Tinnitus and the GP

I'm always surprised by the incidence of tinnitus - one in 10 adults. This means the best part of 200 of my patients are affected, which also means most of them never come and see me about it. Perhaps they research it online, and learn that there is rarely a serious underlying cause, unless it's unilateral. Perhaps the ones who don't seek help really aren't troubled by it, and can manage it with simple lifestyle adaptations.

But one in 100 are severely affected by it - and I seriously doubt I see even that many. Perhaps for them the doom and gloom scenario of no available cure put them off seeing their GP. Perhaps a well-meaning doctor has tried to reassure them about how common it is and how it's 'nothing to worry about' because of the lack of underlying pathology. To a patient overwhelmed by the impact of tinnitus on their day-to-day functioning, that could all too easily be misinterpreted as meaning nobody will take their symptoms seriously, and nobody can help.

The British Tinnitus Association is trying to raise awareness of tinnitus this week, in Tinnitus Awareness Week. In a recent interview with their Chief Executive, David Stockdale, he made it clear that no matter how hard we as GPs work to help our patients with severe tinnitus, their perception is that they aren't getting the support they need.

He has some simple messages about what patients want to know:

  • A positive tone. When we say 'there's no cure' the patient hears 'you'll have to live with these symptoms forever' - and that is neither helpful nor true
  • They aren't going mad - yes, these noises are coming from inside their heads, but that doesn't mean they aren't very real
  • It's doubly important to stress the lack of psychiatric cause if we're going to refer for specialist CBT, which does have a significant evidence base for relief of symptoms (1). If your GP told you tinnitus 'isn't a mental health problem' and promptly referred you for counselling, what would you think?
  • Tinnitus is often linked to presbyacusis, but there is no reliable correlation. Patients with severe presbyacusis may have no tinnitus, and patients with relatively mild hearing loss may be severely affected. Either way, referral for audiometry and provision of hearing aid can help with both their hearing and their tinnitus
  • Many patients will habituate to their tinnitus, with quality of life improving as symptoms gradually settle
  • For severely affected patients, early referral is associated with much better outcomes than delayed referral
  • Referral should ideally be to a specialist tinnitus centre rather than to a general ENT clinic. However, in some areas there is no direct GP access to tinnitus services, so referral may need to go via a general ENT clinic
  • Tinnitus Retraining Centres are not widely available in their 'true' form any more on the NHS. However, a combination of CBT, education and hearing aids or sound therapy, delivered by a tinnitus clinic led by an audiologist with special hearing therapy skills will benefit the majority of severely affected patients.

Management of tinnitus has been difficult to assess reliably because of lack of blinding of studies. A systematic review highlighted the need for further studies to assess conclusively efficacy of other interventions, but did show moderate size benefit for CBT and 'evidence of potential benefit' for SSRIs (1).

Economic modelling of the cost-effectiveness of tinnitus treatment, on the other hand, shows clear conclusions (2):

  • Firstly, treating troublesome tinnitus is cost-effective using criteria usually employed by NICE, with a Cost per QALY Gained (CQG) of £10,600
  • Secondly, the CQG is significantly lower when patients are referred directly to a tinnitus clinic, including an audiologist and counselling services, rather than first to a general ENT clinic and on from there to specialist tinnitus treatment using modified tinnitus retraining therapy (MTRT) or CBT.

The Department of Health (3) recommends five tiers of service for patients with tinnitus, depending on severity and co-morbidities:

1) Self-management

2) Primary care

3) Community-based audiology service (tinnitus clinic)

4) The specialist centre (including audiologist, hearing therapist or rehabilitative audiologist, clinical psychologist, audio-vestibular physician, ENT surgeon, consultant audiologist scientist and nurse, with access to other departments as appropriate)

5) The super-specialist centre (for patients with extremely distressing tinnitus or tinnitus thought to be due to intracranial pathology or related to other audiological conditions).

The paper specifies that audiology-based tinnitus services should provide 'reassurance and information, explanation and advice on tinnitus, use of counselling skills and CBT, information on using relaxation and hearing tactics if necessary, and fitting of hearing aids and referral for assistive listening devices'.

Yet seven years on from these recommendations, there remains significant evidence of a postcode lottery for patients with tinnitus. Highlighted in a useful review of tinnitus management in 2013 (4), an assessment of levels of training and provision of psychological support for tinnitus patients by audiologists showed wide variations across the four countries of the UK, with no report of clinical psychology or audio-vestibular physician involvement in services outside England, little CBT training in Scotland and none in Northern Ireland (5).

After more than quarter of a century in general practice, I'm nothing if not a pragmatist. I know all too well about downward pressure on referrals. I hear regularly of services axed and not replaced. But while tinnitus may not be severe for the majority, it has a major impact on the quality of life and psychological wellbeing of one in 100 of our patients - and the cost-effectiveness of treatment is such that if tinnitus clinics were a drug and NICE turned them down, there would be uproar.

References

1) Hoare D, Kowalkowski V, Kang S et al. Systematic Review and Meta-Analyses of Randomized Controlled Trials Examining Tinnitus Management. Laryngoscope 2011; 121:1555-1564

2) Stockdale D, McFerran D, Brazier P et al. An economic evaluation of the healthcare cost of tinnitus management in the UK in press

3) Department of Health. Provision of Services for Adults with Tinnitus - A Good Practice Guide. Department of Health, January 2009. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093844

4) Baguley D, McFerran D, Hall D. Tinnitus. Lancet 2013; 2013; 382: 9904: 1600-1607 http://dx.doi.org/10.1016/S0140-6736(13)60142-7

5) Hoare D, Broomhead E, Stockdale D et al. Equity and person-centeredness in the provision of tinnitus services in UK National Health Service audiology departments. European Journal for Person Centered Healthcare 2015;3(3): 318-326

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