Clin. Otolaryngol. 1992, 17, 313-316

A survey of tinnitus management in National Health Service hospitals R.R.A.COLES M R C Institute of Hearing Research, University Park, Nottingham NG7 Z R D , U K Accepted for publication 14 January 1992 COLES R . R . A .

(1992) Clin. Otolaryngol. 17, 313-316

A survey of tinnitus management in National Health Service hospitals This paper reports the results of a postal questionnaire survey to ascertain the current status of NHS hospital services for patients with tinnitus. Statistics are given on the various managements used, e.g. about two-thirds of consultants prescribe tinnitus maskers. A total of 66 tinnitus clinics have been identified. The data are interpreted as illustrative of the steady improvements in the last 10-15 years in tinnitus management services. Keywords tinnitus management

hospital services

A postal questionnaire survey was carried out to ascertain the current state of services for patients with tinnitus in National Health Service (NHS) hospitals. There were several reasons for undertaking the survey. First, it seemed to be a timely piece of health services research in its own right. Second, it would be helpful in optimizing the content of the annual series of instructional courses on ‘Tinnitus and its Management’ that have been run in Nottingham since 1981. Third, it would provide an up-to-date, and hopefully nearly comprehensive, list of specialist tinnitus clinics which would be useful for the two national lay organizations seeking to provide help for those suffering from tinnitus: the British Tinnitus Association and the Royal National Institute for the Deaf.

Methods The sampling frame selected for this survey was the membership list of the British Association of Otolaryngologists (BAOL). Virtually all the ENT consultants in the UK are believed to be members of it, as are 12 of the 24 consultant audiological physicians. However, in order to survey current NHS hospital services, the membership list was pruned to delete overseas members, retired members, associate (nonconsultant) members and those not practising in the N H S or in otology, as far as could be identified. Some 458 consultants remained and a questionnaire was mailed to each of them in April 1991. Replies were received from 283 (62%).

The results to follow, unless stated otherwise, are presented as raw numbers followed by two percentages in parentheses: % of the whole sample of 458 and % of the 283 respondents. Since it is likely that most of the non-respondents had rather less interest in tinnitus, it seems probable that the first of the percentages will give a closer representation of the true position.

Results, with specific discussion A total of 70 (15, 25%) consultants indicated that they personally had a special interest in tinnitus, while 106 (23, 37%) regarded the hospital(s) in which they worked as having a tinnitus clinic, defined in the questionnaire as having a special interest or service over and above normal ENT out-patient services. Collectively, 66 hospitals were identified as having such a tinnitus clinic. The consultants were asked how much time they give to counselling a patient whose main complaint is tinnitus (a) in their general out-patient clinic and (b), if appropriate, in their special tinnitus clinic. Of the 283 respondents, 2 (0.7%) indicated that they gave only one minute for such counselling in their general out-patient clinics, 50 (18%) gave 2 4 minutes, 150 (53%) gave 5-10 minutes and 77 (27%) gave over 10 minutes. The corresponding figures for the 54 consultants working in a tinnitus clinic were 4, 2, 17 and 7870, respectively. The writer had previously formed the opinion, from

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R.R.A.Coles

Numbers of consultants (and YOof 458 and of 283) Times per annum

Tinnitus maskers Use of environmental masking Relaxation training therapy Referral to psychiatrist or clinical psychologist

1-10

15-30

40-90

100+

I76 (38.62) 41 (9, 14) 87 (19, 31) 114 (25, 40)

57 (12, 20)

17 (4.6) 84 (18, 30) I8 (4, 6) 2 (0.4. 0.7)

4 (0.9, 1) 43 (9, 15)

