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Progressive Tinnitus Management

Clinical Handbook for Audiologists

Progressive Tinnitus Management
Clinical Handbook for Audiologists

James A. Henry
Tara L. Zaugg
Paula J. Myers
Caroline J. Kendall
Published by:
VA Employee Education System
Long Beach, CA 90822
(562) 826-5505

This volume was prepared for educational use by the Veterans Health Administration. The
focus of the information is to provide guidelines for VA audiologists to conduct the method
of Progressive Tinnitus Management (PTM) with Veteran patients. In general, VA endorses
the method of PTM.

Use of trade or brand names in this publication is for illustrative purposes only and does
not imply endorsement by the Veterans Health Administration.

Certain parts of this publication pertain to copyright restrictions.

All rights reserved.

No copyrighted parts of this publication may be reproduced or transmitted in any form or

by any means, electronic or mechanical (including photocopy, recording, or any
information storage and retrieval system), without permission in writing from the
publisher or copyright owner.

Printed in the United States of America


Foreword vii
Introduction ix
Acknowledgments xii
Authors and Contributors xiii

1 Definitions and Background 1

2 Research Leading to PTM 11
3 Overview of PTM 21
4 Level 1 Triage 35
5 Level 2 Audiologic Evaluation 39
6 Sound Tolerance Evaluation and Management (STEM) 51
7 Level 3 Group Education 57
8 Level 4 Interdisciplinary Evaluation 67
9 Level 5 Individualized Support 77

References 85
A PTM Flowchart 95
B Tinnitus Triage Guidelines 97
C Overview of Objectives and Procedures of the Level 2 Audiologic Evaluation 99
D Tinnitus and Hearing Survey 101
E What to Do When Everyday Sounds Are Too Loud 103
F Tinnitus Handicap Inventory 105
G Hearing Handicap InventoryScreening Version 109
H Tinnitus Problem Checklist 111
I Flowchart for Assessment and Fitting of Ear-Level Instruments 113
J Level 2 Audiologic Evaluation: Special Considerations for Hearing Aids 115
K Sound Tolerance Interview 117
L Sound Tolerance Worksheet 121
M Loudness Discomfort LevelsClinical Guide 123
N Sound Plan Worksheet 125
O Relief Scale 127
P Attention Scale 129
vi Progressive Tinnitus Management: Clinical Handbook for Audiologists

Q Tinnitus Contrast Activity 131

R Level 4 Interdisciplinary Evaluation:Tinnitus Interview 133
S Hospital Anxiety and Depression Scale (HADS) 137
T The Primary Care PTSD Screening Tool (PC-PTSD) 139
U Epworth Sleepiness Scale (ESS) 141
V Level 4 Interdisciplinary Evaluation: Guide to Trial Use of Ear-Level Instruments 143
W Level 4 Interdisciplinary Evaluation: In-Clinic Trial Use of Hearing Aids 145
X Level 4 Interdisciplinary Evaluation: In-Clinic Trial Use of Combination Instruments 147
Y Level 4 Interdisciplinary Evaluation: In-Clinic Trial Use of Noise Generators 149
DVD and CD information 151
Index 153

Also Included:
DVD: Managing Your Tinnitus (for Level 3 group viewing)
CD: PowerPoint files (for Level 3 live presentations)

Tinnitus can dramatically compromise quality of audiologic histories including significant manage-
life, rendering some persons unable to function ment challenges such as posttraumatic stress disor-
as happy, healthy, and productive human beings. der (PTSD). This relatively small proportion of
Tinnitus is one of the most common health con- patients will require highly specialized and indi-
cerns among combat-injured military personnel vidualized support and management.
and veterans, and a major health care problem The authors of the three booksthree audi-
within the VA system. Tinnitus is also a signifi- ologists and one psychologistdraw on years
cant health issue in the general population. Each of research and clinical experience with tinni-
year debilitating tinnitus prompts millions of tus assessment and management in the develop-
persons to seek help from health care providers. ment of the PTM approach. Readers are probably
Unfortunately, the person with tinnitus often does already familiar with the authors peer-reviewed
not benefit from prompt and appropriate care publications on tinnitus. James Henry, PhD is a VA
from physicians and other health care providers. Research Career Scientist at the National Center
Although effective tinnitus management tech- for Rehabilitative Auditory Research (NCRAR).
niques do exist, and all persons with bothersome Tara Zaugg, AuD is a research audiologist at the
tinnitus can be helped, a systematic, logical, and NCRAR. Paula Myers, PhD is Chief of the Audiol-
efficient approach to this large-scale health care ogy Section and Cochlear Implant Coordinator at
problem is desperately needed. The progressive the James A. Haley VA Hospital in Tampa, Florida.
tinnitus management (PTM) method described Caroline Kendall, PhD is a research psychologist
in the new three-book Plural bundle offers such at the VA Connecticut Healthcare System in West
a solution. Haven Connecticut.
The information within the three PTM books is Multiple unique features of the three PTM
evidence-based and clinically-proven. The strategy books contribute importantly to their clinical use-
for assessment and management of tinnitus con- fulness. The first book of the bundle is a clinical
tained within the three books is consistent with the handbook on PTM written for audiologists. The
accumulated clinical experiences of audiologists components of the progressive tinnitus manage-
who provide services to persons with bothersome ment approach are thoroughly explained in nine
tinnitus. In the words of the authors, PTM utilizes chapters. Clinical implementation of PTM is facili-
a hierarchical structure for providing clinical ser- tated with 25 appendices containing a variety of
vices. That is, patients receive services that prog- practical materials such as patient handouts, ques-
ress to higher levels only as needed. For many tionnaires, and procedural guides. The handbook
(perhaps most) prospective patients, timely and also includes a clinically valuable CD with infor-
accurate information about tinnitus coupled with mational PowerPoint presentations plus a DVD
rather generic counseling will allay their concerns containing videos for patients containing, for exam-
and prevent the need for more extensive (and ple, demonstrations of different relaxation tech-
expensive) intervention. At the other end of the tin- niques. The second book is a guide for one-on-one
nitus seriousness spectrum are patients with dis- counseling of patients with tinnitus. In the man-
abling tinnitus and, often, complex health and agement of bothersome tinnitus and hyperacusis
viii Progressive Tinnitus Management: Clinical Handbook for Audiologists

(reduced sound tolerance), patient counseling is an of additional practical information prepared for the
essential and very effective component of interven- patient. The self-help workbook will be very useful
tion. The 300-page counseling guidebook is to augment the services provided by audiologists,
designed and formatted to be used directly in the and also will be invaluable for patients who, for
counseling process, literally interfacing the audiol- various reasons, cannot directly access the services
ogist with the patient. The counseling book also of an audiologist.
includes a 75-minute audio CD with a variety of The three PTM books, with varied accompa-
sound tracks to demonstrate different types of nying educational materials, provide a remarkably
sounds that can be used for managing reactions creative and comprehensive solution for the health
to tinnitus. care problem of tinnitus in both the VA and non-
Consistent with the clinically proven adage VA patient populations. Most audiologists regu-
that knowledge is power, the third book is a self- larly encounter patients who require a compas-
help workbook written for the person with tinnitus. sionate and evidence-based approach for diag-
The workbook provides step-by-step instructions nosis and intervention for bothersome tinnitus.
to facilitate learning how to self-manage reactions Within the PTM book series is all the infor-
to tinnitus. It also includes information on hearing mation and materials an audiologist needs to
protection, relaxation exercises, cognitive behav- provide effective clinical services to this tradition-
ioral therapy (CBT) and 10 appendices chock full ally underserved patient population.

James W. Hall III, PhD

University of Florida

Tinnitus is the perception of sound in the ears or by patients. In 2006 we received a research grant
head that does not have a source outside the body. from VA Rehabilitation, Research and Develop-
The perceived sound is generated within the body ment (RR&D) Service to develop and test a new
and thus has been referred to as a phantom method that was progressive in its approach. The
sound. Most typically, people who experience tin- method was designed to be conducted entirely
nitus have been exposed to loud noise that caused by audiologists, provided patients were referred
damage to the auditory system, resulting in both appropriately to other disciplines as needed. Five
tinnitus and hearing loss. There are numerous other hierarchical levels of clinical services were defined,
causes of tinnitus, as reviewed in Chapter 1. and patients progressed only to the level of care
Tinnitus is a vexing and intractable problem necessary to meet their needs. The intervention
for millions of people. It can cause sleep problems, mainly was educational and was intended to pro-
difficulty concentrating, and can be the cause of mote self-efficacy for managing reactions to tin-
mental health problemsmost commonly anxiety nitus. The overall intent was to meet the needs of
and depression. People who already suffer from patients on an individualized basis, and to provide
mental health conditions may be particularly vul- them with the self-management skills that they
nerable to tinnitus becoming problematic. Interest- would likely need for a lifetime.
ingly, of all the people who experience tinnitus, Following development of our progressive
many more are not bothered by it than those who approach, it became clear that psychological effects
are. This is just one of many aspects of tinnitus that due to tinnitus needed to be addressed. This resulted
make it difficult to provide a clinical program that in the incorporation of cognitive-behavioral ther-
addresses the needs of all patients who report tin- apy (CBT) into the intervention protocol. CBT has
nitus to a health care provider. been used for many years as effective intervention
We have conducted tinnitus clinical research for pain, depression, and anxiety. CBT was adapted
at the Portland VA Medical Center continuously to the management of tinnitus and was shown to
since 1995 (under the auspices of the VA National be effective with many people for that purpose. We
Center for Rehabilitative Auditory Research since now have incorporated key components of CBT
1997). Our initial studies evaluated psychoacous- into the PTM program, resulting in an interdisciplin-
tic aspects of tinnitus. In 1999 we started the first ary approach to providing tinnitus clinical services.
of a series of controlled clinical studies to evalu- The result of these efforts is the development
ate different methods of tinnitus intervention (as of progressive tinnitus management (PTM). The
described in Chapter 2). These clinical studies pro- method continues to evolve, especially with the
vided important efficacy data with respect to the addition of CBT. However, the method has reached
different methods studied, but more importantly a level of development at which it now can be spe-
we learned a great deal about how best to meet the cifically defined with respect to the procedures
needs of patients who suffer from tinnitus. required for its clinical implementation. This book
We determined that a progressive approach provides a description of the clinical procedures
to tinnitus management was essential to most necessary for audiologists to conduct PTM. A sepa-
efficiently address the range of services needed rate book is in preparation that will focus primarily
 Progressive Tinnitus Management: Clinical Handbook for Audiologists

on CBT procedures used by mental health special- hearing disorders; (c) conduct a brief assessment
ists to combine with the audiologic components of tinnitus impact; and (d) (optional) provide edu-
of PTM. cational materials to the patient to facilitate self-
It is acknowledged that numerous methods management. Level 3 Group Education involves
of tinnitus management are in use and that clini- two interactive workshops conducted by an audi-
cians often disagree regarding the most effective ologist, which focus on teaching patients how to
approach. A number of controlled clinical studies use therapeutic sound. In addition, a psychologist
have been completed that demonstrate benefit to (or other qualified mental health professional) con-
the majority of participants enrolled in these stud- ducts three workshops that teach key principles of
ies. However, these studies are not definitive; thus, CBT. The CBT sessions are designed to facilitate
clinicians have the latitude to use any method that specific coping skills to augment the use of thera-
has research support. It is important to recognize peutic sound.
that evidence-based tinnitus interventions use some Although it is optimal that a mental health
combination of three broad components: educa- provider be part of the PTM clinical team, we rec-
tion, relaxation techniques, and therapeutic sound. ognize that this will not always be possible. At a
Addressing some or all of these three components minimum, appropriate mental health providers
in general provides reasonable benefit such that should be identified and then used to refer patients
many patients notice a significant improvement in when mental health services are needed. Audiolo-
their quality of life. Of course, there is no cure for gists should take the lead in implementing PTM,
tinnitus; thus, patients must realize that no matter and adapt the program as necessary to be flexible
which method is applied, their tinnitus perception in how it is implemented to make the most of the
will most likely remain unchanged and that clini- resources available at any one clinic.
cal management focuses on reducing any negative Patients whose needs are not met through
reactions associated with the tinnitus. Level 3 are advised to undergo Level 4 Interdisci-
Although many practitioners already are con- plinary Evaluation. The evaluation should be con-
ducting some form of tinnitus therapy, others have ducted by both an audiologist and a mental health
little to no experience providing tinnitus services. professional (typically a psychologist, as they are
Experienced clinicians generally have definite ideas specifically trained to evaluate and diagnose mental
about how to go about providing tinnitus services health disorders). The audiologist and psychologist
to their patients. These clinicians can adopt PTM work as a team for Levels 4 and 5 collaboratively
as described in this book, or they can use the dif- to determine the best therapeutic approach for the
ferent levels of PTM as a framework within which patient. Level 5 Individualized Support thus can
to conduct their preferred form of therapy. For cli- involve multiple appointments with the audiolo-
nicians with little to no experience, it is suggested gist, the psychologist, or both. Level 5 normally
they start by implementing the first three levels involves up to 6 months of individualized support.
of PTM. With sufficient experience implementing Throughout each level, the goal of intervention is
these lower levels, they can start practicing the for the patient to learn the skills necessary to self-
higher levels (Levels 4 and 5). manage any situation in which his or her tinnitus
The interdisciplinary aspect of PTM requires is problematic.
some further explanation. Level 1 Triage is directed This handbook provides minimal background
to all clinicians (except audiologists or other ear information about tinnitus and focuses on describ-
specialists) who encounter patients complaining of ing the practical information that is necessary to
bothersome tinnitus. Nonaudiologist clinicians are learn how to implement PTM in the clinic. Chap-
provided with guidelines to assist them in properly ter 1 establishes common ground with respect to
referring these patients for appropriate clinical ser- terminology and definitions pertaining to tinnitus
vices. Level 2 Audiologic Evaluation is performed management. Chapter 2 describes how our con-
solely by audiologists who: (a) conduct an audi- trolled clinical studies (and other influences) led
tory assessment; (b) facilitate management of any to the development of PTM. Chapter 3 provides an
Introduction xi

overview of PTM. The remaining chapters detail The workbook includes videos that model much of
the clinical procedures that are used for each of the what is taught during Level 3 Group Education, as
five levels of PTM. These details include numer- well as a CD that describes and demonstrates the
ous forms, questionnaires, clinical cheat-sheets, various uses of therapeutic sound.
and patient handoutsall of which are provided The second book (Progressive Tinnitus Manage-
as appendices. ment: Counseling Guide) is a patient counseling
The goal of intervention with PTM is for guide that is used by audiologists during Level 5
patients to learn how to develop and implement Individualized Support. The book lays flat between
individualized plans to manage their reactions to the clinician and patient, and is used like a flip
tinnitus. These plans involve the use of therapeutic charteach time a page is turned, the page facing
sound and coping techniques. Success in achiev- the clinician provides talking points while the
ing this goal depends largely on patients acquiring opposite page faces the patient and provides short
confidence in applying the self-management strat- bullet points plus graphics that illustrate the main
egies. Breaking the process of learning into small points. A second counseling guide is being devel-
achievable tasks helps to ensure that patients expe- oped for psychologists to implement the CBT com-
rience initial success. This approach is consistent ponents of PTM during Level 5.
with the self-efficacy theory. Research has demon- PTM has been developed to a high degree of
strated that self-efficacy is a good predictor of moti- specificity, but it is important to realize that the
vation and behavior. In general, the experience of methodology is considered a work in progress.
success increases self-efficacy whereas experienc- We are learning continually, from both patients and
ing failure reduces self-efficacy. This is a basic tenet clinicians, and the methodology is revised to be
of intervention with PTM. appropriately responsive to this feedback. Audiol-
Clinical implementation of PTM by audiolo- ogists are encouraged to modify the materials and
gists should involve the use of two additional books procedures as necessary to meet the needs of their
that were prepared to facilitate educating patients patients and their clinics.
in the self-management techniques. The first is a It is our sincere hope that this handbook will
self-help workbook (How to Manage Your Tinnitus: provide you with information that ultimately will
A Step-by-Step Guide) for patients that provides result in improved outcomes for your patients who
step-by-step procedures to learn how to develop need help learning how to manage their reactions
individualized plans for managing their reactions to tinnitus. We always welcome your comments
to tinnitusone using therapeutic sound and the and suggestions to continually improve on these
other using selected coping techniques from CBT. methods.

Development and publication of this book was n Will Murphy (Audiovisual Production
supported by the VA Rehabilitation Research and Specialist, Portland VA Medical Center)
Development (RR&D) Service, the NCRAR, and n Kimberly Owens, MPH (Clinical
VA Employee Education System. Numerous indi- Research Coordinator, Saint Thomas
viduals have contributed in various and significant Research Institute, Nashville, Tennessee)
ways toward this effort, including: n Martin Schechter, PhD (Audiologist,
Portland VA Medical Center)
n Daniel C. Garcia (Graphic Designer, Long n Emily Thielman, MS (Research Assistant,
Beach Employee Education Resource NCRAR, Portland, Oregon)
Center, Long Beach, California) n Dwayne Washington (Audiovisual
n Katie J. Fick, MS (Research Assistant, Production Specialist, Portland VA
James A. Haley Veterans Hospital, Medical Center)
Tampa, Florida) n John C. Whatley, PhD (Project Manager,
n Christine Kaelin, MBA (Clinical Research Birmingham Employee Education
Coordinator, NCRAR, Portland, Oregon) Resource Center, Birmingham, Alabama)
n Robert Kerns, PhD (National Program
Director for Pain Management, Veterans Also, thanks to Stephen Fausti, PhD and Sara Ruth
Health Administration, VA Connecticut Oliver, AuD for their continued support of tinnitus
Healthcare System, West Haven, Connecticut) research and clinical activities at the Portland VA
n David Lehman (Executive Producer, Salt Medical Center. Illustrations were done by Lynn
Lake City Employee Education Resource Kitagawa, MFA, Medical Media Service, VA Medi-
Center, Salt Lake City, Utah) cal Center, Portland, Oregon.
n Marcia Legro, PhD (Research
Psychologist, Seattle, Washington)
Authors and Contributors

James A. Henry, PhD Tara L. Zaugg, AuD

VA RR&D National Center for Rehabilitative VA RR&D National Center for Rehabilitative
Auditory Research (NCRAR) at the Portland Auditory Research at the Portland VA Medical
VA Medical Center, Center,
Portland, Oregon; Portland, Oregon
and Department of Otolaryngology,
Oregon Health and Science University, Special Contributions by:
Portland, Oregon
Marcia Legro, PhD (Chapter 2)
Caroline J. Kendall, PhD Kyle Dennis, PhD (Chapter 3)
VA Connecticut Healthcare System,
Dennis Trune, PhD (Chapter 4)
West Haven, Connecticut;
and Department of Psychiatry, Yale University, Elias Michaelides, MD (Chapter 5)
New Haven, Connecticut
Kathryn Sanders, PhD (Chapter 5)
Paula J. Myers, PhD Lynn Kitagawa, MFA (Illustrations)
VA Audiology Clinic, James A. Haley Veterans
Tampa, Florida
This book is dedicated to our nations military veterans. We thank you for serving our country.
You are the reason we enjoy freedom.

