Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

The recommendations in this guideline apply to all people (adults, children and young people) with tinnitus unless otherwise stated.

Tinnitus and hearing loss can co-exist. For adults with tinnitus and hearing loss this guideline should be read together with the NICE guideline on hearing loss in adults.

1.1 Support and information for people with tinnitus

Tinnitus support

1.1.1 At all stages of care:

  • Discuss with the person with tinnitus, and their family members or carers if appropriate, their experience of tinnitus, including its impact and any concerns.

  • Based on any identified needs, agree a management plan with the person, taking into account their preferences. The plan should include information about tinnitus and opportunities for discussion about different management options.

  • Discuss with the person the results of any recent assessments and their impact on the management plan.

  • With consent from the person or their parent or carer, as appropriate, share the management plan with relevant health, education and social care professionals.

1.1.2 For people with longstanding tinnitus who have delayed accessing care, aim to find out the reason for the delay and why they are accessing care now. This could involve, for example, asking questions about lifestyle factors or changes in health.

For a short explanation of why the committee made the recommendations on support for people with tinnitus and how they might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review A: tinnitus support.

Information

1.1.3 Reassure the person with tinnitus, at first point of contact with a healthcare professional, that:

  • tinnitus is a common condition

  • it may resolve by itself

  • although it is commonly associated with hearing loss, it is not commonly associated with other underlying physical problems

  • there are a variety of management strategies that help many people live well with tinnitus.

1.1.4 Give information about tinnitus at all stages of care. The content should be tailored to the individual needs of the person, and their family members or carers if appropriate, and include information about:

  • what tinnitus is, what might have caused it, what might happen in the future

  • what can make tinnitus worse (for example, stress or exposure to loud noise)

  • safe listening practices (for example, noise protection)

  • the impact of tinnitus (for example, it can affect sleep, see recommendation 1.3.5)

  • investigations (see section 1.4)

  • self-help and coping strategies (for example, self-help books and relaxation strategies)

  • management options (see section 1.5)

  • local and national support groups

  • other sources of information.

1.1.5 When providing information:

  • ensure it is available in appropriate formats such as verbal consultation, written information, leaflets and online in line with the NICE guideline on patient experience

  • take into account accessibility requirements for children, and people with hearing loss, cognitive impairment or visual impairment.

For a short explanation of why the committee made the recommendations on information for people with tinnitus and how they might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review B: patient information.

1.2 Referring people with tinnitus

1.2.1 Refer immediately to a crisis mental health management team for assessment people who have tinnitus associated with a high risk of suicide. If needed, provide a safe place while waiting for the assessment.

1.2.2 Refer immediately, in line with the NICE guideline on suspected neurological conditions, people with tinnitus associated with:

  • sudden onset of significant neurological symptoms or signs (for example, facial weakness), or

  • acute uncontrolled vestibular symptoms (for example, vertigo), or

  • suspected stroke (follow a local stroke referral pathway). For information about diagnosis and initial management of stroke, see the NICE guideline on stroke and transient ischaemic attack in over 16s.

1.2.3 Refer people to be seen within 24 hours, in line with the NICE guideline on hearing loss in adults, if they have tinnitus and have hearing loss that has developed suddenly (over a period of 3 days or less) in the past 30 days.

1.2.4 Recognise that assessment and management of the person's tinnitus may still need to continue following an immediate referral.

1.2.5 Refer people to be seen within 2 weeks for assessment and management if they have tinnitus associated with either of the following:

  • Distress affecting mental wellbeing (for example, distress that prevents them carrying out their usual daily activities) even after receiving tinnitus support at first point of contact with a healthcare professional (see recommendation 1.1.1). Refer in line with local pathways.

  • Hearing loss that developed suddenly more than 30 days ago or rapidly worsening hearing loss (over a period of 4 to 90 days). Refer in line with the NICE guideline on hearing loss in adults.

1.2.6 Refer people for tinnitus assessment and management in line with local pathways if they have any of the following:

  • tinnitus that bothers them despite having received tinnitus support at first point of contact with a healthcare professional (see recommendation 1.1.1)

  • persistent objective tinnitus

  • tinnitus associated with unilateral or asymmetric hearing loss.

1.2.7 Consider referring people for tinnitus assessment and management in line with local pathways if they have any of the following, in line with the NICE guideline on hearing loss in adults:

  • persistent pulsatile tinnitus

  • persistent unilateral tinnitus.