105

(23, 37) 24 ( 5 , 8) 6 (1, 2)

tertiary referrals and medicolegal cases from all over the UK, that tinnitus patients are often not told (or are not told firmly enough that they recall being told) what is the probable cause of the tinnitus, even when the cause is fairly obvious. This view receives some support from the consultants’ reports on this issue: 2 (0.4, 0.7%) said they ‘never’ gave a probable diagnosis, 39 (9, 14%) ‘seldom’. 137 (30,48%) ‘often’ and 105 (23, 37%) ‘nearly always’. Since such information is the essential starting point of helpful counselling, this would seem to be an area of quite easily achievable improvement in tinnitus services. Estimates by the consultants of the numbers of times per annum that certain lines of treatment were prescribed or recommended are given in Tables 1, 2 and 3. The depth of the questions asked does not however permit a useful separation of the reports from those with and without tinnitus clinics. Table 1 shows that about two-thirds of the consultants sometimes prescribe tinnitus maskers. It is encouraging to see such widespread application of this potentially very useful regime of management, which was quite often reported by consultants not claiming to have a specialist tinnitus clinic. However, the actual number of patients receiving such prescriptions is estimated from these data to

I or more

253 (55,891 273 (60,961 10 139 (30, 49) (2, 4) 1 I23 (0.2, 0.4) (27,43)

be only about 3500 a year. This is small if we look at the prevalence of tinnitus:’ in the UK National Study of Hearing, 1% of the adults studied reported tinnitus as having a severe effect on the quality of their life, and 8% reported it as interfering with getting to sleep and/or causing moderate or severe annoyance. With an adult population of about 44 million and a most likely age spread for onsct of tinnitus of, say, 40 years, this means perhaps 90000 new cases of tinnitus per year deserving investigation, counselling and (often) treatment. Even if as many as half of them were sufficiently helped by thorough counselling, 25% by appropriate hearing aid fittings and only half of the remainder needed maskers, their prescription for only about 3500 patients per year would seem to be far short of the real need, perhaps for 10000 patients per year. The reasons for this relatively low use of maskers is probably a combination of limited resources, uncertainty or inexperience of the potential benefits of such treatment, and perhaps in some cases uninterest in non-surgical problems. Relaxation training therapy would not seem to be so widely used, although it is known that NHS facilities for such treatment are supplemented by many of the tinnitus self-help groups. On the other hand, psychological counselling and therapy would probably be much more widely

Numbers of consultants (and % of 458 and of 283) Times per annum 1-10 ~

Local tinnitus self-help group British Tinnitus Association RNID-TSS or its telephone helpline Pamphlets and booklets on coping with tinnitus Books for the layman on tinnitus

15-30

40-90

Table 1. Prescriptions of tinnitus inaskers and other lines of treatment

loo+

I or more

--

I87 (41, 66) 166 (36, 59) 88

(19. 31) I25 (27,441 92 (20, 33)

Table 2. Subjects on which supportive information is given

Tinnitus management survey

Table 3. Drugs prescribed or

3 15

Numbers of consultants (and YOof 458 and of 283) Times per annum

recommended

Intravenous lignocaine

1-10

15-30

40-90

loo+

21

-

-

-

(5, 7)

Carbamazepine (Tegretol) Clonazepam (Rivotril) Other sedatives (day or night) Anti-depressants Serc, Stemetil or Stugeron

used if there were not such a shortage of clinical psychologists in the NHS, and particularly if there were more with a special interest in tinnitus. The data given in Table 2 are reassuring about the fairly widespread knowledge of the help available from lay organiLations and publications. Nevertheless, there is room for improvement, especially concerning the potential usefulness of the R N I D national telephone helpline. However, this had been in operation only since October 1990 and the questionnaires were sent out in April 1991. (Its number is 0345090210. all telephone charges being at local rates.) Table 3 shows that the major usage of pharmacological treatments for tinnitus is either to counteract the main effects of severe tinnitus (tension, insomnia, depression) or to attempt to alter a presumed causative disorder in the labyrinth, with betahistine (Serc) or cinnarizine (Stugeron), or to prescribe prochlorperazine (Stemetil) presumably to control associated vertigo. Intravenous lignocaine is the only pharmacological treatment known to greatly reduce or abolish tinnitus in a high proportion of patients,’ but this lasts for only a few minutes or hours and is not a practicable method of treatment, hence its very infrequent use in the UK. Carbamazepine, taken by mouth, has been reported to have a useful degree of effectiveness by several research teams,’ but the quite low frequency of its use in the UK probably reflects rather poor results with it, which is certainly the author’s personal experience. The benzodiazepines also have anti-convulsant properties and therefore might be expected to reduce tinnitus: of these, clonazepam appears to be the most widely tried for this purpose and perhaps may be the most ~ u i t a b l eHowever, .~ as can be seen from Table 3, it has not found much favour in the UK, perhaps on account of the risk of developing dependency in the prolonged treatment that would be needed for such a chronic condition. Other sedatives are much more widely used, but presumably in the short-term treatment of some of the secondary effects of tinnitus such as tension and/or insomnia.

