Tinnitus (ringing in the ears)

Tinnitus is a sound heard without any outside source producing it. Very many people know it: almost everyone has caught a ringing in the ears after a loud concert, and in some people the sound settles in for good. In itself it is not a disease but a symptom, rather like pain. And one thing is worth grasping from the outset: in most people there is nothing dangerous behind it, but there are several kinds of tinnitus that should not be endured but investigated. The difference between those two situations is the most useful thing to take away from this page.

What it sounds like

Everyone describes it differently: ringing, whistling, hissing, buzzing, humming, rushing, chirping, the sound of water or wind, and sometimes a noise that throbs in time with the heartbeat. It may be in one ear, in both, or felt "inside the head" with no particular location. For some it is constant, for others it comes and goes, for others it shifts through the day.

How loud the sound is and how much it torments are two different things. Someone with a barely audible whistle may lie awake night after night, while someone with a strong hum hardly thinks about it. That does not depend on willpower but on how well the brain has learnt to let the sound pass by unnoticed. Almost all the help available for tinnitus is built on that.

And straight away, the fear most people arrive with: tinnitus does not mean you are losing your mind, and it is not a sign of a brain tumour. The sound genuinely exists — the hearing system produces it, not the imagination.

The tinnitus that must not be shrugged off

This is the part worth reading to the end. Most descriptions of tinnitus boil down to "unpleasant, but nothing to worry about". That holds for a steady sound in both ears. But some features point to other causes, and they need looking at separately:

• tinnitus in one ear only, especially if it has lasted for weeks and hearing in that same ear is poorer or speech on the phone is harder to make out;
• tinnitus that pulses in time with your heartbeat. That sound is made by blood flow, and its cause is vascular or related to the pressure inside the skull; investigation finds it;
• tinnitus together with any hearing loss, however slight;
• tinnitus with dizziness, attacks of spinning, unsteadiness, or a blocked, pressurised feeling in the ear;
• tinnitus that began after a head injury, after a loud blast, or after starting a new medicine;
• tinnitus with discharge from the ear, pain or fever.

There is one more reason for investigating one-sided tinnitus: a benign tumour of the hearing nerve. It is uncommon, it grows slowly, and found in good time it is well controlled — but it can only be found in someone who was sent for the tests.

When waiting is not an option

Set apart and in bold: sudden hearing loss in one ear. Someone wakes up hearing distinctly worse on one side, or not at all, often with noise and a blocked feeling, and usually decides it is a chill or a plug of wax and that it can wait until Monday. It cannot. This is an emergency, and treatment works better the sooner it starts. The window is measured in days, not weeks. It is usually treated with steroids prescribed by a doctor, and you need to be seen the same day or the next, by an ear, nose and throat specialist or at a hospital emergency department.

An ambulance on the single European number 112 is needed if, along with the noise and dizziness, there is a sudden droop of the face, weakness in an arm or leg, slurred speech, double vision or an overwhelming headache. That combination can be a stroke, and there every minute counts.

Where ordinary tinnitus comes from

Most often tinnitus goes hand in hand with hearing loss, including loss the person has not noticed. The logic runs roughly like this: the ear stops delivering part of the range of frequencies, the hearing areas of the brain receive less signal and begin filling the gap themselves — and that home-made sound is what we hear. Hence the main consequence: whatever harms hearing generates noise.

• Age-related hearing loss is the commonest cause.
• Loud sound: factories, building sites, shooting, concerts, headphones. After a single loud exposure the ringing usually clears within a day or two, but such episodes add up.
• A plug of earwax, or infection of the outer or middle ear — among the few causes that resolve quickly and completely.
• Ménière's disease: attacks of vertigo with noise, blockage and fluctuating hearing.
• Medicines: high doses of aspirin, some aminoglycoside antibiotics, loop diuretics, several chemotherapy drugs. The noise usually settles once they are stopped, but that decision belongs to the doctor, not the patient.
• Problems with the jaw joint and tension in the neck muscles: here the noise changes when you clench your teeth or turn your head.
• Anaemia, an overactive thyroid, high blood pressure.

Stress, anxiety and poor sleep do not cause the noise, but they sharply increase how much of it you perceive, and it is easy to end up in a loop: the noise stops you sleeping, lack of sleep makes the noise louder, anxiety turns the volume up again. Breaking that loop often matters more than finding "the cause".

What happens at the appointment

The conversation starts with questions: one ear or both, steady or pulsing, how long for, what came before it, which medicines you take, whether there is hearing loss or dizziness. The answers alone tell the doctor which way to go.

