PONOS Clinic · Tinnitus

Tinnitus: a specialist pathway, step by step

From hearing assessment to neck and jaw involvement. A coordinated pathway with clear, individual goals.

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Dr Evangelos Panagiotakos MD · Turin · Conceptual illustration

One symptom, several aspects to assess

Tinnitus is the perception of sound without an external source. It may affect one ear, both ears or be perceived within the head. ENT and audiological assessment is an essential part of its evaluation.^[1]

Hearing and the ear

Start with the investigations already performed and clarify with your specialist which questions remain unanswered.

Neck and jaw

Assess any neck pain, TMJ disorders and changes in the symptom associated with movement.

Everyday life

Allow time to discuss sleep, concentration and activities that the symptom makes more difficult.

The PONOS contribution. Pain medicine assessment complements ENT and audiological evaluation, particularly when craniofacial pain, neck pain or jaw disorders coexist. Persistent tinnitus alone does not establish a neuropathic cause or automatically indicate a procedure.

When to consult PONOS

persistent tinnitus alongside neck, jaw or craniofacial pain;
changes in the sound with neck or jaw movement;
painful bruxism, clenching or accompanying occipital symptoms;
incomplete benefit from previous care and a need to review the clinical picture as a whole.

When not to wait for a routine appointment. Sudden hearing loss with tinnitus requires urgent assessment, ideally within 24 hours. New neurological symptoms require immediate medical attention. Pulsatile tinnitus or persistent tinnitus on one side should be reported to your clinician for a dedicated assessment.^[2]

The PONOS specialist pathway

Review the history. When the symptom began, how it changes, where it is perceived and which treatments have already been tried.

Bring investigations together. ENT reports, hearing tests and other available investigations are reviewed, with any further assessment coordinated with the specialists involved.

Examine the painful components. The neck, occipital region, TMJ and chewing muscles are assessed in relation to symptoms, without automatically attributing everything to the cervical spine.

Develop an individual proposal. Goals, alternatives and the potential value of selective tests are discussed when there is a specific clinical suspicion.

Measure and reassess. Tinnitus, pain and functional impact are compared over time: improvement in one does not necessarily mean improvement in the others.

The relationship with the neck, jaw and bruxism

Changes in tinnitus with movement may suggest a somatosensory component. On their own, however, they are insufficient to establish a diagnosis: the clinical history, timing in relation to pain and examination findings also matter.^[3]

Temporomandibular region

The PONOS pathway assesses possible TMJ and auriculotemporal involvement, integrating dental and rehabilitation care.

TMJ pain and bruxism →

Cervical and occipital region

Neck pain and occipital symptoms are examined separately from the jaw component, to avoid confusing targets and indications.

Occipital neuralgia →

When ultrasound-guided tests may be considered

Within the PONOS pathway for selected cases with a suspected somatic component, the auriculotemporal nerve and the third occipital nerve may be assessed as distinct targets using an ultrasound-guided diagnostic block with local anaesthetic.

The response is discussed alongside the diagnosis and alternatives. A favourable test contributes to clinical decision-making but does not guarantee a response to subsequent treatment.

Auriculotemporal PRF. If radiofrequency treatment of the auriculotemporal nerve is considered, it is performed in pulsed mode. This is an option for selected patients, with limited evidence in tinnitus, rather than a universal cure. The technique, indications and risks are described on the procedure page.

Coordinated care with realistic goals

Management may include audiological support, hearing aids when indicated for hearing loss, and psychological interventions aimed at reducing distress, such as cognitive behavioural therapy. Choices depend on the individual presentation.^[1]

At PONOS, practical, measurable goals are agreed, distinguishing tinnitus intensity, associated pain and quality of life. Finding that a procedure is not indicated is still a useful outcome of assessment.

What to bring to your appointment

Documentation

ENT reports and hearing tests;
existing investigations and images;
a list of medication and treatments tried;
any dental and cervical assessments.

A brief description

onset, side and pattern of the sound;
any relationship with your heartbeat;
changes with the neck, jaw and pain;
impact on sleep and activities.

Explore your pathway further

Somatic tinnitus

The relationship with the cervical and jaw regions.

Chronic tinnitus

Persistent symptoms and their everyday impact.

Tinnitus and neuropathic pain

A closer look at associated pain presentations.

Let’s start with a clinical assessment

Bring your existing documentation: the consultation helps clarify the contribution of painful components and define the next steps.

Request an assessment Auriculotemporal PRF TMJ pain and bruxism

Frequently asked questions

Does a PONOS consultation replace an ENT assessment?

No. It complements ENT and audiological evaluation, focusing particularly on painful cervical, jaw and craniofacial components.

If tinnitus changes when I move my neck, is it definitely cervical?

No. This is something to report to your clinician and interpret alongside the history and examination; it does not identify the source of the symptom on its own.

Does assessment necessarily involve an injection?

No. Tests are proposed only when they can answer a specific clinical question, after discussing benefits, limitations and risks.

Is PRF offered to every patient?

No. The decision is individual and applies to selected cases. A positive test does not guarantee the outcome, and PRF is not a universal cure for tinnitus.

Can I book if I have already had many investigations?

Yes. Bring reports, images and a list of treatments tried: the pathway starts with your existing documentation and the clinical questions that remain unanswered.

Key references

National Institute on Deafness and Other Communication Disorders. Tinnitus.
NICE. Tinnitus: assessment and management (NG155).
Michiels S et al. Diagnostic Criteria for Somatosensory Tinnitus: A Delphi Process and Face-to-Face Meeting to Establish Consensus. 2018.

General information that does not replace an individual medical assessment. The pathway and any procedures are discussed during the consultation.