Tinnitus Atlas · Case library
Clinical case library
All 135 interactive cases from across the atlas, gathered in one place and grouped by module. Each vignette poses a real decision; choose an option to reveal the reasoning and the teaching point. To study a case in its full context, follow the module link. For self-test questions, see the self-assessment page.
Module 1 · Understanding Tinnitus: A Phantom Sound
A 58-year-old factory supervisor describes a constant high-pitched ringing in both ears for the past year. He sleeps poorly and feels anxious, but his work and conversations are largely unaffected on most days. An audiogram shows a symmetric high-frequency sensorineural dip. He asks whether his tinnitus is dangerous and whether a brain scan is needed.
Which statement best reflects a modern, evidence-based understanding of his presentation?
Module 2 · What Tinnitus Is — Definition and Terminology
A 34-year-old musician reports that for several months she has heard a steady, single high-pitched tone in her right ear. It never forms words or melodies. She is otherwise well, has no psychiatric history, and the tone is present most of the day. She worries she is 'hearing things' and might be losing her mind.
How should you classify and frame her experience?
Module 3 · Subjective vs Objective Tinnitus
A 41-year-old woman with a recent weight gain and headaches reports a 'whooshing' noise in her left ear that beats in time with her pulse and quietens when she presses on the left side of her neck. On auscultation over the mastoid, you hear a soft rhythmic bruit.
What is the most appropriate next step?
Module 4 · Functional vs Structural Tinnitus
A 52-year-old woman reports a constant high-pitched ring in the LEFT ear only for 8 months, with the gradual sense that the left phone earpiece sounds quieter. Otoscopy is normal and there is no pulsatility. Pure-tone audiometry shows a symmetrical mild high-frequency loss on the right but a clearly worse, asymmetric loss on the left.
Which classification best fits this presentation, and what is the most appropriate next step?
Module 5 · Psychoacoustic and Temporal Subtypes
A 34-year-old man describes a whooshing sound in his right ear that he insists 'beats with my pulse'. It is louder when he lies down and he can reduce it by pressing on the right side of his neck. Hearing is subjectively normal. Otoscopy is unremarkable.
Which descriptor is most diagnostically important here, and what should it trigger?
Module 6 · Epidemiology and Burden of Tinnitus
A health system is planning a tinnitus service and asks for the epidemiology. The catchment is 1,000,000 adults. They want a realistic estimate of how many have any tinnitus, how many are likely to be severely bothered, and what the main modifiable risk factor and chief associated condition are.
Which set of figures and associations best reflects current evidence?
Module 7 · Otologic Causes of Tinnitus
A 27-year-old sound engineer reports two weeks of constant high-pitched ringing in both ears after a series of loud festival shifts. He denies vertigo or fullness. A pure-tone audiogram is entirely within normal limits at every standard frequency, and otoscopy and tympanometry are normal.
What best explains his tinnitus despite a normal audiogram?
Module 8 · Neurologic Causes of Tinnitus
A 48-year-old reports six months of constant ringing in the right ear only. She has noticed she now struggles to follow phone calls on that side. Audiometry shows a right high-frequency sensorineural loss with markedly poorer word recognition than the left; the left ear is normal. She has no vertigo and no other neurological complaints.
What is the most appropriate next step?
Module 9 · Vascular Causes (Pulsatile Tinnitus)
A 33-year-old woman with a high BMI describes several months of a whooshing noise in both ears, in time with her pulse, plus daily headaches and brief episodes of visual greying when she stands. Gentle pressure on the side of her neck softens the sound. Fundoscopy shows blurred optic disc margins.
Which diagnosis best fits, and what must be assessed urgently?
Module 10 · Muscular and Mechanical Causes
A 34-year-old singer reports a soft roaring sound in her right ear that has appeared since she lost 9 kg over three months. She says she can hear her own voice booming inside that ear. The noise gets louder as she sustains a long note and almost vanishes when she lies down to rest. On otoscopy the tympanic membrane is seen to move gently in and out as she breathes.
Which mechanism best explains her tinnitus?
Module 11 · Pharmacologic and Ototoxic Causes
A 58-year-old man is receiving cisplatin chemotherapy for a head-and-neck cancer. Before his third cycle he tells the nurse he has developed a constant high-pitched ringing in both ears, worse at night. He has had no hearing complaint until now. His baseline audiogram three weeks ago was normal.
What is the most appropriate immediate response?
Module 12 · Idiopathic Tinnitus and Systemic Links
A 47-year-old woman has had bilateral, non-pulsatile, constant high-pitched tinnitus for eight months. Otoscopy is normal, her pure-tone audiogram is essentially normal, and she takes no ototoxic medication. She scores high on anxiety and depression screening and reports she now lies awake at night focused on the sound. She has also felt unusually tired and cold, with a 3 kg weight gain.
What is the most appropriate next step before labelling her tinnitus idiopathic?
Module 13 · Mechanism: Cochlear Damage and Deafferentation
A 34-year-old sound engineer reports a constant 6 kHz hiss in both ears that started after a single very loud concert two years ago. His pure-tone audiogram is entirely within normal limits (all thresholds 0-10 dB HL). He is frustrated that 'every doctor says my hearing is fine.'
Which mechanism best explains tinnitus despite a normal audiogram in this patient?
Module 14 · Mechanism: Central Gain and Cortical Plasticity
A 58-year-old retired teacher has had a soft high-pitched ringing for three years. She rates its loudness as low, yet she scores in the severe range on a tinnitus distress questionnaire, sleeps poorly, and is markedly anxious and tearful when discussing it. Her audiogram shows a mild high-frequency loss.
Which best explains the mismatch between her low perceived loudness and her severe distress?
Module 15 · Mechanism: Somatosensory Cross-Talk
A 41-year-old office worker with chronic neck pain and frequent jaw clenching reports a constant left-sided ringing. During the consultation you ask her to clench her teeth firmly and then to rotate her head: with each manoeuvre she reports the ringing becomes noticeably louder and higher in pitch. Her audiogram is near-normal.
What does the change in tinnitus with jaw and neck manoeuvres most strongly indicate?
Module 1 · Pathophysiology Overview — A Peripheral Trigger, A Central Disease
A 34-year-old sound engineer reports constant high-pitched ringing for 6 months after a single loud concert. His standard pure-tone audiogram (0.25-8 kHz) is entirely within normal limits in both ears, and he is frustrated that he has been told 'your hearing is normal, there is nothing wrong.'
Which explanation best fits current pathophysiology?
Module 2 · Peripheral Generators — Cochlea, Synaptopathy, Deafferentation
A 27-year-old musician has bilateral high-pitched tinnitus and major difficulty understanding speech in noisy bars, despite a normal standard audiogram (0.25-8 kHz). Otoacoustic emissions are present but reduced at high frequencies, and ABR shows a low-amplitude wave I.
What is the most likely peripheral substrate?
Module 3 · Spontaneous Hyperactivity After Deafferentation
In an animal study, guinea pigs receive a unilateral noise exposure. Recordings are made from the inferior colliculus at intervals afterward. At 1 week, spontaneous firing is elevated; the experimenters then silence the exposed cochlea pharmacologically and re-record at 1 week versus 12 weeks.
