Tinnitus Algorithm

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 Persistent pulsatile tinnitus → Prompt specialist assessment + imaging via local ENT/neurovascular pathway, even if examination is normal — vascular abnormalities, IIH, middle-ear/temporal-bone lesions, high-flow states. More urgent with bruit, neurological signs, visual symptoms, sudden onset or severe headache; papilloedema → same-day ophthalmology and neurology. Persistent unilateral tinnitus → ENT/audiovestibular per local pathway

Sudden sensorineural hearing loss (SSNHL) Sudden hearing loss developing over 3 days or less within the previous 30 days, not explained by wax or middle-ear disease → Immediate ENT/ED — seen within 24 h (NG98). Not automatically 999. Steroids may be considered via the urgent ENT pathway

Unilateral tinnitus + asymmetric hearing loss Stronger indication for specialist assessment → ENT/audiovestibular pathway — consider MRI IAM to exclude acoustic neuroma (vestibular schwannoma). Age over 65 alone is not a separate urgent criterion

Neurological symptoms Facial weakness, diplopia, dysphagia, cerebellar signs, altered consciousness → 999 / Same-day neurology — suspected stroke, 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) typically present with unilateral tinnitus and asymmetric hearing loss — delayed diagnosis leads to larger tumours requiring more complex surgery. Pulsatile tinnitus has a wide differential — venous and arterial vascular abnormalities, idiopathic intracranial hypertension, middle-ear/temporal-bone lesions (paragangliomas) and high-flow states — so NICE NG155 recommends imaging for persistent pulsatile tinnitus. Sudden hearing loss over 3 days or less within the last 30 days needs ENT/ED assessment within 24 hours (NG98); steroid treatment is decided through the urgent ENT pathway. 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 — ENT/audiovestibular per local pathway if persistent; stronger indication with asymmetric hearing loss) vs bilateral (more likely systemic/noise-induced) vs central (in head)

Impact — questionnaires

Use a validated patient-reported outcome measure where helpful, such as the Tinnitus Functional Index (TFI) (NICE NG155), Tinnitus Handicap Inventory or Tinnitus Reaction Questionnaire, according to local service availability. Use the same instrument over time. Do not use a numerical score alone to determine referral or treatment. Assess sleep, anxiety, depression and functional impact

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

NICE NG155 recommends considering the Tinnitus Functional Index (TFI); other validated measures (THI, TRQ) may be used locally. Questionnaires help track impact over time but a score alone should not determine referral or treatment — distress that prevents normal activities warrants prompt referral whatever the score. Laterality is the single most discriminating feature — unilateral tinnitus or asymmetric hearing loss warrants specialist assessment and consideration of 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

Venous and arterial vascular abnormalities (dural AVF, AVM, high jugular bulb, carotid disease), idiopathic intracranial hypertension, middle-ear/temporal-bone lesions (glomus tumour), high-flow states (anaemia, thyrotoxicosis) — all persistent pulsatile tinnitus needs imaging via the specialist pathway

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. Often associated with anxiety/depression — psychological input crucial

Medication-related

Review the medicine and discuss dose reduction or substitution with the prescribing clinician where clinically safe. Do not stop essential aminoglycosides, chemotherapy, loop diuretics or other medicines without specialist involvement. Medication-related tinnitus can be dose-related and may not resolve after withdrawal

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. Idiopathic intracranial hypertension (pseudotumour cerebri) causes pulsatile tinnitus synchronous with pulse and demands same-day 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 → prompt specialist assessment and imaging via ENT/neurovascular pathway

Blood pressure

Measure BP appropriately. Pursue vascular investigation only where the clinical context supports it

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 warrants audiological assessment, specialist referral and consideration of MRI IAMs to exclude acoustic neuroma — a diagnosis that is often delayed.

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

Offer audiological assessment to people with tinnitus (NG155) — direct audiology where locally available for bilateral symmetrical tinnitus without red flags. Documents baseline, identifies SNHL pattern, asymmetry. Not required before urgent ENT referral or every MRI IAM. Do not delay referral for sudden hearing loss waiting for audiometry

Bloods — targeted only

No universal panel (NICE NG155). Consider FBC if anaemia or systemic disease suspected, TFTs if thyroid symptoms/signs or relevant history, glucose / HbA1c if diabetes risk or symptoms, renal function if clinically indicated, ESR/CRP only where inflammatory, infective or vasculitic disease is suspected

BP measurement

Measure appropriately, seated. Target <140/90 under 80 years (NICE NG136); lower targets in CKD with significant proteinuria (NICE NG203). Treat hypertension on its own merits

MRI IAMs Per local pathway

MRI internal auditory meati (the relevant protocol, not a generic MRI brain) is the gold standard for acoustic neuroma. NICE NG155: MRI IAM when tinnitus is associated with neurological, otological, audiological or head-and-neck signs; consider for unilateral/asymmetric non-pulsatile tinnitus even without associated signs. An audiogram is not required before every MRI IAM. Many areas route requests via ENT/audiology — a local-pathway preference, not a NICE requirement

