Tinnitus Algorithm · Reasoning GP

1

Safety

Red Flags — Exclude Serious Pathology First

Done

Screen for sinister causes before managing tinnitus symptomatically. Any red flag = same-day assessment or urgent referral.

Pulsatile / unilateral tinnitus Rhythmic, heartbeat-synchronous sound → 2WW ENT — exclude glomus tumour, AVM, carotid stenosis

Sudden sensorineural hearing loss (SSNHL) >30 dB loss over 3 frequencies in <72 h → Same-day ENT — steroids within 72 h improve outcomes

Unilateral tinnitus + asymmetric hearing loss Especially progressive or >65 years → 2WW ENT — exclude acoustic neuroma (vestibular schwannoma)

Neurological symptoms Facial weakness, diplopia, dysphagia, cerebellar signs → 999 / Same-day neurology — posterior fossa lesion, CPA tumour

Sudden onset with headache + vomiting Thunderclap pattern or meningism → 999 — SAH, meningitis

Objective tinnitus (audible to examiner) Heard with stethoscope → Urgent ENT — vascular malformation, palatal myoclonus

Otoscopy: ear mass or granulation tissue Polyp, cholesteatoma flakes, bleeding from EAC → Urgent ENT — exclude cholesteatoma, malignancy

Vertigo + drop attacks (Tumarkin's) Sudden falls without loss of consciousness → Urgent ENT / audiology — advanced Ménière's disease

Otalgia disproportionate to otoscopy findings Ear pain without obvious cause + ipsilateral tinnitus → Urgent ENT — malignant otitis externa, nasopharyngeal Ca

Child with tinnitus Any age <16 → Urgent paediatric audiology — exclude structural lesion, SNHL

Tinnitus is usually benign but a small but important minority have serious underlying pathology. Acoustic neuromas (vestibular schwannomas) present with unilateral tinnitus and asymmetric hearing loss in up to 90% of cases — delayed diagnosis leads to larger tumours requiring more complex surgery. Pulsatile tinnitus has a vascular cause in approximately 28% of cases including paragangliomas, dural AVFs and carotid artery disease. SSNHL is an otological emergency; high-dose systemic steroids initiated within 72 hours significantly improve hearing recovery (NICE 2018, SIGN 130). Cholesteatoma causes progressive bone erosion and risks meningitis, facial nerve palsy and sigmoid sinus thrombosis if missed.

2

Diagnose

Characterise the Tinnitus — History & Onset

Done

Systematic characterisation identifies aetiology and guides management. Use structured history to distinguish primary from secondary tinnitus.

Onset & duration

Sudden vs gradual? Hours/days/months/years? Any precipitant: loud noise exposure, new medication, head trauma, ear infection, barotrauma?

Character

Ringing, buzzing, hissing, rushing, clicking, pulsing? Tonal vs broad-band? Pulsatile = vascular work-up required

Laterality

Unilateral (more sinister — 2WW ENT if new + hearing loss) vs bilateral (more likely systemic/noise-induced) vs central (in head)

Severity — THI

Use Tinnitus Handicap Inventory (THI): 25-item questionnaire. Grade: 0–16 slight, 17–36 mild, 37–56 moderate, 57–76 severe, 77–100 catastrophic

Associated symptoms

Hearing loss? Vertigo/dizziness? Aural fullness? Otalgia? Hyperacusis? Headache? Neck pain?

Triggers / modifiers

Worse with stress/fatigue/caffeine? Jaw movement worsens → TMJ. Positional changes → vascular. Reduced by masking noise?