Definitions and Background

Tinnitus is a surprisingly complex subject. Numer ears. And, in fact, the word tinnitus is derived
ous books would be required to adequately cover the from the Latin word tinniere, which means to
current body of knowledge. The present handbook ring. Patients report many different soundsnot
focuses on describing procedures for providing just ringingwhen describing the sound of their
clinical services for tinnitus using the methodology tinnitus, as we discuss later in this chapter.
of progressive tinnitus management (PTM).
In this opening chapter we establish common
ground with respect to terminology and contextual Transient Ear Noise
information. Relevant definitions are provided, many
of which are operational due to lack of consensus It seems that almost everyone experiences tran
in the field. Additional background information sient ear noise, which typically is described as a
includes brief descriptions of epidemiologic data, sudden whistling sound accompanied by the per
patient data, and conditions related to reduced tol ception of hearing loss (Kiang, Moxon, & Levine,
erance (hypersensitivity) to sound. 1970). No systematic studies have been published
to date describing the prevalence and properties
of transient ear noise; thus, anything known about
this phenomenon is anecdotal.
Basic Concepts and Terminology
The transient auditory event is unilateral and
seems to occur completely at random without any
Tinnitus is the experience of perceiving sound that thing precipitating the sudden onset of symptoms.
is not produced by a source outside of the body. The Often the ear feels blocked during the episode. The
phantom auditory perception is generated some symptoms generally dissipate within a period of
where in the auditory pathways or in the head or about a minute. Although transient ear noise has
neck. Tinnitus often is referred to as ringing in the been described as brief spontaneous tinnitus
 Progressive Tinnitus Management: Clinical Handbook for Audiologists

(Dobie, 2004b), any reference to tinnitus in this book Somatic Tinnitus (Somatosound)
does not include this auditory phenomenon.
Somatic tinnitus (somatosound) has an origin that
usually is vascular, muscular, skeletal, respiratory,
Chronic Tinnitus or located in the temporomandibular joint (TMJ)
(J. A. Henry, Dennis, & Schechter, 2005). These body
Patients often confuse transient ear noise with sounds thus have an internal acoustic source
chronic tinnitus. What differentiates the two? It has (Dobie, 2004b). Theoretically, the acoustic signal
been suggested that tinnitus is ear noise that lasts associated with any somatosound could be detected
at least five minutes (Coles, 1984; A. C. Davis, 1995; and characterized if the proper sensing equipment
Hazell, 1995). Dauman and Tyler (1992) suggested were available for this purpose.
that the noise must last at least five minutes and
occur at least two times per week. These are rea
Somatosound Pulsatile Tinnitus
sonable criteria to define tinnitus, but superfluous
for the typical patient who experiences tinnitus all The most common type of somatosound is pulsatile
or most of the time. Nonetheless, a distinction must tinnitus (Lockwood, Burkard, & Salvi, 2004). Also
be made between transient ear noise and chronic referred to as venous hum or vascular noise, pulsa
tinnitus, and Dauman and Tylers criteria are suf tile tinnitus pulses in synchrony with the heartbeat
ficient for this purpose. (Sismanis, 2003). There are many potential sites
for pulsatile tinnitus, which often can be identi
fied by an experienced physician (Lockwood et al.,
Origin of Tinnitus: Somatic Versus 2004; Sismanis, 1998; Wackym & Friedland, 2004).
Neurophysiologic It is essential that these patients receive a medical
examination as pulsatile tinnitus might indicate a
By definition, the perception of tinnitus results from more serious medical problem (such as intracranial
activity in the auditory nervous system. The neural and carotid artery abnormalities) (Hazell, 1990;
activity that is perceived as tinnitus can be referred Sismanis, 2007). The condition is treatable in some
to as a tinnitus neural signal. As for most sounds patients (Sismanis, 1998).
that activate the auditory system, at any point in
time the tinnitus neural signal may or may not be Nonpulsatile Somatosounds
part of the conscious experience. Whenever tin
nitus is consciously perceived, the tinnitus neural Somatosounds also can be nonpulsatile, meaning that
signal is undergoing active processing by the audi they have a nonvascular source (typically muscular,
tory cortex (J. A. Henry, Trune, Robb, & Jastreboff, respiratory, or TMJ). Examples of nonvascular con
2007a). Although the final destination of the tin ditions that can cause somatosounds are muscular
nitus neural signal always is the auditory cortex, flutters or spasms and patulous eustachian tube.
the origin of tinnitus can be from either outside or
within the auditory nervous system (referred to as Symptoms of Somatosounds
somatic and neurophysiologic tinnitus, respectively)
(Hazell, 1998a). When evaluating a patient who complains of tinnitus,
If the tinnitus has a somatic origin, it can be it is essential to determine if the symptoms suggest
referred to as somatic tinnitus or somatosound(s). If a somatic origin. If so, then the possibility exists that
the tinnitus has a neurophysiologic origin, it can the tinnitus is amenable to medical management.
be referred to as neurophysiologic tinnitus or sensori Information about diagnosing somatic tinnitus is
neural tinnitus. The word tinnitus generally refers available in several publications (Hazell, 1990; Levine,
to neurophysiologic tinnitus because this is the 2004; Perry & Gantz, 2000; Schwaber, 2003; Wac
condition that is experienced by the great majority kym & Friedland, 2004). (Please see Chapters 4 and
of patients. 5 for further information about somatosounds.)
Definitions and Background 

Somatosounds Require Medical Evaluation cally oriented book. The interested reader has a
choice of myriad publications written on this topic
The presence of somatosounds always indicates the (e.g., Bauer, 2004; Eggermont & Roberts, 2004; P.
need for medical evaluation. The physician (usu J. Jastreboff, 1990; Kaltenbach, Zhang, & Finlay
ally an otolaryngologist or otologist) should have son, 2005; Kaltenbach, Zhang, & Zacharek, 2004;
expertise in the diagnosis and treatment of somatic Nuttall, Meikle, & Trune, 2004; Vernon & Mller,
tinnitus. If the physician cannot resolve the prob 1995).
lem with medical or surgical intervention, then the
audiologist should provide appropriate clinical
services, as described in later chapters. Neurophysiologic Tinnitus Is a Phantom
Auditory Perception

Phantom sensations such as phantom pain and

Neurophysiologic (Sensorineural) phantom limb have characteristics that are analo
Tinnitus gous to those of tinnitus (P. J. Jastreboff, 1990,
1995; Meikle, 1995; Mller, 2003). Tinnitus thus has
By far the majority of patients who complain of been referred to as a phantom auditory perception
tinnitus have neurophysiologic (or sensorineural) tin (P. J. Jastreboff, 1990). Pain and tinnitus are similar
nitus, that is, tinnitus that originates somewhere with respect to their physiology, assessment, and
within the auditory nervous system. Although there treatment (Mller, 1987, 2000). These analogous
is no known cure for neurophysiologic tinnitus, conditions also may have similar neuropathic gen
patients can learn to manage their reactions to tin erating mechanisms. Because of these similarities,
nitus, thereby improving quality of life. strategies of pain management can offer valuable
clues to the management of tinnitus. In fact, the
Origin of Neurophysiologic Tinnitus method of psychotherapy, cognitive-behavioral
therapy (CBT), has been shown to be effective in
All we can know for certain about the origin of treating chronic pain (P. H. Wilson, J. L. Henry, &
a patients sensorineural tinnitus is that it is gen Nicholas, 1993). The success of CBT for the treat
erated somewhere within the auditory nervous ment of pain led to the development of CBT for
system. The cochlea seems a likely site because tinnitus (J. L. Henry & P. H. Wilson, 2001).
damage to the cochlea from noise exposure and
other factors often results in tinnitus. However,
some desperate patients have undergone surgical
severing of cranial nerve VIII, which extends from Subjective Versus Objective Tinnitus
the cochlea to the brain, although it did not stop
their tinnitus (Fisch, 1970; House & Brackmann, Objective Tinnitus
1981; Pulec, 1984). This finding indicated that tin
nitus can be generated centrally. Evidence is accu By definition, objective tinnitus is tinnitus that is
mulating that supports the central generation of audible to the examiner (Dobie, 2004b). Objective
tinnitus (Mller, 2003). Cacace (2003) proposed that tinnitus is relatively rare and always is a somato
central networks of auditory system neurons may sound with an internal acoustic source (which as
be involved in generating and sustaining tinnitus, already discussed indicates an underlying condi
which would explain the persistence of tinnitus fol tion requiring a medical evaluation by an otolar
lowing auditory nerve transection. yngologist or otologist). Not all somatosounds
Understanding the pathophysiology of senso are detectable by the examiner, and thus not all
rineural tinnitus is a goal that is being pursued by somatosounds would meet the definition of objec
an ever increasing number of researchers. Many tive tinnitus. As a somatosound is an acoustically
theories have been proposed regarding tinnitus generated signal, the signal should be detectable
etiology, but are beyond the scope of this clini with proper measurement techniques.
 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Subjective Tinnitus tion, auditory hallucinations have been described

in conjunction with various diseases, injury, trauma,
Subjective tinnitus is perceived only by the patient. bereavement, sensory deprivation, religious expe
Any description of subjective tinnitus comes only riences, near-death experiences, and drugs (Nicol
from the patient, as there are no means to directly son et al., 2006). Auditory hallucinations also may
measure the intensity or other characteristics of the have nothing to do with the ability to hear, as
tinnitus. Tinnitus matching is performed to indirectly people born profoundly deaf can experience them
measure subjective tinnitus, (J. A. Henry, 2004; J. (du Feu & McKenna, 1999; Schonauer, Achtergarde,
A. Henry, Zaugg, & Schechter, 2005a). For the Gotthardt, & Folkerts, 1998).
remainder of this book, the word tinnitus generally Auditory hallucinations occur in 70 to 80%
refers to subjective tinnitus, that is, to neurophysi of patients with schizophrenia (Hugdahl et al.,
ologic or sensorineural tinnitus that does not have 2008). Auditory hallucinations normally ascribed
an internal acoustic source. When patients have to psychiatric illness can be perceived as voices,
somatosounds, behavioral methods can be applied cries, noises, or rarely, music (Wengel, Burke, &
to manage reactions to these sounds if medical Holemon, 1989, p. 163). Musical hallucinations,
management does not resolve the symptoms. however, are not necessarily associated with psy
chopathology, and tend to occur in people with
advancing age and marked hearing loss (Sacks,
Auditory Imagery, Auditory 2008). Bauman (2004) has distinguished two basic
Hallucinations, and Musical Hallucinations types of auditory hallucinationspsychiatric audi
tory hallucinations and nonpsychiatric auditory
Auditory imagery, auditory hallucinations, and hallucinations. People with mental illnesses often
musical hallucinations are different forms of phan experience the former, while people who are hard
tom auditory perceptions. There often is confusion of hearing often experience the latter (pp. 1718).
about how these different auditory perceptions dif Focusing on the latter, nonpsychiatric, type, Bau
fer from tinnitus. man makes the following points:

Auditory Imagery n Auditory hallucinations can consist of

music, sounds, or voices.
Auditory imagery is a normal phenomenon that n Unformed auditory hallucinations
occurs for all people. It generally refers to the imagi sound distorted and indistinct, whereas
nation of sound, such as repeating a phone number in formed auditory hallucinations sound
ones head, or recalling a musical passage (Kraemer, clear and recognizable.
Macrae, Green, & Kelley, 2005; Seal, Aleman, & n Auditory hallucinations typically are
McGuire, 2004). Auditory imaginations can be under experienced by hard of hearing, socially
conscious control, but they also can occur outside of isolated, elderly people who also have
conscious control. When not under conscious con tinnitus.
trol, auditory imaginations can be mildly distressing, n People who experience auditory
as when you have a song stuck in your head. hallucinations typically dont admit to the
Auditory Hallucinations n At least 10% of hard of hearing people
experience auditory hallucinations.
Auditory hallucinations have been estimated to occur n Many people actually find auditory
in 10 to 15% of the general population (Nicolson, hallucinations to be pleasant. Based
Mayberg, Pennell, & Nemeroff, 2006; Sommer et al., on this information, it is reasonable to
2008). Perhaps surprisingly, of those who experi expect some patients to report auditory
ence auditory hallucinations, most do not have a hallucinations that are not associated with
psychotic disorder. In the nonpsychiatric popula psychopathology.
Definitions and Background 

If a patient who reports auditory hallucina (see Chapter 5). Such tinnitus usually is temporary
tions remains unconvinced that the sounds do not (typically lasting 1 to 2 weeks postexposure), but
have an external acoustic source, then the experi can be permanent especially with the use of ami
ence may indicate presence of comorbid mental ill noglycoside antibiotics or the cancer chemothera
ness. In addition, the psychiatric population tends peutic drug cisplatin (Fausti, J. A. Henry, & Frey,
to experience auditory hallucinations as frequent, 1995; Rachel, Kaltenbach, & Janisse, 2002). Aspirin
intrusive, and distressing, whereas the nonpsy (containing salicylate) is well known to cause tem
chiatric population may experience them as more porary tinnitus, although the dosage generally has
positive and nonthreatening (Choong, Hunter, & to be rather high to induce tinnitus (Eggermont,
Woodruff, 2007). One study has reported data sug 2004; Puel & Guitton, 2007). Other medications that
gesting that auditory hallucinations that occur in can cause temporary tinnitus include NSAIDS, loop
nonpsychiatric individuals suggest a general sus diuretics, and quinine. Drugs used to treat mental
ceptibility to schizophrenia (Sommer et al., 2008). health and sleep conditions also may trigger or
Whenever auditory hallucinations are re- exacerbate tinnitus. Patients have reported exacer
ported, patients should be referred to both audiol bation of tinnitus due to alcohol and caffeine.
ogy and mental health for a thorough history and
to evaluate the auditory experiencesto determine
if the sounds are tinnitus or auditory hallucinations Onset of Tinnitus
and to determine if mental illness is involved.
The onset of tinnitus is described as gradual for some
and sudden for others (Axelsson & Barrenas, 1992).
Permanent Versus Temporary Tinnitus In a population study of older adults with tinni
tus, 55% reported a gradual onset, 24% reported a
Tinnitus can be a temporary or a permanent condition. sudden onset, and 21% did not know (Sindhusake,
Golding, et al., 2003). Uncertainty about the onset
Permanent Tinnitus of tinnitus can make it difficult to identify a precip
itating event. Indeed, as discussed further below,
It is, of course, impossible to determine if and when many patients are unable to identify anything that
a persons tinnitus becomes permanent. In general, was associated with the onset of their tinnitus.
the longer a person has experienced tinnitus the
more likely it is to be permanent. A general guide Recent-Onset Tinnitus
line is that tinnitus of at least 12 months duration
has a high likelihood of being a permanent con Some patients report that they have experienced
dition (Dobie, 2004b). However, it also has been tinnitus for only a short period of time, usually
suggested that a person must have experienced measured in weeks or up to a few months. For these
tinnitus for at least two years before it should be patients with recent-onset tinnitus, it first is impor
considered permanent (Vernon, 1996). tant to rule out vestibular schwannoma or any other
medical condition that might be causing the symp
Temporary Tinnitus toms (which is routine practice for audiologists). If
medical causes can be ruled out, an attempt should
Exposure to loud noise can cause temporary thresh be made to determine if psychological factors such
old shift as well as temporary tinnitus (Nuttall et al., as stress, anxiety, depression, or lifestyle changes
2004). Tinnitus induced in this fashion likely will might have triggered the tinnitus onset. Patients al-
resolve within a few days following the insult. ways should be questioned about any exposure to
Repeated episodes of noise exposure increase the loud noise. Identifying a potentially triggering event
likelihood that the tinnitus will become permanent. helps to focus the counseling most appropriately.
Tinnitus also can be induced by a number of Patients with recent-onset tinnitus are particu
medications and drug interactions (DiSorga, 2001) larly susceptible to acquiring fears or concerns that
 Progressive Tinnitus Management: Clinical Handbook for Audiologists

the internal sound indicates the presence of a seri

ous medical condition. These patients may be quite
Epidemiology of Tinnitus
anxious about the potential ramifications of the
auditory symptoms. It therefore is critical to pro Prevalence of Tinnitus
vide them with only positive and reassuring infor
mation to allay any fears. They should be counseled Prevalence estimates from numerous epidemiologic
that (a) their tinnitus may be a temporary condi studies indicate that about 10 to 15% of all adults
tion; (b) they should protect their ears in the pres experience tinnitus (H. J. Hoffman & Reed, 2004).
ence of damaging sound (or to avoid loud sounds The American Tinnitus Association (ATA) esti
entirely) to optimize the potential for spontaneous mates that 40 to 50 million Americans experience
resolution of the tinnitus; (c) tinnitus often raises tinnitus as a chronic condition and that of these,
concerns when it is new, but most people who have 10 to 12 million seek some form of medical help,
long-term tinnitus are not particularly bothered by and 2.5 million are debilitated by their tinnitus
it (Dobie, 2004b; Hallam, Rachman, & Hinchcliffe, (S. C. Brown, 1990). Men have a higher incidence
1984); and (d) if the tinnitus becomes bothersome of tinnitus than women, likely due to occupational
to feel welcome to contact or return to the clinic to and recreational differences (H. J. Hoffman & Reed,
discuss ways to manage their reactions to it. 2004; Meikle & Walsh, 1984).
Some patients may remain unconvinced that
the recent-onset tinnitus does not indicate a more
serious condition, even after thorough audiologic Causes of Tinnitus
and medical evaluations. These patients may need
to be referred to a mental health clinician for assess We often refer to causes of tinnitus (i.e., tinnitus
ment of comorbid psychological conditions. etiology), but in fact we never know the specific
cause of sensorineural tinnitus (J. A. Henry, Dennis,
Delayed-Onset Tinnitus et al., 2005). For example, we may say that noise
exposure caused a persons tinnitus. The noise prob
Delayed-onset tinnitus is thought to occur weeks, ably caused some cochlear damage, but it did not
months, or even years following some precipitat cause the tinnitus. Technically, instead of causes,
ing event (e.g., exposure to loud noise, traumatic we should use terminology that implies indirect
brain injury, treatment with ototoxic medications, causality, such as precipitating factors, events associ
etc.). It is not uncommon for patients to make a ated with tinnitus onset, tinnitus precursor events, and
claim of delayed-onset tinnitus for litigation pur tinnitus triggering events.
poses. The possibility of such a claim being valid
relates to the complex interaction among the pre Auditory Pathologies Associated with Tinnitus
sumed precursor event and more recent events that
might have triggered the tinnitus onset. Evaluating Numerous auditory pathologies have been associated
a claim of delayed-onset tinnitus requires taking with tinnitus. Sweetow (1996) has listed these with
a detailed history that covers all possible circum respect to conductive and sensorineural auditory
stances that might have caused damage to the pathologies (Table 11). It is important to realize that
auditory system. anything that can cause hearing loss also can trigger
A better understanding of the mechanisms of the onset of tinnitus (Coles, 1995; Dobie, 2004b).
tinnitus generation is needed before the existence
of delayed onset of tinnitus can be positively con
firmed or rejected (Humes, Joellenbeck, & Durch, Risk Factors
2006). However, it does seem likely that noise expo
sure or other experiences that could have caused A number of studies have obtained tinnitus epide
auditory damage can result in delayed-onset tin miology data in a systematic fashion. H. J. Hoff
nitus, even when the tinnitus onset occurs years man and Reed (2004) reviewed these studies and
after the event. summarized the various factors that were shown
Definitions and Background 

