Author's response to reviews Title: Treatment options for subjective tinnitus: Self reports from a sample of general practitioners and ENT physicians within Europe and the USA. Authors:

‘The disorder has a considerable heterogeneity and so no single mechanism is likely to explain the presence of tinnitus in all those affected. As such there is no singly effective treatment for the condition, and so choice of clinical intervention is a multi-factorial decision based on many factors, including assessment of patient needs and the healthcare context.’ Introduction: ‘Treatment options. Because there is no single pathophysiological pathway to explain the production of tinnitus, there is no cure [13], nor are there any licensed medications for alleviating the symptoms.’ We note that the Introductory section on pathophysiology already states that tinnitus is not a unitary condition. 3. Last sentence page 3: There are published detailed guidelines for treatment (such as those published by the "Tinnitus Research Initiative" (TRI), and reproduced in A.R. Moller et al eds "Textbook of Tinnitus", 2010 Later in the article we do report the Tinnitus Research Initiative guidelines and provide a reference to the website documentation. This set of guidelines has particular strengths for cases of tinnitus that can be managed by a medical procedure, but subjective tinnitus with no known underlying cause is less well addressed and this is where the major challenge lies for clinical practice. To clarify this point, the last sentence on page 3 has been revised. ‘For subjective tinnitus in particular, an effective therapy option with guidelines about key diagnostic criteria is urgently needed. 4. Last paragraph on page 15: "... important role of GPs and ENTs in the diagnosis and management ....other specialties' are less frequently consulted". The last statement is undocumented. This sentence was part of a summary of our findings that are reported in the preceding pages, but its phrasing was rather ambiguous in its interpretation. We mean to say that the type of professions ‘In those countries surveyed, GPs and ENTs played a frequent role in the diagnosis and management of tinnitus, while such a role for the other professions differed across countries.’ 5. It should be pointed out that audiology is a subspecialty of ENT, whereas it is an independent specialty in other countries (such as the USA). We thank Prof Moller for highlighting this omission. In fact we readily admit that training routes and official recognition of the specialisms are highly likely to contribute to the variability in clinical practice across the different countries. This also relates closely to question 12 raised by Dr Padgham. To adequately deal with this issue, we have added a section on specialist clinical training and healthcare context in the Discussion. See below for this new text. ‘Specialized clinical training in hearing problems The healthcare system would appear to strongly determine how specialist treatment for tinnitus is provided. In this section, we consider the training routes and professional recognition of ENT and audiology specialties across Europe and the US in order to contextualise some of our findings, Otorhinolaryngology represents an established area of health care for disorders of the head and neck, including hearing, balance, sinus, nose, voice, oral cavity, sleep, allergy, and head and neck tumors. Within Europe, the European Union of Medical Specialists (UEMS), founded in 1958, has ensured the quality and harmonization of specialist training in order to support the free movement of qualified physicians and patients. In otorhinolaryngology, this has been achieved through a Charter in 1995 and a European training programme in 2009 for head and neck surgery and ENT specialists (www.orluems.com/index.asp). In the USA, the Accreditation Council for Graduate Medical Education achieves similar aims, with 105 programs in otolaryngology (2011-12) achieving national standards in medical training (www.acgme.org/adspublic/reports/accredited_programs.asp). In general contrast, audiology represents a younger area of health care for hearing and balance disorders, with specialist skills in rehabilitation especially in the provision of hearing aids. In the US, audiology is recognized as an independent profession in its own right, and training and practice are well regulated. In Europe however, the situation is considerably more variable. Although the profession is represented by the European Federation of Audiology Societies (EFAS), founded in 1992, there is no Europe-wide standard for training or professional recognition. Specialist training in the UK and Scandanavia has been well established for many years and EFAS supports a proposal for a ‘General Audiologist profession’ to standardize the training curriculum and professional skills more widely. Training provision is growing in some countries (e.g. Spain now offers two Masters in Audiology courses on this model). However, it remains unclear whether the structure and status of the audiology profession can ever be consistent throughout Europe, given relative strength of the medical professions in certain countries. For example, in Spain, audiology is not an official profession, although hearing-aid technicians were officially recognized in 2001. It is interesting to note that in Europe other professions lay ‘claim’ to audiology and the EU perspective from UEMS is one of audiology as a sub-speciality of ENT. In Italy, audiology was previously a speciality within ENT, but is now divided between ENT and phoniatrics (i.e., speech and language assessment and treatment) (Ferdinando Grandori, personal communication). In Germany, ENTs deal with differential diagnostics and management of hearing loss, while a second, independent ENT specialty combines phoniatrics and pediatric audiology [25]. Of the five European countries surveyed here, the UK is unusual in that audiology is a recognized specialism in its own right and as a consequence is the primary health system provider of treatments for chronic tinnitus [26]. In this respect, the UK system is more similar to that of the US, than its European neighbours. Training routes and recognized specialisms are therefore highly likely to contribute to the variability in clinical practice across the different countries.’ Reviewer: Dirk De Ridder 6. How representative is the study population of ENTs and GPs? Although this is a voluntary sample from those registered in the GP and ENT communities, the demographic distribution of respondents (age, gender, region) is cross-checked against available population statistics for the two professions to provide some assurance about representativeness. This statement is now included in the section on Recruitment. We have also been very careful to check the manuscript so that we do not make any misleading claims. We have amended the title to: ‘Treatment options for subjective tinnitus: Self reports from a sample of general practitioners and ENT physicians within Europe and the USA.’ We have amended the methods on page 10: ‘We use an online questionnaire administered to a sample of physicians to explore ...’ We have amended the conclusions on page 29: ‘From the sample of physicians participating in this survey, a wide variety of treatment approaches (both pharmaceutical and non-pharmaceutical) appear to be employed by GPs and ENTs across Europe and the US’ To our knowledge, at the time of submission there were no published statistics against which we can compare the data to establish its representativeness. Since then, the first author has published a GP survey in England (El-Shunnar et al., 2011). Although many of questions were different, one question asked about referrals. 37% of patients were referred on comparable to the 33% reported in the present study. We report this convergence of findings on page 16. New reference: El-Shunnar S, Hoare DJ, Smith S, Gander PE, Kang S, Fackrell K, Hall DA. (2011) Primary care for tinnitus: practice and opinion among GPs in England. Journal of Evaluation in Clinical Practice. 17(4):684-92. 7. Are these really tinnitus treatment experienced physicians as stated in the manuscript? A definition of what is meant by a tinnitus treatment experienced physician is would be helpful. The phrase ‘tinnitus-treatment experienced physician’ was an operational definition used within the context of this questionnaire survey which simply defines a physician who reported seeing at least one tinnitus patient in the past 3 months. We admit that this definition does not necessarily mean that the physician was an expert in tinnitus and so we have removed this phrase. 8. It would be interesting to see a distribution (how many patients seen by each physician) of the data for each country and for all countries combined. We are pleased to include new tables reporting these data for all tinnitus patient (Table 2) and for new tinnitus consultations only (Table 3). As you can see from the distributions in Table 2 below, the GP data are fairly normally distributed with the most GPs reporting 10-19 consultations in a 3-month period. ENTs typically consult with more patients reporting tinnitus. German ENTs report the highest number of tinnitus consultations (35 ENTs reporting >100 in a 3-month period). In this section of the manuscript we also now report median values, not mean values, to avoid bias from this outlier. Subsequent analyses are reported on a country-by-country basis, so the specific pattern in one country does not bias the overall interpretation of the results.