REASONING GP · Clinical algorithm · Quick reference

Tinnitus in adults — triage and diagnostic approach

Daytime GP and OOH/111. Most tinnitus is bilateral and benign, but the pattern decides the route: sort it by side, rhythm and company, then treat the distress rather than dismissing it.

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AdultsGP + OOHDiagnosis firstv1.0 · Sep 2026

Core rule. Three features triage tinnitus (NG155): which side, is it pulsatile, and what comes with it? Bilateral non-pulsatile tinnitus with symmetrical hearing loss is benign and needs support, not imaging. Unilateral tinnitus, pulsatile tinnitus, and tinnitus with sudden hearing loss, neurology or suicidal distress each leave by a different, faster route. "Nothing can be done" is both untrue and unsafe: it is the sentence that stops the patient reporting a red flag later.

Before any history: is this an emergency now? Stop the consultation and act today if any of these is present

Tinnitus with sudden hearing loss within the last 3 days (immediate ENT, within 24 hours) · with any central sign — facial weakness, diplopia, dysarthria, limb weakness or ataxia, inability to walk unaided · with severe vertigo and deafness · pulsatile tinnitus with severe headache, papilloedema, visual obscurations or neck bruit · after head or neck trauma · with fever, neck stiffness or post-auricular swelling · suicidal ideation or intent, or acute psychological crisis (NG155 requires same-day mental-health assessment). Record onset, side and rhythm; make the call rather than arranging review.

Define the tinnitus in four lines Enough to place the patient in the table below

Side

Unilateral or bilateral? This is the single most useful question. Unilateral (or clearly asymmetric) tinnitus is the vestibular schwannoma presentation and is referred whatever the hearing is. Bilateral and symmetrical is reassuring.

Rhythm

Pulsatile — in time with the heartbeat, whooshing, sometimes audible to the examiner (objective) — is vascular until proven otherwise. Non-pulsatile ringing, hissing or buzzing is the common benign pattern. Clicking suggests palatal or middle-ear myoclonus.

Company

Hearing loss, and whether sudden or gradual, one ear or both · vertigo or imbalance · aural fullness · otalgia or discharge · headache, visual symptoms · neurological symptoms · neck or jaw symptoms, bruxism.

Context and impact

Noise exposure · ototoxic or tinnitus-inducing drugs — aminoglycosides, cisplatin, high-dose aspirin or NSAIDs, loop diuretics, quinine · head injury, ear surgery · anaemia, thyroid disease, hypertension · sleep, concentration, mood, and any thoughts of self-harm; what the patient believes is causing it.

Red-flag screen: trigger → concern → destination → what to do before handover One row is enough; do not add up reassuring features