What pattern best matches the 'centralisation' of hyperactivity?
Module 4 · Neural Synchrony, Bursting and Hyperexcitability
A researcher records from the dorsal cochlear nucleus of two groups of noise-exposed animals. Group A and Group B show the SAME mean spontaneous firing rate, well above unexposed controls. Yet behavioural testing shows that only Group B has reliable evidence of tinnitus. When the spike trains are re-analysed, Group B’s fusiform cells show markedly higher burst index and cross-unit synchrony than Group A’s.
Which interpretation best fits these findings?
Module 5 · The Dorsal Cochlear Nucleus as a Generator
A 41-year-old man developed constant high-pitched tinnitus in the left ear after a single intense noise exposure. His audiogram shows a notch at 4 kHz. During the consultation you notice he can briefly intensify his tinnitus by forcefully clenching his jaw and can soften it by turning his head to the right. He asks whether this means his tinnitus is “coming from his teeth.”
What does the modulability of his tinnitus by jaw and neck manoeuvres most directly indicate about its mechanism?
Module 6 · The Central Gain Mechanism (Homeostatic Plasticity)
A 36-year-old musician reports constant tinnitus and, increasingly, that everyday sounds — cutlery, traffic, conversation in a café — feel painfully loud. To cope, she has been wearing foam earplugs for most of the day and avoiding noisy places for the past three months. She feels her symptoms are slowly getting worse, not better. Her audiogram shows a mild high-frequency loss.
Based on the central-gain model, what is the most appropriate advice?
Module 7 · Tonotopic Map Reorganization and the Edge Effect
A 54-year-old machinist has bothersome tinnitus he describes as a steady high-pitched tone. Pitch-matching localises his tinnitus to about 3.5 kHz. His audiogram shows a classic noise-notch with a sharp drop centred at 4 kHz and recovery at 8 kHz. A research team images his auditory cortex with high-resolution fMRI and reports that his macroscopic tonotopic gradient looks essentially normal compared with hearing-matched controls.
Which interpretation best reconciles his tinnitus pitch with the imaging finding?
Module 8 · Thalamocortical Dysrhythmia and Neural Oscillations
A researcher records resting MEG from a 47-year-old woman with chronic, constant tinnitus and a high-frequency hearing loss. Compared with hearing-matched controls without tinnitus, her auditory cortex shows increased delta and theta power, reduced alpha power, and increased gamma power, with the gamma amplitude phase-locked to the theta rhythm.
Which model best accounts for this constellation of oscillatory findings?
Module 9 · Auditory Cortex and Resting-State Networks
Two patients attend clinic with chronic tinnitus. Both have a symmetrical 40 dB high-frequency sensorineural loss and pitch-matched tinnitus of similar loudness. Patient A has a Tinnitus Handicap Inventory score of 12 and barely notices it during the day; Patient B has a score of 78, sleeps poorly and is highly distressed. Resting-state fMRI shows markedly stronger coupling between auditory cortex and salience/limbic networks in Patient B.
What best explains why two patients with near-identical audiograms and tinnitus loudness differ so greatly in distress?
Module 10 · The Limbic and Emotional Network
Two retired carpenters, both 64, attend the tinnitus clinic. Each has a symmetrical 40 dB high-frequency notch and reports a constant high-pitched ring matched at the same pitch and loudness. The first sleeps normally and says the sound is “just background now.” The second is severely depressed, hypervigilant to the sound, and scores 78 on the Tinnitus Handicap Inventory.
What best explains the difference in suffering between two patients with near-identical peripheral pathology and matched percepts?
Module 11 · Attention, Salience and the Default-Mode Network
A 45-year-old accountant with stable tinnitus says it is “unbearable” on quiet evenings and when trying to fall asleep, but she genuinely forgets it for hours while immersed in spreadsheets during a busy work day. She is frustrated, asking how the same ear can be so loud at night and silent at work.
Which mechanism best explains the day-night fluctuation in her tinnitus prominence?
Module 12 · Predictive Coding — A Bayesian Model of Tinnitus
A 38-year-old musician with a normal standard audiogram develops a constant 6 kHz tone after a loud concert. Extended high-frequency testing shows a subtle notch just above 6 kHz. He is bewildered that he can “hear” a tone so clearly when his hearing test is “normal,” and asks why brief masking gives him minutes of silence afterwards.
Using the predictive-coding / sensory-precision model, which statement best explains his tinnitus and the post-masking relief?
Module 13 · Phantom Perception and the Neuropathic-Pain Parallel
A 54-year-old man develops constant high-pitched left-ear tinnitus six months after a noise-exposure incident. His audiogram shows only a mild 4-kHz notch. He has read that his tinnitus is 'like nerve pain' and asks whether the gabapentin that helped his diabetic foot pain will cure his tinnitus.
What is the most accurate counselling response grounded in the tinnitus-pain parallel?
Module 14 · The Evidence — Neuroimaging and Electrophysiology
A research team reports that, compared with normal-hearing controls, patients with chronic tinnitus show reduced grey matter in auditory cortex and increased resting BOLD signal, and concludes these are 'objective biomarkers of tinnitus.' A reviewer notes that the tinnitus group had an average 35-dB high-frequency hearing loss while controls had normal audiograms.
What is the central methodological flaw in claiming these findings are tinnitus biomarkers?
Module 15 · Unifying Models and What They Mean for Treatment
Two patients attend the tinnitus clinic. Patient A has a 40-dB high-frequency loss, says the tinnitus is 'just there in the background' and is not distressed; she mainly struggles to hear in noise. Patient B has near-normal hearing, a soft tinnitus, but is severely distressed, anxious, sleepless and fixated on the sound.
Using the unified stage model, which treatment emphasis best fits each patient?
Module 1 · How Tinnitus Presents — The Clinical Picture
A 54-year-old man is referred for a steady high-pitched ringing in both ears that he describes as ‘not too loud.’ On structured questioning he reveals he wakes at 3 a.m. unable to get back to sleep, has stopped attending his weekly card game, and is convinced the noise means a brain tumour. His audiogram shows symmetrical high-frequency loss.
What should most shape the management plan for this patient?
Module 2 · Taking the Tinnitus History
A 39-year-old drummer reports a six-week history of left-sided ringing that began after a loud gig. He notices the pitch and loudness shift when he clenches his jaw, and he has longstanding clicking in the same jaw. His hearing feels ‘a bit muffled’ on the left but he has no vertigo, fullness, or pulsing quality to the sound.
Which single history finding most usefully directs the next step?
Module 3 · Pitch, Loudness and Sound Quality
A 61-year-old retired machinist describes a constant high whistle in both ears. On pitch matching it sits around 4 kHz; loudness matching puts it at about 8 dB SL. He rates it 8/10 for how much it bothers him and says he ‘can’t believe something so loud measures so quiet.’ His audiogram shows a 4 kHz noise notch.
How should the clinician interpret the gap between his 8 dB SL match and his 8/10 bother rating?