Table 11.Auditory Pathologies Associated With Tinnitus Table 12.Risk Factors for Tinnitus

Conductive Sensorineural Definite Risk Factors Possible Risk Factors

Impacted cerumen Endolymphatic hydrops Acoustic neuroma Alcohol

External otitis Perilymph fistulas Age Anxiety
Tympanic membrane perforations Noise damage Cardiovascular and Depression
cerebrovascular disease
Otitis media Vestibular schwannoma Familial inheritance
Drugs or medications
External auditory meatus tumors Presbycusis Geographic region
Ear infections/inflammation
Cholesteatoma Viral diseases Health statusfair/poor
Head/neck trauma and
Ossicular chain fixation or Bacterial infections Heavy weight or high body
discontinuity mass index
Ototoxicity Hyper- and hypothyroidism
Atresias Limited education
Meningionoma Loud noise exposure
Otosclerosis Low height
And so forth Mnires disease
Low socioeconomic status
Low weight or low body
And so forth
Presbycusis mass index
Source:Sweetow (1996).
Sudden deafness Rural residence
Smoking (cigarettes)
to be associated with tinnitus. Their summary is Source:Adapted from Epidemiology of Tinnitus, by H. J. Hoffman &
divided between definite and possible risk fac G. W. Reed, 2004, in Tinnitus: Theory and Management by J. B. Snow (Ed.),
(pp. 1641), Lewiston, NY: BC Decker Inc. Copyright 2004 BC Decker, Inc.
tors (Table 12). Thus, people are definitely or Adapted with permission.
possibly more likely to have tinnitus if these fac
tors apply. These epidemiology data reveal factors
that are correlated with the presence of tinnitus and currently, there is no consensus regarding tinnitus
thus are not necessarily causative agents. mechanisms. It is beyond the scope of this book
The most common risk factor for the onset of to go into detail regarding possible mechanisms
sensorineural tinnitus is noise exposure (Axelsson of tinnitus generation. The interested reader is
& Barrenas, 1992; Penner & Bilger, 1995). Also, a advised to review numerous excellent publications
direct correlation exists between degree of hear on this topic (e.g., Baguley, 2002; Eggermont, 2000;
ing loss and prevalence of tinnitus the odds of Kaltenbach, 2000; Mller, 2003; Tyler, 2006; Ver
having tinnitus increase as hearing loss increases non & Mller, 1995). Because everything we hear
(Coles, 2000). This is true regardless of the type or (including tinnitus) results from neural activity in
the cause of the hearing loss. Dobie (2004b) con the auditory nervous system, tinnitus-mechanisms
cluded that tinnitus tends to occur more frequently research has focused on understanding abnormal
in men, the elderly, blue-collar workers, and people neural activity that is associated with tinnitus. Most
with certain health problems. theories involve hair cells, the auditory nerve, and
the central auditory nervous system (J. A. Henry,
Dennis, et al., 2005). A few examples of proposed
mechanisms include (there are many others):
Pathophysiology of Tinnitus
n Hair cells: discordant function between
Many researchers are attempting to discover the inner and outer hair cells (Jastreboff,
pathophysiologic basis of tinnitus, with the ulti 1990); damaged outer hair cells causing
mate goal of finding a cure for tinnitus. Numer excessive release of neurotransmitter
ous theories and models have been proposed; (glutamate) from inner hair cells
 Progressive Tinnitus Management: Clinical Handbook for Audiologists

producing sustained cochlear activity n Tinnitus onset is reported as gradual or

(Patuzzi, 2002). sudden about equally.
n Auditory nerve: synchronization of n Left-sided tinnitus is reported more often
spontaneous activity in auditory nerve than right-sided tinnitus.
fibers due to cross-talk (Eggermont, n More than half of the patients describe
1990; Mller, 1984, 1995); cortical their tinnitus as a single sound (most
reorganization following changes in of the remainder identify two or more
the auditory periphery resulting in a sounds).
disproportionately large number of n Most patients describe their tinnitus
neurons becoming sensitive (tuned) to as ringing or clear tone (3% report
frequencies at upper and lower borders hum, clicking, roaring, or pulse).
representing peripheral hearing loss n 85% of patients indicated that their
(Salvi, Lockwood, & Burkard, 2000). perceived tinnitus loudness was a 5 or
n Central auditory nervous system: more on a 0 to 10 loudness-rating scale
Increased spontaneous activity in the (10 = very loud).
dorsal cochlear nucleus (Brozoski, Bauer,
& Caspary, 2002; Kaltenbach & Afman,
2000; Kaltenbach et al., 2002; Zacharek, Factors Associated with Tinnitus Onset
Kaltenbach, Mathog, & Zhang, 2002).
When OHSU Tinnitus Clinic patients were asked to
describe the circumstances of their tinnitus onset,
43% indicated that no known events were associ
Data from Tinnitus
ated. Most of the remainder reported that one fac
Clinic Patients
tor was associated with their tinnitus onset (8%
reported more than one factor).
Tinnitus Data Archive For those patients describing factors associ
ated with their tinnitus onset, the factors could be
The Oregon Health and Science University (OHSU) placed into one of four broad categories (Meikle
Tinnitus Clinic was started in 1975 (Vernon & et al., 2004): (1) noise-related; (2) head and neck
Schleuning, 1978). Extensive data from thousands trauma; (3) head and neck illness; and (4) other
of patients have been collected, and these data have medical conditions.
been used to develop the Tinnitus Data Archive
(Meikle, Creedon, & Griest, 2004) (http://www The summarized data in the Years Aware of Tinnitus
Archive were collected from 1,630 patients seeking
clinical intervention for their tinnitus and are not OHSU Tinnitus Clinic patients are asked how long
generalizable to individuals with tinnitus who do they have been aware of experiencing tinnitus.
not seek intervention. From the Tinnitus Data Archive (Meikle et al., 2004),
40% of patients had experienced their tinnitus
for 2 years or less; 55% for 5 years or less; 70% for
Main Findings of the Tinnitus Data Archive 10 years or less; and 85% for 20 years or less.

Some of the main findings of the Tinnitus Data

Archive include (J. A. Henry, Dennis, et al., 2005): Types of Sounds Patients Hear

n There are about 2 times more male than Patients are asked to describe what their tinnitus
female patients. sounds like from a list of sounds commonly reported
n 80% of all patients are at least 40 years by patients, or by describing a sound that is not on
of age. the list. The most common sound reported by far
Definitions and Background 

is ringing. The second most common sound is dition of pure hyperacusis causes physical dis
hissing. The third most common sound is clear comfort, but no emotional responses are involved.
tone. Numerous additional sounds are reported, For a given patient with pure hyperacusis, sound
including high-tension wire, buzzing, trans would be uncomfortably loud at levels most peo
former noise, sizzling, crickets, whistle, hum, ple find comfortable regardless of the type of sound.
and clicking. This means that a patient who reports that he or
she can tolerate some sounds at louder levels than
other sounds is probably not experiencing pure
Intermittency of Tinnitus hyperacusis.

From the Tinnitus Data Archive, 91% of patients

reported that their tinnitus is a constant sound. In 5% Misophonia
of patients, tinnitus is intermittent and heard more
than 50% of the time. In 1% of patients, tinnitus is M. M. Jastreboff and P. J. Jastreboff (2002) intro
intermittent and heard less than 50% of the time. duced the term misophonia. The term means dislike
of sound, and implies that there is an emotional
reaction to sound. A misophonic reaction is a learned
response. This means that a misophonic patient
Reduced Tolerance
might report that a particular sound is problem
(Hypersensitivity) to Sound
atic in some situations, but not in others. When
questioned in detail, these patients often report
Hyperacusis often is reported concurrently with reactions that would be inconsistent with pure
tinnitus, and audiologists need to know how to hyperacusis. For example, they might report that
recognize hyperacusis and how to provide appro certain unpleasant sounds become uncomfort
priate intervention if it is a significant condition. ably loud at levels below which pleasant sounds
There is no consensual definition of hyperacusis are tolerated comfortably.
(P. J. Jastreboff & M. M. Jastreboff, 2004; Vernon,
2002). It has been defined as the collapse of loud
ness tolerance so that almost all sounds produce Phonophobia
loudness discomfort (Vernon & Press, 1998). At
the other extreme, clinics have reported that up to P. J. and M. M. Jastreboff (2000) defined use of the
half of their patients experience decreased loud term phonophobia for clinical application. Phono
ness tolerance (Coles, 1996; Gold, Frederick, & phobia is a fear response caused by sound, and is
Formby, 1999; Hazell, 1999; P. J. Jastreboff, 2000). considered a subcategory of misophonia. Miso
When evaluating the patient, the critical factor is phonia can cause any kind of negative emotional
to determine if loudness sensitivity is a significant response, but phonophobia specifically causes a
problem in the patients life. fear reaction. A defining feature of phonophobia
Our definitions of conditions pertaining to is the anticipation that sound will be uncomfort
decreased loudness tolerance are consistent with ably loud. Thus, phonophobia refers to a persons
those published by J. A. Henry, Zaugg, and Schech state of mind with respect to sounds and sound
ter (2005a), which were adapted from P. J. Jastreboff environments.
and Hazell (2004).

Loudness Recruitment
Loudness recruitment often is confused with hyper
Hyperacusis is a physical condition of discomfort acusis (Vernon, 2002). Recruitment refers to abnor
or pain caused by sound. The effect is restricted mally rapid growth in the perception of loudness
primarily to the auditory pathways. Thus, a con (Vernon, 1976). It usually is a phenomenon of cochlear
10 Progressive Tinnitus Management: Clinical Handbook for Audiologists

or sensorineural hearing loss. Recruitment gener is a severe problem for the patient. If so, then
ally is associated with reduced auditory thresholds the patient should receive special treatment that
and normal loudness discomfort levels (Figure 11). focuses on the condition. If the condition is a mild
Thus, the dynamic range is compressed, but there or moderate problem, then the patient needs to be
is normal tolerance to louder sounds. educated about the sensitizing effects of using hear
ing protection, and the desensitizing effects of using
therapeutic sound (Formby & Gold, 2002). Nor
Treatment for Conditions of Reduced mally, the use of sound that is advocated for tinni
Sound Tolerance tus management will indirectly provide adequate
treatment for reduced sound tolerance in mild and
In Chapter 6, we describe methodology for the moderate cases. Consultation with a mental health
treatment of reduced sound tolerance. The over provider might be useful if a patient fears sound
all approach is to first determine if the condition and/or has other intense fears.

Frequency (kHz) Frequency (kHz)

0.25 0.5 1 2 4 8 0.25 0.5 1 2 4 8
0 0
10 10
20 20
30 30
40 40


50 50
Thresholds Thresholds
60 60
70 70 LDLs
80 80
90 90
100 LDLs 100
Figure 11.Tolerance to sound can be estimated by obtaining loudness discomfort levels (LDLs), which indicate the
threshold level at which sound becomes uncomfortably loud. A. LDLs at and above about 100 dB HL are in the normal
range. Note that the hearing sensitivity is reduced in the higher frequencies, resulting in a compressed dynamic range
at those frequenciesand loudness recruitment. However, the LDLs at 100 dB HL reflect normal tolerance to louder
sounds. B. LDLs are reduced to 70 dB HL, indicating a condition of reduced loudness tolerance. From Tinnitus Retraining
Therapy: Patient Counseling Guide (p. 168), by J. A. Henry, D. R. Trune, M. J. A. Robb, & P. J. Jastreboff, 2007, San Diego, CA:
Plural Publishing, Inc. Copyright 2007 by Plural Publishing. Reprinted with permission.

Research Leading to PTM

In 2005, audiologic tinnitus management (ATM) PTM came from clinical experiences with patients
was published as a comprehensive protocol for the and from consultation with experts from different
management of tinnitus by audiologists (J. A. Henry, disciplines whose insights in particular shaped
Zaugg, & Schechter, 2005a, 2005b). ATM was modi- the PTM patient education. PTM is designed to
fied and expanded upon to create five hierarchical address the needs of all patients who complain
levels of clinical management, at which point the about tinnitus while having minimal impact on
name was changed to progressive ATM (PATM) clinical resources.
(J. A. Henry, Zaugg, Myers, & Schechter, 2008a, Prospective, controlled clinical studies are
2008b). PATM now is under revision to incorporate essential to evaluate and document the efficacy of
components of cognitive-behavioral therapy (CBT) tinnitus interventions. We have completed three
to address psychological aspects of tinnitus (J. A. studies and two are underwayboth of which
Henry, Zaugg, Myers, Kendall, & Turbin, 2009). As involve PTM. Conducting these studies required
PATM is evolving to become inherently interdisci- the development of highly specified protocols to
plinary, use of the word audiologic to describe ensure consistent performance of the various inter-
the protocol no longer is appropriate. For that rea- ventions. In addition, procedures were developed
son, the name was shortened to progressive tinni- to efficiently screen and evaluate candidates to
tus management (PTM). determine if they met study inclusion criteria,
The need for a progressive approach to tinni- which differed for each study. Conducting these
tus management became apparent as a result of studies not only provided efficacy data, but also
conducting our series of controlled clinical studies. identified procedures that were most efficient for
The PTM methodology evolved largely as a result clinical application. Each of these studies and the
of these experiences. Additional influences for insights gained from them are described below.
12 Progressive Tinnitus Management: Clinical Handbook for Audiologists

of individuals with severely bothersome tinnitus.

First Study Both methods utilize broadband noise as therapeu-
tic sound, but the application and purpose of the
Our first study evaluated the relative efficacies sound differ substantially between methods (J. A.
of tinnitus masking (TM) and tinnitus retraining Henry, Schechter, Nagler, & Fausti, 2002). With TM,
therapy (TRT) (J. A. Henry, Schechter, et al., 2006a, sound is used to achieve an immediate sense of
2006b). For the study protocol, each of these meth- relief. Immediate relief is irrelevant with TRT
ods involved the use of ear-level devices (hearing because the objective of TRT is to create contrast
aids, noise generators, combination instruments) reduction between tinnitus and the acoustic envi-
and intervention appointments at 0, 3, 6, 12, and 18 ronment to promote habituation (P. J. Jastreboff,
months. Only persons with very problematic tinni- 2004). Our study provided evidence that these dif-
tus would warrant such rigorous, long-term clinical ferent clinical objectives largely were achieved for
procedures. Therefore, it was necessary to carefully the two methods. Thus, a major lesson learned
evaluate study candidates to determine their eligi- from this study was that sound can be used in dif-
bility for receiving one of the interventions. ferent ways to accomplish different therapeutic
Advertising resulted in about 800 callers who objectives. The use of therapeutic sound with PTM
expressed interest in participating. This level of expands on this concept to provide patients with
response greatly exceeded our capacity to conduct an understanding of many different ways that
a full clinical evaluation of each candidate. We sound can be used for tinnitus management. By
therefore devised a three-stage screening protocol. understanding these different strategies for using
For stage 1, a brief series of questions were admin- sound, patients learn to use sound in a targeted
istered to callers to establish that they experienced manner to address any situation in which tinnitus
chronic tinnitus and that the tinnitus was so prob- is problematic.
lematic that 18 months of intervention seemed With PTM, the basic strategies of using
justified. If so, they were invited for a hearing and therapeutic sound with TM and TRT have been
tinnitus assessment (stage 2). Of the 800 callers, 171 retained. However, the terminology and descrip-
(21%) received the stage 2 assessment. Following tions used with patients have been changed. These
the assessment, those who qualified met with one changes were designed to simplify the concepts for
of the tinnitus specialists (stage 3) to discuss results patientsto avoid misconceptions (such as think-
and to ensure a full understanding of all study ing that the purpose of masking is to make the
requirements. Of the 171 who received the stage 3 tinnitus inaudible) and to reduce confusion (such
assessment, 123 qualified and agreed to participate as trying to understand how specifically to achieve
representing only 15% of the original 800 callers. the mixing point with TRT). With PTM, use of
Study outcomes were based on the Tinnitus sound to provide immediate relief is referred to
Handicap Inventory (THI) (C. W. Newman, Jacob- as soothing sound. Soothing sound can be used
son, & Spitzer, 1996; C. W. Newman, Sandridge, & whenever patients wish to reduce stress or tension
Jacobson, 1998). Overall, both TM and TRT cohorts associated with tinnitus. Using sound to create
showed significant improvement on the THI, with contrast reduction is referred to as background
TRT providing greater benefit at 12 and 18 months sound. Patients are advised to use background at
(J. A. Henry, Schechter, et al., 2006a, 2006b). all times as a passive-listening strategy to pay less
attention to their tinnitus. Patients receiving PTM
education learn to distinguish between the differ-
Lessons Learned from First Study ent applications of sound and to select different
applications to accomplish different purposes.
The first study showed that both TM and TRT, For any clinical trial, it is necessary to determine
when conducted in a tightly controlled manner, if a candidates condition warrants the intervention
could provide significant benefit to a large majority being offered. Our unexpectedly high volume of
Research Leading to PTM 13

