Red flag symptoms: Tinnitus

The red flag symptoms associated with tinnitus, including when to make an emergency or urgent clinic referral and possible causes of the condition.

Red flag symptoms

  • Sudden and pulsatile tinnitus
  • Significant neurological signs/symptoms
  • Severe vertigo
  • Sudden unexplained hearing loss
  • Developing after head injury
  • Severe functional or psychological distress

Tinnitus (from the Latin for ringing) is a common ear complaint which can affect people of all ages.

At least 15% of the UK population experience tinnitus at some stage of their life, and for a few patients it can become a significant and permanently bothersome aspect of their subjective everyday well-being.

Tinnitus is defined as perceived noise in one or both ears in the absence of an external stimulus. Patients typically describe whistling, hissing, humming, pulsating or clicking noises, or a mixture of sounds, in some rare cases even voices or music, that plays in a loop (musical tinnitus). Some sample sounds can be found here.

We all have a degree of noise in our ears, probably caused by baseline electrical activity and natural blood flow within the ear. However, these sounds do not normally reach our consciousness.

The possible causes for tinnitus are manifold: noise exposure and hearing loss are the most common culprits, but ear wax, head injuries, infections and certain medications may also lead to (reversible) tinnitus. In many cases tinnitus is likely to be multifactorial. Medications that have been implicated as causes of tinnitus include aspirin, diuretics and certain antibiotics (erythromycin, tetracycline and others).

A triad of rotational vertigo, hearing loss and tinnitus suggests possible Meniere's disease. This is, however, a rare condition (the estimated prevalence is less than 0.5%). Pulsatile tinnitus may indicate a vascular malformation, obstruction (typically in the carotid artery) or a glomus tumour.

Occasionally tinnitus is accompanied by hyperacusis, an exaggerated perception of certain sounds or frequencies. This typically indicates cochlear damage.

When to refer

Patients should be immediately referred to on-call ENT if tinnitus is sudden and pulsatile, is accompanied by significant neurological signs or symptoms (such as facial weakness), severe vertigo or sudden unexplained hearing loss, or has developed after a head injury.

This is to exclude possible cerebrovascular disease, treatable trauma, or a neoplasm such as an acoustic neuroma, vestibular schwannoma, cerebellopontine angle tumour, or glomus tumour etc.

An urgent clinic referral for tinnitus should be done if it is:

  • unilateral
  • pulsatile with gradual onset
  • objective (that is, externally audible to another person)
  • associated with persistent otalgia or otorrhoea (without response to routine treatment – think cholesteatoma)
  • or if there is gradual, progressive or intermittent hearing loss with or without dizziness (such as a first presentation of suspected Meniere's disease, depending on local pathways).

Persistent tinnitus for more than three or six months that is causing significant physical or psychological distress can be referred routinely on clinical judgment. Depending on local pathways, an initial referral to audiology may be preferred or expected.


Many reversible causes of tinnitus such as impacted wax, medication side effects, otitis media/externa, or temporomandibular joint dysfunction can be managed in primary care without specialist input. Chronic tinnitus for harmless reasons usually improves with time by habituation and the goal of treatment of such cases is to reduce the impact of tinnitus on the person's life in the meantime.

Tinnitus is naturally masked by background noise, which is why hearing loss often makes the condition worse. Appropriate background noise (quiet music, the sound of a fan or a water feature) can therefore often improve tinnitus, and hearing aids, maskers and sound therapy are also effective treatments.

Pulsatile tinnitus will need radiological imaging (most likely MRI, sometimes CT or angiography) to exclude skull base tumours and vascular lesions such as arteriovenous malformation and fistulas.

Surgical approaches such as ablation of the auditory nerve can cause permanent hearing loss and exacerbate tinnitus, so should be avoided in most cases.

Acoustic neuromas (vestibular schwannomas), which typically cause unilateral tinnitus, are unlikely to be operated on as they tend to grow extremely slowly, if at all.


Patients often worry that brain tumours or significant cardiovascular events are the cause for their tinnitus. They need to be reassured that such malignant causes are atypical, especially in the absence of any other symptoms.

Many patients notice that stress, anxiety and fatigue worsen tinnitus, and relaxation techniques and antidepressants may be useful to some. Providing reassurance and information can prevent a patient from becoming chronically unwell or from trying unproven and possibly expensive alternative treatments, such as Ginkgo biloba.

While some patients may find tinnitus self-help groups helpful and supportive, for some they may reinforce the illness and exacerbate frustration with the perceived lack of effective medical treatment.

Patients with long-standing tinnitus and dysfunctional coping strategies can have a poor prognosis. However, some specialist clinics might be able to offer successful tinnitus retraining therapy combined with appropriate psychological support to change negative thought patterns and behaviours and reduce feelings of anxiety, anger and hopelessness.

Possible causes
  • Hearing loss
  • Noise exposure
  • Obstruction of ear canal (wax)
  • Infections (otitis externa or media)
  • Medication side-effects
  • Idiopathic
  • Meniere's disease
  • Tumours (acoustic neuroma, glomus tumour)
  • Dr Tillmann Jacobi is a GP in York

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This is an updated version of an article that was first published in February 2010.

Picture: iStock

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