Tinnitus: causes, assessment, and management in Australian practice

What tinnitus is

Tinnitus is the perception of sound — most commonly ringing, buzzing, hissing, or humming — without an external acoustic source. It is a symptom rather than a disease in its own right, and it reflects how the inner ear and the brain’s hearing pathways communicate. Around 10 to 15 per cent of Australian adults experience tinnitus at some point, with roughly 1 to 2 per cent finding it significantly impacts quality of life (HealthDirect; Tinnitus Australia).

In about 99 per cent of cases tinnitus is subjective — only the person experiencing it can hear it — and is linked to changes in the inner ear with secondary changes in how the auditory part of the brain processes sound (RACGP / AJGP 2018). Much less commonly, tinnitus is objective and can be heard by an examiner — usually because of a vascular or muscular source near the ear.

Tinnitus is often categorised as acute (less than three months), chronic (three months or more), and as bothersome or non-bothersome depending on its impact on daily life (NICE NG155). Most tinnitus settles or becomes less intrusive over time as the brain adapts. For those it persists with, guideline-supported management substantially reduces the distress and impact.

This article explains how tinnitus is assessed, what the common causes are, when to seek prompt review, and the management approaches with the best evidence in Australian practice.

Common causes

The single most common pattern is tinnitus accompanying hearing loss — usually age-related (presbycusis) or noise-induced. The inner ear sends a reduced signal to the brain; the brain compensates by amplifying its own internal activity, which is perceived as tinnitus. Even when a standard hearing test looks normal, around one in four people with tinnitus have subtle high-frequency or hidden hearing changes that show on more detailed testing (NICE NG155).

Noise exposure is the dominant driver of tinnitus in younger adults: occupational noise (construction, industry, military, music), recreational exposure (concerts, sporting events, motorsports, firearms), and personal-audio use at high volumes. Around 1.6 million Australians live with noise-induced hearing loss, and the World Health Organization estimates over a billion people globally are at risk from recreational noise.

Wax build-up, middle-ear infection, or fluid behind the eardrum can produce tinnitus that resolves with treatment of the cause. Eustachian tube problems after a cold or with allergies can also cause a temporary tinnitus.

A number of medications can cause or worsen tinnitus, including high-dose aspirin (usually reversible), some non-steroidal anti-inflammatories, certain antibiotics (especially aminoglycosides), some diuretics, certain chemotherapy drugs, quinine, and high-dose macrolide antibiotics. Bring a current medication list to any tinnitus appointment so this can be reviewed (Australian Medicines Handbook; eTG).

Pulsatile tinnitus — tinnitus that beats in time with the heartbeat — has different causes. It can arise from blood vessels close to the ear, including narrowed carotid arteries, abnormal vascular connections, raised pressure within the skull (idiopathic intracranial hypertension), or rare benign tumours. Pulsatile tinnitus warrants prompt review and imaging (NICE NG155; ASOHNS).

Jaw and neck problems — temporomandibular joint dysfunction, dental issues, neck strain, or whiplash — can trigger or worsen tinnitus through shared nerve pathways. This type is often modulated by jaw movement or head position.

Stress, poor sleep, anxiety, and depression do not cause tinnitus, but they substantially amplify how loud and how distressing it feels. This is one of the most important practical findings in tinnitus care: the perceived loudness and the impact on life can be reduced even when the underlying tinnitus signal is unchanged.

Diagnosis and assessment

A thorough GP assessment usually establishes the likely cause and rules out features that need urgent attention.

The history covers: the character of the sound (ringing, buzzing, pulsatile, clicking), whether it is in one ear, both ears, or “in the head”, whether it is continuous or comes and goes, how it started, any associated hearing change, vertigo or balance problems, ear pain, ear discharge, headaches, or facial weakness. The GP will ask about noise exposure (work, leisure, headphones, firearms, military service), recent head or jaw injury, medications, other medical conditions (blood pressure, diabetes, thyroid), and the impact on sleep, work, mood, and concentration.