Medication review

Ototoxic drugs: aminoglycosides, cisplatin, loop diuretics (high dose), quinine, NSAIDs (chronic), aspirin (>3 g/day)

Noise exposure

Occupational (manufacturing, music), recreational (concerts, firearms, headphone use)? Duration and recency

Systemic history

Hypertension, anaemia, thyroid disease, diabetes, autoimmune conditions, otosclerosis family history

The Tinnitus Handicap Inventory (THI) is the validated primary outcome measure in UK tinnitus care (NICE guideline NG155, 2020). It predicts need for specialist input and guides therapy selection: mild THI responds to self-management; severe/catastrophic THI requires MDT input including psychology. Laterality is the single most discriminating feature — unilateral tinnitus with audiometric asymmetry of >15 dB at any frequency warrants MRI IAMs to exclude acoustic neuroma. Medication review is high-yield: aspirin ototoxicity is dose-dependent and reversible on cessation; aminoglycosides cause permanent cochlear damage.

3

Diagnose

Classify the Aetiology — Identify Treatable Causes

Done

Most tinnitus is idiopathic or noise-induced, but systematically exclude treatable causes before labelling as primary tinnitus.

Conductive causes

Impacted wax (most common, treat in primary care), otitis media with effusion, otosclerosis, perforated TM, Eustachian tube dysfunction — all potentially reversible

Sensorineural — acquired

Noise-induced hearing loss (NIHL) — most common SNHL cause globally. Presbycusis (age-related). Ototoxic drugs. Viral (post-COVID tinnitus increasingly recognised)

Sensorineural — disease

Ménière's disease: episodic tinnitus + vertigo + aural fullness + fluctuating low-frequency hearing loss. Acoustic neuroma: unilateral progressive. Autoimmune inner ear disease

Vascular / pulsatile

Benign intracranial hypertension (young overweight women), glomus tumour, carotid stenosis, AVM, high jugular bulb, anaemia — all need urgent investigation

Somatic tinnitus

Modulated by jaw/neck movement → TMJ dysfunction or cervical spine pathology. Refer to dental/physiotherapy as appropriate

Central tinnitus

Post-acoustic trauma, central sensitisation. In-head tinnitus without peripheral cause. Associated with anxiety/depression in 60% — psychological input crucial

Medication-related

Review and trial withdrawal of offending agent if clinically safe. Document before/after THI score

Systemic

Hypertension, anaemia (high-output state → pulsatile), hypothyroidism, diabetes — treat underlying condition first

Identifying a treatable cause changes the management pathway entirely. Wax removal alone resolves tinnitus in a significant proportion of primary care presentations. Ménière's disease requires specialist dietary management, diuretic therapy and potentially intratympanic injections. Benign intracranial hypertension (pseudotumour cerebri) causes pulsatile tinnitus synchronous with pulse and demands urgent ophthalmology assessment for papilloedema to prevent permanent visual loss. Classification into primary vs secondary tinnitus (NICE NG155 framework) ensures patients with reversible causes are not prematurely counselled that tinnitus is permanent.

4

Diagnose

Targeted Examination — Structured Clinical Assessment

Done

A focused 5-minute examination can identify or exclude most serious causes. Document findings carefully.

Otoscopy (bilateral)

Wax impaction (remove if present), TM perforation, retraction pockets, cholesteatoma (white pearly mass, epithelial debris), haemotympanum, OME (amber fluid, hair-line), granulation tissue, foreign body

Tuning fork tests

Rinne: BC > AC = conductive loss (Rinne negative). Weber: lateralises to affected ear (conductive) or away from affected ear (sensorineural). Helps interpret audiogram direction

Cranial nerve exam

CN V (corneal reflex, face sensation), CN VII (facial symmetry), CN VIII (hearing, nystagmus), CN IX/X/XI/XII — any deficits → urgent ENT/neurology

Auscultation over ear/neck

Listen with stethoscope over EAC, mastoid, neck. Audible bruit = objective tinnitus → urgent vascular/ENT referral

BP both arms

Hypertension associated with pulsatile tinnitus. Inter-arm difference >15 mmHg → subclavian steal / aortic coarctation

Whisper test / free-field hearing

Conversational voice at 60 cm, whisper at 60 cm. If fails → audiometry needed. Documents asymmetry between ears

