Tinnitus: Understanding the Ringing in Your Ears and What Can Be Done

• Tinnitus (ringing, buzzing, or hissing in the ears) is a symptom rather than a diagnosis

• In many cases a treatable underlying cause can be identified by an ENT specialist

• Where no cause is found, sound therapy and cognitive behavioural therapy can significantly reduce its impact

• Assessment aims to rule out important underlying conditions before managing the symptom

Tinnitus is the perception of sound — ringing, buzzing, or hissing — generated within the auditory system itself rather than from an external source. It is a symptom of an underlying condition, not a disease in its own right, and in many cases a treatable cause can be found.

Tinnitus — ringing, buzzing, or hissing in the ears — is a symptom rather than a diagnosis, and in many cases a treatable underlying cause can be identified. Assessment by an ENT specialist aims to find and treat that cause, and where none is found, effective management strategies including sound therapy and cognitive behavioural therapy can significantly reduce its impact on daily life.

Tinnitus — the perception of sound in the ears or head without an external source — is one of the most common complaints I encounter in ENT practice. It affects a significant proportion of adults at some point in their lives, and for a smaller but meaningful number, it becomes a persistent and distressing condition that affects sleep, concentration, and quality of life.

This article explains what tinnitus is, what causes it, how it is assessed, and what treatment options are available. Tinnitus is not always curable, but in many cases it can be effectively managed — and in some, a treatable underlying cause can be identified and addressed.

What Does Tinnitus Sound Like?

Tinnitus is not a single sound. Patients describe it in many different ways:

• Ringing — the most commonly reported quality

• Buzzing or humming

• Hissing or whooshing

• Clicking or pulsing

• A high-pitched tone, often in one or both ears

It may be constant or intermittent, present in one ear or both, and vary in pitch and volume. Some patients notice it only in quiet environments; others find it intrudes on daily life regardless of background noise. It can also present with other symptoms such as vertigo.

A particular type — pulsatile tinnitus, where the sound beats in time with the heartbeat — warrants specific investigation, as it can occasionally indicate a vascular cause requiring further assessment.

What Causes Tinnitus?

Tinnitus is a symptom, not a diagnosis. It arises from disruption somewhere along the auditory pathway — from the outer ear, through the middle and inner ear, along the auditory nerve, and into the brain's auditory processing centres.

Common causes include:

Noise-Induced Hearing Loss

Prolonged exposure to loud noise — occupational noise, concerts, earphone use at high volume — damages the hair cells of the inner ear. These cells do not regenerate. The resulting hearing loss is often accompanied by tinnitus, particularly at high frequencies.

Age-Related Hearing Loss (Presbyacusis)

As hearing naturally declines with age, the auditory system may generate tinnitus as a consequence of reduced input from the damaged cochlea. This is one of the most common associations in older adults.

Earwax Impaction

A straightforward and treatable cause. Wax occluding the ear canal changes the acoustic environment and can trigger or worsen tinnitus. Removal often leads to improvement, though not always complete resolution.

Middle Ear Conditions

Otitis media with effusion (glue ear), Eustachian tube dysfunction, and otosclerosis can all produce tinnitus alongside hearing loss or a blocked sensation. These are often amenable to treatment.

Ménière's Disease

A condition of the inner ear characterised by episodes of vertigo, fluctuating hearing loss, a blocked ear sensation, and tinnitus. The tinnitus in Ménière's disease often has a low-pitched, roaring quality and tends to worsen during attacks.

Medications

A number of medications — including certain antibiotics, diuretics, anti-inflammatory drugs, and quinine — are ototoxic and can cause or worsen tinnitus. A thorough medication review is part of any tinnitus assessment.

Temporomandibular Joint (TMJ) Dysfunction

Jaw joint problems can produce tinnitus through their anatomical proximity to the ear. This is a recognised but often overlooked cause, particularly in patients who report tinnitus that changes with jaw movement or teeth clenching.

Rarer Causes

Less commonly, tinnitus may arise from an acoustic neuroma (a benign tumour of the auditory nerve), vascular abnormalities, sudden sensorineural hearing loss or other structural pathology. These require imaging to exclude and are one reason that new or unilateral tinnitus warrants ENT assessment.

