Tinnitus is the unwanted perception of sound, within a person's head, in the absence of sound from the external environment. It may be described as ringing, hissing, buzzing, roaring, or humming. Tinnitus is classified as:
Subjective if the perceived sound can only be heard by the affected individual. Two-thirds of people with subjective tinnitus have a disorder causing hearing impairment (such as age-related hearing loss, noise-induced hearing loss, impacted wax, Meniere’s disease, or otosclerosis). The remaining third have no identifiable underlying abnormality of the auditory system.
Objective if the sound can be heard by the affected individual and the examiner (very rare). This is caused by a physical abnormality that produces sound near to, or within, the ear (for example a vascular abnormality producing a pulsatile sound near to the ear or a high cardiac output state producing pulsatile vibratory sounds).
Approximately 15% of adults report having tinnitus or episodes of tinnitus lasting longer than 5 minutes not related to noise exposure. Approximately 0.5% of adults report having tinnitus that has severely affected their ability to lead a normal life.
Tinnitus can affect quality of life by reducing social interaction and contributing to insomnia, anxiety, depression, and (rarely) suicide.
All people with subjective tinnitus should undergo a formal hearing test (pure tone audiogram with assessment of air and bone conduction) to assess their hearing and distinguish sensorineural from conductive hearing loss.
Referral to an ear, nose, and throat specialist will be necessary if there is:
Subjective unilateral tinnitus with sensorineural hearing loss on formal hearing test.
Subjective bilateral tinnitus with sensorineural hearing loss, which is suspected to be occupational and noise-induced in origin (the person may be eligible for compensation).
Tinnitus associated with conductive hearing loss when a treatable cause cannot be identified in primary care.
Tinnitus secondary to head or neck injury.
Tinnitus of uncertain cause.
Tinnitus causing distress despite initial management in primary care.
If referral to an ear, nose, and throat specialist is not necessary:
Any underlying cause of tinnitus (e.g. impacted wax) should be addressed.
Referral to an audiologist for a hearing aid should be considered if there is hearing loss.
Measures such as the use of sound to reduce the intrusiveness of tinnitus in quiet environments may be useful.
This CKS topic covers the management of tinnitus in adults in primary care. Information is provided about the symptomatic treatment that might be offered upon referral to secondary care for persistent tinnitus.
This CKS topic does not cover, in any detail, the management of tinnitus in secondary care.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
January to April 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.
No new evidence-based guidelines since 1 December 2009.
HTAs (Health Technology Assessments)
No new HTAs since 1 December 2009.
No new economic appraisals relevant to England since 1 December 2009.
Systematic reviews and meta-analyses
Systematic reviews published since the last revision of this topic:
Aazh, H., El Refaie, A., and Humphriss, R. (2011) Gabapentin for tinnitus: a systematic review. American Journal of Audiology 20(2), 151-158. [Abstract]
Hesser, H., Weise, C., Westin, V.Z. and Andersson, G. (2010) A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioural therapy for tinnitus distress. Clinical Psychology Review 31(4), 545-553. [Abstract]
Hoare, D.J., Stacey, P.C., and Hall, D.A. (2010) The efficacy of auditory perceptual training for tinnitus: a systematic review. Annals of Behavioral Medicine 40(3), 313-324. [Abstract] [Free Full-text]
Hobson, J., Chisholm, E., and El Refaie, A. (2010)Sound therapy (masking) in the management of tinnitus in adults (Cochrane Review). The Cochrane Library. Issue 12. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Hoekstra, C.E., Rynja, S.P., van Zanten, G.A., and Rovers, M.M (2011) Anticonvulsants for tinnitus (Cochrane Review). The Cochrane Library. Issue 7. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Kim, J.I., Choi, J.Y., Lee, D.H., et al. (2012) Acupuncture for the treatment of tinnitus: a systematic review of randomized clinical trials. BMC Complementary and Alternative Medicine 12, 97. [Abstract] [Free Full-text]
Martinez-Devesa, P., Perera, R., Theodoulou, M., and Waddell, A. (2010) Cognitive behavioural therapy for tinnitus (Cochrane Review). The Cochrane Library. Issue 9. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Phillips, J.S., and McFerran, D. (2010) Tinnitus Retraining Therapy (TRT) for tinnitus (Cochrane Review). The Cochrane Library. Issue 3. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Randomized controlled trials published since the last revision of this topic:
Cima, R.F.F., Maes, I.H., Joore, M.A., et al. (2012) Specialist treatment based on cognitive behaviour therapy versus usual care for tinnitus: a randomised controlled trial. Lancet 379(9830), 1951-1959. [Abstract]
No new national policies or guidelines since 1 December 2009.
