Cases/Ear, Nose and Throat

Troublesome Tinnitus — Free SCA Practice Case

Hearing-impaired man with troublesome tinnitus

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Arthur Vance

Age

68 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"The ringing in my ears is getting unbearable. It's affecting my sleep and I can't concentrate on anything."

Medical Records

●
PMH:
- ●Bilateral Sensorineural Hearing Loss (Presbycusis) - wears bilateral hearing aids (NHS provided).
- ●Hypertension.
●Medications: Amlodipine 5mg OD.
●Allergies: NKDA.

Recent Notes

●1 Year Ago: Audiology review. Hearing aids re-tubed. Audiogram showed symmetrical moderate high-frequency loss consistent with age.

Patient Script

For the friend playing the patient role

Character Overview: You are Arthur. You are tired and irritable. You struggle to hear the doctor if they mumble or turn away from the camera. You rely on lip-reading to supplement your hearing aids. The noise in your head is making you feel trapped.

Opening Sentence: "Doctor, I need something to stop this noise. It's a high-pitched whistle, like an old TV left on. It's there all the time, but at night... it's deafening. I haven't had a decent night's sleep in weeks."

History if Asked (Data Gathering Phase)

●
The Sound: "It's in both ears, right in the middle of my head. Just a constant high-pitched hiss."
- ●Red Flag Check: "No, it doesn't beat with my heart (not pulsatile). It's not just one side."
●Onset and Duration: "It's been building over a few months, but the last three or four weeks it's really ramped up. I can't point to anything that set it off — no loud noise, no injury. It just crept up on me."
●Associated Symptoms (Neurology/Stroke): "No dizziness. The room doesn't spin." "No weakness in my face or arms." "No double vision."
●The Hearing Aids: "I wear them all day. They actually help a bit — when I have them in, the background noise drowns out the whistling. But I can't sleep with them in. The second I take them out to go to bed, the silence is filled with the noise."
●Medications: "I haven't started anything new. Just my blood pressure pill. I take the odd Ibuprofen for my knees, but maybe only once a week."
●Impact (The "Troublesome" Aspect): "I used to love reading, but I read the same page three times because the noise distracts me. And at night, I lie there for hours listening to it. I'm exhausted."
●Mental Health: "It's getting me down. I feel anxious about going to bed because I know what's coming. I'm not suicidal, but I just want some peace."

ICE — Ideas, Concerns, Expectations

Actor guidance: Arthur does not raise these unprompted. These surface only if the candidate directly explores his perspective.

●Ideas: "I think it might be connected to my hearing going. My father went deaf in his seventies and I remember him complaining about ringing too — so maybe it's just what happens when your ears pack in. I did wonder if it could be my blood pressure tablet doing it, because I read something online about pills causing it."
●Concerns: "Honestly, I'm worried it's going to get worse and I'll never get a proper night's sleep again. I'm already exhausted — I don't know how much more of it I can take. And I suppose in the back of my mind I wonder if there's something more serious going on in my head, though I know that's probably daft."
●Expectations: "I want to know if there's anything that can actually stop it — a tablet, a procedure, anything. And if not, I need some way to cope with it at night so I can sleep. I can't just keep lying there listening to it."

If Asked — Medical History and Medications

Actor guidance: Arthur responds to direct questions about his medical history. He is matter-of-fact and slightly impatient — he doesn't see the relevance unless it's explained to him.

●Amlodipine / Blood pressure: "I've been on the Amlodipine for about five years now. One tablet in the morning. My blood pressure's been fine on it — the nurse checks it every year. I haven't had any side effects from it, no swollen ankles or anything like that."
●Ibuprofen use: "Just the odd one for my knees — maybe one or two a week if they're playing up. I don't take it regularly. Nobody told me it could be a problem."
●Hearing aids and audiology: "I've had the hearing aids for about four years now. NHS ones — they're alright, they do the job. I had them looked at about a year ago, re-tubed and everything. The audiologist said my hearing was about what you'd expect for my age — nothing dramatic, just the usual wear and tear. She didn't mention anything about ringing at that point."
●Any ear drops, syringing, or ear infections: "No, nothing like that. I haven't had any ear infections. I don't use cotton buds or anything in my ears — the audiologist told me not to."

