It’s a common question that many audiologists and ear, nose and throat (ENT) doctors face nearly every day. The short answer is yes – you can have tinnitus but no hearing loss. The complete answer is that tinnitus can arise from a variety of conditions and extrinsic factors that are not always obvious when tinnitus makes its first appearance. Let’s take a deeper look at the causes of and current research surrounding tinnitus.
What is tinnitus?
Shortly put, tinnitus is the presence of sound in one’s head when there is no external sound or noise around. This can be a ringing, whooshing, buzzing, whistling or clicking sound.
The most common cause of tinnitus is hearing loss.
Most commonly, age-related hearing loss, also known as presbycusis, or noise-induced hearing loss is the cause of tinnitus. Tinnitus may also be present in more complex hearing losses, such as conductive or mixed hearing loss, often the result of middle ear involvement. In any case, what researchers have speculated over the years is that tinnitus is the brain’s way of trying to fill in the missing gaps of sound. With hearing loss, the brain is missing auditory stimuli, so the brain is trying to fill in those missing frequencies.
Here are other reasons tinnitus may be present:
- Inner ear pathologies, including, but not limited to: labyrinthitis, vestibular Schwannoma, Ménière’s disease. These are pathologies that may or may not coincide with hearing loss but can be present without it as well. In such cases, dizziness is another common symptom noted alongside tinnitus. It is important in these cases to see your primary care or ENT physician to review your symptoms and perform testing to assess whether the source of the tinnitus is an inner ear pathology.
- Traumatic brain injury and other trauma: including neck trauma or barotrauma, such as that from skydiving, scuba diving or flying on an airplane.
- Headaches and migraines.
- Temporomandibular joint disorder (TMJ): often associated with jaw and ear pain and teeth clenching.
- Ototoxic medications – these are medications that cause damage to the inner ear and may result in hearing loss, tinnitus, or vertigo and dizziness. Common medications that are ototoxic include anti-inflammatory drugs or painkillers, some cancer medications, antibiotics, and diuretics. There is a study from 2011 titled “Ototoxicity: The Hidden Menace,” in which the authors, Bisht and Bist, break down ototoxic medications into categories, and detail whether they affect hearing, tinnitus, or vertigo. The article will be cited in the reference section, and is certainly worth the read to find a more encompassing list of ototoxic medications.
- Lifestyle factors (stress and diet): There has been increasing research and evidence suggesting tinnitus can be present as a result of stress and the things that we eat.
- Stress: In a 2023 research study, Patil et al. reviewed the association between stress, emotion and tinnitus. An interesting takeaway from their research revealed that “mood disorders such as PTSD, insomnia, depression, and anxiety have been linked to the dysfunction of neurotransmitters in the habituation process.” This is critical information, because habituation is probably the number one concept used in addressing tinnitus with cognitive behavioral therapy, and if habituation is disrupted, tinnitus may continue to be prevalent or worsen with negative changes in mood and stress.
- Diet: In a separate 2020 study titled “Relationship Between Diet, Tinnitus, and Hearing Difficulties,” Dawes et al. concluded that higher intakes of calcium, iron and fat were associated with increased odds for tinnitus; whereas vitamin B12 was associated with reduced odds for tinnitus. While these findings are valuable, it is important to consider the researchers' note that single nutrients are not consumed in isolation, and that perhaps examining one's dietary pattern and the relation to tinnitus may be more effective in determining if diet is playing a role.
- Sound therapy and maskers: These can be anything that distracts the brain away from tinnitus. Some people play white noise; others benefit from melodic or classical music, audiobooks, ocean sounds, etc.
- Addressing the source of the issue: If the tinnitus is related to the inner ear, trauma, headaches/migraines, or TMJ, finding a provider who has helped narrow down the source and is making recommendations to remedy that problem may also help reduce tinnitus.
- Talking to your PCP about changing medications that are ototoxic. Medications can be a tricky issue, because there are always going to be trade-offs with the medications one takes. In some cases, changing medications may not be an option, but a discussion with your doctor will confirm this.
- Cognitive Behavioral Therapy (CBT) and mindfulness: CBT is a popular recommendation for those suffering from chronic and debilitating tinnitus. CBT seeks to work with the individual to figure out triggers and sources of stress and emotions that may be contributing to the increase in tinnitus. It also gives the individual the tools they need to modify and change their behaviors in order to improve their state of mind and overall emotional well-being.
For further information on tinnitus, the American Tinnitus Association is an excellent source and includes more information about current research, therapy and peer resource groups. Their website can be reached at ata.org.
References
- Bisht, M., & Bist, S. S. (2011). Ototoxicity: The Hidden Menace. Indian Journal of Otolaryngology and Head & Neck Surgery, 63(3), 255–259. https://doi.org/10.1007/s12070-011-0151-8
- Causes | American Tinnitus Association. (2023, March 3). https://www.ata.org/about-tinnitus/why-are-my-ears-ringing/causes/
- Dawes, P., Cruickshanks, K. J., Marsden, A., Moore, D. R., & Munro, K. J. (2020). Relationship Between Diet, Tinnitus, and Hearing Difficulties. Ear and Hearing, 41(2), 289–299. https://doi.org/10.1097/aud.0000000000000765
- Han, B. I., Lee, H. W., Kim, T. Y., Lim, J. S., & Shin, K. S. (2009). Tinnitus: Characteristics, Causes, Mechanisms, and Treatments. Journal of Clinical Neurology, 5(1), 11. https://doi.org/10.3988/jcn.2009.5.1.11
- Jayaditya Devpal Patil, Manar Abdulkarim Alrashid, Ayah Eltabbakh, & Fredericks, S. (2023). The association between stress, emotional states, and tinnitus: a mini-review. Frontiers in Aging Neuroscience, 15. https://doi.org/10.3389/fnagi.2023.1131979
- Kreuzer, P. M., Landgrebe, M., Schecklmann, M., Staudinger, S., & Langguth, B. (2012). Trauma-Associated Tinnitus: Audiological, Demographic and Clinical Characteristics. PLOS ONE, 7(9). https://doi.org/10.1371/journal.pone.0045599
