Ringing in the ears (tinnitus) is noise originating in the ear rather than in the environment. It is a symptom and not a specific disease. Tinnitus is very common—10 to 15% of people experience it to some degree.

The noise heard by people with tinnitus may be a buzzing, ringing, roaring, whistling, or hissing sound and is often associated with hearing loss. Some people hear more complex sounds that may be different at different times. These sounds are more noticeable in a quiet environment and when people are not concentrating on something else. Thus, tinnitus tends to be most disturbing to people when they are trying to sleep. However, the experience of tinnitus is highly individual. Some people are very disturbed by their symptoms, whereas others find them quite bearable.

Subjective tinnitus is by far the most common type. It is caused by abnormal activity in the part of the brain responsible for processing sound (auditory cortex). Doctors do not fully understand how this abnormal activity develops.

Objective tinnitus is much less common. It represents actual noise created by structures near the ear. Other people can sometimes hear the sounds of objective tinnitus if they listen closely.

Causes

Subjective tinnitus: More than 75% of ear-related disorders include tinnitus as a symptom. The most common causes include

• Exposure to loud noises or explosions (acoustic trauma)
• Aging
• Certain drugs that damage the ear (ototoxic drugs)
• Meniere disease (see Inner Ear Disorders: Meniere Disease)

Other causes include middle ear infections, disorders that block the ear canal (such as an external ear infection [external otitis], excessive ear wax, or foreign bodies), problems with the eustachian tube (which connects the middle ear and the back of the nose) caused by allergies or other causes of obstruction, and otosclerosis (a disorder of excess bone growth in the middle ear). An uncommon but serious cause is an acoustic neuroma, a noncancerous (benign) tumor of part of the nerve leading from the inner ear.

Objective tinnitus: Objective tinnitus usually involves noise from blood vessels near the ear. In such cases, the sound comes with each beat of the pulse (pulsatile). Causes include

• Turbulent flow through the carotid artery or jugular vein
• Certain middle ear tumors that are rich in blood vessels
• Malformed blood vessels of the membrane covering the brain

The most common noise is the sound of rapid or turbulent blood flow in major vessels of the neck. This abnormal blood flow may occur because of a reduced red blood cell count (anemia) or a blockage of the arteries (atherosclerosis) and may be worsened in people with poorly controlled high blood pressure (hypertension). Some small tumors of the middle ear called glomus tumors are rich in blood vessels. Although the tumors are small, they are very near the sound-receiving structures of the ear, and blood flow through them can sometimes be heard (only in one ear). Sometimes, blood vessel malformations that involve abnormal connections between arteries and veins (arteriovenous malformations) develop in the membrane covering the brain (the dura). If these malformations are near the ear, the person sometimes can hear blood flowing through them.

Less commonly, spasms of muscles of the palate or the small muscles of the middle ear cause clicking sounds. These sounds do not follow the beat of the pulse. Such spasms often have no known cause but may be due to tumors, head injury, or diseases that affect the covering of nerves (for example, multiple sclerosis).

Evaluation

Not all tinnitus requires evaluation by a doctor. The following information can help people decide whether a doctor's evaluation is needed and help them know what to expect during the evaluation.

Warning signs: Certain symptoms and characteristics are cause for concern. They include

• Tinnitus in only one ear
• Any neurologic symptoms (other than hearing loss), particularly difficulty with balance or walking, but also vertigo or difficulty seeing, speaking, swallowing, and/or talking

When to see a doctor: People with warning signs should see a doctor right away. People without warning signs in whom tinnitus recently developed should call their doctor, as should people with pulsatile tinnitus. Most people with tinnitus and no warning signs have had tinnitus for a long time. They can discuss the matter with their doctor and be seen at a mutually convenient time.

What the doctor does: Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination may suggest a cause of the tinnitus and the tests that may need to be done (see Table 3: Symptoms of Ear Disorders: Some Causes and Features of Tinnitus).

