What conditions can cause ringing in the ears (tinnitus)?

Conditions That Cause Ringing in the Ears (Tinnitus)

Sensorineural hearing loss is the single most common underlying cause of tinnitus, but the differential diagnosis is extensive and includes auditory, vascular, neurologic, structural, metabolic, and psychiatric etiologies. 1

Primary Auditory System Causes

Hearing-Related Conditions:

• Presbycusis (age-related hearing loss) represents the most common cause in older adults, resulting from progressive degeneration of cochlear hair cells 1
• Noise exposure from occupational or recreational sources (concerts, firearms, machinery) causes cochlear damage and tinnitus 1
• Sudden sensorineural hearing loss presents with acute onset tinnitus requiring urgent evaluation 1
• Cochlear synaptopathy ("hidden hearing loss") triggers auditory nerve fiber degeneration without affecting standard hearing thresholds, causing difficulty understanding speech in noise 1

Middle and External Ear Pathology:

• Cerumen impaction is a simple, reversible cause identifiable on otoscopic examination 1
• Middle ear infection or effusion causes conductive hearing loss with associated tinnitus 1
• Otosclerosis produces conductive hearing loss leading to tinnitus 1

Ototoxic Medications:

• Certain antibiotics, chemotherapy agents (particularly platinum-based drugs like cisplatin), and other medications can cause irreversible cochlear damage 1, 2

Vascular Causes (Typically Pulsatile Tinnitus)

Arterial Pathology:

• Atherosclerotic carotid artery disease is the most frequent vascular cause, accounting for 17.5% of pulsatile tinnitus cases 3
• Arterial dissection represents a potentially life-threatening emergency requiring urgent identification 3
• Fibromuscular dysplasia of carotid arteries can produce turbulent flow 1

Arteriovenous Lesions:

• Dural arteriovenous fistulas account for 8% of pulsatile tinnitus and can lead to hemorrhagic or ischemic stroke if untreated 3
• Arteriovenous malformations create abnormal high-flow vascular connections generating audible turbulent flow 3
• Carotid cavernous sinus fistulas produce characteristic pulsatile symptoms 1

Venous Abnormalities:

• Idiopathic intracranial hypertension is the second most common cause of pulsatile tinnitus, particularly in young overweight women 3
• Transverse sinus stenosis and sigmoid sinus diverticulum or dehiscence are commonly associated with intracranial hypertension 3
• High-riding jugular bulb or dehiscence of the sigmoid plate can transmit vascular sounds 3
• Persistent petrosquamosal sinus and abnormal condylar/mastoid emissary veins represent aberrant venous anatomy 3

Vascular Tumors:

• Paragangliomas (glomus tympanicum/jugulare) account for 16% of pulsatile tinnitus cases and appear as vascular retrotympanic masses 3
• Adenomatous middle ear tumors are less common vascular masses 3

Neurologic Causes

Cranial Nerve and Central Pathology:

• Vestibular schwannoma (acoustic neuroma) almost always causes unilateral tinnitus with asymmetric hearing loss 1
• Cerebellopontine angle masses and auditory pathway lesions can produce tinnitus 1
• Neurodegeneration represents a central nervous system cause 1
• Multiple sclerosis rarely causes tinnitus 4

Intracranial Pressure Disorders:

• Intracranial hypertension (benign or idiopathic) causes both pulsatile and non-pulsatile tinnitus 1
• Spontaneous intracranial hypotension can produce tinnitus 1

Structural and Bony Abnormalities

• Superior semicircular canal dehiscence allows transmission of vascular sounds and body noises 3
• Sigmoid sinus wall dehiscence creates abnormal sound transmission 1
• Paget disease affecting the temporal bone can cause tinnitus 1
• Temporal bone fracture or head trauma with vascular injury produces tinnitus 1

Metabolic and Systemic Causes

• Diabetes and glucose metabolism disorders can disturb inner ear function, as the cochlea depends directly on oxygen and glucose supply 5
• Abnormally low serotonin or high insulin levels may contribute to tinnitus 5

Psychiatric and Psychogenic Factors

• Anxiety and depression are both causes and consequences of tinnitus, creating a bidirectional relationship 1
• Severe psychiatric illness with tinnitus carries increased suicide risk requiring prompt intervention 1

Specific Disease Entities

• Ménière's disease presents with episodic vertigo, fluctuating hearing loss, and tinnitus 1
• Temporomandibular joint disorders and masticatory muscle dysfunction can produce tinnitus 6

Critical Clinical Distinctions

Pulsatile vs. Non-Pulsatile:

• Pulsatile tinnitus (synchronous with heartbeat) has an identifiable structural or vascular cause in over 70% of cases and almost always requires imaging evaluation 3
• Non-pulsatile tinnitus is typically related to sensorineural hearing loss and accounts for 70-80% of cases 1

Objective vs. Subjective:

• Objective tinnitus (audible to examiner) is rare and strongly suggests vascular pathology or neuromuscular causes like palatal myoclonus 1, 7
• Subjective tinnitus (perceived only by patient) is most common and represents phantom auditory perception from abnormal neural activity 8

Unilateral vs. Bilateral:

• Unilateral tinnitus has higher likelihood of identifiable structural cause and warrants imaging to exclude vestibular schwannoma 1
• Bilateral symmetric tinnitus without other features typically does not require imaging 1

Important Clinical Pitfalls

• Approximately 10-15% of adults experience tinnitus, with prevalence increasing with age, and around 20% require clinical intervention 1
• Tinnitus that wakes a patient from sleep is highly unusual and should raise immediate suspicion for objective tinnitus with vascular or neuromuscular etiology 1
• Many patients with tinnitus (up to 50%) do not exhibit associated hearing loss on standard audiometry, making cause identification challenging 7
• The anatomical location of chronic subjective tinnitus is rarely in the ear itself but more often in the central auditory nervous system, reflecting neural plasticity changes 8