Subjective Chronic Tinnitus (Ringing in the Ears)

Definition and epidemiology

Tinnitus is a sound experience perceived without an external acoustic stimulus; it is therefore also described in the literature as a “phantom auditory perception.” Today it is regarded less as an isolated ear problem and more as a response of the central nervous system to changes in the auditory pathways.

Prevalence in adults varies across studies but is about 10-15%. In a small proportion of people (about 1-2%) a “bothersome” tinnitus develops that seriously affects sleep, attention and mood (McCormack et al., 2016).

The most widely accepted mechanism is the “central gain” model: when auditory input reaching the brain decreases because of hair-cell loss or synaptic damage in the cochlea, the central auditory pathways increase their sensitivity to compensate; this heightened neural activity forms the basis of the tinnitus percept (Baguley et al., 2013).

Symptoms and signs

Patients may describe the sound as ringing, buzzing, hissing, a cricket-like chirp or a pulse-synchronous beat. It may be perceived in one ear, both ears or inside the head; it may be continuous or come and go.

The “iceberg model” of tinnitus makes the picture easier to understand: the part above the water is the loudness and quality of the sound, while the main burden that usually stays hidden is sleep problems, difficulty concentrating, anxiety and the habit of focusing on the sound.

If the sound beats in time with the pulse (pulsatile tinnitus), is accompanied by one-sided progressive hearing loss, or starts suddenly, an underlying vascular or retrocochlear cause should be excluded; these findings require further assessment.

Causes and risk factors

The condition most often accompanying tinnitus is hearing loss. Noise-induced damage, age-related hearing loss (presbycusis), otosclerosis, Ménière’s disease and ototoxic drug use are important triggers.

Somatosensory input from the head-neck region and the jaw joint can change tinnitus severity; in this “somatic tinnitus” picture, physiotherapy or a dental evaluation may help.

Stress, sleep deprivation and anxiety disorders do not cause tinnitus directly but markedly increase its perceived severity and distress; management is therefore often multidisciplinary.

Audiological and clinical assessment

Assessment begins with a detailed history and ENT examination. The aim is to distinguish treatable causes (wax, middle-ear pathology, vascular structures) and to separate tinnitus from the difficulties caused by hearing loss.

The audiological battery includes pure-tone audiometry (including high frequencies), speech audiometry, tympanometry, acoustic reflexes and otoacoustic emissions (OAE). When needed, ABR and imaging are planned for retrocochlear differential diagnosis.

• Psychoacoustic measurement: pitch (frequency) and loudness matching.
• Impact scales: THI (Tinnitus Handicap Inventory) and TFI (Tinnitus Functional Index).
• THS (Tinnitus and Hearing Survey): separates difficulties due to hearing loss from tinnitus.
• Visual Analogue Scale (VAS): rates momentary severity and distress.

The THI, whose Turkish validity and reliability have been established, is widely used in clinical follow-up and in tracking treatment response (Aksoy et al., 2007).

Treatment and audiological rehabilitation

Tinnitus has no drug that definitively removes the sound on its own. Current guidelines do not recommend routine drugs, herbal products or dietary supplements; the priority is evidence-based counselling and sound-based approaches (Tunkel et al., 2014).

If hearing loss is present, a hearing aid is among the first-line options; it improves communication, provides natural masking by restoring ambient sounds, and helps balance central gain.

Cognitive Behavioural Therapy (CBT) has the strongest evidence for reducing distress; it does not physically reduce the sound but re-regulates the brain’s threat response to it. Sound enrichment and tinnitus retraining therapy (TRT) support habituation; bimodal neuromodulation devices may help in selected patients (Conlon et al., 2020).

Impact on quality of life and advice

Bothersome tinnitus can lower quality of life by affecting sleep, attention and mood. Patient-reported outcome measures (PROMs) are as important as decibels in tracking treatment success.

Practical advice: avoid complete silence and use soft, neutral background sounds; redirect attention to functional activities rather than locking onto the sound; strengthen sleep hygiene and stress management. Protecting the ears from harmful noise matters; however, because constant earplug use can increase sensitivity, it is recommended only in genuinely noisy environments.