Tinnitus

Dr Jason Roth (MED0001185485) — Specialist Otolaryngologist & Head and Neck Surgeon, specialist registration in Otorhinolaryngology, Head & Neck Surgery.

Please note: Dr Roth’s current practice is focused on rhinoplasty, facelift, neck lift, blepharoplasty, brow lift, and related facial surgery. He is no longer accepting new referrals for tinnitus. This page is retained as a patient information resource. Patients seeking assessment for this condition should speak with their GP about an appropriate specialist referral.

Tinnitus

Tinnitus — from the Latin tinnire, “to ring” — is the perception of sound in the absence of any external acoustic stimulus. It is one of the most prevalent symptoms in medicine: approximately 15–18% of Australians experience tinnitus on a persistent basis, with roughly 2–3% reporting that it significantly affects their quality of life. Tinnitus is not a disease in itself but a symptom — a consequence of altered activity somewhere along the auditory pathway from the cochlea to the auditory cortex. Its causes are numerous, its mechanisms incompletely understood, and its management requires careful assessment to identify and treat any underlying cause before addressing the symptom itself.

All patients with new-onset persistent tinnitus, especially if unilateral, should have a formal audiogram and ENT assessment to exclude serious underlying causes.

The Mechanisms of Tinnitus

The experience of tinnitus arises from abnormal neural activity within the auditory system that the brain misinterprets as sound. This abnormal activity can be generated at multiple levels:

Peripheral (Cochlear) Tinnitus

Damage to the outer hair cells of the cochlea — whether from noise, ototoxic drugs, infection, or ageing — reduces their normal inhibitory output to the auditory nerve. The resulting “deafferentation” causes the auditory nerve to increase its spontaneous firing rate in an attempt to compensate for reduced input, and this increased spontaneous activity is perceived as tinnitus. This is why tinnitus almost always accompanies cochlear hearing loss, and why the pitch of tinnitus typically corresponds to the frequencies most affected by the hearing loss.

Central Tinnitus

In many patients with chronic tinnitus, the primary driver is not peripheral but central — abnormal reorganisation and hyperexcitability within the central auditory pathways, including the cochlear nucleus, inferior colliculus, and auditory cortex. This central plasticity explains why tinnitus can persist even after the peripheral cause has been addressed, and why tinnitus may develop even in patients without measurable hearing loss on standard audiometry (perhaps reflecting subclinical cochlear damage or neural deafferentation not captured by pure tone thresholds).

The Limbic and Emotional Systems

Tinnitus becomes distressing — rather than merely present — through the involvement of the limbic system and the prefrontal cortex. The amygdala assigns emotional significance to the tinnitus signal, and attention networks become locked onto it. This neurological model explains why stress and anxiety amplify tinnitus awareness, why emotional distress does not merely accompany tinnitus but actively worsens it, and why psychological approaches — particularly cognitive behavioural therapy — are among the most effective management tools for chronic distressing tinnitus.

Causes and Classification

Subjective Tinnitus

The most common type — heard only by the patient. Arises from abnormal neural activity in the auditory pathway:

