Tinnitus: ringing and buzzing in the ears
The sound you hear in your ear is real, but it is produced inside the hearing system, not outside it. In most cases it comes with a hearing loss you have not noticed , and treating the hearing also reduces the ringing. 2 forms need checking without delay: when the sound is only in one ear and when it beats in time with your pulse.
What is tinnitus?
Tinnitus is hearing a sound that has no outside source. People describe it as buzzing, whistling, ringing or a cicada-like hiss. It can be heard in one ear, in both or "inside the head", and it is almost always louder in quiet surroundings, at night, when there is nothing else to mask it. The sound is real for you, it is simply produced inside the hearing system.
Tinnitus is not a disease in itself, it is a symptom, and 2 questions decide what happens next. The first is whether it affects both ears or only one. The second is whether the sound beats rhythmically, in time with your pulse.
Tinnitus in both ears that does not pulse is the common form, and in most cases it is linked to hearing.
Tinnitus in one ear and pulsatile tinnitus are investigated differently, which is why this distinction is made in the very first conversation at the practice.
What can cause tinnitus?
When it is related to hearing
- Hearing loss you have not noticed, usually a drop in the high frequencies that does not get in the way of everyday conversation but lets the inner sound come through
- Noise exposure, at work, at concerts or from headphones at high volume
- Earwax or fluid behind the eardrum, which block out surrounding sounds and make the ringing more noticeable
- Ménière's disease, where tinnitus comes together with vertigo and dizziness and a feeling of pressure in the ear
- Otosclerosis and other middle ear conditions
When the cause lies elsewhere
- A blood vessel cause, in pulsatile tinnitus that follows the pulse
- Medicines, such as certain antibiotics, diuretics (water tablets), high doses of aspirin and chemotherapy drugs
- The jaw joint and the neck, when the sound changes as you move your jaw or head
- A condition of the hearing nerve, which is looked into when tinnitus is in one ear only and the audiogram is uneven
Stress, tiredness, caffeine and alcohol do not cause tinnitus. They do make it louder and harder to ignore, which explains why many people notice it more during stressful periods or when they are not sleeping well.
When does tinnitus need to be checked?
A short spell of ringing after loud music, that goes away within 1 or 2 days means nothing. A check is needed in the following cases:
- The tinnitus is in one ear only
- The sound beats rhythmically, in time with your pulse
- It comes with reduced hearing, dizziness or unsteadiness
- It has lasted more than 6 months or keeps you from sleeping and concentrating
- It started after exposure to loud noise or after a head injury
One situation cannot wait. Ringing that suddenly appears in one ear together with hearing loss, within hours or overnight, is treated as sudden hearing loss. It needs a hearing test right away and treatment ideally within the first 2 weeks, because after that the chances of recovery fall.
What happens at the appointment?
First comes your history, and here the details matter: when the sound started, in which ear, whether it is steady or pulsing, what medicines you take, where you have been exposed to noise. This is followed by an ear examination (otoscopy), a look at the ear canal and the eardrum.
Hearing test (audiogram)
This is the test that answers the central question, because most persistent tinnitus comes with a hearing loss that the patient has not noticed. It shows whether there is hearing loss, at which frequencies and, above all, whether the 2 ears differ from each other.
Tympanogram
It shows whether there is fluid in the middle ear, whether the Eustachian tube is working and whether the eardrum has a hole. It matters here, because a fair amount of tinnitus is caused by exactly these problems and settles once they are treated.
When is imaging needed?
In most cases it is not. An MRI scan comes into the discussion when the tinnitus is pulsatile, when it affects one ear with an uneven audiogram or when there are neurological findings. When the ringing is in both ears, does not pulse and hearing is the same on both sides, imaging adds no further information and we do not request it.
Treatment
When there is a treatable cause
Earwax, fluid in the middle ear, a Eustachian tube problem or a condition of the tiny middle ear bones can be treated, and the tinnitus settles along with them. If a medicine is responsible, any change is made together with the doctor who prescribed it, never on your own.
When tinnitus persists
Here the goal changes, and it is worth saying clearly: it is not to switch the sound off, but to stop it from grabbing your attention. This is achievable, and 3 approaches are backed by evidence.
- Hearing aids, when there is also hearing loss. By bringing back the sounds around you, they reduce the contrast that makes the ringing stand out.
- Cognitive behavioral therapy (CBT), the approach with the strongest evidence for persistent, bothersome tinnitus. It does not make the sound quieter, but it reduces its impact on sleep, concentration and mood
- Sound masking, with background sound or a dedicated device, especially at the times when the sound bothers you most.
What has not been shown to help
Clinical guidelines advise against using dietary supplements, such as Ginkgo biloba, melatonin and zinc, to treat persistent tinnitus, and against antidepressants, anti-epileptic drugs and anti-anxiety medicines as routine treatment. We mention this because these are among the first things suggested outside the doctor's office, and the time spent on them is time not spent on something that works.
Frequently asked questions
Often yes, when it is recent and there is a trigger, such as loud noise exposure or a viral infection. When it lasts more than 6 months, the approach changes and the goal becomes reducing the disturbance, not waiting.
Not because the sound has changed, but because your surroundings have. In the quiet there are no other sounds to cover it and your attention turns to it. This is why sound masking helps especially at bedtime.
Stress does not create tinnitus, but it makes it worse and makes it harder to get used to. That is why treatment is not only about the ear.
There is no medicine that cures it. There is treatment for the underlying cause when one is found, and there are proven ways to reduce the disturbance when it persists.
No. It often means that some hearing loss is already there without you having noticed, and that is why a hearing test is done. Tinnitus itself does not cause further hearing loss.
No, and it matters. Pulsatile tinnitus is investigated separately, because it usually comes from the blood vessels and not from the hearing system.
When should you not wait?
Urgent
Sudden ringing with hearing loss in one ear
Hearing test right away, treatment ideally within the first 2 weeks.
Soon
Tinnitus in one ear or pulsatile tinnitus
These do not follow the usual path, they need a different investigation rather than waiting
Medical review: Dr. Ioannis KotrotsosENT Surgeon and Specialist in Phoniatrics and Pediatric Audiology.
Πηγές: Tunkel DE et al., Clinical Practice Guideline: Tinnitus, AAO-HNSF, 2014 · Chandrasekhar SS et al., Clinical Practice Guideline: Sudden Hearing Loss (Update), AAO-HNSF, 2019.
The information on this page is for general information only and does not replace a medical examination. For diagnosis and treatment, please consult a doctor.