The examination includes looking inside both ears with an otoscope, tuning fork tests at the bedside, checking the facial nerve and other cranial nerves, a brief balance check, examination of the jaw and neck, and blood pressure measurement. For pulsatile tinnitus, a stethoscope is used to listen over the ear, neck, and around the eye for a vascular sound.

A formal hearing test (pure-tone audiometry) is recommended for every new tinnitus presentation, even when hearing seems normal (NICE NG155; RACGP / AJGP 2018). Audiology is delivered by an accredited audiologist on referral from any medical practitioner since March 2023, or through the Hearing Services Program for eligible patients (including pensioner concession card holders, DVA card holders, Aboriginal and Torres Strait Islander people aged 50 and over, and NDIS participants).

Additional tests are guided by the findings. An MRI scan of the inner ear and hearing nerve is requested when tinnitus is persistent in one ear only or when there is asymmetric hearing loss, to rule out a benign nerve tumour. Vascular imaging (MRA or MRV) is requested for pulsatile tinnitus. Selected blood tests — full blood count, thyroid function, B12, iron studies, blood glucose — are used where indicated; there is no routine “tinnitus blood panel”.

A short severity questionnaire — the Tinnitus Handicap Inventory or Tinnitus Functional Index — is often used to track impact over time and gauge response to treatment.

Management — what helps

There is no single quick fix for chronic tinnitus, but several approaches have substantial evidence and most people find a meaningful improvement when these are layered together.

Step 1: Treat any treatable contributor

Remove ear wax. Treat ear infections. Review and where possible adjust any medications that contribute. Correct documented thyroid, iron, or B12 problems. Manage temporomandibular joint dysfunction. Manage cardiovascular risk factors where pulsatile tinnitus has a vascular contributor (eTG; AMH).

Step 2: Address hearing loss

When tinnitus accompanies hearing loss, hearing aids are the single most useful intervention (NICE NG155; RACGP / AJGP 2018). They amplify ambient sound, which both improves hearing and substantially reduces tinnitus perception in many people. Eligible Australians can access fully subsidised hearing aids and ongoing audiology through the Hearing Services Program. Hearing aids are not recommended for tinnitus when hearing is normal.

Step 3: Cognitive behavioural therapy for tinnitus

CBT specifically adapted for tinnitus has the strongest evidence base for reducing the impact of chronic bothersome tinnitus on quality of life. A 2020 Cochrane review of 28 randomised trials confirmed CBT reduces tinnitus-related distress, with benefits persisting compared to no intervention, standard audiological care, and tinnitus retraining therapy (Cochrane 2020).

CBT for tinnitus does not aim to make the sound quieter. It targets the thought patterns and attention habits that amplify distress, builds habituation skills, and reduces the avoidance and hypervigilance that make tinnitus harder to live with. In Australia, CBT is accessed through a Mental Health Care Plan from a GP, which provides up to 10 Medicare-subsidised psychology sessions per calendar year. Internet-delivered and app-based CBT programmes are emerging with supporting evidence.

Step 4: Sound therapy

Sound enrichment reduces the contrast between tinnitus and the background, which the brain uses to determine prominence. This can be as simple as a fan, soft music, or a white-noise app, particularly at night. Specialist sound generators and tinnitus retraining therapy combine low-level sound with structured counselling to support habituation; these are usually delivered through audiology services.

Step 5: Treat sleep, mood, and anxiety

Insomnia, anxiety, and depression amplify tinnitus distress. Treating them directly — with CBT for insomnia, with general CBT for anxiety or depression, and with appropriate medication when indicated for the underlying mood condition — reduces tinnitus distress even when loudness is unchanged. This is not the same as treating tinnitus with antidepressants, which the evidence does not support.

What the evidence does not support

Major guidelines including NICE NG155 recommend against prescribing antidepressants, anti-seizure medications, anti-anxiety drugs, or betahistine purely to treat tinnitus. No drug has reliable evidence for treating chronic idiopathic tinnitus itself. Ginkgo biloba has been studied repeatedly and updated Cochrane reviews show little to no effect. Zinc and other supplements help only if a specific deficiency is documented. Lidocaine infusions are not recommended.

