Tinnitus (Ringing in the Ear): Causes, Triggers and What an ENT Can Do

21 July 2026

9 Minutes Read

It usually starts quietly. A faint ringing after a loud concert or a long flight. Most people assume it’ll be gone by morning. And often it is.

But for some people, it doesn’t go. The ringing is still there the next day. And the day after that. Sometimes it changes, becomes a buzzing, a hissing, a pulsing sound. Sometimes it’s louder at night when everything else is quiet. Sometimes it’s there constantly, sometimes it comes and goes. And the longer it stays, the more it starts affecting concentration, sleep, and general quality of life.

Tinnitus, the perception of sound in the ear or head without any external source, is more common than most people realise. And while it isn’t always something that can be switched off entirely, understanding what’s causing it, what makes it worse, and what an ENT can actually do about it changes the picture considerably.

What Is Tinnitus, Exactly?

Tinnitus isn’t a disease on its own. It’s a symptom, a signal that something in the auditory system isn’t working quite as it should. The sound isn’t coming from outside. There’s no external noise. The perception is generated somewhere within the ear or the auditory pathways of the brain.

The sound varies significantly from person to person. Most describe it as:

Ringing, the most commonly reported
Buzzing or humming
Hissing or whistling
Clicking or ticking
Roaring, like wind or rushing water
In some cases, a pulsing sound that seems to beat in time with the heartbeat, this specific type is called pulsatile tinnitus and has its own set of causes worth knowing about

It can affect one ear, both ears, or seem to come from inside the head rather than either ear specifically. It can be constant or intermittent. Mild enough to ignore most of the time, or loud and intrusive enough to make concentration difficult and sleep nearly impossible.

Why Does Tinnitus Happen?

This is where it gets nuanced. Tinnitus isn’t caused by one thing, it’s a symptom that can arise from a range of conditions affecting different parts of the ear and auditory pathway.

Noise-Induced Hearing Loss

This is the most common underlying cause. The inner ear contains thousands of tiny hair cells that convert sound vibrations into electrical signals for the brain to interpret. These cells are delicate and can be permanently damaged by loud noise, a single very loud event, or prolonged exposure to elevated noise levels over time.

When these hair cells are damaged, the auditory system doesn’t just lose hearing, it sometimes generates phantom signals. The brain, no longer receiving normal input from those damaged cells, essentially fills the silence with its own noise. That’s tinnitus.

A significant percentage of people with noise-induced hearing loss have tinnitus alongside it. And noise remains the most preventable cause of both.

Ear Wax Blockage

Impacted ear wax pressing against the eardrum can cause or worsen tinnitus. This is one of the more straightforward causes and one of the more straightforwardly treatable ones. Removing the wax often reduces or resolves the tinnitus in these cases.

Middle Ear Infections and Fluid

Fluid in the middle ear, from an infection or from eustachian tube dysfunction, affects how sound is conducted through the ear and can cause tinnitus alongside the hearing muffling and fullness that fluid produces. Resolving the underlying middle ear condition usually helps.

Age-Related Hearing Loss (Presbycusis)

Hearing loss that develops gradually with age is extremely common, and tinnitus frequently accompanies it. The same mechanism applies, reduced input from ageing hair cells leads to phantom signal generation. Tinnitus in older adults often coexists with measurable hearing loss, and addressing the hearing loss with hearing aids, for example, often reduces tinnitus perception as well.

Ménière’s Disease

Ménière’s disease is a condition of the inner ear characterised by episodes of vertigo, fluctuating hearing loss, a feeling of fullness in the ear, and tinnitus. The tinnitus in Ménière’s often has a low-pitched, roaring quality and tends to be worse during or before an episode of vertigo. It’s caused by abnormal fluid pressure in the inner ear.

Otosclerosis

Otosclerosis is a condition where abnormal bone growth in the middle ear affects the movement of the small bones that conduct sound. It causes progressive conductive hearing loss and is frequently accompanied by tinnitus. It’s more common in women and can run in families.

