What Causes Ringing in the Ears After a Concussion?
Ringing in the ears—known clinically as tinnitus—is one of the more frequently overlooked symptoms following a concussion. For athletes, especially those recovering under the care of athletic trainers or physical therapists, this symptom can be frustrating, persistent, and often misunderstood. Unlike visible injuries, tinnitus is invisible but intrusive, sometimes leading to disrupted sleep, anxiety, or difficulty concentrating.
Studies indicate that tinnitus occurs in many individuals after a concussion, yet it's rarely emphasized during initial evaluations or in return-to-play protocols. This article unpacks the neurological, vestibular, and auditory pathways involved in post-concussion tinnitus, drawing on peer-reviewed research and clinical experience to guide healthcare professionals in identifying, assessing, and managing this complex symptom.
Understanding Tinnitus in the Context of Concussion
Tinnitus refers to the perception of sound—often described as ringing, buzzing, or hissing—in the absence of an external source. It can be intermittent or constant, unilateral or bilateral, and vary in loudness and pitch. After a concussion or mild traumatic brain injury (mTBI), tinnitus can emerge suddenly or develop gradually as other symptoms begin to resolve.
In the study Prevalence of Tinnitus Following Non-Blast Related Traumatic Brain Injury, researchers found that 63.1% of individuals with non-blast TBIs reported tinnitus symptoms, underlining how common this issue is even in less severe brain injuries (source).
Importantly, tinnitus in this context isn't always a standalone symptom. It's often accompanied by ear fullness, dizziness, or sound sensitivity—suggesting more widespread dysfunction across the auditory and vestibular systems.
Objective Concussion Assessments
Anytime, Anywhere
Sway’s FDA-cleared mobile app provides fast, reliable testing for athletic trainers and healthcare professionals.
Concussions can disrupt multiple levels of the auditory system. From the outer ear to the central auditory pathways in the brainstem and cortex, trauma can cause both structural and functional impairments. The Mayo Clinic describes how concussive forces may injure the inner ear, including the cochlea and vestibulocochlear nerve (cranial nerve VIII), potentially leading to tinnitus, hearing loss, and difficulty with auditory processing (source).
Damage to hair cells in the cochlea is a well-established cause of tinnitus in non-traumatic cases. However, in post-concussion patients, the mechanism is often more complex and may include:
Stretching or shearing of auditory nerve fibers
Disrupted connectivity between auditory and limbic regions (e.g., amygdala and hippocampus)
Maladaptive neuroplasticity in auditory cortical areas
Dysregulation of auditory gain control, leading to increased central sensitivity
These central mechanisms may explain why tinnitus following a concussion tends to be louder, more distressing, and more persistent than tinnitus from other causes. A study titled Characteristics of Tinnitus Induced by Head Injury confirmed this, noting that head trauma–related tinnitus often presents with more severe loudness and psychological distress, frequently co-occurring with dizziness and ear pain (source).
Vestibular Involvement: The Overlapping Systems
Auditory and vestibular systems share anatomical proximity and neurological overlap. When concussion affects one, the other is frequently impacted. Patients with vestibular dysfunction often report tinnitus, vertigo, or motion sensitivity. Clinically, this is seen in athletes who experience balance issues, sound-induced dizziness (Tullio phenomenon), or visual motion intolerance alongside tinnitus.
Persistent dysfunction in the vestibular nuclei or inferior colliculus, both of which integrate sensory input from the inner ear and brainstem, can contribute to prolonged auditory disturbances.
Furthermore, hyperacusis—abnormal sensitivity to sound—is commonly observed in post-concussion patients and may exacerbate the perceived intensity of tinnitus. A comprehensive review in Current Treatment Options in Neurology discussed how even mild TBIs can result in significant auditory disturbances, emphasizing the need for early identification and tailored treatment approaches (source).
Why Is Tinnitus Often Missed in Concussion Protocols?
Tinnitus is frequently overlooked in concussion evaluations, partly because it's subjective and not easily quantified. Standard sideline assessments and return-to-play protocols primarily focus on cognitive, visual, and balance-related symptoms, often neglecting auditory dysfunction. This gap in care has real implications.
The article Concussion Management Guidelines Neglect Auditory Symptoms argues that auditory issues—including tinnitus, hearing loss, and sound sensitivity—are under-recognized in clinical practice. The authors urge practitioners to include focused auditory screenings in baseline and post-injury assessments (source).
In practice, athletic trainers and physical therapists often encounter athletes reporting vague complaints like "head feels full" or "there’s a constant ringing I can’t ignore," which may be dismissed without a structured auditory review. As the article stresses, missing these symptoms can delay recovery or lead to misdiagnosis as anxiety or attention disorders.
Real-World Application: Clinical Scenario
Consider a high school soccer player who sustains a mild concussion during practice. By day three post-injury, her balance has improved, but she starts describing a persistent buzzing in her right ear. It interferes with sleep and focus during class. There's no hearing loss, and no visible ear trauma. Without a protocol that addresses auditory symptoms, this could easily be dismissed.
But recognizing the symptom as part of a broader auditory-vestibular syndrome allows for timely intervention. This might include referral for audiological evaluation, vestibular therapy with sound desensitization techniques, and psychological support if the tinnitus begins affecting mood or daily function.
Assessment and Treatment Considerations
A structured approach to evaluation is key. Here are several clinical strategies for healthcare professionals:
Screen for Auditory Symptoms Early Include targeted questions during concussion assessments: “Do you notice any ringing, buzzing, or changes in hearing?” or “Are loud sounds bothering you more than usual?”
Audiological Testing Referral for a full audiometric evaluation can help rule out conductive hearing loss or cochlear damage. Even if audiograms are normal, tinnitus can stem from central dysfunction.
Vestibular Evaluation When tinnitus co-exists with dizziness or imbalance, a vestibular-focused assessment can uncover dysfunctions in the semicircular canals or otolith organs.
Cognitive-Behavioral Therapy (CBT) For patients whose tinnitus is significantly affecting quality of life, CBT has shown effectiveness in reducing distress and improving coping mechanisms.
Vestibular and Sound Therapy Physical therapists trained in vestibular rehab can incorporate habituation techniques. Sound therapy or tinnitus retraining therapy (TRT) may help recalibrate central auditory processing.
Education and Validation Empowering the athlete with knowledge about why tinnitus is happening—and reassuring them that symptoms often improve—can significantly reduce anxiety and promote recovery.
Collaboration is Critical
Managing tinnitus after a concussion isn’t a one-specialist job. Athletic trainers, physical therapists, neurologists, audiologists, and mental health providers must coordinate care. For athletic trainers on the front lines, documenting auditory symptoms early and advocating for comprehensive evaluation is vital. For athletic directors and program decision-makers, integrating auditory symptom tracking into concussion protocols may reduce long-term complications and support safer return-to-play outcomes.
Moving Forward: Include the Auditory System in Concussion Protocols?
The growing body of research leaves little doubt—tinnitus and other auditory symptoms are not rare outliers but common consequences of concussions. They deserve the same clinical attention as headaches or balance problems. Incorporating auditory assessments, even brief screeners, into concussion management can lead to earlier interventions and more complete recoveries.
As science continues to evolve, tools and technologies that support vestibular and auditory evaluations will become increasingly essential. Institutions and clinicians who proactively address these needs will not only improve outcomes but also position themselves as leaders in athlete care and recovery.
🧠 Want to learn more about how integrated concussion care—including auditory and vestibular support—can improve outcomes? Connect with our team to explore evidence-backed solutions that fit your program’s goals and workflow.