No new safety alerts since 1 December 2009.
No changes in product availability since 1 December 2009.
To support primary healthcare professionals:
Diagnose the underlying cause of tinnitus, where possible
Manage the underlying cause of tinnitus, where possible
Manage the distress caused by tinnitus and its complications
Appropriately refer people with tinnitus
Tinnitus is the unwanted perception of sound, within the person's head, in the absence of sound from the external environment. It may be described as a ringing, hissing, buzzing, roaring, or humming. It is classified as:
Subjective tinnitus if the perceived sound can only be heard by the affected individual. This is associated with abnormalities affecting the auditory system (for example noise-induced hearing loss).
Objective tinnitus if the sound can be heard by the affected individual and the examiner. This is caused by a physical abnormality that produces sound near to, or within, the ear (for example a vascular abnormality producing a pulsatile sound near to the ear).
The mechanism producing subjective tinnitus is not completely understood. It has been proposed that:
There is a background of continuous, spontaneous neurological activity from the cochlea that can be experienced as tinnitus by all people in a silent environment. However, tinnitus is not usually experienced because:
Normal environmental sounds mask it.
The central auditory system (in the brainstem and auditory cortex) selectively filters it out.
Tinnitus may be perceived if any or all of the following occur:
Background cochlear activity changes as a result of a disorder of the cochlea.
Masking of background cochlear activity by environmental sound is reduced because of impaired hearing or a quiet environment.
Failure of the central auditory system to selectively filter out background cochlear activity. How and why the central auditory system adapts to allow tinnitus to be perceived rather than filtering it out is poorly understood.
Tinnitus may be exacerbated by focussing attention on it. This is more likely to occur in people with depression or anxiety, especially those with anxiety about the significance of tinnitus.
Tinnitus commonly improves slowly over time by a poorly-understood process of habituation in the central auditory system.
Two-thirds of people with tinnitus have a disorder causing hearing impairment. A third of people have idiopathic tinnitus where no underlying abnormality affecting the auditory system can be identified.
Most commonly, tinnitus is associated with disorders causing sensorineural hearing loss. This includes people with:
Age-related hearing loss (common).
Noise-induced hearing loss (less common).
Meniere's disease (uncommon).
Less commonly, tinnitus is associated with disorders causing conductive hearing loss. This includes people with:
Uncommonly, tinnitus is associated with:
Ototoxic drugs. Drug-induced ototoxicity most commonly causes bilateral tinnitus associated with sensorineural hearing loss. It is more likely to occur with higher doses, especially in elderly people and those with impaired renal or hepatic function. Ototoxic drugs include:
Cytotoxic drugs (including cisplatin and methotrexate) that can cause tinnitus and permanent hearing loss.
Aminoglycoside antibiotics (such as gentamycin) that can cause tinnitus and permanent hearing loss associated with vestibular injury.
Macrolide antibiotics (such as erythromycin and clarithromycin) that can cause tinnitus and reversible hearing loss.
Quinine salts (such as quinine sulphate).
Aspirin and nonsteroidal anti-inflammatory drugs, which can cause tinnitus and reversible hearing loss.
Loop diuretics (including furosemide and bumetanide), which can cause tinnitus and reversible hearing loss.
Ear infections — including otitis media, otitis media with effusion, and chronic suppurative otitis media.
Neurological disorders — including acoustic neuroma (also called vestibular schwannoma) and multiple sclerosis.
Metabolic disorders — including hypothyroidism, hyperthyroidism, and diabetes.
Psychological disorders — including anxiety and depression.
Trauma of the head or neck — that may or may not be associated with hearing loss.
Objective tinnitus is very rare. It is caused by disorders that produce sound within or near to the ear, including:
Vascular disorders that produce pulsatile vibratory sounds, such as:
Arteriovenous malformations and other vascular abnormalities (venous abnormalities tend to produce a continuous humming noise).
