Step 1 of 6
EV · MODERATEConfirm the Complaint
Laterality · pulsatile vs non-pulsatile · acute vs chronic · bothersome vs not
Tinnitus is the perception of sound without an external source. The first task is structural: characterise the symptom along the few axes that drive every downstream decision in this chapter.
- Laterality — unilateral vs bilateral vs central
- Quality — pulsatile vs non-pulsatile · ringing / hissing / clicking / roaring
- Temporal pattern — continuous vs intermittent · acute (≤ 6 mo) vs chronic
- Subjective vs objective — heard only by patient vs audible to examiner
- Bothersome vs non-bothersome — interferes with sleep / concentration / mood
★ High-yield pearls (chapter-wide)
- Tinnitus becomes clinically important not because it is present, but because it is bothersome, unilateral, pulsatile, or associated with hearing loss, vertigo, neurological signs, sleep disturbance, anxiety, or depression.
- Pulsatile tinnitus is structural until imaging proves otherwise — do not reassure prematurely.
- Unilateral tinnitus or asymmetric SNHL triggers MRI IAC, not reassurance.
- Bilateral non-pulsatile tinnitus with symmetric hearing — do not image routinely (AAO-HNS recommendation against).
- Objective tinnitus — look at the palate while listening. Palatal myoclonus diagnoses itself.
- Hearing aids reduce tinnitus loudness perception even when hearing loss is mild — offer for any communication-affecting HL.
- Avoid silence. Sound enrichment is the cheapest, most under-used tinnitus intervention.
- CBT is the best-evidenced specific therapy. Refer early for distressed patients — do not wait for medication to fail.
- Severity scores (THI / TFI) drive management more than audiogram thresholds.
- Screen for sleep, anxiety, depression, and suicidal ideation in severely distressed patients.
- Routine drugs, supplements, and TMS are not recommended for primary tinnitus.
- Somatic modulation is a free diagnostic — clench, open wide, rotate neck. TMJ-modulated tinnitus often responds to a splint.
Evidence base
8 sources- HIGH
Tunkel DE et al. · Otolaryngol Head Neck Surg · 2014Landmark AAO-HNS clinical practice guidelinePMID 25273878
AAO-HNS guideline — foundational reference for the chronic-tinnitus pathway. Defines bothersome vs non-bothersome, primary vs secondary, and the core action items (history, audiogram, distinguish pulsatile, identify unilateral / asymmetric for imaging). Vol 151(2 Suppl):S1-S40.
- HIGH
National Institute for Health and Care Excellence · 2020National guideline (NICE, UK)
NICE NG155 — UK national reference for tinnitus assessment and management. Anchors history-taking, support principles, CBT and amplification recommendations. Companion to the AAO-HNS guideline. London: NICE; 2020.
- HIGH
Baguley D, McFerran D, Hall D · Lancet · 2013Landmark Lancet narrative reviewPMID 23827090
Comprehensive Lancet review — epidemiology, mechanisms (central gain, auditory deafferentation), and current management. Vol 382(9904):1600-1607.
- HIGH
Langguth B et al. · Lancet Neurol · 2013Landmark Lancet Neurology reviewPMID 23948178
Companion Lancet Neurology review — mechanistic / neuromodulation perspective on tinnitus aetiology and management. Vol 12(9):920-930.
- HIGH
Fuller T et al. · Cochrane Database Syst Rev · 2020Cochrane systematic reviewPMID 31912887
Cochrane review — CBT is the best-evidenced intervention for tinnitus-related distress, sleep, and quality-of-life impact. Vol 1(1):CD012614.
- HIGH
Jastreboff PJ & Hazell JW · Br J Audiol · 1993Foundational neurophysiological modelPMID 8339063
Jastreboff–Hazell neurophysiological model — central reorganisation and habituation framework that anchors modern Tinnitus Retraining Therapy. Vol 27(1):7-17.
- HIGH
Chandrasekhar SS et al. · Otolaryngol Head Neck Surg · 2019AAO-HNS clinical practice guidelinePMID 31369359
AAO-HNS Sudden Hearing Loss CPG — companion guideline; informs the sudden-HL red-flag handoff from the tinnitus pathway. Vol 161(1 Suppl):S1-S45.
- HIGH
Moffat DA et al. · J Laryngol Otol · 1994Landmark case seriesPMID 8163910
Moffat–Baguley series establishing that sudden deafness can be the presenting feature of vestibular schwannoma — anchors the unilateral-tinnitus / sudden-HL imaging imperative. Vol 108(2):116-119.