Questionnaire/history: Onset? Quality? Duration? Frequency? Unilateral or bilateral? Continuous or episodic? Pulsatile, and, if so, it is in time with the person's heart? Associated hearing loss? Additional symptoms? - Dizziness? - Vertigo? - Balance problems? - Jaw pain or clicking? - Facial weakness? - Sensitivity to loud noises? Relieving or exacerbating factors (for example background noise, stress, lack of sleep, position)? Severity and its effect on the person's life? History of significant noise exposure from occupational or recreational activities? Objective tinnitus (usually clicking or pulsatile character and can also be heard by the clinician (auscultation of the peri-auricular area and over the temporal bone, orbit and vascular structures of the neck, carotid bruits, jugular venous hum, arteriovenous malformation thrill or myoclonic clicks may be heard)? Subjective tinnitus (not audible with a stethoscope)? Past medical history? - Previous history of ear surgery, infections, injury or head trauma? - Previous history of cardiovascular or metabolic diseases? Current medications (including OTC and herbal remedies)? Drug allergies? Examination: Otoscopy? Weber and Rinne? Palatal myoclonus? Jaw snapping or clicking indicative of TMJ dysfunction? Neurological exam including assessing the cranial nerves? If tinnitus pulsatile: - Head and neck examination? - BP? - Carotid or temporal artery bruits and vascular sounds? - Heart murmurs? Investigations: Considered random or fasting blood glucose, TFT, FBC, lipid levels? Referral: Immediate: - High risk of suicide? - Sudden onset of significant neurological symptoms or signs (eg facial weakness)? - Acute uncontrolled vestibular symptoms (eg vertigo)? - Suspected stroke? - Sudden onset pulsatile tinnitus? - Secondary to head trauma? Within 24 hours: - Hearing loss that has developed suddenly (over a period of 3 days or less) in the past 30 days? Within 2 weeks: - Distress affecting mental wellbeing (eg prevents from carrying out usual daily activities) even after receiving tinnitus support at first point of contact with a healthcare professional - Hearing loss that developed suddenly more than 30 days ago, or rapidly worsening hearing loss (over a period of 4–90 days) - Persistent otalgia or otorrhoea that does not resolve with routine treatment In line with local pathways: - Tinnitus that bothers them despite having received tinnitus support at first point of contact with a healthcare professional - Persistent objective tinnitus - Tinnitus associated with unilateral or asymmetric hearing loss - Persistent pulsatile tinnitus - Persistent unilateral tinnitus Less urgently: - Tinnitus of uncertain cause (including tinnitus that is not associated with hearing loss, ear pain, drainage or malodour, vestibular symptoms or facial weakness and hearing loss that cannot clearly be distinguished as either sensorineural or conductive Management in primary care: Referral if indicated Referral for an audiological assessment for all with tinnitus, particularly if it is persistent (lasting 6 months or more) Treatment of underlaying cause Medication review Discussion using sound therapy

Consideration of a stepped approach to psychological therapies for people with tinnitus-related distress referral for tinnitus counselling or cognitive behavioural therapy: - Digital tinnitus-related cognitive behavioural therapy (CBT) provided by a psychologist - Group-base tinnitus-related psychological interventions, including mindfulness-based cognitive therapy, acceptance and commitment therapy or CBT - Individual tinnitus-related cognitive behavioural therapy (CBT) Treatment of associated depression, anxiety and/or insomnia Hearing aid offered if hearing loss If referral not required: Advised: - Tinnitus is a common condition - It may resolve by itself - Although it is commonly associated with hearing loss, it is not commonly associated with underlying physical problems - Variety of management strategies that help many people live well with tinnitus - Information and self-care advice about tinnitus: ----- What it is ----- 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) ----- Investigations that may be required in secondary care ----- Self-help and coping strategies (for example, self-help books and relaxation strategies) ----- Management options - Local and national charities and support groups: ----- Action on hearing loss (www.actionnonhearingloss.org.uk) — Understanding tinnitus ----- British Tinnitus Association (www.tinnitus.org.uk) — including All about tinnitus, Pulsatile tinnitus andSelf help for tinnitus, helpline number is 0800 018 0527 ----- ENT UK (www.entuk.org) —Tinnitus (ringing in the ear) ----- NHS A to Z (www.nhs.uk) — Tinnitus Follow-up arranged Referral: Immediate: - High risk of suicide? - Sudden onset of significant neurological symptoms or signs (eg facial weakness)? - Acute uncontrolled vestibular symptoms (eg vertigo)? - Suspected stroke? - Sudden onset pulsatile tinnitus? - Secondary to head trauma? Within 24 hours: - Hearing loss that has developed suddenly (over a period of 3 days or less) in the past 30 days? Within 2 weeks: - Distress affecting mental wellbeing (eg prevents from carrying out usual daily activities) even after receiving tinnitus support at first point of contact with a healthcare professional - Hearing loss that developed suddenly more than 30 days ago, or rapidly worsening hearing loss (over a period of 4–90 days) - Persistent otalgia or otorrhoea that does not resolve with routine treatment In line with local pathways: - Tinnitus that bothers them despite having received tinnitus support at first point of contact with a healthcare professional - Persistent objective tinnitus - Tinnitus associated with unilateral or asymmetric hearing loss - Persistent pulsatile tinnitus - Persistent unilateral tinnitus Less urgently: - Tinnitus of uncertain cause (including tinnitus that is not associated with hearing loss, ear pain, drainage or malodour, vestibular symptoms or facial weakness and hearing loss that cannot clearly be distinguished as either sensorineural or conductive Reference(s): NICE CKS: Tinnitus Information for parents/carers: Action on hearing loss British Tinnitus Association ENT UK: Tinnitus (ringing in the ears) NHS A to Z: Tinnitus