British Tinnitus Association

Objective There is currently no singularly accepted definition of hyperacusis. The aim of this study was to determine a definition and description of hyperacusis by clinician consensus. Design A three-round Delphi survey involving hearing healthcare professionals built towards clinical consensus on a definition of hyperacusis. Round 1 involved three open-ended questions about hyperacusis. Seventy-nine statements were generated on descriptions, impact, sounds, and potential features of hyperacusis. Agreement on the relevance of each statement to defining or describing hyperacusis was then measured in Rounds 2 and 3. General consensus was defined a priori as ≥70% agreement, or ≥90 for clinical decision making. Study sample Forty-five hearing healthcare professionals were recruited to take part in this study. Forty-one completed Round 1, 36 completed Round 2, and 33 completed Round 3. Results Consensus was reached on 42/79 statements. From these a consensus definition includes “A reduced tolerance to sound(s) that are perceived as normal to the majority of the population or were perceived as normal to the person before their onset of hyperacusis”. A consensus description of hyperacusis was also determined. Conclusions This consensus definition of hyperacusis will help to determine the scope of clinical practice guidelines and influence needed research on hyperacusis.

BackgroundThe most common management strategy for tinnitus provided in the UK audiology clinics is education and advice. This may also be combined with some form of sound therapy (e.g. digital hearing aids). While education and advice is generally provided by all clinics, there is a marked variability in provision of hearing aids that depends very much on clinical decisions. A recent Cochrane review concluded a lack of evidence to support or refute hearing aid use as a routine intervention for people with tinnitus and hearing loss. This lack of evidence is reflected in the inconsistency of tinnitus management in the UK. The aim of the HUSH trial is to determine the feasibility of conducting a definitive randomised controlled trial (RCT) of the effectiveness and cost-effectiveness of hearing aids for adults with tinnitus and hearing loss.MethodsThis is a multicentre randomised controlled feasibility trial. Up to 100 adults, aged 18 and over, presenting to 5 UK audiology clinics with a complaint of tinnitus and measurable hearing loss are being randomised to receive either (i) education and advice (treatment as usual) or (ii) education and advice with digital hearing aids. Feasibility outcomes are being collected around recruitment, retention, patient and healthcare professional acceptability and clinical outcome assessment. Outcomes are being collected via postal questionnaire at 12 weeks post baseline. A nested interview study will supplement clinical and other outcome data, providing a detailed understanding of participants’ and audiologists’ experience of both tinnitus management and the research processes.DiscussionThis feasibility trial will help us to (i) determine if it is feasible to conduct a multicentre RCT comparing treatment as usual and treatment as usual plus digital hearing aids; (ii) optimise the design of a future definitive, multicentre RCT; and (iii) inform which outcome(s) is/are relevant for patients. This work presents an important first step in determining the effectiveness of hearing aids as a tinnitus management strategy.Trial registrationISRCTN, ISRCTN14218416. Registered on 30 July 2018.

Tinnitus is unusual for such a common symptom in that there are few treatment options and those that are available are aimed at reducing the impact rather than specifically addressing the tinnitus percept. In particular, there is no drug recommended specifically for the management of tinnitus. Whilst some of the currently available interventions are effective at improving quality of life and reducing tinnitus-associated psychological distress, most show little if any effect on the primary symptom of subjective tinnitus loudness. Studies of the delivery of tinnitus services have demonstrated considerable end-user dissatisfaction and a marked disconnect between the aims of healthcare providers and those of tinnitus patients: patients want their tinnitus loudness reduced and would prefer a pharmacological solution over other modalities. Several studies have shown that tinnitus confers a significant financial burden on healthcare systems and an even greater economic impact on society as a whole. Market research has demonstrated a strong commercial opportunity for an effective pharmacological treatment for tinnitus, but the amount of tinnitus research and financial investment is small compared to other chronic health conditions. There is no single reason for this situation, but rather a series of impediments: tinnitus prevalence is unclear with published figures varying from 5.1 to 42.7%; there is a lack of a clear tinnitus definition and there are multiple subtypes of tinnitus, potentially requiring different treatments; there is a dearth of biomarkers and objective measures for tinnitus; treatment research is associated with a very large placebo effect; the pathophysiology of tinnitus is unclear; animal models are available but research in animals frequently fails to correlate with human studies; there is no clear definition of what constitutes meaningful change or “cure”; the pharmaceutical industry cannot see a clear pathway to distribute their products as many tinnitus clinicians are non-prescribing audiologists. To try and clarify this situation, highlight important areas for research and prevent wasteful duplication of effort, the British Tinnitus Association (BTA) has developed a Map of Tinnitus. This is a repository of evidence-based tinnitus knowledge, designed to be free to access, intuitive, easy to use, adaptable and expandable.

BackgroundThere is no standard treatment pathway for tinnitus patients in the UK. Possible therapies include education and reassurance, cognitive behavioural therapies, modified tinnitus retraining therapy (education and sound enrichment), or amplification of external sound using hearing aids. However, the effectiveness of most therapies is somewhat controversial. As health services come under economic pressure to deploy resources more effectively there is an increasing need to demonstrate the value of tinnitus therapies, and how value may be continuously enhanced. The objective of this project was to map out existing clinical practice, estimate the NHS costs associated with the management approaches used, and obtain initial indicative estimates of cost-effectiveness.MethodsCurrent treatment pathways, costs and health outcomes were determined from the tinnitus literature, national statistics, a patient survey, and expert opinion. These were used to create an Excel-based economic model of therapy options for tinnitus patients. The probabilities associated with the likelihood of an individual patient receiving a particular combination of therapies was used to calculate the average cost of treatment per patient, average health outcome per patient measured in QALYs gained, and cost-effectiveness, measured by the average cost per QALY gained.ResultsThe average cost of tinnitus treatment per patient per year is GB£717, equating to an NHS healthcare bill of GB£750 million per year. Across all pathways, tinnitus therapy costs £10,600 per QALY gained. Results were relatively insensitive to restrictions on access to cognitive behaviour therapy, and a subsequent reliance on other therapies.ConclusionsNHS provisions for tinnitus are cost-effective against the National Institute for Health and Care Excellence cost-effective threshold. Most interventions help, but education alone offers very small QALY gains. The most cost-effective therapies in the model were delivered within audiology.