Module 4 · Temporal Pattern, Onset and Fluctuation
A 44-year-old teacher reports a low roaring noise in the left ear that comes and goes. Over the past four months she has had three episodes, each lasting hours, in which the roar grows louder, the ear feels blocked, and the room spins. Between episodes the tinnitus is faint and her hearing seems to recover.
Which feature of the temporal pattern is most diagnostically useful here?
Module 5 · Recognising Pulsatile Tinnitus
A 31-year-old woman with a high body-mass index describes a constant low whooshing in the right ear that beats with her heartbeat. She has noticed she can make it quieter by pressing on the right side of her neck or turning her head to the right. She also reports headaches and brief greying-out of her vision when she stands.
Which combination of findings best characterises this pulsatile tinnitus and guides the next step?
Module 6 · Somatic & Somatosensory Features
A 38-year-old man with longstanding jaw clicking and morning jaw stiffness reports right-sided ringing that began after a period of stress and heavy tooth-grinding. In clinic, when he clenches his teeth and again when he rotates his neck to the right, he reports the ringing briefly becomes louder and higher in pitch. His audiogram is near-normal.
What does the reproducible modulation of his tinnitus by jaw clenching and neck rotation indicate?
Module 7 · Laterality and Clinical Red Flags
A 52-year-old man reports six months of constant ringing he localises clearly to the right ear, with a vague sense that the right side is ‘duller’ on the phone. He has no vertigo, no pulsatile quality and no neurological symptoms. Pure-tone audiometry shows symmetric thresholds down to 2 kHz, then a right-sided drop: 25 dB right versus 5 dB left at 3 kHz, and 40 dB right versus 15 dB left at 4 kHz.
What is the most appropriate next step?
Module 8 · Tinnitus Distress and the Emotional Reaction
Two patients are seen on the same morning. Mr A has a faint, barely matchable high-pitched tinnitus (loudness match ~5 dB SL) but is tearful, sleeping poorly, convinced it signals a brain tumour, and has stopped seeing friends. Mr B has a readily matched, ‘loud’ tinnitus (~20 dB SL) which he describes as a minor nuisance he mostly forgets about. Both have benign, bilateral high-frequency hearing loss and normal imaging.
Which statement best guides their management?
Module 9 · Impact on Sleep and Cognition
A 44-year-old project manager with chronic bilateral tinnitus says the sound itself is ‘tolerable during the day at work’ but unbearable once she lies down in a silent bedroom; she takes over an hour to fall asleep and wakes at 3 a.m. ruminating about it. By afternoon she is exhausted, misses deadlines, and feels her memory is failing. Audiometry shows mild high-frequency loss; mood screen is borderline.
Which intervention best targets the mechanism driving her presentation?
Module 10 · Anxiety, Depression and Suicidality
A 52-year-old man with 8 months of constant high-pitched bilateral tinnitus returns for review. His audiogram shows only mild high-frequency loss and his tinnitus loudness match is low. Yet he appears exhausted and tearful, says he sleeps poorly, has stopped seeing friends, and tells you the noise is “ruining his life and he doesn’t know how much longer he can take it.”
What is the most appropriate next step?
Module 11 · Hyperacusis, Misophonia and Sound Tolerance
A 34-year-old woman with mild tinnitus reports that for the past year she cannot bear the sound of her family eating — chewing and slurping provoke immediate rage and a racing heart, and she now eats alone. The same sounds at low volume on a video still trigger her. Ordinary loud noises such as traffic and a vacuum cleaner do not bother her at all, and her loudness-discomfort levels are normal.
Which condition best explains her presentation, and what does it imply for management?
Module 12 · Special Populations (Paediatric, Elderly, Meniere, Vestibular Migraine)
A 41-year-old woman presents with recurrent attacks of spinning vertigo lasting several hours, accompanied by tinnitus, sensitivity to light and a dull headache. Between attacks she feels well. Her pure-tone audiogram is essentially normal and has not changed over a year of follow-up. She mentions her mother had “migraines.”
What is the most likely diagnosis and the implication for tinnitus-related management?
Module 13 · Questionnaires — THI, TFI and Friends
A 52-year-old man with chronic right-sided tinnitus scored 46 on the THI at baseline (moderate). After three months of sound therapy and counselling his THI is 40. He asks whether he is improving. You also have his TFI: baseline 58, now 44.
How should you interpret these scores?
Module 14 · Psychoacoustic Measures and Severity Grading
A 60-year-old woman reports devastating tinnitus that keeps her awake and has made her stop seeing friends. On testing, her pitch matches to 4 kHz at the edge of her high-frequency loss, her loudness match is just 8 dB SL, and her MML is low. Her TFI is 62 with a high sleep subscale, and her annoyance VAS is 9/10.
How should you grade and act on this presentation?
Module 15 · Clinical Classification and Phenotyping for Management
A 41-year-old presents with left-sided, steady, non-pulsatile tinnitus of four weeks' duration after a viral illness. He is anxious but still working and sleeping. Audiometry shows a mild left high-frequency loss. There are no neurological signs and no rhythmic quality to the sound.
Using the AAO-HNS framework, how is this best classified and managed at this stage?
Module 1 · The Bedside Approach to Tinnitus
A 54-year-old man is referred with three weeks of constant right-sided ringing. He is anxious because a colleague told him tinnitus means a brain tumour. He has no vertigo, no pulsatility, and his GP’s letter notes ‘ears full of wax on the right’. He has not yet had any hearing test.
What is the most appropriate first bedside action?
Module 2 · General and Otoscopic Examination
A 41-year-old woman describes a whooshing noise in the left ear that beats in time with her pulse and is louder when she lies down. On otoscopy you see a reddish mass behind the anteroinferior left tympanic membrane that appears to pulsate.
What is the correct bedside management of this otoscopic finding?
Module 3 · The Neuro-otologic Examination
A 60-year-old man has had progressive left-sided tinnitus and trouble hearing on the telephone with that ear for a year. On examination the left corneal reflex is sluggish and he has slight left facial weakness. Tuning-fork tests suggest a left sensorineural loss. There is no pulsatility.
Which interpretation and next step are most appropriate?
Module 4 · Tuning-Fork Tests (Weber, Rinne)
A 58-year-old man reports six weeks of a constant high-pitched ringing in the LEFT ear with mild reduced clarity on the phone. Otoscopy is normal bilaterally. With a 512 Hz fork, the Weber lateralises to the RIGHT ear and the Rinne is positive (air > bone) in both ears.
What is the most appropriate interpretation and next step?
Module 5 · Auscultation and Inspection for Objective Tinnitus
A 34-year-old woman reports a rhythmic clicking 'like a tiny drum' in both ears, several times a minute, that vanishes when she falls asleep. Otoscopy shows intermittent fine flutter of the tympanic membranes and, with her mouth open, you observe rhythmic contractions of the soft palate at about 2 Hz. There is no pulse-synchronous sound on auscultation of the ears, mastoids or neck.
What is the most likely cause and the most appropriate next consideration?
