Tinnitus (Ringing in the Ears): Causes of Right and Left Ear Ringing

Tinnitus (ringing in the ears) occurs due to damage to the microscopic hair cells in the inner ear, structural degeneration in the auditory nerve, or disruptions in vascular blood flow in the head and neck region. The most common cause of right ear tinnitus is pressure changes in that area, as the venous network on the right side of the brain is typically larger and carries a greater blood flow load due to human anatomical structure. Left ear tinnitus, on the other hand, is often caused by local fluid imbalances specific to the left inner ear, neural sensitivities, or asymmetric vascular narrowing unique to the left side. These perceived sounds, heard without any external physical source, are a direct reflection of cellular or mechanical dysfunctions in the auditory and circulatory systems.

What Is Tinnitus and How Does It Occur?

The hearing process is a flawless mechanism that begins when sound waves from the outside strike the eardrum and continues as the tiny bones in the middle ear transmit these vibrations to the inner ear. In the inner ear, within a structure called the cochlea, there are millions of microscopic hair cells. These hair cells detect fluid vibrations, convert physical movement into electrical signals, and send them to the brain’s auditory center via the auditory nerve. If this system functions properly, we only hear real sounds from the external world. However, when these hair cells are damaged due to exposure to loud noise, infections, aging, or vascular problems, the system begins to malfunction.

Damaged hair cells start sending continuous random electrical signals to the brain even when no external sound waves are present. The brain attempts to interpret these meaningless signals and perceives them as internal sounds. This condition, which resembles the brain turning up its own internal noise to compensate for disrupted communication, can become chronic and severely impair sleep, mental health, and concentration. The difference between hearing the sound occasionally and hearing it continuously depends on the brain’s ability to adapt to it.

The main types of sounds patients report hearing include:

• Ringing
• Buzzing
• Wind-like noise
• Whistling
• Pulsing
• Engine noise
• Clicking

Each of these sounds may indicate a different anatomical or neurological issue. A high-pitched whistling sound usually indicates neural degeneration in the inner ear, whereas a low humming or engine-like sound suggests pressure changes. Sounds resembling a heartbeat often point to vascular problems.

What Are the Differences Between Subjective and Objective Tinnitus?

When entering a medical evaluation process for tinnitus, the first distinction is made based on the nature of the sound source. The vast majority of cases, approximately ninety-five percent, are subjective tinnitus. Subjective tinnitus is a phantom sound that can only be heard by the patient and cannot be detected externally by any device or listener. It has no physical source; the issue arises entirely from abnormal signal generation in the auditory nerves or the auditory cortex of the brain.

The main factors that trigger subjective tinnitus include:

• Aging
• Noise exposure
• Earwax
• Certain medications
• Stress
• Depression

On the other hand, there is a much rarer group that provides very concrete data in terms of diagnosis and treatment. This is called objective tinnitus. In objective tinnitus, there is an actual physical sound generated within or around the ear or inside the head. Another person may hear this sound when placing their ear close to the patient, or a physician may detect it using a stethoscope on the patient’s neck or skull. Objective tinnitus is usually caused by involuntary muscle contractions within the skull, mechanical friction in middle ear structures, or abnormal blood flow in the neck and brain vessels. Since it has a real physical source, identifying and treating the underlying cause is often possible.

What Causes Pulsatile Tinnitus That Sounds Like a Heartbeat?

If you hear a sound in perfect rhythm with your heartbeat, as if a small drum is beating inside your ears or waves are hitting the shore, this is called pulsatile tinnitus. This condition is based on a completely different cause compared to other types of tinnitus. Until proven otherwise, pulsatile tinnitus is considered one of the most important indicators of a vascular issue in the head and neck region.

Under normal conditions, blood flowing through healthy vessels with smooth walls produces no sound. This is called laminar flow. However, when there is narrowing, structural curvature, blockage, or abnormal dilation in the arteries that supply the brain or in the veins (venous sinuses) that carry deoxygenated blood back to the heart, this silent and orderly flow is disrupted. Blood is forced to accelerate when passing through a narrowed area or a sharp bend, creating vortices within itself. This turbulent blood flow is called turbulence. The vibrations and physical sound energy generated when turbulent blood hits the vessel walls are transmitted directly to the auditory organs through the skull bones. As a result, you hear a rhythmic whooshing sound with each heartbeat.

Why Is Right Ear Tinnitus More Common?

