Tinnitus: history, investigation and management

This clinical overview outlines best practice in the assessment and management of tinnitus based on NICE guidance.
Tinnitus: history, investigation and management

Tinnitus is the perception of noises that a patient hears in their head and/or their ear(s) which do not have an external source. Noises can be different and range from ringing, buzzing, whooshing, roaring, humming or whistling and can be low, medium or high pitched in nature. Patients can describe it as a single noise or having multiple elements to it. Patients with pulsatile tinnitus have noises that pulse in time with their heartbeat. Some types of tinnitus can sound like a musical song to patients and is termed musical tinnitus.1,2

Video 1: What does tinnitus sound like? (WARNING: turn volume down when sounds start)


Tinnitus is common and reported in all age ranges even in children. About 1 in 3 people will experience tinnitus in their lives. The proportion of UK patients who suffer with ongoing tinnitus is thought to be about 13%. If this group about 10% have tinnitus that affects their quality of life significantly.1

Aetiology and risk factors1,2,3

The exact cause is unknown. It can develop with aging and the loss of hearing that occurs with advancing years. It can be caused by exposure of loud noises such as working in a noisy environment (factory, loud music/clubs or in the armed forces). 

Otological problems causing tinnitus are presbycusis, sensorineural hearing loss, ear wax, infection, tympanic membrane perforation, noise induced (as above), otosclerosis, and Meniere's disease.

Neurological conditions such as multiple sclerosis or head trauma can be a cause. 

Metabolic issues are also seen to play a role in the development of tinnitus for example hyperlipidaemia (can cause inner ear stroke/ischaemia), vitamin B12 deficiency, diabetes mellitus, hyperthyroidism, hypothyroidism.

Vascular disorders, such as arterial bruits or venous hums, may result in tinnitus.

It is also important to consider ototoxic medications. High risk drugs are aspirin, non-steroidal anti-inflammatory drugs, aminoglycosides, certain narcotics, phosphodiesterase type 5 inhibitors (PDE5i).

Subjective tinnitus is thought more likely with otological problems (i.e. neural activity of biochemical changes) and objective tinnitus is the perception of sounds due to local neighbouring structures (both patient and examiner can hear sounds). 

Classification can be based on origin of the tinnitus i.e. conductive, sensorineural or central.

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  1.  What is tinnitus? British Tinnitus Association, [accessed 13/08/2020]. 
  2. Knott L. Tinnitus. Patient.info, 2020.
  3. Aetiology of tinnitus. BMJ Best Practice, [accessed 13/08/2020]. 
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