[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [ENT](https://durgical.com/en/ent/) › [Ear: approach to complaints](https://durgical.com/en/ent/areas/ear/) › Approach to tinnitus

# 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.

Updated Nov 5, 2026

## Key points

- Most tinnitus is subjective and linked to sensorineural hearing loss.
- All persistent tinnitus deserves otoscopy and audiometry.
- One-sided tinnitus with asymmetric hearing loss: MRI to rule out a vestibular schwannoma.
- Pulsatile tinnitus suggests a vascular cause and almost always needs imaging.
- No drug is approved to cure tinnitus; hearing aids, sound therapy and cognitive behavioural therapy help.

## 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](https://durgical.com/en/conditions/presbycusis/) | Presbycusis | Audiometry and hearing aids |
| [Bilateral after noise exposure](https://durgical.com/en/conditions/hearing-loss/) | Noise-induced hearing loss | Audiometry and hearing protection |
| [One-sided with vertigo attacks and fullness](https://durgical.com/en/conditions/meniere-disease/) | Ménière disease | Audiometry and ENT |
| [One-sided with progressive hearing loss](https://durgical.com/en/conditions/vestibular-schwannoma/) | 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](https://durgical.com/en/conditions/otitis-externa/) | 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.

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## Connections

## Related 5

- [Approach to hearing loss](https://durgical.com/en/ent/approach-to-hearing-loss/)
- [Pure-tone audiometry: how to read an audiogram](https://durgical.com/en/ent/pure-tone-audiometry-how-to-read-an-audiogram/)
- [Ototoxic drugs: which ones, who is at risk and how to monitor](https://durgical.com/en/ent/ototoxic-drugs-which-ones-who-is-at-risk-and-how-to-monitor/)
- [Noise-induced hearing loss and hearing conservation at work](https://durgical.com/en/ent/noise-induced-hearing-loss-and-hearing-conservation-at-work/)
- [Hearing aids and cochlear implants](https://durgical.com/en/ent/hearing-aids-and-cochlear-implants/)

## Related conditions 2

- [Hearing loss (conductive and sensorineural, including sudden hearing loss)](https://durgical.com/en/conditions/hearing-loss/)
- [Ménière disease](https://durgical.com/en/conditions/meniere-disease/)

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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](https://www.ncbi.nlm.nih.gov/books/NBK430809/) (StatPearls Publishing (NCBI Bookshelf), 2023); [Tinnitus](https://www.nidcd.nih.gov/health/tinnitus) (National Institute on Deafness and Other Communication Disorders (NIDCD), 2023); [Sensorineural Hearing Loss](https://www.ncbi.nlm.nih.gov/books/NBK565860/) (StatPearls Publishing (NCBI Bookshelf), 2023); [Vestibular Schwannoma (Acoustic Neuroma) and Neurofibromatosis](https://www.nidcd.nih.gov/health/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.

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/ent/approach-to-tinnitus/