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Expertise in tinnitus is poor among our general practitioners. According to a recent report, this means that many people are suffering unnecessarily.

(Photo: iStock)

One in five Norwegians has tinnitus – but treatment provision is very poor

Researchers have concluded that many people are suffering unnecessarily and that the services for tinnitus patients are inadequate across multiple levels.

Christina Benjaminsen journalist

Presented by: SINTEF

Published 25 October 2023 - 04:30

“Treatment provision is inadequate, and much poorer than is recommended by the EU guidelines on tinnitus diagnostics, examination, and treatment,” Tron Vedal Tronstad says.

He is a research scientist at SINTEF, and one of the authors of a new report about tinnitus.

Already in two major reports from 2003 and 2005, it was determined that changes are needed. However, the recent study reveals that the situation for the patient group has not changed in 20 years. This is despite the conclusions in the reports, which were commissioned by the Directorate of Health and the Ministry of Health, respectively.

Many are suffering unnecessarily

Researchers at SINTEF have been looking into the extent to which previous medical recommendations on the treatment of tinnitus are being followed up by the Norwegian public authorities and healthcare trusts. Their work has been commissioned by the Norwegian Association for the Hard of Hearing.

What is tinnitus?

Tinnitus is a condition caused by neurological activity that leads patients to experience a constant ringing or whistling noise in their ears. It may have several underlying causes, including exposure to loud noises, trauma or stress – doctors are not entirely sure.

The number of affected individuals is increasing, also globally, according to the World Health Organisation (WHO).

Treatment is available and is generally most effective if the patient gets help at an early stage. Tinnitus becomes aggravated if the patient is under stress.

In Norway, as many as 750,000 people have tinnitus accompanied by hearing loss, while another 280,000 suffer without any loss of hearing. Many patients with tinnitus experience improvements when they get hearing aids.

(Source: tinnitus.no (link in Norwegian))

The main conclusion reached by the SINTEF researchers is that many people with tinnitus are suffering unnecessarily.

This is because they are getting the wrong information at the wrong time. Patients currently waiting for an appointment with a specialist could in fact be getting the help they need, simply and effectively, from their general practitioners (GPs).

This results in many patients with tinnitus suffering from anxiety and depression 'as a result of a total lack of knowledge among GPs on patients’ first encounter with the healthcare services', according to the report.

These conclusions are based on a comprehensive analysis of documents and interviews with, among others, ear, nose and throat specialists, audiographers, coaches of people with hearing loss, and individuals with tinnitus.

Large differences in the services offered

The researchers have also revealed major variations in the services available to individuals with tinnitus.

“The report shows that when it comes to tinnitus, Norway fails to adhere to the principle of offering treatment at the lowest level of effective care, which is normally the case elsewhere in our healthcaresystem. This is a cause for concern, especially when we know that as many as one in five Norwegians are suffering from the condition,” Tronstad says.

The services also vary geographically.

Furthermore, the researchers conclude that the patient group is not offered treatment regimes tailored to the severity of their symptoms.

“Our lack of diagnostic expertise means that patients who should have been referred to and examined by a specialist are sent home by their GPs. At the same time, many other sufferers are referred to specialists and sent on extended treatment journeys that are totally unnecessary and expensive to the taxpayer,” Tronstad says.

The researchers also conclude that the lack of diagnostic expertise means that patient pathways are entirely incoherent in the field of tinnitus.

The GP is key

Between 80 and 90 per cent of GPs interviewed responded that they had a moderate to acute need for more knowledge about treating patients with tinnitus.

As many as 40 per cent had had patients with tinnitus symptoms in the last five days of work.

The most important advice offered by the researchers is that efforts should now be made to boost the basic knowledge about this neurological condition among GPs.

This advice is in line with that offered in previous studies. Patients with mild to moderate symptoms, which applies to most, can probably receive adequate help from their GPs. This will save the specialist services from unnecessary work and free up more time and resources for the patients who really need them.

In the report, the researchers point out that e-learning courses containing information about tinnitus, combined with other basic initiatives, ought to be introduced. Such initiatives should be aimed at both GPs and the patient group.

“In fact, initiatives of this type already exist, but they're not well known so very few people take advantage of them,” Tronstad says.

Rejected by specialists

One of the findings the researchers made is that specialised healthcare services tend to neglect professional development in the area of tinnitus, often because it is not deemed sufficiently interesting.

