Key Facts

Tinnitus is the conscious perception of an auditory sensation in the absence of a corresponding external stimulus. It is a symptom rather than a disease and can be associated with almost any disorder of the auditory pathway. Management focuses on reducing distress and improving coping rather than eliminating the sound.

Epidemiology

• Prevalence: 10-15% of UK adults experience tinnitus
• Bothersome tinnitus: 1-2% of the population
• Increases with age (correlates with presbycusis)
• Equal sex distribution
• Strongly associated with hearing loss, noise exposure, and ageing

Aetiology

• Otological: hearing loss (any cause), cerumen impaction, otitis media, Ménière disease, otosclerosis, vestibular schwannoma
• Noise-related: occupational, recreational, acute acoustic trauma
• Neurological: MS, head injury, migraine
• Vascular (pulsatile): glomus tumour (paraganglioma), dural arteriovenous fistula, carotid stenosis, venous hum, benign intracranial hypertension
• Drugs: aspirin (high-dose), NSAIDs, aminoglycosides, loop diuretics, quinine, cisplatin
• Other: temporomandibular joint dysfunction, cervical spine pathology, psychological stress/anxiety

Pathophysiology

• Reduced peripheral auditory input (from hearing loss) leads to maladaptive central auditory neuroplasticity
• Central gain model: the brain increases neural gain to compensate for reduced input, amplifying spontaneous neural activity perceived as tinnitus
• Involvement of limbic system and autonomic nervous system explains the emotional distress
• In pulsatile tinnitus: turbulent blood flow near temporal bone is transmitted to the cochlea

Subjective Tinnitus (Most Common)

• Ringing, buzzing, hissing, whistling, or humming sounds
• Usually bilateral; may be unilateral
• Continuous or intermittent
• Often worse in quiet environments, at night
• Frequently associated with hearing loss

Pulsatile Tinnitus

• Rhythmic sound synchronous with heartbeat
• May be objective (audible with stethoscope over ear/mastoid)
• Suggests vascular aetiology

Associated Features

• Hearing loss (most common association)
• Sleep disturbance
• Anxiety and depression
• Difficulty concentrating
• Hyperacusis (reduced tolerance to sound)

Red Flags

• Unilateral tinnitus (vestibular schwannoma until excluded)
• Pulsatile tinnitus (vascular cause)
• Associated neurological symptoms (facial weakness, numbness, vertigo)
• Sudden onset with hearing loss (sudden SNHL)
• Objective tinnitus (heard by examiner)
• Associated with head trauma

Bedside

• Otoscopy: cerumen, TM abnormalities, vascular mass behind TM (glomus)
• Auscultation over ear/mastoid: objective tinnitus (bruit)
• Tuning fork tests
• Cranial nerve examination
• TMJ assessment

Bloods

• FBC, TFTs, ESR: if systemic cause suspected
• Lipid profile, glucose: vascular risk factors (pulsatile tinnitus)

Imaging

• MRI IAM with gadolinium: for unilateral tinnitus or asymmetric hearing loss (exclude vestibular schwannoma)
• CT temporal bones: if middle ear pathology or pulsatile tinnitus
• CT/MR angiography: for pulsatile tinnitus (vascular cause)
• NICE NG155: routine imaging NOT recommended for bilateral tinnitus without red flags

Special Tests

• Pure tone audiometry: assess hearing (almost all tinnitus patients)
• Tympanometry: middle ear assessment
• Tinnitus questionnaires: Tinnitus Handicap Inventory (THI), Tinnitus Functional Index (TFI)
• Psychological assessment: PHQ-9, GAD-7 for associated depression/anxiety

Non-pharmacological

• Education and reassurance: explaining the mechanism of tinnitus reduces distress significantly
• Cognitive behavioural therapy (CBT): strongest evidence for reducing tinnitus-related distress (NICE NG155)
• Sound therapy: background sound (radio, white noise) reduces contrast between tinnitus and silence
  • White noise generators, nature sounds, tinnitus apps
• Hearing aids: if concurrent hearing loss (amplification reduces central gain and masks tinnitus)
  • Combination devices: hearing aid with integrated tinnitus sound generator
• Tinnitus retraining therapy (TRT): combines counselling with low-level broadband sound (habituation)
• Mindfulness-based interventions: emerging evidence for reducing tinnitus distress
• Sleep hygiene: for tinnitus-related insomnia

Pharmacological

• No drug is specifically licensed or recommended for tinnitus (NICE NG155)
• Antidepressants (SSRIs, e.g. sertraline 50mg OD): for associated depression/anxiety, NOT for tinnitus itself
• Betahistine 16mg TDS: if associated Ménière disease
• Short-term benzodiazepines: rarely, for acute severe distress (risk of dependence)
• Melatonin: may help tinnitus-related sleep disturbance

Surgical

• Treat underlying cause: cerumen removal, grommet insertion, stapedectomy, vestibular schwannoma management
• Cochlear implants: may reduce tinnitus in patients with severe SNHL

Referral Criteria

• ENT/audiology referral: all patients with bothersome tinnitus (NICE NG155)
• Urgent ENT referral: unilateral tinnitus, pulsatile tinnitus, associated neurological symptoms
• Psychology/CBT referral: for tinnitus-related distress, anxiety, depression
• Emergency: sudden hearing loss with tinnitus

• Most patients habituate over time (months to years); tinnitus becomes less noticeable
• 60-80% report significant improvement with CBT or structured management programmes
• 10-15% develop severe, debilitating tinnitus affecting quality of life
• Hearing aids provide significant tinnitus relief in >50% of patients with concurrent hearing loss
• Tinnitus from noise exposure: may be permanent but coping improves with management
• Suicidal ideation occurs in a small minority; screen for mental health impact
• Spontaneous resolution is uncommon in chronic tinnitus (>6 months)

Tinnitus Handicap Inventory (THI) Grading

Causes of Pulsatile Tinnitus

NICE NG155 Key Recommendations