During the medical history, doctors ask about the following:

• The nature of the tinnitus, including whether it is in one or both ears and whether it is constant or pulsatile
• Whether the person has any neurologic symptoms
• Whether the person has been exposed to loud noise or to drugs that can affect the ears

During the physical examination, doctors focus on examining the ears (including hearing) and the neurologic system. They also listen with a stethoscope over and near the person's ear and on the neck for sounds of objective tinnitus. The findings often suggest a cause (see Table 3: Symptoms of Ear Disorders: Some Causes and Features of Tinnitus).

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Some Causes and Features of Tinnitus Cause Common Features* Tests Subjective tinnitus (typically a constant tone and accompanied by some degree of hearing loss) Acoustic trauma (noise-induced hearing loss) History of occupational or recreational exposure to noise Hearing loss A doctor's examination† Aging (presbycusis) Progressive hearing loss, often with family history A doctor's examination† Barotrauma (ear damage due to sudden pressure change) Clear history of ear damage A doctor's examination† Brain tumors (such as acoustic neuroma or meningioma) Tinnitus and often hearing loss in only one ear Sometimes other neurologic abnormalities Gadolinium-enhanced MRI Audiometry Drugs (particularly aspirin, aminoglycoside antibiotics, certain diuretics, and some chemotherapy drugs, including cisplatin) Tinnitus beginning in both ears shortly after starting use of drug Except with aspirin, hearing loss also possible With aminoglycoside antibiotics, possible dizziness and problems with balance A doctor's examination† Eustachian tube dysfunction Often a long history of decreased hearing and frequent colds, and problems clearing ears with air travel or other pressure change May be in one or both ears (often one ear more of a problem than the other) Audiometry Tympanometry Infections (such as otitis media, labyrinthitis, meningitis, or syphilis) History of such infection A doctor's examination† Meniere disease Repeated episodes of hearing loss, tinnitus, and/or fullness in one ear, and severe vertigo Audiometry Vestibular testing Gadolinium-enhanced MRI to rule out acoustic neuroma Obstruction of ear canal (due to wax, foreign object, or external otitis) Only one ear affected Visible abnormalities seen during ear examination, including discharge with external otitis A doctor's examination† Objective tinnitus (typically pulsatile or intermittent) Artery and vein (arteriovenous) malformations of the dura Constant, pulsatile tinnitus in only one ear Usually no other symptoms Possible humming or pulsing noise over the skull heard during examination Magnetic resonance angiography (MRA) or angiography Spasm of muscles of the palate or of the middle ear Irregular clicking or mechanical-sounding noise Possibly other neurologic symptoms (when the cause of the spasm is a neurologic disease such as multiple sclerosis) Possible movement of the palate and/or eardrum when symptoms occur MRI Turbulent blood flow in carotid artery or jugular vein Possible humming or pulsing noise heard over the neck during examination The noise may stop when the doctor pushes on the jugular vein and/or has people turn their head to the side A doctor's examination† Vascular middle ear tumors (such as glomus tumors) Constant, pulsatile tinnitus in only one ear Possible pulsing noise heard over the affected ear during examination Sometimes doctors can see the tumor behind the eardrum when they look in the ear canal with a light CT MRI Angiography (usually done before surgery) *Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present. †Most doctors routinely do a full hearing test (audiometry). CT = computed tomography; MRI = magnetic resonance imaging. Some Causes and Features of Tinnitus Cause Common Features* Tests Subjective tinnitus (typically a constant tone and accompanied by some degree of hearing loss) Acoustic trauma (noise-induced hearing loss) History of occupational or recreational exposure to noise Hearing loss A doctor's examination† Aging (presbycusis) Progressive hearing loss, often with family history A doctor's examination† Barotrauma (ear damage due to sudden pressure change) Clear history of ear damage A doctor's examination† Brain tumors (such as acoustic neuroma or meningioma) Tinnitus and often hearing loss in only one ear Sometimes other neurologic abnormalities Gadolinium-enhanced MRI Audiometry Drugs (particularly aspirin, aminoglycoside antibiotics, certain diuretics, and some chemotherapy drugs, including cisplatin) Tinnitus beginning in both ears shortly after starting use of drug Except with aspirin, hearing loss also possible With aminoglycoside antibiotics, possible dizziness and problems with balance A doctor's examination† Eustachian tube dysfunction Often a long history of decreased hearing and frequent colds, and problems clearing ears with air travel or other pressure change May be in one or both ears (often one ear more of a problem than the other) Audiometry Tympanometry Infections (such as otitis media, labyrinthitis, meningitis, or syphilis) History of such infection A doctor's examination† Meniere disease Repeated episodes of hearing loss, tinnitus, and/or fullness in one ear, and severe vertigo Audiometry Vestibular testing Gadolinium-enhanced MRI to rule out acoustic neuroma Obstruction of ear canal (due to wax, foreign object, or external otitis) Only one ear affected Visible abnormalities seen during ear examination, including discharge with external otitis A doctor's examination† Objective tinnitus (typically pulsatile or intermittent) Artery and vein (arteriovenous) malformations of the dura Constant, pulsatile tinnitus in only one ear Usually no other symptoms Possible humming or pulsing noise over the skull heard during examination Magnetic resonance angiography (MRA) or angiography Spasm of muscles of the palate or of the middle ear Irregular clicking or mechanical-sounding noise Possibly other neurologic symptoms (when the cause of the spasm is a neurologic disease such as multiple sclerosis) Possible movement of the palate and/or eardrum when symptoms occur MRI Turbulent blood flow in carotid artery or jugular vein Possible humming or pulsing noise heard over the neck during examination The noise may stop when the doctor pushes on the jugular vein and/or has people turn their head to the side A doctor's examination† Vascular middle ear tumors (such as glomus tumors) Constant, pulsatile tinnitus in only one ear Possible pulsing noise heard over the affected ear during examination Sometimes doctors can see the tumor behind the eardrum when they look in the ear canal with a light CT MRI Angiography (usually done before surgery) *Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present. †Most doctors routinely do a full hearing test (audiometry). CT = computed tomography; MRI = magnetic resonance imaging.

