01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Tinnitus is the perception of sound without a corresponding external source. The sound may be tonal, hissing, roaring or rhythmic, and its loudness does not reliably predict the severity of distress or the probability of a structural cause. Most cases are associated with auditory dysfunction and are not an emergency. However, laterality and pulse synchrony identify groups needing a more directed assessment, while associated hearing or neurological changes determine how quickly care is required.
Unilateral non-pulsatile tinnitus can justify investigation for asymmetric auditory or retrocochlear disease. Pulsatile tinnitus prompts consideration of vascular flow, a middle-ear lesion, altered venous pressure or rhythmic muscular activity. A normal ear examination does not remove the imaging indication for pulsatile tinnitus. The assessment should also establish the person's main problem: fear of a serious cause, inability to sleep, impaired concentration or distress may need attention while investigations are being arranged.
Key points
- Ask whether the sound is unilateral, bilateral or perceived centrally.
- Establish whether pulsation actually matches the heartbeat rather than simply sounding rhythmic.
- Offer audiological assessment to people with tinnitus.
- Offer imaging for pulsatile tinnitus and select the modality using the examination.
- Consider internal auditory meatus MRI for isolated unilateral non-pulsatile tinnitus.
- Do not routinely image uncomplicated symmetrical non-pulsatile tinnitus.
- Assess sleep, function and mental wellbeing, with urgency guided by actual risk.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Auditory system change
Hearing impairment and altered auditory processing commonly accompany non-pulsatile tinnitus. Ear disease or medication exposure may contribute, but an individual cause is not always identifiable.
Flow or mechanical sound
Vascular flow and pressure changes can generate pulse-synchronous perception, while middle-ear or palatal muscle activity may produce clicking that is rhythmic but not heartbeat-linked.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Altered auditory perception
Reduced or changed auditory input can alter activity within auditory pathways, allowing a sound percept to persist without an external acoustic source.
- 2Transmission of internal sound
Vascular or middle-ear abnormalities can make internal mechanical sounds more perceptible. The relationship to the pulse helps distinguish some of these mechanisms.
- 3Attention and distress
Sleep disruption, threat interpretation and anxiety can increase the salience of tinnitus. Addressing these influences can improve functioning without requiring the sound to disappear completely.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Ask the person to compare the rhythm with their pulse without pressing on their neck. Pulse-synchronous sound suggests a vascular or pressure-related mechanism; clicking that is rhythmic but not synchronous may have a muscular origin. The distinction influences imaging selection.
Record which ear is affected, whether symptoms alternate and whether hearing has changed suddenly, rapidly or gradually. A longstanding bilateral sound with a new unilateral hearing deficit must be assessed on the new feature rather than the age of the tinnitus.
Otoscopy may identify wax, infection, effusion or a retrotympanic abnormality. Examine cranial nerves and ask about vertigo, facial symptoms, headache and visual disturbance. A suspected vascular middle-ear lesion needs specialist assessment; avoid casual instrumentation of an unexplained abnormality.
Pulsatile tinnitus with headache, transient visual dimming or diplopia may accompany intracranial hypertension. Assess vision and the optic discs where competent, and arrange urgent evaluation when visual or neurological concern exists. The tinnitus sound alone cannot establish the cause.
Ask directly about sleep, everyday functioning, anxiety, mood and thoughts of self-harm when indicated by distress. High suicide risk requires immediate crisis assessment and a safe setting while help is arranged. Tinnitus severity questionnaires support care but do not replace conversation.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Audiological assessmentFirst step - Why
- Identify hearing impairment and provide information for treatment and referral.
- Interpretation and limitations
- NICE recommends audiological assessment for tinnitus. Add tympanometry when middle-ear or Eustachian tube dysfunction is suspected. Do not use uncomfortable loudness testing routinely, and do not delay an urgent sudden-hearing-loss referral to obtain a routine audiogram.
- 02
MRI of the internal auditory meati for non-pulsatile tinnitus - Why
- Investigate appropriate unilateral or associated structural features.
- Interpretation and limitations
- Offer MRI when non-pulsatile tinnitus has associated neurological, otological or head-and-neck symptoms or signs. Consider MRI for unilateral or asymmetric non-pulsatile tinnitus without associated abnormalities. If MRI cannot be performed, contrast-enhanced CT of the meati is the NICE alternative.
- 03
Directed imaging for pulsatile tinnitus - Why
- Investigate a vascular, pressure-related, osseous or middle-ear cause.
- Interpretation and limitations
- Offer imaging. For synchronous tinnitus with normal examination and audiology, consider MRA or MRI of the head, neck, temporal bone and internal auditory meati; if these cannot be performed, consider contrast-enhanced CT of those regions. Suspected osseous or middle-ear abnormality instead favours contrast-enhanced temporal-bone CT, followed by MRI when additional soft-tissue assessment is needed.
- 04
Imaging for non-synchronous rhythmic tinnitus - Why
- Investigate a nonvascular rhythmic mechanism when suggested by the assessment.
- Interpretation and limitations
- For non-synchronous pulsatile tinnitus, such as a presentation suggestive of palatal myoclonus, NICE advises considering MRI of the head, or contrast-enhanced head CT when MRI cannot be undertaken. Describe the observed rhythm and examination findings in the request.
