Tinnitus - obsolete July 2022

Overview

Who to refer

Bilateral tinnitus

Most patients with bilateral tinnitus without concerning features do not need referral and can be managed in primary care. See self care resources section below.

Consider a routine referral via eRS if self- help measures are unsuccessful. The audiologists at St Michaels are no longer accepting direct referrals for tinnitus retraining without an initial ENT review, as advised by their AQP contract.

Refer routinely to ENT via eRS if:

• Pulsatile tinnitus
• Unilateral tinnitus (unless sudden sensorineural hearing loss is suspected)
• Tinnitus associated unilateral  or asymmetric hearing loss
• Tinnitus  associated with persistent otalgia or  otorrhoea that doesn't resolve with routine treatment
• Tinnitus associated with  vestibular symptoms (dizziness or vertigo)
• Tinnitus of uncertain cause. This includes people with tinnitus that is not associated with hearing loss, ear pain, drainage or malodour, vestibular symptoms or facial weakness and people with hearing loss that cannot clearly be distinguished as either sensorineural or conductive.
• Tinnitus that is causing distress despite primary care management.

Contact ENT on call team if: 

• Sudden onset sensorineural hearing loss (SSNHL) is suspected
• Sudden onset pulsatile tinnitus (can be associated with SSNHL)
• Sudden onset tinnitus associated with severe vertigo

(the on call team may give advice about immediate care such as high dose steroids, and can then triage to HOT clinic if necessary.)

Red Flags

• Sudden sensorineural hearing loss (SSNHL) - discuss with ENT on call
• Tinnitus associated with head trauma - refer to A and E.
• Tinnitus in association with significant neurological symptoms or signs  - 999 if stroke suspected or consider neurology imaging or referral (unless clear evidence of ear pathology or infection). See also Brain and CNS 2WW indications.

Unilateral or pulsatile tinnitus are often referred urgently, but in the absence of other neurology will be triaged as routine. The pathology being screened for (acoustic neuroma, dural AV fistulae, sigmoid sinus stenosis etc) is all benign. Neurological red flags (cranial nerve palsies etc), will usually be directed via the neuro 2WW pathway.

Before Referral

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

Examination should include tuning fork hearing tests if sudden hearing loss and examination of the ear with an auroscope to look for ear pathology.

Consider bloods if indicated including: FBC, TFT, glucose or HbA1c, Lipids.

Consider red flags and refer appropriately.

Consider reassurance and self care if no indication for secondary care referral.

Consider ENT referral or ENT advice and guidance via eRS if further (non-acute) advice is required.

Self care resources

If ENT referral is not considered appropriate and no concerning underlying cause is suspected then most patients can be managed in primary care. Patients can be reassured that no concerning cause is suspected and should be encouraged to try self help measures.

Distracting background "white noise" (e.g. using radio with low volume at night, white noise devices, smart phone apps) - the theory being by distracting the listener the tinnitus becomes less intrusive/ less of a focus and eventually they are trained to ignore it.

The British Tinnitus Association has information on self help treatments for patients including a helpline (0800 018 0527) and a patient information leaflet.

ENT UK also produces leaflets for patients including for tinnitus.

Tinnitus retraining therapy is a combination of the above distraction techniques plus some cognitive behavioural therapy - an eReferral to ENT at St. Michael's requesting access to Tinnitus Retraining Therapy may help if above measures have been tried and symptoms are particularly intrusive.

Please note that the audiology department at St Michaels are now rejecting referrals for patients with tinnitus and advising that they are referred to ENT clinic initially for assessment.

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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