High cardiac output states may produce pulsatile vibratory sounds, such as:
Patulous eustachian tube — in which the eustachian tube remains open for prolonged periods of time resulting in the abnormal transmission to the ear of the person's own voice, heart beat, or breath sounds.
Myoclonus of palatal or middle ear muscles may cause objective tinnitus by abnormal rhythmic activity. They usually produce a clicking sound.
Data from the National Study of Hearing based on a postal questionnaire of 23,681 randomly-selected people in the UK found that:
Approximately 15% of adults reported having tinnitus or episodes of tinnitus lasting longer than 5 minutes that was not related to noise exposure.
Approximately 0.5% of adults had tinnitus that severely affected their ability to lead a normal life.
The impact of tinnitus on the person ranges from mild annoyance to a severe reduction in quality of their life. It may cause any or all of the following:
Reduced social interaction.
Suicide (a very rare complication).
Determine if the tinnitus is objective or subjective.
Objective tinnitus usually has a vibratory, clicking, or pulsatile character and is audible with a stethoscope. The stethoscope should be placed close to the external auditory meatus, over the carotid arteries, and on the skull in front and behind the ear.
Subjective tinnitus usually has a continuous tone and is not audible with a stethoscope by the examiner.
For people with subjective tinnitus:
The tinnitus is unilateral or bilateral. Bilateral tinnitus may be described as coming from both ears or from within the head. Unilateral tinnitus is localized to one affected ear.
There is a history of significant noise exposure.
The tinnitus developed while taking ototoxic drugs (aspirin, nonsteroidal anti-inflammatory drugs, certain antibiotics, loop diuretics, and cytotoxic drugs).
There is a family history of hearing loss from otosclerosis.
Examine the ear with an auriscope for disorders affecting the middle and outer ear.
Refer the person for a formal hearing test (pure tone audiogram with assessment of air and bone conduction) to assess their hearing and distinguish sensorineural from conductive hearing loss.
Undertake a general neurological assessment, including assessing the cranial nerves for underlying neurological conditions associated with tinnitus (such as acoustic neuroma or multiple sclerosis).
Look for clinical features of anaemia, thyroid disease, and diabetes and consider checking:
Full blood count.
Random or fasting blood glucose.
People are at risk of noise-induced hearing loss if they spend time in an environment, without ear protection, where:
They have to raise their voice to have a conversation with someone 2 metres away for at least part of the day.
They use noisy power tools or machinery for more than 30 minutes a day.
There are noises caused by impacts (for example hammering, drop forging, pneumatic impact tools, explosives, detonators, or guns).
Hearing is likely to become impaired if the person is repeatedly exposed to noise that causes muffled hearing after the exposure, even if this has completely resolved by the next day.
For people with subjective unilateral tinnitus and sensorineural hearing loss, suspect:
Meniere's disease — if there are intermittent episodes of tinnitus, associated with episodes of worsening hearing loss and vertigo generally lasting 1–2 hours. Typically, the tinnitus is low pitched and when severe is associated with a feeling of fullness in the affected ear. The vertigo may be accompanied by nausea and vomiting.
Acoustic neuroma — if tinnitus is continuous, especially if this is associated with progressive or sudden hearing loss. Vertigo may be present. Signs of cranial nerve and brain stem compression may develop with large tumours.
For people with subjective unilateral tinnitus and conductive hearing loss, suspect:
A disorder of the middle or outer ear — if there are signs of these conditions on examination (such as impacted wax, otitis media, or cholesteatoma).
Unilateral otosclerosis — if there are no signs of another disorder affecting the ear, especially if there is a family history of otosclerosis.
For people with tinnitus following a head or neck injury, suspect tinnitus secondary to trauma.
For people with subjective unilateral tinnitus of uncertain cause, refer to an ear, nose, and throat specialist for diagnosis of the underlying cause or confirmation that tinnitus is idiopathic. This includes people with tinnitus that is not associated with hearing loss.
Information about how to determine the underlying cause of subjective unilateral tinnitus is based on the clinical features of the underlying causes described by experts in textbooks and review articles [Noell and Meyerhoff, 2003; Crummer and Hassan, 2004; Bagger-Sjoback and Rask-Anderson, 2008; Ceranic and Luxon, 2008; Merchant et al, 2008; O'Leary, 2008].
