Tinnitus guidance for GPs

This information is intended to help support GPs who see patients with tinnitus

Tinnitus red flags

Firm indications that a patient with tinnitus should be referred onwards include:

• Pulsatile tinnitus
• Tinnitus in association with significant vertigo
• Unilateral or asymmetric 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, we 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 14.4% 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 these people will require specialist support.

Underlying pathology is rare, but be vigilant

In many cases tinnitus is due to 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”; “there are many ways of helping people with tinnitus”. Modern management strategies such as use of hearing aids, counselling and sound therapy or use of psychological treatments such as cognitive behavioural therapy, mindfulness-based cognitive therapy or acceptance and commitment therapy all have evidence of efficacy.

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.

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. 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. There are also many apps for smartphones and similar devices.

For those with hearing loss in addition to tinnitus, many modern hearing aids have builtin sound therapy programs specifically for tinnitus patients. Alternatively, many hearing aids can link wirelessly to sound therapy apps in other electronic devices, Audiology and Hearing Therapy services can advise patients on the most appropriate approach for their situation.

Self-help is often effective

Tinnitus UK provides comprehensive information on tinnitus and common-sense advice on managing symptoms. It also has a network of tinnitus support groups around the country. It runs a freephone telephone helpline 0800 018 0527 as well as offering advice through its website tinnitus.org.uk. Tinnitus UK have developed a free 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 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. They know from the calls they receive, that when early help is given by GPs and secondary services, patients manage their tinnitus more effectively.

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.