The cause of the ringing is often unknown.  It is a phantom sound generated from the brain auditory cortex and other pathways.  In the ear, outer ear infections, wax impaction, ear drum perforations or even mucous in the middle ear will cause tinnitus.  Cochlea or inner ear damage is related to age, trauma (which may be direct trauma or sound trauma) It can also be caused by viruses including COVID and Autoimmune disease including Menieres Syndrome.

Vascular causes, anaemia (with a hyperdynamic circulation), high blood pressure and pregnancy can cause tinnitus.  This is also caused by disease of blood vessels whether arteries or veins and this can occur in the head or in the neck and include glomus tumours narrowing or tortuous arteries, arteria venous fistulae, malformations including aneurysms and vascular compression of inner ear nerves.

The local causes of tinnitus include Temporo Mandibular and teeth abnormalities.

Central causes of tinnitus include tumours such as the acoustic neuromas, strokes, degenerative diseases including Multiple Sclerosis and migraines.

Systemic causes include increased thyroid function, anaemia, diabetes and autoimmune diseases such as Lupus. 

Drugs are also an important cause such as Disprin, usually at a higher dose, non-steroidal anti-inflammatories, chemotherapy, certain antibiotics, anti-depressants and diuretic together with anti-malarial can cause tinnitus.