Understanding Tinnitus

What Is Tinnitus?

Tinnitus is the perception of sound without an actual acoustic source. People may experience it in different ways. For some, the sound seems to come from one ear, both ears, or from the centre of the head. Others describe it as a sound coming from outside their body. The sounds themselves vary widely: buzzing, ringing, hissing, whistling, or roaring are among the most common descriptions. This type, where the sound is heard but no external or internal source is present, is called subjective tinnitus. The vast majority of people with tinnitus experience this form.

In rare cases, tinnitus may be generated by physical vibrations within the body, known as objective tinnitus. This can result from blood flow in the head and neck, small muscle movements in the middle ear or palate, changes in the jaw joint, or sounds created by inner-ear structures themselves. An ear specialist can sometimes hear these vibrations with a stethoscope placed near the ear canal.

How Common Is Tinnitus?

Tinnitus is extremely common. Around 15 percent of the global population are thought to experience it, which equates to about one billion people worldwide. For many, tinnitus is mild and occurs only intermittently. Others find it persistent, intrusive, and distressing. About one in five people cannot even describe the quality of their tinnitus because the sound feels so unusual or indescribable.

What Is Persistent Tinnitus?

Persistent tinnitus is defined as tinnitus lasting more than five minutes at a time. Patterns of persistence vary greatly. Some people hear it constantly during waking hours, while others also perceive it during dreams. For some, it is most noticeable at night or in quiet settings. For others, tinnitus comes and goes in episodes lasting hours, days, or even weeks

It is important to note that no single pattern is necessarily easier or harder to manage. The impact of tinnitus does not depend directly on how often it is heard or how loud it seems. Instead, the key factor is the level of annoyance and anxiety it causes. Research at Hashir International Institute has shown that the distress linked to tinnitus is most closely related to these emotional responses.

Why Does Tinnitus Feel Distressing?

Tinnitus itself does not damage hearing or block awareness of external sounds. A study from the University of California, Irvine, confirmed that people with tinnitus can still detect and discriminate external sounds as well as those without tinnitus. The difficulty comes from how the brain reacts to tinnitus. When it is judged as threatening, worrying, or unbearable, this increases stress and anxiety, which in turn makes the sound feel more intrusive.
Cognitive behavioural therapy (CBT) has been shown to be effective in breaking this cycle. Recent studies, including international collaborations, demonstrate that CBT can reduce tinnitus-related anxiety and annoyance, even when the tinnitus itself does not become quieter. By changing the way we respond to tinnitus, the sound gradually loses its significance and becomes easier to ignore, a process called habituation.

What Causes Tinnitus?

For most people, tinnitus is not linked to a specific disease. However, it can be associated with disorders of the ear and hearing system or with certain medical treatments. Common causes include:

  • Age-related hearing loss (presbycusis)
  • Noise exposure
  • Sudden hearing loss
  • Ear infections or labyrinthitis
  • Ménière’s disease
  • Earwax blockage
  • Otosclerosis
  • Acoustic neuroma or vestibular schwannoma
  • Head or neck trauma such as whiplash
  • Certain medications, including some antibiotics, cancer drugs, antidepressants, and high-dose aspirin
  • Exposure to chemicals such as solvents or fuels

It is important to see an audiologist or ENT specialist to rule out underlying conditions, particularly if tinnitus is one-sided, pulsatile, or associated with sudden hearing changes.

Distorted Hearing and Auditory Processing

Many people with tinnitus also notice changes in how they hear sounds. Distorted hearing can make speech or music sound unclear or unnatural, and in some cases it seems linked to tinnitus itself. Auditory processing disorder (APD), where the brain struggles to interpret sound despite normal hearing thresholds, can also co-exist with tinnitus. People with APD may particularly struggle to follow speech in background noise.

Other Symptoms Linked to Tinnitus

Tinnitus often interacts with other health problems. Headaches are more common in people with tinnitus, and tension in the face and head can increase both symptoms. Some patients also report a sensation of aural fullness, like blocked ears, which may be linked to abnormal muscle activity in the middle ear.

Tinnitus is frequently associated with hyperacusis, where everyday sounds feel too loud or painful. This oversensitivity sometimes develops because people worry that noise might worsen their tinnitus. Hyperacusis and tinnitus are more common among musicians, but they can affect anyone. Both conditions involve the way the brain responds to sound and stress, and CBT can help reduce the cycle of fear and avoidance.

Mental Health and Tinnitus

Feelings of anxiety, low mood, and even depression are common among people with persistent tinnitus. This does not mean that everyone with tinnitus develops a mental health disorder, but the constant sound can place a heavy psychological burden. Research from our clinic has shown that people who grew up with parental mental health difficulties are more likely to experience depression, suicidal thoughts, or sleep problems if they later develop tinnitus. This underlines the importance of psychological support in tinnitus care.

Sleep and Tinnitus

Around 70 percent of patients with tinnitus report some form of sleep difficulty, whether falling asleep, staying asleep, or waking too early. Studies show that the severity of insomnia is linked not to tinnitus loudness, but to the distress and depression it causes. CBT for tinnitus is particularly effective for sleep problems because it addresses the thoughts and behaviours that make tinnitus feel more intrusive at night.
In rare cases, people report hearing tinnitus in their dreams. These patients often experience more distress, as their tinnitus dominates even subconscious experience. Exploding Head Syndrome, where people hear a sudden loud noise while falling asleep, is another phenomenon that can be confused with tinnitus.

Therapy for Tinnitus

There is no proven cure that can remove tinnitus entirely, but there are effective ways to reduce its impact. Many approaches have been tried, from masking devices and sound therapy to mindfulness and relaxation strategies. The strongest evidence supports cognitive behavioural therapy (CBT).
CBT for tinnitus is not about eliminating the sound. Instead, it helps patients understand and change the thoughts, emotions, and behaviours that make tinnitus distressing. This includes:

  • Education about tinnitus and its mechanisms
  • Identifying negative automatic thoughts such as “I’ll never sleep again”
  • Reducing avoidance behaviours, like overusing background noise
  • Learning coping strategies such as SEL (Stop Avoidance, Exposure, and Learn from it) and KKIS (Know, Keep on, Identify, Substitute)
  • Challenging deeper beliefs that keep tinnitus distress alive
  • Integrating skills into everyday life to promote long-term resilience

Studies, including large Cochrane reviews, confirm that CBT significantly improves quality of life for people with tinnitus. It helps reduce anxiety, depression, and distress, even if tinnitus loudness remains the same.

Living Well with Tinnitus

Although tinnitus can be deeply frustrating, it is important to remember that it does not harm hearing and does not block awareness of real sounds. Many people find that once they learn to manage their emotional reaction, tinnitus gradually fades into the background. With the right support, patients can regain control of their lives, improve sleep, reduce anxiety, and focus on what matters most to them.