callers made it immediately evident that method- Lessons Learned from Second Study
ology was needed to provide efficient screening
of individuals who claim to have a problem with This study tested the effectiveness of a unique
tinnitus. In Chapter 3 we discuss how the large protocol of group education for tinnitus. Impor-
majority of people who experience tinnitus are not tantly, although participants did not receive an
bothered by it. Many individuals with nonbother- audiologic evaluation, 93% of the participants
some tinnitus, however, respond to announcements responded sometimes, usually, or always in
about tinnitus trialseven if the announcement response to the questionnaire item Do you expe-
states clearly that the study is for persons who are rience hearing difficulty? In response to another
bothered by tinnitus. We needed methodology to item (Does your tinnitus make it more difficult
query these callers to quickly assess the nature and for you to hear?), 83% responded sometimes,
severity of their tinnitus. It was particularly impor- usually, or always (an additional 8% were
tant to determine if a callers complaint was due unsure). In Chapters 3 and 5 we discuss the con-
more to a hearing problem than to the tinnitus itself cern that many patients who complain about tin-
(J. A. Henry, Zaugg, et al., 2005a; Zaugg, Schechter, nitus mostly are bothered by hearing difficulties.
Fausti, & J. A. Henry, 2002). We have since devel- Thus, when patients seek services for their tinni-
oped and refined screening techniques to differ- tus they may really need a hearing assessment and
entiate hearing problems from tinnitus problems. possibly hearing aids. Not addressing these partici-
Most importantly, we developed the Tinnitus and pants audiologic needs undoubtedly reduced the
Hearing Survey that now is the essential tool used effectiveness of the group education. This insight
with PTM for this purpose (see Chapter 5). confirmed the need to conduct a hearing evalu-
ation and fit hearing aids if necessary as the first
stage of management for tinnitus. For this reason,
the Level 2 Audiologic Evaluation is the first stage
Second Study
of management with PTM, and includes a hearing
evaluation and questionnaires to differentiate hear-
The purpose of our second study was to deter- ing problems from tinnitus-specific problems.
mine the potential benefit of group education as The benefit observed for the education group
intervention for bothersome tinnitus (J. A. Henry, was sustained for 12 months, contrasting with
Loovis, et al., 2007). The educational curriculum results from a similar trial (J. L. Henry & P. H. Wil-
was an adaptation of the structured TRT counsel- son, 1996). In that trial, significant improvement
ing protocol. Participants attended four weekly was observed on the Tinnitus Reaction Question-
1.5-hour classes. Two control groups consisted of naire for the education group immediately fol-
a tinnitus support group and a no-intervention lowing the intervention, but which dissipated by
group. The support group, also involving four 12 months. A major difference between the two
weekly 1.5-hour meetings, was led by a facilitator education groups was that in our study the educa-
who encouraged positive discussion about tinnitus tion group received focused instruction on using
but did not provide education. Veterans with both- constant low-level background sound to facilitate
ersome tinnitus (n = 269) were randomized into habituation to tinnitus. It may be conjectured that
one of the three groups. Outcomes were assessed at the participants applied this information, thus
baseline and at 1, 6, and 12 months. Overall results facilitating the sustained benefit. Using constant
revealed that group education provided significant background sound is a major instructional point
improvement on the Tinnitus Severity Index (R. M. with the PTM education and counseling.
Johnson, 1998) from baseline through 12 months Of the approximately 750 callers who were
(p<.001). Neither of the control groups showed sig- screened, 269 (36%) were enrolled. Thus, although
nificant improvement from baseline to any of the all participants were offered the four education
follow-up time points. classes (those in the control groups could attend
14 Progressive Tinnitus Management: Clinical Handbook for Audiologists

the classes after completing the study), 64% of the ment (based on mean index scores from the Tinnitus
callers declined the opportunity to receive the edu- Handicap Inventory), with no significant differences
cation. Most callers indicated that their tinnitus between groups (publication in preparation).
was not enough of a problem to warrant attending
the classes. This again speaks to the need to pro-
vide a hierarchy of clinical services so as to tailor Lessons Learned from Third Study
services to the individual and to avoid providing
more services than are necessary. It was unexpected that the control group had
Additional insights gained from this study outcomes comparable to TM and TRT. Although
include: (a) a typical noneducational tinnitus sup- intended as a nonspecific-therapy control group,
port group does not seem to benefit the participants the counseling developed for this group was effec-
(thus, any group meetings for patients should tive and subsequently published as part of the
include an appropriate educational component); method referred to as audiologic tinnitus manage-
and (b) individuals who are bothered by tinnitus ment (ATM) (J. A. Henry, Zaugg, et al., 2005b). The
but do not receive clinical services seem to stay at ATM counseling focused on how to use sound and
the same level with regard to how they are affected sound-delivery devices to reduce the impact of tin-
by their tinnitus (the fact that they dont seem to nitus, which was the precursor to the counseling
improve over a period of a year suggests that these we have since developed for PTM. For PTM, these
individuals should receive clinical services). Most basic concepts have been refined and organized
importantly, this study showed clear benefit of pro- into a systematic description of the different ways
viding education in a group setting, which led to that sound can be used to manage tinnitus. Thus,
the development of PTM Level 3 Group Education an insight from the third study was that a single
(J. A. Henry, Zaugg, Myers, Kendall, et al., 2009). approach to using sound may be too restrictive for
addressing all of the different situations when tinni-
tus is problematic for patients. With PTM, patients
are instructed in depth about the different uses of
Third Study
therapeutic sound to empower them to determine
on their own how to use sound in a specific manner
The first study evaluated the methods of TM and whenever their tinnitus is bothersome (J. A. Henry,
TRT to determine their efficacy for veterans who Zaugg, Myers, Kendall, et al., 2009).
are severely bothered by tinnitus. Benefit was evi- As a result of developing the generic coun-
dent, but each method was conducted by an expert seling for the control group, we devised a third
in the respective intervention. This third study was strategy for using therapeutic sound (in addi-
designed to determine if audiologists who are not tion to using soothing sound and background
tinnitus experts can provide effective intervention sound as described under Lessons Learned from
with TM and TRT. The study was conducted at four First Study above). The third strategy was to use
VA hospitals (Bay Pines, Florida; Portland, Oregon; sound for attention diversion, by listening to any-
San Diego, California; and Seattle, Washington). At thing that would engage the mind for a sustained
each site, 3638 veterans with clinically significant period. For PTM, this third strategy is referred to
tinnitus (total n=148) were recruited and ran- as using interesting sound with the purpose of
domized to TRT, TM, or a control group that re- focusing conscious attention away from the tin-
ceived generic tinnitus counseling (i.e., nothing spe- nitus and onto the target sound. Furthermore, the
cific to TM or TRT) and hearing aids (if needed). counseling created for the control group led to our
Participants in all three groups received an initial development of numerous concepts, techniques,
evaluation and attended counseling appointments and tools for using therapeutic sound that now are
at 0, 3, 6, 12, and 18 months. Analyses revealed that described in the PTM self-help workbook and as
each of the three groups showed significant improve- part of the PTM educational counseling.
Research Leading to PTM 15

As for the first study, this third study required

participants who were so bothered by their tinni-
Fourth Study
tus that rigorous, long-term intervention was war-
ranted. Screening methods that we developed as a The fourth study currently is nearing completion
result of the first and second studies were used with at the James A. Haley Veterans Hospital in Tampa,
the third study to ensure that only qualified veter- Florida. This study was designed to develop PTM
ans were enrolled from the 505 candidates. Prior to and to evaluate its clinical efficacy in a pilot study to
completing all of the appointments, however, many compare it to usual care. Usual care (UC) involves
participants realized that the intervention they had services that are typical of what is provided at VA
received was sufficient and that no further services audiology clinics, that is, an audiologic examina-
were needed (30% of the participants dropped out tion, hearing aids if needed, and some minimal
of the studymost for this reason). Although it counseling specific to tinnitus. For this study, UC
was gratifying to observe early therapeutic success, participants can receive ear-level noise generators
it was clear that a progressive approach was needed or combination instruments if deemed necessary
to provide services only to the degree necessary to by the audiologist.
meet individual needs. This progressive approach Development of the PTM implementation
is a hallmark concept for PTMpatients undergo a materials was a substantial undertaking requir-
series of short-term clinical interventions that can, ing two years of continuous effort. Insights gained
if necessary, lead to Level 5 Individualized Support. from our previous trials were applied to the PTM
A comprehensive tinnitus assessment protocol protocol. Five hierarchical levels of PTM were
was developed for use with all participants in this defined and detailed clinical procedures were
study. The protocol was published as one of the two developed for each level. A new counseling proto-
ATM companion articles (J. A. Henry, Zaugg, et al., col was developed that incorporated principles of
2005a), and included: (a) a structured interview to patient education and health literacy to ensure that
identify problematic aspects of tinnitus; (b) a tin- the materials were accessible to as many patients as
nitus psychoacoustic assessment; and (c) in-clinic possible (J. A. Henry, Zaugg, Myers, Kendall, et al.,
trials to determine the potential benefit of ear-level 2009). An online, 18-module training course was
noise generators and combination instruments. The developed for audiologists and numerous materi-
protocol has since been refined for the PTM Level als were developed for audiologists and patients.
4 Interdisciplinary Evaluation, and some compo- Major educational materials were developed to
nents have been adapted for use during the Level 2 implement the protocol at the different levels.
Audiologic Evaluation (J. A. Henry et al., 2008b). As of November 2009, 221 clinical patients
Conducting this study required training 12 were enrolled by telephone in this study109
audiologists at four VA hospitals. The training was were randomized to UC and 112 to PTM. Of these
provided via the VA videoconferencing (V-Tel) 221 patients, 21 who were randomized to UC, and
system. Each study audiologist received about six 26 randomized to PTM, were excluded from study
hours of V-Tel training supplemented by a proce- participation because they did not show up, called
dures manual. This training likely was inadequate to be removed, or had a diagnosed psychotic dis-
for audiologists to perform methodology that nor- order, dementia, or serious health concern. After
mally requires much more training and consider- excluding these 47 patients, 86 PTM patients and
able experience to attain a high level of proficiency. 88 UC patients attended an initial appointment
It was evident that any future tinnitus trials would and completed questionnaires. Of the 86 PTM
require much more intensive training. For our patients, 23 attended at least one of the Level 3
pilot PTM study (described immediately below), Group Education sessions. Following Level 3, four
we developed an extensive online training course patients attended a Level 4 evaluation. Only one
as well as numerous clinical tools to facilitate all PTM patient felt it was necessary to receive Level
aspects of implementing the protocol. 5 Individualized Support. Of the 88 UC patients,
16 Progressive Tinnitus Management: Clinical Handbook for Audiologists

36 attended only the evaluation appointment and Conference Calls Held with PTM Audiologists
52 attended a second appointment to receive hear-
ing aids. As the study is still in progress, analyses During these calls with clinicians and the study
of outcomes are not yet possible to determine how team, semistructured discussions addressed the
well patients do at the different levels of PTM. acceptance and general satisfaction with the proto-
col as well as any difficulties performing each level
of PTM care. Notes from these calls were compiled
Lessons Learned from Fourth Study and reviewed to identify any barriers or facilitators
to the management of tinnitus using PTM. We are
A major goal of this project was to learn about the adapting the program to be responsive to the feed-
process of putting the PTM protocol into clinical back received from these calls.
practice. To do so we conducted several formative
evaluations. (A formative evaluation is a rigorous Clinical Implementation of PTM
assessment process designed to identify potential
and actual influences on the progress and effec- By collecting formative data during the implemen-
tiveness of implementation efforts [Stetler et al., tation of PTM in the Tampa VA Audiology Clinic,
2006].) The results have been applied to our current we learned that preplanning for some of the activi-
research with PTM. ties could improve the implementation process. For
example, prior to starting the program, adminis-
Online Course for Clinicians trators should know that (a) the PTM audiologists
will require release time to complete the Web-
An early, central element of implementing the PTM course; (b) the audiologists will be working with
protocol is clinician education via an online course. psychologists, which will require preplanning with
The Chief of Audiology at the Tampa VA hospital the psychology section of the hospital; (c) patients
made time available for each clinician to complete being seen for tinnitus will need hearing evalua-
the 18-module course. All study audiologists com- tions and may need ear-level devices; and (d) the
pleted the course and responded to embedded PTM protocol necessitates access by audiologists to
questions. These responses were compiled and a meeting room for the Level 3 workshops. We also
analyzed to identify how to improve the course. recommend holding regular calls or meetings with
The online course currently is being revised audiologists who are beginning to use the protocol
and updated, and we are working with VA Employee to address barriers that may arise as they put PTM
Education System to make the course available into practice. Valuable information can be identi-
via the VA Learning Management System (LMS). fied and acted on to improve fidelity to protocol.
This course should become available for use by VA Patients in this pilot study were all veterans
audiologists shortly after the publication of this at the Tampa VA hospital who complained of both-
handbook. We also will attempt to make the course ersome tinnitus. As all of the patients in the PTM
available to non-VA audiologists. cohort were offered tinnitus services beyond Level
When the online course becomes functional, an 2 Audiologic Evaluation, it is clear that the majority
additional need will be to develop a program that of these patients either chose not to receive higher-
simulates a clinical practicum for audiologists who level services or it was too difficult for them to
have received the PTM training. To address this attend the additional visits that were required to
need, future plans include development of a vir- participate in the Level 3 workshops. We will look
tual clinic to computer-simulate patients receiving carefully at the data to determine if patients percep-
clinical services with PTM. The program will depict tions of adequate care following Level 2 are accu-
patients with a variety of clinical presentations and rate. We now are more strongly advising patients to
clinicians will be challenged to make appropriate attend Level3 Group Education to ensure that each
decisions to provide optimal care. patient who is bothered by tinnitus receives the edu-
Research Leading to PTM 17

cation that is essential to learn basic self-manage- format similar to Level 5 Individualized Support
ment skills. We also provided patients in the PTM (J. A. Henry, Zaugg, Myers, Kendall, et al., 2009).
cohort the self-help workbook at the end of Level 2. Telephone appointments alternate between the
We now are recommending that the workbook not psychologist and audiologist for 6 months (total of
be provided to patients until they attend their first seven appointments).
Level 3 workshop (see Chapters 3 and 5). As of November 2009, 172 individuals called
Finally, only a few patients in the PTM cohort about the study. Of these, 36 participants were
required services beyond Level 3. With the addition enrolled, including 15 in the probable-mild TBI
of CBT to the Level 3 protocol, the effectiveness of group, 10 in the moderate/severe TBI group, and 11
the Level 3 workshops is expected to be substan- in the no-TBI group. Twelve-week outcome data are
tially improved, which should ensure that very few available for 23 participants, and 24-week outcome
patients will require Level 4 and 5 services. data are available for 16 participants. Preliminary
results of the primary outcomes can be summarized
as follows. On average, participants lowered their
Baseline THI scores by 13.6 points at the 12-week
Fifth Study
evaluation, and by 21.7 points at 24 weeks. Because
outcome data are incomplete, and because of the
This is an observational pilot study currently being small numbers of participants, these data cannot
conducted to assess an adaptation of the PTM yet be subjected to statistical comparisons.
methodology for use with veterans and active mili-
tary who have experienced traumatic brain injury
(TBI) and also have bothersome tinnitus. As these Lessons Learned from Fifth Study
individuals are located all over the country, we
developed a home-based telehealth method. The This project responds to the need to provide special
procedures are conducted over the telephone, and clinical services for veterans and military person-
intervention materials and questionnaires are deliv- nel who have experienced TBI and also suffer from
ered via the mail/FedEx. The study includes three bothersome tinnitus. Because of the complications
cohorts (all with bothersome tinnitus): (a) probable of TBI, it was necessary to include a neuropsycholo-
mild TBI history; (b) moderate or severe TBI; and gist with expertise in TBI and a clinical psychologist
(c) no TBI. with expertise in tinnitus management to assist in
Interested callers are screened for tinnitus the design and implementation of the trial. These
severity and probable TBI history. Callers who pass collaborators have made the necessary revisions
screening are sent the self-help workbook (2nd to the PTM protocol so that it is appropriate for
edition prepared specifically for this study) along telephone-based administration to TBI patients.
with baseline questionnaires and the informed con- For example, the participants undergo a cognitive
sent form. The research coordinator then conducts screen to determine their abilities to comprehend
informed consent, assesses capacity (cognitive the counseling information and to follow through
ability) for candidates to provide informed consent, with the management recommendations.
and enrolls eligible candidates. Participants attend Prior to the design and development of this
a telephone appointment with the study psycholo- study, it was obvious that psychological concerns
gist who conducts brief cognitive screening and were not adequately addressed by the PTM counsel-
teaches coping techniques for managing reactions ing. This was a shortcoming that is being addressed
to tinnitus based on CBT (J. L. Henry & P. H. Wil- for the first time using the PTM protocol in this
son, 2001). The next appointment is with the study pilot study. The PTM protocol thus is evolving to
audiologist who provides the PTM audiologic/ include counseling that covers all aspects of using
sound-based counseling that normally is provided therapeutic sound as well as addressing psycho-
at Level 3 Group Education, but in a one-on-one logical components of tinnitus. Several researchers
18 Progressive Tinnitus Management: Clinical Handbook for Audiologists

