Ringing in the Ears: What Causes Tinnitus?

What exactly is tinnitus?

Tinnitus is the perception of sound — ringing, buzzing, hissing, clicking, or whooshing — when no outside noise is present. It is not a diagnosis on its own but a symptom of something happening in the auditory system. Nearly everyone experiences a brief episode after a loud concert; the concern arises when the sound is persistent, loud enough to interfere with concentration or sleep, or accompanied by hearing loss 1Ref 1Tunkel DE, Bauer CA, Sun GH, Rosenfeld RM, Chandrasekhar SS, Cunningham ER Jr, et al. (2014).Clinical Practice Guideline: Tinnitus.Core guideline framing tinnitus evaluation, imaging recommendations, and treatment approaches including CBT and sound therapy.

Tinnitus is broadly divided into two types:

• Subjective tinnitus — by far the most common; only the person hears it. This arises from changes in the auditory nerve pathway.
• Objective tinnitus — rare; a clinician can actually hear it with a stethoscope, usually because it comes from a blood vessel or muscle near the ear.

What are the most common causes?

Noise-induced hearing loss is the leading cause. Exposure to loud sound — machinery, concerts, headphones at high volume — damages the hair cells inside the cochlea. Those cells do not regenerate. The auditory nerve then fires abnormally, producing the ringing sound.

Age-related hearing loss (presbycusis) produces tinnitus for a similar reason: gradual hair-cell loss with age, which is very common and thoroughly documented in current guidelines 1Ref 1Tunkel DE, Bauer CA, Sun GH, Rosenfeld RM, Chandrasekhar SS, Cunningham ER Jr, et al. (2014).Clinical Practice Guideline: Tinnitus.Core guideline framing tinnitus evaluation, imaging recommendations, and treatment approaches including CBT and sound therapy3Ref 3Tsai Do BS, Bush ML, Weinreich HM, et al. (2024).Clinical Practice Guideline: Age-Related Hearing Loss.Age-related hearing loss as a common driver of tinnitus in older adults.

Earwax (cerumen) impaction is one of the most easily treated causes. Wax pressing against the eardrum can create or amplify ringing. Removal — done safely by a clinician, not cotton swabs — often resolves it.

Medications — certain antibiotics (aminoglycosides), loop diuretics, high-dose aspirin, some chemotherapy agents, and quinine — can cause or worsen tinnitus. This is called ototoxicity.

Inner-ear conditions such as Meniere's disease cause episodic tinnitus paired with vertigo and fluctuating hearing loss. Otosclerosis (abnormal bone growth in the middle ear) can also be a factor.

Other contributors include temporomandibular joint (TMJ) disorders, head or neck injuries, high blood pressure, anemia, and thyroid dysfunction. In a small number of cases, a benign tumor called an acoustic neuroma (vestibular schwannoma) is responsible — which is one reason new or one-sided tinnitus warrants professional evaluation.

Does tinnitus ever go away on its own?

Short-duration tinnitus after noise exposure often fades within hours to a few days as the auditory system recovers. Tinnitus that persists beyond a few weeks — especially if it is in only one ear, worsening, or accompanied by hearing loss or dizziness — is unlikely to resolve without investigation 1Ref 1Tunkel DE, Bauer CA, Sun GH, Rosenfeld RM, Chandrasekhar SS, Cunningham ER Jr, et al. (2014).Clinical Practice Guideline: Tinnitus.Core guideline framing tinnitus evaluation, imaging recommendations, and treatment approaches including CBT and sound therapy2Ref 2Chandrasekhar SS, Tsai Do BS, Schwartz SR, Bontempo LJ, Faucett EA, Finestone SA, et al. (2019).Clinical Practice Guideline: Sudden Hearing Loss (Update).Urgency of sudden unilateral hearing loss and its relationship to tinnitus red flags.

That said, many people find the perceived loudness of chronic tinnitus diminishes over time through a process called habituation, even if it does not disappear entirely. Auditory therapy and counseling can support this process.

