Tinnitus

Also known as "ringing in ears."

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credits: Sourced from the website Patient UK, authored by Dr Mary Harding, reviewed by Dr Helen Huins (see below). Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

What is tinnitus?

Tinnitus is a noise such as a ringing or buzzing that you can hear, but the noise does not come from outside your ear.

Tinnitus is when you can hear sounds inside your head that are created by your hearing sytem, not your environment. It could be a ringing, humming, pulsing or hissing. It is more prominent in quiet areas or at nighttime. It usually has no particular cause but can be treated.

You can't turn it off or move away from it, so it can be spectacularly annoying.

How bothersome tinnitus is varies vastly between different people or in the same person over time. It may be there a lot of the time, occasionally, or fluctuate between the two. It can involve one ear or both.

Tinnitus is a symptom rather than a disease.

Why do I have it?

There are a number of reasons for tinnitus. The most common situation is that it often comes as an unwanted "added extra" when you develop age-related hearing loss. It may also occur as a consequence of exposure to loud noise, or from working in a noisy place for a long time. Sometimes it is a symptom of other medical conditions, such as Ménière's disease, ear infections or inner ear conditions. Occasionally it's caused by a build-up of wax in the ear (although usually this affects your hearing or you are aware of a blocked feeling in your ear rather than tinnitus). Sometimes there is no obvious reason.

Tinnitus symptoms

Tinnitus is an abnormal noise (or noises) that you can hear. However, the noise does not come from outside your ear.

The sorts of noises that people hear include:

• Ringing
• Buzzing
• Whistles
• Roaring
• Humming
• Machine-type noises
• A pulse or beat which is at the same rate as your pulse

Tinnitus can be either constant or come and go. It can vary in loudness and character from time to time. You can hear the noise or noises in one ear, or in both ears, or it may be difficult to pinpoint where the noise seems to come from.

The noise is often more prominent when you are in a quiet place. For example, when you are in bed and trying to get to sleep. It may also be more noticeable when you're tired.

Some people with tinnitus are also more sensitive to normal everyday sounds. For example, some people with tinnitus find that a radio or TV is painfully loud when it is at a normal volume for most people.

For most people with tinnitus, nobody else can hear the noise. In one very uncommon type of tinnitus (objective tinnitus), the noise can be heard by another person listening very carefully. This is not the usual type of tinnitus and it is rare. It is usually due to a problem with blood or blood vessels, making them pulsate differently to usual.

How common is tinnitus?

Tinnitus is common and can occur at any age. Most people have an occasional episode of tinnitus after going to a loud concert or disco. For most people, this is temporary and soon goes. As many as 1 in 10 people have persistent tinnitus that is mild and not very troublesome. However, about 1 in 100 people have tinnitus which persists most of the time, and severely affects their quality of life. 

Tinnitus causes

In many people with tinnitus, the cause is not known. Tinnitus often develops at the same time as the hearing loss of older age.

Tinnitus can be caused by age-related hearing loss, or by being exposed to a noise like working in a loud factory or being in the armed forces. Often no particular cause is found. Very rarely it can be caused by anaemia, a thyroid problem, medications like aspirin, or a problem in your brain.

In many cases

What seems to happen is that signals are sent from the ear down the ear nerve to the hearing part of the brain. The brain interprets these signals as noise. It is not clear why these signals are sent from the ear. The noise may also originate somewhere else in the hearing nerve pathways in the brain.

In some cases

Sometimes the tinnitus is caused by another condition.

For example:

• Tinnitus often develops at the same time as the hearing loss of older age.
• Ménière's disease: In this condition you develop attacks of dizziness (vertigo), hearing loss and tinnitus. It is due to a problem of the cochlea - a snail-shaped chamber filled with fluid, in the inner ear.
• Exposure to very loud noise: Some people develop persistent tinnitus after being subjected to loud noise for a long time. For example, after years of working in a loud factory. Sometimes permanent tinnitus persists after a one-off loud noise experience. For example, following a rock concert.
• As an uncommon side-effect of some medicines: For example, aspirin, non-steroidal anti-inflammatory drugs (NSAIDs) and quinine.
• Following an ear or head injury.
• Wax blocking the ear.
• Some other ear disorders such as otosclerosis.
• Some uncommon diseases of blood vessels, brain or nerves can cause tinnitus: In these situations you are likely to have other symptoms or signs such as nerve weakness, etc. However, rarely, tinnitus may be the first symptom to develop.
• Tinnitus can sometimes be a feature of a lack of iron in the body (anaemia), thyroid disease or diabetes.
• A tumour called an acoustic neuroma occasionally causes tinnitus; this is usually persistent and in one ear only. If you get the noise only in one ear, it is particularly important that you consult a doctor, so this can be ruled out.
• An ear infection: The tinnitus tends to clear when the infection clears.
• Psychological factors may have a role to play" For example, mild tinnitus that is not bothersome may become more bothersome if you become depressed, anxious or stressed.

How is tinnitus diagnosed?

• There is no definitive test for tinnitus: the diagnosis is based on what you experience.
• Your doctor may organise a hearing test.
• Occasionally a specialist ear doctor may do a brain scan.

Tinnitus tests

When you go to see the doctor, first they will have some questions to help them understand your tinnitus better, and to help them find the cause of it, if there is one. The doctor will usually examine your ears and the nerves around your face and ears.

