Changes

April 2022 — reviewed. A literature search was conducted in April 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. 

Update

Goals

To support primary healthcare professionals to:

• Diagnose the underlying cause of tinnitus, where possible.
• Manage the underlying cause of tinnitus, where possible.
• Manage the distress caused by tinnitus and its complications.
• Appropriately refer people with tinnitus.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

No QIPP - Options for local implementation were found in the search for this topic.

NICE quality standards

No NICE quality standards were found during the search for this topic.

What is it?

• Tinnitus is a symptom, not a disease. It is the perception of sound in the absence of any external auditory stimulus.
  • The sound may be perceived as ringing, roaring, hissing, buzzing, clicking, pulsing, tonal, whistling, or humming, but more complex sounds may also be described. 
  • Tinnitus can be unilateral or bilateral, constant or intermittent, pulsatile (synchronous with the heartbeat, or not) or non-pulsatile.  
• Tinnitus is classified as:
  • Subjective tinnitus if the perceived sound can only be heard by the affected individual. Most cases of tinnitus are subjective tinnitus. It is more likely to be caused by otological problems.
  • Objective tinnitus if the sound can be heard by the affected individual and the examiner. This is rare and affects 1% of people with tinnitus and often has an identifiable and correctable cause, although it can also be due to a serious underlying condition. It occurs due to the perception of sounds produced by neighbouring structures, such as muscular contractions and vascular noise.
• Primary tinnitus is a term that can be used to describe idiopathic tinnitus that may be associated with sensorineural hearing loss. 
• Secondary tinnitus is associated with an underlying cause or diagnosis (other than sensorineural hearing loss).

[Meehan and Nogueira, 2014; Tunkel, 2014; Zimmerman and Timboe, 2014; Cima, 2019; BMJ, 2022; BTA, 2022]

What mechanisms produce tinnitus?

• The pathophysiology of tinnitus is heterogeneous and not completely understood, but is related to aberrant neural activity generated at some level of the auditory system. The tinnitus-related signal is interpreted as an auditory perception and can be associated with distress. 
  • It has been suggested that tinnitus results from an increased firing rate, increased synchrony between neural discharges, or an aberrant pattern of oscillatory activity.
  • In most cases, tinnitus is believed to be associated with some degree of cochlear damage. 
  • The tinnitus-related signal does not cause distress in all people and there are a number of theoretical mechanisms to explain this. 
• The pathophysiology can be considered by the process involved:  
  • Conductive — vibrations in the middle ear.
  • Sensorineural — inner and outer hair cells, auditory nerves, and extrasensory structures.
  • Central — aberrant central processing (this may be triggered by hearing loss). 

[Zimmerman and Timboe, 2014; Cima, 2019; BMJ, 2022]

What causes subjective tinnitus?

• Subjective tinnitus is most commonly caused by an otological problem. Common causes include: 
  • Ear infection — including otitis media and otitis external. 
  • Impacted wax. 
  • Meniere's disease. 
  • Noise-induced hearing loss.
  • Otosclerosis.
  • Ototoxic drugs — the risk of tinnitus is reduced by limiting the dose and duration of treatment and avoiding using more than one ototoxic drug at a time. Ototoxic drugs include:
    • Valproate. 
    • Loop diuretics (including furosemide and bumetanide) can cause tinnitus and reversible hearing loss.
    • Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) can cause tinnitus and reversible hearing loss.
    • Antimalarials (quinine and chloroquine). 
    • Tetracyclines (such as doxycycline and minocycline). 
    • Macrolide antibiotics (such as erythromycin).
    • Aminoglycoside antibiotics (such as gentamicin) can cause tinnitus and permanent hearing loss associated with cochlear damage. 
    • Cytotoxic drugs (including cisplatin) can cause tinnitus and permanent hearing loss. 
  • Presbycusis. 
  • Sensorineural hearing loss. 
  • Tympanic membrane perforation. 
• Subjective tinnitus is also associated with:  
  • Mechanical disorders — including trauma of the head or neck and temporomandibular joint disorders. 
  • Metabolic disorders — including thyroid disorders, diabetes mellitus, hyperlipidemia, vitamin B12 deficiency, and zinc deficiency.
  • Neoplastic conditions — including acoustic neuroma (vestibular schwannoma) or meningioma.       
  • Neurological disorders — including multiple sclerosis.
  • Psychological disorders — it is unclear whether the chronic nature of tinnitus causes depression, or whether tinnitus occurs more often in people with depression as they are more psychologically vulnerable. Anxiety may exacerbate tinnitus. 
  • Vascular disorders — including arterial bruits and venous hums. 