Neck / TMJ examination

Cervical ROM and tenderness (somatic tinnitus). TMJ click, pain on opening jaw, bite asymmetry → refer dental/maxfax

Fundoscopy (if pulsatile)

Papilloedema → raised ICP → same-day ophthalmology + neurology for BIH/SOL

Otoscopy is the single highest-yield examination in primary care tinnitus — wax removal is the most commonly effective treatment. Auscultation for objective tinnitus is underperformed but crucial: a bruit indicates vascular pathology requiring imaging. Cranial nerve examination identifies CPA lesions before imaging is arranged. The combination of asymmetric tuning fork findings + unilateral tinnitus + any hearing asymmetry on whisper test mandates audiological assessment and MRI IAMs to exclude acoustic neuroma — this diagnosis is frequently delayed by 2–4 years in UK practice.

5

Diagnose

Investigations — Targeted, Not Reflexive

Done

Investigations should be guided by history and examination. Bilateral tinnitus with normal ears and no red flags rarely needs extensive work-up at initial presentation.

Pure tone audiogram First-line

Request via audiology for all new tinnitus patients. Documents baseline, identifies SNHL pattern, asymmetry. Essential before ENT referral. Not available same-day in most GP settings — request urgently

Bloods — baseline

FBC (anaemia, polycythaemia), TFTs (hypo/hyperthyroidism), fasting glucose / HbA1c (diabetes), lipids (cardiovascular risk in pulsatile), ESR/CRP (autoimmune, vasculitis)

BP measurement

Both arms, seated. Target <140/90 (or <130/80 if diabetic/renal). Treat hypertension — may directly reduce pulsatile tinnitus

MRI IAMs Specialist-ordered

Gold standard for acoustic neuroma. Ordered by ENT/audiology after asymmetric audiogram. Do not request as GP without ENT input. Gadolinium-enhanced MRI is definitive

CT temporal bones Specialist-ordered

Suspected cholesteatoma, otosclerosis, bony lesion. Ordered by ENT. NOT for soft tissue lesions

MRA / CT angiogram

Pulsatile tinnitus with bruit or vascular risk → arrange via vascular/ENT. Identifies carotid stenosis, AVM, glomus tumour

Tympanometry

Available in many GP surgeries. Type B = flat (OME, perforation). Type C = negative pressure (Eustachian dysfunction). Type A = normal

NOT routinely needed

Routine CT head (low yield without neurological signs), MRI without audiogram first, VEMP, ECoG — specialist tests only when directed

Pure tone audiometry is the cornerstone investigation — it characterises hearing loss type and severity, identifies the audiometric notch of noise-induced hearing loss at 4 kHz, and documents inter-ear asymmetry. NICE NG155 (2020) recommends audiological assessment for all adults with new tinnitus. Thyroid function is worth checking as both hypothyroidism (slow-onset pulsatile due to cardiac output changes) and hyperthyroidism (high-output state) cause tinnitus that resolves with treatment. Ordering MRI IAMs in primary care without an audiogram is poor practice — the audiogram guides the need for and interpretation of imaging.

6

Refer

Referral — Who Needs Specialist Input & When

Done

Most tinnitus (bilateral, symmetrical, without red flags) can be managed in primary care with audiology support. Use urgency criteria below.