- 05
Selective systemic and visual assessment - Why
- Investigate a specific clinical clue beyond the auditory system.
- Interpretation and limitations
- Blood pressure, blood count, thyroid testing or ophthalmic assessment should answer a question raised by the history or examination. Avoid an automatic extensive blood panel for every tinnitus presentation; normal blood tests cannot exclude an indicated structural investigation.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Retrocochlear pathology
A vestibular schwannoma or other cerebellopontine-angle lesion can cause unilateral tinnitus with asymmetric hearing or cranial nerve findings, prompting targeted MRI assessment.
Vascular middle-ear lesion
A paraganglioma or another vascular abnormality may produce pulsatile tinnitus and a retrotympanic finding, requiring specialist imaging and assessment of local anatomy.
Intracranial hypertension
Raised intracranial pressure can produce pulse-synchronous tinnitus with headache or visual symptoms. Threatened vision changes urgency and requires more than routine tinnitus management.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01ImmediateAct on associated urgent featuresFirst stepTinnitus accompanies acute neurological symptoms, uncontrolled vertigo, sudden hearing loss or severe risk.+
- 1Use immediate neurological or stroke referral for new significant neurological signs or acute uncontrolled vestibular symptoms.
- 2Arrange assessment within twenty-four hours when hearing loss developed over three days or less during the previous thirty days.
- 3If there is high suicide risk, refer immediately for crisis mental health assessment and provide a safe place while the assessment is arranged.
- 4Continue appropriate tinnitus support after the emergency issue is addressed rather than assuming the urgent referral completes all care.
02Directed referralArrange timely diagnostic assessmentThe presentation has persistent laterality, pulsation, asymmetric hearing or continuing substantial distress.+
- 1Refer within two weeks when distress still prevents usual activities despite initial tinnitus support, or when hearing loss meets the older-sudden or rapidly worsening criteria.
- 2Refer through local pathways for persistent objective tinnitus, unilateral or asymmetric hearing loss, or tinnitus that remains bothersome after initial support.
- 3Consider referral for persistent unilateral or pulsatile tinnitus and ensure pulsatile symptoms receive the recommended imaging assessment.
- 4Communicate duration, pulse synchrony, hearing changes, examination findings and the person's functional concerns in the referral.
03SupportReduce impact while investigation proceedsThe patient has ongoing tinnitus without an unresolved immediate emergency.+
- 1Explain what the assessment has and has not shown, address specific fears and agree a practical management plan.
- 2Offer amplification when hearing loss affects communication, and consider it with hearing loss even when communication difficulty is not prominent.
- 3For continuing tinnitus-related distress, consider the NICE stepped psychological approach, beginning with digital tinnitus-related CBT and progressing when needed.
- 4Support sleep and coping strategies, review potentially relevant medicines and arrange follow-up to discuss both results and symptoms.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Sleep and concentration impairment
Persistent intrusive tinnitus may make sleep initiation and sustained attention difficult, affecting work, study and daily functioning even when hearing thresholds are relatively preserved.
Psychological distress
Anxiety, low mood and severe distress can accompany tinnitus. Assessment should identify actual risk and route urgent mental health needs without dismissing the auditory symptoms.
Delayed underlying diagnosis
Failure to recognise pulsation, laterality or associated sudden hearing loss may delay investigation of a treatable cause or a time-sensitive auditory disorder.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Check that investigations and referrals have actually occurred, and explain the result in relation to the original concern rather than simply labelling the scan normal.
- Use functional goals, sleep quality and, when useful, the Tinnitus Functional Index to review progress; perceived loudness alone may not reflect meaningful improvement.
- Reassess new hearing loss, changing laterality, neurological symptoms or pulse-synchronous features even when tinnitus has been present for years.
- Review distress and coping at follow-up, including whether the person can manage daily activities and whether additional psychological or mental health support is needed.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
When imaging is unnecessary
NICE advises against imaging symmetrical non-pulsatile tinnitus without associated neurological, audiological, otological or head-and-neck abnormalities. Explaining this decision is part of good care: imaging should answer a plausible clinical question rather than be used solely as a general reassurance test.
Support and evidence boundaries
Some patients find gentle background sound helpful, especially at bedtime. NICE could not make a general recommendation for sound therapy because of the evidence limitations. Present it as an individual coping option without promising a cure or implying that commercial devices are required.
No betahistine for tinnitus alone
NG155 advises against betahistine as a treatment for tinnitus. A separate diagnosis such as Ménière disease may have its own management plan, but the presence of ringing alone does not justify that prescription.
A shared description of risk
Unilateral and pulsatile symptoms warrant attention without implying that a tumour or vascular lesion is the likely outcome for every patient. Explain the reason for referral and the precise symptoms that should prompt faster reassessment.
11Common pitfallsFrequent interpretation and management errors.
- 01
Treating every rhythmic sound as pulse-synchronous can lead to an inappropriate imaging request and obscure muscular causes.
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Using normal otoscopy as a reason to dismiss pulsatile tinnitus contradicts the need for directed imaging despite a normal examination.
- 03
Allowing routine audiology waiting times to delay assessment of recent sudden hearing loss misses a separate urgent pathway.
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Saying nothing can be done overlooks hearing rehabilitation, tinnitus-focused psychological treatment and help with sleep or distress.