HNY Central Digital Repository - York

Tinnitus is the perception of noise in the absence of sound from the external environment. It may be described as a ringing, hissing, buzzing, sizzling, whistling, or humming, and can be constant or intermittent, and unilateral or bilateral. Around 10% of UK adults experience prolonged tinnitus; prevalence increases with age.

“Musical tinnitus” (repetitive melodic noises, sometimes voices) are a rare variation of tinnitus, but are not automatically a sign for a more significant underlying cause.

There can be a multitude of possible physical (and psychological) triggering causes or maintaining factors. Tinnitus may be only temporary, but, even if it persists, can still be reversible, or, at least, modifiable.

Most people who experience tinnitus have some degree of hearing loss. However, it can occur in children and adults who have normal hearing. Sudden or chronic noise exposure (e.g., head phones, machinery, trauma – such as fireworks, shooting etc.) are possible causes.

Refer people with tinnitus immediately/within 24 hours if associated with:

• Sudden onset of significant neurological symptoms/signs or acute uncontrolled vestibular symptoms - refer for neurological assessment or via local stroke referral pathway.
• Significant head trauma with subsequent tinnitus, especially if pulsatile.
• Sudden onset tinnitus and hearing loss in past 30 days - discuss with the on-call ENT team to determine best management.
• Tinnitus associated with a high risk of suicide - refer immediately to a crisis mental health management team for assessment; if needed, provide a safe place while waiting for the assessment
   

Refer people urgently (2WW) if they have tinnitus associated with:

• Sudden hearing loss that developed more than 30 days ago, or rapidly worsening hearing loss (over a period of 4–90 days) – refer to an ENT or audio vestibular service.
• Persistent otalgia or otorrhoea that does not resolve with routine treatment

Refer non-urgently if

• Persistent (>3 months) unilateral tinnitus [consider acoustic neuroma]
• Associated significant deafness and/or vertigo
• Tympanic membrane abnormality
• Persistent pulsatile tinnitus for more than one month without signs of inflammation or infection [consider glomus tumour]
• Hyperacusis, i.e., over-sensitivity to certain noises or frequencies
• Acute onset after head injury; other neurological symptoms, or severe vertigo
• Persistent intrusive tinnitus [consider all the above, but also possible psychological element and stress]

• Reassure (if referral not required). Patients with bilateral tinnitus without hearing loss will often benefit from reassurance and advice on the natural history of tinnitus (it usually becomes less intrusive and can disappear) and simple recommendations for distraction with external noise.
• Treat the underlying cause and offer advice where possible e.g., impacted wax, otitis media/externa, foreign body or TMJ dysfunction. Check for any discharge or bleeding. Where applicable, advise patients to purchase treatments OTC for conditions such as impacted wax.
• Review current medications – which may cause or contribute to tinnitus e.g. valproate; loop diuretics, aspirin and NSAIDs can cause tinnitus and reversible hearing loss; antimalarials; tetracyclines; macrolide antibiotics (e.g. erythromycin); aminoglycoside antibiotics (e.g. gentamicin) and cytotoxic drugs can cause tinnitus and permanent hearing loss associated with cochlear injury. Please refer to the BNF.
• Discuss management of psychological symptoms, especially anxiety type symptoms.
• If patients ask, reassure patients that pathology such as acoustic neuromas or vascular lesions (glomus tumours etc) are largely slowly progressing phenomenon and only sometimes need intervention.

None

Investigations prior to referral – none

Information to include in referral letter

• Nature of tinnitus; ear/ears affected; hearing loss, timeline
• Findings on physical examination (wax, signs for infection, any apparent hearing loss)
• Relevant past medical / surgical history
• Current regular medication
• Smoking status

Patient information leaflets/ PDAs

Provide information about local and national charities and support groups, including:

• Action on hearing loss - Understanding tinnitus.
• British Tinnitus Association produces an extensive range of tinnitus-related information leaflets including All about tinnitus, Pulsatile tinnitus, and Self help for tinnitus. The telephone helpline number is 0800 018 0527.
• ENT UK About tinnitus.
• NHS.uk information on Tinnitus
• Patient.co.uk information on Tinnitus

References

NICE CKS Management of tinnitus March 2020

NICE NG155: Tinnitus: assessment and management March 2020

Responsible GP: Tillmann Jacobi

Responsible Consultant: Alastair Mace