Sensorineural hearing loss: The most common association. Age-related cochlear degeneration (presbycusis) and noise-induced hearing loss together account for the majority of tinnitus presentations. The audiogram typically shows high-frequency sensorineural hearing loss, and the tinnitus is described as a high-pitched ringing or hissing.
Noise exposure: Acute acoustic trauma (concert, explosion, gunshot) produces immediate tinnitus that may be accompanied by temporary threshold shift (temporary hearing loss). If the exposure is repeated or severe enough, permanent cochlear damage and permanent tinnitus result.
Conductive hearing loss: Earwax, middle ear effusion, perforated eardrum, and Eustachian tube dysfunction can all cause or worsen tinnitus by reducing the masking effect of environmental sound on the internal auditory signal.
Ménière’s disease: A triad of episodic vertigo, fluctuating sensorineural hearing loss, and tinnitus (often low-pitched and associated with a sense of fullness or pressure in the ear). The tinnitus characteristically fluctuates with Ménière’s episodes.
Acoustic neuroma (vestibular schwannoma): A benign tumour on the vestibular nerve (cranial nerve VIII) at the internal auditory canal. Unilateral tinnitus — especially with asymmetric sensorineural hearing loss or unilateral hearing loss — is a red flag requiring MRI imaging to exclude acoustic neuroma. The tumour itself does not cause tinnitus through compression but through its effects on cochlear blood supply and auditory nerve function.
Ototoxic medications: Aminoglycoside antibiotics (gentamicin, tobramycin), platinum-based chemotherapy agents (cisplatin, carboplatin), high-dose loop diuretics (frusemide), and quinine are well-established cochlear toxins. Tinnitus may be the first symptom of ototoxicity — patients on these medications should report any new tinnitus promptly.
Other: Head injury, viral labyrinthitis, autoimmune inner ear disease, sudden sensorineural hearing loss, middle ear inflammation, and — rarely — multiple sclerosis affecting the auditory pathway.

Objective (Pulsatile) Tinnitus

Pulsatile tinnitus — a tinnitus that is synchronous with the heartbeat — is a distinct and important category requiring specific investigation. The sound is generated by turbulent blood flow near the cochlea and is transmitted through the temporal bone. Causes include:

Glomus tumour (paraganglioma): A vascular tumour of the middle ear (glomus tympanicum) or jugular bulb (glomus jugulare). On otoscopic examination, a red or blue-tinged pulsatile mass may be visible through the eardrum. Requires CT/MRI imaging and specialist management.
Aberrant internal carotid artery or high jugular bulb: Anatomical variants in which a major vessel is unusually close to or within the middle ear space.
Carotid artery stenosis or arteriovenous malformation: Less common but potentially serious causes requiring vascular imaging.
Benign intracranial hypertension (idiopathic intracranial hypertension): A condition of raised intracranial pressure without structural cause, typically affecting overweight women of childbearing age. Causes pulsatile tinnitus (often described as a whooshing) and may also cause visual obscurations and headache. Requires neurological assessment and LP if suspected.
Benign causes: The majority of pulsatile tinnitus is benign — related to altered haemodynamics from anaemia, thyroid disease, hypertension, or simply turbulent flow in the sigmoid sinus. Nevertheless, all pulsatile tinnitus warrants formal assessment to exclude the serious causes above.

Assessment

The assessment of tinnitus involves a structured history (onset, laterality, character, pulsatility, associated symptoms — hearing loss, vertigo, ear fullness, facial symptoms), examination, and investigations:

Otoscopy and microsopy: To identify any outer or middle ear cause — wax, perforation, middle ear effusion, or a visible vascular mass
Pure tone audiometry with tympanometry: Essential in all cases — characterises the hearing loss pattern associated with the tinnitus and provides the baseline for management
MRI of the internal auditory canals: Mandatory in all cases of unilateral tinnitus (particularly with asymmetric hearing loss), to exclude acoustic neuroma. A dedicated contrast-enhanced MRI is the gold standard.
MRI or CT for pulsatile tinnitus: MR angiography, CT angiography, or dedicated temporal bone CT depending on the clinical picture
Blood tests: In selected cases — thyroid function, FBC (anaemia), glucose, lipids, autoimmune markers

Management

Treat the underlying cause

Where a treatable ear condition underlies the tinnitus — earwax impaction, middle ear effusion, Eustachian tube dysfunction, otosclerosis, or an ototoxic medication — addressing it may substantially reduce or resolve the tinnitus. This reinforces the importance of thorough assessment before commencing long-term tinnitus management for what may be a readily treatable cause.

Hearing aids

For patients with concurrent hearing loss — the most common scenario in tinnitus — hearing aids are one of the most effective interventions for tinnitus management. By amplifying environmental sound, they enrich the acoustic environment, reduce the contrast between tinnitus and background sound, and promote central auditory pathway normalisation. Many modern hearing aids also have built-in tinnitus masking programmes.

