Tinnitus: the sound of silence

Tinnitus is heterogenous in both its presentation and its causes. It can be frustrating for patients and clinicians as there is much misinformation and misunderstanding around its aetiology and treatment options. In some people, tinnitus can cause significant distress, reduced quality of life and may even contribute to suicidal ideation. However, most cases of tinnitus can be treated successfully, and patients can be reassured that there are many management techniques that can reduce its impact including sound therapy, stress reduction and treatment of other underlying causes.

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Published: 24 February 2023

Key practice points:

  • Tinnitus is the perception of a sound without a corresponding external source; it is often described as a high-pitched ringing or buzzing, but in some cases music or voices may be perceived. It can be viewed as a hallucination or phantom perception.
  • In most people with tinnitus some degree of hearing loss is present, but it can also be related to high levels of stress or to physical or emotional trauma
  • Patients with tinnitus and suspected hearing loss should ideally be referred to an audiologist for a hearing assessment. The Weber and Rinne tests can be used in a general practice setting to differentiate conductive and sensorineural hearing loss.
    • Sudden sensorineural hearing loss that has started in the last 30 days is an otologic emergency; the patient should be urgently referred to or discussed with an otolaryngologist
  • Secondary causes of tinnitus are rare but need to be considered as they may be treatable and sometimes require urgent attention.
    • Conductive hearing loss can be a cause of secondary tinnitus, e.g. due to cerumen impaction; other causes include Ménière’s disease and vestibular schwannoma (also known as acoustic neuroma).
    • Patients with pulse-synchronous tinnitus should be investigated for underlying vascular abnormalities which may be reversible
  • Consider how tinnitus is impacting on the patient’s quality of life; for some people it causes significant distress and disability. Assess for symptoms of depression and anxiety, which are more common in people with tinnitus.
  • Providing education about tinnitus is an important first step for all patients following diagnosis. Reassure them that tinnitus does not mean they will go deaf and that there are effective strategies to improve their symptoms and make life with tinnitus more manageable.
  • There is a lack of evidence of benefit for any pharmacological treatments for tinnitus, however, patients may find that their symptoms improve with the use of medicines prescribed for concomitant conditions, e.g. depression
  • Management strategies should be tailored to the patient and may include:
    • Sound therapy – use of specific noises to make tinnitus less noticeable and promote habituation
    • Lifestyle changes such as stress reduction and sleep hygiene
    • Cognitive behavioural therapy (CBT) – while CBT specifically focused on tinnitus is not widely available in New Zealand, audiologists specialising in tinnitus may be able to offer treatment based on similar principles. Online CBT may be useful for some patients.
  • Patients with tinnitus that is severely impacting their quality of life should be referred to an audiologist, ideally one who specialises in tinnitus management. In those with hearing impairment, use of hearing aids may also alleviate their tinnitus.

This is a revision of a previously published article. What’s new for this update:

  • General article revision
  • Addition of sections on:
    • Descriptions of tinnitus associated with specific causes
    • Tinnitus-related distress
    • Ménière’s disease
    • Preventing noise-induced hearing loss
    • Resources for patients with tinnitus

Tinnitus is the conscious awareness of sound without an identifiable corresponding external source.1 Tinnitus sounds vary, but are most commonly reported as a ringing, humming, hissing or roaring or a sound like static or cicadas. Some people experience complex auditory hallucinations, such as music or voices.2 Tinnitus can result from any disturbance to the ear or auditory pathway, although a cause is not always found.3

Primary tinnitus (sometimes called idiopathic tinnitus) describes tinnitus caused by symmetric sensorineural hearing loss.3 This includes age-related hearing loss (presbycusis) and noise-induced hearing loss. Primary tinnitus is the most common diagnosis in patients presenting with tinnitus.3

Secondary tinnitus describes tinnitus with an identifiable cause other than symmetric sensorineural hearing loss.3 Causes include cerumen impaction, infections, medicines and tumours (Figure 1). Although secondary tinnitus is less common than primary tinnitus it is important to identify as many of its causes are treatable.3

Objective tinnitus is a subset of secondary tinnitus where sounds made by internal vascular or muscular structures in the head or neck can be heard with a stethoscope.1

Subjective tinnitus is a broad term used to describe all non-objective forms of tinnitus.1

Tinnitus-related distress, sometimes referred to as bothersome tinnitus, occurs when the emotional response to tinnitus causes cognitive dysfunction and autonomic arousal, leading to behavioural changes and functional disability.4 For further information, see: “Tinnitus-related distress”.