61 (13, 22)

12

(3, 4)

107 (23, 38)

6

( I , 2) 4

(0.9, 1) 21 (5, 7)

99

16 (3, 6) 41 (9. 14)

(IS, 24)

21

(5- 7)

(22. 35)

68

I or more

I

-

1 (0.2, 0.4) 4 (0.9, 1) 3 (0.7, I ) 12 (3, 4)

(0.2, 0.4) ~

68 (15, 24) 17

(4, 6 ) 1 133 (0.2. 0.4) (29. 47) 1 119 (0.2, 0.4) (26, 42) 5 126 (1, 2) (28, 45)

Further comments and general discussion One-third of the respondents offered further comments, mostly in the final ‘Any other information’ section of the questionnaire. Several indicated that their tinnitus clinic was delegated to non-medical staff, usually hearing therapists but sometimes chief technicians, and that their own medical input was limited to a basic ENT consultation. For some this was a matter of choice, i.e. regarding it as the proper arrangement, whilst others indicated a desire to d o more but had insufficient resources other than occasionally to devote extra time to the medical counselling of those tinnitus patients particularly needing it. In the author’s view the ideal is a tinnitus-clinic team, with designated sessions from a consultant otologist or audiological physician, supported by one or more hearing therapists, scientists or audiology technicians, and working in close liaison with a clinical psychologist and with a local self-help group to provide lay counselling and relaxation training therapy. However, most departmcnts have to make d o with less than this ideal and certainly the compromises indicated in some of the comments received are much better than having n o tinnitus clinic. Where therc is no such clinic at all, this may frequently be due to lack of resources but in some instances it is probably a combination of relative lack of interest, disbelief in the usefulness of maskers, frustration at not being able to cure the condition or offer any drug with a reasonably high degree of effectiveness, and uncertainty even as to the need for such a clinic. Indeed, one comment read: ‘Does “special clinic” status help or hinder the management of the condition?’ The finding of 66 hospitals with special facilities for people with tinnitus is a good deal more encouraging than the mere 29 tinnitus clinics ascertained recently’ in a survey of 430 hospitals listed in the Medical Directory as having a consultant E N T surgeon on its staff: unfortunately, that report did not say how a tinnitus clinic had been defined or to whom in

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R.R.A.Coles

the hospitals the questionnaire had been sent, factors which may account for its apparent insensitivity. Let us hope that the progress made in the last 15 years towards improving services for the many people severely troubled by tinnitus will not be endangered by the current reorganization of the NHS.

Acknowledgements The author wishes to express his thanks to Lucy Whitehurst for her work in analysing the data provided by this survey. He also thanks his fellow members of the BAOL who completed the survey questionnaire, and for their many useful and revealing comments.

References I COLESR.R.A. (1984) Epidemiology or tinnitus. I Prevalence. J . Laryngol. Ofol.(Suppl. Q), 7-1 5 2 MELDING P.S., GWDEYR.J.& THORNEP.R.(1978) The use of intravenous lidocaine in the diagnosis and treatment of tinnitus. J . Laryngol. Oral. 92, I 15-12 I 3 MELIXNG P.S. & G ~ ~ DR.J. E Y(1978) The treatment of tinnitus with oral anti-convulsants. J . Laryngol. Otol. 93, 11 1-122 4 LECHTENBERG R. & SHULMAN A. (1984) Benzodiazepines in the treatment of tinnitus. J . Laryngol. Otol. (Suppl. 9), 271-276 5 WILLIAMS R.G. (1991) Tinnitus Clinics. Rr. J . Audio/. 25, 283