HNY Policy and Pathway Repository - Humber

The following information  is adapted with thanks from work produced by the London Tinnitus Clinic - Tinnitus Guidance for General practitioners.

Definition

What the patient will need on diagnosis

• Explanation of the condition
• Further information and reassurance
• A diagnosis
• Advice on what they can do to assist themselves - relaxation, ear protection in noisy environments, self help support, healthy diet and exercise, sleep management and informing family friends and work colleagues
• Offer support to discuss techniques for reducing symptoms - GP, Practice nurse or HCS with knowledge

Although there is no cure for tinnitus, there are interventions available which can make a real and positive difference.  By ensuring that the patient is informed of the diagnosis and available information and strategies to manage tinnitus increases the effectiveness of self management of tinnitus.

Patients in the acute stage of the condition often display high levels of anxiety.  The central nervous system is influenced by the limbic system, within the brain, which controls emotions and mental state.  It is well researched that when a person becomes more stressed, anxious or excited, this can increase awareness of the tinnitus symptoms.

If the patient is severely effected or has any of the red flag symptoms, refer to the appropriated support as detailed in the red flag table.

Tinnitus Guidance for General Practitioners

Patient Information Leaflet - Tinnitus

Types of Tinnitus

Subjective tinnitus - is the most common type of tinnitus and is described as persistent noise that can only be heard by the person who has it.  Often reported as a high or low pitch noise or buzzing/hissing noise.  Some patients may state that they are having difficulty hearing because of the internal tinnitus sounds.

Objective tinnitus - is uncommon and on examination can be heard by others.  It is caused by stenosis within blood vessels, middle ear muscle contractions or a variety of other somatosounds.

Pulsating tinnitus - is a form of objective tinnitus which is reported by the patient as a persistent rhythmic noise which is often heard in time with the patients heart beat.  Pulsating tinnitus is caused by some change in blood flow in the vessels near the ear or to a change in awareness of that blood flow.

Musical tinnitus (Musical Hallucination) - is a rare condition and differs from the hissing or buzzing as the patient will report hearing music when none is being played.  Musical tinnitus can be very distressing due to the continual and repetitive nature of the tune or melody that is being perceived.

Hyperacusis - is a condition of over sensitivity to even moderately loud sounds.  It is assumed to be caused by a similar brain mechanism to tinnitus and can be improved by sound therapy over a period of weeks or months to "desensitize" by gradually and systematically increasing sound to the patient.

Guidance on Investigation and Diagnosis

History:

• obtain medical history, including:
• ear and hearing problems
• environmental factors (noise exposure)
• ototoxic medication use
• assessment of current medical and psychological health
• unilateral or bilateral
• history of significant noise exposure
• family history of hearing loss from otosclerosis

Examination:

If subjective tinnitus:

• tinnitus is not audible with a stethoscope
• use an auriscope for disorders of middle and outer ear

If objective tinnitus:

• • tinnitus is audible with a stethoscope
• • place stethoscope close to the external auditory meatus, over the carotid arteries, and on the skull in front and behind the ear

Include

• Examination of ears for wax foreign bodies, perforation, erythema, effusion or a mass.  
• Unusual features of the ear canal or tympanic membrane may need investigation (see red flags)
• Rinne's test and Weber's test to differentiate sensorineural from conductive hearing loss
• Cranial nerve examination
• General neurological assessment

Check if the patient has hyperacusis

• Hearing sounds disproportionately loud  which causes pain or discomfort
• Often occurs with tinnitus, but not always
• Avoiding loud noise or wearing ear defenders regularly - this can lead to greater sensitivity so advise steps for desensitization