For people with bilateral subjective tinnitus and sensorineural hearing loss, suspect tinnitus secondary to:
Age-related hearing loss — in older people who do not have a history of exposure to noise or ototoxic drugs.
Noise-induced hearing loss — if there is a history of significant noise exposure.
Drug-induced ototoxicity — if the tinnitus developed while taking aspirin, nonsteroidal anti-inflammatory drugs, certain antibiotics, loop diuretics, and cytotoxic drugs.
For people with bilateral subjective tinnitus and conductive hearing loss, suspect:
Bilateral otosclerosis. This is more likely if there is a family history of otosclerosis and there are no signs of another disorder affecting the ear.
A disorder of the middle or outer ear — if there are signs in both ears of conditions such as bilateral impacted wax, or bilateral otitis media.
Suspect tinnitus secondary to head or neck injury, multiple sclerosis, diabetes, or thyroid disease if these conditions are present and other causes have been ruled out.
For people with bilateral subjective tinnitus of uncertain cause, refer to an ear, nose, and throat specialist for diagnosis of the underlying cause or confirmation that the tinnitus is idiopathic. This includes people with tinnitus that is not associated with hearing loss.
Information for determining the underlying cause of subjective bilateral tinnitus is based on the clinical features of the underlying causes described by experts in textbooks and review articles [Noell and Meyerhoff, 2003; Crummer and Hassan, 2004; Baguley and McCombe, 2008; Baguley et al, 2008; Merchant et al, 2008; O'Leary, 2008].
Refer all people with objective tinnitus to an ear, nose, and throat specialist for diagnosis of the cause.
Scenario: Management: provides advice on:
The management of tinnitus in primary care.
When to refer people with tinnitus for secondary care assessment and management.
The management that might be offered following referral to secondary care.
Refer all people with objective tinnitus to an ear, nose, and throat specialist.
Refer to an ear, nose, and throat specialist people with subjective tinnitus, following a formal hearing test, who have:
Unilateral tinnitus associated with a sensorineural hearing loss. This includes people with suspected:
Bilateral tinnitus associated with sensorineural hearing loss that is suspected to be caused by occupational noise-induced hearing loss when the person is eligible for compensation.
Tinnitus associated with conductive hearing loss when a treatable cause (such as otitis media or impacted wax) cannot be identified and managed in primary care. This includes people with conditions such as:
Unilateral or bilateral otosclerosis.
Otitis media with effusion.
Chronic suppurative otitis media.
Tinnitus secondary to head or neck injury.
Tinnitus of uncertain cause. This includes people with tinnitus that is not associated with hearing loss and people with hearing loss that cannot clearly be distinguished as either sensorineural or conductive.
Tinnitus that is causing distress despite primary care management.
Primary care management is suitable for people with subjective tinnitus, following a formal hearing test, who have:
Tinnitus associated with conductive hearing loss when a clear cause (such as impacted wax or otitis media) can be identified and treated in primary care.
Bilateral tinnitus associated with sensorineural hearing loss, when:
Noise-induced hearing loss that is not related to the person's occupation can be confidently diagnosed. Specialist assessment is required for people with occupational noise-induced hearing loss when the person is eligible for compensation.
Age-related hearing loss can be confidently diagnosed.
Assess the underlying cause of tinnitus (see Assessment).
If indicated, refer the person for specialist assessment and management.
Treat the underlying cause of tinnitus when possible, for example by treating impacted wax or otitis media.
Tinnitus is common and usually improves with time, for most people, by a process of habituation.
The goal of treatment is to reduce the impact of tinnitus on the person's life.
The person's beliefs about tinnitus; and address any unfounded anxieties.
Anxiety and stress, and manage these if they are present. A patient information leaflet on relaxation techniques is available from the British Tinnitus Association.
Depression, and manage this if it is present (see the CKS topic on Depression).
Insomnia, and manage this if it is present (see the CKS topic on Insomnia).
Advise about using sound enrichment to reduce the impact of tinnitus.
Provide a hearing aid for people with hearing loss. Refer the person to an audiologist for this.
Arrange follow up to assess the person's response to treatment. Refer people who cannot be adequately managed in primary care.