Then the ears are examined, and sometimes the whole thing ends with a plug of wax being washed out. The main test for persistent tinnitus is audiometry, which measures hearing frequency by frequency; it reveals losses the person had no idea about and largely shapes what comes next. One-sided tinnitus, asymmetrical hearing loss or a pulsing sound lead to further tests, imaging included, to look at the hearing nerve and the blood vessels.

It helps to write down beforehand which medicines you take and to think back to whether you ever spent a stretch of your life in loud noise at work: those two questions come up almost every time.

Why silence makes it worse

Tinnitus stands out the quieter it is around you. That is why it is unbearable at night, in an empty flat, and at the very moment you lie down and are left alone with yourself. Hence a simple but effective rule: avoid total silence.

This is called sound enrichment. Almost any quiet background sound works: a fan, rain or waves from an app, soft instrumental music, the radio turned right down. The sound should sit just below the noise in your ears — not drown it out, but give your attention something else to hold on to. There are dedicated masking devices too, but you can start with whatever is already in the house.

Sleep is the other half of the same job. Regular hours, a bedroom without screens, less caffeine and alcohol in the evening, background sound overnight. For someone who has not slept for weeks because of the noise, help with sleep usually achieves more than any course of "circulation" treatment.

The same principle underlies retraining sound therapy: a steady quiet background plus an explanation of how tinnitus works, so that the brain gradually stops flagging the sound as important. It takes time, but it has no side effects.

What genuinely helps you live with it

The honest answer first: there is no tablet that removes tinnitus. There are, however, several approaches that change life noticeably, and they are not about the sound but about your relationship with it.

Hearing aids. If there is hearing loss, this is the single most effective thing available. The aid restores the missing sounds, the brain no longer has to invent them, and for many people the noise recedes into the background. People often put an aid off for years, reckoning they "still hear well enough", without realising they are paying for it in tinnitus.

Cognitive behavioural therapy. This is not a way of "learning to put up with it". The work is on the thoughts and reactions that make the noise unbearable: the fear that it is permanent, the constant checking of "is it louder now?", the avoidance of quiet rooms and busy places. In studies it is the most reliably effective approach for distressing tinnitus — it does not remove the sound, but it sharply reduces the suffering. It is delivered face to face, in groups, or through programmes and apps.

And now for what gets sold most eagerly. Supplements and "circulation" remedies have no evidence of benefit in tinnitus — that covers ginkgo biloba, vitamin and mineral formulas "for hearing", and drips "to improve blood flow to the brain". There is no medicine designed to abolish tinnitus; drugs are used when there is something to treat: anxiety, depression, insomnia, Ménière's disease. If you are promised that a course of injections will take the noise away, nothing supports that promise.

And one consoling fact that is rarely said out loud: in many people tinnitus does fade over time, or stops being noticed, even when the sound itself is physically unchanged.

How to protect your hearing

Here there is something you can control, and it is the one part of the subject where prevention definitely works. Noise destroys the hair cells of the inner ear, and they do not grow back: every loud episode is banked permanently.

• At a concert, in a club, on a shooting range, using an angle grinder or a road breaker — wear plugs. Plain foam ones cost next to nothing and cut the risk appreciably; musicians' filters attenuate evenly and do not spoil the sound.
• With headphones, use this rule: if the person next to you can hear your music, or you have to raise your voice to be understood, it is too loud. On noisy transport the answer is not more volume but noise-cancelling headphones, because they let you listen quieter.
• Give your ears breaks. After a loud day, hearing needs a few hours of calm.
• Ringing after a concert is not a harmless souvenir but a signal that the dose was too much. If it lasts longer than a day, get it checked.
• Keep cotton buds out of your ears: they pack the wax down and damage the skin of the canal.

Online consultation

A remote appointment answers the central question of this subject very well: what kind of tinnitus you have and how urgent it is. The doctor will ask in detail about which side, the character of the sound and whether it pulses, about hearing, dizziness and the medicines you take, and will say what to do: book an audiometry with an ear, nose and throat specialist without hurry, be seen today, or call an ambulance. Online is also a convenient place to go through an audiogram you already have, to weigh up whether a hearing aid makes sense, to build a plan for sleep and sound enrichment, and to review medicines that may have affected your hearing. What cannot be done by video is looking inside the ear, measuring hearing and syringing out wax; sudden hearing loss, pulsing tinnitus or tinnitus on one side call for a face-to-face examination, and it should not be put off.

This material is for information only and does not replace medical advice.