Expertise in tinnitus is poor among our general practitioners. According to a recent report, this means that many people are suffering unnecessarily. Stock 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 treatment provision offered to patients is failing at many levels.

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 health trusts. Their work has been commissioned by the Norwegian Association for the Hard of Hearing.

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

So says Tron Vedel Tronstad, who is an acoustician and research scientist at SINTEF, and one of the authors of the report called “Riktig ut fra start (Right from the start…).

Two major studies were published as long ago as 2003 and 2005, both recommending that changes were needed. However, the recent study has revealed that the situation in the patient population hasn’t changed in the last twenty years. This is in spite of the conclusions of the two previous studies, which were commissioned by the Norwegian Directorate of Health and the then Ministry of Health, respectively.

Key facts: 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 sufferers is on the increase, both in Norway and 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. Very many sufferers experience improvement if they are fitted with hearing aids.

You can find out more about tinnitus here.

Many are suffering unnecessarily

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).

The result of this is that many sufferers are also afflicted with anxiety and depression which, according to the researchers’ report, is “the result of a total lack of knowledge among GPs on patients’ first encounter with the health services”.

These conclusions are based on a comprehensive analysis of documents, combined with qualitative interviews with ear, nose and throat specialists, audiographers, coaches of people with hearing loss, as well as tinnitus sufferers themselves.

Major variation in treatment provision

The SINTEF researchers have also revealed major variations in the treatment provision available to tinnitus sufferers.

“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 health system”, says Tronstad. “This is a cause for concern, especially when we know that as many as one in five Norwegians are suffering from the condition”, he says. Treatment provision also varies according to where in the country you live.

Moreover, the researchers have concluded that the patient population is not offered differentiated treatment regimes tailored to the severity of the condition.

“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”, says Tronstad. “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.

The SINTEF report also concludes by saying that our lack of diagnostic expertise means that patient pathways are entirely incoherent in the field of tinnitus. 

Facts about 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 tinnitus sufferers) from 2005, all arrive at the same conclusions that can be summarised as follows:

  • There is a need to establish a Norwegian tinnitus expertise centre.
  • Each regional health trust should establish a call centre for tinnitus sufferers.
  • 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 health 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, advisory services, Tinnitus Retraining Therapy (TRT, which involves the unlearning of tinnitus noise and multisensory attention training), masking treatments and the use of specialist hearing aids.
  • Regional health trusts should establish multidisciplinary treatment teams equipped with the skills to treat those patients suffering most from the condition.
  • 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.

The GP is key

Between 80 and 90 per cent of GPs interviewed by the SINTEF researchers responded that they had a moderate to acute need for more knowledge about the treatment of tinnitus sufferers. As many as 40 per cent had seen patients with tinnitus complaints during their last five days at 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.

We note also that the most effective treatment is to fit sufferers with some form of hearing aid. Most people with tinnitus also suffer from some loss of hearing. Because tinnitus is a neurological condition that results in patients hearing ringing or other sounds, this disruptive noise will be weaker and less dominant when ‘the sound’ in their ears is louder.

This advice is in line with that offered in the previous studies. Patients with mild to moderate symptoms, which is the case for the majority of sufferers, 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 their 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 population.

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

Rejected by specialists

One of the findings made by the SINTEF researchers revealed that skills development in tinnitus is largely rejected by professionals in specialist health care services because the subject is not regarded as interesting enough.

However, these services also have a ‘duty of care’ – in other words, an obligation to offer treatment. The researchers have 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. Photo: Thor Nielsen

Georg Træland is a technical audiologist currently heading the tinnitus clinic at Sørlandet Hospital. He has been working with tinnitus and the treatment of this patient population for his entire career.

He was a major contributor to both the 2003 and 2005 reports referred to by the researchers and is very familiar with the problem that tinnitus patients are considered ‘non-profitable’.

The reason is that the most severely afflicted sufferers constitute a patient population that requires long-term, multidisciplinary monitoring, which is very expensive.

Moreover, Træland’s experience has clearly demonstrated that it is essential that sufferers get the right help at an early stage in their treatment journeys.

“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.

“We note also that the most effective treatment is to fit sufferers with some form of hearing aid”, says Træland. Most people with tinnitus also suffer from some loss of hearing. Because tinnitus is a neurological condition that results in patients hearing ringing or other sounds, this disruptive noise will be weaker and less dominant when ‘the sound’ in their ears is louder.

“Just to highlight one major problem linked to the treatments offered to this patient population, it is that there is too little knowledge about both the neurological aspects of the condition, and what treatments should be offered, and when”, he says.

“The SINTEF report is called “Riktig ut fra start…” (Right from the start…) – a very apt and descriptive title”, says Træland.

Hoping that 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”, she says. “This is why we commissioned the report. We now have documentary evidence that almost nothing has changed in the last twenty years. This in spite of the clear conclusions set out in the 2003 and 2005 reports which both recommended that something had to be done”, says Venås.

“The time for Health and Care Services Minister Ingvild Kjerkol to take action is now overdue”, says Venås. “Today one in five Norwegians are suffering from tinnitus, and the number of sufferers 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”, says Tron Vedul Tronstad. “The main findings of these reports are supported by our evaluations and the interviews we’ve conducted with the patient population and treatment providers”, he says.