Glynnis Tidball, MSc, Registered Audiologist (biography and disclosures)
A) I am the audiologist that runs the St. Paul’s Hospital Tinnitus Clinic mentioned in the article. Patients pay the hospital for the services they receive here as tinnitus management is not covered by MSP.
B) Widex, a hearing instrument manufacturer, sponsors me to give presentations and pays for my registration fee at international tinnitus conferences. The article describes the benefits of hearing instruments but does not specifically identify Widex which is one of several manufacturers that make instruments for hearing loss and tinnitus management.
C) I have no financial interest in Sound IdEARS clinic.
What care gaps or frequently asked questions I have noticed
Tinnitus has an estimated prevalence of 10-15% and is a common complaint in family practice. As a “tinnitus audiologist”, I often receive queries from family physicians and other healthcare professionals about the diagnostic significance of tinnitus and how to help patients optimally manage their symptom.
Data that answers these questions or gaps
Tinnitus is a symptom associated with many underlying or contributing conditions:
- Otologic: impacted cerumen, presbycusis (age-related hearing loss), acute or long-term noise exposure, otitis media, otosclerosis (pulsatile and non-pulsatile tinnitus), Ménière’s disease, glomous jugulare tumour (pulsatile tinnitus), vestibular schwannoma (acoustic neuroma), hearing loss secondary to infectious disease or autoimmune deficiency, trauma, superior semicircular canal dehiscence (pulsatile tinnitus), long-term deafness or auditory deprivation (musical hallucinations)
- Neurologic: acquired brain injury, multiple sclerosis, seizure disorder
- Vascular (presents as pulsatile tinnitus): arteriovenous malformation, glomus jugulare tumour, carotid artery bruits, dehiscent jugular bulb, benign intracranial hypertension
- Metabolic: thyroid dysfunction, anaemia, diabetes mellitus
- Musculoskeletal: temporomandibular disorders, cervical dysfunction, myoclonus of palatal or stapedius muscles
- Drugs: includes aminoglycoside antibiotics, cisplatin, NSAIDs, quinine, loop diuretics
- Psychogenic: chronic or acute stress, psychosis (intelligible verbal hallucinations)
Unilateral or pulsatile tinnitus, severe and incapacitating tinnitus, or tinnitus accompanied by a sudden change in hearing, ear pain or dizziness are diagnostically significant and warrant referral to an otolaryngologist.
Treatment of the underlying pathology is essential, often time-sensitive, and may eliminate tinnitus or the tinnitus may resolve spontaneously.
Once the necessary investigations and medical management are complete, patients are often told that there is no cause for alarm, that the tinnitus may be with them for life and that they need to learn to live with it. This may be all the reassurance some patients need, but for others, hearing, “Learn to live with it,” leaves them feeling hopeless, directionless, and even despondent.
Patients with distressing tinnitus frequently report sleep disturbances, difficulty with concentration, significant mood changes, and tension and fatigue due to persistent stress arousal. Factors that most often contribute to tinnitus distress are hearing impairment, decreased sound tolerance and psychological factors.
What I recommend (practice tip): How family physicians can help
What is the best course of management for patients whose tinnitus persists and especially for those who find that tinnitus is disabling?
1. Provide patients with reassuring and accurate information.
Family physicians can assist by listening to patients, validating their experience and undertaking to get them help and reliable information. Resources for patients, listed at the bottom of this article, can help patients manage the way that tinnitus affects them while they wait to be seen by specialists. For some patients, reliable information may be all that is needed.
“What I really needed from my family doctor was more information… specifically that tinnitus is not a medical threat and that in almost all cases you can manage the condition and lead a productive life.”
2. Ask about hearing.
Hearing loss accompanies tinnitus in approximately 90% of patients. Patients often feel that tinnitus and not hearing loss makes it hard for them to hear. In fact, they may be unaware that they would have the same hearing problems even if they did not have tinnitus, or they may not be aware that they are straining to hear at all. Consequently they may disregard the potential benefits of hearing aids in managing tinnitus.
Family physicians can help patients differentiate the effects of hearing loss from those of tinnitus and encourage patients to address hearing impairment, especially if this is the primary complaint.
I probe for hearing difficulties by asking a patient if they have trouble hearing in groups or noisy environments, or if family members observe that the TV volume is “too loud” or that frequent repetition is needed when communicating.
Adult patients can self-refer to private practice clinics for a hearing assessment if hospital audiology testing has not been ordered by otolaryngology. A registered audiologist (who may also be a hearing instrument provider) can perform a diagnostic hearing test and will have had some training in tinnitus assessment and management. A registered hearing instrument provider can perform a basic hearing test.
I encourage patients to consider a trial of hearing instruments (hearing aids or tinnitus combination instruments) if hearing loss is present or if tinnitus is sufficiently disabling. Addressing even a very mild hearing loss can decrease tinnitus awareness.