The internal anatomy of our skull, especially the vascular network, is not perfectly symmetrical between the right and left sides. During anatomical development, in the vast majority of individuals, the main venous system that carries deoxygenated blood from the brain becomes wider and more dominant on the right side. This is known as right venous dominance.

The wider veins on the right side (transverse and sigmoid sinuses) mean that most of the returning blood from the brain is carried through these vessels. Because all this heavy traffic flows through the right side, even a slight increase in pressure, a minor change in intracranial fluid balance, or a millimetric narrowing in the vessel wall can create intense turbulence that resonates directly in the right ear. Since a large volume of blood is already trying to pass through, the reaction to narrowing becomes much louder. Similarly, structural curvatures that develop in the carotid arteries on the right side of the neck due to age or blood pressure are also perceived directly as right ear tinnitus.

What Conditions Might Left Ear Tinnitus Indicate?

Although tinnitus in the left ear is less common than in the right, if it is concentrated in only one ear, it may indicate conditions that require careful evaluation. Of course, just like in the right ear, earwax blockage, middle ear infection, or simple fluid accumulation can also cause tinnitus in the left ear. However, if the problem is persistent and affects only the left side, specific diseases that disrupt the architecture of the inner ear should be considered.

Conditions suspected on the left side include:

• Meniere’s disease
• Acoustic neuroma
• Venous narrowing
• Eardrum damage
• Otosclerosis

Meniere’s disease, characterized by increased pressure of inner ear fluid, and acoustic neuroma, a slowly growing benign tumor on the auditory nerve, are among the most prominent causes of unilateral tinnitus. If the tinnitus in the left ear is pulsatile, it may indicate that the individual has a rare anatomical condition called left venous dominance and that the problem originates in the brain veins on the left side. Even systemic conditions such as severe anemia or thyroid disorders may sometimes first manifest as tinnitus in the more sensitive left ear.

Can Idiopathic Intracranial Hypertension (Pseudotumor) Cause Tinnitus?

Idiopathic Intracranial Hypertension (IIH), increasingly common with modern lifestyles, is a condition in which the pressure of the cerebrospinal fluid that protects and nourishes the brain rises without a known cause. It is also known as a “pseudotumor” because, although there is no actual tumor mass, the pressure inside the skull increases as if there were a large mass compressing everything. The condition is more commonly seen in young women of reproductive age who have weight-related issues.

The primary victims of this increased intracranial pressure are the veins (venous sinuses) on the surface of the brain, which have relatively soft walls. As the pressure increases, these soft-walled vessels cannot withstand the external compressive force and begin to narrow. As the vessel narrows, blood must accelerate to pass through the constricted area, creating severe turbulence. Therefore, the two most common complaints in IIH patients are persistent severe headaches and continuous pulsatile tinnitus synchronized with the heartbeat. If this cycle of vessel narrowing is not broken, pressure continues to increase and can compress the optic nerves, potentially leading to permanent vision loss.

What Tests Are Required When Vascular Tinnitus Is Suspected?

When pulsatile tinnitus is identified in the patient’s history, after an ear, nose, and throat examination, mapping of the skull and neck vessels is required. The process typically begins with non-invasive radiological methods that are quick and comfortable for the patient. Computed Tomography (CT), CT Angiography, and CT Venography are particularly effective in showing the relationship between bone structures at the skull base and blood vessels.

Magnetic Resonance Imaging (MRI) and MR Venography (MRV) are excellent tools for examining the brain’s soft tissues and especially the brain’s venous system in three dimensions. These techniques can clearly visualize structural narrowing, abnormal dilation, or external compression by masses such as tumors. Color Doppler Ultrasonography is used to measure blood flow velocity in the carotid and jugular vessels in the neck. However, all these methods are like static snapshots and may sometimes be insufficient to show real-time blood flow dynamics and microscopic leaks within vessels.

Why Is Digital Subtraction Angiography (DSA) Important in Tinnitus Diagnosis?

When standard imaging methods cannot clearly explain the cause of vascular tinnitus or when it is necessary to plan definitive treatment for a detected vascular condition, Digital Subtraction Angiography (DSA), the gold standard method in this field, is used. Instead of taking external images, DSA involves directly entering the vessels and capturing a high-resolution, real-time video of the entire circulatory system.