999 Emergency

Sudden tinnitus + neurological deficit (facial droop, dysphagia, ataxia), thunderclap headache + tinnitus, acute SSNHL (>30 dB in <72 h) — same-day ENT or acute medical

Same-day ENT

Acute SSNHL (must start oral prednisolone 1 mg/kg/day max 60 mg while awaiting ENT). Otorrhoea + suspected cholesteatoma

2WW ENT

Unilateral pulsatile tinnitus (any age). Unilateral tinnitus + asymmetric audiogram. Tinnitus + unexplained otalgia. Head and neck cancer suspicion

Urgent ENT (<4 wks)

Objective tinnitus (audible on auscultation). Tinnitus + new facial nerve weakness. Failed conservative management 3 months + worsening THI. Suspected BIH (papilloedema)

Routine ENT / Audiology

Bilateral symmetrical tinnitus + significant SNHL on audiogram. THI severe/catastrophic not improving with primary care management. Request audiogram first

NHS audiology (direct)

Many areas accept direct GP referral for tinnitus assessment + hearing aid assessment without ENT. Check local pathway. Most appropriate first step for bilateral tinnitus

Psychological therapies

THI moderate–severe + significant distress → refer to IAPT/tinnitus-specific CBT. Tinnitus-related CBT shown to reduce THI by 8–10 points (NNT ~3). Also refer if comorbid depression/anxiety

Dental / maxfac

Suspected TMJ dysfunction (jaw-modulated tinnitus, click, bite abnormality) → dental assessment. Occlusal splint may help

Vascular surgery

Carotid bruit + pulsatile tinnitus → carotid duplex, vascular surgery input if significant stenosis

Direct audiology referral is the most efficient pathway for uncomplicated tinnitus in most NHS areas — it provides audiometry, hearing aid fitting (masking effect reduces perceived tinnitus severity), and tinnitus counselling. ENT referral is appropriate when pathology may require medical or surgical intervention. The British Tinnitus Association (BTA) and NICE NG155 both recommend CBT as the most evidence-based psychological intervention — it improves quality of life and tinnitus distress even when the tinnitus itself does not change in loudness. Early psychological referral for high THI scores prevents chronic distress and sick leave.

7

Treat

Treatment — Stepwise Management Approach

Done

Important: There is no NICE-approved pharmacological cure for primary tinnitus. Management is multimodal. Treat underlying causes first. Drug therapy is for comorbidities (sleep, anxiety, depression), not tinnitus itself.

Acute SSNHL (emergency only)

Prednisolone Systemic steroid

1 mg/kg/day (max 60 mg) orally for 7 days, taper over 7 days. Start same-day while awaiting ENT. Improves hearing recovery — evidence for tinnitus improvement less robust but standard of care

Tinnitus + depression / anxiety

SSRI / SNRI Antidepressant

Treat comorbid depression/anxiety vigorously — these amplify tinnitus distress. Sertraline 50 mg OD (titrate to 100–200 mg) or escitalopram 10 mg OD. Not for tinnitus itself

Tinnitus-related insomnia

Short-term hypnotic or melatonin Sleep

Melatonin 2 mg modified-release (if >55 yrs — licensed). Zopiclone 7.5 mg OD for max 2–4 weeks only. Sleep hygiene first-line. Chronic benzodiazepines contraindicated — worsen long-term outcomes

Ménière's disease (confirmed)

Betahistine Histamine analogue

Betahistine 16 mg TDS (titrate to 24 mg TDS if tolerated). Evidence modest but NICE-accepted for vestibular symptoms. Low side-effect burden. Trial for minimum 3 months

Sound-Based & Psychological Therapies — First-Line for Primary Tinnitus

Step 1Education & reassurance — explain mechanism, reinforce that tinnitus is rarely sinister, set realistic expectations. BTA leaflets. Average 6-week natural improvement in new tinnitus

Step 2Sound enrichment — avoid silence. Background radio/TV, fan noise, nature sounds. Silence makes tinnitus louder by contrast. Free apps: ReSound Relief, Resound Tinnitus Relief, BTA Sound Oasis

Step 3Hearing aids (if SNHL present) — amplification of ambient sound reduces tinnitus contrast effect. Available via NHS audiology. Improves tinnitus in ~50% of patients with hearing loss

Step 4Tinnitus Retraining Therapy (TRT) — structured sound therapy + counselling delivered by audiologist. Reduces THI by ~15 points on average. 12–18 month programme. Available via ENT/audiology