have conducted clinical trials that support CBT as (Bartnik, Fabijanska, & Rogowski, 2001; Berry, Gold,
an effective psychological method for managing Frederick, Gray, & Staecker, 2002; Herraiz, Hernan-
tinnitus (Martinez Devesa, Waddell, Perera, & The- dez, Plaza, & de los Santos, 2005; Herraiz, Hernandez,
odoulou, 2007). Thus, CBT was incorporated into Toledano, & Aparicio, 2007); and (d) neuromonics
the PTM method. The components of CBT that are tinnitus treatment (P. B. Davis, Paki, & Hanley,
being used include training in behavioral modifica- 2007). Our first clinical study (see First Study above)
tion (stress management via relaxation techniques demonstrated that all types of ear-level devices
and scheduling pleasant activities), as well as cog- (hearing aids, sound generators, and combination
nitive restructuring (step-by-step examination of instruments) could be used effectively with both
changing thoughts to acquire a more positive atti- TM and TRT (J. A. Henry, Schechter, et al., 2006a,
tude about tinnitus). Thus, abbreviated telephone- 2006b). Our third clinical study (see Third Study
based CBT was developed to incorporate essential above) extended the first clinical trial and showed
features of this psychotherapy. that TM, TRT, and a nonspecific control group all
The addition of CBT to the PTM protocol provide significant benefit to subjects. Folmer and
required expansion of the self-help workbook to Carroll (2006) evaluated 150 patients who attended
include the new information. We developed a sec- a comprehensive tinnitus management clinic, in-
ond edition of the workbook that is mailed to all cluding patients who (a) used hearing aids (n = 50);
participants in this pilot study (J. A. Henry, Zaugg, (b) used ear-level noise generators (n = 50); and (c)
Myers, & Kendall, 2009). This new workbook also did not use ear-level devices (n = 50). Significant im-
contains two DVDs that supplement the written provement was experienced by all three groups.
material: (a) interactive video that guides patients Notably, the patients who used hearing aids and noise
through the material normally presented in PTM generators experienced significantly greater benefit
Level 3 Group Education; and (b) demonstrations of than did the patients who did not receive devices.
relaxation training exercises including deep breath- As a whole, these many studies comprise a
ing and imagery. We recently completed the third strong body of support for the efficacy of using
edition of the workbook based on feedback from therapeutic sound to manage tinnitus. It should be
subjects using it during this pilot study, which is noted, however, that the evidence does not demon-
being distributed to all VA audiologists and also is strate that any one of these methods is superior to
in publication for non-VA use (J. A. Henry, Zaugg, any other. Rather, it appears that any judicious use
Myers, & Kendall, 2010a). The workbook contains of sound seems to be helpful for managing tinnitus,
a DVD and CD that were developed through VA and it may be that some methods are more helpful
Employee Education System. in certain situations and for certain patients. Clearly,
research is needed that systematically evaluates the
different parameters of sound to determine which
parameters provide the greatest benefit and under
Additional Evidence
what conditions. With PTM, the overriding philos-
Supporting PTM ophy is that therapeutic sound provides the great-
est benefit when patients are informed about the
Numerous studies have supported the use of thera- different uses of sound for tinnitus management,
peutic sound for tinnitus management. Evidence and when patients learn how to develop, on their
has been provided by these studies supporting the own, sound-management plans to address spe-
beneficial use of: (a) hearing aids (Del Bo & Ambro- cific situations when their tinnitus is problematic.
setti, 2007; Folmer & Carroll, 2006; Saltzman & PTM utilizes procedures that encourage patients to
Ersner, 1947; Surr, Kolb, Cord, & Garrus, 1999; Surr, incorporate good self-management practices.
Montgomery, & Mueller, 1985; Trotter & Donaldson, CBT is an evidence-based and appropriate
2008); (b) ear-level masking devices (Folmer & Car- addition to PTM to address the psychological com-
roll, 2006; Hazell et al., 1985; Schleuning, Johnson, & ponents of tinnitus distress that are so common
Vernon, 1980; Stephens & Corcoran, 1985); (c) TRT with these patients. CBT is a type of psychother-
Research Leading to PTM 19

apy that targets specific thoughts, core beliefs, and tic sound and coping skills can be used to manage
negative appraisals of situations that are uncon- reactions to tinnitus. Patients are then taught how
structive (and may cause distress) while providing other sound-based methods use therapeutic sound.
tools for implementing more adaptive behavioral Patients should have this understanding before
and cognitive modifications (Beck, 1995; Sweetow, committing to an expensive and time-consuming
2000). Martinez Devesa et al. (2007) conducted a clinical protocol. This also is the reason that fitting
meta-analysis of six randomized, controlled studies ear-level noise generators or combination instru-
(285 participants) of CBT for tinnitus. They found ments is not normally advocated until Level 4.
significant improvement in quality of life (decrease Patients need to be fully informed before making
of global tinnitus severity) for those receiving CBT such consequential decisions.
compared to those who did not receive CBT. Tinnitus research has been conducted at the
Portland VA Medical Center since 1995 (under the
auspices of the NCRAR since 1997). In 1999 we
began a series of clinical trials to evaluate different
methods of tinnitus management, which provided
the experience and data that led to development
The five levels of PTM provide a logical, sequential of the PTM model of care. The basic content of
means of working collaboratively with a patient to the PTM protocol (i.e., the levels of care) has been
best determine the patients needs and to provide defined from the results of our years of research.
only the services that are needed. PTM patients The addition of CBT techniques to the PTM proto-
receive only basic audiology services and tinnitus col addresses psychological aspects of tinnitus and
education (from an audiologist and a psychologist) thereby is expected to improve the effectiveness of
through Level 3, which do not require a major com- PTM. The basic PTM protocol continues to provide
mitment on the part of either the clinician or the a framework for progressive management for
patient. Included in the education are thorough clinical expediency, but the clinical services pro-
explanations of the different ways that therapeu- vided now are of a more interdisciplinary nature.

Overview of PTM

In this chapter, we provide an overview of pro- which can make a meaningful difference in quality
gressive tinnitus management (PTM). We start by of life.
describing basic principles that undergird the PTM What do we mean by manage reactions to
protocol. We then provide summaries of each of the tinnitus? Note that we avoid the word treatment,
different levels of PTM, followed by case studies which might be interpreted by patients to mean
that exemplify the individualized nature of provid- that a circumscribed course of treatment will per-
ing hierarchical services with PTM. manently quiet or eliminate their tinnitus. Such an
outcome typically is what patients want, and they
often are not interested in receiving clinical services
if those services will not cure their tinnitus. Patients
Basic Premises for PTM
need to be informed that although tinnitus cannot
be cured they can learn to manage their reactions to
Manage Reactions to Tinnitus it, thereby improving their quality of life.
Any reference to managing tinnitus really
Chronic tinnitus (as distinct from somatosounds) means managing reactions to tinnitus. Managing
reflects malfunction somewhere within the audi- tinnitus might be misinterpreted to mean man-
tory system. The phantom perception of sound is aging the sound of tinnitus or doing something
a symptom of the malfunction. Normally, the mal- to make the tinnitus quieter. Because we cannot
function cannot be corrected and intervention can- change tinnitus itself, tinnitus management should
not permanently reduce the loudness/intensity of be interpreted to mean making lifestyle adjustments
the symptom. Considering that reducing the loud- to reduce any reactions to tinnitus. Reactions
ness of tinnitus normally is not an option, the next pertains to any negative effects of tinnitus on qual-
best thing is to help patients live more comfortably ity of life, such as sleep disturbance, concentration
with their tinnitus. The focus of PTM is to teach difficulties, or any negative emotions that are asso-
patients how to manage their reactions to tinnitus, ciated with tinnitus.
22 Progressive Tinnitus Management: Clinical Handbook for Audiologists

By learning to self-manage their reactions to n The disruption causes a noticeable

tinnitus, patients are empowered by gaining the reduction in quality of life.
ability to know how to address any situation in n The benefit from intervention would
which their tinnitus is bothersome or intrusive. outweigh the cost and effort (i.e., the
Patients need varying levels of support and guid- effort would be worth it).
ance from providers before becoming self-sufficient
in this process. Thus, there is a level of participa- The tinnitus pyramid (Figure 31) depicts
tion required of patientsthey are expected to be how individuals who experience tinnitus are dis-
engaged in the collaborative self-management tributed with respect to how the tinnitus impacts
process (J. A. Henry, Zaugg, Myers, Kendall, et al., their lives (Dobie, 2004b). The pyramid shows that
2009) until they are able to independently manage the majority of these people either are not bothered
their reactions to tinnitus (see Chapter 7). by it or they require only some basic education.
Intervention with PTM specifically involves Approaching the top of the pyramid are people who
activities designed to reduce reactions to tinnitus have progressively more severe problems caused
(no attempt is made to alter the tinnitus sound). by tinnitus. The top contains the relatively few
In addition, patients with tinnitus are taught basic patients who are debilitated by their tinnitus.
concepts of hearing conservation. Learning these Most patients do not require extensive (or expen-
concepts is universally important and is particu- sive) clinical intervention to learn how to manage
larly necessary for anyone who experiences tinni- their reactions to tinnitus. We therefore developed a
tus to minimize the potential for exacerbation of hierarchical approach to efficiently provide clinical
the tinnitus symptom. services to patients having diverse levels of need.
Figure 32 shows the five levels of PTM, which are
described in detail as the primary focus of this book.
Clinical Services Should Be Progressive The observation that the majority of indi-
viduals who experience tinnitus do not require in-
As mentioned in Chapter 1, epidemiologic stud- tervention has been supported by numerous subject-
ies reveal that chronic tinnitus is experienced by recruitment efforts for controlled studies conducted
about 10 to 15% of all adults (H. J. Hoffman & Reed, at the Portland VA Medical Center (under the aus-
2004). However, the condition is clinically signifi- pices of the National Center for Rehabilitative Auditory
cant for only about 20% of those who experience Research, NCRAR) to evaluate methods of tinnitus
tinnitus (A. Davis & Refaie, 2000; P. J. Jastreboff & intervention (see Chapter 2). For each study, we are
Hazell, 1998). contacted by large numbers of individuals who are
Tinnitus that is clinically significant indi- interested in participating. However, just experienc-
cates that the tinnitus causes functional impairment ing tinnitus is not justification for receiving therapy
to such a degree that clinical intervention is war- that is designed to address reactions to tinnitus. As
ranted. Although difficult to define, some criterion explained in Chapter 2, we had to develop screening
level of functional impairment would categorize an methodology to determine if a person requires interven-
individual as requiring clinical intervention. Deter- tion. Furthermore, individuals who do require inter-
mining this criterion level must be based on the vention have different levels of need, ranging from brief
persons perception of the need for intervention. counseling to individualized, ongoing therapy
As a general guide, tinnitus is likely to be clinically thus the rationale for progressive clinical services.
significant if the person agrees with each of the fol- The overall goal of the hierarchical approach
lowing statements: used with PTM is to minimize the impact of tin-
nitus on patients lives as efficiently as possible.
n The tinnitus disrupts at least one The model is designed to be maximally efficient to
important life activity. have the least impact on clinical resources, while
n The degree of disruption is more than still addressing the needs of all patients who com-
trivial. plain of tinnitus.
Debilitating tinnitus
Population of
adults who
Bothersome tinnitus -
seek clinical intervention
(~20% of all those who
experience tinnitus)
(1015% of
all adults)

Nonbothersome tinnitus
(~80% of all those who
experience tinnitus)

Figure 31.The Tinnitus Pyramid (Dobie, 2004b). The concept depicted here is
that the pyramid contains the entire population of people who experience chronic
tinnitus.The majority of these people (in the lower part of the pyramid) are not par-
ticularly bothered by their tinnitus. Many of these people only want assurance that
their tinnitus does not reflect some serious medical condition (those in the middle
of the pyramid). Relatively few have tinnitus that requires some degree of clinical
intervention (toward the top of the pyramid). A very small fraction has debilitating
tinnitus (in the top of the pyramid).

5 Individualized Support

4 Interdisciplinary Evaluation
more severe
problems caused 3 Group Education
by tinnitus
2 Audiologic Evaluation

1 Triage

Bothersome tinnitus

Nonbothersome tinnitus

Figure 32. Five levels of progressive tinnitus management (PTM) superimposed

on the Tinnitus Pyramid (see Figure 31). Each higher level reflects a greater intensity
of clinical services, and patients progress only to the level needed.

24 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Use an Interdisciplinary Approach is knowledgeable about the multiple causes and pre-
sentations of tinnitus. However, this is not practical
The initial evaluation for a patient who complains or realistic in many cases. Guidelines are provided
of tinnitus usually can be conducted by an audi- in Chapters 4, 5, and 8 for determining when a med-
ologist and in many cases the audiology assess- ical evaluation is necessary. For example, pulsatile
ment (with the possibility of fitting hearing aids) is tinnitus often has an identifiable site, for which there
the only service needed. However, many patients are many potential causes. All patients who present
require referral for additional evaluations, and with pulsatile tinnitus should receive a medical
some patients require tinnitus-specific interven- evaluationprimarily to rule out pathology (e.g.,
tion. Because of the multiple dimensions of prob- glomus tumor) that requires medical intervention.
lematic tinnitus, clinical services are optimized by
using an interdisciplinary approach. Mental Health Professional
Clinical evaluations help determine the range
and types of services needed to manage the full Some patients with tinnitus present with behav-
scope of medical, rehabilitation, and psychosocial iors that indicate the need for an evaluation by a
aspects of tinnitus. Members of the tinnitus man- psychiatrist, psychologist, or other licensed mental
agement team administer a variety of assessment health professional. Most mental/emotional disor-
instruments and then, for difficult cases, meet as a ders are not so obvious and require special evalu-
group to integrate results into a plan of care tailored ations to establish their existence and significance.
to the individual needs of the patient. The scope of A relatively high proportion of patients concerned
care depends on the severity of perceived tinnitus about tinnitus suffer from depression and/or anxi-
and medical and psychological issues. Intervention ety (Dobie, 2003; Halford & Anderson, 1991; Kirsch,
for tinnitus typically requires audiology and men- Blanchard, & Parnes, 1989). Patients suspected of
tal health services but may involve medical and having these problems should be referred for eval-
prosthetic services. uation by a mental health professional. Patients
also should be referred immediately to a mental
Audiologist health professional if they report suicidal or violent
thoughts, or if they report bizarre symptoms such
Audiologists are essential for providing clinical ser- as hearing voices.
vices for tinnitus (J. A. Henry, Zaugg, et al., 2005a). Tinnitus can be associated with post-traumatic
Although audiologists can independently perform stress disorder (PTSD). PTSD is a constellation of
all aspects of clinical services for many patients, it mental, emotional, and physical symptoms that can
is vital that they refer patients to other health care follow the experience of a traumatic event. Although
professionals as the presenting symptoms warrant. commonly associated with military veterans, PTSD
Audiologists must be aware of certain tinnitus- affects all strata of the population and all manner
specific symptoms that indicate the need for medi- of psychological trauma. Untreated PTSD can
cal evaluation services. Audiologists also must be impede rehabilitation efforts, including the clinical
aware of symptoms consistent with medical and management of tinnitus. Failure to properly refer
psychological conditions. Optimally, audiologists patients for possible PTSD, depression, and/or
who provide tinnitus services should work with an chronic anxiety reduces the likelihood of achieving
interdisciplinary tinnitus team. the desired outcomes from tinnitus intervention.
Sleep disturbance is the nonauditory problem
Physician Ear Specialist most frequently reported by patients with tinnitus
(Erlandsson, 2000; Jakes, Hallam, Chambers, & Hinch
Ideally, every patient complaining of tinnitus would cliffe, 1985; Meikle & Walsh, 1984; Tyler & Baker,
receive a complete head and neck examination from 1983). Patients who report sleep problems also tend
an otolaryngologist, otologist, or neuro-otologist who to have the most severe tinnitus. Sleep problems
Overview of PTM 25

may be mitigated by teaching sleep-management Focus on Patient Education as Intervention

techniques that are included in both the psycho-
logic and audiologic portions of the PTM counsel- Clinical intervention with PTM relies on a struc-
ing (and in the PTM self-help workbook). If these tured program of patient education. The education
efforts are not successful, then the patient may need consists primarily of teaching patients how to use
referral to a sleep disorders specialist, physician, or sound and coping techniques to manage their reac-
mental health professional. tions to tinnitus. More specifically, patients learn
how to develop and implement individualized plans
Prosthetics for using therapeutic sound and apply principles of
cognitive-behavioral therapy (CBT) to manage their
Some aspects of PTM incorporate instruments tinnitus. Success in achieving these goals depends
including hearing aids, ear-level noise generators largely upon patients acquiring confidence in apply-
(maskers) and combination instruments (com- ing the self-management strategies. Breaking the
bined hearing aid and masker), as well as wear- process of learning how to manage tinnitus into
able and tabletop devices that are used for sound small achievable tasks helps to ensure that patients
therapy purposes. Involvement of prosthetics and experience initial success. This approach is in accor-
sensory aids staff (at VA, military, and some other dance with the self-efficacy theory (Bandura, 1977).
hospitals and clinics) ensures that appropriate tech- Research has demonstrated that self-efficacy is a good
nology will be available to patients with tinnitus. predictor of motivation and behavior. In general,
the experience of success increases self-efficacy
while experiencing failure reduces self-efficacy.
Start with Audiologic Assessment Unique aspects of intervention with PTM
include: (a) its emphasis on collaborative man-
Patients complaining of tinnitus need an audiologic agement by patient and clinician, leading to self-
assessment for two basic reasons. First, they must management by the patient; (b) development and
be evaluated to determine if referral to a physician use of sound-based therapy that is customized to
is warranted. Second, tinnitus usually is associ- address patients individual needs; (c) application
ated with some degree of hearing loss (Axelsson & of evidence-based principles of patient education
Ringdahl, 1989; A. Davis & Refaie, 2000; J. L. Henry and health literacy; (d) use of multiple modalities to
& P. H. Wilson, 2001; Vernon, 1998). Our research provide education within different levels of PTM;
has revealed that the great majority of patients and (e) inclusion of essential components of CBT
who complain of tinnitus also complain of hear- to teach coping skills (J. A. Henry, Zaugg, Myers,
ing problems (J. A. Henry, Loovis, et al., 2007). An Kendall, et al., 2009).
audiologic examination should be the clinical start- PTM education is provided to patients at
ing point for all patients who complain of tinnitus, Levels 2, 3, and 5, but in a different format at each of
unless urgent medical services are required. these levels. Going from lower to higher levels the
In addition to the audiology testing, a brief education becomes increasingly more personalized.
assessment should be performed to determine At Level 2, patients can receive the self-management
if intervention specific to tinnitus is warranted. workbook (although it is recommended to give the
Patients with tinnitus commonly (and erroneously) workbook to patients at the start of Level 3 inter-
attribute hearing problems to tinnitus (Coles, 1995; vention). The workbook contains step-by-step instruc-
Dobie, 2004b; Zaugg et al., 2002). It therefore is crit- tions for patients to learn the self-management
ical to determine how much of the patients com- techniques on their own. All patients with tinnitus-
plaint is due to a hearing problem and how much is specific problems are advised to participate in the
due specifically to the tinnitus. PTM utilizes a brief workshops that comprise Level 3 Group Educa-
questionnaire (Tinnitus and Hearing Surveysee tion. At Level 5, the education is provided in a one-
Chapter 5) to help make this determination. on-one format.
26 Progressive Tinnitus Management: Clinical Handbook for Audiologists