However, these services also have a ‘duty of care’ – in other words, an obligation to offer treatment.

The researchers also revealed that there is no financial incentive for hospitals and clinics to offer thorough diagnostics and effective medical treatments for tinnitus.

Researcher Tron Vedul Tronstad pictured outside his acoustics lab at SINTEF.

Technical audiologist and head of the tinnitus clinic at Sørlandet Hospital, Georg Træland, has spent his entire career working with tinnitus and the treatment of this patient group.

He contributed to both reports that the researchers refer to and is well aware of the problem that tinnitus patients are ‘non-profitable’.

The reason is that the most severely afflicted patients are a group that requires interdisciplinary follow-up over a long period, which is very expensive.

His experiences also clearly indicate that getting the right help at an early stage in their treatment journey is essential:

“I have seen innumerable cases of patients who, having initially reported tinnitus symptoms, later recover or experience these as less debilitating as soon as they receive the correct information about what tinnitus actually is,” he says.

According to Træland, they also see that the most effective treatment is to get a hearing aid. Most people with tinnitus also have hearing loss. Because tinnitus is a neurological condition that results in patients hearing ringing or other sounds, the disruptive noise will appear weaker and less dominant when ‘the sound’ in their ears becomes louder.

"If we were to identify one main problem with the services offered to this patient group, it is that there is too little knowledge about both the neurological aspects of the condition, and which treatment should be offered when," he says.

Hopes the report has a real impact

Inger Helene Venås is General Secretary of the Norwegian Association for the Hard of Hearing. She is very pleased that the report is clear in its conclusions.

“We were already aware that treatment provision for tinnitus sufferers in Norway is inadequate. This is why we commissioned the report. We have now documented that almost nothing has changed in the last 20 years, despite the clear conclusions set out in the 2003 and 2005 reports which both recommended that something had to be done,” she says.

According to Venås, the time for Health and Care Services Minister Ingvild Kjerkol to take action is now overdue.

“Today, one in five Norwegians have tinnitus. The number of those affected is on the increase. According to the WHO, this is a global phenomenon. It is now essential that the ministry starts taking this matter seriously. In practice, the conclusions we’ve now delivered represent a list of policy actions that have to be taken in order to improve the treatment provision available to this group of patients,” she says.

Venås is fully supported by the researchers who prepared the report.

“Our advice is that the government acts immediately on the recommendations set out by the authors of the 2003 and 2005 reports. The main findings of these reports are supported by our evaluations and the interviews we’ve conducted with the patient greoup and treatment providers,” Tron Vedul Tronstad concludes.

Recommendations for treatment provision:

The recently published SINTEF report, as well as the reports ‘Utredning og behandling av pasienter med tinnitus’ (The diagnosis and treatment of patients with tinnitus) from 2003, and ‘Behandlingstilbud for tinnitusrammede’ (Treatment provision for those affected by tinnitus) from 2005, all arrive at the same conclusions:

A Norwegian tinnitus expertise centre is needed.
Each regional health trust should establish a call centre for tinnitus.
The current educational programmes held at the various so-called ‘learning and mastery centres’ should be expanded.
It is essential to differentiate between the diagnostic approaches offered to different patients. A better distinction must be made at both GP and specialist levels between patients who simply require straightforward advice and those who need continuous follow-up by a specialist.
The specialist healthcare services must offer a broad audiological and medicinal approach.
GPs must have sufficient knowledge of tinnitus to enable them to distinguish between patients who simply require straightforward advice and those who should be referred to specialists.
First-line treatments should include cognitive behavioural therapy (CBT), advisory services, Tinnitus Retraining Therapy (TRT), masking treatments, and the use of specialist hearing aids.
Regional health trusts should establish multidisciplinary treatment teams equipped with the skills to treat those with the most severe symptoms.
Services manned by experienced and suitably trained tinnitus sufferers must be made available.
It is prerequisite that if a uniform service provision is to be made available in all health regions in Norway, an elevation of expertise in both the primary and specialist health care services is essential.

Reference:

Lippestad et al. 'Riktig ut fra start ... En kartlegging av behandlingstilbudet for personer med tinnitus' (Right from the start... A survey of treatment options for people with tinnitus), Report from SINTEF, 2023. Summary (link in Norwegian).