The procedure typically begins by inserting a millimetric sheath into an artery in the groin area. Thin, flexible catheters are guided through the vascular pathway to the neck and brain vessels. With the help of a special contrast agent injected through the catheter, the speed of blood flow, how it passes through the smallest capillaries in the brain, and how it returns through the veins are displayed in real time on a monitor. The most critical part of the procedure is measuring the blood pressure inside the vessel digitally by placing the catheter before and after the narrowing in patients with venous sinus stenosis. If a significant pressure difference is detected, it confirms that the vessel is the definitive source of the tinnitus, and the treatment strategy is determined immediately.

How Is Venous Sinus Stenting Performed in the Treatment of Tinnitus?

If DSA measurements confirm that narrowing in the brain veins is causing tinnitus and increased intracranial pressure, venous sinus stenting is performed either in the same session or in a planned session. This is a remarkable interventional radiology technique that resolves the problem by accessing the vessels internally without the need for open brain surgery.

A closed stent is delivered to the narrowed area via microcatheters advanced through the groin artery. These stents are made of a special metal alloy called nitinol, composed of nickel and titanium. Nitinol has the unique property of expanding on its own by adapting to body temperature and vessel structure while maintaining its shape memory. Once released in the narrowed area, the stent gradually expands, gently pushing the compressed vessel walls outward and restoring the vessel to its normal width. As soon as the vessel opens, the turbulent and rapid blood flow ceases, and the flow becomes smooth like a calm river. Most patients report that the pulsatile sound that had persisted for months or years disappears immediately or is dramatically reduced right after the procedure.

Can Dural Arteriovenous Fistula (DAVF) Cause Tinnitus and Brain Hemorrhage?

Tinnitus can sometimes be not just a nuisance but an early warning sign of a life-threatening condition such as a brain hemorrhage. Dural Arteriovenous Fistula (DAVF) is a completely abnormal vascular connection between high-pressure arteries that supply the brain membranes and low-pressure veins that carry deoxygenated blood from the brain.

In normal circulation, there are fine capillary networks between arteries and veins that absorb pressure. In the case of a fistula, this capillary cushion is absent. Blood pumped forcefully from the heart flows directly into thin-walled veins. This situation, similar to forcing high-pressure water into a delicate hose, creates extreme turbulence. The sound of this abnormal flow resonates within the skull and is perceived as intense, high-frequency tinnitus. More dangerously, the thin-walled veins exposed to high pressure may swell, enlarge, and eventually rupture, leading to a fatal brain hemorrhage. Therefore, these lesions must be treated once diagnosed.

How Do Glomus Tumors Trigger Tinnitus?

Glomus tumors (paragangliomas), which can develop just behind the eardrum, in the middle ear cavity, or around the carotid artery in the neck, are masses that, despite being benign, can cause serious problems due to their anatomical effects. Their most characteristic feature is their extremely rich blood supply, forming a dense network of vessels within themselves.

To sustain themselves, these tumors draw large amounts of blood from surrounding arteries. As blood flows through the tumor’s complex and chaotic vascular channels, it produces a very loud blood flow noise. Since the tumor is located at the core of the hearing mechanism or very close to it, this intense sound is perceived directly as pulsatile tinnitus synchronized with the heartbeat. As the tumor grows, it may push the eardrum and ossicles, causing conductive hearing loss. The only definitive treatment for these tumors is surgical removal. However, because they are filled with blood, operating directly on them may cause uncontrollable bleeding. Therefore, interventional radiologists first intervene by entering the vessels supplying the tumor and injecting microscopic particles to cut off its blood supply. This devascularizes the tumor, allowing surgeons to operate in a safer, bloodless environment.

Are the Causes of Tinnitus Different in the Elderly and in Children?

The mechanisms underlying tinnitus differ significantly across different stages of life. In elderly individuals, tinnitus is usually the cumulative result of environmental wear, cellular aging, and systemic diseases. Years of exposure to urban noise, the natural degeneration of inner ear cells, and conditions such as hypertension and diabetes that damage small vessels are the main contributors. Additionally, the ototoxic effects of multiple medications commonly used in older age can exacerbate tinnitus.

In children, the situation is different. If a child reports ringing in the ears, the most common cause is fluid accumulation in the middle ear due to frequent upper respiratory infections or problems with the eardrum. However, if a child reports hearing a pulsing or rhythmic noise, this should never be underestimated. Pulsatile tinnitus in children may be the first and only sign of congenital vascular malformations (arteriovenous malformations) or dangerous blood clots (venous thrombosis) in the brain veins due to infection. Therefore, advanced radiological imaging should be performed without delay.

Are Endovascular Treatments for Tinnitus Safe?

