Tinnitus is considered a symptom of many medical conditions, making its diagnosis and treatment challenging to health care providers (Drugs Aging. 2004;21(5):297; J Clin Neurol. 2009 Mar;5(1):11; Am Fam Physician. 2004 Jan 1;69(1):120; Rehabil Psychol. 2008;53(2):128; Cleve Clin J Med. 2011;78(5):31). Medical intervention may offer reassurance, uncover the cause of the tinnitus, and provide patients with the opportunity for management or treatment (Cleve Clin J Med. 2011). However, those not accessing help for tinnitus have a greater risk of having an undiagnosed hearing problem that may adversely affect their quality of life and health status (Hearing Journal. 2007;60(4):24). This descriptive summary of the literature discusses the available research (published between 1980 and 2016) on the clinical management of tinnitus from a health care provider's perspective.
HEALTH PROFESSIONAL PERSPECTIVE
Nine papers (eight studies) using mixed methods were included in this summary (see Table 1). Most health professionals surveyed included general practitioners (GPs), audiologists, ENT specialists, as well as otolaryngologists, audiological physicians, hearing therapy staff, neurologists, psychologists, psychiatrists, alternative therapy practitioners, and management-level clinicians. These studies identified several possible barriers to help-seeking that tinnitus patients may encounter. Listed in approximate order of how they may arise along the clinical pathway, these barriers include time, referrals, education and knowledge, health provider approach, assessment, services, and treatments.
BARRIER 1: TIME
Time was a common issue raised by most of the studies. In this review, this factor is divided into two categories: consultation and wait times.
General out patient clinics reported that 71.7 percent of ENT specialists spent less than 10 minutes of counseling with patients (Clin Otolaryngol Allied Sci. 1992 Aug; 17(4):31). Of these ENTs, 18.7 percent performed less than four minutes of counseling. Among ENT specialists in tinnitus clinics, 78 percent reported counseling patients for 10 minutes or longer. Among audiologists, the reported median time for counseling was 10 minutes (Hear Rev. 2008;15(13):14). As both ENT specialists and audiologists provide specialized care for otological problems, counseling for 10 minutes or less may not be sufficient for some patients with tinnitus. Health professionals (GPs, ENT specialists, and audiology staff) also reported that their time with patients was restricted (Redmond. RNID, 2010).
Within the U.K. National Health System (NHS), the average reported length of a consultation with an audiologist was 60 minutes for diagnostic assessment or management and 85 minutes for combined appointments (J Eval Clin Pract. 2012 Apr;18(2):326). Allocated diagnostic assessment appointment times ranged from 15 to 150 minutes, while clinical management and combined appointments with audiologists ranged from 45 to 150 minutes. Therefore, patients with combined appointments received less time (38%) with an audiologist.
Varying wait times for specialist care were reported, particularly for ENT, audiology, counseling, and mental health services (Redmond. RNID, 2010). In another study, audiologists reported issues with wait times for specialist care, from four to eight weeks (45%), less than four weeks (24%), eight to 12 weeks (20%), 12 to 16 weeks (8%), and over 16 weeks (3%; BMC Health Services Research. 2011;11:162). Wait times were reported to be an average of 18 weeks, with 66 percent of patients waiting at least 13 weeks and, in some areas, up to 45 weeks. The Good Practice Guide (GPG) for tinnitus intervened by setting standards for an average wait time and a minimum of 18 weeks from consulting a GP to seeing a specialist. Follow-up research on wait times (NHS) reported some improvements, particularly GPs referring patients directly to audiological care and the introduction of the Any Practitioner Qualified (APQ) structure (Eur J Pers Cent Healthc. 2015;3(3):318). It is possible that the stress of long wait times to see a specialist may exacerbate a patient's tinnitus.
BARRIER 2: QUALITY AND APPROPRIATENESS OF REFERRALS
In a study of audiologists in the NHS, opinions on referrals from GPs were mixed. Eighteen percent of audiologists effective referrals, 20 percent reported improvement was needed with referrals, 27 percent reported ineffective referrals, and 31 percent had no comment as many of their patients were from ENTs (BMC Health Services Research. 2011;11:162). Of those, 27 percent of audiologists who found referrals to be ineffective noted the following as the main issues that affected GP referrals: negative counseling, GPs being barriers to specialized care, and lack of knowledge of assistance for tinnitus. In another study, audiologists recommended for referral pathways to be made clearer to GPs (Redmond. RNID, 2010). The availability of services also affects referrals and will be discussed later in this article.
BARRIER 3: EDUCATION AND KNOWLEDGE
Studies suggested that education and knowledge regarding tinnitus varied among all health care providers. In one study, 57 percent of GPs reported never receiving training. Among the GPs who underwent training, 50 percent completed it over 10 years ago (Redmond. RNID, 2010). The same study also reported that 53 percent of GPs rated their knowledge as average or below, while 77 percent wanted to receive more training on tinnitus management. In another study, GPs reported referring to and using the GPG (J Eval Clin Pract. 2011 Aug;17(4): 684). A follow-up is warranted to see if use of the manual improves patient management. A study that surveyed GPs using a visual analog scale (VAS) indicated an average satisfaction rating of 5.9/10 for their tinnitus services. This correlated with the average patient ratings of 5.4/10.
GPs with a reported interest in ENT medicine had a significantly higher self-mean and patient mean scores; therefore, training of GPs in some areas of ENT medicine could be beneficial for patients.
ENTs also reported being unable to access further education (Redmond. RNID, 2010). Audiologists (40%) reported a need to improve the awareness of GPs and ENTs about tinnitus clinics and available management strategies (BMC Health Services Research. 2011;11:162). Another study reported that about 44 percent of audiologists had not attended a course on tinnitus, and that audiologists read an average of five books or articles on tinnitus (Hear Rev. 2008).