Social History and Lifestyle Impact

Actor guidance: Arthur shares this naturally in conversation — it comes out when discussing how the tinnitus affects him, not as a list.

●Occupation / daily life: Arthur is retired. He was a postal worker for over thirty years. He lives alone — his wife passed away six years ago. He keeps himself busy with gardening, reading, and volunteers one morning a week at a local charity shop. He has two grown-up children who live nearby and visit regularly.
●Lifestyle impact: "The worst thing is the evenings. I used to enjoy the quiet — a bit of reading, a cup of tea, the radio on low. Now the quiet is the enemy. As soon as things go still, the noise fills everything. I've stopped volunteering on Thursdays because I was so tired I couldn't concentrate on the till. My daughter noticed I was snapping at the grandchildren last weekend — that's not me. I just can't cope when I'm this tired."
●Alcohol and smoking: "I have the odd glass of wine with dinner, nothing much. I gave up smoking twenty years ago."

If Asked — Associated Symptoms

Actor guidance: Arthur answers direct questions about symptoms briefly and naturally. He is cooperative but may show mild impatience if the relevance is not clear to him.

●If asked about hearing getting worse recently: "I don't think so — it's been much the same. The hearing aids help. It's the noise that's the new problem, not the hearing."
●If asked about ear pain: "No, no pain in my ears at all."
●If asked about ear discharge: "No, nothing coming out of them."
●If asked about fullness or blocked sensation in the ears: "No, they don't feel blocked. It's not like that — it's just the noise."
●If asked about headaches: "No, I don't get headaches."
●If asked about jaw pain or clicking: "No, my jaw's fine."
●If asked about neck pain or stiffness: "My neck gets a bit stiff sometimes, but nothing out of the ordinary for my age."
●If asked about recent infections or colds: "No, I haven't been ill. No colds or anything."
●If asked about exposure to loud noise: "Not recently. I mean, years ago at work the sorting office could be noisy, but nothing lately."
●If asked about stress or anxiety beyond what's mentioned: "I wouldn't say I was a stressed person normally. It's the tinnitus that's making me anxious — not the other way around."
●If asked about caffeine intake: "I have two or three cups of tea a day. Nothing excessive."
●If asked about any changes in vision: "No, my eyes are fine."
●If asked about nausea or vomiting: "No, nothing like that."
●If asked about facial numbness or tingling: "No, nothing like that at all."

Responses to Management (The Negotiation Phase)

●
If the Doctor mumbles or looks down:
- ●Reaction: Leans in, frowns. "Sorry Doctor, I missed that. Can you look at the camera so I can see your lips?" (Tests communication skills).
●
If the Doctor prescribes Betahistine (Serc):
- ●Reaction: "My mate takes that for dizziness. Will it stop the noise? I don't want to take pills if they don't work."
●
If the Doctor suggests 'Sound Enrichment':
- ●Reaction: Skeptical. "You mean put more noise in? How will that help me sleep?" (Needs explanation of distraction/habituation).
●
If the Doctor explains sound enrichment clearly (e.g. bedside sound generator, fan, radio static, nature sounds app):
- ●Reaction: Cautious but willing. "I suppose I could try it. I'd rather that than more tablets. What kind of sounds work best?"
●
If the Doctor suggests CBT or psychological therapy for tinnitus:
- ●Reaction: Initially resistant. "I don't need a therapist — I need the noise to stop." But if the doctor explains it's specifically designed for tinnitus and helps with the distress and sleep: "Well, if it's specifically for this and not just talking about my feelings, I'd be willing to give it a go."
●
If the Doctor offers referral to audiology / tinnitus clinic:
- ●Reaction: Positive. "Yes, please. I'd like to see someone who specialises in this. I feel like I'm going round in circles on my own."
●
If the Doctor says 'There is no cure':
- ●Reaction: Deflated. "So I just have to live with it? Is that it?"
●
If the Doctor acknowledges the impact and validates the distress:
- ●Reaction: Softens. "Thank you. I know it probably doesn't sound like much to other people, but it really is driving me mad. I just needed someone to take it seriously."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 2: Clinical Management and Medical Complexity

