Tinnitus (ringing in the ears): causes, tests and ways to cope

Many people notice a ringing or buzzing in their ears at some point. For some it fades, and for others it lasts and affects sleep and mood. This review uses information from the NHS, the US National Institute on Deafness and Other Communication Disorders (NIDCD) and MedlinePlus.

1. Introduction

Tinnitus means hearing sounds that do not come from an outside source. The NHS says it is not usually a sign of anything serious and may improve on its own ^[1]. The NIDCD estimates that 10 to 25% of adults have it, and that children can too. When it lasts three months or longer it is called chronic ^[2].

2. Signs and symptoms

People describe ringing, buzzing, whooshing, humming, hissing, throbbing, roaring, clicking, or even music or singing. It can be heard in one ear, both ears or inside the head, and it may come and go or be constant ^{[1, 2, 3]}. It can be soft or loud, and high or low pitched ^{[2, 3]}. Severe tinnitus can interfere with hearing, work or sleep ^[3].

Most tinnitus is subjective, which means only the person can hear it. Rarely, a doctor can hear the sound with a stethoscope, called objective tinnitus, and this type often has a treatable cause ^[2].

3. Causes and risk factors

The cause is often unclear. The NHS, NIDCD and MedlinePlus list these possibilities ^{[1, 2, 3]}:

• Hearing loss, including age-related loss, which is strongly linked to tinnitus, though not everyone with hearing loss has it
• Exposure to loud noise, from work, concerts or sporting events
• Earwax or fluid from an ear infection blocking the ear canal, and ear or sinus infections
• Ménière's disease, an inner ear condition that can cause balance problems and hearing loss
• Head or neck injury
• Jaw joint problems, such as clenching or grinding the teeth
• Heart or blood vessel problems
• Conditions such as diabetes, thyroid disorders, migraine, anaemia (anemia) or multiple sclerosis
• Anxiety or depression
• Side effects of some medicines, including some antibiotics, anti-inflammatory pain relievers, aspirin, chemotherapy drugs and antimalarials

The NIDCD notes that some people develop tinnitus for no known reason ^[2].

4. Diagnosis and tests

The NHS says a doctor will check the ears for treatable causes such as earwax or an ear infection, and may check your hearing. You may be referred to a specialist for more tests ^[1]. The NIDCD explains that the first visit is usually to a primary care doctor, who reviews your history and medicines. An ear, nose and throat (ENT) doctor may examine the head, neck and ears, and an audiologist can measure hearing and assess the tinnitus. Imaging such as MRI, CT or ultrasound may be ordered, especially for tinnitus that pulses with the heartbeat, to look for structural or medical causes ^[2].

5. Treatment and management

The NIDCD says that if a physical cause such as earwax or a jaw problem is found, treating it can remove or greatly reduce the sound, although many people have symptoms for months or years ^[2].

Sound therapy. The NIDCD describes tabletop or smartphone sound generators, which can help with relaxation or sleep, wearable sound generators, and hearing aids, which are a main option when hearing loss is also present ^[2]. MedlinePlus mentions sound-masking devices ^[3], and the NHS says soft music or other sounds can help distract you from tinnitus ^[1].

Talking therapies. The NHS says that when the cause cannot be treated, you may be referred for digital cognitive behavioural therapy (CBT), usually offered first, tinnitus counselling, or tinnitus retraining therapy, which uses sound therapy for severe or lasting tinnitus. It says it is unclear whether retraining therapy works for everyone ^[1]. The NIDCD says education about tinnitus can reduce anxiety, and CBT helps change distressing thoughts ^[2].

Medicines and supplements. The NIDCD says no medicine is specifically approved for tinnitus. The NIDCD adds that antidepressants or anti-anxiety medicines may help mood or sleep. Vitamins, herbal extracts and supplements are often advertised, but none has been proven effective ^[2]. Always tell your doctor about everything you take.

6. Prevention and self-care

The NIDCD links noise to tinnitus and lists avoiding loud noise among ways to cope ^[2]. The NHS suggests these self-help steps ^[1]:

• Relax, for example with deep breathing or yoga.
• Build a bedtime routine and cut down on caffeine to help sleep.
• Avoid stress and loud background noise where possible.
• Avoid total silence. Soft music or sound therapy can distract you.
• Try not to focus on the sound. Hobbies and activities can help.
• Consider a support group.

7. Special groups

Children can have tinnitus too ^[2]. The NIDCD notes that severe tinnitus can lead to anxiety or depression, and the NHS advises seeing a doctor if tinnitus makes you anxious or low ^{[1, 2]}. Tinnitus is rarely linked to a serious medical problem, but the NIDCD says tinnitus that pulses needs to be evaluated ^[2].

8. When to see a doctor

The NHS advises seeing a doctor if tinnitus is regular or constant, is getting worse, or affects your sleep, concentration or mood, or makes you anxious or low. Ask for an urgent appointment if the sound beats in time with your pulse ^[1]. The NIDCD also advises that pulsing tinnitus be evaluated ^[2].

The NHS says to go to hospital or call for emergency help if tinnitus starts after a head injury, or comes with sudden hearing loss, weakness of the facial muscles or vertigo, a spinning feeling. Do not drive yourself, and take your medicines with you ^[1].

In an emergency, call your local emergency number (112 in India, 911 in the United States).

9. Conclusion

Tinnitus is common and usually not caused by a serious problem, but it can be distressing. A doctor can check for treatable causes, and sound therapy, hearing aids, talking therapies and self-help can make it easier to live with. Your doctor decides which approach is right for you.