What causes constant tinnitus (ringing in the ears) and how is it treated?

Constant Hissing in the Ears (Tinnitus)

Constant hissing in your ears is most commonly caused by sensorineural hearing loss, and while no cure exists, the most effective treatment combines hearing aids (if hearing loss is present) with sound therapy and cognitive behavioral therapy-based counseling to improve quality of life. 1, 2

Understanding What Causes Your Tinnitus

Sensorineural hearing loss is the single most common underlying cause of constant tinnitus, particularly when you have bothersome symptoms and no obvious ear pathology. 2 This affects over 50 million people in the United States, with prevalence of 10-15% in adults, increasing dramatically with age—from 1.6% in adults aged 18-44 years to 9.0% in those over 60 years. 1, 2

Primary causes to consider:

• Noise exposure (occupational or recreational) is a major preventable cause 2
• Age-related hearing loss (presbycusis) is extremely common 2
• Ototoxic medications can trigger tinnitus 2
• Sudden sensorineural hearing loss requires urgent evaluation 2

Secondary causes requiring identification:

• Otosclerosis (conductive hearing loss) 2
• Menière's disease 2
• Anxiety and depression can both contribute to and result from tinnitus 2

Critical Warning Signs Requiring Immediate Evaluation

You need urgent imaging and specialty referral if your tinnitus is:

• Pulsatile (rhythmic, synchronous with heartbeat)—this suggests vascular pathology in over 70% of cases and can indicate life-threatening conditions like dural arteriovenous fistula or arterial dissection 3
• Unilateral (one-sided only) 1
• Associated with neurological symptoms 3
• Accompanied by severe anxiety or depression—suicide risk is increased and requires prompt psychiatric intervention 1, 2

Diagnostic Approach

For constant, non-pulsatile, bilateral tinnitus (like hissing):

• Comprehensive audiologic examination is essential, including pure tone audiometry, speech audiometry, and acoustic reflex testing 1
• Imaging is NOT typically indicated for bilateral, non-pulsatile tinnitus without localizing features 3
• Thorough otoscopic examination to rule out cerumen impaction, infection, or middle ear pathology 4

For pulsatile or unilateral tinnitus:

• High-resolution CT temporal bone (non-contrast) OR CT angiography of head and neck with contrast as first-line imaging 3
• MRI with contrast and MR angiography reserved for cerebellopontine angle lesions or when CT/CTA are negative but suspicion remains high 3

Treatment Strategy

Most Effective Evidence-Based Approach:

The strongest evidence supports combining sound therapy with CBT-based counseling, though availability of tinnitus-specific CBT is limited. 5

1. Hearing aids when hearing loss is identified (even mild or unilateral):

• This addresses the underlying sensorineural hearing loss that drives most tinnitus 5
• Amplification can be combined with masking devices 6

2. Sound therapy (wide-band noise):

• Masking with hearing aids or tinnitus maskers is 82% effective in suppressing tinnitus 6
• Provides auditory stimulation that reduces tinnitus perception 5

3. Cognitive behavioral therapy (CBT):

• Indicated for patients with significant distress 5
• Addresses the anxiety, depression, and quality of life impacts 1

What Does NOT Work:

No effective drug treatments are available for primary tinnitus, despite extensive research. 5 Surgical intervention for associated otological pathology might treat that condition, but the tinnitus typically persists. 5

Common Pitfalls to Avoid

• Missing pulsatile tinnitus: Always ask if the sound is rhythmic with heartbeat—this changes everything and requires vascular imaging 3
• Dismissing psychiatric comorbidity: Approximately 20% of adults with tinnitus require clinical intervention, and those with severe anxiety or depression need immediate psychiatric referral due to suicide risk 1, 2
• Ordering unnecessary imaging: Bilateral, non-pulsatile tinnitus without focal findings does NOT need imaging 3
• Promising a cure: Tinnitus is a symptom, not a disease, and most treatments focus on improving quality of life rather than eliminating the sound 1, 5

Practical Management Algorithm

Step 1: Determine if tinnitus is pulsatile or non-pulsatile 3

• If pulsatile: Order imaging (CT temporal bone or CTA) and refer to ENT urgently 3
• If non-pulsatile: Proceed to Step 2

Step 2: Assess for unilateral vs bilateral 1

• If unilateral: Consider imaging to rule out acoustic neuroma; refer to ENT 4
• If bilateral: Proceed to Step 3

Step 3: Obtain comprehensive audiologic testing 1

• If hearing loss present: Fit hearing aids as primary intervention 5
• If no hearing loss: Proceed to Step 4

Step 4: Screen for anxiety and depression 1, 2

• If severe psychiatric symptoms: Urgent psychiatric referral 1
• If mild-moderate distress: Offer sound therapy and CBT-based counseling 5

Step 5: Implement combination therapy 5

• Sound therapy (masking devices or environmental sound enrichment) 6
• CBT-based counseling when available 5
• Reassurance that most patients adapt over time 2