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Tinnitus: assessment and management

NICE guideline [NG155] Published: 11 March 2020

Introduction

Tinnitus, the perception of sound in the absence of an external source, affects up to 1 in 5 people in the UK and significantly burdens healthcare resources.

Remember tinnitus is a symptom not a disease.

Prevention: Noise Exposure: 60/60 Rule

60/60 rule, never turn your volume up past 60%, and only listen to music with earbuds for a maximum of sixty minutes per day.

The rise in tinnitus numbers is due to the increasing and aging UK population. However, a recent study from Statistics Canada    revealed that 80% of adults aged 19 to 29 reported using headphones or earbuds connected to audio devices in the past year had rates of tinnitus over one third higher than for older adults.

Diagnoses not to miss

  • Vestibular schwannoma: Benign tumour on 8th cranial nerve/cerebropontine angle. Unilateral/asymmetrical sensorineural hearing loss, tinnitus, vertigo, facial weakness/numbness
  • Stroke: Patients presenting with the classic stroke symptoms may also have sudden onset tinnitus and/or vertigo and/or hearing loss if the arterial supply to the labyrinth is affected eg. Anterior inferior cerebellar artery infarcts
  • Ménière’s disease (endolymphatic hydrops): Vertigo (lasting 20 mins - hours), tinnitus, fluctuating/sensorineural hearing loss, aural fullness
  • Cholesteatoma: Epidermal skin from the ear canal or outside surface of the eardrum, does not belong in the middle ear. May present with otorrhoea, mixed or conductive hearing loss, tinnitus, vertigo, facial nerve palsy
  • Sudden sensorineural hearing loss: a rapid loss of hearing that occurs suddenly or over a period of up to 72 hours. May present with tinnitus and vertigo
  • Glomus jugulare tumour: Rare slow-growing, vascular tumours of a group called paragangliomas. The most common symptoms are deafness and pulsatile tinnitus. There may be associated vertigo

Examination

  • Otoscopic examination
  • Check cranial nerves for focal neurological signs
  • Rinne and Weber tests

Rinne test

  • Comparison of air conduction (AC) and bone conduction (BC) sensitivity
  • Tuning fork is alternated between entrance of ear canal and mastoid process
  • Rinne Positive: Tuning fork is louder via AC = sensorineural hearing loss (SNHL)
  • Rinne Negative: Tuning fork is louder on mastoid = conductive hearing loss (CHL)

Weber test

  • Test of lateralisation and therefore may be used for patients who report unilateral hearing loss.
  • The tuning fork is placed midline on the patients’ forehead.
  • If sound lateralises to ear with loss = conductive hearing loss as the improved bone conduction is due to the occlusion effect.
  • If sound lateralises to ear without loss = sensorineural hearing loss or mixed hearing loss (MHL) as the best cochlea is detecting the signal. In normal hearing= midline.

Whisper test

A simple and accurate test for detecting hearing impairment:

  1. The examiner stands at arm's length (0.6 m) behind the seated patient (to prevent lip-reading) and whispers a combination of three numbers and letters (for example, 4-K-2) and then asks the patient to repeat the sequence.
  2. The examiner should quietly exhale before whispering to ensure as quiet a voice as possible.
  3. If the patient responds incorrectly, the test is repeated using a different number/letter combination. The patient is considered to have passed the screening test if they repeat at least three out of a possible six numbers or letters correctly (i.e 50% correct).
  4. Each ear is tested individually, starting with the ear with better hearing. During testing, the non-test ear is masked by gently occluding the auditory canal with a finger and rubbing the tragus in a circular motion.
  5. The other ear is assessed similarly with a different combination of numbers and letters.

  • Consider blood tests to rule out potential causes of tinnitus e.g. diabetes and thyroid tests.
  • Offer audiometry to anyone who reports hearing loss or fails the whisper test, has unilateral tinnitus or tinnitus of more than 6 months duration.
  • Explore effect on social wellbeing, QOL, daily activities (eg. via Tinnitus Functional Index questionnaire).

When to refer and timescales

Referrals to ENT (red flags) Referrals for support (usually CBT)
Unilateral tinnitus
Pulsatile tinnitus
Focal neurological abnormality (eg possible stroke presentation which would need acute admission)
Asymmetric hearing loss		 Significant distress
Impact on mental health

Refer immediately for potential admission:

  • To a crisis mental health management team for assessment for people who have tinnitus associated with a high risk of suicide
  • Tinnitus associated with sudden onset of significant neurological symptoms or signs (for example, facial weakness)
  • Tinnitus associated with acute uncontrolled vestibular symptoms (for example, vertigo)
  • Tinnitus associated with suspected stroke symptoms

Refer to ENT for tinnitus assessment and management if:

  • Tinnitus bothers them despite having received tinnitus support at first point of contact with a healthcare professional
  • Persistent objective tinnitus
  • Tinnitus associated with unilateral or asymmetric hearing loss

Consider referring to ENT for tinnitus assessment and management if:

  • Patients have persistent pulsatile tinnitus
  • Patients have persistent unilateral tinnitus

Patients who do not meet the criteria for ENT referrals or referrals for support can be managed in primary care.

1. Education

Many who present are concerned that tinnitus may be a sign of a more serious condition, or result in progressive hearing loss or deterioration. Therefore education is key:

  • E.g. for those with mild symptoms, offer an explanation and an information leaflet

National support groups and resources to signpost patients to (see below for links):

  • British Tinnitus Association
  • Royal National Institute of Deaf People (RNID)

2. Medical Management

  • There are no perfect studies looking at the treatment of tinnitus – they all have short periods of follow-up, there are no standardised assessments and risk of bias is high
  • There are currently no medications, supplements or herbal remedies that have any evidence to significantly reduce the severity of tinnitus
  • If there is co-existing psychological problems/insomnia, managing this with medication (in addition to other strategies) may reduce the impact of tinnitus on quality of life
  • NICE advises not to offer betahistine to people with tinnitus as evidence suggests it does not improve tinnitus symptoms and has side effects notably in the gastrointestinal tract

3. Acoustic Stimulation

Possible strategies for those who do not require hearing aids include:

  • Broadband noise generators (which are also available via tinnitus apps)
  • Music

4. Psychological Treatments

There are two aims of psychological treatment:

  1. To decrease the negative effect of tinnitus on the individual
  2. To treat associated mental health problems, e.g. anxiety and depression

Psychological techniques you can consider signposting to or recommending:

  1. Mindfulness
  2. Relaxation training, because stress and tension impair the individual's ability to cope with tinnitus e.g. breathing exercises and progressive muscle relaxation
  3. Attention refocusing

If a person does not benefit from the first psychological intervention or declines an intervention, then consider a stepped approach and referral to secondary care.

Psychological therapies for people with tinnitus-related distress

NICE recommends considering a stepped approach in the following order:

  1. Digital tinnitus-related cognitive behavioural therapy (CBT)
  2. Group-based tinnitus related psychological interventions including mindfulness-based cognitive therapy acceptance and commitment therapy (ACT), or CBT
  3. Individual tinnitus related CBT

References

Useful resources

Resources from the British Tinnitus Association:

Resources from Action on Hearing Loss:

You may find it helpful to direct people to the BTA online shop to purchase additional equipment to help manage their tinnitus, such as sleep phones or pillow speakers:

Specific resources for telephone/skype consultations, managing tinnitus whilst socially distancing:


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