GPAtlas🧭 When to suspect
Tinnitus is the perception of sound – typically ringing, buzzing, hissing, whooshing or humming – in the ears or head in the absence of any external acoustic source. It is a symptom, not a disease, and one of the commonest reasons for an audiological consultation: around one in seven UK adults experience it, generating over a million GP consultations a year. Most tinnitus is subjective (heard only by the patient) and benign, closely linked to hearing loss and the loss of background sound that would otherwise mask it.
Objective tinnitus – a genuine noise generated within the body that the examiner can also hear – is uncommon and always warrants a search for a structural or vascular cause. The two skills that matter in primary care are to characterise the tinnitus (its laterality, whether it is pulsatile, and any associated hearing loss or neurology) and to recognise the small minority of presentations that signal serious pathology. The pattern does most of the diagnostic work.
| Tinnitus pattern | What it suggests / action |
|---|---|
| Bilateral, non-pulsatile, symmetrical (often with hearing loss) | The common, benign pattern – usually age-related (presbycusis) or noise-induced; no imaging needed if examination is normal. |
| Unilateral or asymmetrical | Exclude retrocochlear pathology, particularly vestibular schwannoma (acoustic neuroma) – consider MRI of the internal auditory meati. |
| Pulsatile (synchronous with the heartbeat) | Suspect a vascular cause (e.g. carotid disease, dural arteriovenous fistula, glomus tumour, idiopathic intracranial hypertension) – needs imaging. |
| Objective (audible to the examiner) | Uncommon – points to a vascular, structural or myoclonic cause; refer for specialist assessment. |
| Sudden onset with hearing loss | Possible sudden sensorineural hearing loss – a time-critical emergency requiring referral within 24 hours. |
Common contributors to bear in mind include hearing loss and presbycusis, noise exposure, impacted earwax, ototoxic medication, stress and anxiety, and cardiovascular or metabolic disease. The severity of tinnitus does not track the severity of any hearing loss, and tinnitus can occur with entirely normal hearing.
Source: NICE NG155 · NICE NG98
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