Ringing in the ears, known as tinnitus, affects about 14.4% of adults worldwide. It can sound like ringing, buzzing, hissing, or clicking, and it ranges from a mild background nuisance to a severe disruption of daily life. The causes span from noise damage and hearing loss to jaw problems, blood vessel conditions, and medication side effects.
How the Brain Creates Phantom Sound
Most people assume ringing in the ears starts in the ear itself. In reality, the sound is generated by the brain in response to changes in the signals it receives from the inner ear. When the tiny hair cells inside your inner ear are damaged (by noise, aging, or other insults), they send fewer signals to the brain. The brain compensates by turning up its own activity, essentially amplifying neural “noise” to fill in the gap. Neurons that lost their input start responding to signals from neighboring neurons instead, and their spontaneous firing rates increase across multiple structures in the auditory pathway.
This process also reduces the brain’s natural ability to suppress unwanted neural activity. Inhibitory circuits that normally keep things quiet get dialed down, which can unmask areas of hyperactivity. The result is a phantom sound percept: your brain interprets its own heightened electrical activity as real sound, even though no external sound exists. This is why roughly 10% of adults who experience tinnitus have it chronically, lasting more than three months, while about 2% experience it severely.
Noise Exposure
Loud noise is the single most preventable cause of tinnitus. Sounds at or above 85 decibels can damage hearing over time. That’s roughly the level of heavy city traffic, a lawnmower, or a loud restaurant. A single blast at or above 120 decibels, like a gunshot or an explosion, can cause immediate hearing loss and tinnitus. The damage happens to the delicate hair cells lining the cochlea. Once destroyed, these cells don’t regenerate in humans, so the hearing loss and any accompanying ringing are typically permanent.
Occupational noise exposure (construction, manufacturing, military service) and recreational exposure (concerts, headphones at high volume, motorsports) are the most common culprits. The ringing often matches the frequency range where your hearing has been lost, because those are the frequencies where your brain is working hardest to compensate for missing input.
Age-Related Hearing Loss
Gradual hearing loss with aging, called presbycusis, is one of the most common triggers. As you age, hair cells in the inner ear naturally deteriorate, particularly those responsible for high-frequency sounds. The brain responds with the same compensatory changes described above: increased spontaneous firing, reduced inhibition, and reorganization of its sound-processing maps. Progressive age-related loss of central inhibition can unmask areas of neural hyperactivity that may have been quietly building for years due to earlier noise exposure or other damage, which explains why tinnitus often appears later in life even when the original insult happened decades earlier.
Medications That Affect the Inner Ear
Certain medications are ototoxic, meaning they can damage hearing structures and trigger tinnitus. The risk generally depends on the dose and duration of use. Common categories include:
- High-dose aspirin and related compounds, which can cause reversible tinnitus that fades after stopping the medication
- Certain antibiotics (particularly macrolides like azithromycin and clarithromycin), especially at high doses over long periods
- Chemotherapy drugs, particularly platinum-based agents used in cancer treatment
- Loop diuretics, often prescribed for heart failure and kidney disease
- Some biologics, including immunotherapy and disease-modifying drugs
If you notice ringing after starting a new medication, that’s worth bringing up with your prescriber. In some cases the tinnitus resolves after the drug is stopped or the dose is adjusted, though with certain chemotherapy agents the damage can be permanent.
Jaw and Neck Problems
In about two-thirds of people with tinnitus, the perceived sound can be changed by muscle contractions or movements of the neck, head, or jaw. This is called somatosensory tinnitus, and it points to a direct connection between the musculoskeletal system and the brain’s hearing centers.
The key structure involved is the dorsal cochlear nucleus in the brainstem, which receives input from both the auditory system and the somatosensory system (the network that processes touch, pressure, and body position). When the jaw joint is inflamed or the surrounding muscles are tense, as happens with temporomandibular joint (TMJ) disorders, the altered signals traveling through this shared pathway can amplify or even generate tinnitus. After cochlear damage, the brain actually increases its reliance on somatosensory input to the hearing pathway, which is why jaw and neck problems can worsen tinnitus that started from a completely different cause.
Eustachian Tube Dysfunction
Your eustachian tubes connect your middle ears to the back of your throat, equalizing air pressure and draining fluid. When these tubes don’t open and close properly, fluid builds up and pressure changes in the middle ear, which can produce ringing, muffled hearing, and ear pain. Allergies, sinus infections, colds, and changes in altitude are common triggers. The tinnitus from eustachian tube dysfunction is often temporary and resolves once the underlying congestion or infection clears, but chronic cases left untreated can lead to lasting hearing damage.
Blood Vessel and Cardiovascular Causes
Pulsatile tinnitus is a distinct type: instead of a constant ringing, you hear a rhythmic whooshing or thumping that matches your heartbeat. This is often caused by turbulent blood flow near the ear, and unlike most tinnitus, it has a physical sound source that a doctor can sometimes hear with a stethoscope placed near the ear or on the neck.
Vascular causes include narrowing of the carotid arteries (from atherosclerosis), arteriovenous malformations (abnormal connections between arteries and veins), dural arteriovenous fistulas, carotid or vertebral artery dissection, fibromuscular dysplasia, and aneurysms. High blood pressure can also contribute by increasing the force of blood flow through vessels near the ear. Pulsatile tinnitus warrants medical evaluation because some of its causes, particularly fistulas and dissections, require treatment.
Metabolic and Systemic Conditions
Diabetes can damage the small blood vessels and nerves of the inner ear over time, according to the CDC, which is why people with diabetes have higher rates of both hearing loss and tinnitus. The mechanism mirrors how diabetes damages blood vessels in the eyes and kidneys: chronically elevated blood sugar injures the walls of tiny vessels, reducing blood flow to structures that depend on it. Thyroid disorders, iron-deficiency anemia, and autoimmune conditions affecting the inner ear can also produce tinnitus through related pathways involving inflammation or impaired circulation.
When Ringing Affects Only One Ear
Tinnitus in just one ear deserves closer attention. One possible cause is an acoustic neuroma (vestibular schwannoma), a noncancerous tumor that grows on the nerve connecting the inner ear to the brain. About 9 out of 10 people with an acoustic neuroma experience hearing loss in only one ear, and ringing in the affected ear is a common early symptom. Balance problems may develop as the tumor grows. These tumors are treatable, but early detection matters for preserving hearing and avoiding complications. One-sided tinnitus can also result from an ear infection, earwax blockage, or Ménière’s disease, but the possibility of a tumor is the main reason it’s taken seriously.
Subjective vs. Objective Tinnitus
The vast majority of tinnitus is subjective, meaning only you can hear it. There is no external sound being produced; the perception is entirely generated by neural activity in the auditory system. Objective tinnitus is rare and involves an actual physical sound source inside or near the ear, loud enough that an examiner can detect it with a stethoscope. Causes include blood vessel abnormalities, muscle spasms of the tiny muscles in the middle ear (the tensor tympani and stapedius), and palatal muscle clonus, which produces a rhythmic clicking. The distinction matters because objective tinnitus often points to a specific, identifiable, and sometimes treatable structural cause.