[Meehan and Nogueira, 2014; Yew, 2014; Zimmerman and Timboe, 2014; BMJ, 2022] 

What causes objective tinnitus?

• Objective tinnitus is very rare. It is caused by conditions that produce sound within or near to the ear, and is commonly associated with venous and arterial abnormalities, including: 
  • Aortic stenosis and mitral regurgitation.
  • Arteriovenous malformations and benign venous 'hums'.
  • Carotid or vertebral artery stenosis, tortuosity, dissection, or aneurysm.
  • High jugular bulb. 
  • Vascular tumours.
• Other causes include: 
  • Acoustic neuroma (vestibular schwannoma). 
  • Anaemia, or other high cardiac output states.  
  • Benign intracranial hypertension. 
  • Middle ear inflammation.
  • Muscle contractions (palatal myoclonus), such as tensor veli palatini or tensor tympani contractions. Middle ear myoclonus is usually unilateral and produces a clicking or buzzing sound. Soft palate movements can also cause a clicking sound. 
  • Paget's disease and otosclerosis. 
  • Patulous eustachian tube — can occur after adenoidectomy or weight loss. Clicking sounds occur with swallowing.
  • Temporomandibular disorders. 
  • Thyrotoxicosis. 

[Meehan and Nogueira, 2014; Tunkel, 2014; Yew, 2014; Zimmerman and Timboe, 2014; Cima, 2019; BMJ, 2022]

How common is it?

• Tinnitus is a very common symptom.
  • Around 13% of adults in the UK (7.1 million people) experience prolonged tinnitus. 
  • The prevalence of tinnitus increases with age, but it can occur at any age, including in children.
  • Men and women are affected equally.
  • A multi-country cross-sectional population study conducted in 12 European countries found a prevalence of any tinnitus of 14.7%, with severe tinnitus in 1.2% of participants [Biswas, 2022].     
• Tinnitus is more common in people with hearing loss, but its severity does not correlate with the extent of hearing deficit.
• An increased prevalence of tinnitus has also been reported in people with a history of loud noise exposure from work or leisure activities, and people with obesity, hypertension, diabetes mellitus, dyslipidaemia, or anxiety disorder [Tunkel, 2014]. 

[Cima, 2019; BTA, 2022]

What are the complications?

• The impact of tinnitus on health-related quality of life is variable — most people are less severely affected, but others may experience:
  • Anxiety. 
  • Depression. 
  • Impaired concentration.
  • Interference with daily activities.
  • Loneliness, withdrawal, and social isolation.
  • Sleep disturbance. 
  • Suicide (a very rare complication).

[Henry et al, 2010; Tunkel, 2014; BMJ, 2022]

What is the prognosis?

• Most tinnitus is mild in severity and improves over time, or after treatment.  
  • However, in a minority of cases, tinnitus can persist for many years, causing significant distress where specialist support is required. 
  • Symptoms which persist for 6 months or longer are less likely to improve spontaneously.
• Around 20% of adults with tinnitus require clinical intervention [Tunkel, 2014]. 

[Tunkel, 2014; BMJ, 2022; BTA, 2022]

How do I assess someone with tinnitus?