Interventional radiology techniques used in the treatment of vascular tinnitus are classified as minimally invasive procedures, meaning they cause minimal disruption to the body. In the past, solving a vascular problem in the brain required large and risky neurosurgical operations involving opening the skull. Today, all brain vessels can be accessed through a tiny entry point in the artery in the groin.

During the procedures, general anesthesia or deep sedation is administered, and patients feel no pain. High-tech imaging systems display the interior of the vessels with millimetric precision on large screens. Numerous safety protocols are implemented to prevent materials from entering the wrong vessel during procedures such as stent placement or fistula closure. As with any medical procedure, there are minor risks such as clot formation in the vessel or allergic reactions to contrast material. However, in well-equipped and experienced centers, the rate of serious complications in these closed vascular interventions is extremely low. Patients are usually discharged the next day, completely free from the tinnitus that had been disturbing their sleep for months or years.

What Lifestyle Changes Should Be Made in Non-Vascular Tinnitus?

If all angiographic studies, MRIs, and tests show no narrowing, tumor, or fistula in the brain vessels, the tinnitus is considered subjective and caused by neural sensitivity in the inner ear. In such non-vascular tinnitus, there is no magical surgery or pill that directly silences the sound. The main goal of treatment is to reduce the brain’s sensitivity to the sound, help it move into the background (habituation), and manage stress. Changing daily habits is the most critical part of this process.

Recommended lifestyle changes include:

• Low-sodium diet
• Regular exercise
• Caffeine restriction
• Nicotin avoidance
• Use of white noise

Reducing salt intake decreases fluid retention in the body, thereby relieving pressure in the inner ear. Eliminating substances that directly stimulate the nervous system and constrict capillaries—such as coffee, tea, carbonated drinks, and cigarettes—prevents unnecessary stimulation of auditory nerves. At night, when tinnitus is most disturbing, the sound of a small fan or static noise between radio channels can significantly help the brain shift attention away from tinnitus and make it easier to fall asleep. Additionally, in cases accompanied by hearing loss, using a hearing aid amplifies external sounds and masks the internal ringing.

Which Medical Department Should You Visit for Tinnitus?

If you have persistent tinnitus, the process must be managed carefully and step by step. Your first stop should always be an Ear, Nose, and Throat (ENT) specialist. Hardened earwax in the ear canal, a perforation in the eardrum, or a middle ear infection can often be treated quickly, eliminating the tinnitus. A detailed hearing test at this stage also helps evaluate the condition of your auditory nerves.

If the ENT specialist finds no anatomical issue in your hearing system and your tinnitus is in the form of a pulse-synchronized sound, whooshing, or engine-like noise, an interventional radiology specialist should be involved. These physicians specialize in diagnosing and treating vascular diseases and can detect even the smallest vascular narrowing, intracranial pressure abnormalities, or hidden fistulas that may be missed in standard imaging using advanced angiographic techniques. The most important thing tinnitus patients should know is that they are not helpless, and before being told to “learn to live with it,” especially vascular causes must be thoroughly investigated using advanced endovascular imaging methods.

Prof. Dr. Özgür KILIÇKESMEZ

Prof. Dr. Özgür Kılıçkesmez is one of Türkiye’s leading interventional radiology and neuroradiology specialists, focusing on minimally invasive endovascular treatments. His primary areas of expertise include aneurysm and stroke treatments, embolization procedures, non-surgical treatments of thyroid and parathyroid diseases, interventional oncology, and peripheral vascular interventions. He currently serves as the Head of the Interventional Radiology and Neuroradiology Department at Istanbul Memorial Göztepe Hospital.
Graduating from Istanbul University Cerrahpaşa Faculty of Medicine in 1997, Prof. Dr. Kılıçkesmez received advanced training in interventional radiology and oncology as a Clinical Fellow at London Guy’s & St Thomas’ and King’s College Hospital between 2012 and 2013. He earned the title of Professor in 2020 and, in the same year, became the Founding Interventional Radiologist at SBÜ Çam and Sakura City Hospital. He also holds the EBIR (European Board of Interventional Radiology) certification.
Prof. Dr. Kılıçkesmez has 94 international and 40 national publications and over 2500 citations. He serves as a reviewer for prestigious journals such as the American Journal of Roentgenology (AJR) and Diagnostic & Interventional Radiology. With his clinical and academic expertise, he is a nationally and internationally recognized authority in stroke treatment, brain aneurysm, embolization, tumor ablation, and minimally invasive treatments of thyroid/parathyroid diseases.