I’m both interested in and disturbed by what some doctors have said to patients at the first consultation for tinnitus, an annoying perception of sound that comes from somewhere within their heads. Not many of these patients are referred to me – most come of their own accord for a second opinion. What they tell me their doctor said is a lesson in how not to communicate with patients, and I think worth repeating here.
The most common doctor diagnosis, treatment and reassurance is a curt, “You’ve got tinnitus, and there’s nothing you or we can do. Learn to live with it.”
Few patients can be more anxious. For most, tinnitus is a minor annoyance, no cause for concern, not due to any serious illness, and simple reassurance is all that is needed. The unfortunate other end of the scale is the tinnitus sufferer tormented by the incessant buzzing in his or her head, and whose life becomes consumed by efforts to escape the distraction. Helping these patients is a real challenge, some driven as far as suicide.
At first glance certainly the first and last parts of the doctor’s statement are true. The middle is a common and mistaken assumption by many doctors, perhaps a bit of medical ignorance, but hardly negligent. Or is it? Overall, I’m disturbed by the callousness of this dismissal, for the following reasons.
Tinnitus is a symptom, not a disease. The original statement is analogous to saying “You’ve got a backache.” Putting only a name to a symptom is a start, but not very helpful in the long term.
The possibility that tinnitus is due to a disease process is ignored. Tinnitus may be pulsatile or continuous. If in time with a patient’s heartbeat, (i.e. pulsatile), there is a reasonable possibility of some disturbance in vascular flow in the neck, skull or brain, varying from as minor a problem as a small and insignificant kink in the normal internal carotid artery due to minor arteriosclerosis, to major challenges like vascular tumors filling large areas of the head and brain. Pulsatile tinnitus should be investigated, by careful clinical examination and usually an MRI angiogram.
Continuous tinnitus is often described as “buzzing, like the sea, or crickets” may be due to an abnormality anywhere in the hearing system. It can be something as minor as wax in the ear canal. Or as major as a tumor of the vestibulocochlear nerve – an acoustic neuroma. The commonest cause is going to be a degree of nerve deafness due to common everyday wear and tear. But a diagnosis still needs to be made. The statement closes the door on the possibility of diagnosing and removing the cause, and risks missing serious pathology.
“There’s nothing you or we can do.” I guess what the doctor means is, “There’s no medication shown to reduce tinnitus,” which at this point in time is generally true. Intravenous lidocaine has been shown to be effective in the very short term, but is very toxic and impractical in any form for tinnitus sufferers. There are other medications thought to have some benefit, but results of studies are variable. Unfortunately for tinnitus there is no magic bullet. But “we cannot write a prescription” should be very distinct from “there’s nothing you can do.”
There is a lot a doctor can do for a sufferer, given a basic understanding of tinnitus, and a diagnosis is a good place to start.
First, for idiopathic or sensorineural hearing loss-related tinnitus, the exclusion of serious pathology is very helpful for the anxious patient – an MRI scan of the brain has a good therapeutic effect in offering reassurance. In my opinion, the worst sufferers have little chance of overcoming tinnitus until an MRI scan convinces them there is no tumor inside their heads. Second, an explanation as to why tinnitus is there in the first place is essential, i.e. “sound perception due to nerve activity within the brain, which is usually not heard by the conscious brain, but which becomes heard due to other abnormalities” or, in other words, a “raising of sensitivity to natural brain ‘sound’, which is not usually heard.”
The majority of patients are happy with just an explanation, especially when they realize that if they focus attention on the tinnitus, it will naturally become louder. Advice to “learn to ignore tinnitus” is very different to “learn to live with it.”
The latter advice is impossible to follow without a basic understanding of why the tinnitus is there, and why distraction techniques are so important in learning to ignore it. The patients have to be given the tools to “learn to live with it” – on its own that advice is as meaningless as is “learn to read” to someone who is illiterate.
Those seriously affected by tinnitus may find wearing hearing aids or tinnitus maskers – hearing-aid like fittings that mask the tinnitus sound with another – very useful. Some may need antidepressants to deal with the associated comorbidities.
And there are conditioning and behavior modification therapies specifically designed to treat tinnitus – tinnitus can and should be cured by, among others, audiologists and other professionals who are specially trained to deal with difficult cases.
The majority of my patients need little more than a history, quick physical examination, a hearing test, an MRI scan in selected cases, and then twenty minutes of detailed explanation and communication. But omit the explanation, and all the rest is money and effort wasted, with little chance of cure.
I was taught to make my goal in medicine application of the three important principles – to do no harm, sometimes heal, and comfort always.
Saying, “You’ve got tinnitus, and there’s nothing you or we can do. Learn to live with it,” is a poor five second substitute for a thirty minute communication.
Martin Young is an otolaryngologist and founder and CEO of ConsentCare.
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