Tinnitus is a common symptom experienced by 10-15% of the population with about 8% of the population seeking advice from their GP. Although most people who experience tinnitus are not unduly bothered by it, for some it may have a marked effect on their life.

However, tinnitus almost always improves over time, because in most cases it gets less annoying with time as the brain loses interest in it. In some cases the tinnitus even disappears. This process is called habituation, but the length of time for habituation to occur varies in individuals.

Currently, there is still a lack of standardised practice in both primary (GP led) and secondary (specialist led) care. The Department of Health produced the Provision of Services for Adults with Tinnitus: A Good Practice Guide which set out a vision in 2009:

“The vision for services for people with tinnitus is for a stepped approach to care across different levels of a network, based on high quality local audiology services, which triage patients and refer them on efficient referral pathways to specialist and supra-specialist care.”

This document provides practical guidance for commissioning tinnitus services.

Visiting your GP

Most people who experience tinnitus initially consult their GP.

Prior to visiting your GP it may be useful to write down your worries, fears and concerns and any questions that you may have.

The majority of GPs will take a history, examine the ears with an otoscope (a magnified light source), remove wax, treat any underlying infections, and provide advice and reassurance. Some may perform other investigations such as a blood pressure check. Some will refer on to support groups and give information leaflets or suggest that you contact the British Tinnitus Association. A few may prescribe medication.

If your tinnitus is distressing, unilateral (in one ear only), pulsatile (in time with your heartbeat or other rhythm) or if you have other symptoms such as hearing loss, it is usual to be referred to a tinnitus clinic within a hospital ENT or Audiology Department. Some hospital departments or private tinnitus clinics may accept self-referrals.

In the absence of a cure, many people with tinnitus are told that there is no treatment available and they should “learn to live with it.” The BTA believes this is not acceptable or true. Don’t be afraid to ask your GP for a referral if none is forthcoming or if you have more questions about your tinnitus.

Any Qualified Provider (AQP)

Many areas now offer adults the choice of NHS hearing aid providers with the aim of being seen closer to home with shorter waiting times. This service, free at the point of delivery, is aimed at the over 55s with suspected age related hearing loss.

People with troublesome or asymmetrical (one sided), or pulsatile tinnitus should not be offered this option and instead should be referred into appropriate tinnitus services by the GP.

At the tinnitus clinic

Various health professionals may be involved in the management of tinnitus at the tinnitus clinic.

At the tinnitus clinic you may be seen by a medically qualified doctor (Ear, Nose and Throat Surgeon or Audiovestibular Physician) or by an Audiologist or Hearing Therapist (who will be scientifically qualified)

Nurse practitioners, hearing aid practitioners, psychologists and physiotherapists may have an input and many specialised tinnitus clinics have multi-disciplinary involvement. Length of appointments will vary and some clinics have linked appointments with two or more professionals.

During the clinic appointment you will be asked about your tinnitus and have a full medical, social and noise exposure history taken. It is usual to have an ear examination with an otoscope and a hearing test. A hearing test involves listening to sounds in a sound-proof room and pressing a button every time you hear a sound until the faintest sounds you can hear in each ear are found. A few clinics may perform tests to match the pitch and loudness of your tinnitus. These pitch matching tests do not affect the management options open to you.

You may be given a tinnitus assessment questionnaire. These, together with open ended questions, help to assess the impact of the tinnitus and any other associated symptoms such as hearing loss, hyperacusis and dizziness.

If your tinnitus is pulsatile (varies in time with your heartbeat) the clinician may listen around your ear and neck with a stethoscope to identify any sounds audible to the examiner.

Some further investigations may be requested. These investigations depend on the description of your symptoms and the results of the initial examination. Such tests may include magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computerised tomography (CT) or ultra sound scans and, less often, blood tests.

The main reason for requesting an MRI is to exclude a very rare condition called vestibular Schwannoma (also known as an acoustic neuroma) which is a benign growth on the balance nerve. Occasionally balance tests, electrophysiological tests or oto-acoustic emissions may be performed.

The aim of the assessment is to identify any treatable causes and then come up with an individual management plan.

Treatment options

The Advancing Quality Alliance Right Care Shared Decision Making Programme suggests that patients ask 3 questions to help become involved in any healthcare decisions:

1. What are my options?

2. What are the pros and cons of each option for me?

3. How do I get support to help me make a decision that is right for me?

There are many ways to help manage tinnitus and live well, although the majority of tinnitus cannot be helped by surgery or medication, The Department of Health Provision of Services for Adults with Tinnitus: A Good Practice Guide stated that people with tinnitus will be offered, as appropriate, the following forms of management:

Information/education - most people find that being given a detailed explanation of tinnitus together with being told “it will almost certainly improve” hugely beneficial and reassuring. Tinnitus does spontaneously decrease over time in the vast majority of cases.

Hearing aids - correcting even quite a mild hearing loss can be very helpful because it brings in sounds that you may not hear. This makes the tinnitus less audible and removes the strain from hearing. It may also reverse tinnitus related changes in the brain. Sometimes a combination device (both a hearing aid and wearable sound generator) may be fitted.

Counselling - addressing underlying worries and concerns and getting support with your tinnitus can be effective.

Relaxation therapy - many people find that their tinnitus is worse when they are stressed but better when they are relaxed.

Sleep management - some people with troublesome tinnitus have sleep difficulties and specific advice on what to do at home to help you sleep (sleep hygiene) will be beneficial.

Sound enrichment therapy - the use of sound, either desk-top devices or wearable sound generators to help both reduce the starkness of the tinnitus and promote habituation.

Cognitive behavioural therapy (CBT) - this is a specific form of therapy which addresses any negative thoughts you may have about your tinnitus and through both counselling and practice help to change these thoughts.

Tinnitus retraining therapy (TRT) (habituation therapy) - modified versions of this therapy are available based on the Jastreboff neurophysiological model which use counselling and sound enrichment.

Psychological support - this may be offered to help people with tinnitus deal with accompanying feelings of anxiety and depression.

Medication - it is possible that some people may benefit from medication such as anti-anxiety medication, anti-depressants or sleeping tablets for other conditions they have in addition to their tinnitus. There is no medication for tinnitus.

However, whilst most clinics offer counselling, education and hearing aids the availability of CBT and psychological support is variable.

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