The sound that arrived in the quiet

TINNITUS

6 min read

It is a single pitch, high and thin, and it is loudest the moment the house goes silent. The leading explanation is not that something in the ear broke. It is that the brain, receiving less input from the inner ear, turned up its own volume.

The pitch is there. You are not listening too hard or worrying yourself into hearing things. Something in the auditory pathway changed, and you are hearing the change.

Tinnitus in its most common form is the perception of a sound without an external source. In a 2024 population analysis published in The Lancet Regional Health, the estimated prevalence in US adults was 11.2 percent, representing roughly 27 million people. It increases with age in both sexes. Women who experience it tend to report higher severity than men, though overall prevalence is similar once age, hearing status, and noise exposure are accounted for.

In human inner ear tissue, two subtypes of oestrogen receptor have been identified: one in the spiral ganglion, where sound is converted to nerve impulses, and another in the stria vascularis, which maintains the chemical environment of the cochlear fluids. A 2023 systematic review found that these receptors are positioned to influence cochlear blood flow, neural transmission, and fluid balance.

When oestrogen levels shift during the menopausal transition, that positioning makes the inner ear a plausible site of change. But plausible is not established. No study has directly measured whether falling oestrogen produces the auditory shift a person notices.

One of the more studied models for how tinnitus arises is called central gain. When input from the cochlea drops, whether from noise exposure, ageing, or other causes, the brain’s auditory processing centres compensate by increasing their own activity.

A 2014 review in Frontiers in Neurology described this as a compensatory increase in neural amplification: the auditory cortex, receiving less signal, turns up its sensitivity. The sound a person hears may be the artefact of that compensation. The model comes primarily from animal studies, and its translation to any individual’s experience is not direct. But it offers the clearest framework the field currently has.

WHAT IT DOES NOT ESTABLISH

No study has directly measured whether declining oestrogen causes the central gain increase in human subjects. Sleep disruption, noise history, medication, and ordinary age-related cochlear change are all contributors in population data. A person experiencing tinnitus in midlife cannot tell from the sound alone which factor is dominant.

CENTRAL AUDITORY GAIN

When input from the ear falls, the auditory cortex raises its own sensitivity. In animal models, spontaneous neural firing rates climb after cochlear damage. The Central Gain Model proposes that tinnitus is the perceptual consequence: a sound generated internally by a system compensating for reduced external input.

Reported in population studies

11.2%

of US adults report tinnitus, roughly 27 million people

~80%

of people with tinnitus also have some degree of hearing loss, often undetected

The second figure is the one worth sitting with. If the sound is there, a hearing test is not optional reassurance. It is the first step toward understanding what changed, and whether the brain is compensating for a loss you have not noticed yet.

THE INTERVENTION WITH THE STRONGEST EVIDENCE

Cognitive behavioural therapy for tinnitus

MODERATE-CERTAINTY EVIDENCE

A 2020 Cochrane review of 28 randomized controlled trials with 2,733 participants found that CBT probably reduces the negative impact of tinnitus on quality of life compared with audiological care alone, at moderate certainty of evidence. Adverse effects were rare. The review found weak or absent effects on perceived loudness. CBT does not make the sound quieter. It changes how much the sound produces distress.

“Consider a stepped approach to treat tinnitus-related distress in adults whose tinnitus is still causing an impact on their emotional and social wellbeing, and day-to-day activities, despite having received tinnitus support.”

NICE NG155, TINNITUS: ASSESSMENT AND MANAGEMENT, 2020

WHAT IT IS NOT

CBT for tinnitus is not a cure and not a way to make the sound quieter. The Cochrane review found weak or absent effects on perceived loudness. The benefit is in reducing the degree to which the sound interferes with sleep, concentration, and daily life. It works on the brain’s response to the signal, not on the signal itself.

WHEN TO CALL

The tinnitus pulses in time with your heartbeat, or sounds like a rhythmic whooshing rather than a steady tone. Both the AAO-HNSF and NICE guidelines recommend imaging for pulsatile tinnitus to rule out vascular causes.

You lost hearing suddenly, over three days or fewer, in the past month. NICE recommends referral to be seen within 24 hours.

The sound is in one ear only, particularly if it arrived alongside dizziness or any change in facial sensation. The AAO-HNSF guideline recommends audiologic evaluation and may recommend MRI to rule out uncommon but treatable causes.

THIS WEEK

Tonight, before you lie down, set a sound source in the room. A fan on low, a phone playing quiet rain, a radio between stations. Set the volume so the room is no longer silent but the sound does not demand attention. This is called sound enrichment. It does not treat the tinnitus itself, but it reduces the contrast between quiet and the signal.

If the sound has been present for six months or longer, or if it affects your sleep or concentration, ask your doctor for a hearing assessment. It can identify contributing hearing loss and opens the door to referral for tinnitus support or CBT.

Notice when the pitch changes or recedes. End of day, silence, poor sleep. Keeping a loose track of when it is louder and when it fades is the beginning of understanding which variable amplifies it for you.

There is no switch that turns the tone off. But the research on central gain says something that matters: the volume is not fixed. It is the brain’s response to a signal gap, and that response shifts with what you give it to process. A quiet room is the worst acoustic environment for a sound that lives in the auditory cortex. A room with something low and steady in it is already a different room.

ONE TAP, NO FORM

What does the sound do to your night?

Tapping opens a pre-written reply. Nothing is public, nothing goes to a list. What most readers tap decides what gets explained next.

It is loudest when I lie down and the house goes quiet

It wakes me or keeps me from falling back asleep

It is there during the day too, not just at night

None of these, but something changed

Or write in your own words. Every reply is read.

Read recent issues

EVERY SOURCE READ FOR THIS ISSUE

Seven sources: one Cochrane systematic review, one population analysis, one nationwide cohort study, one systematic review on sex hormones and auditory function, one Lancet seminar on tinnitus, one narrative review on central gain, and one clinical practice guideline.

1	Cognitive behavioural therapy for tinnitus Cochrane systematic review, Fuller et al., 2020

2	Tinnitus prevalence, associated characteristics, and related healthcare use in the United States Population analysis, Lancet Regional Health – Americas, 2024

3	Hormone replacement therapy decreases the risk of tinnitus in menopausal women: a nationwide study Cohort study, Chen et al., Oncotarget, 2018

4	Sex differences and the effect of female sex hormones on auditory function: a systematic review Systematic review, Frontiers in Human Neuroscience, 2023

5	Tinnitus Seminar, Baguley et al., The Lancet, 2013

6	Central gain control in tinnitus and hyperacusis Narrative review, Auerbach et al., Frontiers in Neurology, 2014

7	Clinical practice guideline: tinnitus Clinical practice guideline, Tunkel et al., AAO-HNSF, 2014

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