Tinnitus

Overview

ENT Clinics are currently under extreme pressure as a result of COVID recovery and increased demand for appointments.

Please consider using primary care management pathways where possible and only refer patients if these options have been exhausted. When referring, please also warn patients of long waits for outpatient appointments. The ENT service kindly requests that if patients approach referrers requesting an appointment to be expedited not to ask them to ring the hospital as they will not be able to help. Only submit written requests to expedite if there is clinical deterioration or concern. Do not submit another eRS referral in this situation as these requests will be returned.

Current waits for outpatient clinics in ENT are as follows (January 2024):

• Otology- 8 months
• Rhinology- 6 months
• Head and Neck- 5 months

The guide below has been developed from national guidelines with advice on local referral pathways from the ENT and audiology department at St Michaels Hospital, Bristol.

Tinnitus is a common symptom, affecting around 10% of UK adults. It is defined as the perception of sound in the absence of an external source. It may be highly variable and often described as a ringing, hissing, buzzing, whooshing, whistling, or humming. Tinnitus can be constant or intermittent, unilateral or bilateral, pulsatile or non-pulsatile. Tinnitus is classified as:

• Subjective tinnitus (more common) if the perceived sound can only be heard by the affected individual. This is caused by a change in the way sound is perceived by the central nervous system. 

• Objective tinnitus (affecting 1% of people with tinnitus) if the sound can be heard by the affected individual and the examiner. This may originate from an identifiable source that produces sound near to, or within, the ear (for example a vascular abnormality producing a pulsatile sound near to the ear, or muscle related noise).

Assessment in primary care

See CKS guidelines for advice on How to assess someone with tinnitus

History

All  patients suffering from tinnitus should be asked whether the tinnitus is:

• unilateral or bilateral
• non-pulsatile or pulsatile
• associated with otalgia, otorrhoea, dizziness or hearing loss
• how it is affecting their daily life / mental health.

Examination

• Otoscopy - the ear canal and tympanic membranes should be examined by otoscopy.
• Tuning fork hearing test should be performed.
• Cranial nerves should be assessed.
• If the tinnitus is pulsatile, then auscultate for heart murmurs and carotid/mastoid bruits.
• Wax occlusion should be treated with drops, as per local guidelines. 

Investigations

Consider screening for features of anaemia, thyroid disease, hyperlipidaemia, and diabetes.

Who to refer

See Red Flag section below for indications for immediate or urgent referral.

Management in Primary Care

Many cases of tinnitus (both unilateral and bilateral) will be short lived and self limiting. Referral should only be considered if there are red flags or symptoms are more persistent (>3 months) or troubling. Please see Management in Primary care section below for further advice.

Referral criteria for non-urgent referral to Audiology (non-AQP)

Patients with persistent unilateral or bilateral tinnitus that has persisted for >3 months and is not responding to self-help may be referred to Audiology (non- AQP) as long as there are no red flags or contraindications (such as active discharging ears, pulsatile tinnitus or otalgia). 

Patients with non- acute unilateral as well as bilateral symptoms can now be referred to this service as they can arrange ENT review or MRI scan if indicated. See Referral section below for details.

Referral criteria for ENT 

Patients should be referred to ENT via eRS routinely if there are no red flags and Audiology (non-AQP) is not appropriate i.e. there is pain, discharge or pulsatile tinnitus.

Referrals not stating the above criteria clearly, may be returned.

Ears must not be occluded by wax and referrals that do not state this clearly will be returned..

(*Please note that audiology AQP providers can only accept referrals for assessment of patients (aged 18 and over) who have suspected hearing loss, and will not accept referrals for patients requiring assessment or treatment of tinnitus itself. AQP providers may reject referrals where an assessment for tinnitus is requested so please bear this in mind when making a referral. A full list on contraindications is available on the e-RS Directory of Services or on the Audiology page.)

Red Flags

Indications for immediate or fast track referral

• Tinnitus in association with neurological symptoms or signs– call 999 if stroke suspected or consider neurology imaging or referral. See also Brain and CNS 2WW indications.
• Tinnitus associated with head trauma - refer to A and E.
• Patients with severe distress or suicidal ideation as a result of their tinnitus should also be referred urgently to local mental health crisis teams for support.

Indications for ENT Hot Clinic Referral

(via e-RS referral to ENT hot clinic, or phone discussion with on-call ENT team)

After initial assessment in primary care, the following cases should be referred for ENT Hot Clinic review:

• Tinnitus associated with suspected sudden sensorineural hearing loss (as confirmed by tuning fork tests). Consider starting high dose oral steroid therapy (oral prednisolone 1mg/kg up to 60 mg once daily, unless contra-indicated) whilst awaiting urgent clinic review. 

• Sudden onset tinnitus associated with severe vertigo. 