Tinnitus Retraining Therapy (TRT)

The most evidence-based specialist treatment for distressing tinnitus. TRT is based on the neurophysiological model of tinnitus — the understanding that tinnitus distress arises from conditioned limbic and autonomic nervous system responses to a neutral auditory signal. It combines directive counselling (explaining the mechanism and demystifying the experience) with sound enrichment (broadband sound therapy to reduce auditory contrast) to promote habituation — the brain learning to classify the tinnitus as a neutral, non-threatening signal and filtering it from conscious awareness. A typical TRT course lasts 12–18 months.

Cognitive Behavioural Therapy (CBT)

CBT has the strongest evidence base of any psychological intervention for tinnitus distress. It targets the dysfunctional thought patterns, catastrophic interpretations, and avoidance behaviours that maintain tinnitus distress. CBT does not reduce the loudness of tinnitus but consistently reduces its impact on mood, sleep, and quality of life — the dimensions of tinnitus that most determine its burden. CBT delivered by an appropriately trained psychologist or via validated online programmes (Tinnitracks, CBT-T app) is effective and accessible.

Sound therapy and masking

Enriching the sound environment — using white noise machines, nature sounds, or music — reduces the contrast between tinnitus and background sound and promotes habituation. This is particularly important during quiet periods such as lying in bed at night, when tinnitus is most noticeable in the absence of competing environmental sound. Tinnitus maskers (devices that generate broadband sound delivered to the ear) may be prescribed as part of TRT or as standalone therapy.

Sleep management

Sleep disturbance is one of the most disabling aspects of tinnitus and a major contributor to the downward spiral of distress, fatigue, and heightened awareness. Sleep hygiene advice, stimulus control techniques, and background sound at night can meaningfully improve sleep quality and reduce the perceived severity of tinnitus.

Please note: Dr Roth’s practice provides thorough evaluation and investigation of tinnitus, and can treat any identified treatable cause. Tinnitus Retraining Therapy and Cognitive Behavioural Therapy are not offered at this practice. Patients requiring these treatments are referred appropriately. The Hearing and Balance Centre at St Vincent’s Hospital, Darlinghurst, operates a specialist tinnitus clinic. Northern Beaches Audiology, co-located with the practice, provides hearing aid assessment and fitting for patients with concurrent hearing loss.

Dr Roth’s Clinical Perspective

The most important thing to establish at a tinnitus assessment is whether there is an identifiable and treatable underlying cause. For most patients with chronic bilateral tinnitus associated with age-related hearing loss, the answer is that there is no specific cause to treat — which is not a satisfying answer, but it is an honest one, and it redirects the conversation toward management rather than cure. For patients with unilateral tinnitus, pulsatile tinnitus, or tinnitus with associated asymmetric hearing loss or vestibular symptoms, the assessment is more urgent: these presentations require imaging to exclude a structural cause before any reassurance is appropriate.

I am direct about the fact that tinnitus is not cured by most treatments. What management achieves — tinnitus retraining, sound therapy, hearing aid fitting where applicable, cognitive behavioural approaches — is a reduction in the degree to which tinnitus intrudes on daily life. For patients whose tinnitus is significantly affecting sleep and concentration, that is a meaningful and achievable goal. But I do not use the word cure with tinnitus patients because it sets an expectation the evidence does not support.

— Dr Jason Roth, MBBS, FRACS (ORL-HNS)

Dr Jason Roth — Specialist Otolaryngologist Sydney

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Dr Roth consults from Dee Why on Sydney’s Northern Beaches. A GP referral is recommended. All consultations involve a thorough assessment and a detailed discussion of your options — there is no obligation to proceed.

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(02) 9982 3439

Dr Jason Roth (MED0001185485) — Specialist Otolaryngologist & Head and Neck Surgeon.

Dr Jason Roth | MBBS, FRACS (ORL-HNS) | MED0001185485
Specialist Otolaryngologist & Head and Neck Surgeon
Specialist registration — Otorhinolaryngology, Head & Neck Surgery
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