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Causes and related factors
Tinnitus retraining therapy
Psychological treatments
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© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 1 of 11

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Tinnitus: Ringing in the Ears

An Overview

By the Vestibular Disorders Association

What is tinnitus?

Tinnitus is abnormal noise perceived in

one or both ears or in the head. Tinnitus

(pronounced either “TIN-uh-tus” or “tin-

NY-tus”) may be intermittent, or it might

appear as a constant or continuous

sound. It can be experienced as a ringing,

hissing, whistling, buzzing, or clicking

sound and can vary in pitch from a low

roar to a high squeal.

Tinnitus is very common. Most studies

indicate the prevalence in adults as falling

within the range of 10% to 15%, with a

greater prevalence at higher ages,

through the sixth or seventh decade of

life.

1

Gender distinctions are not

consistently reported across studies, but

tinnitus prevalence is significantly higher

in pregnant than non-pregnant women.

The most common form of tinnitus is

subjective tinnitus, which is noise that

other people cannot hear. Objective

tinnitus can be heard by an examiner

positioned close to the ear. This is a rare

form of tinnitus, occurring in less than 1%

of cases.

Chronic tinnitus can be annoying,

intrusive, and in some cases devastating

to a person’s life. Up to 25% of those

with chronic tinnitus find it severe enough

to seek treatment.

It can interfere with a

person’s ability to hear, work, and

perform daily activities. One study

showed that 33% of persons being

treated for tinnitus reported that it

disrupted their sleep, with a greater

degree of disruption directly related to

the perceived loudness or severity of the

tinnitus.

5,6

Causes and related factors

Most tinnitus is associated with damage

to the auditory (hearing) system,

although it can also be associated with

other events or factors: jaw, head, or

neck injury; exposure to certain drugs;

nerve damage; or vascular (blood-flow)

problems. With severe tinnitus in adults,

coexisting factors may include hearing

loss, dizziness, head injury, sinus and

middle-ear infections, or mastoiditis

(infection of the spaces within the

mastoid bone). Significant factors

associated with mild tinnitus may include

meningitis (inflammation of the membra-

nous covering of the brain and spinal

cord), dizziness, migraine, hearing loss,

or age.

Forty percent of tinnitus patients have

decreased sound tolerance, identified as

the sum of hyperacusis (perception of

over-amplification of environmental

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◦ Page 2 of 11

sounds) and misophonia/ phonophobia

(dislike/fear of environmental sounds).

While most cases of tinnitus are

associated with some form of hearing

impairment, up to 18% of cases do not

involve reports of abnormal hearing.

Ear disorders

Hearing loss from exposure to loud

noise:

Acute hearing depends on the

microscopic endings of the hearing nerve

in the inner ear. Exposure to loud noise

can injure these nerve endings and result

in hearing loss. Hearing damage from

noise exposure is considered to

be the leading cause of tinnitus.

Presbycusis: Tinnitus can also be related

to the general impairment of the hearing

nerve that occurs with aging, known as

presbycusis. Age-related degeneration of

the inner ear occurs in 30% of persons

age 65–74, and in 50% of persons 75

years or older.

Middle-ear problems: Tinnitus is

reported in 65% of persons who have

preoperative otosclerosis (stiffening of

the middle-ear bones),

with the tinnitus

sound typically occurring as a high-

pitched tone or white noise rather than

as a low tone.

Otitis media (middle-ear

infection) can be accompanied by

tinnitus, which usually disappears when

the infection is treated. If repeated infec-

tions cause a cholesteatoma (benign

mass of skin cells in the middle ear

behind the eardrum), hearing loss, tinni-

tus, and other symptoms can result.

Objective tinnitus has been associated

with myoclonus (contraction or twitching)

of the small muscles in the middle

ear.

14,15

Conductive hearing loss resulting

from an accumulation of earwax in the

ear canal can sometimes cause tinnitus.

Vestibular disorders: Hearing

impairment and related tinnitus often

accompany dysfunction of the balance

organs (vestibular system). Some ves-

tibular disorders associated with tinnitus

include Ménière’s disease and secondary

endolymphatic hydrops (resulting from

abnormal amounts of a fluid called

endolymph collecting in the inner ear)

and perilymph fistula (a tear or defect in

one or both of the thin membranes

between the middle and inner ear).