• Tinnitus associated with other ENT pathology that would warrant urgent review (such as non-resolving otitis externa, necrotising otitis externa, complications of acute otitis media)

Notes on Unilateral or Pulsatile Tinnitus - advice from local ENT specialists

Unilateral or pulsatile tinnitus is sometimes referred urgently due to concerns that these are red flags, but in the absence of other neurology or otology features, will be triaged as routine*. The pathologies being screened for (vestibular schwannoma, AV fistulae, vascular malformations, sigmoid sinus stenosis, etc) are all benign)

*NICE guidelines do advise to 'refer people immediately (to be seen within a few hours, or more quickly if necessary) with: Sudden onset pulsatile tinnitus.' However, local ENT specialists advise this is not considered an indication for immediate referral unless other concerns exist such as neurological symptoms or signs consistent  with an acute neurovascular event.

Management

Management in primary care

Most patients with non-pulsatile tinnitus and no other concerning symptoms/signs can be assessed for underlying causes and managed safely in primary care by directing patients to self-help resources. Many cases of tinnitus are self-limiting and short-lived. The initial management of tinnitus involves:

• Reassurance (in the absence of any concerning features);
• A clear explanation of tinnitus and understanding of its nature;
• Assessment and treatment of associated hearing loss (via AQP audiology);
• Sound enrichment or “masking” therapies (playing pleasant sounds to help distract the hearing part of the brain);
• Identification and management of triggers including stress, poor sleep, lack of exercise;
• Management of psychological response to tinnitus, including general well-being measures, stress reduction, relaxation therapies, sleep hygiene, mindfulness and cognitive behavioural therapy;
• Management of associated mental health conditions such as depression or anxiety.

Self-care tinnitus resources

Please consider providing the resources below to the patient:

British Tinnitus Association

The British Tinnitus Association has information on tinnitus and self-help treatments, including a helpline (0800 018 0527) and a patient information leaflets.

(www.tinnitus.org.uk) 

ENT UK (the national specialist body for ENT)

ENT UK produces information leaflets on a number of ENT conditions, including for tinnitus.

(https://www.entuk.org/tinnitus-ringing-ears) 

Video resources

What’s that ringing in your ears? - Marc Fagelson - YouTube

This 5:38 minute TED talk explains what tinnitus is.

(https://www.youtube.com/watch?v=TnsCsR2wDdk)

Tinnitus retraining therapy is a combination of information sessions, an explanation of the management techniques plus some cognitive behavioural therapy - an eReferral to Audiology (non-AQP) at St. Michael's requesting access to Tinnitus Retraining Therapy may help if above measures have been tried and symptoms are particularly intrusive. 

Referral

Referral and Advice Options

• ENT Hot Clinic RAS via e-RS if there are red flags as detailed above.
• ENT advice and guidance via e-RS if (non-acute) advice is required that is not covered in the page above.
• Audiology (non-AQP) via e-RS if no red flags or exclusions (see Audiology (non-AQP section below)
• ENT (otology) via e-RS for patients where there are concerns about underlying ear problems and referral criteria are met (see referral criteria in 'who to refer' section above) 

Tinnitus Retraining

If self care advice and management in primary care (see management section above) has not been effective then consider requesting tinnitus retraining as below:

• Audiology (non- AQP) via eRS requesting tinnitus retraining therapy.

Audiology (non-AQP) Referral

Patients with persistent unilateral or bilateral tinnitus (>3 months and not responding to self-help) may be referred to Audiology (non- AQP) as long as there are no red flags or contraindications (see exclusions below)

Patients with non- acute unilateral as well as bilateral symptoms can now be referred to this service as they can arrange ENT review or MRI scan if indicated. 

This is a comprehensive service for adults experiencing hearing and communication difficulties with or without tinnitus who would benefit from hearing assessment to support GP care and rehabilitation including the options of trying hearing aids with aftercare and support (1). 

Procedures performed: 

Hearing needs assessment including full medical history, hearing tests, otoscopy, development of a personalised care plan, rehabilitation, information, provision and fitting of hearing aids (where clinically appropriate)

Exclusions:

• Persistent pain, either ear (pain in or around the ear lasting more than 7 days in the last 90 days and not resolved as a result of prescribed treatment
• History of discharge (other than wax) either ear within the last 90 days, which has not responded to prescribed treatment, or is recurrent
• Sudden loss or sudden deterioration of hearing (sudden = within 72 hours/3 days – refer via locally agreed urgent care pathways). Prompt treatment may increase the likelihood of recovery.
• Rapid loss or rapid deterioration of hearing (rapid = 90 days/3 months or less)
• Fluctuating hearing loss, other than associated with colds.
• Abnormal auditory perceptions (dysacuses)
• Vertigo not fully resolved or recurrent. (Classically described as an hallucination of movement, but includes any dizziness or imbalance that may indicate otological, neurological or medical conditions, eg spinning, swaying or floating sensations and veering to the side when walking)
• Altered sensation of numbness in the face or observed facial droop.
• Ear examination reveals complete or partial obstruction of the external auditory canal preventing examination of the eardrum. If wax is obscuring the eardrum the GP surgery should arrange wax removal before referral.
• Ear examination reveals abnormal appearance of the outer ear and/or eardrum (eg. Inflammation of the external auditory canal, perforated eardrum, active discharge, eardrum retraction, growths, swelling of the outer ear or blood in the canal).

(Patients with exclusions should be referred via other appropriate ENT pathways if required).

Resources

(1) Audiology (non- AQP) Adult Tinnitus Pathway (October 2023)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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