Tinnitus: Ringing in the Ears - An Overview
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Tinnitus: Ringing in the Ears
An Overview
By the Vestibular Disorders Association
What is tinnitus? to seek treatment.4 It can interfere with a
Tinnitus is abnormal noise perceived in person’s ability to hear, work, and
one or both ears or in the head. Tinnitus perform daily activities. One study
(pronounced either “TIN-uh-tus” or “tin- showed that 33% of persons being
NY-tus”) may be intermittent, or it might treated for tinnitus reported that it
appear as a constant or continuous disrupted their sleep, with a greater
sound. It can be experienced as a ringing, degree of disruption directly related to
hissing, whistling, buzzing, or clicking the perceived loudness or severity of the
sound and can vary in pitch from a low tinnitus.5,6
roar to a high squeal.
Causes and related factors
Tinnitus is very common. Most studies Most tinnitus is associated with damage
indicate the prevalence in adults as falling to the auditory (hearing) system,
within the range of 10% to 15%, with a although it can also be associated with
greater prevalence at higher ages, other events or factors: jaw, head, or
through the sixth or seventh decade of neck injury; exposure to certain drugs;
life.1 Gender distinctions are not nerve damage; or vascular (blood-flow)
consistently reported across studies, but problems. With severe tinnitus in adults,
tinnitus prevalence is significantly higher coexisting factors may include hearing
in pregnant than non-pregnant women.2 loss, dizziness, head injury, sinus and
middle-ear infections, or mastoiditis
The most common form of tinnitus is (infection of the spaces within the
subjective tinnitus, which is noise that mastoid bone). Significant factors
other people cannot hear. Objective associated with mild tinnitus may include
tinnitus can be heard by an examiner meningitis (inflammation of the membra-
positioned close to the ear. This is a rare nous covering of the brain and spinal
form of tinnitus, occurring in less than 1% cord), dizziness, migraine, hearing loss,
of cases.3 or age.7
Chronic tinnitus can be annoying, Forty percent of tinnitus patients have
intrusive, and in some cases devastating decreased sound tolerance, identified as
to a person’s life. Up to 25% of those the sum of hyperacusis (perception of
with chronic tinnitus find it severe enough over-amplification of environmental
© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 1 of 11sounds) and misophonia/ phonophobia Objective tinnitus has been associated
(dislike/fear of environmental sounds).8 with myoclonus (contraction or twitching)
While most cases of tinnitus are of the small muscles in the middle
associated with some form of hearing ear.14,15 Conductive hearing loss resulting
impairment, up to 18% of cases do not from an accumulation of earwax in the
involve reports of abnormal hearing.9 ear canal can sometimes cause tinnitus.
Ear disorders Vestibular disorders: Hearing
Hearing loss from exposure to loud impairment and related tinnitus often
noise: accompany dysfunction of the balance
Acute hearing depends on the organs (vestibular system). Some ves-
microscopic endings of the hearing nerve tibular disorders associated with tinnitus
in the inner ear. Exposure to loud noise include Ménière’s disease and secondary
can injure these nerve endings and result endolymphatic hydrops (resulting from
in hearing loss. Hearing damage from abnormal amounts of a fluid called
noise exposure is considered to endolymph collecting in the inner ear)
be the leading cause of tinnitus. and perilymph fistula (a tear or defect in
one or both of the thin membranes
Presbycusis: Tinnitus can also be related between the middle and inner ear).
to the general impairment of the hearing
nerve that occurs with aging, known as Vestibulo-cochlear nerve damage
presbycusis. Age-related degeneration of and central auditory system changes
the inner ear occurs in 30% of persons The vestibulo-cochlear nerve, or eighth
age 65–74, and in 50% of persons 75 cranial nerve, carries signals from the
years or older.10 inner ear to the brain. Tinnitus can result
from damage to this nerve. Such damage
Middle-ear problems: Tinnitus is can be caused by an acoustic neuroma,
reported in 65% of persons who have also known as a vestibular schwannoma
preoperative otosclerosis (stiffening of (benign tumor on the vestibular portion
the middle-ear bones),11 with the tinnitus of the nerve), vestibular neuritis (viral
sound typically occurring as a high- infection of the nerve), or microvascular
pitched tone or white noise rather than compression syndrome (irritation of the
as a low tone.12 Otitis media (middle-ear nerve by a blood vessel).
