When should a patient with tinnitus (ringing in the ears) be referred to an Ear, Nose, and Throat (ENT) specialist?

When to Refer a Patient with Tinnitus to ENT

You should refer a patient with tinnitus to an ENT specialist when they have unilateral or pulsatile tinnitus, persistent symptoms lasting 6 months or longer, associated hearing difficulties, focal neurologic abnormalities, asymmetric hearing loss, or when the tinnitus is bothersome and requires specialized management beyond primary care counseling. 1

Red Flags Requiring Immediate ENT Referral

The following presentations mandate specialist evaluation:

• Unilateral tinnitus - This requires imaging to exclude vestibular schwannoma or other retrocochlear pathology 1
• Pulsatile tinnitus - Nearly always requires vascular imaging (CTA or MRA) to identify potentially treatable vascular abnormalities such as arteriovenous malformations, dural fistulas, or glomus tumors 1, 2
• Focal neurologic abnormalities - Any accompanying neurologic deficits warrant immediate specialist referral and imaging 1
• Asymmetric hearing loss - This pattern raises concern for vestibular schwannoma and requires MRI of the internal auditory canals 1
• Tinnitus severe enough to wake the patient from sleep - This highly unusual presentation suggests objective tinnitus from vascular or neuromuscular causes requiring thorough evaluation 3

Timing of Audiologic and ENT Referral

Prompt Referral (Within Days to Weeks)

• Comprehensive audiologic examination is mandatory for patients with unilateral tinnitus, persistent tinnitus (≥6 months), or any associated hearing difficulties 1, 2
• Patients with sudden onset unilateral tinnitus should be evaluated urgently to rule out sudden sensorineural hearing loss, which requires time-sensitive treatment 3

Routine Referral (Within Months)

• Patients with persistent, bothersome tinnitus lasting 6 months or longer should be referred for specialized management options including cognitive behavioral therapy, hearing aid evaluation, and sound therapy 1, 2
• Those with documented hearing loss and bothersome tinnitus benefit from hearing aid evaluation, even if hearing loss is mild or unilateral 1, 2

Patients Who Do NOT Require ENT Referral

You can manage the following patients in primary care without specialist referral:

• Bilateral, non-pulsatile tinnitus without hearing loss, neurologic symptoms, or other concerning features 1
• Non-bothersome tinnitus of any duration - these patients simply need reassurance and education 1, 2
• Recent onset tinnitus (< 6 months) that is bilateral and non-bothersome, after performing targeted history and physical examination to exclude secondary causes 1

Primary Care Management Before Referral

When tinnitus does not meet referral criteria, provide the following:

• Education and counseling about the benign nature of most tinnitus, natural history, and management strategies 1, 2
• Reassurance that tinnitus is common (10-15% of adults) and most patients adapt over time 2, 3
• Identification and treatment of contributing factors such as cerumen impaction, ototoxic medications, or noise exposure 1, 3

Critical Psychiatric Screening

• Screen all tinnitus patients for severe anxiety and depression - these patients require urgent intervention due to documented increased suicide risk 2, 3
• This psychiatric comorbidity may itself warrant referral to mental health services in addition to ENT evaluation 2

Common Pitfalls to Avoid

• Do not order imaging for bilateral, non-pulsatile tinnitus without neurologic abnormalities or asymmetric hearing loss - this is explicitly not recommended and wastes resources 1
• Do not dismiss unilateral tinnitus as benign without audiologic testing and consideration of imaging - vestibular schwannomas present this way 1
• Do not overlook mild hearing loss - even mild or unilateral hearing loss warrants hearing aid evaluation as this can significantly improve tinnitus 1, 2
• Do not prescribe medications (antidepressants, anticonvulsants, anxiolytics) or dietary supplements (Ginkgo biloba, zinc, melatonin) for primary tinnitus treatment - these lack evidence and are explicitly not recommended 1, 2

Documentation for Referral

When referring to ENT, provide:

• Duration and laterality of tinnitus 1
• Results of any hearing testing or tympanometry performed 1
• Associated symptoms (hearing loss, vertigo, neurologic symptoms) 1
• History of noise exposure, ototoxic medications, or head trauma 1
• Psychiatric comorbidities and impact on quality of life 2