A hearing test is usually done. In the common type of hearing test, sounds of varying frequency are played to you through headphones. You press a button when you hear a sound. This results in a graph being produced which shows if you have any hearing loss and, if so, which type of hearing loss. Along with the hearing test, you will often have tympanometry, which is a test of the eardrum and the bones of the middle of your ear. A probe is placed in your ear (which feels much like when the doctor looks inside your ear), a tone is produced and the pressures changed in your ear. The response is then measured.

An underlying ear problem can usually be ruled out by this examination and hearing test.

Further tests such as a brain scan are done in a few cases, although this is not necessary for most people with tinnitus. For example, a brain scan may be advised if you have one-sided tinnitus and an underlying brain disorder is suspected. In some cases, a blood test may be done. This might be to test to check that you don't have a problem with your thyroid gland, anaemia or diabetes if any of these are suspected.

Tinnitus treatment

In most cases there is no easy cure. Some people are helped by understanding the problem and knowing that they do not have a serious underlying condition.

There are no good medications for tinnitus but many things can help.

• Distract yourself from the tinnitus by having a window open or leaving the radio on quietly in the background.
• A sound generator (which looks like a hearing aid) produces soothing sounds and can be worn through the day.
• Tinnitus retraining therapy at a specialist clinic can be effective but takes about a year.

Is there a tinnitus cure?

In a small number of cases there is an underlying cause which may be corrected. For example, if a side-effect of a medicine that you are taking is causing tinnitus then a change of medication may cure the problem. If earwax or an ear infection is the cause then again, once this is cleared, the tinnitus settles.

Antidepressant medicines called selective serotonin reuptake inhibitors (SSRIs) have helped people in whom the tinnitus causes anxiety and/or depression.

In most cases there is no easy cure. Some people are helped by understanding the problem and knowing that they do not have a serious underlying condition. With time, the tinnitus may become less of a problem as you adjust to it.

In addition, the following often help:

Alternative sounds

If possible, avoid being in quiet or silent rooms. You are more likely to focus on the tinnitus and be distressed by it if there is nothing else to listen to. Other more pleasant sounds can be distracting and help to make the tinnitus less noticeable. This is sometimes called sound therapy. For example, listen to the radio, TV, or stereo. Perhaps leave a window open so outside sounds are more evident. Some people wear a sound generator. This looks similar to a hearing aid but makes a pleasant sound which helps to mask the unpleasant tinnitus noise. Some people use CD or MP3 players to listen to pleasant sounds.

Bedtime

Tinnitus is often most noticeable when you are quiet and trying to get off to sleep. If you play a radio or stereo it can help to mask the tinnitus noise until you drop off to sleep. (One with a timer is best so it switches itself off when you are asleep.) Some people connect a radio or stereo to special pillow speakers which go under the pillow. This enables them to listen to the music or radio without anyone else being disturbed. Some specially designed pillows have speakers actually inside the pillow itself which you connect to your radio or stereo.

Hearing aids

If you have any deafness, even just a slight hearing loss, a hearing aid may help. The aid boosts normal sounds which you may not otherwise hear. These may override the tinnitus noise.

Stress anxiety and depression

Some people become anxious or stressed by tinnitus. This can make things worse. You may benefit from learning ways to relax and to combat stress. There are other leaflets in this series which offer advice on easing stress and anxiety. If you become particularly anxious or become depressed it is best to see a doctor for advice on treatment.

Cognitive behavioural therapy is a brain-training psychological therapy which may also help you deal with the effect tinnitus has on you.

Are there specialist tinnitus clinics?

Some ear departments have specialist tinnitus clinics. These offer such things as counselling, advice on sound therapy, relaxation techniques and other advice on ways to cope with living with tinnitus.

For example, in severe cases, a treatment called tinnitus retraining therapy (TRT) may be used. Some studies show that this can help in up to three in four cases. TRT aims to help the brain learn to ignore the tinnitus. (The tinnitus is not stopped but the aim is to become less bothered by it.) TRT involves wearing a sound generator (described above). This therapy is accompanied by regular counselling sessions which aim to help you cope with the tinnitus. TRT can take as long as a year. You gradually learn not to focus on your tinnitus until it becomes much less bothersome, even without using the sound generator.

Prognosis

What is the outlook?

Many people with tinnitus improve, with or without any treatment. Between 2 and 5 out of every 10 people with tinnitus improve within five years. Even if it does not go completely, it can become less severe or less frequent. How troublesome tinnitus is tends to go up and down.

For some people, tinnitus is just a little annoying. On the other end of the scale, for others it can really reduce their enjoyment of life.

It may:

• Cause problems sleeping (insomnia).
• Cause anxiety.
• Lead to depression. Some research suggests an association with increased risk of suicide, although this has been disputed.
• Result in reduced social interaction. 

About the author

Dr Mary Harding

BA, MA, MB BChir, MRCGP, DFFP

Mary qualified at Cambridge in 1989. She joined EMIS as an author in 2013. Mary is a part-time, salaried GP at The Village Surgery, Wheathampstead and previously for 12 years in Welwyn Garden City. Mary is also an appraiser and Senior Appraiser for NHS England, in the Central Midlands area team.

Dr Helen Huins

MB BS Lond, DCH, DRCOG, MRCGP, JCPTGP, DFFP

Helen qualified at Guy’s Hospital in 1989 and left London in 1990 to settle in the countryside. She works as a GP partner in a rural dispensing practice and is passionate about family medicine and continuity of care with interests in sport and nutrition. Helen has been a member of the EMIS authoring team since 1995.

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