infection) can be accompanied by
tinnitus, which usually disappears when The perception of chronic tinnitus has
the infection is treated. If repeated infec- also been associated with hyperactivity
tions cause a cholesteatoma (benign in the central auditory system, especially
mass of skin cells in the middle ear in the auditory cortex.16 In such cases,
behind the eardrum), hearing loss, tinni- the tinnitus is thought to be triggered by
tus, and other symptoms can result.13 damage to the cochlea (the peripheral
© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 2 of 11hearing structure) or the vestibulo- Pulsatile tinnitus is a rhythmic pulsing
cochlear nerve. sound that sometimes occurs in time
with the heartbeat. This is typically a
Head and neck trauma result of noise from blood vessels close
Compared with tinnitus from other to the inner ear. Pulsatile tinnitus
causes, tinnitus due to head or neck is usually not serious. However,
trauma tends to be perceived as louder sometimes it is associated with serious
and more severe. It is accompanied by conditions such as high or low blood
more frequent headaches, greater pressure, hardening of the arteries
difficulties with concentration and (arteriosclerosis), anemia, vascular
memory, and a greater likelihood of tumor, or aneurysm.
depression.17
Other possible causes
Somatic tinnitus is the term used when Other conditions have been linked to
the tinnitus is associated with head, neck, tinnitus: high stress levels, the onset of
or dental injury—such as misalignment of a sinus infection or cold, autoimmune
the jaw or temporomandibular joint disorders (such as rheumatoid arthritis
(TMJ)—and occurs in the absence of or lupus), hormonal changes, diabetes,
hearing loss. Characteristics of somatic fibromyalgia, Lyme disease, allergies,
tinnitus include intermittency, large depletion of cerebrospinal fluid, vitamin
fluctuations in loudness, and variation in deficiency, and exposure to lead. In
the perceived location and pattern of its addition, excessive amounts of alcohol or
occurrence throughout the day.18 caffeine exacerbate tinnitus in some
people.
Medications
Many drugs can cause or increase Diagnosis
tinnitus. These include certain non- Examination by a primary care physician
steroidal anti-inflammatory drugs will help rule out certain sources of
(NSAIDs, such as Motrin, Advil, and tinnitus, such as blood pressure or
Aleve), certain antibiotics (such as medication problems. This doctor can
gentamicin and vancomycin), loop also, if necessary, provide a referral
diuretics (such as Lasix), aspirin and to an ear, nose, and throat specialist (an
other salicylates, quinine-containing otolaryngologist, otologist, or
drugs, and chemotherapy medications neurotologist), who will examine the ears
(such as carboplatin and cisplatin). and hearing, in consultation with an
Depending on the medication dosage, the audiologist. Their evaluations might
tinnitus can be temporary or permanent.3 involve extensive testing that can include
an audiogram (to measure hearing), a
Vascular sources tympanogram (to measure the stiffness
of the eardrum and help detect the
© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 3 of 11presence of fluid in the middle ear), approaches are available, including
otoacoustic emissions testing (to provide medication, dietary adjustments,
information about how the hair cells of counseling, and devices that help mask
the cochlea are working), an auditory the sound or desensitize a person to it.
brainstem response test (to measure how Not every treatment works for every
hearing signals travel from the ear to the person.
brain and then within parts of the brain),
electrocochleography (to measure how Masking devices
sound signals move from the ear along A masking device emits sound that
the beginning of the hearing nerve), obscures, though does not eliminate, the
vestibular-evoked myogenic potentials tinnitus noise. The usefulness of maskers
(to test the functioning of the saccule is based on the observation that tinnitus
and/or inferior vestibular nerve), blood is usually more bothersome in quiet
tests, and magnetic resonance imaging surroundings20 and that a competing
(MRI). Neuropsychological testing is also sound at a constant low level, such as a
sometimes included to screen for the ticking clock, whirring fan, ocean surf,
presence of anxiety, depression, or radio static, or white noise produced by a
obsessiveness—which are understandable commercially available masker, may
and not uncommon effects when tinnitus disguise or reduce the sound of tinnitus,
has disrupted a person’s life. thus making it less noticeable. Some
tinnitus sufferers report that they sleep
Treatment better when they use a masker. In some
If a specific cause of the tinnitus is users, maskers produce residual
identified, treatment may be available to inhibition—tinnitus suppression that lasts
relieve it. For example, if TMJ for a short while after the masker has
dysfunction is the cause, a dentist may been turned off.