The Audiologists Role as Patient Educator educational and counseling materials and should
be adopted during all interactions with patients.
Patient education is the most important aspect of
providing intervention with PTM. Thus, one of the
audiologists primary roles in this program is that Refer Patients Appropriately
of patient educator. Training received by audiolo-
gists generally does not include theories and con- Because tinnitus can be a multidimensional problem,
cepts of patient education for achieving changes in a team approach is the ideal. The team approach,
behavior. We previously have published a descrip- however, currently is seen in very few clinics.
tion of the principles of education used with PTM Therefore, it is vitally important that patients are
(J. A. Henry, Zaugg, Myers, Kendall, et al., 2009). referred as appropriate to other health care profes-
The information in that article can help audiologists sionals. Ideally, PTM services will be a joint effort
better understand their role as patient educator between audiology and psychology, with inclusion
and maximize their effectiveness in implementing of otolaryngology, psychiatry, and other disciplines
the educational components of PTM. as needed. Mental health professionals who receive
tinnitus referrals should have expertise in provid-
ing psychological interventions for patients with
Address the Problem of Low chronic health conditions and at least be familiar
Health Literacy with the nature of tinnitus within the context of
comorbid psychological problems.
Nearly one third of English-speaking adults in the
United States have low health literacy (Gazmara-
rian et al., 1999; Nielsen-Bohlman, Panzer, & Kin-
Five Levels of PTM
dig, 2004; Williams et al., 1995). Those with low
health literacy have an incomplete understand-
ing of their health problems, and are more likely Synopsis
to report poor health, have more hospitalizations
and higher health care costs, as well as suffer worse The PTM Flowchart (Appendix A) shows the five
health outcomes overall (Baker, Parker, Williams, hierarchical levels of clinical services with PTM.
Clark, & Nurss, 1997; Howard, Gazmararian, & The hierarchy of services starts with Level 1 Tri-
Parker, 2005; Weiss, Hart, McGee, & DEstelle, 1992; age at the bottom of the flowchart. Level 1 Triage
Weiss & Palmer, 2004). Tinnitus disproportionately provides guidelines for all clinics where patients
affects the populations most likely to have low with tinnitus are likely to be encountered. Level 1
health literacy: older adults and low-income indi- Triage on the flowchart includes a large rectangu-
viduals (S. C. Brown, 1990; Doak, Doak, & Root, lar text box that describes the criteria for referring
1996; Heller, 2003; H. J. Hoffman & Reed, 2004; patients who complain of tinnitus. Depending on
Sindhusake, Mitchell, et al., 2003). the patients symptoms and other diagnostic fac-
Even literate persons may have difficulty tors, there are four possible referrals (as indicated
understanding health information, so training clini- by the four columns in the text box): (1) Refer to
cians to communicate in ways that reach low-literate audiology; (2) Refer to ENT (i.e., refer to otolaryn-
patients is good for all patients (Mayeaux et al., gology) for a nonurgent appointment; (3) Refer to
1996). There is general consensus among health lit- emergency care or ENT for an urgent appointment
eracy and communication experts that the seven that will take place on the same day the symptoms
strategies we have described previously (J. A. are reported; (4) Refer to mental health or emer-
Henry, Zaugg, Myers, Kendall, et al., 2009) can help gency care for further assessment of concerning
improve provider-patient communication (Doak et mental health symptoms.
al., 1996; Williams, Davis, Parker, & Weiss, 2002). Level 2 of PTM is the Audiologic Evalua-
These strategies are incorporated into the PTM tion, during which it is determined whether or
Overview of PTM 27

not the patient will participate in Level 3 Group The primary objective of the Level 2 Audiologic
Education. During the Level 2 evaluation, patients Evaluation is to assess the potential need for a
also are screened for severely reduced tolerance medical examination and/or audiologic interven-
to sound (hyperacusis). If they fail the screening, tion (audiologic intervention can include inter-
then they should participate in the sound tolerance vention for hearing loss, tinnitus, and/or reduced
evaluation and management (STEM) protocol, as sound tolerance). Sometimes it also is appropri-
indicated on the figure. The STEM protocol should ate to screen for mental health conditions that can
resolve the hyperacusis problem, at which time the interfere with successful self-management of reac-
patient should be evaluated to determine if further tions to tinnitus. Screening methodology is avail-
tinnitus services are needed. If so, then the patient able, but not required, at this level to determine
is advised to participate in Level 3 Group Educa- if a patient should be referred for a mental health
tion (shown on the flowchart by the arrow leading assessment. When indicated, brief questionnaires
from the STEM box to Level 3). can be administered to assess the potential need
Patients who need clinical services beyond for referral to a mental health clinic. Patients pri-
Level 3 can schedule an appointment for a Level4 mary care providers should be notified when their
Interdisciplinary Evaluation. The Level 4 evalu- patients report feeling sad, isolated, agitated, or
ation (ideally performed by an audiologist and a anxious. This information should be documented
psychologist) will be used to determine if Level 5 in the medical record along with behavioral obser-
Individualized Support is warranted. vations such as crying or angry outbursts.
The Level 2 evaluation always includes a stan-
dard audiologic evaluation and brief written ques-
Level 1 Triage tionnaires to assess the relative impact of hearing
problems and tinnitus problems. Patients who require
Level 1 is the triage level for referring patients amplification are fitted with hearing aids, which
at the initial clinic point-of-contact. often can result in satisfactory reduction in reac-
tions to tinnitus with minimal education and sup-
port specific to tinnitus (J. A. Henry, Zaugg, Myers,
Tinnitus triage guidelines were developed for & Schechter, 2008c; J. A. Henry, Zaugg, etal., 2005b;
nonaudiologist health care providers who encoun- Searchfield, 2005). Patients who report any degree
ter patients complaining of tinnitus. Patients com- of a tinnitus problem following these basic services
plain of tinnitus in many different clinical settings. are advised to attend Level 3 Group Education.
Health care providers often do not know how to Patients who report a severe problem with
refer these patients appropriatelyor whether to reduced sound tolerance are scheduled for STEM,
refer them at all. The tinnitus triage guidelines can which then becomes the focus of clinical manage-
be used to help guide referral practices for clinicians ment. (STEM is described fully in Chapter 6, and a
encountering patients reporting tinnitus. The guide- brief summary is provided below.)
lines are consistent with accepted clinical practices
(Harrop-Griffiths, Katon, Dobie, Sakai, & Russo,
1987; J. A. Henry, Zaugg, et al., 2005a; J. L. Henry & Patient Self-Help Workbook
P. H. Wilson, 2001; Wackym & Friedland, 2004).
The self-help workbook provides a description
of key information that is covered during
Level 2 Audiologic Evaluation Level 3 Group Education.

Level 2 is the audiologic evaluation, which

includes a brief assessment of the impact of A special workbook (How to Manage Your Tinnitus:
tinnitus on the patients life. A Step-by-Step Workbook) (J. A. Henry et al., 2010a)
has been developed that provides patients with the
28 Progressive Tinnitus Management: Clinical Handbook for Audiologists

core PTM counseling information that is offered 6). Testing for loudness discomfort levels can be
both in Level 3 Group Education and Level 5 performed, but is not required. If treatment for
Individualized Support. The workbook provides reduced sound tolerance is needed, then the use of
detailed information and instructions for devel- ear-level devices (noise generators or combination
oping individualized action plans to self-manage instruments) is a consideration. Special procedures
reactions to tinnitus using therapeutic sound and have been developed to evaluate patients for these
coping techniques. Videos and a sound demonstra- devices. The STEM protocol continues for as long
tion CD are included in the workbook to supple- as reduced sound tolerance is a significant problem
ment the written material. for the patient. Once the sound tolerance problem
Although the workbook is designed to be is under control, then it is determined whether the
used by patients to learn the different self-help patient should continue to receive tinnitus-specific
techniques, it has been our experience that many clinical services. If so, then the patient normally is
patients have difficulty benefiting from the work- advised to participate in Level 3 Group Education.
book without at least some guidance and support
from a clinician. Indeed, some patients can receive
full benefit from using the workbook without addi- Level 3 Group Education
tional intervention. However, patients are more
likely to benefit from the workbook if it is provided Level 3 provides group education workshops
in the context of a group with guided activities for patients who require tinnitus-specific
led by a clinician. We recommend providing the intervention.
workbook to patients when they attend their first
Level 3 workshopfor reasons that are explained
in Chapter 5. Level 3 Group Education is for patients who have
attended the Level 2 Audiologic Evaluation and feel
that they need additional clinical services to learn
Sound Tolerance Evaluation and how to manage their reactions to tinnitus. Level 3 is
Management (STEM) the first level within PTM for which patients receive
focused intervention for a tinnitus problem. The
STEM provides adjunct procedures to evaluate group education is presented as classroom-style
and treat a severe sound tolerance problem. sessions of PTM counseling that are facilitated by
the use of PowerPoint presentations. (Note that the
PowerPoint files for these presentations are pro-
During the Level 2 Audiologic Evaluation, patients vided on a CD that is attached to the back of this
are screened for a sound tolerance problem (hyper- handbook.) As mentioned above, patients should
acusis and/or misophonia) using the Tinnitus and receive a copy of the self-help workbook at the start
Hearing Survey (see Chapter 5). The survey includes of the first session. The normal intervention within
two questions specific to reduced sound tolerance, Level 3 is for patients to attend two sessions facili-
which generally are adequate to determine if the tated by an audiologist, combined with three ses-
patient has a severe problem with reduced sound sions facilitated by a psychologist or other mental
tolerance. These patients are considered special health provider.
cases and their progress through PTM is tempo- In general, there are several advantages to a
rarily suspended while they undergo STEM. Some group education format (Mensing & Norris, 2003;
patients also may express a strong desire to simply S. R. Wilson, 1997): (a) Group sessions are both cost-
concentrate on addressing sound tolerance prob- effective and time-efficient. Education and support
lems rather than tinnitus. These patients should can be provided to more patients in less time, maxi-
have the option of attending the STEM program. mizing available resources; (b) When education is
The STEM protocol starts with an assess- the primary intervention modality, group educa-
ment of the problem, which relies mainly upon tional intervention can be equally or more effec-
a special sound tolerance interview (see Chapter tive than providing the education on an individual
Overview of PTM 29

basis because of the group-interaction dynamic; gist, the participants should have learned how to
(c) Patients often are more motivated to attend develop, implement, evaluate, and revise a sound
group rather than individual sessions because of plan to manage their most bothersome tinnitus sit-
the encouragement and support that they receive uation. They are encouraged to use the Sound Plan
from each other; and (d) Patients who participate Worksheet on an ongoing basis to write additional
in groups tend to form a sense of camaraderie that sound plans to address other bothersome tinni-
further motivates them to attend the sessions. tus situations. Additional group sessions with the
Recent evidence supports the use of group audiologist can be scheduled if needed.
education as a basic form of tinnitus intervention. The group education sessions led by a psy-
Group education has been shown to be effective as chologist focus on teaching three cognitive-behav-
part of a hierarchical tinnitus management program ioral therapy (CBT) coping techniques: relaxation,
at a major tinnitus clinic (C. W. Newman & San- cognitive restructuring (changing thoughts),
dridge, 2005; Sandridge & C. W. Newman, 2005). and attention diversion (planning pleasant activi-
In addition, we completed a randomized clinical ties). During the first of three sessions with the
trial (see Chapter 2) evaluating group education psychologist, the principles of CBT are explained,
for tinnitus in almost 300 patients that showed sig- and participants use the PTM Changing Thoughts
nificantly more reduction in tinnitus severity for and Feelings Worksheet (J. A. Henry et al., 2010a).
patients in the education group as compared to two The provision of CBT for chronic problems other
control groups (J. A. Henry, Loovis, et al., 2007). than tinnitus often involves six to eight sessions (J.
PTM group education has been carefully devel- L. Henry & P. H. Wilson, 2001). For PTM, only cer-
oped to assist patients in directly addressing those tain components of CBT are taught to minimize the
life situations when their tinnitus is problematic. number of group sessions and because other com-
The counseling focuses on facilitating self-efficacy ponents of CBT, such as education about tinnitus,
and was developed using well-documented prin- are provided elsewhere during Level 3 and Level 5.
ciples of patient education and health literacy (J. A. Patients should have the option of attend-
Henry, Zaugg, Myers, Kendall, et al., 2009). PTM ing additional sessions if further CBT counseling
counseling thus does not just educate patients about is needed. These additional sessions normally are
tinnitusit is designed to teach patients how to self- offered to patients following, and depending on
manage their reactions to tinnitus. These patients are the results of, the Level 4 Interdisciplinary Evalu-
empowered to make informed decisions about self- ation. During Level 5 Individualized Support, all
management, protecting their ears, and further tin- CBT modules including psychoeducation, preven-
nitus intervention options. tion, and planning for relapse and flare-ups are
During the first session with the audiologist, presented in detail according to results of the Level
the principles of using sound to manage reactions 4 Interdisciplinary Evaluation.
to tinnitus are explained, and participants use the
PTM Sound Plan Worksheet (J. A. Henry, Zaugg,
Myers, & Kendall, 2009; J. A. Henry et al., 2010a) to Level 4 Interdisciplinary Evaluation
develop an individualized sound plan to use to
manage their most bothersome tinnitus situation. Level 4 involves in-depth evaluation of
They are instructed to use the sound plan until the patients who require services beyond Level 3
next session with the audiologist (approximately Group Education.
two weeks later), at which time they discuss their
experiences using the plan and its effectiveness.
The audiologist facilitates the discussion and Patients who are unable to satisfactorily manage
addresses any questions or concerns. Further infor- their reactions to tinnitus following completion of
mation about managing reactions to tinnitus is then PTM Levels 2 and 3 require a full evaluation to
presented, and the participants revise their sound determine their needs for further intervention. Such
plan based on the discussion and new information. an in-depth evaluation is not warranted for the great
By the end of the second session with the audiolo- majority of patients who are able to self-manage
30 Progressive Tinnitus Management: Clinical Handbook for Audiologists

reactions to tinnitus with the information and sup- who has been properly trained to use screening
port provided in Levels 2 and 3. tools and who has resources for responding to the
The Level 4 Interdisciplinary Evaluation should outcomes of these screeners. In instances where
include assessments by both an audiologist and a audiologists (or other nonmental health care pro-
psychologist (or other mental health provider). The viders) are performing screening for referral to
audiologist should discuss use of devices and deter- mental health, collaborations with primary care
mine if individualized support from an audiologist are essential to allow for immediate referrals and
is warranted. The psychologists assessment should follow-up as warranted based on mental health
include screening for psychological conditions that screeners. Medical centers and outpatient clinics
may need to be addressed and a determination vary in the types and availability of mental health
if individualized support from a psychologist is clinicians. When appropriate mental health care pro
warranted. Thus, two appointments normally are viders are unavailable, collaboration with primary
required at this levelone with an audiologist and care is necessary to ensure patients receive the best
one with a psychologist. Ideally, after both evalua- care available at that site.
tions the audiologist, psychologist, and patient will It should be mentioned that these Level 4 eval-
come to agreement concerning if and how Level 5 uations should take into account patients impres-
intervention should be conducted. sions about the education they received from the
The audiologic tinnitus assessment includes Level 3 classes. It is important to know how useful
written questionnaires, a structured interview, the information was to patients to focus on build-
and, optionally, a psychoacoustic assessment of ing skills that are most likely to provide benefit.
tinnitus perceptual characteristics. The question- Taking this patient-centered approach can help
naires and interview are the key to determining patients feel that they are part of the decision-mak-
how the tinnitus impacts the patients life and if ing process, and increases the likelihood that inter-
individualized support from an audiologist is vention will be successful.
indicated. Special procedures have been devel-
oped for selecting sound-generating devices for Level 5 Individualized Support
tinnitus management using therapeutic sound,
including ear-level noise generators and combina- Level 5 is the provision of one-on-one support
tion instruments, and personal listening devices. for patients who require longer-term interven-
The audiology portion of the Level 4 evaluation is tion from an audiologist and/or a psychologist.
used to determine if Level 5 Individualized Sup-
port from an audiologist is needed. However,
patients who are fitted with ear-level noise genera- Level 5 Individualized Support involves repeated
tors or combination instruments must progress to appointments with an audiologist and/or a men-
Level 5 to ensure proper utilization of the devices. tal health provider (typically a psychologist) who
Screening for symptoms of mental health dis- provide one-on-one individualized support to the
orders is considered a requirement at Level 4 if patient. If ear-level devices are involved in the
the patient is not already receiving mental health management program, then appointments with an
services. Such screenings would include inquiries audiologist are essential to ensure that the devices
about depressive and anxious symptomatology, are working properly and that the patient is using
sleep problems, and significant life stressors that the devices in a manner that is optimal for tinnitus
may be contributing to ones inability to cope. It management. Any psychologist providing Level 5
is best for the mental health evaluation to be per- Individualized Support should have experience or
formed by a psychologist or other mental health adequate training in providing CBT. This founda-
care provider who is qualified to conduct diagnos- tion is essential to provide effective care.
tic evaluations. If assessment by a mental health The audiologic counseling information is
care provider is not possible, basic screening for essentially the same as what was covered during
these symptoms can be conducted by any clinician Level 3 Group Education. However, for Level 5, the
Overview of PTM 31

