In India, pulsatile tinnitus, bilateral is managed by ophthalmologists. Tinnitus is the perception of sound — most often a ringing, hissing, buzzing, or whooshing — without any external source, generated by maladaptive plasticity in the central auditory pathway after the brain loses its normal input from the cochlea. Roughly 14% of adults worldwide and around 50 million Americans experience tinnitus, with about 2% reporting it as severely disabling (Jarach JAMA Neurol 2022; Bhatt JAMA OHNS 2016).
Tinnitus (ICD-10: H93.1) is the conscious perception of an auditory sensation in the absence of a corresponding external acoustic stimulus. It is a symptom, not a disease — generated almost entirely within the central nervous system after cochlear damage reduces afferent input and triggers compensatory changes along the auditory pathway from cochlear nucleus through inferior colliculus to primary and secondary auditory cortex. The AAO-HNS 2014 guideline divides tinnitus along several clinically useful axes: primary (idiopathic, often associated with sensorineural hearing loss) versus secondary (caused by a specific identifiable disorder such as vestibular schwannoma, Meniere disease, or a vascular lesion); subjective (heard only by the patient, more than 99% of cases) versus objective (a real acoustic signal audible to the examiner, usually pulsatile or muscular); and persistent (lasting six months or more) versus recent-onset. About 80% of patients also have measurable sensorineural hearing loss, and roughly 20% experience associated hyperacusis.
The key symptoms of Pulsatile tinnitus, bilateral are: Persistent ringing, hissing, buzzing, roaring, or cricket-like sound heard in one or both ears in the absence of an external source, often more noticeable in quiet environments and at bedtime., Constant or near-constant perception in most patients, though intensity typically waxes and wanes with stress, fatigue, caffeine, and ambient noise., Pitch most commonly in the high-frequency range (3-8 kHz), matching the audiometric region of associated sensorineural hearing loss in roughly 80% of patients., Worsening of perceived loudness in silent environments, in bed at night, and after prolonged exposure to loud noise such as concerts, machinery, or firearms., Co-existing hearing difficulty, especially understanding speech in background noise, present in approximately 80% of tinnitus sufferers., Hyperacusis — discomfort or pain from ordinary environmental sounds at moderate volume — affects around 20% of patients with bothersome tinnitus., Sleep disturbance: difficulty falling asleep, fragmented sleep, and early-morning waking, reported by roughly 50% of patients with persistent bothersome tinnitus..
Diagnosis of tinnitus is primarily clinical and follows the AAO-HNS 2014 guideline framework. The starting point is a structured history — laterality (unilateral or bilateral), character (pulsatile or non-pulsatile), onset, duration, association with hearing loss or vertigo, prior noise exposure, head injury, current medications, and impact on sleep, mood, and function. Physical examination includes otoscopy to exclude cerumen impaction and middle ear pathology, cranial nerve testing, auscultation of the neck and periauricular region for bruits in pulsatile tinnitus, and head and neck examination for masses. A comprehensive audiological evaluation — pure-tone audiometry, speech audiometry, tympanometry, otoacoustic emissions, and acoustic reflex testing — is recommended for any patient with persistent tinnitus or asymmetric symptoms. Tinnitus pitch matching, loudness matching, and minimum masking level are documented at specialist centres. Standardised severity instruments such as the Tinnitus Handicap Inventory (THI) or Tinnitus Functional Index (TFI) quantify distress and guide treatment intensity. Imaging is targeted, not routine: the AAO-HNS guideline recommends MRI of the internal auditory canals for any strictly unilateral or pulsatile tinnitus, and CTA, MRA, or MRV for pulsatile tinnitus to exclude vascular causes such as dural arteriovenous fistula, sigmoid sinus diverticulum, or idiopathic intracranial hypertension. Laboratory testing (thyroid function, fasting glucose, lipids) is reserved for cases with specific suggestive features. Critically, the guideline strongly recommends against routine imaging in patients with bilateral, non-pulsatile, symmetric tinnitus, which represents the great majority of cases and rarely yields treatable findings.
Tinnitus is rarely cured but is highly manageable in the majority of patients. Without active treatment, roughly 25% of patients experience spontaneous improvement over two years, 50% remain stable, and 25% worsen. With structured care — hearing aids where indicated, sound therapy, and cognitive behavioural therapy — clinically meaningful reductions in Tinnitus Handicap Inventory scores occur in 60-70% of patients, and most are able to live without daily preoccupation. Severely distressing tinnitus persists in approximately 2% of the adult population, and these patients carry an elevated risk of depression, anxiety, and insomnia that requires integrated mental health care. The strongest individual prognostic factors are duration (recent-onset tinnitus has the best chance of habituation), comorbid hearing loss (treatable with hearing aids), psychiatric comorbidity (treatable with CBT and where needed medication), and continued noise exposure (modifiable with protection). Once tinnitus has been present for over a year and the patient has engaged with evidence-based care, complete resolution is uncommon — but successful habituation, in which the sound is still detectable but no longer occupies attention, is achieved by most patients.
Refer to an otolaryngologist or audiologist when tinnitus persists beyond six months, is strictly unilateral or pulsatile, is accompanied by hearing loss or vertigo, follows head or noise injury, or causes meaningful sleep, mood, or concentration impairment. Urgent referral is indicated for sudden hearing loss with new tinnitus, pulsatile tinnitus with neurological features, and tinnitus with suicidal ideation. Primary care can deliver education, basic counselling, and a hearing-aid referral for uncomplicated bilateral non-pulsatile tinnitus.
Find specialists →Acute-onset tinnitus after a single loud noise exposure typically resolves within 24-48 hours; persistence beyond two weeks warrants audiology assessment. Tinnitus from a clear cause (wax, ototoxic drug, sudden sensorineural hearing loss treated within 72 hours) can resolve within days to a few weeks. For chronic idiopathic tinnitus, hearing aids fitted appropriately tend to reduce awareness within 4-12 weeks; CBT produces measurable improvement over 8-12 weeks of weekly sessions and persists at 6-12 month follow-up; tinnitus retraining therapy is a 12-24 month protocol. Habituation is typically gradual rather than dramatic — most patients describe a slow fading of the emotional charge of the sound over months.
Regular moderate aerobic exercise is safe and beneficial in tinnitus. Aim for 150 minutes per week of activity such as walking, cycling, or swimming. Exercise improves sleep, mood, and vascular health and reduces tinnitus-related distress in observational data. There is no need to avoid physical activity because of tinnitus, and rest does not relieve it. Wear hearing protection if your exercise environment is noisy (motorised sports, shooting ranges, indoor cycling classes with loud music).
Look for an otolaryngologist with subspecialty interest in neuro-otology, or an audiologist with tinnitus-specific training (TRT or CBT certification). Ask whether the practice routinely performs full audiological evaluation, uses validated severity instruments such as THI or TFI, offers hearing-aid fitting on site, has psychology access for CBT, and follows the AAO-HNS clinical practice guideline. For pulsatile tinnitus, seek a centre with neuroradiology and interventional neuroradiology services. Continuity is important — tinnitus care is a long arc of habituation, not a one-visit fix.
Medically reviewed by AIHealz Medical Editorial Board · May 12, 2026
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