Trigger / red flag	Leading concern · destination	Do now · do not delay
Tinnitus with sudden hearing loss, onset within the last 3 days, with normal otoscopy — so the loss is sensorineural. The patient who woke with a blocked, ringing ear, at any age.	Sudden sensorineural hearing loss Refer immediately — seen within 24 hours · NG98 / NG155	Otoscopy both ears plus Weber and Rinne: normal drums with Weber lateralising to the better ear is sensorineural. Telephone ENT the same day — steroids and audiometry have a window of days. Onset 4–30 days ago is still urgent, to be seen within 2 weeks. Do not prescribe a decongestant, nasal steroid or antibiotic and review, and do not soften wax and wait.
Tinnitus with a central or cranial-nerve sign: facial weakness, diplopia, dysarthria, dysphagia, limb weakness or ataxia, inability to walk unaided; or acute severe vertigo with deafness.	Posterior circulation or AICA infarct · brainstem or cerebellar lesion 999 now	A labyrinthine infarct presents as "labyrinthitis" with tinnitus and deafness. Say "acute vestibular syndrome with hearing loss, query posterior stroke": CT misses about half of posterior strokes, so MRI is the test. Do not give a vestibular sedative and review.
Pulsatile tinnitus, synchronous with the pulse; worse on exertion or bending; a bruit over the neck, mastoid or orbit; a red or blue mass behind the drum on otoscopy; obesity in a young woman with headache and visual obscurations.	Dural AV fistula · carotid stenosis or dissection · glomus tumour · idiopathic intracranial hypertension Urgent ENT with imaging — within 2 weeks 999 if papilloedema, neurology or a bruit after trauma	Pulsatile tinnitus is an imaging diagnosis (MRI/MRA or CT angiography) and is never reassured away. Examine the drum for a vascular mass, auscultate the neck and mastoid, check BP, and look at the fundi — papilloedema with pulsatile tinnitus is IIH and threatens sight. Check FBC and TFT for anaemia and thyrotoxicosis as high-flow causes.
Unilateral or clearly asymmetric tinnitus, with or without hearing loss or imbalance; also unilateral tinnitus persisting after wax removal or a treated infection.	Vestibular schwannoma · other retrocochlear lesion Urgent ENT or audiology for MRI of the internal auditory meati · NG98	Refer on the side, even when the audiogram looks normal — unilateral tinnitus alone qualifies. Document the side, the otoscopy and the tuning-fork findings. Do not wait for a repeat audiogram in 6 months, and do not attribute a unilateral noise to "stress" or to a symmetrical noise exposure.
Tinnitus with a middle-ear or infective cause needing action: foul painless discharge, attic crust or a retraction pocket (cholesteatoma) · severe unremitting otalgia with granulation in diabetes or immunosuppression · fever with post-auricular swelling or a protruding pinna · new facial palsy.	Cholesteatoma · necrotising otitis externa · mastoiditis Same-day ENT 999 if neurological features or systemically unwell	These are structural or osteomyelitic problems: a further course of drops or oral antibiotics with review is not a safe plan. Record the drum appearance, the facial nerve and the glucose where relevant.
Significant psychological distress: tinnitus-related insomnia with exhaustion, inability to function, marked anxiety or depression, and above all ideas of self-harm or suicide.	Mental-health emergency — tinnitus distress is a recognised suicide risk Same-day mental-health assessment · NG155	Ask the question directly; NG155 requires it, because severity of the noise and severity of distress are only loosely related. Arrange same-day crisis assessment where there is risk, and refer the tinnitus itself for specialist psychological support in parallel — not one after the other. Never say "you will have to live with it".
Objective or rhythmic non-pulsatile tinnitus: clicking heard by the examiner or in time with palatal movement; tinnitus that changes with jaw or neck position.	Palatal or middle-ear myoclonus · patulous Eustachian tube · TMJ or cervical cause Urgent ENT if objective Dental / physio if positional	Watch the palate and auscultate the ear — an examiner-audible noise is by definition not subjective tinnitus and needs ENT. Positional or jaw-related tinnitus with a normal ear may respond to TMJ or neck treatment, but still needs hearing assessment.
Tinnitus with a head-and-neck cancer feature: an unexplained persistent neck lump · unilateral middle-ear effusion in an adult, especially with nasal obstruction or epistaxis · persistent unexplained sore throat, hoarseness or dysphagia · oral ulceration or a mass lasting over 3 weeks.	Nasopharyngeal, laryngeal or other head-and-neck cancer Urgent suspected-cancer referral within 2 weeks · NICE NG12	A unilateral effusion in an adult is a nasopharyngeal carcinoma until the postnasal space has been examined (NG98 requires urgent ENT) — it is not adult glue ear for a nasal spray. Examine the neck and mouth and ask directly about nasal obstruction and epistaxis. Hoarseness beyond 3 weeks in a smoker aged 45 and over is its own NG12 route.

Trigger / red flag

Leading concern · destination

Do now · do not delay

Tinnitus with sudden hearing loss, onset within the last 3 days, with normal otoscopy — so the loss is sensorineural. The patient who woke with a blocked, ringing ear, at any age.

Sudden sensorineural hearing loss
Refer immediately — seen within 24 hours · NG98 / NG155

Otoscopy both ears plus Weber and Rinne: normal drums with Weber lateralising to the better ear is sensorineural. Telephone ENT the same day — steroids and audiometry have a window of days. Onset 4–30 days ago is still urgent, to be seen within 2 weeks. Do not prescribe a decongestant, nasal steroid or antibiotic and review, and do not soften wax and wait.

Tinnitus with a central or cranial-nerve sign: facial weakness, diplopia, dysarthria, dysphagia, limb weakness or ataxia, inability to walk unaided; or acute severe vertigo with deafness.

Posterior circulation or AICA infarct · brainstem or cerebellar lesion
999 now

A labyrinthine infarct presents as "labyrinthitis" with tinnitus and deafness. Say "acute vestibular syndrome with hearing loss, query posterior stroke": CT misses about half of posterior strokes, so MRI is the test. Do not give a vestibular sedative and review.