Testing: Possible tests include

• Formal hearing test (including tympanometry―see Hearing Loss and Deafness: Testing)

Most people should have a formal hearing test done by either the doctor or a hearing specialist (audiologist). People with tinnitus in only one ear and hearing loss should have gadolinium-enhanced magnetic resonance imaging (MRI). People with tinnitus in only one ear and normal hearing should have an MRI if tinnitus lasts more than 6 months. People with pulsatile tinnitus often require magnetic resonance angiography (MRA—see Common Imaging Tests: Magnetic Resonance Angiography (MRA)) and sometimes angiography.

Treatment

Attempts to identify and treat the disorder causing tinnitus are often unsuccessful. However, correcting any hearing loss (for example, with a hearing aid) relieves tinnitus in some people.

Various techniques can help make tinnitus tolerable, although the ability to tolerate it varies from person to person. Many people find that background sound helps mask the tinnitus and helps them fall asleep. Some people play background music. Other people use a tinnitus masker, which is a device worn like a hearing aid that produces a constant level of neutral sounds. For the profoundly deaf, an implant in the cochlea (the organ of hearing) may reduce tinnitus but is only done for people with severe to profound hearing loss in both ears. If these standard techniques are not helpful, people may want to seek treatment in clinics that specialize in the treatment of tinnitus.

Key Points

• Most tinnitus is due to causes that are not dangerous, for example, exposure to loud noise, aging, Meniere disease, and use of certain drugs.
• In many cases, the cause is unknown.
• Findings that are of concern include tinnitus accompanied by any neurologic symptoms and tinnitus in only one ear (particularly when accompanied by hearing loss, dizziness, and/or balance difficulty).
• Tinnitus rarely can be stopped, but certain techniques help people manage their symptoms effectively.

Last full review/revision January 2013 by Debara L. Tucci, MD, MS