Tinnitus

Flowchart

Red flags requiring urgent ENT referral

• Associated sudden sensorineural hearing loss

• Associated facial nerve palsy

• Neurological signs

• Severely affected mental health, suicidal ideation - urgent crisis team / psychiatry review

Assessment and recognition

History

• What are the noises like?

• How long has the noise been there?

• One side or both?

• Continuous or pulsatile?

• If pulsatile, is it synchronous with your pulse?

• Any recent trauma (including barotrauma)?

• Any pain, discharge, vertigo or hearing loss?

• Is it affecting your sleep?

• What are your current coping strategies?

• Any changes to medications? (It is worth checking in the BNF. Ask about salicylates, aminoglycosides, loop diuretics)

• PMH: previous ear operations, previous radiotherapy to the head, CNS infections.

• Psychiatric history including anxiety, stress and depression

Examination

• Otoscopy (usually normal unless other symptoms are present)

• Cranial nerve examination especially VII

• Cerebellar examination

• Rinne's test and Weber's test

Differential diagnosis and primary care management

Tinnitus can be divided into objective and subjective forms. Objective tinnitus is rare and results from noise generated by structures near the ear. Subjective tinnitus (more common) is defined as hearing a non-specific sound in the absence of external stimuli. It generally happens because of abnormal processing of sound by the brain with neurocognitive overlay. The degree and nature of tinnitus can vary between individuals: some individuals struggle to function and sleep due to the intrusive nature of the tinnitus. Labile emotional states and psychiatric conditions can exacerbate the symptoms, which then make the condition worse. It is important to educate patients about how it arises, and that the treatment is generally based on retraining therapy, coping strategies and CBT. Further information is available on the British Tinnitus Association website (https://www.tinnitus.org.uk), which should be passed onto all patients with tinnitus.

Causes of subjective tinnitus

• Idiopathic - the largest group, with normal or near-normal hearing. Management is based on coping strategies and tinnitus retraining therapy.

• Presbyacusis - age-related hearing loss. Diagnosed on audiometry. These patients tend to do well with tinnitus retraining and coping strategies or hearing aids: refer to audiology in first instance. 

• Noise-induced hearing loss - patients have a history of recreational or professional noise exposure. They may or may not have used ear defenders.  Audiometry helps confirm the diagnosis. These patients tend to do well with tinnitus retraining and coping strategies or hearing aids.

• Barotrauma - These patients would have had a history of barotrauma (diving, flying etc). Tympanograms may show a flat trace (type B tympanogram) or skewed trace (type C tympanogram). The condition is usually self-limiting and these patients tend to do well with tinnitus retraining and coping strategies.

• Vestibular schwannoma (acoustic neuroma) - These patients classically present with unilateral tinnitus and asymmetrical hearing loss of sensorineural pattern which can be confirmed on an MRI. They can also be vertiginous. Red flag signs include facial nerve and other cranial nerve palsies, cerebellar pathology from compression and altered neurological status. Refer routinely, not via cancer-wait pathway.

• Medications - Lots of drugs such as salicylates, aminoglycosides, loop diuretics and platinum-based chemotherapy can cause tinnitus. The onset of tinnitus is usually associated with the use of the drug. Many of these drugs can also results in hearing loss and dizziness.

• Meniere's disease - This is a rare disease that results in a triad of episodic unilateral hearing loss, tinnitus/aural fullness and vertigo. Patients require an audiogram and MRI IAM as part of the diagnostic pathway. There is good evidence to suggest that betahistine has no effect in its treatment, and emerging evidence to show that intratympanic steroids are beneficial. 

• Ear canal obstruction - Rarely, wax impaction and foreign bodies can cause tinnitus. Refer to ENT emergency clinic if not clearing with sodium bicarbonate drops.

Objective tinnitus

• Arteriovenous malformations - Rare causes of unilateral pulsatile tinnitus. Patients may rarely have a bruit over the skull or around the periauricular region. MRI or CT angiogram will help confirm diagnosis. These pathologies are usually dealt with by ENT, neurosurgeons and/or interventional radiologists.

• Myoclonus - These patients present with irregular clicking or mechanical sounds in the ear. Examination may reveal palatal or tympanic membrane movements synchronous to the sounds. These patients should be referred to ENT routinely for further investigations (MRI + tympanogram).

• Turbulent flow in great vessels of the neck - these patients tend to have a humming pulsatile sound which improves on turning their neck (compression of jugular vein or carotid artery). Auscultation of the neck can confirm the diagnosis. A carotid doppler should be performed to exclude carotid artery stenosis or aneurysm and referred to vascular surgeons if necessary

• Paraganglioma - rare, benign vascular tumours of the head and neck, middle ear or skull base.  They may produce unilateral pulsatile tinnitus, and can present as a bluish mass behind the TM or a mass in the neck depending on site. Diagnosis is confirmed on MR/CT angiography. Refer to ENT/Otology/H&N as appropriate.

Referral pathways to ENT

Same day

• Patients with facial nerve or cranial nerve palsies

• Those with other neurological signs should be referred to neurology / neurosurgery

• Those with suicidal ideation should be referred to crisis team / psychiatry

Cancer pathway

• None

ENT emergency clinic

• Infections that are not responding in primary care

• Foreign bodies or wax that requires removal

Routine

• All other tinnitus (unilateral or bilateral)

Author: Mr Ananth Vijendren BM MRCS MRCS (ENT) FRCS (ORL-HNS) PhD, Consultant Otologist/ENT Surgeon, Lister Hospital, Stevenage