What can be done for a patient experiencing noise in the ear?

Management of Tinnitus (Noise in the Ear)

Immediate Clinical Assessment: Determine Tinnitus Type

The first and most critical step is to determine whether the tinnitus is pulsatile (synchronous with heartbeat) or non-pulsatile, as this fundamentally changes your diagnostic approach and urgency. 1, 2

For Pulsatile Tinnitus (Rhythmic, Heartbeat-Synchronous):

• Pulsatile tinnitus requires imaging evaluation in nearly all cases because over 70% have an identifiable structural or vascular cause, including life-threatening conditions like dural arteriovenous fistula or arterial dissection 2, 3
• Perform otoscopic examination immediately to identify vascular retrotympanic masses (paragangliomas appear as red pulsatile masses behind the eardrum) 2, 3
• Order CT angiography (CTA) of head and neck with contrast as first-line imaging when otoscopy is normal, using mixed arterial-venous phase to capture both arterial and venous pathology 2, 3
• Order high-resolution CT temporal bone (non-contrast) instead if you visualize a vascular retrotympanic mass on otoscopy 2, 3
• Common causes include atherosclerotic carotid disease (17.5% of cases), idiopathic intracranial hypertension (second most common, especially in young overweight women), paragangliomas (16%), and dural arteriovenous fistulas (8%, life-threatening) 2

For Non-Pulsatile Tinnitus (Steady Ringing, Buzzing, Hissing):

Most non-pulsatile tinnitus is benign and strongly associated with sensorineural hearing loss, requiring no imaging unless specific red flags are present. 1, 4

Determine If Imaging Is Needed for Non-Pulsatile Tinnitus

Order imaging (MRI internal auditory canals with contrast) ONLY if any of these red flags are present: 1, 5

• Unilateral or asymmetric tinnitus 1, 5
• Asymmetric hearing loss on audiometry 1, 2
• Focal neurological abnormalities 1, 5
• Duration less than 6 months with sudden onset 1

Do NOT order imaging for bilateral, symmetric, non-pulsatile tinnitus without localizing features—this represents inappropriate resource utilization with no benefit. 1, 2

Audiologic Evaluation

Order comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for: 1, 5

• Any unilateral tinnitus 1, 5
• Persistent tinnitus (≥6 months duration) 1, 5
• Any patient reporting hearing difficulties 1, 5
• Ideally within 4 weeks of presentation 2

This is critical because even mild or unilateral hearing loss benefits from hearing aid intervention, and many patients don't recognize their own hearing loss 1, 6

Evidence-Based Treatment for Persistent, Bothersome Tinnitus

First-Line Interventions:

1. Cognitive Behavioral Therapy (CBT):

• CBT has the strongest evidence for improving quality of life in tinnitus patients and should be recommended for all patients with persistent, bothersome tinnitus 1, 6, 5
• CBT addresses the emotional and psychological impact rather than eliminating the sound itself 1, 6

2. Hearing Aids:

• Recommend hearing aid evaluation for ANY documented hearing loss, even if mild or unilateral 1, 6, 5
• Hearing aids provide significant relief and have strong evidence for benefit 1, 6

3. Education and Counseling:

• Provide all patients with education about tinnitus mechanisms, natural history, and management strategies 1, 5
• Explain that tinnitus represents a symptom rather than a disease, and that the brain can learn to habituate to the sound over time 1, 4

4. Sound Therapy:

• May be offered as a management option for symptomatic relief, though evidence is less robust than for CBT 1, 5
• Wide-band sound therapy can provide masking and habituation 6

Treatments to AVOID

Do NOT recommend the following due to insufficient evidence and potential harms: 1, 5

• Antidepressants, anticonvulsants, or anxiolytics for routine tinnitus treatment 1, 5
• Intratympanic medications 1, 5
• Dietary supplements (Ginkgo biloba, melatonin, zinc) 1, 5
• Transcranial magnetic stimulation 5

Exception: Treat comorbid depression or anxiety as separate conditions if present, as tinnitus patients with severe psychiatric comorbidities have increased suicide risk and require prompt mental health intervention 1, 2

Special Considerations

For Medication-Induced Tinnitus (e.g., Cisplatin):

• No treatment can reverse established ototoxicity 1
• Hearing aids and CBT remain beneficial for symptom management 1

For Tinnitus with Ménière's Disease:

• Manage the underlying vestibular disorder rather than treating tinnitus specifically 1

Follow-Up Strategy:

• Distinguish bothersome from non-bothersome tinnitus to prioritize intervention 1, 5
• Patients with persistent symptoms (≥6 months) require different counseling about natural history than those with recent onset 1, 5
• Long-term follow-up is necessary as 10-15% of bilateral tinnitus cases have identifiable underlying causes that may only become apparent over time 1

Critical Pitfalls to Avoid

• Missing pulsatile tinnitus: Always ask specifically if the sound is rhythmic with heartbeat—this changes everything 2, 3
• Dismissing pulsatile tinnitus without imaging: This can miss life-threatening dural AVF or arterial dissection 2, 3
• Ordering imaging for bilateral non-pulsatile tinnitus: This wastes resources and has no benefit 1, 2
• Overlooking mild hearing loss: Even mild or unilateral hearing loss benefits from amplification 1, 6
• Prescribing medications without evidence: Avoid antidepressants, anticonvulsants, or supplements for tinnitus itself 1, 5
• Missing idiopathic intracranial hypertension: Young overweight women with pulsatile tinnitus and headaches need urgent evaluation to prevent vision loss 2