What are the possible causes and treatments for ear wooshing, potentially related to tinnitus, in a patient with a history of ear infections and exposure to loud noises?

Ear Wooshing: Diagnostic Approach and Management

"Ear wooshing" most likely represents pulsatile tinnitus if it synchronizes with your heartbeat, or non-pulsatile tinnitus if it's a continuous sound—and the critical first step is determining which type you have, because pulsatile tinnitus almost always requires imaging to rule out vascular abnormalities, while non-pulsatile tinnitus typically does not. 1, 2

Immediate Diagnostic Clarification Required

First, determine if the "wooshing" is truly pulsatile:

• Pulsatile tinnitus = repetitive sound that beats in sync with your heartbeat 3, 1
• Non-pulsatile tinnitus = continuous or constant sound without synchronization to pulse 3, 4

This distinction is critical because pulsatile tinnitus requires imaging (CTA or MRA) to evaluate for vascular abnormalities, arteriovenous malformations, or intracranial hypertension, while bilateral non-pulsatile tinnitus typically does not require imaging. 3, 1, 2

Essential Initial Evaluation

Perform otoscopic examination immediately to exclude simple treatable causes before ordering expensive studies: 2

• Cerumen impaction (can cause tinnitus and fullness) 3, 4
• Retrotympanic mass 2
• Acute otitis externa or middle ear infection 2, 4

Obtain comprehensive audiometry if: 1, 2

• Tinnitus is unilateral 1, 2
• Symptoms persist ≥6 months 1
• Associated with hearing loss or ear fullness 2
• History of loud noise exposure (you mentioned this) 4

When Imaging Is Required vs. Not Required

Imaging (CTA or MRA) IS required for: 3, 1, 2

• Truly pulsatile tinnitus (synchronous with heartbeat) 3, 1, 2
• Unilateral tinnitus with asymmetric hearing loss on audiometry 1, 2
• Focal neurological abnormalities 1, 2

Imaging is NOT cost-effective or necessary for: 1, 2

• Bilateral, non-pulsatile, symmetric tinnitus without neurological deficit 1, 2
• This represents the most common pitfall—ordering unnecessary brain imaging for benign bilateral tinnitus 2

Evidence-Based Treatment Approach

For persistent, bothersome tinnitus (regardless of cause):

Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent tinnitus, according to the American Academy of Otolaryngology-Head and Neck Surgery. 1, 2

Hearing aid evaluation should be recommended even if mild or unilateral hearing loss is identified on audiometry—this is particularly relevant given your history of loud noise exposure. 1, 2

Education and counseling about tinnitus management strategies should be provided to all patients. 1

Critical Red Flags Requiring Urgent Evaluation

Seek immediate otolaryngology referral if: 1, 2

• Truly pulsatile tinnitus (synchronous with heartbeat) 1, 2
• Unilateral symptoms with asymmetric hearing loss 1, 2
• Focal neurological abnormalities 1, 2
• Foul-smelling ear discharge 1
• Sudden hearing loss over 72 hours (requires urgent steroid consideration) 1

Common Pitfalls to Avoid

Do not dismiss "wooshing" without clarifying if it's truly pulsatile—this can delay diagnosis of potentially serious vascular pathology. 1

Do not order imaging for bilateral non-pulsatile tinnitus—this is unnecessary and not cost-effective according to the American Academy of Otolaryngology-Head and Neck Surgery. 1, 2

Do not prescribe medications for tinnitus without evidence—antidepressants and supplements lack efficacy data and can cause harm. 1, 2

Do not overlook simple treatable causes like cerumen impaction or otitis externa before pursuing expensive workup. 2, 4

Special Considerations for Your History

Given your history of ear infections and loud noise exposure: 4

• Sensorineural hearing loss from noise exposure is a common cause of subjective tinnitus 4
• Previous ear infections could have caused conductive hearing loss contributing to symptoms 4
• Audiometry is particularly important to differentiate these causes and guide treatment 1, 2

If you have severe anxiety or depression related to the tinnitus, immediate psychiatric intervention is required due to increased suicide risk in tinnitus patients with co-existing psychiatric illness. 2