Step 5CBT for tinnitus — NICE-recommended psychological therapy. Online (RNID iCBT programme, SilenceRx) or face-to-face via IAPT. Reduces tinnitus-related distress, improves quality of life even without loudness reduction. NNT ≈ 3 for meaningful THI improvement

Step 6Mindfulness-based stress reduction (MBSR) — 8-week structured programme. Evidence-base growing. Reduces emotional reactivity to tinnitus. Can be self-directed or via IAPT/psychology. MBSR apps: Headspace, Calm

NOT recommendedAvoid: Ginkgo biloba (no evidence above placebo — NICE NG155 2020), acupuncture (insufficient evidence), carbamazepine (evidence poor, significant side effects), hyperbaric oxygen (investigational only)

NICE NG155 (2020) explicitly states no pharmacological treatment has sufficient evidence to be recommended for primary tinnitus. Ginkgo biloba, widely used in Europe, was shown to be no better than placebo in multiple RCTs. CBT has the strongest evidence base (Cochrane review 2020, 28 RCTs): it does not reduce tinnitus loudness but significantly reduces tinnitus-related distress, depression, anxiety and quality-of-life impact. Sound enrichment works through habituation — the auditory cortex adapts faster when contrast with tinnitus is reduced. Betahistine's role in Ménière's remains controversial (INVEST trial, 2016) but it is widely used and has a good safety profile. The key clinical message: tinnitus management is about reducing distress, not eliminating the sound.

8

Lifestyle

Lifestyle Modifications — Evidence-Based Interventions

Done

Lifestyle changes are primary treatment, not optional extras. Address each domain at every review. Frame these as active management tools.

Noise protection Wear hearing protection (≥26 dB SNR ear defenders) in noisy environments (>85 dB). Limit headphone use — no more than 60% max volume for 60 minutes/day (WHO 60/60 rule). Prevents NIHL progression

Avoid silence Maintain low-level background sound at all times, especially at night. Free tinnitus sound apps: ReSound Relief, Resound Tinnitus Relief. Fan, running water, or radio can be used. Reduces the contrast effect that amplifies perceived tinnitus

Caffeine reduction Limit to <200 mg/day (approx 2 cups coffee). Trial caffeine abstinence for 4–6 weeks — some patients report 20–30% loudness reduction. Caffeine increases sympathetic arousal which worsens tinnitus perception

Alcohol reduction Excessive alcohol dilates cochlear blood vessels, alters endolymph production. UK Chief Medical Officer limit: ≤14 units/week. Particularly relevant in Ménière's disease — low-salt, low-alcohol diet reduces episode frequency

Stress management Stress is the strongest modifiable amplifier of tinnitus distress. Structured relaxation: diaphragmatic breathing (4-7-8 technique), progressive muscle relaxation, yoga. Refer to IAPT if stress is primary driver. Reduces sympathetic nervous system hyperactivity

Sleep hygiene Consistent bed/wake times, cool dark room, avoid screens 1 hour pre-bed. Tinnitus is loudest when trying to sleep — use sound enrichment at bedside. CBT-I (Cognitive Behavioural Therapy for Insomnia) more effective than hypnotics long-term

Physical activity 150 min moderate aerobic exercise per week (NHS guidelines). Exercise improves cochlear blood flow, reduces anxiety/depression, and improves sleep — all of which reduce tinnitus distress. Swimming and cycling are particularly low-risk for noise exposure

Salt restriction (Ménière's only) Target <1.5 g sodium/day (equivalent to <3.75 g salt). Reduces endolymph volume fluctuations. Reduces episode frequency in confirmed Ménière's. Read food labels — processed foods are the main sodium source

Smoking cessation Smoking causes cochlear vasoconstriction and accelerates NIHL progression. Refer to NHS Stop Smoking Service. Nicotine replacement therapy (NRT) does not worsen tinnitus. Smoking cessation improves overall cardiovascular health reducing vascular tinnitus

