Approach to tinnitus
- Approach to a complaint
Tinnitus usually comes with hearing loss; what matters is whether it is one-sided, pulsatile or comes with red flags.
What it is
Tinnitus is a sound a person hears without an outside source. It is almost always subjective and linked to age-related or noise-induced hearing loss, but it can also come from wax, otitis, drugs, Ménière disease or a vestibular schwannoma. Objective tinnitus, which the examiner can hear, and pulsatile tinnitus, which follows the heartbeat, point to vascular or muscular causes. The approach looks for a treatable cause, rules out dangerous ones with audiometry and imaging when needed, and measures the impact on sleep and mood.
Key questions in the history
- Is it pulsatile, continuous or clicking?
- One ear, both, or «inside the head»? Since when?
- Is there hearing loss (sudden or progressive), vertigo or aural fullness?
- Noise exposure, head or neck injury, jaw problems?
- Which medicines does the patient take (anti-inflammatories, some antibiotics, antidepressants, other ototoxic drugs)?
- How does it affect sleep, concentration and mood? Any thoughts of death?
Causes and classification
- Subjective (only the patient hears it): the most common; linked to age-related or noise-induced hearing loss, wax, otitis, ototoxic drugs, Ménière disease or vestibular schwannoma.
- Objective (the examiner can hear it): vascular (for example an aneurysm), tensor tympani spasm or temporomandibular dysfunction.
- Pulsatile (follows the heartbeat): points to a vascular cause and often has an identifiable cause.
- By side: bilateral symmetric (age, noise, drugs) versus one-sided (wax, otitis, Ménière, schwannoma).
- By impact: tolerated versus disabling, with insomnia, anxiety or depression.
Step-by-step approach
- Ask whether it is pulsatile, which side, when it began and whether there is hearing loss, vertigo or fullness.
- Review noise, head or neck injury and ototoxic drugs.
- Do otoscopy (wax, otitis, a reddish mass behind the eardrum) and, if pulsatile, auscultate the neck and around the ear.
- Use tuning forks and order pure-tone audiometry.
- If it is one-sided with asymmetric hearing loss, order MRI.
- If it is pulsatile, order imaging (MRI, CT or vascular ultrasound) according to the suspected cause.
- Measure the impact: sleep, anxiety, depression and suicidal thoughts.
Differential diagnosis of tinnitus
| Pattern | Likely cause | What to do |
|---|---|---|
| Bilateral, older adult with high-tone hearing loss | Presbycusis | Audiometry and hearing aids |
| Bilateral after noise exposure | Noise-induced hearing loss | Audiometry and hearing protection |
| One-sided with vertigo attacks and fullness | Ménière disease | Audiometry and ENT |
| One-sided with progressive hearing loss | Vestibular schwannoma | MRI |
| Pulsatile | Vascular cause | Imaging and referral |
| New after starting a drug | Ototoxicity | Review the drug with the prescriber |
| One-sided with a blocked canal | Wax or otitis externa | Cleaning or topical treatment |
Red flags
- Pulsatile tinnitus, especially with a bruit or a mass behind the eardrum.
- One-sided tinnitus with asymmetric hearing loss.
- Tinnitus with sudden hearing loss.
- Tinnitus with neurological signs, facial palsy or new headache.
- Severe distress, depression or suicidal thoughts.
Next step / Initial management
- All persistent tinnitus: otoscopy, tuning forks and audiometry; treat wax or otitis if present.
- Management: explanation and reassurance, hearing aids if there is hearing loss, sound therapy and cognitive behavioural therapy.
- Antidepressants or anxiolytics only for associated mood or sleep problems, not to cure the tinnitus.
- Urgent ENT referral if there is sudden hearing loss, and to the emergency department if there are neurological signs.
- Soon (priority) ENT referral if pulsatile or one-sided; suicidal thoughts: same-day mental health assessment.
Test yourself
Think of the answer, then tap the question to see it.
A 35-year-old woman hears a whooshing sound in her right ear that keeps time with her pulse. What type of tinnitus is it and what comes next?
Pulsatile tinnitus, pointing to a vascular cause: otoscopy, auscultation, imaging and priority ENT referral.
What separates objective from subjective tinnitus?
Objective tinnitus can be heard by the examiner (for example vascular or muscular); subjective tinnitus, far more common, is heard only by the patient.
A 50-year-old man has tinnitus only in the left ear and asymmetric left sensorineural hearing loss. Which test do you order?
MRI of the internal auditory canals to rule out a vestibular schwannoma.
What helps chronic tinnitus with no treatable cause?
Education, hearing aids if there is hearing loss, sound therapy and cognitive behavioural therapy; no drug is approved to cure it.
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Tinnitus (StatPearls Publishing (NCBI Bookshelf), 2023); Tinnitus (National Institute on Deafness and Other Communication Disorders (NIDCD), 2023); Sensorineural Hearing Loss (StatPearls Publishing (NCBI Bookshelf), 2023); Vestibular Schwannoma (Acoustic Neuroma) and Neurofibromatosis (National Institute on Deafness and Other Communication Disorders (NIDCD), 2017).
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Representative model, for educational purposes only.