Module 6 · Tinnitus Pitch Matching
A 47-year-old machinist with bilateral high-pitched tinnitus and a noise-notch audiogram (worst at 4 kHz) is being pitch-matched. On the first attempt he matches to 2 kHz, but the result varies widely between trials. When you present tones one octave above and below each candidate, he consistently prefers the higher option.
What is the best interpretation and action?
Module 7 · Tinnitus Loudness Matching
A 58-year-old man with a high-frequency sensorineural hearing loss describes his right-ear tinnitus as ‘unbearable, the loudest thing in my life’. You pitch-match it to 6 kHz, where his threshold is 55 dB HL. On loudness matching the tinnitus equals a 6 kHz tone presented at 62 dB HL.
How should you record and interpret this loudness match?
Module 8 · Minimum Masking Level
A 47-year-old woman with bilateral high-pitched tinnitus undergoes psychoacoustic testing. Her tinnitus pitch-matches to 6 kHz and loudness-matches to 9 dB SL. A broadband noise just covers the tinnitus at 14 dB SL, and the masking curve is congruent across frequencies. She has no sound intolerance.
Based on these psychoacoustic findings, what is the most appropriate counselling about sound-based treatment?
Module 9 · Residual Inhibition Testing
A 52-year-old man with chronic 5 kHz tinnitus is tested. After a 60-second broadband masker presented 10 dB above his minimum masking level is switched off, he reports that his tinnitus has completely vanished. It stays silent for about 25 seconds, then fades back to its usual level over the next two minutes.
How should this finding be classified and used?
Module 10 · Somatosensory and TMJ Bedside Assessment
A 34-year-old graphic designer reports a steady high-pitched right-sided tinnitus for six months, worse on long workdays. Audiogram is normal. During the bedside examination, a forceful jaw clench makes the tinnitus noticeably louder and slightly higher in pitch, and firm pressure over the right masseter reproduces the effect; she also admits to morning jaw soreness and tooth-grinding. Neck rotation does nothing.
What is the most appropriate next step?
Module 11 · Neck and Vascular Examination (Pulsatile)
A 41-year-old woman with a BMI of 34 describes a continuous left-sided whooshing in time with her pulse for three months, plus morning headaches and brief greying of vision when she stands. Otoscopy is normal. The tinnitus disappears completely when you apply gentle pressure low on the left side of her neck and gets louder when she leans forward. There is no audible bruit.
Which interpretation and action best fit these bedside findings?
Module 12 · Bedside Hearing and Speech Checks
A 58-year-old man presents with a two-month history of constant left-sided ringing and a sense that the phone is 'harder to hear' on the left. In clinic you perform a whispered-voice test: he repeats your whispered number-letter sets correctly on the right but gets none correct on the left, even on a second attempt, with the right tragus masked. Finger rub confirms he cannot hear it on the left at a distance where he hears it easily on the right. Otoscopy is normal bilaterally.
What is the most appropriate next step?
Module 13 · Bedside Distress and Psychometric Screening
A 52-year-old man with chronic bilateral high-pitched tinnitus and mild high-frequency hearing loss is seen at follow-up. His matched tinnitus loudness is only 6 dB SL. On screening he marks loudness 4/10 but annoyance 9/10, his THI is 72, his PHQ-9 is 18 with a positive response to the self-harm item, and he reports waking nightly.
Which finding should most change your immediate management at this visit?
Module 14 · Red Flags on Examination
A 47-year-old woman reports tinnitus in her right ear only over the past four months. Audiometry shows a right-sided high-frequency sensorineural loss with word recognition of 64% on the right versus 96% on the left. Otoscopy is normal, tuning forks show Weber lateralising to the left with a positive Rinne bilaterally, and there are no other neurological signs.
What is the most appropriate next step?
Module 15 · A Systematic Bedside Protocol
A clinician sees a 60-year-old with three months of left-sided non-pulsatile tinnitus. Pressed for time, they perform pitch and loudness matching, document a THI of 30, reassure the patient, and book a routine review. No tuning-fork test, speech discrimination or red-flag check was done.
What is the principal flaw in this consultation?
Module 1 · The Diagnostic Work-up — What to Order and When
A 54-year-old man reports constant high-pitched ringing in both ears for two years, slightly worse on the left. He has a long history of occupational noise exposure. There is no vertigo, no pulsatility, and no neurological symptoms. Otoscopy is normal.
What is the single most appropriate first investigation?
Module 2 · Pure-Tone Audiometry (incl. high-frequency)
A 29-year-old musician complains of a persistent high-pitched whistle in both ears after years of amplified rehearsals. His standard pure-tone audiogram (250 Hz to 8 kHz) is entirely within normal limits. He is frustrated at being repeatedly told his hearing is 'perfect'.
Which test is most likely to reveal the cochlear basis of his tinnitus?
Module 3 · Speech Audiometry
A 61-year-old woman has had progressive tinnitus and reduced hearing in the right ear over 18 months. Pure-tone audiometry shows a mild-to-moderate right sensorineural loss (PTA 40 dB). Her right word recognition score is only 36%, far poorer than expected for that degree of loss, and performance-intensity testing shows the score falling at higher intensities. The left ear is normal.
Which finding most strongly justifies MRI of the internal auditory canals?
Module 4 · Tympanometry and Acoustic Reflexes
A 52-year-old woman reports a steady low buzzing tinnitus in the right ear with slowly progressive hearing difficulty over two years. Otoscopy is normal. Pure-tone audiometry shows a mild conductive loss with a small air-bone gap and a dip at 2 kHz on bone conduction. Tympanometry is type As bilaterally, right worse than left, and acoustic reflexes are absent on the right.
Which interpretation best fits this immittance picture?
Module 5 · Otoacoustic Emissions (and SOAEs)
A 30-year-old musician complains of a high-pitched ringing tinnitus in both ears after years of stage exposure. His pure-tone audiogram is within normal limits (all thresholds 0-15 dB HL up to 8 kHz). He is anxious that ‘nothing is wrong’ means the tinnitus is purely psychological.
Which test would best demonstrate an objective cochlear basis for his tinnitus?
Module 6 · ABR and Electrocochleography
A 45-year-old man has a 6-month history of right-sided high-pitched tinnitus with mild asymmetric high-frequency sensorineural hearing loss (right worse than left) and reduced right word recognition out of proportion to his thresholds. He has no contraindication to MRI. An audiologist offers to book an ABR to screen for a tumour.
What is the most appropriate next investigation?
Module 7 · Extended High-Frequency Audiometry & Hidden Hearing Loss
A 29-year-old sound engineer reports a constant high-pitched ring in both ears and difficulty following conversation in busy bars, worse over the last year. His standard pure-tone audiogram is normal (thresholds 5–15 dB HL, 250 Hz–8 kHz) and tympanograms are type A bilaterally. He is frustrated that he has been told his ears are “fine.”
Which set of investigations is most likely to demonstrate an objective auditory abnormality in this patient?
