Ringing in one ear: causes, red flags and when to get it checked

Tinnitus is a sound with no external source. It is usually a sign that the hearing pathway, from the cochlea to the brain, is receiving less input than usual. The brain increases its own gain and creates a phantom sound. In one ear it is most often due to local ear conditions or one-sided hearing loss.

• Earwax or a foreign body in the canal.

• Noise exposure, either a recent loud event such as a concert or long-term noise from work, leading to one-sided or asymmetric hearing loss.

• Age-related hearing loss, which is often slightly worse on one side.

• Ear infection, fluid behind the drum, or eustachian tube problems.

• Medicines that can affect hearing: high-dose aspirin, some antibiotics (aminoglycosides), loop diuretics, and certain chemotherapy drugs.

• Meniere disease: ringing, fullness, fluctuating hearing loss and vertigo attacks.

• Jaw joint or neck problems that modulate the sound.

• Vestibular schwannoma (acoustic neuroma): a benign nerve tumour that causes one-sided ringing with hearing loss, and is rare.

• Vascular causes of pulsatile tinnitus, including narrowed or abnormal vessels, raised intracranial pressure, and glomus tumours.

Hearing that is worse on one side, vertigo, facial numbness or weakness, a sound that pulses with the heartbeat, tinnitus after a head injury, or sudden onset with hearing loss warrant investigation.

• Call 999: ringing with sudden facial droop, severe headache, slurred speech or weakness.

• Same-day or next-day GP or ENT: sudden one-sided hearing loss with ringing.

• GP within weeks: ringing in one ear only that persists beyond a few weeks, or pulsing with the heartbeat.

• Routine GP: tinnitus in both ears with gradual hearing loss, or after noise exposure.

The doctor asks about the character of the sound (ringing, hissing or pulsing), onset, hearing change, noise exposure, medicines, dizziness, facial symptoms, sleep, mood and how much it bothers you. Examination includes the ear canals and drums, tuning-fork tests, listening over the neck and skull for a bruit, and checking cranial nerves.

• Pure-tone audiometry: the key test for asymmetry and hearing loss.

• MRI of the internal auditory canals: for confirmed asymmetric hearing loss or unilateral tinnitus with other signs.

• MR or CT angiography: if pulsatile tinnitus suggests a vascular cause.

• Blood pressure and blood tests: to exclude contributory conditions.

• Tympanometry: for middle-ear problems.

Protect your ears from loud noise, and use background sound or gentle noise at night so the ringing is less noticeable. Cognitive behavioural therapy and tinnitus retraining are effective for distress. Limit caffeine if it worsens the sound, and treat anxiety and poor sleep. Hearing aids help when there is hearing loss.

The NHS route is a GP, then audiology or ENT. Private audiology and ENT clinics offer hearing tests and MRI directly, and tinnitus counselling is available.