Refractory or severe tinnitus

For tinnitus that remains very bothersome despite first-line measures, tertiary tinnitus clinics provide multidisciplinary input from audiology, ENT, and clinical psychology. Cochlear implants substantially reduce tinnitus in a high proportion of recipients with severe-profound hearing loss. Bimodal neuromodulation devices (combining sound with tongue tip stimulation) have emerging evidence with around 58 per cent of people experiencing a clinically meaningful response, but are currently self-funded in Australia and not subsidised through the PBS or Medicare.

When to see a GP

Make an appointment with your GP for any new tinnitus that:

• Lasts more than a week or two
• Affects sleep, concentration, mood, or work
• Comes with a sense of fullness or blockage in the ear
• Comes with reduced hearing on one or both sides
• Comes and goes with episodes of dizziness

The first GP visit usually leads to an ear examination, a medication review, a referral for a formal hearing test, and a discussion of what is contributing and what helps.

Red flags — seek urgent review

Same-day medical review is appropriate for any of the following:

• Sudden hearing loss with tinnitus. Sudden sensorineural hearing loss is a medical emergency. Treatment with oral corticosteroids is most effective within the first two weeks of onset, and the window for benefit narrows quickly thereafter.
• Tinnitus only in one ear that persists. A persistently one-sided tinnitus warrants assessment to rule out a benign nerve tumour (vestibular schwannoma), particularly when accompanied by one-sided hearing loss.
• Pulsatile tinnitus — tinnitus that beats in time with the heartbeat. This pattern can reflect a vascular cause and warrants imaging.
• Tinnitus with severe vertigo or balance problems, particularly if combined with hearing change or nausea.
• Tinnitus with new severe headache, vision changes, facial weakness, or other neurological symptoms.
• Tinnitus accompanied by suicidal thoughts or severe distress. Tinnitus distress can be profound. Distress severity, rather than loudness, is what drives risk. Crisis support is available through Lifeline on 13 11 14 and Beyond Blue on 1300 22 4636.

Self-care that helps

• Protect your ears from further loud noise. Use earplugs at concerts and noisy events, keep personal-audio volumes moderate, and use hearing protection at work where noise exposure is a risk.
• Avoid silence at night. Use background sound (fan, soft music, white noise) when going to sleep.
• Look after sleep. Consistent bedtime, dark room, screens off well before bed. Treat sleep apnoea if present.
• Look after mood and stress. Exercise, time outdoors, and connection with people all reduce stress, which reduces tinnitus impact.
• Limit substances that worsen tinnitus or sleep. Alcohol, nicotine, and high caffeine intake can each contribute.
• Avoid focusing on tinnitus when possible. Counterintuitively, paying close attention to the sound tends to make it louder; engaged activity tends to make it recede.

For more patient-oriented Australian information: HealthDirect — Tinnitus, Better Health Channel — Tinnitus, and Tinnitus Australia.

What this article is and is not

This is general health information drawn from current Australian and international clinical guidelines, including the RACGP / AJGP 2018 review of tinnitus, Therapeutic Guidelines (eTG complete), the Australian Medicines Handbook, NICE NG155, and the Cochrane review of CBT for tinnitus. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about assessment, hearing aids, psychology, and any further investigations are made with your own GP and the appropriate audiology or specialist services.

For acute mental-health crisis: Lifeline 13 11 14 · Beyond Blue 1300 22 4636.

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Sources cited

1. RACGP / AJGP — A review of tinnitus (2018)
2. Therapeutic Guidelines — eTG complete
3. Australian Medicines Handbook
4. Department of Health — Hearing Services Program
5. HealthDirect — Tinnitus
6. Better Health Channel — Tinnitus
7. Tinnitus Australia (Soundfair)
8. Australian Society of Otolaryngology, Head & Neck Surgery
9. NICE NG155 — Tinnitus: assessment and management (2020)
10. Cochrane — Cognitive behavioural therapy for tinnitus (Fuller 2020)