Module 8 · Psychoacoustic Measurement (pitch, loudness, MML, RI)
A 54-year-old woman with high-frequency sensorineural hearing loss has a steady “hissing” tinnitus. On the instrumented battery her pitch match is around 6 kHz, her loudness match is 8 dB SL, her minimum masking level is low, and she shows positive-partial residual inhibition for about a minute after a narrow-band masker. She is convinced her tinnitus must be “extremely loud” to feel this intrusive.
How should these psychoacoustic results be interpreted for her?
Module 9 · Patient-Reported Outcome Measures in the Work-up
A 47-year-old man with mild high-frequency hearing loss has bilateral tinnitus matched at 7 kHz and 10 dB SL, with a low minimum masking level (i.e. easily masked). His baseline THI is 78 (catastrophic), his PHQ-9 indicates moderate depression, and his PSQI shows poor sleep. He asks why his “quiet” tinnitus is wrecking his life.
What does combining his psychoacoustic and patient-reported data tell you about the best initial direction of management?
Module 10 · Laboratory and Blood Work-up
A 38-year-old woman reports bilateral tinnitus that has worsened over six weeks, accompanied by progressive, fluctuating hearing loss in both ears and morning joint stiffness. Otoscopy and tympanometry are normal; audiometry shows a falling SNHL not present a year ago.
Which laboratory pathway is most appropriate and time-critical here?
Module 11 · Imaging — Who to Scan and Why
A 52-year-old man reports tinnitus that whooshes in time with his pulse in the left ear, worse when lying down and partly relieved by pressing on the left side of his neck. Otoscopy is normal; standard audiometry is symmetrical and near-normal.
What is the most appropriate imaging response?
Module 12 · MRI in Tinnitus (IAC/brain, vestibular schwannoma)
A 47-year-old woman has 8 months of constant left-sided tinnitus. Audiometry shows a left high-frequency SNHL that is 20 dB worse than the right at 4 and 8 kHz; word recognition is disproportionately poor on the left. Otoscopy and tympanometry are normal.
What is the most appropriate next investigation?
Module 13 · CT and Vascular Imaging for Pulsatile Tinnitus
A 41-year-old woman with a BMI of 34 reports a whooshing noise in her right ear, in time with her pulse, for three months. It is louder when she lies down, softer when she presses on the right side of her neck, and she has had morning headaches and brief greying-out of vision on standing. Otoscopy is normal; no retrotympanic mass. Auscultation reveals a soft hum over the right mastoid that disappears with light jugular compression.
What is the most appropriate first-line imaging strategy?
Module 14 · Emerging and Research Investigations (fMRI/PET/EEG/MEG)
A 38-year-old man with chronic bilateral non-pulsatile tinnitus and a near-normal audiogram brings a magazine article about an fMRI study showing 'tinnitus in the brain'. He asks you to arrange a functional MRI to confirm his tinnitus is real and to measure how bad it is, because his insurer is disputing his claim.
How should you counsel him about functional imaging for his tinnitus?
Module 15 · Building a Stratified, Cost-aware Work-up
A 55-year-old man is referred with two months of continuous, non-pulsatile ringing in BOTH ears. He has no vertigo, no neurological symptoms, and no asymmetry on examination. His audiogram shows a symmetric high-frequency sensorineural loss consistent with his decades of factory noise exposure. He is distressed and asks for 'all the scans and blood tests to find the cause'.
What is the most appropriate investigation plan?
Module 1 · The Management Philosophy — No Cure, Much Help
A 52-year-old man with constant high-pitched tinnitus for 8 months, accompanied by mild high-frequency hearing loss, tells you he has read online that “nothing can be done” and has stopped seeing doctors. He is sleeping poorly and avoids quiet rooms because the silence makes the sound worse. He asks you directly: “Can you make it go away?”
What is the most appropriate framing of his management?
Module 2 · Patient Education and Reassurance
A 38-year-old woman presents two weeks after sudden onset of bilateral non-pulsatile tinnitus following a loud concert. She is tearful, has been searching the internet at night, and is convinced she has a brain tumour and will go deaf. Audiometry shows a mild noise-notch at 4 kHz bilaterally. Neurological examination is normal and there are no red-flag features.
What is the most appropriate initial management?
Module 3 · The Evidence Base and Clinical Guidelines
A 60-year-old woman with bothersome bilateral tinnitus for over a year, mild symmetrical high-frequency hearing loss and no red-flag features, brings a printout of an online clinic offering high-dose ginkgo biloba, zinc tablets and a course of transcranial magnetic stimulation, advertised to “cure” tinnitus. She asks whether she should pay for this package.
Based on current clinical practice guidelines, what is the most appropriate advice?
Module 4 · Addressing Modifiable Factors
A 58-year-old man with chronic constant bilateral tinnitus and a mild high-frequency sensorineural hearing loss attends. He takes ibuprofen 400 mg three to four times daily for knee osteoarthritis, drinks six cups of coffee a day, and reports that he has cut himself off from concerts and noisy gatherings, often wearing earplugs even at home because he is frightened of making the tinnitus worse.
Which intervention is the most appropriate and highest-yield first step?
Module 5 · Hearing Aids in Tinnitus Management
A 64-year-old retired teacher reports two years of constant high-pitched bilateral tinnitus. She is increasingly distressed, convinced she needs a drug to silence it. On testing she has a symmetrical moderate high-frequency sensorineural hearing loss she had attributed to 'people mumbling'. She has no red-flag features and a normal otoscopy.
What is the most appropriate first-line management to offer?
Module 6 · Pharmacotherapy — Why No Cure Exists
A 47-year-old woman with chronic non-pulsatile bilateral tinnitus has read online about a 'tinnitus pill' and asks you to prescribe a medication to cure her tinnitus. She has co-existing moderate depression and significant insomnia, both clearly worsening her distress. Her hearing is near-normal and there are no red flags or features of a specific treatable ear disease.
What is the most appropriate and honest pharmacological approach?
Module 7 · Antidepressants (for distress and comorbidity)
A 54-year-old man has had bilateral high-pitched tinnitus for eight months following age-related hearing loss. He now describes low mood, early-morning waking, loss of interest in his hobbies and a PHQ-9 score of 16. He asks whether a tablet could 'switch off the noise'. His audiogram shows a symmetrical high-frequency loss; otoscopy and neurological examination are normal.
What is the most appropriate next step?
Module 8 · Anxiolytics and Anticonvulsants
A 47-year-old woman reports a sudden, intermittent clicking, machine-gun-like sound in her right ear that comes in brief bursts many times a day, lasting seconds each, for the past three months. It is not a steady ringing. Her hearing is normal and otoscopy is unremarkable. She is frustrated that a previous clinician's prescription of gabapentin did nothing.
Which treatment is most likely to help, and why?
Module 9 · Other Drugs and Intratympanic Therapy
A 39-year-old woman with chronic, stable, bilateral subjective tinnitus and normal hearing asks her ENT surgeon to 'inject something into the ear to cure the noise', having read online about intratympanic injections. She has no vertigo, no sudden hearing change, and no red flags. Her main current problem is that the tinnitus keeps her awake.
What is the most appropriate, evidence-based response?
