What is the best approach to manage a patient experiencing tinnitus (ringing in the ears) only at night, potentially related to stress, anxiety, or sleep disorders?

Tinnitus Only at Night: Management Approach

For a patient experiencing tinnitus exclusively at night, the most important first step is to determine whether the tinnitus is pulsatile (synchronous with heartbeat) or non-pulsatile, as this fundamentally changes both the urgency and diagnostic pathway. 1

Initial Clinical Assessment

Determine the exact character of the nighttime tinnitus:

• Ask specifically if the sound is rhythmic and matches the heartbeat (pulsatile) versus constant ringing/buzzing (non-pulsatile) 1
• Assess whether it occurs in one ear only (unilateral) or both ears (bilateral) 1, 2
• Evaluate for any associated symptoms including hearing loss, vertigo, headaches, or vision changes 1, 3
• Perform otoscopic examination to identify vascular retrotympanic masses or cerumen impaction 1, 4

The nighttime-only pattern suggests environmental factors rather than structural pathology, as true vascular or structural causes produce continuous symptoms that become more noticeable in quiet environments rather than appearing de novo at night. 5, 6

Imaging Decision Algorithm

Do NOT order imaging if the tinnitus is:

• Bilateral, symmetric, and non-pulsatile 1, 3, 2
• Not associated with hearing loss, focal neurologic deficits, or other red flags 1, 2

DO order imaging (high-resolution CT temporal bone or CTA head/neck) if ANY of the following are present:

• Pulsatile quality (even if only at night) 1, 3
• Unilateral presentation 1, 2
• Asymmetric hearing loss on examination 1, 2
• Any focal neurological abnormalities 1, 2

Audiologic Evaluation

Order comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) if: 2

• Tinnitus is unilateral 2
• Patient reports any hearing difficulties 2
• Tinnitus has persisted for 6 months or longer 2

Even mild or unilateral hearing loss warrants hearing aid evaluation, as amplification provides significant relief for tinnitus patients with associated hearing loss. 7, 2

Evidence-Based Treatment for Non-Pulsatile Nighttime Tinnitus

First-line interventions:

• Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus 7, 2
• Sound therapy (white noise machines, fans, or environmental sounds) specifically at bedtime to mask the tinnitus in the quiet nighttime environment 7, 2
• Education and counseling about tinnitus mechanisms and management strategies 7, 2

If hearing loss is identified (even mild):

• Recommend hearing aid evaluation, as hearing aids provide significant relief even for mild or unilateral hearing loss 7, 2

Treatments to AVOID

Do NOT recommend the following due to lack of evidence and potential harm: 7, 2

• Antidepressants, anticonvulsants, or anxiolytics for routine tinnitus treatment 7, 2
• Dietary supplements including Ginkgo biloba, melatonin, or zinc 7, 2
• Intratympanic medications 7, 2

Exception for psychiatric comorbidity: If the patient has severe anxiety or depression (not just mild distress from tinnitus), these conditions require prompt identification and treatment due to increased suicide risk in tinnitus patients with psychiatric illness. 1, 3 However, treat the psychiatric condition itself, not the tinnitus with these medications.

Special Considerations for Nighttime-Only Pattern

The nighttime-only presentation most likely represents:

• Increased awareness in quiet environments rather than true intermittent tinnitus 5, 6
• Possible stress/anxiety-related exacerbation that peaks at bedtime 5
• Sleep-related factors including sleep position affecting venous drainage (though this would suggest pulsatile quality) 3

If truly transient (lasting only minutes at night):

• Observation and monitoring may be appropriate for episodes without other symptoms 8
• However, increasing frequency, duration, or development of associated symptoms requires more urgent evaluation 8

Common Pitfalls to Avoid

• Do not dismiss nighttime tinnitus as purely psychological without proper evaluation - perform targeted history, physical examination, and audiometry as indicated 5, 2
• Do not order MRI or CT imaging for bilateral, symmetric, non-pulsatile tinnitus - this represents inappropriate resource utilization with no benefit 1, 3, 2
• Do not overlook mild hearing loss - obtain audiometry even when patients don't report hearing difficulties, as mild hearing loss benefits from amplification 7, 2
• Do not prescribe medications without clear psychiatric indication - antidepressants and anxiolytics lack evidence for tinnitus treatment and may cause side effects 7, 2