Digital self-management BTA (British Tinnitus Association) website and helpline: 0800 018 0527. NHS online tinnitus guide. Apps: Oto (tinnitus CBT app, NHS-endorsed in some regions). Encourage self-monitoring with THI at home every 4–8 weeks

The neurophysiological model of tinnitus (Jastreboff 1990, basis of TRT) shows that emotional reaction and sympathetic nervous system activation are the primary drivers of tinnitus distress — not the loudness of the sound itself. Most people with tinnitus habituate naturally within 6–18 months if they receive good lifestyle advice and avoid behaviours that perpetuate hypervigilance. Caffeine and alcohol produce measurable changes in cochlear blood flow. Sound enrichment is the most universally effective immediate strategy: the auditory cortex decreases its attention to tinnitus when provided with competing stimuli. Physical exercise improves cochlear blood supply and reduces the amygdala reactivity that underlies tinnitus distress.

9

Safety

Follow-Up & Safety-Netting — When to Review & Escalate

Done

Most tinnitus improves with time and support. Set clear review plan. Always safety-net for new red flags. Document THI at each review to track trajectory.

2–4 weeks

Review new presentations. Confirm ototoxic medication stopped/changed if applicable. Check audiology referral sent. Repeat THI — if worsening despite initial advice → escalate

6–8 weeks

Audiogram result review. If audiogram shows SNHL → ensure ENT/audiology referral made. THI reassessment. Review sleep and mood — initiate antidepressant if indicated

3 months

Full review of symptom trajectory. THI score comparison. If stable/improving → reinforce self-management. If THI still moderate–severe → confirm psychological referral active, chase audiology appointment

6 months

Long-term monitoring visit. Reassess blood pressure, medication list for new ototoxins. Review need for ongoing audiology/psychology input. Consider discharge to self-management if THI improving and stable

Annual

Patients with SNHL or Ménière's: annual audiological review via audiology. Reassess cardiovascular risk factors (BP, lipids, glucose). Review hearing aid function if fitted

999 immediately

New neurological deficit (facial palsy, diplopia, ataxia, dysphagia), thunderclap headache, sudden onset of bilateral severe tinnitus with deafness

Same-day GP / 111

Acute new unilateral hearing loss (SSNHL — start steroids). Sudden worsening of pre-existing tinnitus with new symptoms. Otorrhoea from ear with known cholesteatoma. New onset of pulsatile quality in previously steady tinnitus

Return if

Tinnitus character changes (e.g., steady → pulsatile). New lateralisation of previously bilateral tinnitus. New associated dizziness/vertigo. THI score increasing despite management. Concerns about mental health / suicidal ideation related to tinnitus distress

Mental health monitoring

Screen for depression/suicidality at each visit in high THI patients. PHQ-9 and GAD-7 at baseline and 3 months. Tinnitus-related suicidality is rare but documented — take seriously. Refer urgently to IAPT or mental health crisis if needed

Medication monitoring

Betahistine: no routine blood monitoring required. SSRIs: review at 2 and 6 weeks. Prednisolone (acute): blood glucose monitoring in diabetics; BP monitoring; GI protection with PPI if >1 week course

The natural history of tinnitus is favourable in the majority: 80% of patients show meaningful improvement in tinnitus-related distress within 12–18 months with appropriate support. However, a subset (~10–15%) develop chronic, severe tinnitus with significant quality-of-life impact. Regular THI monitoring detects this trajectory early and allows timely specialist input. Mental health vigilance is essential: depression and anxiety are 2–3× more common in tinnitus patients than the general population; severe tinnitus-related psychological distress occasionally presents with suicidal ideation, particularly in professionals facing career impact from hearing loss. New pulsatile quality or lateralisation of tinnitus after initial assessment should always prompt re-evaluation — new vascular or intracranial pathology can present this way.