be able to relieve symptoms by
realigning the jaw or adjusting the bite Hearing aids are sometimes used as
with dental work. If an infection is the maskers. If hearing loss is involved,
cause, successful treatment of the properly fitted hearing aids can improve
infection may reduce or eliminate the hearing and may reduce tinnitus
tinnitus. temporarily. However, tinnitus can
actually worsen if the hearing aid is set at
Many cases of tinnitus have no an excessively loud level.
identifiable cause, however, and thus
are more difficult to treat. Although a Cochlear implants, used for persons who
person’s tolerance of tinnitus tends to are profoundly deaf or severely hard-of-
increase with time,19 severe cases can hearing, have been shown to suppress
be disturbing for many years. In such tinnitus in up to 92% of patients.21,22
chronic cases, a variety of treatment This is likely a result of masking due to
© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 4 of 11newly perceived ambient sounds or from
electrical stimulation of the auditory In one comparison of the effectiveness of
nerve. tinnitus masking and TRT as treatments,
masking was found to provide the
Other devices under development may greatest benefit in the short term (three
eventually prove effective in relieving to six months), while TRT provided the
tinnitus. For example, the recently greatest improvement with continued
introduced acoustics-based Neuromonics treatment over time (12–18 months).25
device involves working with an
audiologist who matches the frequency Psychological treatments
spectrum of the perceived tinnitus Chronic tinnitus can disrupt
sound to music that overlaps this concentration, sleep patterns, and
spectrum. This technique aims to participation in social activities, leading
stimulate a wide range of auditory to depression and anxiety. In addition,
pathways, the limbic system (a network tinnitus tends to be more persistent
of structures in the brain involved in and distressful if a person obsesses
memory and emotions), and the about it. Consulting with a psychologist
autonomic nervous system such that a or psychiatrist can be useful when the
person is desensitized to the tinnitus. emotional reaction to the perception of
Assessing the true effectiveness of this tinnitus becomes as troublesome as the
device will require further scientific tinnitus itself 19 and when help is
study, although observations from needed in identifying and altering
an initial stage of clinical trials indicate negative behaviors and thought
that the device can reduce the severity patterns.
of symptoms and improve quality of
life.23 Medication
No drug is available to cure tinnitus;
Tinnitus retraining therapy however, some drugs have been shown to
Tinnitus retraining therapy (TRT) is be effective in treating its psychological
designed to help a person retrain the effects. These include anti-anxiety
brain to avoid thinking about the medications in the benzodiazepine family,
tinnitus. It employs a combination of such as clonazepam (Klonopin) or
counseling and a non-masking sound lorazepam (Ativan); antidepressants in
that decreases the contrast between the the tricyclic family, such as amitiptyline
sound of the tinnitus and the (Elavil) and nortriptyline (Aventyl,
surrounding environment.24 The goal is Nortrilen, Pamelor); and some selective
not to eliminate the perception of the serotonin reuptake inhibitors (SSRIs),
tinnitus sound itself, but to retrain a such as fluoxetine (Prozac).26,27,28,29
person’s conditioned negative response
(annoyance, fear) to it.
© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 5 of 11Other drugs have been anecdotally been shown to be very short term.35
associated with relief of tinnitus. These The effect of such tinnitus treatment
include certain heart medications, is thought to occur in the central
anesthetics, antihistamines, statins, auditory pathway rather than
vitamin or mineral supplements, in the cochlea.36
vasodilators, anticonvulsants, and various Scientists demonstrated that the
homeopathic or herbal preparations. anticonvulsant gabapentin
Scientific evidence is lacking to support (Neurontin) is no more effective than
the effectiveness of many of these placebo in treatment of tinnitus.37,38
remedies.27,30,31 Some appear to be When scientists reported their
placebos, while some are possibly mildly finding that Ginkgo biloba extracts
or temporarily effective but with potential and placebo treatments produce
side effects that are serious. very similar results, they also noted
that use of the extract could lead to
Examples of recent research studies on adverse side effects, especially if
some of these anecdotal treatments used unsupervised and with other
follow, although this list is not medications.39,40
exhaustive:
In assessing the effectiveness of Some alternative approaches may
atorvastatin (Lipitor) in the eventually yield helpful options in
treatment of tinnitus, scientists tinnitus treatment. However, most
observed a trend toward relief of scientists agree that additional well-
symptoms; however, this trend was constructed research is needed before
not statistically significant when any anecdotally associated preparation
compared with results produced by can be applied as a proven and effective
administration of a placebo.32 treatment option.
The relationship between low blood
zinc levels and subjective tinnitus Surgery
was inspected in a small placebo- Treating tinnitus with surgery is
controlled study. Administration of generally limited to being a possible
oral zinc medication produced results secondary outcome of surgery that is
that prompted the researchers to used in cases when the source of the
note that additional tests were tinnitus is identified (such as acoustic
needed to investigate whether neuroma, perilymph fistula, or
duration of treatment might be a otosclerosis) and surgical intervention is
significant factor.33 required to treat that condition.41
Immediate suppression of subjective
tinnitus has been observed in Other proposed treatments
patients administered intravenous Stress-reduction techniques are often
lidocaine,34 although such relief has advocated for improving general health,
© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 6 of 11as they can help control muscle groups at home and avoiding listening to music
and improve circulation throughout the at high volume can both help reduce
body. Such relaxation training, risk.48
the use of biofeedback to augment
relaxation exercises, and hypnosis have Other important factors are exercising
been suggested as treatments for daily, getting adequate rest, and having
tinnitus. Limited research is available on blood pressure monitored and controlled,
the effectiveness of these methods. if needed. Additional precautionary
measures include limiting salt intake,
Acupuncture, electrical stimulation, avoiding stimulants such as caffeine and
application of magnets, electromagnetic nicotine, and avoiding ototoxic drugs
stimulation, and ultrasound have been known to increase tinnitus (some of
found to be placebo treatments for which are listed above under “Causes and
tinnitus or to have limited scientific Related Factors”).
support for their effectiveness.27,30,42,43
Summary
Recent and ongoing research studies Tinnitus is a common condition that can
have attempted to assess whether disrupt a person’s life. Our understanding
transcranial magnetic stimulation could of the mechanisms of tinnitus is
be an effective tinnitus treatment. This incomplete, and many unknown factors
application is based on the thought that remain. These limitations contribute to
tinnitus is associated with an irregular the lack of medical consensus
activation of the temporoparietal cortex about tinnitus management, stimulate
(a part of the brain), and thus that continued research efforts, and motivate
disturbing this irregular activation could anecdotal and commercially based
result in transient reduction of speculation about potential but unproven
tinnitus.44,45,46 treatments. Prior to receiving any
treatment for tinnitus or head noise, it is
Prevention important for a person to have a
Precautionary measures to help lessen thorough examination that includes an
the severity of tinnitus or help a person evaluation by a physician. Understanding
cope with tinnitus are related to some of the tinnitus and its possible causes is an
the causes and treatments listed above. essential part of its treatment.
Avoiding exposure to loud sounds
(especially work-related noise) and References
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Martin W. Effects of repetitive transcranial
magnetic stimulation (rTMS) on chronic VEDA’s publications are protected under
tinnitus. Acta Oto-laryngologica copyright. For more information, see our
Supplementum 2006;556:96–101. permissions guide at www.vestibular.org.
46. Smith JA, Mennemeier M, Bartel T,
Chelette KC, Kimbrell T, Triggs W, This document is not intended as a substitute
for professional health care.
Dornhoffer JL. Repetitive transcranial
magnetic stimulation for tinnitus: a pilot
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