Temporary tinnitus. Exposure to loud sounds can cause temporary tinnitus symptoms. Repeated exposure to sound that is loud enough to induce tinnitus can lead to permanent hearing damage (see: “Preventing noise-induced hearing loss”).5

The epidemiology of tinnitus

The prevalence of tinnitus among adults in New Zealand is unclear and global estimates vary considerably. This is likely related to the difficulties defining and measuring tinnitus. A 2022 systematic review of articles published between 1972 and 2021 calculated a pooled prevalence of adults with any form of tinnitus to be 14%.6

There is inconsistent evidence regarding sex differences in tinnitus.6 While some international studies have reported that males are at higher risk of tinnitus,7, 8 others report a higher prevalence in females or no difference between the sexes.6, 9 Occupation may be a confounding factor; exposure to loud noises and hearing loss are associated with tinnitus (see below),7 and males are often over-represented in industries where this is a factor, e.g. automotive and construction workers.10, 11

Tinnitus has been reported more commonly in people of European ethnicity compared to other ethnicities.12, 13 The reason for this is unclear but is likely to be underpinned by ethnicity-associated differences in socioeconomic factors and access to health services.

Risk factors for tinnitus

  • Hearing loss. It is estimated that 50 – 90% of people with tinnitus have some degree of hearing loss.5, 14
  • Older age. Tinnitus prevalence increases with age.1 This relationship is likely associated with progressive age-related hearing loss.5
  • Noise exposure. Occupational or recreational noise exposure is associated with the development of tinnitus and is often accompanied by noise-induced hearing loss.1
  • Smoking. Current smokers are 21% more likely to experience tinnitus than people who have never smoked.15

Tinnitus is a heterogeneous condition and for most patients, the aetiology of their tinnitus will be unclear.5 If symptoms of tinnitus are reported, a focused history and physical examination can identify any red flags that would indicate urgent referral is required or potential secondary causes that can be addressed (Figure 1).3, 16

* In patients with asymmetric hearing loss consider both bilateral and unilateral causes

Patients with vestibular schwannoma do not always have vertigo and focal neurological features

Figure 1. Diagnostic algorithm for patients presenting with tinnitus.3, 5, 16

Ask the patient to describe the tinnitus. What does it sound like? Is it heard in one ear, both ears or elsewhere inside the head? Is it pulsatile? Is it intermittent or continuous? Does anything make it better or worse?3 For descriptions associated with particular causes of tinnitus, see Table 1.

The presence of associated symptoms may increase suspicion of an underlying cause. Consider middle ear pathology if the patient reports otalgia, otorrhoea or aural fullness.16 Vertigo may indicate an inner ear disorder or a central cause, e.g. vestibular schwannoma (acoustic neuroma), vestibular migraine or stroke.16 Patients with Ménière’s disease usually present with the distinctive combination of episodic vertigo and fluctuating unilateral aural symptoms, including tinnitus, low- and medium-pitch hearing loss and aural fullness (see: “Ménière’s disease”).19

A review of the patient’s medicines may also reveal potential causes of tinnitus (Table 2). Ask about use of over-the-counter medicines, e.g. NSAIDs, aspirin.16

Otoscopic examination may reveal cerumen impaction, otitis externa, otitis media, tympanic membrane perforation or a foreign body in the external auditory canal.16

Tympanometry may be helpful if middle ear pathology is suspected, e.g. in unexplained conductive hearing loss.22 In patients with pulsatile tinnitus, auscultate the carotid arteries at the base of the neck, the carotid bifurcation and the angle of the jaw. Also listen in the periauricular area and with the stethoscope placed over the ear.16