Module 10 · Supplements and Complementary Therapy
A 58-year-old man with chronic bilateral tinnitus and mild high-frequency hearing loss has been buying high-dose ginkgo and zinc for six months, spending considerable money, with no change in his tinnitus. He takes warfarin for atrial fibrillation. He asks whether he should ‘double the dose’ or add a herbal blend he saw advertised as a tinnitus cure.
What is the most appropriate response?
Module 11 · The Placebo Effect and Trial Design
A device company presents an open-label study: 100 patients with chronic tinnitus used a new sound-wearable for eight weeks; 62% reported their tinnitus was ‘better’ on a single global question. There was no control group and patients knew they were receiving the active device. The company markets this as proof the device reduces tinnitus.
How should a clinician interpret this evidence?
Module 12 · Managing Comorbidities (sleep, anxiety, depression)
A 46-year-old woman with chronic tinnitus reports that the sound itself is ‘tolerable in the day’ but she lies awake for hours each night, has become irritable and tearful, and dreads the silence of bedtime. Audiometry shows only mild high-frequency loss. Her THI is moderate but her main complaint is exhaustion and low mood from months of broken sleep.
What is the most appropriate initial management focus?
Module 13 · Psychological Therapies — CBT, ACT, MBSR
A 44-year-old teacher has had constant high-pitched tinnitus for 8 months following a noise exposure. Her audiogram shows only a mild high-frequency notch. She is sleeping poorly, has stopped attending choir because silence between songs makes the tinnitus 'unbearable', and is convinced it signals a brain tumour despite a normal MRI. Her THI is 64 (severe).
Which is the most appropriate first-line treatment to recommend?
Module 14 · Stepped Care and Severity Stratification
A tinnitus clinic is redesigning its pathway. Three new referrals arrive the same morning: Patient A, THI 12, no sleep or mood problems, wants 'to know it isn't serious'; Patient B, THI 44, irritable, poor concentration, normal mood screen; Patient C, THI 72 with a positive depression screen and fleeting thoughts of self-harm.
How should the clinic allocate these three patients under a stepped, stratified-care model?
Module 15 · The Multidisciplinary Management Approach
A 58-year-old man with chronic bilateral tinnitus, a moderate symmetric high-frequency hearing loss, comorbid depression on a stable SSRI from his GP, and a THI of 60 is referred to a tinnitus service. He also reports jaw clicking and worse tinnitus when he clenches.
Which management plan best reflects a multidisciplinary approach?
Module 1 · Retraining the Brain — The Habituation Paradigm
A 52-year-old accountant with mild high-frequency hearing loss has had constant left-sided ringing for 8 months. He sleeps with the bedroom in total silence because, he says, ‘I want to hear if it changes.’ He reports it is worst at night and is now affecting his work concentration. His audiogram shows no asymmetry warranting imaging, and otoscopy is normal.
Which initial advice best reflects the habituation paradigm?
Module 2 · The Jastreboff Neurophysiological Model
Two patients attend the same clinic. Both are 60, both have symmetric moderate high-frequency hearing loss, both describe a 6 kHz hiss present for a year, and both match their tinnitus to a similar pitch and loudness. One runs marathons and barely thinks about the sound; the other has stopped working, sleeps poorly, and describes constant dread that ‘something is destroying my brain.’
According to the Jastreboff model, what best explains the difference in their suffering?
Module 3 · The Principle of Habituation
A 45-year-old teacher returns 10 weeks into a sound-enrichment and counselling programme, frustrated. ‘The ringing is exactly as loud as before — this isn’t working.’ On closer questioning she admits she now sleeps through the night, no longer panics when she notices it, and went a whole afternoon last week without thinking about it once. She is considering stopping treatment.
What is the most appropriate response?
Module 4 · TRT — Directive Counselling
A 52-year-old accountant with mild high-frequency hearing loss has had constant tinnitus for four months. She is convinced it signals a brain tumour, checks it obsessively, and sleeps poorly. Otological and imaging work-up is normal. She asks her audiologist what to do next.
Which intervention best reflects the directive-counselling component of TRT for this patient?
Module 5 · TRT — The Sound Therapy Component
A 40-year-old man with normal-hearing audiometry begins TRT for intrusive tinnitus. At his fitting he asks the audiologist to set his new ear-level sound generators 'loud enough that I can't hear the ringing at all'.
How should the audiologist set the sound generators, and why?
Module 6 · TRT Categories and the Treatment Protocol
A 35-year-old sound engineer reports moderate tinnitus and says that ordinary environmental sounds, like dishes clattering, now feel uncomfortably loud and that this is his most disabling symptom. His audiogram is essentially normal and he does not report prolonged worsening after sound exposure.
Which TRT category and matched protocol best fits this patient?
Module 7 · Sound Enrichment and Environmental Sound
A 52-year-old teacher with normal hearing reports bilateral high-pitched tinnitus that is barely noticeable during her busy school day but becomes 'unbearable' the moment she lies down in her quiet bedroom, delaying sleep by over an hour. Audiometry and otoscopy are normal. She is anxious that the night-time loudness means her tinnitus is getting worse.
What is the most appropriate first-line advice?
Module 7 · Masking and Residual-Inhibition Therapy
A 52-year-old man with bilateral high-frequency hearing loss and constant tonal tinnitus is fitted with ear-level sound generators. He tells his audiologist he sets them as loud as he can tolerate because 'that’s the only level that makes the ringing go away completely', and he wears them all day. After three months he reports the tinnitus is just as intrusive whenever the devices are off, and that he now struggles to follow conversations while wearing them.
What is the most appropriate adjustment to his sound therapy?
Module 7 · Notched and Customised Sound Therapy
A 38-year-old musician describes a clear, single-pitch tinnitus that she matches reliably to a 4 kHz tone. Her hearing is near-normal with only a slight notch at 4 kHz. She is highly motivated, listens to music for hours daily, and asks whether there is a sound-based treatment 'targeted at the actual frequency' rather than generic white noise.
Which tailored sound therapy is best matched to this patient, and how should it be framed?
Module 7 · Neuromodulation and Bimodal Stimulation
A 45-year-old woman with chronic (3-year) bilateral subjective tinnitus and mild hearing loss has tried hearing aids and counselling with partial benefit. She has read about 'brain stimulation for tinnitus' online and has been offered, at a private clinic, a course of rTMS advertised as a 'proven cure'. She asks for your advice on neuromodulation options.
What is the most appropriate, evidence-based advice?
Module 7 · Integrating CBT and Mindfulness
A 52-year-old man with mild high-frequency hearing loss has had constant tinnitus for 14 months. He has been using a well-fitted combination hearing aid with a sound generator for 4 months and reports the sound is now slightly less prominent in busy environments. However, he remains highly distressed: he describes lying awake convinced the tinnitus signals a brain tumour, has stopped going to restaurants, and his THI score has barely moved (from 68 to 62). MRI was normal.
What is the most appropriate next step in his management?
