Takeaway: Tinnitus is rarely a life-threatening problem, but it can certainly threaten a person’s quality of life.

How they tinkle, tinkle, tinkle,

In the icy air of night!

While the stars that oversprinkle

All the heavens, seem to twinkle

With a crystalline delight;

Keeping time, time, time,

In a sort of Runic rhyme,

To the tintinnabulation that so musically wells

From the bells, bells, bells, bells,

Bells, bells, bells—

From the jingling and the tinkling of the bells.

—Excerpt from “The Bells” by Edgar Allan Poe 

The opening stanza of Edgar Allan Poe’spoem “The Bells” describes the “crystalline delight” of happy sleigh bells. From there, he describes increasingly discordant and then utterly overwhelming pealing, jangling, ghastly moaning of the bells, bells, bells, bells, bells. If you live with tinnitus, you know exactly how this feels. 

The term tinnitus, pronounced either as TIN-nuh-tus or tin-NIGHT-us, comes from the Latin word tinnire, which means “to ring or tinkle.” This word root gives us the wonderful onomatopoeia, tintinnabulation: ringing of bells. And, of course, it refers to the sensation often described as “ringing in the ears.”

This sounds fairly benign, but for many people, tinnitus is a potentially disabling problem that clangs and bangs and smashes away at their quality of life. But what is tinnitus? How common is it? And above all, what can be done about it? Is there any way to cut through the noise to arrive at some solid answers?

What is Tinnitus?

The most common forms of tinnitus are a form of aural mirage: the perception of a stimulus that isn’t actually present. It has many presentations. It has been described as nonverbal ringing, buzzing, hissing, or clicking. Other sources add blowing, whining, roaring, rumbling, and whooshing. It may be one-sided or bilateral, or it may change back and forth. The exact sound or pitch may vary from one person to another and from day to day—even moment to moment, depending on external issues like stress, how much sleep the person has had, whether they have sinus or ear congestion, the ambient air pressure, and several other factors.  

Sometimes tinnitus is the result of acoustic trauma, a severe ear infection, or a head injury. It is often described as a symptom of some other problem—high blood pressure, for instance, or a rare kind of tumor that might impact the acoustic nerve. In fact, up to 200 medical conditions list tinnitus as a possible symptom, and several hundred medications list it as a possible side effect. But tinnitus also occurs as a freestanding disorder, often accompanied by some level of age-related hearing loss, but not necessarily tied to any underlying pathology. In rare cases, it can be an indicator of a potentially dangerous issue, like a cerebral aneurysm or a brain tumor.

Tinnitus is rarely a life-threatening problem, but it can certainly threaten a person’s quality of life. 

Tinnitus is extremely common, affecting 10–15 percent of the US population: between 30 million and 50 million Americans. Of those, more than half describe their condition as chronic and burdensome. Many of these are people who served in the military—tinnitus is the leading service-related disability, affecting well over 2 million veterans.¹

Pathophysiology

Although tinnitus is common and can be serious, much about this condition is not understood. It appears to be a possible result of a few problems, or combinations of problems, and this of course makes it difficult to pin down or treat with any specificity.

At its core, tinnitus is a hallucination of sound. It is internally generated, persistent, and involuntary. It is often connected to hearing loss, and the leading theory suggests it is the result of the brain “filling in” for missing information. Experts compare it to phantom limb pain experienced by people who have had an amputation: The sensory neurons in the stump continue to initiate signals, and the brain wrongly assigns the source of those signals to a missing part of the body. But neuroplasticity allows this feedback loop to become firmly established, with the growth of additional synapses and neurotransmitter secretions that support the ongoing mistaken perception. In this way, tinnitus has much in common with chronic pain and central sensitization: The central nervous system adapts (or maladapts) to signals, even though those signals do not give accurate information about a stimulus. (And our attention to this sensation makes it feel more extreme—my tinnitus is roaring as I work on this column.)

We won’t go into the neuroanatomy and physiology of possible tinnitus pathways, but if this topic interests you, I recommend you consult the resource list for this column because it contains several articles on the topic. The key factors appear to be whether the misfiring nerves are in the ears or in the brain, or both; which sets of neurons in the ear are affected; and the triggers that cause the nerves to misfire.

