2Taking the Tinnitus History

FOnset, trigger and time course

Start at the beginning. When did it start, and what was happening — a loud concert, a viral illness, a new drug, a head injury, a stressful period? Sudden unilateral onset, especially with hearing change, carries more weight than a gradual bilateral creep. [2014]

Then map the time course. By convention tinnitus is acute under three months, subacute from three to six, and chronic beyond six months. Chronicity matters because it shifts the goal from cure toward habituation, and because longstanding tinnitus is more often accompanied by entrenched distress. Ask too whether it is constant or comes and goes — intermittent and fluctuating tinnitus has its own differential. [2013]

FCharacter, pitch and laterality

Let the patient describe the sound in their own words, then translate it. Tonal sounds (ringing, whistling, hissing) usually accompany sensorineural hearing loss; noise-like sounds (buzzing, roaring) point variously to low-frequency or Menieric processes; rhythmic sounds (pulsing, clicking) flag an objective, often vascular or muscular, generator. [2013]

Laterality is a key triage variable. Genuinely unilateral or markedly asymmetric tinnitus, particularly with asymmetric hearing loss, raises the question of a retrocochlear lesion such as a vestibular schwannoma and lowers the threshold for imaging. Bilateral, symmetric, in-the-head tinnitus is reassuringly common and benign.

TModulating factors

Ask deliberately what changes the tinnitus. If clenching the jaw, turning or pressing on the neck, or pressing periauricular trigger points alters the loudness, pitch or location, the tinnitus has a somatic component and a musculoskeletal target. [2015] Patients with temporomandibular disorder are over-represented among those with modifiable tinnitus. [2011]

Other modulators carry their own meaning: tinnitus that loudens in silence and softens in background sound supports habituation-based sound enrichment; tinnitus that tracks stress and attention points to the limbic loop; and substances — caffeine, alcohol, and certain medications — should be logged because patients often suspect them even where evidence is weak. [2013]

TAssociated symptoms and the red-flag screen

Tinnitus rarely arrives alone, and its companions are diagnostic gold. Screen explicitly for hearing loss (especially asymmetric), vertigo or imbalance, aural fullness, and otalgia or otorrhoea. The triad of fluctuating low-tone tinnitus, episodic vertigo and fullness suggests Menieric disease; pulsatile tinnitus with headache and visual obscurations suggests raised intracranial pressure. [2014]

Embedded in this screen is the red-flag review: unilateral tinnitus, pulsatility, asymmetric hearing loss, sudden onset, focal neurology, and otalgia/otorrhoea each lower the threshold for imaging or onward referral. The history is where these flags are caught.

CDrug and noise exposure

Take a focused exposure history. Ototoxic and tinnitus-associated drugs — high-dose salicylates, aminoglycosides, loop diuretics, platinum chemotherapy, and some NSAIDs — should be reviewed against the onset timeline, since some are reversible on withdrawal. [2013] A noise history, occupational and recreational, contextualises a high-frequency notch on the audiogram and the matching high-pitched tinnitus.

This is also where you ask about a family history of hearing loss and about prior ear surgery or barotrauma. The aim is to anchor the percept to a plausible peripheral story, which both reassures the patient and rationalises any further testing.

CImpact and the patient’s beliefs

Finally — and never last in importance — characterise the impact. How is sleep? Concentration? Mood? Work and relationships? Brief, validated questionnaires (covered later) formalise this, but the open question ‘how much does it affect your life?’ already separates the bothered from the unbothered. [2014]

Then elicit the patient’s beliefs. Many fear the sound signals a tumour, impending deafness, or madness; these catastrophic interpretations amplify distress and are eminently correctable with explanation. Asking ‘what do you think is causing it?’ and ‘what are you most worried about?’ is itself a therapeutic act, and it shapes the counselling that follows. [2013]