Temporomandibular Joint (TMJ) Disorders

The temporomandibular joint the jaw joint, sits very close to the ear. Problems with this joint, including grinding the teeth, jaw misalignment, or joint inflammation, can cause referred tinnitus alongside jaw pain, clicking, and headaches. This type of tinnitus may worsen with chewing or jaw movement.

Medications

A significant number of medications can cause or worsen tinnitus as a side effect. These are called ototoxic medications. Common ones include:

High-dose aspirin and NSAIDs
Certain antibiotics, particularly aminoglycosides
Some chemotherapy drugs
Loop diuretics in high doses
Quinine-based medications

If tinnitus appeared or worsened shortly after starting a new medication, this connection is worth raising with the prescribing doctor.

Cardiovascular and Blood Flow Issues

Pulsatile tinnitus, the type that pulses in time with the heartbeat is different from the more common continuous tinnitus. It often has a vascular cause. Blood flow turbulence near the ear, high blood pressure, abnormal blood vessels, or increased blood flow from anaemia can all produce this pulsing sound.

Pulsatile tinnitus needs investigation specifically directed at ruling out vascular causes, it’s not something to attribute to stress and move on from without proper assessment.

Acoustic Neuroma

An acoustic neuroma, also called a vestibular schwannoma is a benign tumour growing on the nerve that connects the inner ear to the brain. Tinnitus in one ear, particularly when accompanied by one-sided hearing loss or balance issues, warrants investigation to rule this out. It’s not common, but it’s one of the reasons one-sided tinnitus with other symptoms gets taken more seriously.

Stress and Anxiety

Stress doesn’t directly cause tinnitus, but it significantly affects how loudly and intrusively it’s perceived. People in periods of high stress or anxiety consistently report their tinnitus being more noticeable and harder to ignore. The relationship works in both directions, tinnitus causes stress, and stress amplifies tinnitus perception. Understanding this cycle is part of managing the condition.

What Makes Tinnitus Worse?

Even when a cause has been identified and treated, certain things consistently make tinnitus more intrusive:

Silence – paradoxically, very quiet environments make tinnitus more noticeable. The brain has less external sound to focus on, so the internal noise stands out more. This is why tinnitus often feels worst at night.
Caffeine – coffee and tea in large quantities can worsen tinnitus for some people, though this is individual.
Alcohol – particularly in larger amounts, alcohol can temporarily intensify tinnitus.
Loud noise exposure – repeated noise exposure without ear protection worsens the underlying hearing damage that drives tinnitus.
Sleep deprivation – poor sleep lowers the threshold for tinnitus perception and makes it harder to habituate to.
Certain medications – as mentioned, some drugs worsen tinnitus as a direct effect.
Salt intake – particularly relevant for Ménière’s disease, where high salt intake worsens the fluid pressure in the inner ear.

Identifying personal triggers through observation makes a real practical difference to day-to-day management.

What an ENT Actually Does

When a patient presents with tinnitus, the ENT’s job is first to understand what’s driving it, because treatment depends entirely on the cause.

Full Ear Examination

The ENT examines the ear canal and eardrum to check for wax, infection, fluid, or eardrum abnormalities. Simple causes like impacted wax are identified and dealt with at this point.

Hearing Assessment Audiometry

A formal hearing test is almost always done as part of a tinnitus evaluation. Pure tone audiometry maps hearing across different frequencies, identifying the degree and pattern of any hearing loss. The relationship between where hearing loss exists and the pitch of the tinnitus is often informative, tinnitus frequently occurs at the frequency where hearing loss is most significant.

Tympanometry

A test of eardrum and middle ear function, checking for fluid, eardrum stiffness, or other middle ear issues.

Specialist Investigations

Depending on what the initial assessment finds:

MRI of the internal auditory canals – if one-sided tinnitus, one-sided hearing loss, or balance issues suggest a possible acoustic neuroma or other lesion on the auditory nerve
CT scan – for structural issues, otosclerosis assessment, or pulsatile tinnitus investigation
Vascular imaging – if pulsatile tinnitus suggests a vascular cause

What Can Actually Be Done About Tinnitus?

This is the question patients most want answered and the honest answer is that it depends on the cause, and for many people it’s about management rather than cure.