What will an ENT or audiologist actually do?

A specialist evaluation typically includes:

1. A thorough history — onset, character of the sound, whether it is one or both ears, any associated symptoms, medication list, and noise exposure history. 2. Otoscopy — examining the ear canal and eardrum to look for wax, infection, or structural problems. 3. Audiogram — a formal hearing test to quantify any hearing loss and its pattern. 4. Tinnitus matching — the audiologist plays tones to estimate the pitch and loudness of your tinnitus, which helps guide treatment. 5. Imaging — an MRI or CT scan is ordered selectively, usually when tinnitus is one-sided, pulsatile, or associated with neurological symptoms 1Ref 1Tunkel DE, Bauer CA, Sun GH, Rosenfeld RM, Chandrasekhar SS, Cunningham ER Jr, et al. (2014).Clinical Practice Guideline: Tinnitus.Core guideline framing tinnitus evaluation, imaging recommendations, and treatment approaches including CBT and sound therapy.

The American Academy of Otolaryngology–Head and Neck Surgery clinical practice guideline emphasizes that imaging should not be routine for bilateral, non-pulsatile tinnitus without red-flag features 1Ref 1Tunkel DE, Bauer CA, Sun GH, Rosenfeld RM, Chandrasekhar SS, Cunningham ER Jr, et al. (2014).Clinical Practice Guideline: Tinnitus.Core guideline framing tinnitus evaluation, imaging recommendations, and treatment approaches including CBT and sound therapy.

What treatments exist?

There is no single cure-all for tinnitus, but several approaches reduce its impact:

• Hearing aids — if hearing loss is present, amplifying external sound effectively reduces the brain's focus on internal noise. This is often the highest-yield intervention.
• Sound therapy / masking — white noise machines, sound apps, or notched-music therapy create competing sounds that reduce the perceived prominence of tinnitus.
• Tinnitus retraining therapy (TRT) — a structured combination of counseling and sound therapy that helps the brain habituate to the signal.
• Cognitive behavioral therapy (CBT) — addresses the distress and sleep disruption that tinnitus causes, and has good evidence for improving quality of life even when the tinnitus itself does not change 1Ref 1Tunkel DE, Bauer CA, Sun GH, Rosenfeld RM, Chandrasekhar SS, Cunningham ER Jr, et al. (2014).Clinical Practice Guideline: Tinnitus.Core guideline framing tinnitus evaluation, imaging recommendations, and treatment approaches including CBT and sound therapy.
• Treating the underlying cause — clearing impacted wax, adjusting an ototoxic medication (with physician guidance), or treating Meniere's disease may reduce or resolve tinnitus.

The guideline recommends against routinely offering medications like antihistamines, benzodiazepines, or dietary supplements (including ginkgo biloba) for tinnitus, as evidence for these is lacking 1Ref 1Tunkel DE, Bauer CA, Sun GH, Rosenfeld RM, Chandrasekhar SS, Cunningham ER Jr, et al. (2014).Clinical Practice Guideline: Tinnitus.Core guideline framing tinnitus evaluation, imaging recommendations, and treatment approaches including CBT and sound therapy.

How can I protect my hearing going forward?

Noise exposure is the most preventable cause. Practical steps:

• Use earplugs or noise-canceling headphones in loud environments (concerts, power tools, shooting ranges).
• Follow the 60/60 rule for headphones: no more than 60% of maximum volume for no more than 60 minutes at a stretch.
• Step away from loud noise for at least 15 minutes per hour.
• Get a baseline audiogram if you work in a noisy occupation — occupational hearing conservation programs are regulated for good reason.

People who already have tinnitus can often protect their remaining hearing and prevent worsening by being consistent about hearing protection.

How can Gale help?

Tinnitus evaluation sits squarely with an ENT (otolaryngologist) or audiologist — Gale can help you find one, prepare your history before that appointment, and coordinate any primary-care workup (blood pressure, thyroid, medication review) that might be contributing.