Executive summary
- Most tinnitus is benign and often co-exists with hearing loss — early reassurance and hearing assessment matter.
- Screen for urgency: sudden neurological symptoms, acute uncontrolled vestibular symptoms, suspected stroke, or tinnitus with sudden hearing loss needs urgent referral.
- Ask about impact: sleep, concentration, mental wellbeing; severe distress can require faster pathway input.
- Check ears: wax, otitis externa/media, middle ear effusion; address reversible contributors.
- Investigations are targeted: audiology for most; imaging primarily for unilateral/asymmetric non-pulsatile tinnitus with features, and pulsatile/objective tinnitus per pathway.
- Management is multimodal: education + hearing strategies, hearing aids where indicated, sound therapy options, and psychological interventions (e.g., CBT approaches) for distress.
Assessment in primary care
- Characterise the tinnitus: unilateral vs bilateral; intermittent vs constant; pulsatile vs non-pulsatile; sudden onset vs gradual; “objective” (others can hear) vs subjective.
- Associated symptoms: hearing loss (new/sudden/rapidly worsening), vertigo, otalgia/otorrhoea, aural fullness, headache, neuro symptoms (facial weakness, ataxia), jaw pain/temporomandibular symptoms.
- Triggers and exposures: noise exposure, recent infection, medication review (ototoxic potential), caffeine/alcohol, stress and sleep disruption.
- Impact: ask directly about sleep, anxiety, low mood, function, and suicidal ideation when distress is high.
- Exam: otoscopy + cranial nerves; consider BP/pulse (pulsatile tinnitus may relate to vascular drivers).
Urgent referral triggers (high yield)
- Immediate escalation: tinnitus with sudden onset neurological deficits, suspected stroke, or acute uncontrolled vestibular symptoms.
- Hearing loss time window matters: tinnitus with sudden hearing loss (over ≤3 days) within the past 30 days is typically a 24-hour urgent assessment trigger (local ENT/audiovestibular pathway).
- Mental health emergency: tinnitus associated with high suicide risk needs urgent crisis mental health assessment (and a safe environment while waiting).
- Fast-track assessment: severe distress affecting daily activities despite initial support; unilateral/asymmetric hearing loss with tinnitus; persistent objective tinnitus; persistent pulsatile/unilateral tinnitus per pathway.
Management in primary care (what actually helps)
- Reassurance + education: normalise tinnitus, explain that many people adapt, and set expectations (symptom fluctuates; stress + poor sleep can amplify perception).
- Hearing support: arrange audiology/hearing assessment; optimise hearing aids if hearing loss is present (often improves tinnitus intrusiveness).
- Self-management: safe listening (noise protection), reduce silence (low-level background sound at night), relaxation strategies, and sleep support if insomnia emerges.
- Distress pathway: consider psychological interventions for tinnitus-related distress (CBT-style approaches, structured support programmes) via local services.
- Avoid “chasing cures”: repeated unstructured medication trials rarely help; prioritise evidence-based pathways and functional goals (sleep, concentration, distress reduction).
Frequently asked questions
Does tinnitus always mean there is something structurally wrong?
No. Tinnitus is common and often relates to hearing pathway changes (including age/noise-related loss). Serious underlying disease is less common; the key is to recognise urgent features and route appropriately.
When should I worry about pulsatile tinnitus?
Persistent pulsatile tinnitus warrants pathway assessment because vascular causes are possible. Combine history/exam with targeted referral; imaging is usually arranged through ENT/audiology pathways.
What is the quickest “win” I can offer?
Treat reversible ear problems (wax/infection), arrange hearing assessment, and give structured advice on reducing silence and stress. Many patients improve with these basics.
Are hearing aids relevant if the person mainly complains of tinnitus?
Yes — if hearing loss is present, optimising hearing can reduce tinnitus prominence and improve coping.
What if distress is the main problem?
Treat distress as the primary target: assess risk, provide early support, and refer to tinnitus services/psychological interventions via local pathway. Safety-net clearly.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.