Tinnitus guidance for GPs

British Tinnitus Association


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Tinnitus red flags

  • Firm indications that a patient with tinnitus should be referred onwards include:
    • pulsatile tinnitus
    • tinnitus in association with significant vertigo
    • unilateral tinnitus
    • tinnitus in association with asymmetric hearing loss
    • tinnitus causing psychological distress
    • tinnitus in association with significant neurological symptoms and/or signs
  • Although many tinnitus patients do not fit into any of these imperative categories, clinicians involved in tinnitus care are firmly of the opinion that all patients with the symptom should at the very least receive an audiological assessment. Local factors will determine whether this is undertaken in primary or secondary care

At any point in time around 10% of the population experience tinnitus

  • Both sexes are equally affected and although tinnitus is more common in the elderly it can occur at any age, including childhood. The perceived sound can have virtually any quality—ringing, whistling, and buzzing are common—but more complex sounds can also be described

Most tinnitus is mild

  • In fact it is relatively rare for it to develop into a chronic problem of life-altering severity. The natural history of tinnitus in most patients is of an acute phase of distress when the problem begins, followed by improvement over time. But for a minority of patients the distress is ongoing and very significant, and they will require specialist support

Underlying pathology is rare, but be vigilant

  • In many cases, tinnitus is due to heightened awareness of spontaneous electrical activity in the auditory system that is normally not perceived. It can however be a symptom of treatable and significant otological pathology, such as a vestibular schwannoma or otosclerosis

Tinnitus can be associated with a blocked sensation

  • For reasons that are not clear, tinnitus and sensorineural hearing loss can give rise to a blocked feeling in the ears despite normal middle ear pressure and eardrum mobility. Otoscopy and, if available, tympanometry can exclude Eustachian tube dysfunction. Decongestants and antibiotics are rarely helpful

Giving a negative prognosis is actively harmful

  • It is all too common to hear that patients have been told nothing can be done about tinnitus. Such negative statements are not only unhelpful but also tend to focus the patient's attention on their tinnitus and exacerbate the distress. A positive attitude is generally helpful and there are many constructive statements that can be made about tinnitus, such as 'Most tinnitus lessens or disappears with time'; 'most tinnitus is mild'; 'tinnitus is not a precursor of hearing loss'

There is no direct role for drugs

  • Although they can be used to treat associated symptoms such as vertigo, insomnia, anxiety, or depression. There is also no conventional or complementary medication that has been shown to have specific tinnitus ameliorating qualities and there is anecdotal suggestion that repeatedly trying unsuccessful therapies worsens tinnitus

Referral routes for tinnitus patients

  • Referral routes vary and depend on local protocols and commissioning, but in the majority of cases referrals are directed to ENT or audiology services. Common sense dictates that when there are possibilities of self-harm or of psychological crisis, then urgent mental health support is indicated

Tinnitus is more common in people with hearing loss

  • Tinnitus prevalence is greater among people with hearing impairment but the severity of the tinnitus correlates poorly with the degree of hearing loss. It is also quite possible to have tinnitus with a completely normal pure tone audiogram

Hearing aids are helpful if there is associated hearing loss

  • Straining to listen can allow tinnitus to emerge or, if already present, to worsen. Correcting any hearing loss reduces listening effort and generally reduces the level of the tinnitus
  • Hearing aids are useful even if the hearing loss is relatively mild and at a level where aids would not normally be considered. Some modern hearing aids have sound therapy devices incorporated within the aid specifically for tinnitus patients. Department of Health guidelines have emphasised the value of audiometry in a tinnitus consultation, and this is the definitive basis for decisions about hearing aid candidacy
  • If in doubt, refer for an audiological opinion. In our view, all people who describe tinnitus deserve an audiological assessment. Decisions on when to start using a hearing aid and what sort to use are up to the individual patient and audiologist

Avoiding silence is helpful

  • Having continuous, low level, unobtrusive sound in the background can reduce the starkness of tinnitus. Sounds can be quiet, uneventful music, a fan, or an indoor water feature. Alternatively, there are inexpensive devices that produce environmental sounds, these are particularly useful at bedtime. They can be purchased online from the BTA at tinnitus.org.uk or by calling 0114 250 9933

Self-help is often effective

  • The BTA provides comprehensive information on tinnitus and common sense advice on managing symptoms. It also has a network of tinnitus support groups around the country. It runs a freephone telephone helpline 0800 018 0527 as well as offering advice through its website tinnitus.org.uk
  • The BTA has also produced a new online resource aimed specifically at patients who have recently developed tinnitus and want some simple, clear information and advice: Take on Tinnitus. takeontinnitus.co.uk includes facts, tips, exercises, and videos which give patients ideas for self-management
  • Please do pass on the details of the Take on Tinnitus website, the BTA site tinnitus.org.uk and helpline 0800 018 0527 to your tinnitus patients so that we can help you provide the support they need in the early stages of tinnitus management. We know from the calls we receive, that when early help is given by GPs and secondary services, patients manage their tinnitus more effectively

References

full guideline available from...
British Tinnitus Association, Ground Floor, Unit 5, Acorn Business Park, Woodseats Close, Sheffield S8 0TB
Email—info@tinnitus.org.uk; website—tinnitus.org.uk; (helpline—0800 018 0527)

British Tinnitus Association. Tinnitus Guidance for GPs. February 2017


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