Focused neurological examination including cranial nerves and cerebellar function may reveal a neurological deficit suggestive of vestibular schwannoma or stroke.16 Examine the temporomandibular joint (TMJ) for tenderness and crepitus. TMJ syndrome or tinnitus that changes with orofacial movement may indicate a somatosensory mechanism.5

Table 1. Descriptions of tinnitus associated with specific causes.16–18

Description Potential cause
Bilateral ringing/buzzing/hissing Symmetrical sensorineural hearing loss (primary tinnitus)
Pulsatile (particularly if tinnitus is pulse-synchronous) Vascular tinnitus
Rhythmic clicking Palatal myoclonus
Unilateral Conductive hearing loss, Ménière’s disease, vestibular schwannoma (acoustic neuroma), vestibular migraine, stroke
Breath autophony, voice autophony and aural fullness Patulous Eustachian tube, dehiscent semicircular canal
Intermittent roaring sound (with low- and medium-pitch hearing loss, aural fullness and vertigo) Ménière’s disease
Sounds that vary with head and neck movement Somatosensory tinnitus

Table 2. Examples of ototoxic medicines.20, 21

Medicine Time to recovery after discontinuation
Loop diuretics*, e.g. furosemide Unknown; possibly up to 24 hours**
Aspirin and other NSAIDs* Up to three days
Macrolide antibiotics*, e.g. erythromycin, clarithromycin and azithromycin Up to three weeks
Aminoglycosides, including ear drops* (e.g. neomycin and framycetin) and intravenous gentamicin Irreversible
Antineoplastic platinum derivatives, especially cisplatin Irreversible

*Usually only ototoxic at high doses or in overdose

Loop diuretics may compound irreversible ototoxicity in patients taking cisplatin or aminoglycosides

**Based on in vitro data

Tinnitus often occurs alongside hearing loss, however, the degree of hearing loss does not always match the severity of the tinnitus.5 Identifying the type of hearing loss can help to establish an underlying cause.

By definition, people with primary tinnitus have symmetric sensorineural hearing loss.3 Conductive hearing loss or unilateral sensorineural hearing loss indicates secondary tinnitus (Figure 1).3

Enquire about hearing difficulties and occupational and recreational noise exposure.22 A brief hearing check can be performed by the clinician rubbing their fingers together behind the patient’s ear or using a soft whisper and assessing whether they can hear the noise.23 If hearing loss is suspected, referral to an audiologist for a full diagnostic hearing assessment is recommended.22

Tuning fork tests

When hearing loss is suspected from the history or a brief hearing check, the Weber and Rinne tuning fork tests can be used to check for the presence of, and differentiate between, conductive hearing loss and sensorineural hearing loss (Table 3).25 Both tests operate on the principle of comparing air conduction to bone conduction and should be used together.25

Best practice tip: Tuning fork tests are not diagnostic and should be used to help direct further assessment. They may not produce accurate results in patients with severe sensorineural hearing loss (see below),28 and do not replace referral to an audiologist for a full diagnostic hearing assessment.

Table 3. Interpretation of Weber and Rinne test results.22, 25

Hearing Weber* Rinne
Normal Midline Positive
Sensorineural hearing loss Unaffected ear Positive
Conductive hearing loss Affected ear Negative

*Side the tuning fork is heard best

Positive Rinne test – air conduction better than bone conduction; negative Rinne test – bone conduction better than air conduction

The impact of tinnitus on day-to-day life varies widely, from minimal disruption to significant distress and disability requiring more intensive management (see: “Tinnitus-related distress”).4, 35 Tinnitus is reported as being bothersome in up to 20% of affected people.5

When taking a medical history in patients with tinnitus:

  • Ask about the effect it has on sleep, employment, study, leisure activities and relationships with family and friends36
  • Ask about hyperacusis, where ordinary sounds are perceived as unbearable and painfully loud; this is common in people with tinnitus and can significantly affect quality of life37
  • Screen for symptoms of depression and anxiety, which occur more frequently in people with tinnitus (see below)36

Tinnitus-related distress

Most people report that tinnitus becomes less noticeable over time, similar to becoming accustomed to background sounds in the daily environment, e.g. air conditioning or a clock ticking. This process is known as habituation.3