For a short explanation of why the committee made the recommendations on referring people with tinnitus and how they might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence reviews C-D: symptoms and features for urgent and non-urgent referral.

1.3 Assessing the impact of tinnitus using questionnaires

1.3.1 Consider using the Tinnitus Functional Index for adults to assess how tinnitus affects them.

1.3.2 If questionnaires cannot be used (for example, because of language issues or cognitive impairment) consider using other measures such as visual analogue scales.

1.3.3 Consider using an age- or ability-appropriate measure (such as a visual analogue scale) for children and young people to assess how tinnitus affects them.

For a short explanation of why the committee made the recommendations on assessing tinnitus using questionnaires and how they might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review E: questionnaires to assess tinnitus.

Assessing how tinnitus affects quality of life

1.3.4 Discuss with the person with tinnitus, and their family members or carers if appropriate, how the condition affects their quality of life (home, social, leisure, work and school).

For a short explanation of why the committee made the recommendation on assessing how tinnitus affects quality of life and how it might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review G: assessing quality of life.

Assessing how tinnitus affects sleep

1.3.5 Ask people with tinnitus if they have problems sleeping because of tinnitus. If they do, consider screening with a questionnaire (such as the Insomnia Severity Index). Discuss the results with them and how this might inform their management plan.

For a short explanation of why the committee made the recommendation on assessing sleep and how it might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review F: assessing psychological impact.

Assessing the psychological impact of tinnitus

Adults

1.3.6 Be alert at all stages of care to the impact of tinnitus on mental health and wellbeing in adults. If there are concerns, follow the recommendations in the NICE guideline on common mental health problems.

1.3.7 Consider using the tinnitus questionnaire (TQ) or mini-TQ alongside the Tinnitus Functional Index in adults with tinnitus if further assessment of the psychological effects of tinnitus is needed.

1.3.8 If there are concerns about depression or anxiety in adults, a healthcare professional competent in mental health assessment should:

  • carry out an assessment using a questionnaire (for example, those in the recommendations on assessment in the NICE guideline on common mental health problems), or an ability-appropriate measure

  • consider assessment using the Clinical Outcomes in Routine Evaluation – Outcome Measure

  • agree an action plan, if needed, in line with the recommendations on assessment in the NICE guideline on common mental health problems.

Children and young people

1.3.9 Be alert at all stages of care to the behavioural and psychological wellbeing of all children and young people presenting with tinnitus. Talk to them, and their family members or carers if appropriate, about how they feel.

1.3.10 If there are concerns about depression in children and young people, follow the recommendations in the NICE guideline on depression in children and young people.

For a short explanation of why the committee made the recommendations on assessing the psychological impact of tinnitus and how they might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review F: assessing psychological impactv.

1.4 Investigations

Audiological assessment

1.4.1 Offer an audiological assessment to people with tinnitus. For recommendations on assessing and managing hearing loss in adults, see the NICE guideline on hearing loss in adults.

1.4.2 Consider tympanometry when middle-ear or Eustachian tube dysfunction, or other causes of conductive hearing loss contributing to tinnitus, are suspected.

1.4.3 Do not offer acoustic reflex testing or uncomfortable loudness levels/loudness discomfort levels testing as part of an investigation of tinnitus.

1.4.4 Do not offer otoacoustic emissions tests as part of an investigation of tinnitus unless the tinnitus is accompanied by other symptoms and signs.

For a short explanation of why the committee made the recommendations on audiological assessment and how they might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review H: audiological assessment.

Psychoacoustic tests

1.4.5 Do not offer psychoacoustic tests, for example pitch and loudness matching, to assess tinnitus.

For a short explanation of why the committee made the recommendation on psychoacoustic tests and how it might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review I: psychoacoustic measures.

Imaging

Non-pulsatile tinnitus

1.4.6 Offer MRI of internal auditory meati (IAM) to people with non-pulsatile tinnitus who have associated neurological, otological or head and neck signs and symptoms. If they are unable to have MRI (IAM), offer contrast-enhanced CT (IAM).

1.4.7 Consider MRI (IAM) for people with unilateral or asymmetrical non-pulsatile tinnitus who have no associated neurological, audiological, otological or head and neck signs and symptoms. If they are unable to have MRI (IAM), consider contrast-enhanced CT (IAM).

1.4.8 Do not offer imaging to people with symmetrical non-pulsatile tinnitus with no associated neurological, audiological, otological or head and neck signs and symptoms.

To find out why the committee made the recommendations on non-pulsatile tinnitus and how they might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review J: imaging to investigate the cause of non-pulsatile tinnitus.