CT temporal bones Specialist-ordered

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

MRA / CT angiogram

All persistent pulsatile tinnitus → imaging via the specialist pathway (NG155): synchronous → MRA/MRI or contrast CT depending on suspected pathology and MRI suitability; suspected temporal-bone/middle-ear pathology → contrast CT temporal bones; non-synchronous (e.g. palatal myoclonus) → MRI head or contrast CT

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 for non-pulsatile tinnitus without neurological or other concerning signs; universal blood panel; ECG (consider only with palpitations, syncope/presyncope, relevant cardiac disease or drug-related arrhythmia concern); 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. An audiogram helps interpret imaging but is not required before every MRI IAM; follow the local ENT/audiology pathway for who requests 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. Simplified pathway for new non-pulsatile tinnitus: history (onset, laterality, hearing loss, vertigo, otalgia, noise, trauma, medication, mental-health impact) → otoscopy, cranial nerves, basic hearing assessment → offer audiology → treat wax, infection or conductive disease → persistent unilateral tinnitus or asymmetric hearing loss → ENT/audiovestibular pathway and consider MRI IAM → bilateral symmetrical with normal examination → reassurance, tinnitus support, self-management → persistent distress → tinnitus-related psychological pathway. Make local ENT/audiology pathways explicit. Use urgency criteria below.

999 Emergency

Tinnitus or sudden hearing loss with focal neurological signs (facial droop, dysphagia, ataxia) or suspected stroke, thunderclap headache, severe systemic illness, altered consciousness or airway compromise. Isolated sudden hearing loss is not automatically 999 — see same-day row

Same-day ENT

Sudden hearing loss over 3 days or less within the previous 30 days, not explained by wax or middle-ear disease → immediate ENT/ED, seen within 24 hours (NG98); ENT decides on steroids — start oral prednisolone only if ENT advises while awaiting review. Suspected cholesteatoma with facial weakness, vertigo, severe pain or neurological signs. Papilloedema → same-day ophthalmology/neurology (suspected IIH). High suicide risk → immediate mental-health crisis assessment (NG155)

Urgent ENT

Persistent pulsatile tinnitus (any age, unilateral or bilateral) → imaging via ENT/neurovascular pathway. Unilateral tinnitus + asymmetric hearing loss. Sudden hearing loss presenting after 30 days or rapidly progressive (within 2 weeks — NG98). Tinnitus + unexplained otalgia. Otorrhoea + suspected cholesteatoma without complications. Head and neck cancer suspicion

Urgent ENT (<4 wks)

Objective tinnitus (audible on auscultation). Tinnitus + new facial nerve weakness (same-day if acute). Persistent unilateral tinnitus (per local pathway). Persistent distress despite initial support

Routine ENT / Audiology

Bilateral symmetrical tinnitus + significant SNHL on audiogram. Tinnitus-related distress preventing normal activities and not improving with primary care management (whatever the questionnaire score)

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

Tinnitus-related distress → NICE NG155 stepped approach: (1) digital tinnitus-related CBT; (2) group-based psychological interventions such as CBT, mindfulness-based CBT or ACT; (3) individual CBT if required. Also refer if comorbid depression/anxiety (NHS Talking Therapies)

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 where hearing loss affects communication, and tinnitus counselling. ENT referral is appropriate when pathology may require medical or surgical intervention. Tinnitus UK (formerly the British Tinnitus Association) 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 significant tinnitus-related distress helps prevent chronic distress and sick leave.

7

Treat

Treatment — Stepwise Management Approach

Done

Important: There is no licensed or guideline-recommended drug treatment for primary tinnitus (NICE NG155, 2020). Management is multimodal. Treat underlying causes first. Drug therapy is for comorbidities (sleep, anxiety, depression), not tinnitus itself. SSNHL and Ménière's disease are separate conditions managed through their own ENT pathways — the cards below are not tinnitus treatments.

Acute SSNHL (emergency only)

Prednisolone Systemic steroid

ENT-led decision: steroids may be considered, with regimen and contraindications set by the urgent ENT pathway. Do not routinely start in primary care — only on ENT advice when review is delayed. Arrange immediate ENT/ED assessment within 24 hours (NG98)

Tinnitus + depression / anxiety

SSRI / SNRI Antidepressant

Treat depression or anxiety when present, on their own pathway — these amplify tinnitus distress. Do not prescribe SSRIs/SNRIs solely to reduce tinnitus

Tinnitus-related insomnia

Sleep hygiene, sound enrichment, CBT-I Sleep

Use sleep hygiene, tinnitus sound enrichment and CBT-I where available. Zopiclone and melatonin are not tinnitus treatments; reserve hypnotics for severe insomnia, used briefly according to local prescribing policy. Avoid chronic benzodiazepines

Ménière's disease (confirmed)

Betahistine Histamine analogue

Do not offer betahistine to treat tinnitus (NICE NG155). It may be used for Ménière's disease/vertigo according to the local ENT pathway (dose per NICE/SPC) — not as a tinnitus treatment

