This document has been created to support GPs who see tinnitus patients.
We want to provide simple and clear advice which can be passed on, to support those who need help. We hope you will find the guidance of help, and if you have any questions please don’t hesitate to get in touch via [email protected].
Tinnitus red flags
Firm indications that a patient with tinnitus should be referred onwards include:
- Pulsatile tinnitus
- Tinnitus in association with significant vertigo
- Unilateral tinnitus
- Tinnitus in association with asymmetric hearing loss
- Tinnitus causing psychological distress
- Tinnitus in association with significant neurological symptoms and/or signs
Although many tinnitus patients do not fit into any of these imperative categories, clinicians involved in tinnitus care are firmly of the opinion that all patients with the symptom should at the very least receive an audiological assessment. Local factors will determine whether this is undertaken in primary or secondary care.
At any point in time around 13% of the population experience tinnitus
All genders are equally affected and although tinnitus is more common in the elderly it can occur at any age, including childhood. The perceived sound can have virtually any quality – ringing, whistling and buzzing are common – but more complex sounds can also be described.
Most tinnitus is mild
In fact, it is relatively rare for it to develop into a chronic problem of life-altering severity. The natural history of tinnitus in most patients is of an acute phase of distress when the problem begins, followed by improvement over time. But for a minority of patients, the distress is ongoing and very significant, and they will require specialist support.
The underlying pathology is rare, but be vigilant
In many cases, tinnitus is due to the heightened awareness of spontaneous electrical activity in the auditory system that is normally not perceived. It can, however, be a symptom of treatable and significant otological pathology, such as a vestibular schwannoma or otosclerosis.
Tinnitus can be associated with a blocked sensation
For reasons that are not clear tinnitus and sensorineural hearing loss can give rise to a blocked feeling in the ears despite normal middle ear pressure and eardrum mobility. Otoscopy and, if available, tympanometry can exclude Eustachian tube dysfunction. Decongestants and antibiotics are rarely helpful.
Giving a negative prognosis is actively harmful
It is all too common to hear that patients have been told nothing can be done about tinnitus. Such negative statements are not only unhelpful but also tend to focus the patient’s attention on their tinnitus and exacerbate the distress.
A positive attitude is generally helpful and there are many constructive statements that can be made about tinnitus, such as “Most tinnitus lessens or disappears with time”; “most tinnitus is mild”; “tinnitus is not a precursor of hearing loss”.
There is no direct role for drugs
Although they can be used to treat associated symptoms such as vertigo, insomnia, anxiety or depression. There is no conventional or complementary medication that has been shown to have specific tinnitus ameliorating qualities and there is anecdotal suggestion that repeatedly trying unsuccessful therapies worsens tinnitus.
The NICE guideline on tinnitus specifically recommends against the use of betahistine for tinnitus (though this drug can still be used to treat vertigo in suspected Ménière’s disease.)
Referral routes for tinnitus patients
Referral routes vary and depend on local protocols and commissioning, but in the majority of cases, referrals are directed to ENT or audiology services. Common sense dictates that when there are possibilities of self-harm or of psychological crisis, then urgent mental health support is indicated.
Tinnitus is more common in people with hearing loss
Tinnitus prevalence is greater amongst people with hearing impairment but the severity of the tinnitus correlates poorly with the degree of hearing loss. It is also quite possible to have tinnitus with a completely normal pure tone audiogram.
Hearing aids are helpful if there is associated hearing loss
Straining to listen can allow tinnitus to emerge or, if already present, to worsen. Correcting any hearing loss reduces listening effort and generally reduces the level of the tinnitus. Hearing aids are useful even if the hearing loss is relatively mild and at a level where aids would not normally be considered. Some modern hearing aids have sound therapy devices incorporated within the aid specifically for tinnitus patients.
The NICE guideline emphasises the value of audiometry in a tinnitus consultation, and this is the definitive basis for decisions about hearing aid candidacy. If in doubt, refer for an audiological opinion. In our view, all people who describe tinnitus deserve an audiological assessment. Decisions on when to start using a hearing aid and what sort to use are up to the individual patient and audiologist.
Avoiding silence is helpful
Having continuous, low level, unobtrusive sound in the background can reduce the starkness of tinnitus. Sounds can be quiet, uneventful music, a fan or an indoor water feature. Alternatively, there are inexpensive devices that produce environmental sounds, these are particularly useful at bedtime. They can be are available via the BTA.
There are also many apps for smartphones and similar devices. Audiology and Hearing Therapy services can advise patients on the most appropriate sounds for their situation.
Self-help is often effective
The BTA provides comprehensive information on tinnitus and common sense advice on managing symptoms. We also has a network of tinnitus support groups around the country. We run a freephone telephone helpline 0800 018 0527 as well as offering advice through our website.
The BTA have developed an online resource aimed specifically at patients who have recently developed tinnitus and want some simple, clear information and advice: Take on Tinnitus (takeontinnitus.co.uk) includes facts, tips, exercises and videos which give patients ideas for self-management.
Please do pass on the above details to your tinnitus patients so that we can help you provide the support they need in the early stages of tinnitus management. We know from the calls we receive, that when early help is given by GPs and secondary services, patients manage their tinnitus more effectively.
Further information
The NICE tinnitus guideline can be accessed from: nice.org.uk/guidance/ng155.
The Royal College of GPs has a module on tinnitus assessment and management as part of the Essential Knowledge Update Programme.
If you would like further copies of this document you can download it here, or request printed copies via [email protected].
tinnitus guidance for gps
This guidance has been endorsed by the British Academy of Audiology
Updated 28 March 2022
Authors: Professor David Baguley NIHR Biomedical Research Unit in Hearing, the University of Nottingham and Mr Don McFerran, ENT Surgeon (retired) and President, British Tinnitus Association
Version 2.1
To be reviewed March 2025
David and Don are co-authors, with Laurence McKenna, of the self-help book “Living with tinnitus and hyperacusis” (Sheldon Press, 2021)
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