What are the treatment options for constant tinnitus (ringing in the ear) and a clogged ear sensation?

Treatment for Constant Tinnitus and Clogged Ear Sensation

Start with an immediate otoscopic examination to rule out cerumen impaction, middle ear infection, or retrotympanic mass—these simple, treatable causes must be excluded before pursuing expensive workup or complex treatments. 1

Initial Evaluation Steps

Perform otoscopy first to identify:

• Cerumen impaction (treatable with carbamide peroxide drops for up to 4 days) 1, 2
• Acute otitis externa 1
• Middle ear effusion or infection 1, 3
• Retrotympanic masses 1

Obtain a targeted history focusing on:

• Whether tinnitus is unilateral or bilateral 4, 1
• Whether tinnitus is pulsatile (synchronous with heartbeat) or non-pulsatile 5, 1
• Duration of symptoms (recent onset vs. ≥6 months) 4, 5
• Associated hearing difficulties 4, 5
• Presence of focal neurological abnormalities 4, 5

Audiologic Testing

Order comprehensive audiometry promptly if tinnitus is:

• Unilateral 4, 5
• Persistent ≥6 months 4, 5
• Associated with hearing difficulties 4, 5

This testing identifies underlying sensorineural hearing loss, which is present in most patients with bothersome tinnitus. 4, 6

Imaging Studies—When to Order

DO NOT order imaging if tinnitus is bilateral, symmetric, non-pulsatile, and without neurological deficits. 5, 1

DO order imaging in these specific situations:

• Pulsatile tinnitus: Requires CT or MR angiography to evaluate vascular abnormalities 5, 1, 7
• Unilateral tinnitus: Requires MRI of internal auditory canals with contrast to exclude vestibular schwannoma 5, 1
• Asymmetric hearing loss: Warrants imaging to rule out acoustic neuroma 4, 5
• Focal neurological abnormalities: Requires neuroimaging 4, 5

Evidence-Based Treatment Algorithm

For Patients with Hearing Loss (any degree, even mild or unilateral):

Recommend hearing aid evaluation—this provides significant relief even with minimal hearing loss. 4, 5, 1

For All Patients with Persistent, Bothersome Tinnitus:

Recommend Cognitive Behavioral Therapy (CBT)—this has the strongest evidence for improving quality of life in tinnitus patients. 4, 5, 1

Provide education and counseling about:

• Natural history of tinnitus 4, 5
• Management strategies 4, 5
• Realistic expectations (no cure exists; treatment focuses on symptom management) 8

Consider sound therapy as an adjunctive option for symptomatic relief. 4, 5

Treatments to AVOID

Do NOT routinely prescribe:

• Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment (insufficient evidence, potential harm) 4, 5, 8
• Intratympanic medications (lack of evidence) 4, 8
• Dietary supplements including Ginkgo biloba, melatonin, or zinc (no consistent benefit) 4, 5
• Transcranial magnetic stimulation (not recommended for routine use) 4

Critical Safety Considerations

Identify patients with severe anxiety or depression immediately—these patients require prompt psychiatric intervention due to increased suicide risk in tinnitus patients with psychiatric comorbidities. 4, 5, 1

Common Clinical Pitfalls

• Failing to perform otoscopy before ordering expensive imaging studies 1
• Ordering brain imaging for bilateral, symmetric, non-pulsatile tinnitus without neurological deficit (wastes resources) 1
• Overlooking mild hearing loss that could benefit from hearing aids 5, 1
• Prescribing medications without clear evidence of benefit 5, 1
• Missing simple treatable causes like cerumen impaction 1

Treatment for Cerumen Impaction (If Present)

If cerumen is identified on otoscopy:

• Use carbamide peroxide 5-10 drops twice daily for up to 4 days 2
• Tilt head sideways and keep drops in ear for several minutes 2
• Flush with warm water using soft rubber bulb syringe after treatment 2
• Do not use if: ear drainage, ear pain, eardrum perforation, or recent ear surgery 2