Pulsatile tinnitus, synchronous with the pulse; worse on exertion or bending; a bruit over the neck, mastoid or orbit; a red or blue mass behind the drum on otoscopy; obesity in a young woman with headache and visual obscurations.

Dural AV fistula · carotid stenosis or dissection · glomus tumour · idiopathic intracranial hypertension
Urgent ENT with imaging — within 2 weeks 999 if papilloedema, neurology or a bruit after trauma

Pulsatile tinnitus is an imaging diagnosis (MRI/MRA or CT angiography) and is never reassured away. Examine the drum for a vascular mass, auscultate the neck and mastoid, check BP, and look at the fundi — papilloedema with pulsatile tinnitus is IIH and threatens sight. Check FBC and TFT for anaemia and thyrotoxicosis as high-flow causes.

Unilateral or clearly asymmetric tinnitus, with or without hearing loss or imbalance; also unilateral tinnitus persisting after wax removal or a treated infection.

Vestibular schwannoma · other retrocochlear lesion
Urgent ENT or audiology for MRI of the internal auditory meati · NG98

Refer on the side, even when the audiogram looks normal — unilateral tinnitus alone qualifies. Document the side, the otoscopy and the tuning-fork findings. Do not wait for a repeat audiogram in 6 months, and do not attribute a unilateral noise to "stress" or to a symmetrical noise exposure.

Tinnitus with a middle-ear or infective cause needing action: foul painless discharge, attic crust or a retraction pocket (cholesteatoma) · severe unremitting otalgia with granulation in diabetes or immunosuppression · fever with post-auricular swelling or a protruding pinna · new facial palsy.

Cholesteatoma · necrotising otitis externa · mastoiditis
Same-day ENT 999 if neurological features or systemically unwell

These are structural or osteomyelitic problems: a further course of drops or oral antibiotics with review is not a safe plan. Record the drum appearance, the facial nerve and the glucose where relevant.

Significant psychological distress: tinnitus-related insomnia with exhaustion, inability to function, marked anxiety or depression, and above all ideas of self-harm or suicide.

Mental-health emergency — tinnitus distress is a recognised suicide risk
Same-day mental-health assessment · NG155

Ask the question directly; NG155 requires it, because severity of the noise and severity of distress are only loosely related. Arrange same-day crisis assessment where there is risk, and refer the tinnitus itself for specialist psychological support in parallel — not one after the other. Never say "you will have to live with it".

Objective or rhythmic non-pulsatile tinnitus: clicking heard by the examiner or in time with palatal movement; tinnitus that changes with jaw or neck position.

Palatal or middle-ear myoclonus · patulous Eustachian tube · TMJ or cervical cause
Urgent ENT if objective Dental / physio if positional

Watch the palate and auscultate the ear — an examiner-audible noise is by definition not subjective tinnitus and needs ENT. Positional or jaw-related tinnitus with a normal ear may respond to TMJ or neck treatment, but still needs hearing assessment.

Tinnitus with a head-and-neck cancer feature: an unexplained persistent neck lump · unilateral middle-ear effusion in an adult, especially with nasal obstruction or epistaxis · persistent unexplained sore throat, hoarseness or dysphagia · oral ulceration or a mass lasting over 3 weeks.

Nasopharyngeal, laryngeal or other head-and-neck cancer
Urgent suspected-cancer referral within 2 weeks · NICE NG12

A unilateral effusion in an adult is a nasopharyngeal carcinoma until the postnasal space has been examined (NG98 requires urgent ENT) — it is not adult glue ear for a nasal spray. Examine the neck and mouth and ask directly about nasal obstruction and epistaxis. Hoarseness beyond 3 weeks in a smoker aged 45 and over is its own NG12 route.

Safety rule. Loudness does not indicate seriousness, and distress does not indicate benignity — severe distress occurs with quiet tinnitus and vice versa. Noise exposure, wax and a recent cold are common and explain bilateral tinnitus; none of them explains a unilateral or pulsatile noise. If a row applies and the safe destination is unavailable, escalate rather than observe.

Colour is semantic: red = emergency or same-day · amber = urgent assessment · blue = define/assess · green = primary-care management · purple = uncertain / specialist route (including 2WW). Continued on page 2: examination, classification, pattern classifier, routine referral, primary-care management, endpoint.

