Intended for healthcare professionals

Primary Care 10-minute consultation


BMJ 2005; 330 doi: (Published 27 January 2005) Cite this as: BMJ 2005;330:237
  1. S Alam Hannan, specialist registrar1,
  2. Farhhan Sami, GP principal2,
  3. Michael J Wareing (, consultant otologist1
  1. 1 Department of Otolaryngology: Head and Neck Surgery, St Bartholomew's and the Royal London Hospitals, London EC1A 7BE
  2. 2 The Moorings Practice, Kenley, Surrey CR8 5DG
  1. Correspondence to: M Wareing


An elderly widower complains of ringing in his ears. He denies any associated symptoms. He takes atenolol for hypertension. Tired and anxious, he wants to know what is wrong.

What issues you should cover

Tinnitus—the sensation of noises in the ears or head not attributable to any perceivable external sound—is common. Is the tinnitus subjective? Uncommon objective tinnitus can be heard by others. The temporomandibular joint, eustachian tube, palate, and carotid artery can produce usually innocent somatosounds.

Character of sound—Ringing, hissing, or buzzing suggest inner ear or central pathology. Popping, clicking, or banging suggest problems in the external or middle ear or palatal problems. Pulsatile sounds may indicate anxiety or acute inflammatory ear conditions but also vascular causes, including tumours (glomus, carotid body), carotid stenosis, arteriovenous malformations, intracranial aneurysms, and high cardiac output states. “Voices” need psychiatric referral.

Balance—Bilateral tinnitus is usually innocuous; unilateral tinnitus may …

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