What is tinnitus and how common is it?
Tinnitus (ringing in the ears) is the perception of ringing, humming, buzzing or whistling in the ear or inside the head even though there is no real external sound source. It is not a disease but a symptom of an underlying problem. It is very common in the population; a significant proportion of adults experience temporary tinnitus at some point in their lives, while in some the complaint becomes permanent and can reach a level that affects quality of life. Its frequency increases with age, because there is a strong link between hearing loss and tinnitus.
What are the symptoms?
Patients may describe the sound as ringing, humming, buzzing, whistling, a cricket-like chirping or a sound that beats like a pulse. The sound may be in one ear or both, and may be heard continuously or intermittently. It is more likely to be noticed in quiet surroundings, especially at night before going to sleep, because ambient noise cannot mask it. In some patients tinnitus is accompanied by hearing loss, a feeling of fullness in the ear or dizziness. Long-standing tinnitus can lead to sleep disturbance, difficulty concentrating, anxiety and, over time, depressive symptoms; for this reason, the effect on the person’s quality of life is as important in the evaluation as the severity of the complaint.
Causes and risk factors
The most common cause is hearing loss due to damage to the hearing cells in the inner ear; this damage can develop naturally with age, or it can result from long-term noise exposure. A single exposure to sudden, intense noise (such as an explosion or a loud concert) can also lead to permanent tinnitus. Earwax blocking the outer ear canal, middle ear infection, middle ear diseases such as otosclerosis, Meniere’s disease and certain medications (high-dose aspirin, certain antibiotics and chemotherapy drugs) are among the conditions that can cause tinnitus. High blood pressure, vascular abnormalities or benign tumours around the inner ear nerve (vestibular schwannoma) are rare but important causes of pulsatile (pulse-like) or one-sided tinnitus. Stress, lack of sleep and excessive caffeine intake can worsen existing tinnitus, but they are less likely to cause it on their own.
When should you see a doctor?
Seeing an ENT specialist is recommended for one-sided tinnitus, tinnitus accompanied by hearing loss or dizziness, pulsatile tinnitus and complaints lasting longer than a few weeks. Tinnitus accompanied by sudden hearing loss is regarded as an emergency; in this case an ENT specialist should be seen the same day, without waiting, because starting treatment early directly affects the chance of recovery.
Diagnostic process
The evaluation begins with a detailed history (the onset and character of the tinnitus, whether it is one-sided or two-sided, noise exposure, medications being used) and an ear examination. On otoscopic examination the outer ear canal and eardrum are assessed; simple causes such as an earwax blockage can be identified at this stage. Audiometry (a hearing test) is performed to assess hearing function; this test both reveals the relationship between the tinnitus and hearing loss and forms the basis for treatment planning. In cases of one-sided tinnitus, asymmetric hearing loss or suspected neurological signs, magnetic resonance imaging (MRI) is requested to evaluate the inner ear nerve and the surrounding structures. In pulsatile tinnitus, imaging can be extended to investigate vascular causes. Where necessary, blood pressure measurement and blood tests are also added to the evaluation.
Treatment options
Cause-directed treatment
Treatment is directed first and foremost at the underlying cause. In tinnitus due to an earwax blockage, removing the wax markedly reduces the complaint in most patients and may eliminate it completely; however, complete resolution cannot be guaranteed in every patient. In conditions such as middle ear infection or otosclerosis, the relevant treatment (antibiotics, surgery) is given. If a medication thought to be causing the tinnitus is being used, a change of medication is considered where possible. In tinnitus due to Meniere’s disease, efforts are made to bring the complaints under control with salt restriction, diuretic treatment and management of attacks. If a structural cause such as a vestibular schwannoma is found, observation, radiotherapy or surgery are considered depending on its size and rate of growth.