REASONING GP · Tinnitus in adults — triage and diagnostic approach

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Focused examination and investigation Remote assessment cannot do otoscopy, tuning forks or auscultation, so it cannot triage tinnitus safely

Ears

Otoscopy both ears: wax, perforation, effusion, attic crust or retraction (cholesteatoma), granulation, and any red or blue mass behind the drum (glomus). Whispered voice test. Weber and Rinne — Weber to the worse ear is conductive, to the better ear is sensorineural.

If pulsatile

Auscultate over the mastoid, the ear canal, the orbit and the neck for a bruit; check BP and pulse rhythm; fundoscopy for papilloedema; look for anaemia and thyrotoxicosis. An examiner-audible noise makes it objective tinnitus.

Beyond the ear

Cranial nerves including the facial nerve; gait and coordination if any imbalance. Neck and supraclavicular nodes; mouth and oropharynx. Jaw movement and tenderness, and cervical spine movement, where the noise is positional.

Tests

Audiological assessment for everyone with persistent tinnitus (NG155) — it drives both the referral route and hearing-aid fitting. FBC, TFT and glucose where a high-flow or metabolic cause is possible. Imaging is requested via ENT. No routine imaging for bilateral non-pulsatile tinnitus with symmetrical hearing.

Classify: three exits, not two The question is never "is it real" but "which route and how much distress"

Serious cause or crisis

Sudden hearing loss, central sign, pulsatile tinnitus, unilateral tinnitus, cholesteatoma or infective complication, NG12 feature, or suicidal distress. Output: name the concern, use the destination above, record side, rhythm, otoscopy and tuning forks.

Benign pattern, manage in primary care

Bilateral non-pulsatile tinnitus, normal otoscopy, symmetrical hearing, no red flag, distress manageable. Output: explanation, audiology referral, hearing aids where there is loss, sleep and sound-enrichment advice, review date.

Unclassified / high impact

Bilateral tinnitus but with unexplained asymmetry, fluctuation, or disabling impact on sleep, mood or function. Output: do not stop at reassurance — state the uncertainty, send the §6 route, and name the reviewer and timeframe.

Pattern classifier: side, rhythm, company Only once the red-flag screen is negative

Tinnitus with age-related or noise-induced loss

Bilateral, non-pulsatile ringing or hissing with symmetrical sensorineural loss; worse in quiet and at night. The commonest pattern by far. Hearing aids often reduce the tinnitus as well as the loss — audiology is the treatment route, not a formality.

Conductive / wax or effusion

Tinnitus with fullness and a conductive loss; wax or fluid on otoscopy. Should resolve when the cause is treated — re-test hearing and re-ask about the tinnitus afterwards; persistence, or any unilateral element, becomes an §6 or page-1 route.

Drug-related

Onset or worsening after aminoglycosides, cisplatin, high-dose aspirin or NSAIDs, loop diuretics or quinine. Reconcile dates against onset. High-dose salicylate tinnitus is reversible; aminoglycoside and cisplatin damage usually is not — seek advice the same day rather than completing the course.

Ménière's disease

Episodic vertigo of 20 minutes to 12 hours with fluctuating unilateral hearing loss, tinnitus and aural fullness. Needs audiometry and ENT confirmation — not a primary-care label, and the unilateral element still requires imaging to exclude a schwannoma.

Somatosensory / TMJ or cervical

Tinnitus modulated by jaw clenching, neck position or pressure over the TMJ, with a normal ear and normal hearing. Often with bruxism or neck pain. Treat the jaw or neck and reassess — but still arrange audiology.

Do not label by default

"Just stress" or "just wax" for a unilateral or pulsatile noise. "Normal for your age" without an audiogram. Musical hallucination or voices is not tinnitus. And distress is not proportional to loudness — always ask about sleep, mood and self-harm.

Refer routinely from this consultation Not same-day, not urgent — the cases that leave by letter; §7 is what primary care manages today

Persistent tinnitus with hearing loss → audiology for assessment and hearing aids, which treat both (NG155, NG98) · persistent bothersome tinnitus with normal hearing → audiology or a tinnitus service for sound therapy · significant distress, insomnia or low mood but no crisis → tinnitus-specific CBT, the best-evidenced intervention (NG155) · suspected otosclerosis (Rinne negative, normal drum) → ENT · Ménière's or fluctuating unilateral symptoms → ENT with audiometry · positional or TMJ-related tinnitus → dental or physiotherapy alongside audiology · severe or profound loss not benefiting from aids → cochlear implant assessment (TA566). State the side, rhythm and impact in the letter.