0 / 28 indicators checked+0−0

Positive (0/14)

Negative (0/14)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

Tinnitus: Characterisation and the Key Differential

●Tinnitus is the perception of sound in the absence of an external acoustic stimulus. In primary care, it is most commonly bilateral, non-pulsatile, and high-pitched — arising from reduced cochlear input triggering compensatory central auditory hyperactivity.
●The single most important clinical distinction is pulsatile vs non-pulsatile. Pulsatile tinnitus (a rhythmic sound synchronous with the heartbeat) has a vascular differential — glomus tumour, arteriovenous malformation, idiopathic intracranial hypertension — and requires ENT referral regardless of other features.
●Unilateral tinnitus is the second key flag. Unilateral or significantly asymmetric tinnitus warrants ENT assessment to exclude a vestibular schwannoma (acoustic neuroma), even in the absence of hearing loss.
●Bilateral, continuous, non-pulsatile tinnitus in a patient with known sensorineural hearing loss — as in this case — is the classic presentation of tinnitus associated with presbycusis. It does not require ENT referral as a first step.

Red Flags Requiring Urgent Action

●Sudden sensorineural hearing loss (SSNHL): Sudden onset of hearing loss or tinnitus developing over less than 72 hours requires same-day ENT assessment. High-dose oral corticosteroids within 24–48 hours of onset significantly improve outcomes; delay reduces efficacy.
●Neurological symptoms: Tinnitus accompanied by facial weakness, diplopia, dysarthria, sudden vertigo, or limb incoordination should prompt immediate assessment for posterior fossa or cerebellopontine angle pathology, including stroke.
●Acute pulsatile tinnitus: Sudden onset of pulsatile tinnitus, particularly with headache or visual symptoms, raises the possibility of idiopathic intracranial hypertension and requires urgent review.
●Severe psychological distress or suicidality: Chronic tinnitus is associated with significant rates of depression and anxiety. Any disclosure of suicidal ideation requires immediate risk assessment and appropriate mental health intervention.

Referral Pathways

●Audiology / Hearing Therapy (first-line for this case): Bilateral non-pulsatile tinnitus with known hearing loss should be referred to audiology or a specialist tinnitus service for comprehensive assessment, sound therapy advice, and tinnitus retraining therapy (TRT). This is the correct pathway per NICE CKS.
●ENT Specialist: Indicated for unilateral or asymmetric tinnitus, pulsatile tinnitus, objective tinnitus (audible to the examiner), conductive hearing loss, or abnormal otoscopy.
●Do not refer to ENT routinely for bilateral non-pulsatile tinnitus without red flags — this is an incorrect and resource-intensive pathway.

Investigating and Modifying Contributing Factors

●Ototoxic medications: A medication review is mandatory in any new tinnitus presentation. Regular use of NSAIDs (including ibuprofen) is associated with tinnitus and cochlear damage at higher doses. Arthur's intermittent ibuprofen use for knee pain should be discussed — advise substituting paracetamol as the preferred analgesic where possible.
●Amlodipine is not a recognised cause of tinnitus. It should not be stopped or switched in a patient with well-controlled hypertension on this basis alone — this concern should be addressed directly and clearly with the patient.
●Other ototoxic agents to consider in general practice include loop diuretics (furosemide at high doses), aminoglycoside antibiotics, and some cytotoxic drugs — relevant when reviewing the medication list.
●Cerumen, otitis media, and otosclerosis should be excluded clinically if not already done, as these cause conductive hearing loss and may exacerbate tinnitus perception.

