1. Remember that tinnitus can occur at any age
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 may also be described.
2. Reassure patients that tinnitus usually improves
Most tinnitus is mild - it is relatively rare for tinnitus to develop into a chronic, severe problem. In most patients the natural history of tinnitus 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.
3. Be aware that tinnitus is most 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.
4. In the absence of genuine congestion, decongestants won’t help
For reasons that are not clear, tinnitus and sensorineural hearing loss can cause 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.
5. Avoid giving a negative prognosis
Patients are often told that nothing can be done about tinnitus, but negative statements such as this are unhelpful and tend to focus the patient’s attention on their tinnitus and exacerbate the distress. Where possible, try to make constructive statements about tinnitus, such as: ‘most tinnitus lessens or disappears with time’, ‘most tinnitus is mild’, ‘tinnitus is not a precursor to hearing loss’.
6. Suggest using sounds to reduce the starkness of the tinnitus
Useful sources of sound to reduce the starkness of tinnitus include quiet uneventful music, a fan or a water feature. There are inexpensive devices that produce environmental sounds, and these are particularly useful at bedtime. They can be purchased online from the British Tinnitus Association or by calling 0800 018 0527
7. Consider a hearing aid, even if hearing loss is mild
Hearing aids are helpful for patients with tinnitus because straining to hear causes increased central auditory gain and this increased sensitivity can allow tinnitus to emerge or, if already present, to worsen. So hearing aids are useful even if the hearing loss is relatively mild and an aid would not normally be considered. Recent 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.
8. Be vigilant for underlying pathology
Underlying pathology is rare - in many cases tinnitus is due to heightened awareness of electrical activity in the auditory system that is normally not perceived. But tinnitus can be a symptom of treatable and significant otological pathology, such as a vestibular schwannoma or otosclerosis. Be especially vigilant if the tinnitus has a pulsatile quality or is unilateral (although tinnitus can be unilateral before becoming bilateral, there is no specific evidence on whether GPs should ‘wait and see’).
9. There is no direct role for drugs
Drugs can be used to treat symptoms associated with tinnitus, such as vertigo, insomnia, anxiety or depression. But there are no conventional or complementary medications that have been shown to specifically ameliorate tinnitus, and there is anecdotal suggestion that repeatedly trying unsuccessful therapies worsens tinnitus.
10. Encourage self-help
Self-help is often effective - the British Tinnitus Association provides excellent information on tinnitus and common sense advice on managing symptoms.
Mr Don McFerran is a consultant ENT surgeon at Essex County Hospital, and Dr David Baguley is head of audiology at Addenbrooke’s Hospital, Cambridge.
Dr Baguley and Mr McFerran are co-authors, along with Mr Laurence McKenna, of the self-help book “Living with Tinnitus and Hyperacusis” (Sheldon Press, 2010). The book is available to purchase from the BTA or by calling 0114 250 9933.
