B-QuiCK: Tinnitus

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B-QuiCK: Tinnitus


  • Determine tinnitus characteristics)

* In patients with asymmetric hearing loss consider both bilateral and unilateral causes

Patients with vestibular schwannoma do not always have vertigo and focal neurological features

Diagnostic algorithm for patients presenting with tinnitus.


  • Also perform:
  • A medicines review for potential ototoxic causes of tinnitus
  • An otoscopic examination and tympanometry to investigate possible external or middle ear pathology
  • A focused neurological examination including cranial nerves and cerebellar function
  • Assessment of the temporomandibular joint, jaw and neck in patients
  • Assess hearing loss:
  • Refer to an audiologist for a full diagnostic hearing assessment if possible
    • A brief check can be performed by rubbing your fingers together behind the patient's ear or using a soft whisper and assessing whether they can hear the noise
    • Use the Weber and Rinne tuning fork tests to help differentiate conductive hearing loss from sensorineural hearing loss


Interpretation of Weber and Rinne test results.

Hearing Weber* Rinne
Normal Midline Positive
Sensorineural hearing loss Unaffected ear Positive
Conductive hearing loss Affected ear Negative

*Side the tuning fork is heard best

Positive Rinne test – air conduction better than bone conduction; negative Rinne test – bone conduction better than air conduction


  • Evaluate the impact of tinnitus on the patient’s quality of life:
  • Ask about the effect tinnitus has on sleep, employment, study, leisure activities and relationships with family and friends
  • Assess for symptoms of depression and anxiety
  • Patients with the following red flags should be discussed with or referred to an otolaryngologist:

    • Tinnitus with a focal neurological deficit: urgent referral
    • Tinnitus with vestibular symptoms, e.g. vertigo, loss of balance: urgent referral if symptoms severe
    • Tinnitus with sudden hearing loss (onset over three days or less): urgent referral if within 30 days

    • Pulsatile tinnitus

    • Tinnitus with unilateral or asymmetric hearing loss
  • Management

    • Address treatable causes of secondary tinnitus
    • Improve hearing loss if there is a modifiable cause, e.g. refer for aural microsuction, hearing aids
    • Address lifestyle factors, e.g stress reduction, sleep, diet, exercise, and provide education and reassurance for patients and their family/whānau
    • Sound enrichment (neutral noises at a volume just quieter than the perceived tinnitus) can relieve symptoms and promote habituation
    • Pharmacological treatments are not recommended for the management of tinnitus; only prescribe medicines to treat concomitant conditions
    • For patients with tinnitus-related distress, encourage lifestyle changes to reduce stress and good sleep hygiene
      • Cognitive behavioural therapy (CBT) can be effective for alleviating distress in patients with tinnitus but tinnitus-focused CBT is not widely available in New Zealand; discuss with an audiologist who specialises in tinnitus
    • Consider discussion with an audiologist or otolaryngologist for patients with primary tinnitus that still causes significant distress after management in primary care
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