What could cause tinnitus in a 54-year-old female?

Causes of Ringing in the Ears (Tinnitus) in a 54-Year-Old Female

The most common cause of tinnitus in a 54-year-old woman is sensorineural hearing loss, particularly age-related hearing loss (presbycusis), which accounts for the majority of cases in this age group. 1

Primary Causes to Consider

Age-Related and Noise-Induced Hearing Loss

• Sensorineural hearing loss is the single most common underlying cause of tinnitus, particularly in patients with bothersome tinnitus and no obvious ear pathology. 1
• Presbycusis (age-related hearing loss) represents a gradual, progressive decline in the ability to perceive high-frequency tones due to degeneration of hair cells in the ear and is the most common cause in older adults. 2
• Age is the strongest demographic risk factor, with tinnitus prevalence increasing from 1.6% in adults aged 18-44 years to 9.0% in those over 60 years. 1
• Noise exposure from occupational or recreational sources (concerts, firearms, loud work environments) can cause both tinnitus and hearing loss. 1

Ototoxic Medications

• Certain medications can trigger tinnitus, including aspirin, NSAIDs, aminoglycoside antibiotics, loop diuretics, and chemotherapy agents. 1
• A thorough medication review is essential, as drug-induced tinnitus may be reversible with discontinuation. 3

Otologic Causes

• Cerumen impaction is a simple, treatable cause that should be ruled out during physical examination. 4
• Otosclerosis causes conductive hearing loss and can lead to tinnitus. 1
• Menière's disease presents with episodic vertigo, fluctuating hearing loss, and tinnitus. 1

Red Flag Causes Requiring Urgent Evaluation

Pulsatile Tinnitus

• If the tinnitus is pulsatile (synchronous with heartbeat), this requires immediate imaging evaluation because over 70% of cases have an identifiable vascular or structural abnormality. 1
• Atherosclerotic carotid artery disease is the most frequent cause of pulsatile tinnitus (17.5% of cases). 5
• Dural arteriovenous fistulas account for 8% of pulsatile tinnitus cases and can lead to hemorrhagic or ischemic stroke if untreated. 5
• Paragangliomas (glomus tumors) account for 16% of pulsatile tinnitus cases and appear as vascular retrotympanic masses. 5

Unilateral or Asymmetric Tinnitus

• Unilateral tinnitus with asymmetric hearing loss raises concern for vestibular schwannoma (acoustic neuroma) and requires MRI of internal auditory canals with contrast. 1
• Sudden sensorineural hearing loss with tinnitus requires prompt identification and intervention. 1

Psychogenic and Neurologic Factors

• Anxiety and depression are psychogenic factors that can contribute to tinnitus severity and distress. 1
• Patients with tinnitus accompanied by severe anxiety or depression require prompt identification and intervention due to increased suicide risk. 1
• Neurodegeneration can be a neurologic cause of tinnitus in this age group. 1

Diagnostic Approach Algorithm

Step 1: Characterize the Tinnitus

• Determine if the tinnitus is pulsatile vs. non-pulsatile, as this fundamentally changes the diagnostic workup. 1
• Assess if it is unilateral vs. bilateral and whether there is associated hearing loss. 6
• Ask about quality of sound (ringing, buzzing, clicking, pulsations, roaring). 1

Step 2: Physical Examination

• Perform otoscopic examination to identify cerumen impaction, middle ear effusion, or retrotympanic masses. 5
• For pulsatile tinnitus, auscultate over the neck, periauricular area, and mastoid to detect objective tinnitus. 1
• Conduct neurologic examination to detect focal deficits. 1

Step 3: Audiometric Testing

• Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for any unilateral tinnitus or tinnitus present for 6 months or longer. 6
• This should be performed within 4 weeks for unilateral or persistent cases. 5

Step 4: Imaging Decisions

• For bilateral, symmetric, non-pulsatile tinnitus without neurologic abnormalities or asymmetric hearing loss, imaging is NOT recommended. 1
• For pulsatile tinnitus, order CT angiography (CTA) of head and neck with contrast or high-resolution CT temporal bone as first-line imaging. 5
• For unilateral tinnitus with asymmetric hearing loss, order MRI of internal auditory canals with contrast to evaluate for vestibular schwannoma. 5

Common Pitfalls to Avoid

• Do not dismiss pulsatile tinnitus as benign without imaging, as treatable and life-threatening causes are common. 5
• Do not order imaging for bilateral, symmetric, non-pulsatile tinnitus, as this represents inappropriate resource utilization with no benefit. 5
• Do not miss medication-induced tinnitus by failing to perform a thorough medication review, including over-the-counter NSAIDs and aspirin. 1
• Do not overlook mild hearing loss that could benefit from hearing aid amplification, even when patients don't report hearing difficulties. 5
• Screen for anxiety and depression, as approximately 20% of adults with tinnitus require clinical intervention for associated psychological distress. 1