process.

Recently beneficial results have been reported using deep brain stimulation. In theory, this alters unwanted neural circuits.

Primary to management is that tinnitus patients must never be told to live with it. Emphasis should be on reducing stress and given a program to follow. Tinnitus Retraining Therapy and Neuronomics are common programs used in therapy by individuals trained in their application. In Tinnitus Retraining the patient adapts to hearing the tinnitus; in Neuronomics the patient learns to ignore the tinnitus.

A hearing aid is always of benefit when tinnitus is associated with hearing loss. Some aids come with built-in soothing or masking sounds. Success is variable.

Medication such as alprazolam can reduce symptoms, but can have adverse effects including habituation.

Anti-depressants may be indicated for patients who do not respond to protocol therapy.

Prevention

  • Earwax removal. Removing an earwax blockage can decrease tinnitus symptoms.
  • Treating a blood vessel condition. Underlying blood vessel conditions may require medication, surgery or another treatment to address the problem.
  • Hearing aids. If your tinnitus is caused by noise-induced or age-related hearing loss, using hearing aids may help improve your symptoms.
  • Changing your medication. If a medication you’re taking appears to be the cause of tinnitus, your doctor may recommend stopping or reducing the drug, or switching to a different medication.

Noise suppression

Many times, tinnitus can’t be cured. But there are treatments that can help make your symptoms less noticeable. Your doctor may suggest using an electronic device to suppress the noise. Devices include:

  • White noise machines. These devices, which produce a sound similar to static, or environmental sounds such as falling rain or ocean waves, are often an effective treatment for tinnitus. You may want to try a white noise machine with pillow speakers to help you sleep. Fans, humidifiers, dehumidifiers and air conditioners in the bedroom also produce white noise and may help make tinnitus less noticeable at night.
  • Masking devices. Worn in the ear and similar to hearing aids, these devices produce a continuous, low-level white noise that suppresses tinnitus symptoms.

Counseling

Behavioral treatment options aim to help you live with tinnitus by helping you change the way you think and feel about your symptoms. Over time, your tinnitus may bother you less. Counseling options include:

  • Tinnitus retraining therapy (TRT). TRT is an individualized program that is usually administered by an audiologist or at a tinnitus treatment center. TRT combines sound masking and counseling from a trained professional. Typically, you wear a device in your ear that helps mask your tinnitus symptoms while you also receive directive counseling. Over time, TRT may help you notice tinnitus less and feel less distressed by your symptoms.
  • Cognitive behavioral therapy (CBT) or other forms of counseling. A licensed mental health professional or psychologist can help you learn coping techniques to make tinnitus symptoms less bothersome. Counseling can also help with other problems often linked to tinnitus, including anxiety and depression. Many mental health professionals offer CBT for tinnitus in individual or group sessions, and CBT programs are also available online.
  • Hearing aids. Many people who have tinnitus also have hearing loss. Hearing aids may help provide relief from tinnitus by making sounds louder and the tinnitus less noticeable. For example, hearing aids may increase the volume of soft sound in your environment, like the noise made by your refrigerator. Obviously, hearing aids make it easier for you to hear, which may make it easier for you to ignore tinnitus.
  • Sound generators. These devices produce and deliver sounds to your ears that mask tinnitus. For example, the sound generator may deliver soothing sounds like a shower or quiet rain. Some people may benefit by using hearing aids that include sound generators.
  • Environmental enrichment devices. You can create your own way of masking tinnitus. Tabletop sound machines that generate soothing background noise, recordings of music, nature or other sounds or apps for smartphones and tablets can make tinnitus less noticeable.
  • Relaxation techniques. Tinnitus can be frustrating and stressful. Stress and frustration may make tinnitus more noticeable. Learning techniques to increase relaxation and ease stress can help people better deal with the frustrations of tinnitus.

Can I do anything to prevent tinnitus or keep it from getting worse?

Noise-induced hearing loss, the result of damage to the sensory hair cells of the inner ear, is one of the most common causes of tinnitus. Anything you can do to limit your exposure to loud noise—by moving away from the sound, turning down the volume, or wearing earplugs or earmuffs—will help prevent tinnitus or keep it from getting worse.

What are researchers doing to better understand tinnitus?

Along the path a hearing signal travels to get from the inner ear to the brain, there are many places where things can go wrong to cause tinnitus. If scientists can understand what goes on in the brain to start tinnitus and cause it to persist, they can look for those places in the system where a therapeutic intervention could stop tinnitus in its tracks.

In 2009, the National Institute on Deafness and Other Communication Disorders (NIDCD) sponsored a workshop that brought together tinnitus researchers to talk about the condition and develop fresh ideas for potential cures. During the course of the workshop, participants discussed a number of promising research directions, including:

  • Electrical or magnetic stimulation of brain areas involved in hearing. Implantable devices already exist to reduce the trembling of Parkinson’s disease and the anxieties of obsessive-compulsive disorder. Similar devices could be developed to normalize the neural circuits involved in tinnitus.
  • Repetitive transcranial magnetic stimulation (rTMS). This technique, which uses a small device placed on the scalp to generate short magnetic pulses, is already being used to normalize electrical activity in the brains of people with epilepsy. Preliminary trials of rTMS in humans, funded by the NIDCD, are helping researchers pinpoint the best places in the brain to stimulate in order to suppress tinnitus. Researchers are also looking for ways to identify which people are most likely to respond well to stimulation devices.
  • Hyperactivity and deep brain stimulation. Researchers have observed hyperactivity in neural networks after exposing the ear to intense noise. Understanding specifically where in the brain this hyperactivity begins and how it spreads to other areas could lead to treatments that use deep brain stimulation to calm the neural networks and reduce tinnitus.
  • Resetting the tonotopic map. Researchers are exploring how to take advantage of the tonotopic map, which organizes neurons in the auditory cortex according to the frequency of the sound to which they respond. Previous research has shown a change in the organization of the tonotopic map after exposing the ear to intense noise. By understanding how these changes happen, researchers could develop techniques to bring the map back to normal and relieve tinnitus.

Why do I have this noise in my ears?

Although we hear tinnitus in our ears, its source is really in the networks of brain cells (what scientists call neural circuits) that make sense of the sounds our ears hear. A way to think about tinnitus is that it often begins in the ear, but it continues in the brain.

Scientists still haven’t agreed upon what happens in the brain to create the illusion of sound when there is none. Some think that tinnitus is similar to chronic pain syndrome, in which the pain persists even after a wound or broken bone has healed.

Tinnitus could be the result of the brain’s neural circuits trying to adapt to the loss of sensory hair cells by turning up the sensitivity to sound. This would explain why some people with tinnitus are oversensitive to loud noise.

Tinnitus also could be the result of neural circuits thrown out of balance when damage in the inner ear changes signaling activity in the auditory cortex, the part of the brain that processes sound. Or it could be the result of abnormal interactions between neural circuits. The neural circuits involved in hearing aren’t solely dedicated to processing sound. They also communicate with other parts of the brain, such as the limbic region, which regulates mood and emotion

What should I do if I have tinnitus?

The first thing is to see your primary care doctor, who will check if anything, such as ear wax, is blocking the ear canal. Your doctor will ask you about your current health, medical conditions, and medications to find out if an underlying condition is causing your tinnitus.

If your doctor cannot find any medical condition responsible for your tinnitus, you may be referred to an otolaryngologist (commonly called an ear, nose, and throat doctor, or an ENT). The ENT will physically examine your head, neck, and ears and test your hearing to determine whether you have any hearing loss along with tinnitus. You might also be referred to an audiologist who can also measure your hearing and evaluate your tinnitus.

References

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