Vestibulo-cochlear nerve damage

and central auditory system changes

The vestibulo-cochlear nerve, or eighth

cranial nerve, carries signals from the

inner ear to the brain. Tinnitus can result

from damage to this nerve. Such damage

can be caused by an acoustic neuroma,

also known as a vestibular schwannoma

(benign tumor on the vestibular portion

of the nerve), vestibular neuritis (viral

infection of the nerve), or microvascular

compression syndrome (irritation of the

nerve by a blood vessel).

The perception of chronic tinnitus has

also been associated with hyperactivity

in the central auditory system, especially

in the auditory cortex.

In such cases,

the tinnitus is thought to be triggered by

damage to the cochlea (the peripheral

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◦ Page 3 of 11

hearing structure) or the vestibulo-

cochlear nerve.

Head and neck trauma

Compared with tinnitus from other

causes, tinnitus due to head or neck

trauma tends to be perceived as louder

and more severe. It is accompanied by

more frequent headaches, greater

difficulties with concentration and

memory, and a greater likelihood of

depression.

Somatic tinnitus is the term used when

the tinnitus is associated with head, neck,

or dental injury—such as misalignment of

the jaw or temporomandibular joint

(TMJ)—and occurs in the absence of

hearing loss. Characteristics of somatic

tinnitus include intermittency, large

fluctuations in loudness, and variation in

the perceived location and pattern of its

occurrence throughout the day.

Medications

Many drugs can cause or increase

tinnitus. These include certain non-

steroidal anti-inflammatory drugs

(NSAIDs, such as Motrin, Advil, and

Aleve), certain antibiotics (such as

gentamicin and vancomycin), loop

diuretics (such as Lasix), aspirin and

other salicylates, quinine-containing

drugs, and chemotherapy medications

(such as carboplatin and cisplatin).

Depending on the medication dosage, the

tinnitus can be temporary or permanent.

Vascular sources

Pulsatile tinnitus is a rhythmic pulsing

sound that sometimes occurs in time

with the heartbeat. This is typically a

result of noise from blood vessels close

to the inner ear. Pulsatile tinnitus

is usually not serious. However,

sometimes it is associated with serious

conditions such as high or low blood

pressure, hardening of the arteries

(arteriosclerosis), anemia, vascular

tumor, or aneurysm.

Other possible causes

Other conditions have been linked to

tinnitus: high stress levels, the onset of

a sinus infection or cold, autoimmune

disorders (such as rheumatoid arthritis

or lupus), hormonal changes, diabetes,

fibromyalgia, Lyme disease, allergies,

depletion of cerebrospinal fluid, vitamin

deficiency, and exposure to lead. In

addition, excessive amounts of alcohol or

caffeine exacerbate tinnitus in some

people.

Diagnosis

Examination by a primary care physician

will help rule out certain sources of

tinnitus, such as blood pressure or

medication problems. This doctor can

also, if necessary, provide a referral

to an ear, nose, and throat specialist (an

otolaryngologist, otologist, or

neurotologist), who will examine the ears

and hearing, in consultation with an

audiologist. Their evaluations might

involve extensive testing that can include

an audiogram (to measure hearing), a

tympanogram (to measure the stiffness

of the eardrum and help detect the

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◦ Page 4 of 11

presence of fluid in the middle ear),

otoacoustic emissions testing (to provide

information about how the hair cells of

the cochlea are working), an auditory

brainstem response test (to measure how

hearing signals travel from the ear to the

brain and then within parts of the brain),

electrocochleography (to measure how

sound signals move from the ear along

the beginning of the hearing nerve),

vestibular-evoked myogenic potentials

(to test the functioning of the saccule

and/or inferior vestibular nerve), blood

tests, and magnetic resonance imaging

(MRI). Neuropsychological testing is also

sometimes included to screen for the

presence of anxiety, depression, or

obsessiveness—which are understandable

and not uncommon effects when tinnitus

has disrupted a person’s life.

Treatment

If a specific cause of the tinnitus is

identified, treatment may be available to

relieve it. For example, if TMJ

dysfunction is the cause, a dentist may

be able to relieve symptoms by

realigning the jaw or adjusting the bite

with dental work. If an infection is the

cause, successful treatment of the

infection may reduce or eliminate the

tinnitus.