Module 7 · Evidence and Comparative Efficacy
A device company markets a wearable sound generator, citing a published study in which 40 patients' mean THI fell from 58 to 41 over 6 months of daily use, described as a 'statistically significant improvement'. There was no control group. A patient brings the brochure and asks whether the device is proven to work better than the counselling and CBT you have offered.
What is the most accurate response to the patient?
Module 7 · Personalising the Therapy Plan
A 34-year-old graphic designer has had bilateral high-pitched tinnitus for 8 months. Audiometry is entirely normal. She is not especially frightened of the tinnitus but finds it intolerable in her silent home studio and cannot fall asleep; her THI is 44 (moderate). She has tried a phone masking app inconsistently. She has no anxiety or depression, and the tinnitus is not modulated by jaw or neck movement.
What is the most appropriate personalised first-line plan?
Module 8 · Sound Generators and Wearable Devices
A 44-year-old man with normal hearing and constant, intrusive tonal tinnitus is fitted with ear-level sound generators and instructed to use them daily. At his 3-month review he reports no benefit. On questioning, he admits he wears them for only about 20 minutes a day because he initially set them 'as loud as possible to blot the tinnitus out' and found them irritating, so he keeps taking them off.
What is the most appropriate next step?
Module 9 · Hearing Aids and Combination Devices
A 67-year-old retiree describes constant bilateral tinnitus that troubles him most during quiet evenings, and his family complains he has the television too loud and frequently asks people to repeat themselves. Audiometry shows a symmetrical moderate high-frequency sensorineural hearing loss. He has not previously tried any device.
What is the most appropriate first-line management?
Module 1 · When Procedures Help — Treat the Cause, Select Carefully
A 44-year-old office worker has had constant, non-pulsatile high-pitched tinnitus in both ears for three years. Audiometry shows a mild symmetrical high-frequency sensorineural loss. MRI and otoscopy are normal. She has tried hearing aids and a course of CBT with partial benefit and now asks to be referred for “an operation to cure the noise” she read about online.
What is the most appropriate response regarding surgical or interventional treatment?
Module 2 · Surgery for the Underlying Ear Disease
A 38-year-old woman has a 5-year history of progressive right-sided conductive hearing loss with a continuous low-pitched tinnitus in the same ear. Tympanometry and a normal drum with an absent stapedial reflex and a carhart notch on audiometry suggest otosclerosis; CT confirms an otosclerotic focus. She asks whether the proposed stapedotomy will cure her tinnitus.
How should you counsel her about the tinnitus outcome of stapedotomy?
Module 3 · Cochlear Implantation and Tinnitus Suppression
A 59-year-old man developed profound left-sided sensorineural hearing loss with persistent, distressing left-sided tinnitus after a viral illness; the right ear is normal-hearing. Hearing aids and a CROS trial have not helped the tinnitus, and he asks whether anything can be done about both the deafness and the noise.
Which statement best reflects the role of cochlear implantation here and the expected tinnitus effect?
Module 4 · Cochlear Implant for Single-Sided Deafness with Tinnitus
A 44-year-old develops sudden profound sensorineural hearing loss in the right ear after a viral illness. The hearing does not recover. Eighteen months later she is functioning well at work but is tormented by a constant high-pitched tinnitus localised to the right (deaf) ear, scoring 76 on the THI. Sound therapy, masking and structured counselling over a year have not helped. MRI shows a patent right cochlea and a clearly present right cochlear nerve. Her left ear is normal.
Which intervention is most likely to relieve her dominant complaint?
Module 5 · Implants When a Cochlear Implant Is Not Possible (ABI, etc.)
A 22-year-old with neurofibromatosis type 2 has bilateral vestibular schwannomas. The larger right tumour is to be resected and the surgeon expects the right cochlear nerve to be sacrificed; the left ear is already deaf from previous surgery. He also describes a distressing constant tinnitus on the right. He asks whether an implant placed during the tumour operation will both restore hearing and cure his tinnitus.
What is the most appropriate counselling and plan?
Module 6 · Intervention for Pulsatile Tinnitus — Overview
A 39-year-old woman reports a six-month history of a whooshing sound in the left ear that beats in time with her pulse and keeps her awake. She finds that pressing gently on the left side of her neck makes the sound disappear, and turning her head to the left softens it. Otoscopy is normal. She is overweight and has recently had transient visual obscurations and headaches.
What is the most appropriate next step?
Module 7 · Sigmoid Sinus and Jugular Bulb Procedures
A 41-year-old woman with a BMI of 33 reports a 9-month history of a right-sided whooshing noise synchronous with her pulse; it stops when she presses on her right neck. Otoscopy is normal. High-resolution temporal bone CT shows a right sigmoid sinus diverticulum with overlying bony dehiscence, and CT venography shows narrowing of the right transverse sinus.
What is the most appropriate next step before offering sigmoid sinus wall reconstruction?
Module 8 · Dural AV Fistula and Endovascular Treatment
A 55-year-old man has a 6-month history of a left-sided pulsatile whooshing that does NOT change with neck pressure. A bruit is audible over the left mastoid. MR angiography suggests abnormal early venous filling near the left transverse sinus. Digital subtraction angiography confirms a dural arteriovenous fistula at the transverse-sigmoid junction with retrograde reflux into cortical veins.
Which feature most strongly determines that this fistula should be treated rather than observed?
Module 9 · Glomus Tumour (Paraganglioma) Management
A 38-year-old woman presents with right-sided pulsatile tinnitus and mild conductive hearing loss. Otoscopy shows a small red mass behind the inferior part of an intact eardrum that blanches with pneumatic pressure. CT shows a soft-tissue mass confined to the middle-ear promontory with no jugular foramen erosion. Biochemical screening for catecholamine excess is negative.
What is the most appropriate management?
Module 10 · Superior Semicircular Canal Dehiscence Repair
A 44-year-old woman reports a 2-year history of hearing her own heartbeat in the right ear, an echoing of her own voice, and brief vertigo when she hums loudly or strains. Audiometry shows a 30 dB low-frequency air–bone gap on the right with normal tympanometry and present acoustic reflexes. cVEMP threshold on the right is 60 dB nHL (left 90 dB).
What is the most appropriate next step to confirm the suspected diagnosis before discussing surgery?
Module 11 · IIH and Venous Sinus Interventions
A 31-year-old woman with a BMI of 34 describes a 9-month history of a continuous whooshing in the left ear, synchronous with her pulse, plus morning headaches and transient greying of vision on standing. The whooshing stops when she presses on the left side of her neck. Fundoscopy shows bilateral papilloedema and MR venography reveals a focal left transverse-sinus stenosis.
Which initial management is most appropriate?
Module 12 · Middle-Ear and Palatal Myoclonus — Surgery and Botulinum Toxin
A 26-year-old man reports a regular clicking in both ears, about two clicks per second, present for 4 months and audible to his partner at night. It does not change with loud sound but he can sometimes interrupt it by yawning. Otoscopy is normal; flexible nasendoscopy shows rhythmic contractions of the soft palate synchronous with the click. MRI of the brainstem is normal.
After conservative measures and a clonazepam trial have failed, what is the most appropriate targeted treatment?