audiologist uses a book to facilitate the counseling

(Progressive Tinnitus Management: Counseling Guide)
(J. A. Henry, Zaugg, Myers, & Kendall, 2010b). The
book is laid flat on a table between clinician and The five levels of PTM provide a logical, sequen-
patient, and works like a flip chart to guide both tial means of working collaboratively with patients
the audiologist and the patient through the coun- to best determine their needs and to provide only
seling protocol. Patients should attend at least two the level of care that is needed. It is a basic phi-
Level 5 appointments, but they can attend as many losophy of PTM that educating the patient is the
as needed. The typical schedule includes appoint- most important concern. Thus, patients receive
ments at 1, 2, 4, and 6 months following the Level 4 only basic audiology services and self-help educa-
Interdisciplinary Evaluation. tion through Level 3. Included in that education
The psychological counseling at Level 5 is a thorough explanation of the different ways
involves a review of the techniques taught dur- that sound can be used to manage reactions to tin-
ing Level 3 Group Education (and included in nitus. And, as part of that explanation, patients
the self-help workbook) and an individualized are taught how sound is used with other sound-
examination of the patients unique achievements based methods of tinnitus management (e.g., tin-
and challenges so far during PTM. Patients learn nitus retraining therapy). Patients should have this
more about setting and achieving goals via behav- understanding before potentially committing to an
ioral modification by tracking their progress using additional clinical protocol that may be expensive
clearly defined measures of change. For example, and time-consuming. An important reason why
if a patient is having difficulty managing stress, fitting ear-level noise generators or combination
charting stress on a 1-to-10-scale can be effective instruments is not advocated until Level 4 is that
for quantifying the patients response to stress and patients need to be fully informed before making
observing change as a result of modifications in such decisions.
behavior. During Level 5, patients learn how to Additionally, there continues to be great
accept their individual strengths and weaknesses stigma associated with psychological interventions.
while gaining a sense of control in the event that Audiologists must be on the frontlines educating
change is realistic and obtainable. patients about the use of psychological interven-
During Level 5 the audiologist and psychologist tions for health conditions. Audiologists can help
should collaborate with each other and with the patients with tinnitus feel less concerned about this
patient to determine what is necessary to provide stigma if they explain the goals of CBT. CBT has
adequate benefit to the patient. Occasional appoint- been effective in helping patients deal with chronic
ments with both providers may be helpful for clari- pain (patients who receive CBT for pain even report
fying the goals of the interventions and emphasizing decreased levels of pain) (B. M. Hoffman, Papas,
a team approach to providing tinnitus care. Options Chatkoff, & Kerns, 2007). The analogy between
for the patient beyond six months of Level 5 include pain and tinnitus is especially useful in introduc-
ongoing psychological symptom management (if ing the goals of psychological management for tin-
warranted), further audiologic intervention (coun- nitus. Patients should be reassured that clinicians
seling and/or use of ear-level instruments), or other do not think tinnitus is a psychological disorder
forms of tinnitus intervention that can be provided nor do we think it is in their heads. It may be
by an audiologist (tinnitus masking, tinnitus retrain- important for some patients to hear that clinicians
ing therapy, or neuromonics tinnitus treatment). believe their tinnitus is real and very disturbing to
Some patients may require psychiatric manage- them as a validation of their concerns and distress
ment to address persistent or more serious mental upon introducing the psychologists role.
health symptoms that may become evident at any If a patient reaches Level 5, then one-on-one
level of PTM. If a psychologist is collaborating then support is needed for the patient to better under-
that clinician should make such a referral to psy- stand the concepts and receive help in trying to
chiatry or the primary care provider. learn how to self-manage reactions to tinnitus.
32 Progressive Tinnitus Management: Clinical Handbook for Audiologists

(This is a skill patients likely will need for the rest Case Study: Sam
of their lives so it is important that they fully grasp
the concepts.) Furthermore, tinnitus is a dynamic n Level 1: Sam was referred to audiology
symptom that may change dramatically over the by primary care for tinnitus and hearing
course of the patients lifetime. If none of the efforts loss complaints.
expended through Level 5 works for the patient, n Level 2: Audiologic evaluation revealed a
then the logical next step is to attempt to modify high frequency sensorineural hearing loss
the procedures, or to try other forms of therapy. As bilaterally. Sam was advised and agreed
a result of participating in PTM, patients become to be fitted with hearing aids. The brief
fully educated about the different uses of sound, tinnitus assessment revealed clinically
and are in a position to make informed decisions significant tinnitus. Sams primary care
about committing to another form of therapy. provider and a mental health provider
PTM is a program that is efficient for audiolo- were immediately notified due to his
gists and psychologists and is designed to work in statement Im not sure how much I can
the best interest of patients to help them learn how go on living with this tinnitus.
to self-manage their reactions to tinnitus without n Level 3: Sam attended group education
getting involved in expensive therapy. If a clini- sessions with the audiologist and psychol-
cian is committed to one of these other methods, ogist and reported that the education was
then the framework of PTM can be helpful to more not enoughhe was still very troubled by
systematically make decisions about the need for his tinnitus and wanted more assistance.
a high level of intervention. The interdisciplinary n Level 4: Sam returned for an inter
approach of PTM can be modified based on a par- disciplinary evaluation. The hearing aids
ticular clinics resources and staffing. Some clinics were returned for credit and combination
employ health psychologists or clinical psycholo- instruments were ordered. He and
gists who specialize in auditory disorders, and the psychologist agreed that further
who may be especially adept at responding to the psychological intervention had potential
psychological needs of patients with tinnitus. Other to be helpful.
clinics do not have such clinical resources. n Level 5: Sam received individualized
The PTM model is designed for implementa- ongoing intervention with an audiologist
tion at any clinic that desires to optimize resource- to optimize the use of his combination
fulness, cost efficiency, and expedience in working instruments and to more fully understand
with patients who complain of tinnitus. Use of these the PTM techniques. He met individually
recommendations should lead to more widespread with a psychologist to optimize the use of
and consistent tinnitus assessment and interven- coping techniques based on CBT.
tion by clinicians. Each level of PTM is described
in detail in this book.
Case Study: Betty

n Level 1: Betty was referred to audiology

Case Studies
by primary care due to a report of
intermittent tinnitus bilaterally.
The following case studies illustrate the PTM n Level 2: Audiologic evaluation revealed
approach employed for three patients (Sam, Betty, that Betty had normal hearing bilaterally.
and Joe). These are somewhat random examples, Assessment of impact of tinnitus revealed
but they illustrate the range of problems reported that Betty was mildly impacted by her
by patients and the adaptive nature of PTM to tinnitus. Betty was counseled regarding
address individual needs. the test results and her tinnitus. She
Overview of PTM 33

was invited to attend Level 3 Group involved hyperacusis, misophonia,

Education. and phonophobia. Treatment therefore
n Level 3: Betty participated in the required counseling and support by
group education workshops conducted both an audiologist and a psychologist.
by an audiologist. She obtained the In addition, he was fitted with a
information needed to self-manage her combination instrument in his left ear
reactions to tinnitus by optimizing her and a noise generator in the right ear,
lifestyle and using low level sounds in and sound was added very gradually via
her environment when the tinnitus was these devices and in his environment.
bothersome. She deferred instruction on His sound tolerance recovered over
CBT education or further referral and will a six-month period to the degree that
contact the clinic if changes or problems tinnitus became the primary problem.
are noted. He was advised to attend Level 3 Group
n Level 3: Joe participated in all of the
Case Study: Joe
group education workshops conducted
by both the audiologist and psychologist.
n Level 1: Joe was referred to audiology by
Joe learned from the audiologist how
his psychologist due to reports that he
to use sound to decrease his awareness
dislikes hearing sound and has very
of tinnitus and to continue increasing
bothersome tinnitus. He stopped socializ-
his tolerance to sound. During the CBT
ing last year and avoids all activities that
workshops he learned the importance
involve moderate levels of sound. The
of staying active to distract himself from
psychologist has been treating him for PTSD.
his tinnitus. He became less isolated
n Level 2: Audiologic evaluation revealed
and began meeting with friends again.
that Joe had moderate hearing loss in his
The referring psychologist learned
left ear but normal hearing in his right
about tinnitus from the PTM team
ear. (Referral to otolaryngology and
and incorporated skills taught during
subsequent imaging with MRI indicated
PTM into his PTSD treatment. Joe
no lesions or malformations.) The
continues to receive regular follow up
brief assessment of tinnitus and sound
from his psychologist. It was decided
tolerance revealed that Joe was severely
to not schedule him for a Level 4
impacted by both of these conditions.
Interdisciplinary Evaluation from the
Because of his severe sound tolerance
audiologist. However, the psychologist
problem, Joe was advised to participate in
and audiologist will consult in
the STEM program (see Chapter 6).
approximately 3 months to determine if a
n STEM: The evaluation determined
Level 4 evaluation is warranted.
that Joes sound tolerance problem

Level 1 Triage

This and the remaining chapters focus on describ- to tinnitus often are best managed using an inter-
ing detailed procedures for conducting PTM. The disciplinary approach, thus proper referral and
present chapter describes procedures for triag- inclusion of a psychologist and otolaryngologist
ing patients when they complain of tinnitus at on the tinnitus team (when possible) are critical
any clinic. Patients report tinnitus to healthcare components of PTM.
providers in many different clinicsnot just oto- When a patient complains of tinnitus, the pri-
laryngology and audiology. Direct points of contact mary concerns are to determine (in order of decreas-
include primary care, psychology, psychiatry, neu- ing priority) if the patient: (a) has a serious medical
rology, and oncology. Providers in these (and other) condition (physical or mental) requiring immedi-
departments may be unaware of clinical resources ate medical attention; (b) experiences symptoms of
that are available when patients complain of tin- a nonurgent medical condition indicating the need
nitus. Guidelines are needed so that clinicians can for a medical examination; (c) experiences symp-
refer these patients to receive appropriate care. toms of a nonurgent psychological condition indi-
A guide (Tinnitus Triage GuidelinesAppen- cating the need for mental health screening; and
dix B) has been developed to provide to clinicians (d) has been referred or has none of the symptoms
as a resource to know how to appropriately refer listed above, indicating the current need for an
their patients who complain of tinnitus. The evi- audiologic examination.
dence for these guidelines is based on best prac-
tices for referring these patients (Harrop-Griffiths
et al., 1987; J. A. Henry, Zaugg, et al., 2005a; J. L.
Tinnitus Triage Guidelines
Henry & P. H. Wilson, 2001; Wackym & Friedland,
2004). Audiologists see patients in any of PTM Lev-
els 2 to 5, and more comprehensive referral guide- The Tinnitus Triage Guidelines (Appendix B) can
lines have been developed for audiologists to use be used by providers as a quick guide for triaging
in these levels (J. A. Henry et al., 2008b). Reactions patients who complain of tinnitus. Following these
36 Progressive Tinnitus Management: Clinical Handbook for Audiologists

guidelines should result in appropriate care in most ruptures, immune-mediated mechanisms, abnor-
cases. It needs to be emphasized, however, that the mal cellular stress responses within the cochlea,
guidelines are greatly simplified for clinical expe- and ion transport problems of the stria vascularis
diency. It goes without saying that clinicians must (Merchant, Adams, & Nadol, 2005; Trune, 2004). If
use their clinical judgment to determine the best left untreated, the hearing loss will resolve partially
course of action for each patient. Another caveat is or completely in at least 50% of these patients. This
that clinical services for tinnitus are far from being recovery rate may be improved with corticosteroid
standardized. Clinicians who provide tinnitus ser- (glucocorticoid) treatments, particularly if deliv-
vices often use very different approaches. Patients ered intratympanically (Hamid & Trune, 2008).
who are referred should be advised to become well Although recovery with glucocorticoids often is
informed before agreeing to undergo any medical interpreted as an underlying cochlear inflamma-
procedure or to enroll in any therapeutic program. tion etiology, numerous inner ear ion homeostasis
PTM Level 1 Triage shown in the PTM Flow- mechanisms also are controlled by corticosteroids
chart (Appendix A) includes a large rectangular (Merchant et al., 2005; Trune, 2004). Thus, conclu-
text box that lists the basic criteria for referring sions about etiology based on treatment response
patients who complain of tinnitus. Depending on can be debated, although lack of recovery with glu-
the patients symptoms and other diagnostic fac- cocorticoids indicates that other treatment options
tors, there are four possible referrals (as indicated should be pursued.
by the four columns in the text box), which are ISSHL has been referred to as an otologic
described below. The Tinnitus Triage Guidelines emergency (Goodhill & Harris, 1979). Failure to
(Appendix B) is an information sheet that can be refer a patient with ISSHL for same-day ENT or
distributed to providers as a quick guide for triag- urgent care can jeopardize the patients chances of
ing their patients who complain about tinnitus. The recovering hearing function. The time course from
guidelines can be distributed to clinics that are the onset of symptoms until the initiation of corti-
likely to encounter these patients. The PTM Flow- costeroid therapy can be a factor in the chances of
chart (Appendix A) can be printed on the back side recoverythe more expediently these patients are
of the guidelines (Appendix B) to provide a single seen, the better their prognosis (Jeyakumar, Fran-
sheet with the essential triage/referral information. cis, & Doerr, 2006).

Emergency TriageUrgent Care or Triage Patient to Mental Health

Some patients require mental health assessment,
Idiopathic sudden sensorineural hearing loss (ISSHL) either because of obvious manifestations of mental
or facial palsy indicates an urgent need to be seen health problems or because of expressed suicidal
by otolaryngology or urgent care. ISSHL has been or homicidal ideation. If there is a question about
defined as hearing loss of at least 20 dB across three the patients mental health, then screening tools are
adjacent audiometric test frequencies (Battaglia, available to assist in determining the need for refer-
Burchette, & Cueva, 2008). However, at the time ral (J. A. Henry et al., 2008b). Some patients experi-
of initial report, patients usually do not have the ence extreme anxiety or depression in reaction to
results of an audiogram. Thus, if the patient reports tinnitus and should be referred to a mental health
an unexplained decrease in hearing sensitivity, provider the same day symptoms are reported
then ISSHL should be suspected. The loss typically although this would not be an emergency referral.
occurs over the course of three days or less and has Suicidal or homicidal ideation warrants special
no clear precipitating cause. attention, and referral guidelines are available for
Although the etiology of ISSHL is unknown, these patients (G. K. Brown, Henriques, Sosdjan, &
possible causes include labyrinthitis (viral or bacte- Beck, 2004; Hawton, 2001; Kessler, Borges, & Wal-
rial), vascular disruption, labyrinthine membrane ters, 1999).
Level 1 Triage 37

In preparation for possible referrals, it is best to These audiologists also generally work within a net-
establish a relationship with local emergency men- work of providers who specialize in tinnitus. Access
tal health providers, such as the nearest emergency to such a network is important to the patient.
room, in-house security personnel, or on-call men- It commonly is reported that many patients
tal health providers. Many sites now have a suicide with tinnitus also suffer from a loudness tolerance
coordinator. Such mental health providers possess problem (usually referred to generically as hyper-
the skills and resources for assessing and respond- acusissee Chapter 1 for related definitions). In
ing to a patients risk of suicide or violence. reality, most patients suspected as hyperacusic
do not require intervention specific to loudness
tolerance. Treatment for the condition generally
Triage Patient to Otolaryngology requires a program of systematic exposure to sound,
which is accomplished when implementing sound
Health care providers should refer patients to oto- therapy for tinnitus. For patients with a severe
laryngology if certain symptoms coexist with the hyperacusis problem, specific therapeutic programs
tinnitus. Patients require a medical examination are available (J. A. Henry, Trune, et al., 2007a).
and a hearing assessment if their symptoms suggest Chapter 6 describes the program that is used with
a somatic origin of tinnitus (e.g., pulsatile tinnitus), PTM for patients who have a severe loudness toler-
or if there is ear pain, drainage, or malodor. (Please ance problem.
see Chapters 1 and 5 for information about somato-
sounds.) Vestibular symptoms also require referral
to otolaryngology. The urgency of these referrals is
determined by the clinician. Referral to audiology
also is indicated in these casesideally, patients
should see an audiologist first so that audiologic Patients complain of tinnitus in many different clin-
test results are available to the otolaryngologist. ics. However, most providers do not know what to
tell these patients, nor do they know how to refer
them most appropriately. Normally, a referral to
Triage Patient to Audiology audiology is appropriate. However, there are symp-
toms that suggest urgent or other care is required.
Patients complaining of tinnitus should be referred We have explained those symptoms and provided
to audiology if symptoms suggest that a medical the Tinnitus Triage Guidelines (Appendix B), which
examination is not necessary. These patients require can be distributed to any clinic that would be the
a hearing assessment by an audiologist in addition point of contact for patients who complain about
to a brief assessment of the severity of the tinnitus tinnitus. These guidelines are appropriate for the
(see Chapter 5) (J. A. Henry et al., 2008b). Triag- majority of patients who complain of tinnitus, but
ing patients to audiology requires: (a) symptoms they do not address all patients. It was noted above
suggest a neurophysiologic (not somatic) origin that the clinician is the final arbiter of any decision
of tinnitus; (b) no ear pain, drainage, or malodor; to refer a patient.
(c) no vestibular symptoms; (d) no physical trauma, Different methods for managing reactions to
facial palsy, or ISSHL; and (e) no obvious mental tinnitus can be beneficial to patients when offered
health symptoms or suicidal ideation. by qualified tinnitus specialists. Thus, it is essential
It is important to refer patients to audiologists to inform patients who complain of tinnitus that
who have expertise in tinnitus management. These good services are available, but that they must be
audiologists have the ability to implement several careful to obtain services only from qualified prac-
different options for intervention, including use titioners. Due to the subjective nature of tinnitus, a
of ear-level devices (hearing aids, maskers, and great many tinnitus therapies have been developed
combination instruments), educational therapies, that have no scientific basis. Patients bothered by
and specific sound-based methods of intervention. tinnitus have been known to try just about anything
38 Progressive Tinnitus Management: Clinical Handbook for Audiologists

in an effort to obtain relief. It is unfortunate that this responsibility of providing accurate and positive
condition is vulnerable to questionable practices. information to these patients and referring them
Medical providers of all disciplines thus have the appropriately for any needed services.

