What Causes Your Intermittent Ringing in the Ears
Your intermittent ear ringing (tinnitus) is most likely caused by sensorineural hearing loss, which is the single most common underlying cause of tinnitus, even when you're not aware of any hearing problems. 1
Primary Causes to Consider
Sensorineural hearing loss is responsible for the majority of tinnitus cases and can occur without you noticing significant hearing difficulty in daily life. 1 This includes:
- Age-related hearing loss (presbycusis) - The strongest risk factor, with prevalence increasing dramatically from 1.6% in adults aged 18-44 to 9.0% in those over 60 years 1
- Noise exposure - Both occupational (machinery, loud work environments) and recreational (concerts, firearms, headphones) can trigger tinnitus and hearing loss 1
- "Hidden hearing loss" (cochlear synaptopathy) - This causes irreversible degeneration of auditory nerve fibers without affecting standard hearing tests, leading to difficulty understanding speech in noisy environments 1
Other Important Causes
Medication-related tinnitus can occur from ototoxic drugs, including chronic acetaminophen use, which warrants counseling about tinnitus risk particularly with daily or near-daily use. 1, 2
Ear-specific problems that should be ruled out include:
- Cerumen (earwax) impaction 3
- Middle ear infection or fluid 3
- Otosclerosis (abnormal bone growth affecting hearing) 1
Neurologic and psychological factors can contribute:
- Anxiety and depression are psychogenic factors that can both cause and worsen tinnitus 1
- Neurodegeneration can be an underlying neurologic cause 1
Critical Red Flags Requiring Urgent Evaluation
You need immediate medical attention if your tinnitus is accompanied by:
- Pulsatile quality (rhythmic sound synchronizing with your heartbeat) - This often indicates vascular abnormalities requiring thorough evaluation 1, 4
- Unilateral tinnitus (only one ear) - This increases suspicion for acoustic neuroma and requires comprehensive audiological examination 3
- New neurological symptoms (weakness, numbness, vision changes, severe headache) 5
- Severe anxiety or depression - This requires prompt intervention due to increased suicide risk in tinnitus patients with psychiatric comorbidity 1, 5
The Diagnostic Approach You Should Expect
Initial evaluation should include:
- Otoscopic examination to identify cerumen impaction, middle ear infection, or masses 6
- Comprehensive audiological testing, especially if tinnitus is unilateral or persistent 5
- Assessment for hearing loss patterns and degree 6
Imaging is NOT routinely indicated for symmetric, bilateral, non-pulsatile tinnitus without other concerning features. 6 However, imaging becomes necessary if you have:
Common Pitfalls to Avoid
Don't dismiss ear fullness or blockage - This is the primary presenting symptom of sudden hearing loss, and both patients and physicians often delay evaluation because it seems non-specific, but new-onset ear blockage warrants prompt evaluation. 6
Don't assume all tinnitus needs imaging - Imaging is unrevealing and not indicated for tinnitus related to medications, noise-induced hearing loss, presbycusis, or chronic bilateral hearing loss. 6
Don't ignore the psychological impact - The nearly universal accompanying tinnitus in sudden hearing loss frequently contributes intensely to anxiety and depression, and approximately 20% of adults with tinnitus require clinical intervention. 6, 1
What Happens Next
Most tinnitus (85-90% of cases) remains idiopathic despite thorough evaluation, meaning no specific underlying cause is identified at presentation. 6 However, this doesn't mean it's untreatable - available interventions include hearing aids (even for mild or unilateral hearing loss), sound therapy, and cognitive behavioral therapy-based counseling. 7
Long-term follow-up is recommended because some patients will have an underlying cause identified that may not be evident at initial presentation, and up to a third of cases may have a cause identified only after extended monitoring. 6