What is the most likely cause of persistent subjective tinnitus in a 54-year-old woman?

Diagnosis of Buzzing in the Ears in a 54-Year-Old Woman

The most likely cause of persistent buzzing (tinnitus) in a 54-year-old woman is sensorineural hearing loss, particularly age-related hearing loss (presbycusis), which is the single most common underlying cause of subjective tinnitus in this demographic. 1

Primary Diagnostic Consideration

• Sensorineural hearing loss accounts for the vast majority of subjective tinnitus cases, especially in middle-aged adults with bothersome tinnitus and no obvious ear pathology 1
• Presbycusis represents a gradual, progressive decline in high-frequency hearing due to hair cell degeneration and is the most common cause in older adults 1
• 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

Critical Initial Assessment Steps

First, determine if the tinnitus is pulsatile (synchronous with heartbeat) or non-pulsatile, as this fundamentally changes the diagnostic approach and urgency 1, 2:

• Non-pulsatile, bilateral tinnitus (described as buzzing, ringing, or hissing) strongly suggests sensorineural hearing loss and does NOT require imaging 1
• Pulsatile tinnitus has an identifiable structural or vascular cause in over 70% of cases and requires urgent imaging evaluation 2

Second, assess for unilateral versus bilateral presentation 1:

• Bilateral, symmetric tinnitus points toward presbycusis or noise-induced hearing loss 1
• Unilateral tinnitus raises concern for vestibular schwannoma (acoustic neuroma) and requires MRI with contrast 1

Essential Diagnostic Workup

Obtain comprehensive audiologic examination within 4 weeks, including pure tone audiometry, speech audiometry, and acoustic reflex testing 1:

• This identifies the degree and pattern of hearing loss
• Even mild or unilateral hearing loss can benefit from hearing aid intervention 1
• Asymmetric hearing loss mandates MRI of internal auditory canals with contrast to exclude retrocochlear pathology 1

Perform targeted otoscopic examination to identify simple, reversible causes 1:

• Cerumen impaction (easily treatable) 1
• Middle ear effusion or infection 1
• Vascular retrotympanic masses (paragangliomas) 2

Secondary Causes to Consider in This Age Group

• Noise exposure (occupational or recreational) can cause tinnitus and hearing loss 1
• Menière's disease presents with episodic vertigo, fluctuating hearing loss, and tinnitus 1
• Ototoxic medications (certain antibiotics, loop diuretics, high-dose aspirin) 1
• Otosclerosis causes conductive hearing loss with associated tinnitus 1

When Imaging IS Required

Do NOT order imaging for bilateral, symmetric, non-pulsatile tinnitus without localizing features, as this represents inappropriate resource utilization 1, 2:

However, imaging is mandatory if any of the following red flags are present 1, 2:

• Pulsatile quality (synchronous with heartbeat)
• Unilateral presentation
• Asymmetric hearing loss on audiometry
• Focal neurological abnormalities
• Severe enough to wake patient from sleep

Psychosocial Screening

Screen for severe anxiety or depression, as these patients require prompt identification and intervention due to increased suicide risk 1:

• Approximately 20% of adults with tinnitus require clinical intervention 1
• Anxiety and depression can be both cause and consequence of tinnitus 1

Common Pitfalls to Avoid

• Ordering MRI or CT for bilateral, symmetric, non-pulsatile tinnitus without red flags—this is low-yield, expensive testing with no benefit 1, 2
• Dismissing pulsatile tinnitus as benign without imaging—treatable and life-threatening vascular causes are common 2
• Missing mild hearing loss by not obtaining audiometry when patients don't report hearing difficulties 1
• Overlooking medication-induced tinnitus by failing to review ototoxic drug exposure 1

Most Likely Diagnosis Algorithm

For a 54-year-old woman with buzzing tinnitus:

1. If bilateral, non-pulsatile, constant buzzing → Presbycusis (age-related sensorineural hearing loss) is most likely 1
2. Confirm with audiometry showing bilateral high-frequency hearing loss 1
3. No imaging needed unless red flags present 1
4. Treatment focuses on hearing aids (even for mild loss) and cognitive behavioral therapy 1