• Take a medical history and ask about: 
  • The onset, quality, duration, severity and frequency of the tinnitus. 
  • The features of tinnitus: 
    • Unilateral or bilateral. 
    • Continuous or episodic.
    • Pulsatile, and, if so, do they recognize a pattern of it being in time with their heart rate. 
  • Associated symptoms such as hearing loss, dizziness, vertigo, balance problems, jaw pain or clicking, facial weakness, sensitivity to loud noises, stress, visual changes or headache.
  • Any relieving or exacerbating factors (for example background noise, stress, lack of sleep, head position, jaw movements). 
  • The impact of tinnitus — consider using the Tinnitus Functional Index. If questionnaires cannot be used (for example, because of language issues or cognitive impairment) consider using a visual analogue scale.
    • Discuss with the person, and their family members or carers if appropriate, how the condition affects their quality of life (home, social, leisure, work). 
    • Ask the person if they have problems sleeping because of tinnitus — consider using the Insomnia Severity Index and discuss the results with the person. 
    • Be alert to the impact of tinnitus on mental health — consider using the tinnitus questionnaire (TQ) or the mini-TQ in addition to the Tinnitus Functional Index if further assessment of the psychological effects of tinnitus is needed. If there are concerns about depression or anxiety carry out an appropriate mental health assessment. For more information, see the CKS topics on Depression and Generalized anxiety disorder. 
  • Current medications, including over-the-counter and herbal remedies. 
  • History of significant noise exposure from occupational or leisure activities. 
  • A history of ear surgery, infections or injury, head trauma, or any nose, throat, orthopaedic, cervical, or dental conditions. 
  • A history of cerebrovascular accident or transient ischaemic attack. 
  • Comorbidities, such as cardiovascular or metabolic diseases, or mental health disorders. 
• Perform an examination of the head and neck. 
  • Examine the ears, nose, and throat. 
    • Use an otoscope to detect disorders affecting the middle and outer ear (for example wax, otitis externa, otitis media with effusion, perforation of the tympanic membrane, and cholesteatoma). For more information, see the CKS topics on Earwax, Otitis externa, and Otitis media with effusion.
    • Use Weber and Rinne tuning fork tests to identify sensorineural or conductive hearing loss. 
    • Observe the palate for palatal myoclonus. 
  • Palpate the temporomandibular joint and examine the jaw for any snapping or clicking indicative of temporomandibular joint dysfunction. For more information see the CKS topic on Temporomandibular disorders (TMDs).
  • Perform a focused neurological assessment, to exclude motor and sensory deficits and exclude any cranial nerve problems. 
• If an underlying disorder is suspected (for example, anaemia, thyroid disease, hyperlipidaemia, or diabetes) consider arranging investigations including:
  • Blood glucose.
  • HbA1c.  
  • Thyroid function. 
  • Full blood count. 
  • Lipid levels. 
  • Urea and electrolytes. 
• If tinnitus is pulsatile, focus on possible cardiovascular disease or vascular lesions.
  • Perform a head and neck examination, a general cardiovascular examination, and include auscultation/palpation of the head and neck, the skull and mastoid prominences, and orbits. 
  • Auscultation over the neck, mastoid, and ear canal may reveal a carotid bruit, venous hum, arteriovenous malformations, or myoclonic clicks. 

How do I determine the cause of tinnitus?

• For people with:
  • Objective tinnitus — refer these people to an ear, nose, and throat specialist for investigation and treatment. 
  • Subjective unilateral tinnitus and sensorineural hearing loss, suspect:
    • Meniere's disease — if there are episodes of tinnitus associated with hearing loss and vertigo, generally lasting 15 minutes to 24 hours. Tinnitus may be associated with a feeling of fullness in the affected ear. Note: tinnitus is mostly unilateral, but can be bilateral in 10-30% of cases.
    • Acoustic neuroma (vestibular schwannoma) — dizziness may also be present. Signs of cranial nerve and brainstem compression and hydrocephalus may develop with large tumours. 
  • Subjective bilateral tinnitus and sensorineural hearing loss, suspect tinnitus secondary to: 
    • Noise-induced hearing loss — if there is a history of significant noise exposure. 
    • Drug-induced ototoxicity — if the tinnitus developed while taking ototoxic drugs (for example aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs], certain antibiotics, loop diuretics, or cytotoxic drugs).
    • Age-related hearing loss — in older people who do not have a history of exposure to noise or ototoxic drugs. 
  • Subjective unilateral or bilateral tinnitus and conductive hearing loss, suspect:
    • A disorder of the middle or outer ear — if there are signs of these conditions on examination (such as impacted wax, otitis media, or cholesteatoma). For more information, see the CKS topics on Cholesteatoma, Earwax, and Otitis media with effusion.
    • Otosclerosis — there may be a family history. Tinnitus is characterized by a hissing sound, humming sound, or discrete tones.
• Suspect tinnitus secondary to head or neck injury, multiple sclerosis, diabetes, or thyroid disease if these conditions are present and other causes have been ruled out.

Scenario: Management of tinnitus

From age 16 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of tinnitus.

Search dates

August 2017 - April 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• Exp tinnitus/, tinnitus.tw. tinnitus.ti,ab.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.