Clinical Management: The Core Framework

●Explanation of mechanism: Explain that tinnitus is a real auditory experience generated by the brain in response to reduced input from the inner ear — not imagined, and not a sign of serious intracranial pathology. Accessible framing: 'Your brain is turning up the volume to compensate for what it's not hearing from the ear.' This reframing is central to reducing catastrophic interpretation.
●Habituation: The majority of people with tinnitus find it becomes significantly less intrusive over time as the auditory cortex learns to deprioritise the signal. Management should be framed as supporting this natural process — reducing distress and reactivity — rather than eliminating the sound.
●Sound enrichment: The therapeutic principle is that low-level continuous background sound reduces the contrast between silence and the tinnitus signal, making it less perceptible and less distressing. For night-time — the most troublesome context for Arthur — recommend a bedside sound generator, fan, radio on low volume, or a nature sounds or white/pink noise app. The sound should be present but clearly below the level of the tinnitus, not masking it completely.
●Hearing aid optimisation: In patients with hearing loss, hearing aids are a first-line tinnitus management tool as well as a hearing aid. Consistent daytime use reduces the perceptual contrast that drives tinnitus awareness. At the next audiology review, aids with integrated tinnitus masking programmes should be considered.
●Sleep hygiene: Address sleep disturbance directly alongside sound enrichment. Key principles: consistent sleep and wake times, avoiding caffeine after early afternoon, a wind-down routine, and keeping the bedroom environment calm. Do not prescribe hypnotics as a first-line response to tinnitus-related insomnia.

Psychological Therapies: The Stepped Care Approach

●
If tinnitus-related distress is present, offer psychological support in a stepped sequence:
1. ●Digital tinnitus-focused CBT — self-directed, accessible immediately (e.g. via NHS apps or the British Tinnitus Association)
2. ●Group-based interventions — mindfulness-based cognitive therapy (MBCT), ACT, or group CBT
3. ●Individual tinnitus-focused CBT — delivered by a psychologist, for those not responding to lower-intensity support
●Tinnitus-focused CBT specifically targets the distress response and sleep disruption associated with tinnitus — it is not generic counselling. This distinction is important when explaining it to a patient who resists 'therapy.' Frame it as a practical skill-based intervention for managing a specific symptom.
●Do not prescribe antidepressants or anxiolytics as a first-line response to tinnitus distress. Comorbid depression or anxiety should be assessed and managed independently using standard frameworks.

Treatments That Are Not Recommended

●
Per NICE CKS, the following should not be offered for tinnitus:
- ●Betahistine (Serc) — no evidence of benefit for tinnitus (it has a role in vertigo associated with Menière's disease, but not in tinnitus per se)
- ●Ginkgo biloba or other herbal supplements
- ●Acupuncture
- ●Dietary supplements
●Prescribing these represents a clear negative indicator and reflects unfamiliarity with current guidelines.

Safety-Netting

●
Advise Arthur to return promptly if:
- ●The tinnitus becomes unilateral or pulsatile
- ●There is any sudden change in hearing
- ●Neurological symptoms develop (dizziness, facial weakness, visual disturbance, coordination problems)
- ●Mood deteriorates significantly or sleep deprivation becomes unmanageable
●These specific symptoms should be named explicitly — safety-netting should not be left as a generic 'come back if it gets worse.'

Follow-Up and Continuity

●Arrange a follow-up in 4–6 weeks to review the effectiveness of initial strategies (sound enrichment, sleep hygiene), check mood and sleep, and discuss the outcome of audiology referral.
●Tinnitus is a chronic condition requiring ongoing support. A single-consultation discharge is not appropriate.

Information and Patient Support

●British Tinnitus Association (BTA): www.tinnitus.org.uk — self-help resources, helpline, peer community, and written information on sound therapy
●RNID: www.rnid.org.uk — practical resources for people with hearing loss and tinnitus
●NHS A to Z: Tinnitus — clear lay information for initial self-education
●Providing at least one specific resource gives the patient something concrete to act on between appointments and reduces the sense of isolation common in chronic tinnitus.

Mapped to the RCGP curriculum topic: Ear, Nose and Throat.

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