Tinnitus is sometimes discussed as an objective or subjective condition. Objective tinnitus, which is audible to other people as well as the patient, is quite rare, accounting for less than 1 percent of all cases. The sound is usually coordinated with the heartbeat—this is sometimes called pulsatile tinnitus—or musculoskeletal movement following a trauma. Objective tinnitus is more likely to be a symptom of a serious underlying problem than subjective tinnitus. Dysfunctional blood vessels in the neck or brain may be at fault, and this requires medical attention as quickly as possible. Subjective tinnitus, which covers more than 99 percent of cases, is experienced only by the patient. It can be associated with many problems, but the two most common are hearing loss and acoustic injury. Age-related hearing loss (sometimes called presbycusis) may be the most common factor in subjective tinnitus, although not every person with hearing loss has ringing in the ears. Loud noises that damage mechanisms in the inner ear can also cause tinnitus—this is acoustic injury. Acoustic injury can occur with ongoing loud headphone use, occupational hazards like working around noisy machinery, or with single events like bomb blasts.

Other contributors to subjective tinnitus include a wide range of possibilities, including the following noncomprehensive list:

• Atherosclerosis in the carotid arteries  
• Barometric trauma 
• Brain tumors 
• Buildup of wax or having a foreign object in the ear canal 
• Caffeine, nicotine, and/or alcohol use 
• Cerebral aneurysm 
• Congestion of ears or sinuses 
• COVID-19 and long COVID 
• Depression or anxiety (this can be circular: tinnitus can also lead to depression and anxiety)  
• Ear and sinus infection 
• Head, neck, or dental trauma 
• Hormonal shifts related to menopause 
• Hypertension 
• Hypo- or hyperthyroidism 
• Lyme disease 
• Ménière’s disease 
• Migraine 
• PTSD 
• Temporomandibular joint disorders 
• Thoracic outlet syndrome 
• Traumatic brain injury, concussion  

In addition, tinnitus may develop as a side effect of starting or stopping many medications. Aspirin, ibuprofen, and some other nonsteroidal anti-inflammatories may do this, as well as tricyclic antidepressants, beta blockers, ACE inhibitors, and many more. 

How is Tinnitus Treated?

No single treatment protocol solves the problem of tinnitus for most patients. Ruling out other causes and reducing the negative impacts of this condition may involve multiple care providers, including family physicians, audiologists, otolaryngologists, neurologists, and psychiatrists or psychologists. 

The two most used strategies include various appliances for the ears and cognitive behavioral therapy (CBT). These may be even more effective in combination.

An assortment of devices that help filter sound or incorporate the patient’s tinnitus tones into embedded music have been helpful for many people. Sound machines, mobile phone apps that promote relaxation with specially designed exercises, and similar interventions are widely available, as is evidenced by a quick online search for “app for tinnitus” that yielded 14.1 million entries.

The goal of CBT is not to eliminate the perception of noise, but to strengthen coping mechanisms. This strategy shows consistent improvement in depression and quality-of-life scores for people struggling with tinnitus.

A few medications have been tried for tinnitus, including antiseizure drugs and some antidepressants and antianxiety medications, but the results have not been consistent enough for this to be considered a normal protocol.

Can Massage Therapy Help? Maybe. Sometimes. 

Very limited data has been gathered on the interface between massage therapy and tinnitus. This is at least partly because the origins of these phantom noises are still not fully understood. One study made the case that tinnitus can be connected to both somatosensory factors (this refers to general sensory distortions like temperature, texture, and proprioception) and to somatomotor issues, which is to say musculoskeletal and fascial influences.² This finding proposes that tinnitus is a situation where manual therapies could have a positive impact. 

Another research team looked at incorporating manual therapies along with exercise and education for people who have tinnitus associated with temporomandibular joint (TMJ) disorders. This study includes some detailed descriptions of the work: “an oscillatory TMJ inferior glide accessory mobilization of mandible distraction intervention for 90 seconds. In addition, different manual therapies were applied, including pressure release, soft-tissue mobilization, or longitudinal strokes of the following cranio-cervical musculature: masseter, temporalis, sternocleidomastoid, and upper trapezius. These muscles were chosen because their pain referral is perceived around the TMJ, the ear, or the orofacial area and can contribute to tinnitus.” This team found that adding massage of the neck and jaw muscles led to better outcomes compared to standard care.³

A small-scale and completely unscientific poll of convenience-sampled massage therapists (i.e., people who responded to my Facebook post) yielded an interesting variety of responses about their work in the context of tinnitus. A general theme was that when tinnitus was related to muscle tension, TMJ dysfunction, or sinus congestion, various types of massage therapy were useful, at least in the short term. People described using myofascial release, cupping, lymphatic drainage, and craniosacral work with some success, although the duration of effect was not clear. But when the tinnitus arose from an acoustic injury or other type of trauma, bodywork appeared to be less helpful. And one person reported the onset of new tinnitus symptoms after receiving forceful bodywork to the neck: a truly adverse event!