Recommend the use of sound to reduce the intrusiveness of tinnitus in quiet environments. This may be especially useful when the person is trying to sleep, work, or read in a quiet environment.
Advise the person to experiment with different sounds to find what suits them best in different situations. Options include:
Opening a window to let in sounds from the outside.
Leaving a television or radio on in the background.
Static noise from a radio that has been tuned to be between stations.
Noise from a fan.
Recorded sounds associated with relaxation (such as running water, rain, or bird song) produced by a bedside generator. Some sound generators and MP3 players can be plugged into pillow speakers, reducing the audibility of these sounds to the person's partner.
Advise the person to experiment with the volume of sound.
Lower sound volumes that do not completely mask tinnitus may help to control the intrusiveness of the tinnitus to an acceptable level. Some experts believe that constant exposure to a very low level of tinnitus helps the person develop habituation to their tinnitus, reducing its intrusiveness in the long term.
Higher sound volumes may completely mask tinnitus when in use, but may make the tinnitus more noticeable for some people when the sounds are turned off. Significant noise exposure should be avoided to prevent hearing damage and exacerbation of tinnitus.
Patient information leaflets are available from the British Tinnitus Association, including:
Tinnitus retraining therapy is used to reduce the impact of tinnitus and help habituation develop. It is composed of two main elements: sound therapy and counselling.
Sound therapy involves providing a background of sound at a level just below that of the tinnitus. This is usually for 6–20 hours a day and particularly when the environment is quiet.
The sound may be provided by a portable (wearable) noise generator (previously called a masker) or a combination device that contains both a hearing aid and a sound generator.
This background level of sound reduces the intrusiveness of tinnitus without completely masking it. It is thought that by only partially masking it, habituation to tinnitus can develop.
Providing information about how tinnitus develops and how it can be influenced.
Helping the person deal with any stress and other problems they may have.
Identifying and dealing with any false beliefs, attitudes, or fears the person has about tinnitus.
CKS found no evidence to guide the primary care management of tinnitus. Management recommendations are based entirely on expert opinion.
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of Tinnitus.
Date unrestricted – December 2009
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
|/||indicates a MeSh subject heading with all subheadings selected|
|.tw||indicates a search for a term in the title or abstract|
|exp||indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree|
|$||indicates that the search term was truncated (e.g. wart$ searches for wart and warts)|
Topic specific literature search sources
Sources of guidelines
Medline (with guideline filter)
Sources of systematic reviews and meta-analyses
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NHS Economic Evaluations
Health Technology Assessments
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
Sources of national policy
Health Management Information Consortium (HMIC)
Bagger-Sjoback, D. and Rask-Anderson, H. (2008)
Baguley, D.M. and McCombe, A. (2008)
Baguley, D.M., Reid, E., and McCombe, A. (2008)
British Tinnitus Association (2005) Update on the management of tinnitus by Audiologists. ..British Tinnitus Association.www.tinnitus.org.uk
British Tinnitus Association (2009) Tinnitus - guidelines for primary care. ..British Tinnitus Association.www.tinnitus.org.uk
Ceranic, B. and Luxon, L.M. (2008)
Coles, R.R.A. (1984) Epidemiology of tinnitus: (1) prevalence. Journal of Laryngology and Otology Supplement 9, 7-15.
Handscomb, L. and McKinney, C. (2006) Sound therapy. ..British Tinnitus Association.www.tinnitus.org.uk [Free Full-text]
Henry, J.A., Dennis, K.C. and Schechter, M.A. (2005) General review of tinnitus: prevalence, mechanisms, effects, and management. Journal of Speech Language and Hearing Research : JSLHR 48(5), 1204-1235. [Abstract]
HSE (2005) Protect your hearing or lose it!. ..Health and Safety Executive.www.hse.gov.uk [Free Full-text]
Khot, A. and Polmear, A. (Eds.) (2006) Practical general practice: guidelines for effective clinical management. 5th edn. London: Butterworth Heinnman.
Merchant, S.M., McKenna, M.J., Browning, G.G. et al. (2008)
Noell, C.A. and Meyerhoff, W.L. (2003) Tinnitus. Diagnosis and treatment of this elusive symptom. Geriatrics 58(2), 28-34. [Abstract]
O'Leary, S. (2008)
Tyler, R.S. (2006)