Tinnitus (Adult)

Tinnitus is defined as a persistent perception of sound with no external stimulus. Tinnitus is very common with 1/3 of the adult population experiencing at some point but only 1% have it severely enough to seriously affect their quality of life. It is a serious condition and can have negative effects on mental health including suicide, these patients tend to be older males with a previous history of depression or anxiety.

Important history and examination points

• Establish if the tinnitus is pulsatile or non-pulsatile
• Is it unilateral or bilateral
• Is it associated with hearing loss
• Associated vestibular symptoms
• Neurological symptoms or other cranial nerve palsies
• Assessment of current mental state.

Initial management in primary care

• Ear wax is a common cause of conductive hearing loss therefore treat appropriately (see guidance)
• Reassurance is key and offer information to patients regarding their condition (leaflet and websites below)
• Patients can often find getting to sleep an issue therefore noise generators or a pillow radio/sound box can be useful in masking and helping patients sleep.

Identify those that need further management and referral as below. Please note unilateral tinnitus is not an urgent referral.

Pulse Synchronous Tinnitus

Some tinnitus has a pulsatile nature but is not in time with the pulse and is not therefore due to a vascular cause. Firstly it is important to check that the sound the patient hears is in time with their pulse. Only they will be able to tell this. If it is in time with the heartbeat then the patient should be examined for heart murmurs and carotid bruits.

Conductive hearing loss may cause pulsatile synchronous tinnitus, so if they have an obvious cause of this such as ear wax or middle ear effusion, or if they are known to have a cause of conductive hearing loss such as otosclerosis this may be the cause and should be treated in primary care if appropriate.

Anaemia and hyperthyroidism may also cause pulse synchronous pulsatile tinnitus, so blood tests to exclude these conditions are important and should be carried out before referral.

Emergency

• Immediate (01382 660111)
  • Crisis mental health management team for people who have a high risk of suicide and difficulty coping with tinnitus
  • Associated with acute neurological signs or symptoms that may indicate a stroke.

Routine

• To audiology if the tinnitus is:
  • Bilateral or unilateral non pulsatile
  • Associated with either unilateral or bilateral hearing loss (long standing)
  • Persistent and causing reduction in quality of life.
• To ENT:
  • Pulse synchronous tinnitus (please ensure the ear is free of wax and include in the referral FBC & TFT results and examination findings in the ears and neck to include auscultation for bruits.)
  • Associated vestibular symptoms
  • Long standing neurological or other cranial nerve palsies.

• Type Tinnitus into staffnet to access lots of patient information
• The British Tinnitus Association (BTA)
• Naturecare relaxation – sound devices and CDs and pillow speakers

NICE guidance