Treating the Underlying Cause

Where a specific cause exists and can be addressed, treating it helps tinnitus significantly:

Removing impacted ear wax often reduces or resolves tinnitus
Treating middle ear infection or fluid improves tinnitus alongside hearing
Addressing otosclerosis through surgery (stapedectomy) can improve both hearing and tinnitus
Stopping or changing an ototoxic medication may reduce drug-induced tinnitus
Managing Ménière’s disease reduces the frequency and severity of episodes including tinnitus

Hearing Aids

For patients with hearing loss alongside tinnitus, hearing aids serve a double function. They amplify external sound, which reduces the contrast between the tinnitus and the outside world, making the tinnitus less prominent. Many modern hearing aids also have built-in tinnitus sound therapy features. For many patients with hearing-loss-related tinnitus, a well-fitted hearing aid is one of the most effective management tools available.

Sound Therapy

The principle behind sound therapy is that background sound reduces the contrast between silence and tinnitus, making it less intrusive. This can be as simple as keeping a fan running at night, using a white noise machine, or streaming gentle ambient sound through an app or device. For more structured approaches, sound therapy delivered through hearing aids or dedicated tinnitus maskers provides a low-level background sound that partially masks or blends with the tinnitus.

Tinnitus Retraining Therapy (TRT)

TRT is a structured therapeutic approach combining sound therapy with counselling. The goal isn’t to eliminate the tinnitus, it’s to change the brain’s response to it. Through a process called habituation, the brain gradually learns to classify the tinnitus signal as unimportant background noise, similar to how people stop consciously hearing the hum of an air conditioner after a while. TRT takes time, usually six months to two years, but the outcomes for well-selected patients are good.

Cognitive Behavioural Therapy (CBT)

CBT for tinnitus doesn’t change the sound itself, it changes how the person responds to it. The distress, anxiety, and sleep disruption that tinnitus causes are often what makes it so disabling. CBT addresses the thought patterns and emotional responses around the tinnitus, reducing the distress and improving quality of life even when the tinnitus itself remains. There’s good evidence supporting CBT for tinnitus management.

Medical Management for Specific Conditions

For Ménière’s disease dietary measures (low salt, adequate hydration), medications to manage fluid pressure, and in some cases procedures to reduce inner ear fluid or pressure. For TMJ-related tinnitus dental or physiotherapy management of the jaw joint. For pulsatile tinnitus with a vascular cause management of the underlying vascular condition.

What Doesn’t Work

It’s worth being straightforward about this. There’s no proven medication that reliably cures tinnitus. Various supplements, ginkgo biloba, zinc, magnesium, are frequently marketed for tinnitus, but the evidence supporting them is weak. Many patients try them without significant benefit. That doesn’t mean nothing helps, it means the evidence base sits with the approaches above rather than supplements or unverified remedies.

When Should You See an ENT?

For tinnitus that appears briefly after loud noise exposure and settles within a day or two, immediate medical attention usually isn’t necessary, though it’s a reminder to protect hearing better going forward.

See an ENT without significant delay if:

Tinnitus has been present for more than two weeks
It’s in one ear only, particularly important to investigate
There’s hearing loss alongside the tinnitus
Tinnitus is pulsing in time with the heartbeat
There’s dizziness or balance disruption alongside tinnitus
Tinnitus appeared after starting a new medication
It’s significantly affecting sleep, concentration, or daily life

Final Thoughts

Tinnitus is one of those conditions that gets dismissed too often, by people who have it and by those around them. It’s invisible, it’s subjective, and it doesn’t show up on a scan. But for the people experiencing it significantly, the impact on sleep, concentration, and mental wellbeing is very real.

The good news is that proper assessment changes the picture. For some, a simple cause is found and treated. For others, structured management approaches make the tinnitus significantly less disruptive even when it can’t be eliminated entirely. Neither outcome is possible without starting with a proper evaluation.

Our ENT specialist assesses tinnitus thoroughly, identifying contributing causes, arranging appropriate investigations, and guiding patients through the management options that are most likely to help their specific situation. If you’ve been hearing sounds that shouldn’t be there, come in for an assessment rather than waiting and hoping it resolves on its own.