Tinnitus (ringing in the ears) is a common symptom that presents as hearing unwanted noise in the head or ears. About 10-15 percent of the population report frequent or prolonged tinnitus, with an increasing prevalence among older adults up to 70 years of age (Tyler. Tinnitus handbook. Singular, 2000; Møller. Textbook of Tinnitus. New York: Springer, 2011). Apart from being associated with hearing loss, age, and exposure to loud noise, recent theories describe tinnitus as a neurological problem resulting from negative plasticity in the brain (Shargorodsky. Am J Med 2010;123:711-8 http://www.ncbi.nlm.nih.gov/pubmed/20670725; Kaltenbach. Hear Res 2005:206[1-2]:200-26 http://www.ncbi.nlm.nih.gov/pubmed/16081009; Roberts. J Neurosci 2010;30:14972–14979 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073522/; Eggermont. Front Syst Neurosci 2012;6:53 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3394370/; Saunders. J Commun Disord 2007;40:313-34 http://www.ncbi.nlm.nih.gov/pubmed/17418230; Tass. Restor Neurol Neurosci 2012;30:137-159 http://www.ncbi.nlm.nih.gov/pubmed/22414611). For some, tinnitus can have a serious impact on quality of life, prompting sleep difficulties, concentration issues, and psychological effects (Tyler. Tinnitus handbook. Singular, 2000; Henry. J Speech Lang Hear Res 2005;48:1204-35 http://www.ncbi.nlm.nih.gov/pubmed/16411806; Lasisi. Ann Otol Rhinol Laryngol 2011;120:226–230 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097393/; Baguley. Br Med Bull 2002;63:195-212 http://bmb.oxfordjournals.org/content/63/1/195.full.html). Although not generally life threatening in itself, tinnitus is also linked to serious health conditions such as vascular disease, diabetes, autoimmune and degenerative neural disorders, and generalised anxiety disorder (Shargorodsky. Am J Med 2010;123:711-8 http://www.ncbi.nlm.nih.gov/pubmed/20670725). As such, those seeking help for tinnitus should be investigated for these health conditions as well as hearing issues (Newman. Cleve Clin J Med 2011;78:312-9 http://www.ncbi.nlm.nih.gov/pubmed/21536826; Crummer. Am Fam Physician 2004;69:120-26 http://www.aafp.org/afp/2004/0101/p120.html; Langguth. Prog Brain Res 2007;166: 525-36 http://www.ncbi.nlm.nih.gov/pubmed/17956816; Searchfield. Eval Health Prof 2011;34: 421-8 http://www.ncbi.nlm.nih.gov/pubmed/21224266).
Kaltenbach suggests treatment and management of tinnitus should address three components: the acoustic component (the unwanted tinnitus sound), the attentional component (level of focus on the unwanted sound), and the emotional component (level of response to the unwanted sound) (HJ 2009;62:26-29 http://journals.lww.com/thehearingjournal/Fulltext/2009/02000/Insights_on_the_origins_of_tinnitus__An_overview.5.aspx). However, little is known about help-seeking for tinnitus—whether treatment addresses the acoustic, attentional and emotional components, and whether help-seekers are satisfied with the help they receive. The small number of available studies suggests that the majority of those seeking help for tinnitus do not undertake treatment and are likely to report moderate to low satisfaction with diagnosis and/or treatment (if treatment is provided) (Naughton. Cork Association for the Deaf, 2004 https://www.deafhear.ie/DHFiles/docs/2024.pdf; Redmond. London: RNID; 2010 https://www.actiononhearingloss.org.uk/about-us/northern-ireland/improving-tinnitus-services-in-northern-ireland.aspx; George. Br J Audiol 1991;25:331-6 http://www.ncbi.nlm.nih.gov/pubmed/1742559; Newall. HJ 2001;54:14-18 http://journals.lww.com/thehearingjournal/Fulltext/2001/11000/Tinnitus_in_older_people__It_is_a_widespread.5.aspx). These studies indicate that health services for tinnitus require significant improvement. Health professionals and researchers also agree that diagnostics and treatment for tinnitus require improvement (Hoare. Eval Health Prof 2011;34:413-20 http://www.ncbi.nlm.nih.gov/pubmed/21177640; Hall. Clin Invest 2013;3:21-8 http://www.future-science.com/doi/abs/10.4155/cli.12.129; Hall. BMC Health Serv Res 2011;11:302 http://www.ncbi.nlm.nih.gov/pubmed/22053947; El-Shunnar. J Eval Clin Pract 2011;17:684-92 http://www.ncbi.nlm.nih.gov/pubmed/?term=Primary+care+for+tinnitus%3A+practice+and+opinion+among+GPs+in+England; Davis. Int J Otolaryngol 2012;2012:290291 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399359/; Gander. BMC Health Serv Res 2011;11:162 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3144449/). Currently, little is known about tinnitus help-seeker satisfaction with diagnosis and treatment with little data available using validated patient satisfaction surveys. The purpose of this study is to examine help-seeking for tinnitus and help-seeker satisfaction with diagnosis and treatment, considering factors such as tinnitus distress and health status.