Many cases of tinnitus have no

identifiable cause, however, and thus

are more difficult to treat. Although a

person’s tolerance of tinnitus tends to

increase with time,

severe cases can

be disturbing for many years. In such

chronic cases, a variety of treatment

approaches are available, including

medication, dietary adjustments,

counseling, and devices that help mask

the sound or desensitize a person to it.

Not every treatment works for every

person.

Masking devices

A masking device emits sound that

obscures, though does not eliminate, the

tinnitus noise. The usefulness of maskers

is based on the observation that tinnitus

is usually more bothersome in quiet

surroundings

and that a competing

sound at a constant low level, such as a

ticking clock, whirring fan, ocean surf,

radio static, or white noise produced by a

commercially available masker, may

disguise or reduce the sound of tinnitus,

thus making it less noticeable. Some

tinnitus sufferers report that they sleep

better when they use a masker. In some

users, maskers produce residual

inhibition—tinnitus suppression that lasts

for a short while after the masker has

been turned off.

Hearing aids are sometimes used as

maskers. If hearing loss is involved,

properly fitted hearing aids can improve

hearing and may reduce tinnitus

temporarily. However, tinnitus can

actually worsen if the hearing aid is set at

an excessively loud level.

Cochlear implants, used for persons who

are profoundly deaf or severely hard-of-

hearing, have been shown to suppress

tinnitus in up to 92% of patients.

21,22

This is likely a result of masking due to

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◦ Page 5 of 11

newly perceived ambient sounds or from

electrical stimulation of the auditory

nerve.

Other devices under development may

eventually prove effective in relieving

tinnitus. For example, the recently

introduced acoustics-based Neuromonics

device involves working with an

audiologist who matches the frequency

spectrum of the perceived tinnitus

sound to music that overlaps this

spectrum. This technique aims to

stimulate a wide range of auditory

pathways, the limbic system (a network

of structures in the brain involved in

memory and emotions), and the

autonomic nervous system such that a

person is desensitized to the tinnitus.

Assessing the true effectiveness of this

device will require further scientific

study, although observations from

an initial stage of clinical trials indicate

that the device can reduce the severity

of symptoms and improve quality of

life.

Tinnitus retraining therapy

Tinnitus retraining therapy (TRT) is

designed to help a person retrain the

brain to avoid thinking about the

tinnitus. It employs a combination of

counseling and a non-masking sound

that decreases the contrast between the

sound of the tinnitus and the

surrounding environment.

The goal is

not to eliminate the perception of the

tinnitus sound itself, but to retrain a

person’s conditioned negative response

(annoyance, fear) to it.

In one comparison of the effectiveness of

tinnitus masking and TRT as treatments,

masking was found to provide the

greatest benefit in the short term (three

to six months), while TRT provided the

greatest improvement with continued

treatment over time (12–18 months).

Psychological treatments

Chronic tinnitus can disrupt

concentration, sleep patterns, and

participation in social activities, leading

to depression and anxiety. In addition,

tinnitus tends to be more persistent

and distressful if a person obsesses

about it. Consulting with a psychologist

or psychiatrist can be useful when the

emotional reaction to the perception of

tinnitus becomes as troublesome as the

tinnitus itself

and when help is

needed in identifying and altering

negative behaviors and thought

patterns.

Medication

No drug is available to cure tinnitus;

however, some drugs have been shown to

be effective in treating its psychological

effects. These include anti-anxiety

medications in the benzodiazepine family,

such as clonazepam (Klonopin) or

lorazepam (Ativan); antidepressants in

the tricyclic family, such as amitiptyline

(Elavil) and nortriptyline (Aventyl,

Nortrilen, Pamelor); and some selective

serotonin reuptake inhibitors (SSRIs),

such as fluoxetine (Prozac).

26,27,28,29

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◦ Page 6 of 11

Other drugs have been anecdotally

associated with relief of tinnitus. These

include certain heart medications,

anesthetics, antihistamines, statins,

vitamin or mineral supplements,

vasodilators, anticonvulsants, and various

homeopathic or herbal preparations.

