Tinnitus
Exam Tips
- In OSCE history, classify tinnitus early: unilateral/bilateral, pulsatile/non-pulsatile, constant/intermittent, and impact on sleep/mood/function.
- Pulsatile tinnitus is a red-flag pattern for vascular or intracranial pathology; examine for bruits and arrange urgent specialist assessment when concerning features are present.
- Always perform otoscopy plus Rinne/Weber; conductive clues suggest treatable outer/middle-ear disease.
- Unilateral tinnitus with asymmetric SNHL or cranial nerve signs should trigger suspicion for vestibular schwannoma and MRI IAM referral.
- Distress severity does not reliably correlate with audiogram deficit; use a validated severity tool and assess mental health risk.
- Image cue for revision: see standard ENT textbook figures for audiogram patterns in presbycusis vs noise-induced loss and vascular causes of pulsatile tinnitus.
Definition
Tinnitus is the perception of sound without an external acoustic source and is a symptom rather than a diagnosis in itself. It may be subjective (heard only by the patient, most common) or objective (rare, audible to the examiner), and can be unilateral or bilateral, constant or intermittent, and pulsatile or non-pulsatile.
Pathophysiology
The mechanism is heterogeneous and involves abnormal neural activity somewhere along the auditory pathway. In many patients, peripheral cochlear injury (for example hair-cell damage from age, noise, or ototoxic exposure) reduces normal input and drives maladaptive central gain, increased spontaneous firing, neural synchrony, and abnormal oscillatory activity that is perceived as sound. Conductive mechanisms (middle-ear vibration phenomena), sensorineural mechanisms (cochlea/auditory nerve), and central mechanisms (auditory network reorganization) can all contribute. Distress severity is influenced by limbic/autonomic coupling, so symptom burden does not always match audiometric hearing loss.
Risk Factors
- Increasing age (presbycusis)
- Pre-existing hearing loss (sensorineural or conductive)
- Occupational or recreational loud-noise exposure
- Ototoxic medicines (for example aminoglycosides, high-dose salicylates/NSAIDs, loop diuretics, macrolides, cisplatin)
- Ear disease (wax impaction, otitis media/externa, tympanic membrane pathology, otosclerosis, Meniere's disease)
- Cardiometabolic disease (hypertension, diabetes, dyslipidaemia, obesity)
- Head/neck trauma and temporomandibular disorders
- Anxiety and depression
Clinical Features
Symptoms
- Perceived ringing, buzzing, hissing, roaring, clicking, humming, or whistling
- Unilateral or bilateral tinnitus; constant or episodic pattern
- Pulsatile tinnitus (synchronous with heartbeat) suggesting vascular aetiology
- Associated hearing loss, aural fullness, hyperacusis, or sound sensitivity
- Vertigo/dizziness (consider Meniere's disease or vestibular pathology)
- Sleep disturbance, impaired concentration, irritability, anxiety, low mood
- Jaw pain/clicking or symptom change with jaw/head movement (TMJ/cervical contribution)
Signs
- Otoscopic abnormalities: impacted wax, otitis externa/media, perforation, cholesteatoma features
- Tuning-fork findings of conductive or sensorineural hearing loss (Rinne/Weber)
- Palatal or middle-ear myoclonus causing objective clicking tinnitus
- TMJ tenderness/clicking or restricted jaw movement
- Head/neck bruit on auscultation in pulsatile tinnitus
- Focal neurological or cranial nerve deficits (possible retrocochlear pathology)
Investigations
Management
Lifestyle Modifications
- Explain tinnitus mechanisms and provide safety-net advice; validate distress and set realistic expectations
- Treat reversible ear causes promptly (for example wax, infection, middle-ear disease)
- Sound enrichment (background sound, bedside masker/apps) and hearing aids when hearing loss is present
- Noise protection in high-exposure settings while avoiding excessive silence
- Sleep hygiene, stress reduction, and referral for CBT-based tinnitus support when distress is significant
- Address mental health comorbidity and suicide risk when present
Pharmacological Treatment
No specific anti-tinnitus drug
- No medicine is licensed in the UK to cure primary subjective tinnitus
Avoid routine use of benzodiazepines, anticonvulsants, or steroids solely for chronic primary tinnitus unless another clear indication exists.
Treat contributory otological disease
- Sodium bicarbonate 5% ear drops: 3-4 drops once or twice daily for up to 7 days for wax softening
- Acetic acid 2% ear spray: 1 spray three times daily for otitis externa (if tympanic membrane intact)
Check tympanic membrane status before topical otic therapy; avoid potentially ototoxic ear drops when perforation/grommet is present unless specialist-directed.
Manage associated Meniere's symptoms when relevant
- Betahistine: typically 16 mg three times daily (maintenance often 24-48 mg/day in divided doses)
Used for vertigo control in Meniere's rather than as a direct tinnitus cure; review response and adverse effects.
Treat comorbid depression/anxiety when diagnosed
- Sertraline: start 50 mg once daily, titrate up to 200 mg once daily if needed
Use standard mental-health indications and monitoring. Warn about early agitation/suicidality risk in younger adults and potential interactions (for example with NSAIDs increasing bleeding risk).
Medication safety review
- Review and reduce/stop non-essential ototoxic medicines where clinically safe (for example high-dose aspirin, NSAIDs, loop diuretics, aminoglycosides, macrolides, cisplatin)
Do not discontinue essential medicines (for example chemotherapy or heart-failure diuretics) without specialist input; aminoglycosides and cisplatin can cause permanent cochlear damage.
Surgical / Interventional
- No surgery for primary idiopathic tinnitus itself
- Condition-directed procedures: stapedotomy/stapedectomy for otosclerosis, cholesteatoma surgery, tympanoplasty where indicated
- Vascular intervention for objective/pulsatile causes (for example embolisation or vascular surgery for AV malformation/aneurysm) after specialist assessment
- Vestibular schwannoma management (active surveillance, stereotactic radiosurgery, or microsurgical resection) in MDT setting
Complications
- Sleep disturbance
- Impaired concentration and reduced work performance
- Anxiety and depressive symptoms
- Social withdrawal and reduced quality of life
- Rarely, suicidal ideation or self-harm risk
Prognosis
Most people have mild symptoms that improve over time or after treatment of contributory pathology. Persistent tinnitus beyond about 6 months is less likely to resolve spontaneously, and a minority develop chronic distress requiring multidisciplinary input. Around one in five adults with tinnitus may require clinical intervention.