What is the diagnosis and treatment for a patient with buzzing in both ears, potentially related to loud noise exposure or underlying hearing loss?

Bilateral Tinnitus: Diagnosis and Management

A patient with buzzing in both ears most likely has primary subjective tinnitus associated with sensorineural hearing loss, and the initial evaluation should focus on identifying treatable causes through targeted history, otoscopic examination, and comprehensive audiologic testing—not imaging. 1, 2

Initial Clinical Assessment

The first priority is distinguishing whether this tinnitus is bothersome versus non-bothersome, as this determines the intensity of intervention required. 1 Approximately 20% of adults with tinnitus require clinical intervention, while most adapt over time. 2

Critical History Elements to Obtain

• Duration: Tinnitus lasting ≥6 months is considered persistent and warrants comprehensive evaluation 1, 3
• Laterality: Bilateral tinnitus is typical for primary tinnitus; unilateral raises concern for acoustic neuroma 1, 2
• Quality: Buzzing, ringing, clicking, or pulsations—pulsatile quality fundamentally changes the diagnostic approach 2, 4
• Noise exposure history: Occupational or recreational loud noise is a major modifiable risk factor 2
• Impact on quality of life: Sleep disturbance, anxiety, depression, or extreme life changes 1
• Associated symptoms: Hearing loss, vertigo, ear fullness, or focal neurologic deficits 1

Critical pitfall: Patients with severe anxiety or depression accompanying tinnitus require immediate identification and intervention due to suicide risk. 1, 2

Physical Examination Priorities

• Otoscopic examination: Identify cerumen impaction (simple, reversible cause), middle ear effusion, or vascular retrotympanic masses 2, 3
• Auscultation: Over neck, periauricular area, and mastoid to detect objective tinnitus 2
• Neurologic examination: Assess for focal deficits suggesting intracranial pathology 2

Diagnostic Testing Strategy

Audiologic Evaluation

Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for:

• Any unilateral tinnitus 1, 3
• Persistent tinnitus (≥6 months) 1, 3
• Tinnitus associated with hearing difficulties 1, 3

Timing: Audiometry should be performed within 4 weeks for unilateral or persistent cases. 2 Even patients who don't report hearing difficulties may have mild hearing loss benefiting from amplification. 2

Imaging Decision Algorithm

The American Academy of Otolaryngology makes a strong recommendation AGAINST imaging for bilateral, non-pulsatile tinnitus without focal neurologic abnormalities or asymmetric hearing loss. 1, 3 This represents inappropriate resource utilization with no benefit. 2

Imaging IS indicated if any of the following are present:

• Unilateral or asymmetric tinnitus 1, 3
• Pulsatile quality 2, 4
• Focal neurologic abnormalities 1, 3
• Asymmetric hearing loss on audiometry 1, 2

For these cases, MRI of internal auditory canals with contrast is the appropriate study to exclude vestibular schwannoma. 2

Most Likely Diagnosis

Sensorineural hearing loss (SNHL) is the single most common underlying cause of bilateral, non-pulsatile tinnitus, particularly in bothersome cases without obvious ear pathology. 1, 2 The prevalence increases dramatically with age: 1.6% in adults 18-44 years, 4.6% in ages 45-64, and 9.0% in those over 60. 1

If noise exposure history is present, this represents a modifiable risk factor that should be addressed to prevent progression. 2

Treatment Approach for Persistent, Bothersome Tinnitus

Evidence-Based Interventions

Cognitive behavioral therapy (CBT) is the ONLY treatment proven to improve quality of life in tinnitus patients. 5, 3 The American Academy of Otolaryngology recommends CBT for patients with persistent, bothersome tinnitus. 3

If hearing loss is documented on audiometry, recommend hearing aid evaluation. 1, 3 Hearing aids provide significant relief even for mild or unilateral hearing loss. 2

Sound therapy may be offered as a treatment option, though evidence is inconclusive. 5, 3

Patient Education

Provide education about:

• Tinnitus mechanisms and natural history 2, 3
• Management strategies 3
• Realistic expectations (32-65% of sudden hearing loss cases recover spontaneously, but chronic tinnitus often persists) 1

Treatments to AVOID

The American Academy of Otolaryngology recommends AGAINST:

• Antidepressants, anticonvulsants, or anxiolytics for routine treatment 3
• Intratympanic medications 3
• Ginkgo biloba, melatonin, zinc, or dietary supplements 3
• Transcranial magnetic stimulation 3

Exception: Antidepressants may help with comorbid mood disorders, and melatonin may help with sleep disturbance, but these treat associated symptoms rather than tinnitus itself. 5

Follow-Up Considerations

For patients with partial or no improvement, ongoing management requires a team approach involving otolaryngology, audiology, and potentially psychology. 1 Long-term follow-up is essential as some underlying causes may not be evident at initial presentation. 1

Avoidance of further noise exposure is critical to prevent development or progression of tinnitus. 5