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

Step 1Education & reassurance — explain mechanism, reinforce that tinnitus is rarely sinister, set realistic expectations. Tinnitus UK leaflets. Many people improve as they habituate

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 — offer amplification when hearing loss affects communication; consider where communication is not clearly affected (NICE NG155). Not for people without hearing loss. Available via NHS audiology

Step 4Sound therapy / Tinnitus Retraining Therapy (TRT) — structured sound therapy + counselling delivered by audiologist, where available via ENT/audiology. NICE does not recommend a specific sound-therapy package as universally superior

Step 5Tinnitus-related CBT — stepped (NICE NG155) — (1) digital tinnitus-related CBT (e.g. online programmes); (2) group-based CBT, mindfulness-based CBT or ACT; (3) individual CBT if required. Reduces tinnitus-related distress and improves quality of life even without loudness reduction

Step 6Mindfulness-based approaches — group-based mindfulness-based CBT is part of the NICE stepped approach. Reduces emotional reactivity to tinnitus. Can be self-directed or via NHS Talking Therapies/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)

Next steps: see Ménière's disease · Depression · Insomnia

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 (BEMED trial, Adrion et al. BMJ 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

Offer practical, individualised advice: avoid excessive noise exposure, use appropriate hearing protection in loud environments, maintain regular sleep and activity, reduce alcohol if excessive, stop smoking, and trial avoidance of individually identified triggers. Avoid unnecessary restrictive diets, particularly where evidence is limited.

Noise protection Avoid excessive noise exposure and use appropriate hearing protection in loud environments; keep personal-listening volumes moderate. Avoid over-protection in ordinary environments. Helps prevent 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

Individual triggers (e.g. caffeine) If the patient links caffeine or another trigger to their tinnitus, a trial of avoidance is reasonable; do not insist on restriction without evidence

Alcohol reduction Reduce alcohol if excessive (UK Chief Medical Officer limit: ≤14 units/week). Avoid alcohol as a sleep aid. In Ménière's disease, dietary measures can be discussed via the ENT pathway

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 NHS Talking Therapies 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 Maintain regular activity (NHS physical activity guidelines) — supports mood and sleep, which can reduce tinnitus distress. Not a treatment for the tinnitus itself

Diet in Ménière's disease Dietary measures such as salt reduction can be discussed in confirmed Ménière's, but there is insufficient basis for a universal sodium target. Avoid unnecessary restrictive diets

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 Tinnitus UK (formerly British Tinnitus Association) website and helpline: 0800 018 0527. NHS online tinnitus guide. Apps: Oto (tinnitus CBT app, NHS-endorsed in some regions). Signpost to digital tinnitus-related CBT where available (first step of the NICE stepped approach)

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. Many people with tinnitus habituate over time with good advice and support, avoiding behaviours that perpetuate hypervigilance. Sound enrichment is a practical immediate strategy: the auditory cortex decreases its attention to tinnitus when provided with competing stimuli. Regular sleep and activity support mood, which influences 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. Where helpful, use the same validated questionnaire (e.g. TFI) over time to track impact — not as a referral threshold.

2–4 weeks

Review new presentations. Confirm any ototoxic medication has been reviewed with the prescribing clinician. Check audiology referral sent. If distress or impact worsening despite initial advice → escalate

6–8 weeks

Audiogram result review. If audiogram shows SNHL → ensure ENT/audiology referral made. Reassess impact. Review sleep and mood — treat depression or anxiety on its own pathway if present

3 months

Full review of symptom trajectory. If stable/improving → reinforce self-management. If distress persists → confirm stepped 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 impact improving and stable

Longer term

Audiology review as arranged by the audiology/ENT service (not routinely annual for all). Review hearing aid function if fitted

999 immediately

New neurological deficit (facial palsy, diplopia, ataxia, dysphagia) or suspected stroke, thunderclap headache, altered consciousness, severe systemic illness

Same-day GP / 111

Sudden hearing loss over 3 days or less within 30 days → immediate ENT/ED, seen within 24 hours (steroids only via the ENT pathway). 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. Distress or impact increasing despite management. Concerns about mental health / suicidal ideation related to tinnitus distress

Mental health monitoring

Assess sleep, anxiety, depression and functional impact; use PHQ-9/GAD-7 when clinically appropriate, not automatically at every visit. Ask about suicidal thoughts — high suicide risk requires immediate crisis-team assessment (NG155). Refer promptly if distress prevents normal activities, even without a severe questionnaire score

Medication monitoring

Betahistine (Ménière's only): no routine blood monitoring required. Antidepressants (for depression/anxiety): review per their own pathway. Prednisolone (acute, ENT-led): blood glucose monitoring in diabetics; BP monitoring; GI protection with PPI if >1 week course

The natural history of tinnitus is favourable for most people with appropriate support, but a subset develop chronic, severe tinnitus with significant quality-of-life impact. Asking about impact at review (with the same validated questionnaire where helpful) detects this trajectory early and allows timely specialist input. Mental health vigilance is essential: depression and anxiety are more common in people with tinnitus; 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.