e-learning – Tinnitus

This is a new guideline from NICE published in Mar 2020 on the management of tinnitus.

I will summarise the advice below. There isn't much new in this for us, but I would highlight that they encourage us to explore a patient's mental health from their initial presentation.

What advice and information can we give to patients?

We can reassure patients that:

  • tinnitus is common.
  • it may resolve by itself.
  • it is commonly associated with hearing loss, but isn’t commonly associated with other physical conditions.
  • a variety of strategies can help patients with their symptoms.

Among the normal information we would give to patients, NICE also advises the following:

  • What can make it worse – eg stress / loud noise exposure..
  • Safe listening practices – eg noise protection.
  • Self-help and coping strategies.
  • Support groups.

Who should we refer and with what speed?

Immediate referral is indicated if there is:

  • a high risk of suicide.
  • sudden onset of significant neurological symptoms or signs (eg facial weakness).
  • acute uncontrollable vestibular symptoms (eg vertigo).
  • suspected stroke.

Within 24 hrs referral is indicated if there is:

  • hearing loss that has developed suddenly over 3d or less and in the last 30d.

Within 2 weeks referral is indicated if there is:

  • distress that is affecting mental wellbeing (eg unable to do ADLs), even after receiving first-line advice as above.
  • hearing loss that developed suddenly > 30d ago.
  • rapidly worsening hearing over 4 – 90d.

In line with local pathways referral is indicated if there is:

  • tinnitus that bothers them, despite advice as above.
  • persistent objective tinnitus.
  • unilateral or asymmetrical hearing loss.

Consider referring in line with local pathways if there is:

  • persistent pulsatile tinnitus.
  • persistent unilateral tinnitus.

What questionnaires can we use to aid our assessment?

We should be screening all patients presenting with tinnitus for depression and anxiety.

We should be asking about their quality of life and the impact of their tinnitus on it, including employment or education.

In children, you may want to use a visual analogue scale (no specific ones were advised).

In addition the following questionnaires can be considered:

  • Tinnitus functional index (TFI)– for adults – to see how it impacts on them.
  • Insomnia severity index - looks generally at insomnia.
  • Tinnitus questionnaire (TQ), or mini TQ alongside TFI to assess psychological distress. Unfortunately I can't find a link to the tinnitus questionnaire that allows you to easily do it. If anyone knows of one - please add it to the comments and I can link to it here.
  • Clinical Outcomes in Routine Evaluation – this gives an outcome measure. It can be done before and after treatment to assess response.

What investigations should we be offering?

Audiology - to everyone.

Tympanometry - can be considered if there is evidence of middle ear or Eustachian or other conductive problems.

MRI scanning.

  • Offer to all patients with non-pulsatile tinnitus where there are associated neurological, ontological or other head and neck signs and symptoms.
  •  Consider for patients with unilateral or asymmetrical non-pulsatile tinnitus without features as above.
  • Pulsatile tinnitus.

How should we manage patients?

Hearing aids. These only offer benefit if there is hearing loss associated. They should be offered if the hearing loss is affecting their ability to communicate  and can be considered even if it isn't.

Sound therapies. There isn't enough evidence here to make a recommendation.

Psychological therapies. CBT can be used. This can be group, digital or individual.

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