I ask patients to discuss their hearing instrument providers’ experience and success with tinnitus management and to commit to having several follow-up appointments to get the instrument(s) fit correctly. Patients may benefit from special instruments or modifications to standard fitting procedures when tinnitus is bothersome and especially when decreased sound tolerance is present. I remind patients that they can return instruments during the trial period if they are unhappy with the product or service.
“In the past I’ve been told to basically live with the tinnitus and that ear devices just don’t work. I now know this to be false. I have only had the devices since 1:00 PM yesterday and right from turning them on I became aware of sounds that I had not heard for years. I’ve also not noticed the tinnitus much at all… My first workgroup meeting was just 2 hours ago and I really noticed my hearing ability was much better.”
3. Identify and address psychological contributors to tinnitus distress.
Tinnitus may first emerge or be reported as louder during periods of high stress. Psychological disorders are co-morbid in a significant portion of patients with tinnitus.
Management of psychological co-morbidities may benefit tinnitus directly or improve a patient’s ability to manage the tinnitus. Cognitive behavioural therapy (CBT) – which currently has the strongest evidence of any tinnitus treatment –and to some degree educational counselling, can help address “thought errors” that contribute to a patient’s negative reaction to tinnitus. Stress reduction, relaxation exercises and mindfulness-based therapies may also help to reduce stress arousal that exacerbates tinnitus distress.
“I realized that I had been blaming all my health problems on tinnitus. Now the tinnitus doesn’t seem to be such a big problem.”
4. Let patients know that additional help is available if they need it.
Audiologists have basic training in managing tinnitus and can provide general tinnitus counselling. Audiologist and non-audiologist hearing instrument providers can provide patients with hearing aids and tinnitus instruments (hearing aids with a built-in sound generator).
Patients who report that tinnitus is having a significant impact on their lives may require the help of a provider that specializes in tinnitus.
Two hearing health care clinics that provide specialized tinnitus care in BC are the St. Paul’s Hospital Tinnitus Clinic and Sound idEARS Tinnitus Clinic, both in Vancouver.
The St. Paul’s Hospital Tinnitus Clinic provides a 3-hour group tinnitus session facilitated by a tinnitus audiologist. The audiologist discusses management options and answers patients’ questions about tinnitus. Individual counselling sessions are available to those needing additional care or who might have difficulty participating in a group environment. Patients can schedule themselves for a group session provided that they have submitted a copy of an otolaryngology consult letter and recent hearing test. Physicians can obtain a PDF of the St. Paul’s Hospital Tinnitus Clinic pamphlet by emailing firstname.lastname@example.org or can download it from http://www.providencehealthcare.org/tinnitus-clinic/ More information is available on the web site www.sphtinnitus.weebly.com (beta site).
Sound idEARS fits a variety of instruments for tinnitus management and offers individual tinnitus counselling. The clinic web site is http://www.soundidears.com/.
“Listening to a qualified person such as my clinician provided me with answers to all my questions, so much better than reading it out of a book.”
5. Let patients know about funding options for hearing instruments and tinnitus clinic services.
WorksafeBC, Veterans Affairs Canada and RCMP Health Services will fund hearing instruments, bedside sound generators and counselling (group or individual “Tinnitus Retraining Therapy”) for individuals with an approved tinnitus claim. Individuals with tinnitus subsequent to a MVA can request coverage of necessary devices and “Tinnitus Retraining Therapy” through ICBC.
Patients under care of the Ministry of Social Development can have their hearing instrument provider request funding for amplification for management of hearing loss. The Ministry does not typically approve instruments for tinnitus.
Extended care plans may provide partial coverage of hearing instruments.
Take-home point: Tinnitus is a symptom that merits diagnostic consideration. Family doctors can help patients struggling with tinnitus by considering hearing and psychological factors that might exacerbate tinnitus and by providing patient with appropriate information about tinnitus care options and resources.
Resources for professionals
Tinnitus: Questions to reveal the cause, answer to provide relief. http://www.jfponline.com/fileadmin/jfp_archive/pdf/5307/5307JFP_AppliedEvidence1.pdf
Resources for patients
- St. Paul’s Hospital Tinnitus Clinic web site www.sphtinnitus.weebly.com (beta site)
- American Tinnitus Association www.ata.org
- British Tinnitus Association www.tinnitus.org.uk/
- Living With Tinnitus and Hyperacusis by L. McKenna. D. Baguley and D. McFerran
- Tinnitus Treatment Toolbox by J. Mayes
- Dr David Baguley, PhD, Don McFerran, FRCS, Prof Deborah Hall, PhD, et al. Tinnitus. The Lancet, Volume 382, Issue 9904, 9-15 November 2013, Pages 1600-1607, ISSN 0140-6736 (http://www.sciencedirect.com/science/article/pii/S0140673613601427, View with UBC or CPSBC)
- Kenneth S Yew. Diagnostic Approach to Patients with Tinnitus. American Family Physician, January 15, 2014, Volume 89, Number 2 http://www.aafp.org/home.html Copyright © 2014 American Academy of Family Physicians (View with UBC) Handout: http://www.aafp.org/afp/2014/0115/p106-s1.html