The study commenced in 2010 on the help-seeking behaviours of two tinnitus cohorts. Cohort 1 included 150 people recruited through public advertisements for volunteers in the metropolitan area of Perth, Western Australia. Potential participants were advised of the inclusion criteria; over 18 years of age, in good general health, and able to respond positively to the question, “Have you experienced any prolonged ringing, buzzing, or other sounds in your ear(s) or head more than once a week lasting for 5 minutes or longer in the past year?” (Aran. Tinnitus 91 – Proceedings of the Fourth International Tinnitus Seminar. Amsterdam: Kugler, 1992). Cohort 2 was composed of 131 people recruited from the Busselton Health Study, an aging population (1946-1966) in the Shire of Busselton, Western Australia. A preliminary assessment of the BHS data revealed that 20 percent of participants (n=200 in a total cohort of 1004) self-reported tinnitus. Those who took part answered yes to the tinnitus classification criteria used in this study (Aran. Tinnitus 91 – Proceedings of the Fourth International Tinnitus Seminar. Amsterdam: Kugler, 1992).
The cohorts were askd to complete five surveys. A shortened version of the Tinnitus Sample Case History Questionnaire (TSCHQ) was used to collect information on tinnitus and help-seeking (Langguth. Prog Brain Res 2007; 166:525-36 http://www.ncbi.nlm.nih.gov/pubmed/17956816). The Tinnitus Reaction Questionnaire (TRQ) measured tinnitus distress; a TRQ score of below 17 was considered sub-clinical tinnitus (Vieira. Int Tinnitus J 2011;16:111-7 http://www.ncbi.nlm.nih.gov/pubmed/22249869). The Glasgow Health Status Inventory (GHSI) measured health status regarding tinnitus (Hawthorne. Int J Audiol 2002;41:535-44 http://www.ncbi.nlm.nih.gov/pubmed/12477174). The Patient Satisfaction with Communication (PSC) survey measured diagnosis satisfaction of tinnitus (Schofield. Ann Oncol 2003;14:48-56 http://www.ncbi.nlm.nih.gov/pubmed/12488292). The Functional Assessment of Chronic Illness Therapy–Treatment Satisfaction–General (FACIT-TS-G) survey measured treatment satisfaction of tinnitus (Webster. Health Qual Life Outcomes 2003;1:79 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC317391/).
The results showed that 60 percent of cohort 1 and 43.5 percent of cohort 2 sought help for tinnitus, but less than 30 percent of help-seekers from both cohorts were given treatment. Also, many patients sought treatment after the initial treatment. In both cohorts, most of those who sought help were dissatisfied with the diagnosis. In cohort 1 in particular, most were dissatisfied with the treatment. The most frequently visited health professionals for a diagnosis of tinnitus were general practitioners (cohort 1:27.8%; cohort 2:43.9%), ENT specialists (cohort 1:33.3%; cohort 2:14%) and audiologists (cohort 1:27.8%; cohort 2:31.6%). Health professionals provided less than 10 percent of treatment to help-seekers, general practitioners (cohort 1:7.8%; cohort 2:1.8%), ENT specialists (cohort 1:7.8%; cohort 2:3.5%) and audiologists (cohort 1:8.9%; cohort 2:1.8%). For the measures of satisfaction of initial diagnosis and initial treatment, 65.5 percent (cohort 1) and 60 percent (cohort 2) were dissatisfied with their initial diagnosis, and 66.7 percent (cohort 1) and 33.3 percent (cohort 2) were dissatisfied with their initial treatment. Satisfaction for diagnosis and/or treatment for both cohorts was not associated with cohort, gender, hearing loss, medication, health provider, anxiety, depression, tinnitus distress or health status, nor was diagnosis satisfaction linked to treatment satisfaction. There were differences between the cohorts relating to tinnitus characteristics, help-seeking, seeking more than one treatment, tinnitus distress, and health status.
This study examined the help-seeking behaviors of two tinnitus cohorts. Two surveys measured satisfaction with diagnosis and treatment provided by general practitioners, ENT specialists, and audiologists. The findings concur with previous research that help-seeker satisfaction with clinical diagnosis is low, treatment rates of tinnitus are very low, and treated patients often require more than one treatment. No significant associations were found between patient satisfaction and the type of health professional seen, suggesting that all health professionals involved in tinnitus diagnosis and treatment require further education and training. Factors such as cohort, gender, hearing loss, medication, health professional, anxiety, depression, age, tinnitus distress, and health status were found to be not associated with patient satisfaction. These results indicate that regardless of the help-seeker's reported tinnitus distress, health status, other health issues or factors such as gender and age, satisfaction rating for diagnosis and/or treatment is low. More research is required on factors that may affect satisfaction. In this study it was important to have two samples to investigate whether self-selection bias affected satisfaction. Self-selection did not appear to have an effect on satisfaction. However, it appeared to have an impact on the nature of tinnitus, help-seeking, tinnitus distress, and health status.
The study's findings show that the majority of help-seekers in the two cohorts reported low levels of satisfaction with their diagnosis, and that most did not have treatment. They also showed dissatisfaction with health providers expected to specialize in tinnitus management. Help-seekers who received treatment reported low satisfaction and sought further treatment. No other factors were found to be linked with diagnosis and/or treatment satisfaction (including tinnitus distress and health status) in either of the cohorts. Differences between the cohorts had little impact on their perceptions of diagnosis and/or treatment. Unfortunately, this study found that help-seeking for tinnitus is a disappointing experience. Improvements in the clinical management of tinnitus are needed to increase patient satisfaction.
The author would like to acknowledge adjunct professor Rob Eikelboom for his contribution to the study, the Busselton Health Study researchers for access to population data on tinnitus, Dr. Joanne Edmondston for her editorial contribution, and the Australian Postgraduate Award (APA) and Ear Science Institute Australia (ESIA) for research support.