Reasoning GP · Algorithm · 1-page summary
Tinnitus in adults
For: adults with new or persistent tinnitus, daytime GP and OOH/111. Not for: under-16s → Urgent paediatric audiology; confirmed Ménière's (ENT pathway).
Core rule: triage by side, rhythm and company (NG155). Bilateral non-pulsatile tinnitus with symmetrical hearing is benign and needs support, not imaging. Unilateral, pulsatile, sudden hearing loss, neurology or suicidal distress each leave by a faster route. Never say “nothing can be done”.
0Stop — act now — 999 or same-day, before any history
- Central or cranial-nerve sign (facial weakness, diplopia, dysarthria, dysphagia, limb weakness, ataxia, cannot walk unaided), acute severe vertigo with deafness, suspected stroke, altered consciousness, severe systemic illness, airway compromise → 999 Say “query posterior stroke”: CT misses about half; MRI is the test.
- Thunderclap headache with vomiting, or meningism (SAH, meningitis) → 999
- Sudden hearing loss (over ≤3 days) within the past 30 days, not explained by wax or middle-ear disease → Immediate ENT/ED, seen within 24 h — not automatically 999. Do not wait for audiometry.
- Suicidal ideation or intent, or acute psychological crisis → Immediate crisis assessment if high risk (NG155). Record onset date, side and rhythm; make the call rather than arranging review.
1Triage — side, rhythm, company
| Pattern | Route |
|---|---|
| Pulsatile | Vascular until proven otherwise → imaging for all persistent cases (block 2) |
| Unilateral / asymmetric | Vestibular schwannoma pattern → ENT/audiovestibular, whatever the hearing |
| Objective clicking | Examiner hears it: myoclonus → Urgent ENT |
| Bilateral, steady | Symmetrical hearing, no red flag → benign (blocks 4–5) |
2Screen — one row is enough
- Persistent pulsatile → Urgent ENT/neurovascular imaging, even if examination normal. Papilloedema (IIH) → Same-day ophthalmology/neurology; neurology or bruit after trauma → 999
- Unilateral tinnitus, even after wax or infection treated → ENT/audiovestibular per local pathway; consider MRI IAM. With asymmetric hearing loss → Urgent ENT
- Sudden hearing loss >30 days ago or rapidly progressive → Urgent ENT within 2 weeks (NG98)
- Necrotising otitis externa (diabetes, granulation), mastoiditis, new facial palsy → Same-day ENT. Cholesteatoma → Urgent ENT
- Head and neck cancer: neck lump, adult unilateral effusion, persistent hoarseness or dysphagia, oral ulcer >3 weeks → Suspected cancer pathway (NG12)
3Assess — face to face only
☐ Otoscopy both ears ☐ Whisper, Weber, Rinne (Weber to better ear = sensorineural) ☐ Cranial nerves, gait ☐ Neck, mouth, jaw ☐ Pulsatile: auscultate ear, orbit, neck; BP; fundi ☐ Drugs: aminoglycosides, cisplatin, high-dose aspirin/NSAIDs, loop diuretics, quinine
Audiology for all persistent tinnitus. Bloods only if indicated. Not routinely: CT head, blood panel, ECG.
4Classify — only if the screen is negative
- Age- or noise-related — bilateral, symmetrical loss, worse in quiet → audiology; aids help the tinnitus too.
- Wax or effusion — conductive loss → treat, re-test, re-ask; persisting or unilateral → block 2.
- Drug-related — match dates to onset. Aminoglycoside or cisplatin → advice same day; never stop essential drugs without the specialist.
- Ménière's — vertigo 20 min–12 h, fluctuating unilateral loss → ENT with audiometry; still image.
- TMJ / neck — changes with jaw or neck, normal ear → dental or physio, plus audiology.
- Unclassified / high impact — asymmetry, fluctuation or disabling impact → state uncertainty, refer, name reviewer and timeframe.
5Treat today — only these
- Explain: very common, not a tumour in the bilateral non-pulsatile pattern; habituation usual; distress is treatable.
- Sound and sleep: sound enrichment, not silence; sleep hygiene; no alcohol as a sedative. Protect from loud noise, not ordinary noise.
- Reversible contributors: remove wax and re-test; review ototoxic drugs; treat anaemia, thyroid disease, hypertension.
- No drug treats tinnitus: no antidepressant, benzodiazepine, betahistine or ginkgo for the noise. Steroids for sudden loss only on ENT advice — doses: NICE/SPC, BNF, local formulary.
6Refer routinely
- Bilateral symmetrical, no red flags → direct audiology; hearing aids where loss affects communication.
- Distress without crisis (promptly if it stops normal activities, whatever the score) → stepped tinnitus CBT: digital → group CBT, mindfulness-based CBT or ACT → individual. Treat mood disorder on its own pathway, in parallel.
- Otosclerosis (Rinne negative, normal drum) → ENT. Severe loss not helped by aids → cochlear implant assessment.
7Never reassure by
- “Just stress” or “just wax” for a unilateral or pulsatile noise.
- A normal examination in persistent pulsatile tinnitus — image it.
- “Normal for your age” without an audiogram.
- Quiet tinnitus — distress and seriousness are not proportional to loudness.
- Treating an adult unilateral effusion as glue ear with a nasal spray.
- A remote consultation: no otoscopy, tuning forks, bruit check or fundi.
8Safety-net — say it, then document it
999 “Call 999 for new facial weakness, double vision, unsteadiness, difficulty swallowing, or a sudden severe headache.” Same day “Contact us the same day if the tinnitus becomes one-sided, starts beating in time with your pulse, or comes with sudden hearing loss, dizziness, facial weakness, severe headache or visual change — and straight away if you feel unable to cope or have thoughts of harming yourself.”
Remote or OOH: convert to face-to-face or emergency assessment if new and unilateral, pulsatile, or with hearing loss, vertigo, facial weakness, headache or crisis-level distress. Review new presentations at 2–4 weeks.
✓Safe to manage in primary care only if — all five, documented
No block 0–2 row applies; bilateral and non-pulsatile
Both ears examined; Weber and Rinne match otoscopy
Hearing symmetrical or audiology referred; drugs reviewed
Sleep, mood and self-harm asked and recorded
Explanation, sound advice, written safety-net; review booked
Summary of the full Reasoning GP tinnitus algorithm, which holds the detail, examination, investigations and evidence. Sources: NICE NG155, NG98, NG12 (updated April 2026), NG128, NG225, TA566; MHRA; Tinnitus UK. Clinical reference — follow local ENT, audiology and mental-health policies and check doses: NICE/SPC, BNF.