Tinnitus is the perception of sound without an external source. It may sound like ringing, buzzing, hissing, humming or clicking and can affect one or both ears. Although tinnitus is usually not a sign of a serious disease, persistent or unilateral tinnitus should be assessed by an ENT specialist or audiologist.
What causes tinnitus?
Tinnitus is commonly associated with hearing loss, particularly age-related hearing loss and hearing damage caused by prolonged exposure to loud noise. Other possible causes include earwax, middle-ear problems, certain medications and, less commonly, disorders affecting the auditory nerve or brain.
Our understanding of tinnitus has changed considerably. It is no longer thought of simply as a noise generated by the ear. In many patients, tinnitus appears to involve changes in the way the central auditory system and auditory cortex process sound following a reduction or alteration in auditory input.
One influential explanation is the Jastreboff neurophysiological model. This model proposes that tinnitus involves an interaction between auditory activity and networks responsible for attention, emotion and the autonomic nervous system. The perception of tinnitus can therefore become much more troublesome when the brain attaches significance or threat to the sound.
It is important to emphasise that the Jastreboff model is a useful framework rather than a complete explanation of all tinnitus. Tinnitus is biologically heterogeneous, and different patients may have different underlying mechanisms.
Is tinnitus caused by hearing loss?
In many cases, hearing loss is an important factor in tinnitus. When auditory input from the cochlea is reduced, the brain appears to undergo compensatory changes in the central auditory pathways. Research has demonstrated changes in spontaneous neural activity and auditory processing following hearing loss, although the precise mechanisms remain an active area of research.
This helps explain why tinnitus can sometimes be perceived even when the ear itself is no longer generating an abnormal sound. The tinnitus may partly represent the brain’s response to altered or reduced auditory information.
Why does tinnitus sometimes become so intrusive?
The loudness of tinnitus and the amount of distress it causes are not necessarily the same thing.
Attention is particularly important. If you repeatedly check your tinnitus — Is it louder today? Has the pitch changed? Can I still hear it? — you are effectively training your brain to monitor the signal.
I describe this to patients as “introspective hypervigilance”: repeatedly turning attention inwards to check on the tinnitus. This can make an otherwise relatively unimportant auditory signal much more noticeable.
This does not mean that tinnitus is imaginary or “all in the mind”. Attention is a fundamental part of how the brain processes sensory information. One of the aims of treatment is therefore to reduce the importance attached to tinnitus and allow the brain to habituate to the sound.
Can hearing aids help tinnitus?
If tinnitus is associated with hearing loss, hearing aids can be helpful. By restoring access to environmental sounds and speech, hearing aids may reduce the contrast between tinnitus and the surrounding acoustic environment. Some modern hearing aids also contain dedicated tinnitus features, including the ability to introduce therapeutic or masking sounds.
Hearing aids should not be regarded as a cure for tinnitus, and their benefit varies between individuals. NICE recommends amplification for people with tinnitus and hearing loss when appropriate.
What is TinniSoothe?
TinniSoothe is a newer wearable sound-therapy device designed to provide adjustable external sound. The principle is consistent with the broader concept of sound enrichment: providing another auditory stimulus may make tinnitus less prominent and potentially assist habituation.
However, it is important to distinguish a promising treatment concept from a treatment supported by strong clinical evidence. The evidence specifically supporting TinniSoothe remains limited, and it should not currently be presented as a proven cure for tinnitus.
Is tinnitus linked to anxiety and mental health?
There is a significant relationship between tinnitus, anxiety, depression and sleep disturbance. Severe tinnitus can affect sleep, concentration and mood. Conversely, anxiety, stress and increased vigilance can make tinnitus more intrusive.
This does not mean that psychological treatment suggests tinnitus is psychological. Instead, treatments such as cognitive behavioural therapy (CBT) address the attention, emotional and behavioural responses that can maintain tinnitus-related distress. NICE recommends psychological therapies for people whose tinnitus is causing significant distress.
When should unilateral tinnitus be investigated?
Persistent tinnitus in one ear should not simply be ignored.
Most unilateral tinnitus is not caused by a serious condition. Nevertheless, persistent one-sided tinnitus, particularly when associated with asymmetric hearing loss, dizziness, neurological symptoms or other ear symptoms, warrants appropriate assessment.
An assessment will usually include a detailed history and examination together with a hearing test. In selected patients, an MRI scan of the internal auditory canals may be recommended to exclude uncommon but important causes, such as a vestibular schwannoma. NICE recommends considering MRI in appropriate patients with persistent unilateral non-pulsatile tinnitus.
What is the best treatment for tinnitus?
There is no single treatment that works for everyone. Management depends on the underlying cause and the degree of distress.
For many patients, the most useful approach is a combination of:
- Identifying and treating an underlying ear or hearing problem
- Hearing aids where hearing loss is present
- Sound enrichment or selected tinnitus sound therapies
- Reducing excessive attention and “introspective hypervigilance”
- Addressing sleep, anxiety and psychological distress
- Tinnitus-focused CBT or other evidence-based psychological approaches when required
The aim is not necessarily to make tinnitus disappear completely. For many people, successful treatment means reaching a point where the tinnitus is still occasionally detectable but no longer commands attention or affects everyday life.
In summary
Tinnitus is a complex interaction between the auditory system and the brain. Hearing loss is an important contributor in many patients, but the impact of tinnitus is also strongly influenced by attention, emotion and the brain’s response to the perceived sound.
If tinnitus is persistent, troublesome or particularly affecting one ear, it is worth having it properly assessed. Understanding the cause is often the first step towards making tinnitus less intrusive and improving quality of life.