The only decisions that belong in this consultation What primary care manages today

Explanation, and the words to use

Explain that tinnitus is generated by the hearing system, is very common, is not a sign of a brain tumour in the bilateral non-pulsatile pattern, and usually becomes less intrusive as the brain habituates — and that treatment exists for the distress. Never say "nothing can be done" or "you must live with it": it prevents habituation and stops the patient returning if something changes.

Sound and sleep

Sound enrichment rather than silence — a fan, background music or a bedside sound generator; avoid total quiet at bedtime. Sleep hygiene, since insomnia drives most of the distress. Advise against alcohol as a sedative.

Hearing and hearing protection

Arrange audiology; where there is loss, hearing aids are a tinnitus treatment, not only a hearing one. Advise hearing protection for noise exposure, but warn against over-protection in ordinary environments, which worsens hyperacusis.

Reversible contributors

Remove wax and re-test. Review ototoxic and salicylate drugs. Treat anaemia, thyroid disease and uncontrolled hypertension. Address caffeine, nicotine and alcohol where the patient links them, without insisting on restriction that has no evidence.

Distress — ask every time

Screen for insomnia, anxiety, depression and self-harm or suicidal thoughts (NG155). Manage the mood disorder on its own pathway; refer for tinnitus-specific CBT in parallel. No drug treats tinnitus itself — do not start an antidepressant, benzodiazepine, betahistine or ginkgo for the noise; treat a diagnosed mood or sleep disorder on its own merits.

Sudden hearing loss, pulsatile or unilateral tinnitus, cholesteatoma, stroke, suicidal distress

The referral is the management. Do not reassure, do not prescribe instead, do not "review in 6 weeks". Record the exact onset date, the side and the rhythm — for sudden loss the treatment window depends on it.

Endpoint and documentation Finish with one of four conclusions

1 · Time-critical

Immediate ENT, 999 or crisis route taken; suspected diagnosis, onset date, side and rhythm, otoscopy, Weber and Rinne, fundi if pulsatile, who was spoken to.

2 · Urgent

Urgent ENT or audiology referral with the 2-week expectation; the question asked (unilateral, pulsatile, asymmetric, objective), findings, and the deadline.

3 · Benign pattern managed

Pattern recorded, explanation given, audiology referred, sound and sleep advice, reversible contributors addressed, distress screen documented, review date.

4 · Unclassified / high impact

Uncertainty or impact stated; §6 referral sent with date; interim sound and sleep plan; review owner and timeframe; escalation criteria.

Why a primary-care conclusion is safe today, in one line: no row on the page-1 screen applies · tinnitus is bilateral and non-pulsatile · both ears examined and recorded · Weber and Rinne consistent with the otoscopy · hearing symmetrical or referred for audiometry · drugs reviewed · distress, sleep and self-harm asked about and recorded · explanation, sound advice and a written safety-net given, with a booked review. Safety-net wording: 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.

OOH / remote limitation. A telephone or video consultation cannot do otoscopy, tuning forks, auscultation for a bruit or fundoscopy, and therefore cannot exclude sudden sensorineural loss, a vascular cause or a schwannoma. Convert to face-to-face or emergency assessment for tinnitus that is new and unilateral, pulsatile, or accompanied by hearing loss, vertigo, facial weakness or headache, or where the patient describes crisis-level distress.

Clinical decision support only; follow local ENT, audiology and mental-health policies and check doses against the current BNF. Source hierarchy: NICE guidelines and CKS first, then BNF/MHRA for doses and safety, then national specialty guidance. Sources: NICE NG155 Tinnitus: assessment and management · NG98 Hearing loss in adults · NG12 Suspected cancer (May 2025) · NG128 Stroke and TIA · NG225 Self-harm · TA566 Cochlear implants · NICE CKS Tinnitus, Hearing loss in adults, Earwax · BNF · MHRA · British Tinnitus Association patient resources. Review after any guidance or medicines-safety update, otherwise every 6 months. © Reasoning GP · gpreasoning.uk