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Tinnitus Care Pathway Overview

This pathway has been published with the aim of streamlining services and supporting GPs in providing best practice care to their Tinnitus sufferers. The aim of the pathway is to ensure that only appropriate patients are referred into secondary care, and that all primary care options have been exhausted.

Please click the relevant flowchart box to be taken directly to textual information

                 

Red Flags
Auditory:
  • Tinnitus associated with sudden sensorineural hearing loss occurring within 3 days or less, contact on-call ENT Senior House Officer (SHO) on the SAME DAY OF PATIENT REVIEW- to be seen in the EMERGENCY ENT clinic

Neurological:

  • Tinnitus associated with unexplained neurological symptoms. Refer to Consultant led ENT Out-patient clinic on an URGENT basis

Practice Point

Please see the "Urgent Care:general" section on G-care for SWAST's guidance on Requesting Ambulance Transport (999 or Urgent)

Presentation

Tinnitus is a conscious awareness of a sound in the ears or head that is not due to an external noise. Tinnitus usually arises as a result of the abnormal firing of nerve cells in the area of the brain which processes sound (neural synchrony). It can affect one or both ears, and be of a different nature, sound and intensity in either ear.

The main cause of tinnitus is hearing loss. We all lose our hearing to some extent during life.

There are many different trigger for tinnitus such as exposure to loud noise, ear or head injuries, a build-up of ear wax, diseases of the ear, ear infections and side effects of medication or a combination of these.

Patients in the acute stage of the condition often display high levels of anxiety. The central auditory system is influenced by the limbic system within the brain, which controls emotions and mental state. When a person is stressed, anxious or excited this can increase the awareness of tinnitus symptoms.

Differential Diagnosis

The differential diagnosis for tinnitus includes:

  • Ear wax
  • Hyperacusis
  • Foreign body in ear
  • Hearing loss
  • Headache
  • Depression
  • Post-Traumatic Stress Disorder (PTSD)
  • Otitis media
  • Systemic precipitants
  • Vertigo
  • Psychiatric issues
  • Anxiety
  • Obsessive Compulsive Disorder (OCD)
Initial Primary Care Assessment
  • Assess the patient for any Red Flag symptoms and refer accordingly- see pathway above
  • Examine the ear with an auriscope for disorders affecting the middle and outer ear. Pathology of external ear or middle ear- refer to ENT outpatient clinic.
  • Check ears for wax. If present in excess, clear it and see the tinnitus improves over the next 4-6 weeks - if not refer to pathway above.
  • Undertake a general neurological assessment, including assessing the cranial nerves for underlying neurological conditions associated with tinnitus.
  • Look for clinical features of anaemia, thyroid disease, and diabetes and consider checking:
    • Full blood count
    • Thyroid function
    • Random or fasting blood glucose
  • 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 cartoid arteries, and on the skull in front and behind the ear. If the tinnitus is objective refer to an ear, nose and throat (ENT) specialist.

Subjective tinnitus usually has a continous tone and is not audible with a stethoscope by the examiner:

  • Determine if tinnitus is unilateral or bilateral
  • Unilateral refer to Ear, nose and Throat (ENT) Department
  • Bilateral tinnitus - refer to tinnitus pathway above
Initial Primary Care Management

Primary care management is suitable for people who meet ALL of the following criteria:

  • Subjective bilateral tinnitus
  • Patient report NO hearing loss
  • Patients sleep and concentration is not affected with tinnitus
  • Patients sleep and concentration is affected BUT they have developed their own coping mechanism to manage their tinnitus

  • Explain the condition and address any unfounded anxieties
  • Manage other conditions which may be present
  • Further advice available online- Please see Online Patient Resources section

  • Accessing self-help and support group information from a reliable source such as British Tinnitus Association (please see Patient Information and Leaflets section) or Gloucester Tinnitus Support Group (see Community Resources section for further information).
  • Sleep management - soft music, sound generators, avoid stimulants before bed time
  • Sound Therapy- experimenting with different sounds to find out what suits them best in different situations e.g. opening a window to let in sound from outside, leaving a television on in the background or noise from a fan. It may also be useful to experiment with the volume of sound. Significant noise exposure should be avoided to prevent hearing damage and exacerbation of tinnitus.
  • Cognitive Behavioural Therapy (CBT) - helps to examine thought patterns and beliefs
  • Counselling - this can help with understanding the condition and how it can be managed. It can also help to deal with stress
  • Relaxation Therapy - mindfulness techniques, yoga
  • Family Support - Telling friends, colleagues and family so that there is understanding at home and work
  • Ear, Nose and Throat Department (ENT) Advice and Guidance - Gloucestershire Hospitals Foundation Trust (GHFT) offer an Ear, Nose and Throat (ENT) Advice and Guidance service to GPs via e-Referral Service (eRS) and can provide advice on the management of individual patients if required.
When to Refer
  • Red Flag symptoms
  • Objective tinnitus, unilateral tinnitus and associated hearing loss
Ongoing Care
  • Self-management
  • Relaxation techniques
  • Sound therapy
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