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:
• Characterise the tinnitus: its laterality, whether it is pulsatile, and any associated hearing loss or neurology.
• Recognise the small minority of presentations that signal serious pathology.
The pattern does most of the diagnostic work.
| Tinnitus pattern | What it suggests and 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:
• Hearing loss and presbycusis.
• Noise exposure.
• Impacted earwax.
• Ototoxic medication.
• Stress and anxiety.
• 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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