Tinnitus is common, annoying, and sometimes debilitating. Millions of people report that it negatively impacts their lives. No treatment is universally effective; it seems to be something many of us simply have to learn to live with. So that becomes the challenge: if massage therapy can lessen symptoms, that’s wonderful. But another way to think about our work is to help people live with this condition and still have a good quality of life—and that seems like an achievable goal. (For more on this, please see the video that accompanies this article, “Tinnitus.”)

We don’t know if Edgar Allan Poe had tinnitus, but “The Bells” could hint at it. From the introductory stanza about lovely sleigh bells, the poem intensifies into descriptions of discordant clanging, finally reaching the peak where the King of Ghouls relentlessly rings his iron bells (oh, the melancholy menace of their tone!) . . .

And he dances, and he yells,

Keeping time, time, time,

As he knells, knells, knells,

In a happy Runic rhyme,

To the rolling of the bells—

Of the bells, bells, bells—

To the tolling of the bells,

Of the bells, bells, bells, bells—

Bells, bells, bells—

To the moaning and the groaning of the bells. 

Notes

1. A. Henton and T. Tzounopoulos, “What’s the Buzz? The Neuroscience and the Treatment of Tinnitus,” Physiological Reviews 101, no. 4 (2021): 1,609–32, https://doi.org/10.1152/physrev.00029.2020.

2. Rob A. B. Oostendorp et al., “Cervicogenic Somatosensory Tinnitus: An Indication for Manual Therapy? Part 1: Theoretical Concept,” Manual Therapy 23 (2016): 120–3, https://doi.org/10.1016/j.math.2015.11.008.

3. Pablo Delgado de la Serna et al., “Effects of Cervico-Mandibular Manual Therapy in Patients with Temporomandibular Pain Disorders and Associated Somatic Tinnitus: A Randomized Clinical Trial,” Pain Medicine 21, no. 3 (2020): 613–24, https://doi.org/10.1093/pm/pnz278.

Resources

American Tinnitus Association. “Why Are My Ears Ringing?” Accessed March 24, 2023. www.ata.org/about-tinnitus/why-are-my-ears-ringing/.

Centers for Disease Control and Prevention. “Public Health and Scientific Information.” Accessed April 6, 2023. www.cdc.gov/nceh/hearing_loss/public_health_scientific_info.html.

ENT Health. “Tinnitus.” Accessed March 24, 2023. www.enthealth.org/conditions/tinnitus/.

Han, B. I. et al. “Tinnitus: Characteristics, Causes, Mechanisms, and Treatments.” Journal of Clinical Neurology 5, no. 1 (2009): 11. https://doi.org/10.3988/jcn.2009.5.1.11.

Kay, C. et al. “Improving Tinnitus with Mechanical Treatment of the Cervical Spine and Jaw.” Journal of the American Academy of Audiology 24, no. 7 (2013): 544–55. https://doi.org/10.3766/jaaa.24.7.3.

Kesser, B. “Tinnitus Takedown: Top Tips from a Hearing Specialist.” SciTechDaily. Accessed March 24, 2023. https://scitechdaily.com/tinnitus-takedown-top-tips-from-a-hearing-specialist/.

National Institute on Deafness and Other Communication Disorders. “Tinnitus.” Last modified March 27, 2023. Accessed March 24. 2023. www.nidcd.nih.gov/health/tinnitus. 

National Library of Medicine. “Tinnitus.” Accessed March 24, 2023. https://medlineplus.gov/tinnitus.html.

Newman, C. W., G. P. Jacobson, and J. B. Spitzer. “Development of the Tinnitus Handicap Inventory.” Archives of Otolaryngology–Head and Neck Surgery 122, no. 2 (February 1996): 143–8. https://doi.org/10.1001/archotol.1996.01890140029007.

NovoPsych. “Tinnitus Handicap Inventory (THI).” Accessed March 25, 2023. https://novopsych.com.au/assessments/diagnosis/tinnitus-handicap-inventory-thi/.

Resound. “Types of Tinnitus.” Accessed April 6, 2023. www.resound.com/en-us/hearing-loss/tinnitus/types.

Shore, S. E., L. E. Roberts, and B. Langguth. “Maladaptive Plasticity in Tinnitus–Triggers, Mechanisms, and Treatment.” Nature Reviews Neurology 12, no. 3 (2016): 150–60. https://doi.org/10.1038/nrneurol.2016.12.