Module 13 · Invasive Neuromodulation (DBS, Cortical, Invasive VNS)
A 44-year-old man has had severe, unilateral, pure-tone tinnitus for six years following sudden sensorineural hearing loss. His Tinnitus Handicap Inventory is 78. He has completed CBT, sound therapy, a full course of rTMS and a trial of a bimodal device, all without durable benefit. He has read about 'brain implants for tinnitus' and asks to be referred for deep brain stimulation. Psychological screening is clear and he understands the experimental nature.
What is the most appropriate next step?
Module 14 · Microvascular Decompression of the Cochleovestibular Nerve
A 51-year-old woman reports two years of brief, staccato clicking bursts in her right ear, like a distant typewriter, occurring many times a day with silent gaps between. Hearing is near-normal. MRI with 3D-CISS shows an AICA loop in contact with the right eighth nerve. A trial of carbamazepine abolishes the bursts within days, but she develops an intolerable rash.
What is the most appropriate management to discuss?
Module 15 · Patient Selection and the Evidence — A Cautious Algorithm
A 39-year-old man with a 3-year history of a constant, non-pulsatile high-pitched tone in both ears and a mild high-frequency hearing loss has tried hearing aids and sound therapy with limited relief. He is highly distressed (THI 70) and, having researched online, demands 'whatever operation will get rid of it'. Examination, audiometry pattern and history reveal no pulsatile quality and no focal structural feature.
What is the most appropriate response?
Module 1 · Tinnitus as a Window on Systemic Disease
A 58-year-old man is referred with 4 months of bilateral, mildly fluctuating ringing tinnitus. He has put on no weight, feels well, but mentions he started a third antihypertensive recently and his home blood-pressure readings have been running high. Otoscopy and pure-tone audiometry are essentially normal for age.
What is the most appropriate next step?
Module 2 · Cardiovascular Disease and Hypertension
A 46-year-old woman describes a 'whooshing' sound in her right ear that beats in time with her heartbeat and is worse when she lies down. She is otherwise well. On examination you place the stethoscope over the right side of her neck and hear a soft bruit; pressing gently on the neck momentarily changes the sound.
What does this presentation most strongly suggest, and what is the next step?
Module 3 · Anaemia and Haematologic Causes
A 34-year-old woman with heavy menstrual periods reports 3 months of a bilateral 'whooshing' tinnitus that beats with her pulse, together with tiredness and breathlessness on the stairs. Her conjunctivae look pale. Otoscopy and audiometry are normal.
Which investigation is most likely to reveal a treatable cause?
Module 4 · Thyroid and Endocrine Causes
A 52-year-old woman is referred with a 6-month history of constant high-pitched tinnitus in both ears. She has gained weight, feels persistently cold and tired, and her skin is dry. Audiometry shows a mild bilateral high-frequency sensorineural loss. Otoscopy is normal.
Which single investigation is most likely to reveal a reversible systemic cause of her tinnitus?
Module 5 · Metabolic Disease, Diabetes and Deficiencies
A 58-year-old man with a 10-year history of poorly controlled type 2 diabetes reports gradually worsening bilateral tinnitus and difficulty hearing in noise. He also has background diabetic retinopathy and reduced sensation in his feet. Audiometry confirms a symmetrical high-frequency sensorineural hearing loss.
What best explains the relationship between his diabetes and his tinnitus?
Module 6 · Autoimmune and Inflammatory Causes
A 34-year-old woman presents with 8 weeks of fluctuating, worsening hearing in both ears, accompanied by tinnitus and intermittent dizziness. Over the past week she has also developed red, gritty, painful eyes. Inflammatory markers are raised. MRI of the internal auditory meati is normal.
Which diagnosis best fits this picture, and what is the key first management step?
Module 7 · Neurologic Systemic Causes
A 31-year-old woman with obesity describes 4 months of a rhythmic whooshing in her right ear, synchronous with her pulse, plus a dull headache that is worst when she wakes and improves through the day. She has had two episodes of brief greying-out of vision when she stands. Otoscopy and the audiogram are normal.
Which single examination finding would most strongly support the leading diagnosis?
Module 8 · Infections and Post-infective Tinnitus
A 47-year-old man reports 6 weeks of progressive, fluctuating hearing loss and tinnitus in both ears, with brief spells of unsteadiness. He has no preceding loud-noise exposure. He recently completed treatment for a sexually transmitted infection but did not return for follow-up. The audiogram shows fluctuating sensorineural thresholds.
Which investigation should be prioritised?
Module 9 · Renal, Hepatic and Electrolyte Causes
A 63-year-old woman on maintenance haemodialysis for stage 5 CKD reports bilateral tinnitus and a sensation of fullness that she notices is loudest just before her dialysis sessions and eases afterwards. She was recently treated with a course of intravenous gentamicin and vancomycin for a line infection.
What is the most important immediate action?
Module 10 · Medication-Induced Tinnitus and Polypharmacy
A 72-year-old man with heart failure and chronic kidney disease is admitted with pneumonia and started on intravenous gentamicin while continuing his regular furosemide. He also takes naproxen for knee pain. On day four he reports a new, constant high-pitched ringing in both ears and difficulty hearing the ward staff.
What is the single most important immediate action?
Module 11 · TMJ, Cervical and Musculoskeletal Causes
A 34-year-old woman reports six months of left-sided buzzing tinnitus that began after a period of work stress. Her audiogram is normal. On examination she has masseter tenderness and clicking of the left TMJ, and she notices that the buzzing gets noticeably louder when she clenches her teeth and softer when she relaxes the jaw.
Which finding most strongly supports a somatic (TMJ-related) cause and guides management?
Module 12 · Psychiatric and Functional Contributors
A 48-year-old man has had moderate bilateral tinnitus for a year. His audiogram shows only mild high-frequency loss and his matched tinnitus loudness is low. Yet he is severely disabled: he has stopped working, sleeps poorly, checks his ears constantly, and tearfully says he 'cannot go on like this'. He scores high on a depression screen.
What is the most appropriate management priority?
Module 13 · Unusual and Rare Forms of Tinnitus
A 58-year-old man with no psychiatric history and a 30 dB bilateral high-frequency hearing loss reports that for three months he has clearly heard hymns and old folk tunes, especially in quiet rooms at night. He knows they are not really playing and is mortified, fearing dementia. Examination and cognition are normal.
What is the most appropriate first step?
Module 14 · The Systemic Work-up: History, Examination and the Rational Blood Panel
A 34-year-old woman presents with several months of bilateral non-pulsatile tinnitus, fatigue and breathlessness on exertion. She has heavy periods and is a vegetarian. Otoscopy and audiometry are essentially normal.
Which initial investigations are most rational?
Module 15 · Integrating Systemic Causes: When to Suspect, Whom to Involve, and How to Co-manage
A 72-year-old woman has new left-sided tinnitus with reduced hearing over two weeks, plus a recent temporal headache, scalp tenderness on combing her hair, and pain in her jaw when chewing. Her ESR and CRP are markedly elevated.
What is the most appropriate immediate action?