Scientific evidence is lacking to support

the effectiveness of many of these

remedies.

27,30,31

Some appear to be

placebos, while some are possibly mildly

or temporarily effective but with potential

side effects that are serious.

Examples of recent research studies on

some of these anecdotal treatments

follow, although this list is not

exhaustive:



In assessing the effectiveness of

atorvastatin (Lipitor) in the

treatment of tinnitus, scientists

observed a trend toward relief of

symptoms; however, this trend was

not statistically significant when

compared with results produced by

administration of a placebo.



The relationship between low blood

zinc levels and subjective tinnitus

was inspected in a small placebo-

controlled study. Administration of

oral zinc medication produced results

that prompted the researchers to

note that additional tests were

needed to investigate whether

duration of treatment might be a

significant factor.



Immediate suppression of subjective

tinnitus has been observed in

patients administered intravenous

lidocaine,

although such relief has

been shown to be very short term.

The effect of such tinnitus treatment

is thought to occur in the central

auditory pathway rather than

in the cochlea.



Scientists demonstrated that the

anticonvulsant gabapentin

(Neurontin) is no more effective than

placebo in treatment of tinnitus.

37,38



When scientists reported their

finding that Ginkgo biloba extracts

and placebo treatments produce

very similar results, they also noted

that use of the extract could lead to

adverse side effects, especially if

used unsupervised and with other

medications.

39,40

Some alternative approaches may

eventually yield helpful options in

tinnitus treatment. However, most

scientists agree that additional well-

constructed research is needed before

any anecdotally associated preparation

can be applied as a proven and effective

treatment option.

Surgery

Treating tinnitus with surgery is

generally limited to being a possible

secondary outcome of surgery that is

used in cases when the source of the

tinnitus is identified (such as acoustic

neuroma, perilymph fistula, or

otosclerosis) and surgical intervention is

required to treat that condition.

Other proposed treatments

Stress-reduction techniques are often

advocated for improving general health,

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◦ Page 7 of 11

as they can help control muscle groups

and improve circulation throughout the

body. Such relaxation training,

the use of biofeedback to augment

relaxation exercises, and hypnosis have

been suggested as treatments for

tinnitus. Limited research is available on

the effectiveness of these methods.

Acupuncture, electrical stimulation,

application of magnets, electromagnetic

stimulation, and ultrasound have been

found to be placebo treatments for

tinnitus or to have limited scientific

support for their effectiveness.

27,30,42,43

Recent and ongoing research studies

have attempted to assess whether

transcranial magnetic stimulation could

be an effective tinnitus treatment. This

application is based on the thought that

tinnitus is associated with an irregular

activation of the temporoparietal cortex

(a part of the brain), and thus that

disturbing this irregular activation could

result in transient reduction of

tinnitus.

44,45,46

Prevention

Precautionary measures to help lessen

the severity of tinnitus or help a person

cope with tinnitus are related to some of

the causes and treatments listed above.

Avoiding exposure to loud sounds

(especially work-related noise) and

getting prompt treatment for ear

infections have been identified as the two

most important interventions for reducing

the risk of tinnitus.

Wearing ear

protection against loud noise at work or

at home and avoiding listening to music

at high volume can both help reduce

risk.

Other important factors are exercising

daily, getting adequate rest, and having

blood pressure monitored and controlled,

if needed. Additional precautionary

measures include limiting salt intake,

avoiding stimulants such as caffeine and

nicotine, and avoiding ototoxic drugs

known to increase tinnitus (some of

which are listed above under “Causes and

Related Factors”).

Summary

Tinnitus is a common condition that can

disrupt a person’s life. Our understanding

of the mechanisms of tinnitus is

incomplete, and many unknown factors

remain. These limitations contribute to

the lack of medical consensus

about tinnitus management, stimulate

continued research efforts, and motivate

anecdotal and commercially based

speculation about potential but unproven

treatments. Prior to receiving any

treatment for tinnitus or head noise, it is

important for a person to have a

thorough examination that includes an

evaluation by a physician. Understanding

the tinnitus and its possible causes is an

essential part of its treatment.

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permissions guide at www.vestibular.org.

This document is not intended as a substitute

for professional health care.

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