For some people tinnitus can become extremely loud and bothersome, significantly affecting their quality of life.3 Negative interpretations of the sounds they perceive cause them to pay increased attention to their tinnitus.4 Heightened awareness of tinnitus is a barrier to habituation and causes autonomic arousal and emotional distress; the experience of distress reinforces the person’s negative interpretations.4 This cycle can lead to avoidance behaviours, hypervigilance and tinnitus catastrophising.4

When severe, tinnitus-related distress results in functional disability and reduced quality of life. People report difficulty concentrating, communicating, and sleeping.3 These difficulties impact employment, social relationships and leisure activities.3

Reasons for tinnitus-related distress are multifactorial and may include health anxiety, past experience and current life situation.4 Personality factors have a significant influence, e.g. tendencies to hold negative beliefs about self and the world.4 Depression and anxiety are often co-morbid with tinnitus.4 This relationship is complex, as tinnitus can contribute to depression and anxiety, but these conditions also modify interpretations of tinnitus.4 People with tinnitus-related distress are at increased risk of suicidal ideation.16 For further information, see: “Management of tinnitus-related distress”.

Some causes of secondary tinnitus can be managed in primary care, e.g. otitis media, otitis externa, accessible foreign object in the external auditory canal, reversible medicine-induced ototoxicity.3 Patients with cerumen impaction should be referred for aural microsuction, although cost may be a barrier for some. For many patients, symptoms will resolve with treatment; reassess those whose tinnitus or hearing loss persists.3

  • Refer patients with red flags to secondary care

    Patients with any of the following features should be discussed with or referred to an otolaryngologist (referral to an audiologist or other specialist may also be appropriate depending on the suspected underlying cause):36, 38

    • Tinnitus with a focal neurological deficit: urgent referral
    • Tinnitus with vestibular symptoms, e.g. vertigo, loss of balance: urgent referral if symptoms severe
    • Tinnitus with sudden hearing loss (onset over three days or less): urgent referral if within 30 days
    • Pulsatile tinnitus
    • Tinnitus with unilateral or asymmetric hearing loss
  • Primary tinnitus is managed by identifying and treating hearing loss, providing appropriate education and addressing contributing lifestyle factors, e.g. stress.1, 3 Cognitive behavioural therapy (moderate to high quality evidence) and sound enrichment (low quality evidence) could also be considered to reduce the negative impact that tinnitus-related distress has on a patient’s quality of life.3

    Evaluate hearing loss if present – patients with primary tinnitus or secondary tinnitus that has not resolved after routine treatment, e.g. microsuction, should be referred to an audiologist for pure-tone audiometry to further assess their degree of hearing loss.3 Hearing aids may be appropriate for some patients with hearing loss, and may also improve their tinnitus symptoms (if there are no other triggers).5 The use of hearing aids to relieve tinnitus in people who do not have hearing loss is not recommended.5

    Provide education and reassurance – education and reassurance are an important part of the management of a patient with tinnitus because their understanding of tinnitus can affect the degree of disability it causes.36 At their first appointment, patients should receive tinnitus education relevant to their health literacy level.36 In some situations, it may be beneficial to provide tinnitus education to family/whānau as well.5

    Explain that tinnitus is often associated with or caused by hearing loss.5 Reduced hearing means the brain does not receive the same sound signals it used to, so the brain “turns up the volume” to try to detect the missing sounds—this can result in tinnitus.39 Patients should be reassured that tinnitus does not make hearing loss worse, and it is only rarely associated with more serious medical conditions.5

    Address lifestyle factors – stress is an important underlying factor in tinnitus; approximately 65% of people with chronic tinnitus also have stress symptoms.40 An increase in stress may exacerbate tinnitus or make the experience more distressing.5 Other lifestyle factors such as sleep, diet and exercise can also affect tinnitus.5 Patients may be able to identify and manage certain triggers for their symptoms, allowing for more control over their tinnitus.