Symptomatic and supportive treatment
When the underlying cause cannot be corrected or no clear cause can be found (idiopathic tinnitus), treatment aims to manage the complaint and make it easier for the patient to cope with the sound. If there is accompanying hearing loss, using a hearing aid both improves hearing and, by amplifying ambient sounds, makes the tinnitus less noticeable. With sound therapy, low-level white noise or nature sounds are used to prevent the tinnitus sound from becoming dominant. Tinnitus retraining therapy is a method that combines counselling and sound therapy and aims to reduce the brain’s reaction to the tinnitus sound over time. Relaxation techniques, improving sleep patterns and, where needed, psychological support for managing anxiety can also be added to treatment.
Recovery and follow-up
In tinnitus due to earwax or simple middle ear problems, correcting the underlying cause reduces the complaint in a short time in most patients and may eliminate it completely; complete resolution cannot be guaranteed in every patient. In chronic tinnitus due to hearing loss, since the aim is not to eliminate the complaint completely but to make it easier for the person to cope with the sound, the effect of methods such as sound therapy and tinnitus retraining therapy usually appears gradually over weeks to months. Regular follow-up is important for monitoring changes in hearing function, assessing the response to treatment and updating the approach when necessary. In patients with pulsatile or one-sided tinnitus, follow-up is continued in cooperation with the relevant specialties (such as neurology and neurosurgery) depending on the imaging results.
Prevention
Using ear protection in noisy environments, keeping the volume below 60 percent of the maximum when listening to music through headphones, and avoiding putting objects such as cotton swabs into the ear are important simple measures for reducing the risk of developing tinnitus. Wearing ear protection during one-off intense noise exposures such as loud concerts, workshop environments or the use of firearms is also effective in preventing sudden and permanent hearing damage. Regular exercise, a balanced diet and keeping blood pressure under control can indirectly reduce the risk of tinnitus by supporting blood circulation in the inner ear.
The psychological impact of tinnitus and quality of life
Over time, some patients with chronic tinnitus may develop distractibility, sleep disturbance, increased anxiety and, in some cases, depressive symptoms. This is related less to the loudness of the sound than to the attention and meaning the person attaches to it; tinnitus of the same loudness may be barely noticeable to one person yet cause serious distress to another. For this reason, the treatment plan addresses not only the sound itself but also the reaction the person develops to it. Cognitive behavioural therapy is a method that has been found effective in managing tinnitus-related anxiety and sleep problems, and when necessary it can be combined with tinnitus retraining therapy or sound therapy. Staying in regular contact with a specialist — without taking the complaints lightly, but also without falling into unnecessary worry — is one of the most important parts of long-term management.
Differences in tinnitus in children and older adults
In children, tinnitus can develop as a result of middle ear infections or an earwax blockage; when the underlying cause is treated, it usually decreases markedly or disappears. Because children may not be able to describe their complaints adequately, it may be noticed through changes in behaviour, distractibility or sleep problems; for this reason it is important for parents to take the complaints their children voice seriously. In older adults, tinnitus is mostly seen together with age-related hearing loss (presbycusis) and is usually two-sided; in this group, using a hearing aid both improves hearing and makes coping with tinnitus markedly easier.
Frequently asked questions
Is ringing in the ears always a sign of a serious disease? No, it is most often related to age-related changes in the inner ear or temporary noise exposure. However, tinnitus that is one-sided, pulsatile or accompanied by hearing loss must always be evaluated.
Does tinnitus go away completely? It depends on the cause; tinnitus due to earwax or middle ear problems usually decreases once the cause is corrected and may disappear completely; complete resolution cannot be guaranteed in every patient. In chronic tinnitus due to hearing loss, the aim is less to eliminate the sound completely than to make it easier for the person to cope with it.
What should I do if I have tinnitus together with sudden hearing loss? This is an emergency; because starting treatment early increases the chance of recovery, an ENT specialist should be consulted the same day, without waiting.
Does a hearing aid help with tinnitus? Yes, especially in patients with accompanying hearing loss, a hearing aid both improves hearing and can reduce how noticeable the tinnitus is.
Do caffeine and stress make tinnitus worse? Although they do not directly cause it, they can worsen existing tinnitus; regular sleep, stress management and cutting down on caffeine can help ease the complaints.
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Back to the short articleThis article is for general information; please consult your physician for diagnosis and treatment.