Subjective tinnitus: ringing in the ears, causes and coping

The NHS defines tinnitus as hearing noises that do not come from an outside source. NHS inform notes that it is often called ringing in the ears but is not just ringing: people describe buzzing, humming, grinding, hissing, whistling, music or singing, and sometimes noises that beat in time with the pulse. The NHS adds that you may hear the sounds in one or both ears or in the head, and that they may come and go or be constant.

The word subjective is used when only the person themselves can hear the sound, which is by far the commonest situation. Sounds that a clinician can also hear, sometimes with a stethoscope, are called objective tinnitus and are less common. Tinnitus is a symptom, not a disease in its own right, and it can have several different causes.

NHS inform says most people have tinnitus for a short time after exposure to loud noise, such as after a music concert. It also says tinnitus affects people of all ages including children, is more common in people over 65, and will sometimes get better over time, either by disappearing or by the body getting used to it.

It is not always clear what causes tinnitus. The NHS says it is often linked to some form of hearing loss, Ménière disease, conditions such as diabetes, thyroid disorders or multiple sclerosis, anxiety or depression, and certain medicines. It names some chemotherapy medicines, antibiotics, non-steroidal anti-inflammatory drugs and aspirin as medicines that can cause tinnitus as a side effect.

NHS inform adds inner ear damage from repeated exposure to loud noises, earwax build-up, a middle ear infection and otosclerosis, an inherited condition where abnormal bone growth in the middle ear causes hearing loss. It says tinnitus can develop slowly or happen suddenly. Do not stop prescribed medicines because you suspect they cause tinnitus; speak to the prescriber or a pharmacist first.

The NHS draws clear lines. Go to A&E or call 999 if you have tinnitus after a head injury, or tinnitus with sudden hearing loss, weakness in the muscles of your face, or a spinning sensation (vertigo). Do not drive yourself to A&E; ask someone to drive you or call 999, and bring any medicines you take.

Ask for an urgent GP appointment if your tinnitus beats in time with your pulse. For less urgent situations, the NHS and NHS inform both advise seeing a GP if you have tinnitus regularly or constantly, if it is getting worse, or if it is bothering you, for example affecting sleep or concentration or making you feel anxious or depressed. Sudden hearing loss in one ear is an emergency in its own right, whatever the tinnitus is doing.

The NHS says the GP will look in your ears to see whether something treatable, such as an ear infection or earwax build-up, is responsible, and may check for hearing loss. You may be referred to a specialist for further tests and treatment. NHS inform says the doctor can refer if needed.

The NHS says the GP may also check for hearing loss, and that if you have hearing loss, hearing aids may be recommended. Where no cause is found or it cannot be treated, you may be referred for a talking therapy.

NHS inform says there is currently no treatment for tinnitus that works for everyone. If an underlying condition is causing it, treating that may help. If no cause can be found, treatment focuses on managing it day to day: sound therapy, counselling, cognitive behavioural therapy (CBT) and tinnitus retraining therapy.

The NHS adds that your GP or specialist may refer you for a talking therapy if the cause is unknown or cannot be treated. Digital CBT, delivered through an online programme or app, is usually offered first. CBT aims to change how you think about tinnitus and reduce anxiety, counselling helps you learn about tinnitus and ways of coping, and tinnitus retraining therapy uses sound therapy to retrain the brain to tune out and be less aware of the sound. The NHS says tinnitus retraining therapy may be available on the NHS for severe or persistent tinnitus, that it is unclear whether it works for everyone, and that it is widely available privately. If you have hearing loss, hearing aids may be recommended.

The NHS and NHS inform list the same practical measures:

• Try to relax: deep breathing or yoga may help.

• Improve your sleep with a bedtime routine and by cutting down on caffeine.

• Avoid things that can make tinnitus worse, such as stress or loud background noise.

• Join a support group; talking to other people with tinnitus may help you cope.

• Do not aim for total silence: soft music or sounds (sound therapy) can distract you from the tinnitus.

• Try not to focus on it, as this can make it worse; hobbies and activities may take your mind off it.

On the NHS the route usually runs from GP to audiology or ENT, with talking therapies via digital CBT. Access to specialist tinnitus clinics varies across the UK. The NHS names Tinnitus UK as a source of self-help information and a free helpline and local support groups.

Private audiologists commonly offer tinnitus assessments, sound generators and retraining therapy. Because no treatment suits everyone, ask what outcome a provider expects, how long therapy lasts, what it costs in total and how progress will be measured. Treat claims of a guaranteed cure with caution.