    For most people with tinnitus, their symptoms become less noticeable and less annoying over time, although they may not completely go away.5 In some cases tinnitus can be completely eliminated, particularly when the cause of hearing loss is treatable.1

    Hearing a ringing or buzzing noise in the complete absence of sound is a normal phenomenon.39 Therefore it is understandable that people with tinnitus usually find it most noticeable in quiet settings, such as lying in bed. Patients may be able to improve tinnitus symptoms in these situations by adding a background sound source.41 Suggest trying a sound that has a similar pitch and character as their tinnitus. Neutral noises like a fan or nature sounds are more effective than active sound from music, television or radio. The best volume for background noise is just quieter than the perceived tinnitus sounds; this aids habituation as the tinnitus and background noise mix together, helping the brain realise the tinnitus is not a “threat”.42 Sound enrichment is an ongoing area of research and while there is a lack of evidence to recommend one specific method over another, there is currently no evidence of harm; a trial and error approach may be required to identify which conditions work best for a particular patient.

    • Smartphone apps are available that play white noise or nature sounds. There are also options on platforms such as Spotify, Apple Music, YouTube and SoundCloud. Specialised bedside sound enrichment devices can be purchased online.
    • An audiologist who specialises in tinnitus management can advise on other sound enrichment devices including wearable noise generators which are fitted to the ears and hearing aids with sound enrichment features.

    Many medicines have been trialled in patients with tinnitus, but none have sufficient evidence to recommend them for routine use. Guidelines recommend against use of betahistine, benzodiazepines, antidepressants and anticonvulsants for most people with tinnitus, although betahistine may be used to treat patients with Ménière’s disease (see: “Ménière’s disease”).3, 36

    Patients with depression and tinnitus are still likely to benefit from antidepressants; effective treatment of depression may also alleviate their tinnitus.16

    • Stress reduction. Techniques include breathing exercises, guided relaxation and mindfulness (see: “Resources for patients with tinnitus”). Lifestyle changes to reduce stress may also be beneficial.5
    • Sleep hygiene. Tinnitus often disturbs sleep, and the resulting tiredness may exacerbate tinnitus. Encourage good sleep hygiene. Sound enrichment at night may be helpful.5
    • For further information on sleep hygiene and the treatment of insomnia, see: bpac.org.nz/2017/insomnia-1.aspx

    • Cognitive behavioural therapy (CBT). This is the most researched psychological intervention for tinnitus, and it may incorporate relaxation techniques, behavioural sleep management and sound enrichment. CBT is effective at alleviating distress in patients with tinnitus, but does not usually reduce the presence or perceived loudness of tinnitus.37 Tinnitus-focused CBT is not widely available in New Zealand, but audiologists specialising in tinnitus may be able to offer treatment based on similar principles.
    • Referral. Patients with primary tinnitus that still causes significant distress after management in primary care should be referred to an audiologist (who specialises in tinnitus), or an otolaryngologist.

    Tinnitus information

    Information on tinnitus from Health Navigator.

    Tinnitus tunes

    Online resource combining education, sound therapy and relaxation techniques. Payment is required for full access, so this may not be an option for some patients.

    Tinnitus resources

    Information and links from Tinnitus Australia.

    Audio relaxation exercises

    Exercises including breathing, muscle relaxation and guided visualisation developed by Australian mental health organisation Beyond Blue.

    Just a thought

    Online cognitive behavioural therapy resource for people with mild-to-moderate anxiety and depression. Produced in New Zealand. Currently no tinnitus-specific resources.


    Thank you to Dr Michael Bergin, Consultant Otolaryngology Head and Neck Surgeon, Christchurch, Te Whatu Ora Waitaha Canterbury and Duncan Hann, Senior Clinical Audiologist, Dilworth Hearing, Christchurch for expert review of this article.

    N.B. Expert reviewers do not write the articles and are not responsible for the final content. bpacnz retains editorial oversight of all content.

    This resource is the subject of copyright which is owned by bpacnz. You may access it, but you may not reproduce it or any part of it except in the limited situations described in the terms of use on our website.

    Article supported by the South Link Education Trust

    Narayanan Rajan 21 Jun 2023 11:07

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