How Is Tinnitus Assessed?

A thorough tinnitus assessment begins with a detailed clinical history. I ask about:

• The character, laterality, and duration of the tinnitus

• Whether it is constant or fluctuating

• Whether it pulses with the heartbeat

• Associated symptoms — hearing loss, vertigo, ear fullness, pain

• Noise exposure history and medication use

• The impact on sleep, concentration, and daily life

Examination includes otoscopy to assess the ear canal and eardrum, and tuning fork tests to characterise any hearing loss. Flexible nasolaryngoscopy may be performed if Eustachian tube dysfunction or other upper airway pathology is suspected.

Formal audiometry — a hearing test — is an important part of most tinnitus assessments. Many patients with tinnitus have some degree of hearing loss they were not aware of.

Where pulsatile tinnitus is present, or where the clinical picture suggests a structural cause, imaging (MRI or CT) may be arranged.

What Can Be Done About Tinnitus?

Treating the Underlying Cause

Where a specific, treatable cause is identified — earwax, middle ear effusion, otosclerosis, medication side effects — addressing it directly may significantly reduce or resolve the tinnitus. This is why thorough assessment matters before accepting tinnitus as simply something to live with.

Hearing Aids

In patients with significant hearing loss, hearing aids amplify environmental sound and reduce the contrast between the tinnitus and the acoustic background. Many modern hearing aids also incorporate tinnitus masking features. The relationship between hearing loss and tinnitus means that treating the former often helps with the latter.

Sound Therapy

Sound enrichment — using background sound to reduce the contrast between tinnitus and silence — is a cornerstone of tinnitus management. This does not need to be expensive technology: fans, nature sound apps, or low-volume radio can all help, particularly at night when quiet environments make tinnitus more noticeable.

Structured sound therapy as part of a tinnitus retraining programme works on the principle of habituation — gradually training the brain to classify the tinnitus signal as neutral rather than threatening, reducing the emotional response to it over time.

Cognitive Behavioural Therapy (CBT)

For patients significantly distressed by tinnitus, CBT delivered by a trained psychologist or audiologist has the strongest evidence base of any psychological intervention. It does not reduce the volume of tinnitus but changes the way the brain responds to it, reducing distress and improving quality of life.

Lifestyle Factors

Caffeine, alcohol, and stress all have the potential to worsen tinnitus in susceptible individuals. Sleep deprivation creates a cycle where tinnitus disrupts sleep and poor sleep amplifies tinnitus perception. Addressing sleep and stress is often an underestimated component of management.

What Does Not Work

There is currently no medication proven to cure tinnitus. Many supplements and devices are marketed for tinnitus with limited or no evidence. I am always willing to discuss what patients have tried or are considering — but it is important to approach unproven treatments with appropriate scepticism.

Living With Tinnitus

For many patients, the most important thing to understand is that tinnitus, while real and sometimes very distressing, is not dangerous, does not indicate impending deafness, and does not in itself cause hearing loss. The emotional response to tinnitus — the anxiety and hypervigilance it can generate — often amplifies its perceived volume and intrusiveness.

Habituation is the goal for most patients with chronic tinnitus: not silence, but a state in which the sound is present but no longer intrusive. This is achievable for the majority of patients with the right support and approach.

When to Seek Assessment

I would recommend an ENT assessment for tinnitus if:

• It is present in one ear only — unilateral tinnitus warrants investigation

• It pulses in time with the heartbeat

• It is accompanied by hearing loss, vertigo, or ear fullness

• It has started suddenly

• It is causing significant distress, affecting sleep or daily function

• It has not been previously investigated

Tinnitus that has been present for many years in both ears without associated symptoms is less likely to have an identifiable underlying cause — but even in these cases, assessment can provide reassurance and access to management strategies.

Book a Tinnitus Assessment

If you are troubled by tinnitus, an ENT assessment can help identify whether there is a treatable cause and guide you toward effective management.

Absolute ENT is based at Camden Medical Centre, 1 Orchard Boulevard, #09-08, Singapore. Contact the clinic by WhatsApp on +65 8060 8079 or email camden.mmc@gmail.com.