Psychological support, particularly cognitive behavioral therapy (CBT), is highlighted in tinnitus research as a modality that can assist with the management of problematic tinnitus (Clin Psychol Rev. 2011 Jun;31(4):545). Audiologists may require counseling training. However, it was reported that many audiologists fail to undertake any training due to lack of funding or time (Redmond. RNID, 2010). Another more recent study reported that 96 percent (142/147) of audiologists and hearing care staff in the NHS had undertaken some professional development training to support patients with tinnitus, and 82 percent (121/147) indicated that patients were given written information on tinnitus (Eur J Pers Cent Healthc. 2015).
BARRIER 4: HEALTH PROVIDER APPROACH
One study reported that some GPs were perceived to lack interest in patients presenting with tinnitus (Clin Otolaryngol Allied Sci. 1992). This study reported that 14.7 percent of GPs seldom to never provided a diagnosis for these patients. An audiological study suggested that improper referrals from GPs highlighted negative counseling and advising patients that “nothing can be done” might prevent or hinder the patient from being properly assessed and accessing at the very least management treatment (BMC Health Services Research. 2011;11:162).
BARRIER 5: ASSESSMENT VARIATIONS
In a study that surveyed GPs on their methods of assessment and examination according to the GPG for tinnitus, GPs reported that eight of the 11 recommendation questions on tinnitus history were used (J Eval Clin Pract. 2011). They also reported 95 percent assessing tinnitus onset and 94 percent assessing laterality (whether tinnitus was in the head or ears). Assessments of tinnitus pulsatility and hypersensitivity to noise were reported as 39 percent and 23 percent, respectively. GPs with an interest in tinnitus or ENTs were found to be more likely to investigate pulsatility of tinnitus, as this type of tinnitus usually has a physical cause such as hypertension or otitis media and can be treated. This study also found that 99 percent of GPs surveyed performed otoscopy (examination of the ear), 26 percent performed a carotid bruit (checking the blood flow in the carotid artery), 38 percent performed a cranial nerve examination, and 31 percent performed a tuning fork test. These results suggest disparate assessment practices for tinnitus.
For the assessment of tinnitus in audiology, the NHS recommended audiometry, reflexes, otoacoustic emissions, psychoacoustic tinnitus measures (masking level and loudness), screening for anxiety and depression, and a self-report measure for tinnitus (J Eval Clin Pract. 2012). The survey revealed that 91 percent performed an audiological examination, usually an audiogram, and only two percent performed otoacoustic admissions and reflexes. Tinnitus assessment involved either a structured interview (69%), visual analog scale (VAS; 17%), psychoacoustic measures (17%) of pitch or loudness, or a questionnaire (67%). According to the GPG for tinnitus, certain procedures are recommended, though not compulsory, and tailored to factors such as the amount of time allocated for a patient or the location of a clinic.
BARRIER 6: LACKING SERVICES
About 65 percent of audiologists said they lacked the option to refer tinnitus patients to a clinical psychologist (BMC Health Services Research. 2011;11:162). Audiologists reported that open access to audiology clinics for patients and long-term support services for chronic tinnitus were essential. However, these services are not always locally available to patients. Audiologists in the same study reported difficulty accessing rehabilitation, surgery, and psychiatric care for their patients. Audiologists and hearing therapy staff reported variability in the availability of psychological services or support (CBT-trained audiology staff) and self-help groups (Eur J Pers Cent Healthc. 2015).
BARRIER 7: INEFFECTIVE TREATMENT
Most health care providers (GPs and ENTs) reported dissatisfaction with the recommended medications prescribed for acute and chronic tinnitus (BMC Health Services Research. 2011;11:302). The estimated treatment success rates by health providers were 22 to 37 percent (GPs) and 20 to 57 percent (ENTs) for chronic tinnitus; for acute tinnitus, the average was higher (GPs 37-51% and ENT 43-61%). GPs and ENTs all reported that the low success rate of treatments was an issue in treating subjective tinnitus (GPs 37-60% and ENTs 36-55%). In another study, audiologists reported that 20 percent of patients were not sufficiently serviced with existing treatments, but 60 percent of patients had minor to major relief of tinnitus from hearing aids (Hear Rev. 2008).
Two additional issues were raised by the studies reviewed. First, clinical auditing using validated measures within and across clinics to check the outcomes of tinnitus treatments was not a common practice, although follow-up research suggested that the use of validated questionnaires is increasing (Eur J Pers Cent Healthc. 2015). Second, there is a gap between the theoretical and actual management of patients in a tinnitus clinic (J Eval Clin Pract. 2012). For example, while psychological support or counseling reported benefit in tinnitus literature (Clin Psychol Rev. 2011; Int J Audiol. 2016 Sep;55(9):514), other studies indicated that referrals to psychological care and/or counseling were seldom (BMC Health Services Research. 2011;11:162;Eur J Pers Cent Healthc. 2015). Few patients were referred to psychologists partly due to the lack of these services or awareness of the benefits of counseling and a lack of availability of these services (J Audiol Med. 1993;2:1; BMC Health Services Research. 2011;11:162; J Eval Clin Pract. 2011; Eur J Pers Cent Healthc. 2015). Follow-up research has subsequently shown some improvement in training for audiologists in psychological support (Eur J Pers Cent Healthc. 2015).
Additional research on help-seeking among tinnitus patients and other barriers to their care could improve patient-centered care and benefit patients and practitioners along the clinical pathway.