Pulsatile tinnitus

1.4.9 Offer imaging to people with pulsatile tinnitus.

  • For people with synchronous pulsatile tinnitus, consider:

    • magnetic resonance angiogram or MRI of head, neck, temporal bone and IAM if clinical examination and audiological assessment are normal, or contrast-enhanced CT of head, neck, temporal bone and IAM if they cannot have magnetic resonance angiogram or MRI

    • contrast-enhanced CT of temporal bone if an osseous or middle-ear abnormality is suspected (for example, glomus tumour), followed by MRI if further investigation of soft tissue is required.

  • For people with non-synchronous pulsatile tinnitus (for example, caused by palatal myoclonus) consider MRI of the head, or if they cannot have MRI, contrast-enhanced CT of the head.

For a short explanation of why the committee made the recommendation on pulsatile tinnitus and how it might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review K: imaging to investigate the cause of pulsatile tinnitus.

1.5 Management of tinnitus

Amplification devices

1.5.1 Offer amplification devices to people with tinnitus who have a hearing loss that affects their ability to communicate. For adults, follow the recommendations on hearing aids in the NICE guideline on hearing loss in adults.

1.5.2 Consider amplification devices for people with tinnitus who have a hearing loss but do not have difficulties communicating.

1.5.3 Do not offer amplification devices to people with tinnitus but no hearing loss.

For a short explanation of why the committee made the recommendations on amplification devices and how they might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review M: sound therapy and amplification devices.

Sound therapy

The committee were unable to make recommendations for practice in this area. They made a recommendation for research.

For a short explanation of why the committee were unable to make recommendations on sound therapy see rationale.

Full details of the evidence and the committee's discussion are in evidence review M: sound therapy and amplification devices.

Psychological therapies for people with tinnitus-related distress

1.5.4 Consider a stepped approach to treat tinnitus-related distress in adults whose tinnitus is still causing an impact on their emotional and social wellbeing, and day-to-day activities, despite having received tinnitus support. If a person does not benefit from the first psychological intervention they try or declines an intervention, offer an intervention from the next step in the following order:

  • digital tinnitus-related cognitive behavioural therapy (CBT) provided by psychologists

  • group-based tinnitus-related psychological interventions including mindfulness-based cognitive therapy (delivered by appropriately trained and supervised practitioners), acceptance and commitment therapy or CBT (delivered by psychologists)

  • individual tinnitus-related CBT (delivered by psychologists).

For a short explanation of why the committee made the recommendation on psychological therapies for people with tinnitus-related distress and how it might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review L: psychological therapies.

Betahistine

1.5.5 Do not offer betahistine to treat tinnitus.

For a short explanation of why the committee made the recommendation on betahistine and how it might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review N: betahistine.

Combining therapies

The committee were unable to make recommendations for practice in this area. They made a recommendation for research.

For a short explanation of why the committee were unable to make recommendations on combining therapies see rationale.

Full details of the evidence and the committee's discussion are in evidence review P: combinations of management strategies.

Neuromodulation

The committee were unable to make recommendations for practice in this area. They made a recommendation for research.

For a short explanation of why the committee were unable to make recommendations on neuromodulation see rationale.

Full details of the evidence and the committee's discussion are in evidence review O: neuromodulation.

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline.

Digital tinnitus-related cognitive behavioural therapy

Digital CBT is a form of CBT delivered using digital technology, such as a computer, tablet or phone. Common components of digital tinnitus-related CBT are similar to those used in face-to-face CBT (for example, positive imagery and learning to identify and challenge unhelpful thoughts). People using digital CBT are more likely to have less direct contact with healthcare professionals during the intervention compared with face-to-face interventions.

Objective tinnitus

Tinnitus that occurs as a result of noise generated in the ear that can be detected by the examiner. It is less common than subjective tinnitus.

Refer immediately

To be seen by the specialist service within a few hours, or even more quickly if necessary.

Tinnitus-related distress

Tinnitus that is having an impact on emotional and social wellbeing and day-to-day activities.

Tinnitus support

A term used to describe a session that includes a 2-way process of information-giving and discussion to help the healthcare professional understand the difficulties and goals of the person with tinnitus. This discussion occurs between the person with tinnitus, and their family members or carers if appropriate, and the healthcare professional. A management plan is also jointly developed and the person is supported to continue with the plan or modify it as necessary. This process is sometimes known as tinnitus counselling.

  • National Institute for Health and Care Excellence (NICE)