Level 2 Audiologic Evaluation

Tinnitus is a symptom of dysfunction within the The Level 2 evaluation includes a standard
auditory system, and usually is associated with comprehensive hearing evaluation as well as writ-
some degree of hearing loss (Axelsson & Ringdahl, ten questionnaires to assess the patients perception
1989; A. Davis & Refaie, 2000; J. L. Henry & P. H. of the relative impact of hearing and tinnitus prob-
Wilson, 2001; Vernon, 1998). As stated in Chapter lems. Patients who require amplification receive
3, an audiologic examination should be the clinical hearing aids, which can result in satisfactory man-
starting point for all patients who complain of tin- agement of reactions to tinnitus with minimal edu-
nitus, unless urgent medical services are required. cation and support. Any patient who experiences
In addition to the audiology testing, it is critical to problematic tinnitus (even if they will receive hear-
determine how much of a patients complaint is due ing aids) is advised to participate in the Level 3
to a hearing problem and how much is due specifi- Group Education workshops.
cally to the tinnitus. A brief assessment should be
performed to determine if intervention specific to
tinnitus is warranted.
Tinnitus and Hearing Survey
The objectives of the Level 2 Audiologic Eval-
uation are to determine the potential need for (a) a
medical examination (usually from an otologist As discussed in Chapter 3, patients who report
or otolaryngologist); (b) mental health screening problems with tinnitus may really be experiencing
(from a psychologist, psychiatrist, or other mental problems with hearing. The Tinnitus and Hearing
health provider); and/or (c) audiologic intervention Survey (THS; Appendix D) is a brief questionnaire
(which can include intervention for hearing loss, designed specifically to assist patients and clini-
tinnitus, and reduced tolerance to sound) (J. A. cians in determining how much of a patients
Henry et al., 2008b). (Appendix C provides an over- reported problem is due to tinnitus and how much is
view of objectives and procedures of the Level 2 due to hearing problems. The survey also contains
Audiologic Evaluation.) two items that screen for sound tolerance problems.
40 Progressive Tinnitus Management: Clinical Handbook for Audiologists

The THS contains three sections. Section A also suffer from hyperacusis. In reality, many or
includes four statements that address tinnitus- most patients who are identified as hyperacusic
specific problems unrelated to hearing problems. do not require intervention specific to sound toler-
Section B contains four statements that focus on com- ance. Treatment for reduced sound tolerance usually
mon hearing problems. The Section B statements requires a program of systematic exposure to sound.
are phrased to minimize any perceived effects of The PTM sound therapy approach simultaneously
tinnitus on hearing function. Higher scores for Sec- addresses reduced sound tolerance. Therefore,
tion A indicate a tinnitus-specific problem, whereas sound therapy should be the starting point for PTM
higher scores for Section B indicate a hearing patients who have reduced sound tolerance and
problem. Results of this survey, along with results are able to participate in a program of sound-based
of the hearing evaluation, provide the clinician tinnitus therapy. The key concern for audiologists
with the information needed to differentiate tinni- is to determine if reduced sound tolerance will
tus-specific problems from hearing problems. Sec- interfere with the intervention. Of course, it should
tion C asks patients if they have sound tolerance be the patients decision to focus on addressing
problems. Affirmative responses to Section C sound tolerance rather than tinnitus.
should be discussed with patients to determine the
potential need to temporarily suspend the PTM
protocol to focus on treating the sound tolerance Using the Tinnitus and Hearing
problem. Survey to Determine Candidacy for
After completing the THS, patients should
Level 3 Group Education
understand that the problems listed in Section A
are problems that can be addressed with tinnitus
management. Section B problems can be addressed Section A of the THS is used to assist in determining
with intervention specific to hearing, regardless if a patient should attend Level 3 Group Education.
of the cause of the hearing problem. Section C Following the steps below can help to ensure that
addresses possible sound tolerance problems. patients do not attend the Level 3 workshops with
Patients who have tinnitus-specific problems the misconception that they will learn to manage
should be advised to participate in Level 3 Group a hearing-in-noise problem (which patients often
Education. Attending the Level 3 workshops will believe is the result of the tinnitus blocking sounds
include provision of the self-help workbook (How to they are trying to hear.)
Manage Your Tinnitus: A Step-by-Step Workbook) (J. A.
Henry et al., 2010a). Management options for hearing- n Explain that group education focuses on
related problems include amplification, assistive lis- finding ways to manage tinnitus-related
tening devices, and auditory rehabilitation services. problemsthe workshops do not focus
Management options for sound tolerance problems on hearing-related problems.
include a special sound tolerance handout (What to n Confirm that the patient is interested
Do When Everyday Sounds Are Too LoudAppen- in attending workshops that address
dix E), sound desensitization procedures, and par- tinnitus-related problems.
ticipation in the sound tolerance evaluation and n Ensure that the patient understands that
management (STEM) protocol (for patients who participating in Level 3 Group Education
would have difficulty participating in Level 3 Group does not preclude receiving concurrent
Education because of reduced sound tolerance). services for managing hearing problems.
n Ensure that the patient does not have a
sound tolerance problem to such a degree
PTM Approach to Managing Sound that it would be difficult to participate in
Tolerance Problems the Level 3 workshops.

Tinnitus clinicians and researchers often report that If the above requirements are met, then the patient
a relatively high percentage of patients with tinnitus likely is a candidate for Level 3 Group Education.
Level 2 Audiologic Evaluation 41

Patient Example: Linda tolerance is such a problem that the patient can-
not continue with the normal PTM protocol, then a
Using the THS, a patient (Linda) provides a low separate protocol should be undertaken to address
score for Section A (tinnitus section) and a high the sound tolerance problem. The STEM proto-
score for Section B (hearing section), but reports col (Chapter 6) was developed for this purpose.
a severe tinnitus problem. The Level 2 Audiologic Once the sound tolerance problem is sufficiently
Evaluation reveals that Linda has noise induced, resolved, then the patient can re-enter the PTM
high frequency, sensorineural hearing loss. Linda protocol if necessary to address any tinnitus prob-
states that the problems listed in Section B are lems. Normally, reentry into PTM would involve
those that she finds most irritating and upset- the patient attending the Level 3 workshops (see
ting, and she believes those problems are caused Appendix A).
by the tinnitus. After explaining the objectives of
Level 3 Group Education, the audiologist helps her
to recognize that she probably would not benefit
from a class that focuses on Section A problems. Tinnitus Handicap Inventory
She understands that audiologic management is
needed to address the Section B problems. She is Standardized tinnitus questionnaires are used
happy to receive the self-help workbook (How to to obtain a global index score of a patients per-
Manage Your Tinnitus: A Step-by-Step Workbook) to ceived tinnitus severity, and many questionnaires
learn more about her tinnitus. are available for this purpose (C. W. Newman &
Sandridge, 2004). A tinnitus-severity index score
from a tinnitus questionnaire, however, should not
Using the Tinnitus and Hearing Survey be relied on as the sole indicator of the degree to
to Determine Need for Intervention for which tinnitus affects a patients life (as explained
Reduced Sound Tolerance in the next section).
A tinnitus questionnaire provides a standard-
Section C of the THS is used to assist in determining ized baseline of the patients perceived problem
if a patient needs intervention for reduced sound due to tinnitus, and it is essential to acquire this
tolerance. Following the steps below can help to baseline prior to any testing or counseling. We rec-
ensure that reduced sound tolerance is addressed ommend using the Tinnitus Handicap Inventory
when needed. (THIAppendix F) (C. W. Newman et al., 1996)
for this purpose because it is one of the most widely
Section C, Item 1 used and best documented of the tinnitus question-
naires that currently are available. For manage-
Any patient who reports a sound tolerance prob- ment with PTM, the THI can serve as the primary
lem (of any degree) should receive the sound toler- outcome instrument. Patients should complete the
ance handout (What to Do When Everyday Sounds THI to assess outcomes at intervals (e.g., every
Are Too LoudAppendix E). 3 months) during ongoing intervention, and prior
to terminating intervention.
Section C, Item 2 The THI contains 25 statements, and response
choices are no (0 points), sometimes (2 points),
If a patient reports that a sound tolerance problem and yes (4 points). The index score ranges from 0 to
would make it difficult to attend the Level 3 work- 100. Handicap severity can be categorized based on
shops, this should be thoroughly discussed to ascer- the THI index score as follows (Handscomb, 2006):
tain that the patient would indeed have difficulty
attending a group workshop specifically because n Severe (58100)
of a sound tolerance problem (and not because of n Moderate (3856)
some other reason such as social anxiety, transpor- n Mild (1836)
tation problems, severe hearing loss, etc.). If sound n No handicap (016)
42 Progressive Tinnitus Management: Clinical Handbook for Audiologists

A change in the total index score of at least 20 points tool for all patients undergoing Level 2 Audiologic
has been reported to indicate a statistically and Evaluation. Results of the HHI provide additional
clinically significant change in self-perceived tinni- information to better understand how much of a
tus handicap (C. W. Newman & Sandridge, 2004). patients complaints about tinnitus may be attrib-
A 10-question screening version of the THI utable to hearing handicap, which contributes to a
(THI-Ssee Appendix F) also can be used (C. W. more accurate interpretation of patients responses
Newman, Sandridge, & Bolek, 2008). The THI-S to the THI and THS.
includes 10 of the same questions as the full-length Four versions of the HHI can be used. The
THI and usually takes less than two minutes to com- Hearing Handicap Inventory for the Elderly (HHIE)
plete. Comparison of the THI-S to the THI revealed is intended for patients age 65 and older (Ventry
a high correlation (r= 0.90). An index score of at & Weinstein, 1982). The Hearing Handicap Inven-
least 6 points (out of a possible 40 points) on the tory for Adults (HHIA) is intended for patients less
THI-S was established as a fence for recommend- than 65 years of age (C. W. Newman, Weinstein,
ing follow-up. A change of more than 10 points is Jacobson, & Hug, 1990). Both the HHIE and HHIA
considered a significant clinical difference. are 25-item self-assessment scales that include two
subscales (emotional and social/situational). The
HHIA differs from the HHIE only in that it includes
How Do the Tinnitus Handicap Inventory questions about occupational effects of hearing
and Tinnitus and Hearing Survey Differ? loss. The screening versions of the HHIE (HHIE-S)
and the HHIA (HHIA-S) each include 10 items and
The THI and THS are used to accomplish different can be completed in 5 minutes or less (Lichtenstein,
objectives, and each is important for PTM. Bess, Logan, & Burger, 1990; Ventry & Weinstein,
The THI is a statistically validated and widely 1983). The HHIE-S can be used with all patients
recognized tool for assessing self-perceived tinnitus and is recommended for routine use at the Level 2
handicap, making it appropriate for standardized Audiologic Evaluation (Appendix G).
assessment of outcomes of clinical intervention.
A patients index score from any tinnitus question-
naire, including the THI, is vulnerable to influence
Assessment of Auditory Function
from hearing problems and cannot be relied on as
the sole indicator of candidacy for Level 3 Group
Education. A standard audiologic evaluation provides the
The THS is not a validated outcome instru- information necessary to determine need for refer-
ment, and therefore should not be used as a pri- ral for medical evaluation and to determine can-
mary measure of outcome of intervention. The didacy for audiologic hearing intervention. This is
THS was designed to differentiate tinnitus-specific routine practice for audiologists, but some of the
versus hearing-specific problems, which is helpful procedures warrant special considerations when
for determining if a patient should attend Level 3 patients present with tinnitus.
Group Education. The THS can be used informally Otoscopy is performed routinely prior to plac-
to monitor relative progress alleviating tinnitus ing earphones for audiometric testing. Even a small
problems versus hearing problems. amount of cerumen on the tympanic membrane can
create a mass effect resulting in a high frequency
conductive hearing loss and tinnitus (Schechter &
J. A. Henry, 2002). Therefore, it is important to con-
Hearing Handicap Inventory
sider this possibility when performing otoscopy.
Pulsed tones often are recommended for use
The Hearing Handicap Inventory (HHI) is a self- when evaluating pure-tone thresholds in patients
administered questionnaire that assesses self- with tinnitus (Douek & Reid, 1968; Fulton & Lloyd,
perceived handicap imposed by hearing loss. Use of 1975; Green, 1972; Yantis, 1994). Investigations,
the HHI is recommended as a standard assessment however, have revealed that hearing thresholds
Level 2 Audiologic Evaluation 43

generally are the same whether tones are presented n Symptoms consistent with Mnires
in the pulsed or continuous mode (J. A. Henry & disease
Meikle, 1999; Hochberg & Waltzman, 1972; Mineau n Symptoms consistent with somatic
& Schlauch, 1997). It is acceptable to use either origin (i.e., vascular, muscular, skeletal,
pulsed or continuous tones for threshold testing, respiratory, or TMJ) of tinnitus (see next
although the use of pulsed tones may assist some section below)
patients in distinguishing between the tones and n Ear pain, drainage, or malodor
the tinnitus, especially when the tinnitus pitch is n Vestibular symptoms
close to the test frequency. n New-onset tinnitus or hearing loss
Some patients with tinnitus have trouble tol- n Progressive tinnitus (tinnitus that is
erating louder sounds, and some report that loud perceived as changing in loudness, pitch,
sounds make their tinnitus louder. It is important and/or timbre over time)
to use caution when conducting suprathreshold n Significant conductive loss of
audiometric testing. The following guidelines can undetermined etiology
be helpful: n Unilateral or grossly asymmetric hearing
n Use the softest effective masking sounds
during traditional audiometry (the need The most common type of tinnitus is associated
for masking can be reduced by using with noise-induced hearing loss. These patients
insert earphones that increase interaural usually report that their tinnitus has been fairly
attenuation). stable for years. This common form of tinnitus can-
n Use conservative levels of sound during not be corrected surgically, nor is it life threatening.
word recognition testing. Although a medical exam always is in the patients
n Approach reflex threshold and decay best interest, an otologic exam may be eliminated
testing with particular caution as some if all of the following conditions apply:
patients have trouble tolerating the
n All symptoms and conditions that indicate
sounds used in these tests. In no instance
the need for referral to otolaryngology
should pure tones be delivered above
(listed above) have been ruled out.
105 dB HL. Speech stimuli should not be
n Patient reports a history of noise exposure
delivered above 100 dB HL.
and concurrent or subsequent onset of
n Tinnitus is symmetric and nonpulsatile.
Assessment of Potential Need for n Audiogram is consistent with a diagnosis
Otolaryngology Exam of symmetric sensorineural hearing loss.

As the ideal, every patient complaining of tinnitus Symptoms of Somatosounds

would be examined by an otolaryngologist or otol-
ogist (Perry & Gantz, 2000). However, this may not We briefly described somatic tinnitus (somato-
be practical or realistic in some settings. Audiolo- sounds) in Chapter 1. It is important for clinicians to
gists sometimes are the only health care providers realize that many sounds of the head and neck are
who evaluate patients with tinnitus complaints. normal (Hazell, 2003). When we swallow we hear a
Audiologists must be aware of symptoms and con- clicking sound. There is a great deal of blood puls-
ditions that indicate the need for referral to otolar- ing through the head and neck at any given time
yngology, which include: causing constant loud pulsations (that we normally
dont perceive). The carotid artery passes within
n Symptoms consistent with vestibular about 6mm of the cochlea, and we occasionally can
schwannoma or other retrocochlear hear sounds of the heart through this artery. Addi-
pathology tional sounds are caused by joints and muscles, the
44 Progressive Tinnitus Management: Clinical Handbook for Audiologists

eustachian tube, and air passing through the air- pani syndrome (Hazell, 1998b). A patulous eusta-
ways. Although all of these sounds are considered chian tube remains open abnormally. This condition
normal, they become abnormal when heard on a often is misdiagnosed as a blocked eustachian tube
daily basis or when they cause distress. (Schuknecht, 1993). Symptoms can include a sense
Somatosounds generally can be categorized of ear fullness, respiratory noises, and autophony
as pulsatile and nonpulsatile (Hazell, 1998b). Pul- (abnormal loudness of ones own voice). Palatonal
satile somatounds include venous hums, vascular myoclonus is caused by rapid contractions of the
loops, and carotid transmissions. Venous hums are soft palate musculature (Hazell, 1998b; Lockwood
caused by turbulent blood flow through the jugular et al., 2004). These contractions may be associated
bulb, which is a protrusion into the mastoid cavity with contractions of other muscles in the head and
(close to the middle ear) of the internal jugular vein. neck. The contractions can cause the eustachian
A large amount of blood flows rapidly through the tube to open and close, giving the perception of
jugular vein, causing vibration of the vein walls an irregular clicking/snapping sound in one or
that is perceived as a humming noise. This is easily both ears. Tensor tympani syndrome is caused by
evaluated by an otolaryngologist and is a benign spasms of the tensor tympani muscle that produces
condition. Vascular loops within the internal audi- a fluttering low frequency sound (Hazell, 1998b).
tory canal can compress the auditory nerve (Nuttall The sound may be correlated with the sensation of
et al., 2004). This compression can cause auditory an insect fluttering in the ear canal. This condition
nerve activity that may be perceived as sound, generally is benign but may be alleviated by sec-
which may be pulsatile (Mller, 1995; Nuttall tioning of the tensor tympani muscle.
etal., 2004). Surgery can remediate tinnitus caused
by vascular compression of the auditory nerve. Somatically Modulated Tinnitus
Carotid transmissions refers to any transmission of
sound to the cochlea from the carotid artery. This Some patients report that movements or manipula-
often is caused by stenosis of the carotid artery, but tions of the eyes, head, neck, jaw, or shoulder can
also can include transmission of heart murmurs cause changes in the loudness or pitch of their tinni-
(Hazell, 1998b; Lockwood et al., 2004). tus. This phenomenon is referred to as somatically
There are many other potential causes of pulsa- modulated tinnitus. It has been reported by some
tile tinnitus, which have been described (Lockwood investigators that the phenomenon is much more
et al., 2004; Sismanis, 1998, 2003, 2007). Although prevalent than previously thoughtwith up to 80%
rare, life-threatening pathology may be associated of patients reporting that their tinnitus can be mod-
with pulsatile tinnitus (Sismanis, 2007). It thus is ulated somatically when asked the right questions
critical to establish an appropriate diagnosis for (Levine, 2004). If a patient does report that move-
these patients. In general, a patient with pulsatile ment of the head or neck can change the loudness
tinnitus should be medically evaluated to rule out or pitch of the tinnitus, then the question arises as
potential vascular or neurologic conditions that to how to properly refer these patients. In general,
require medical or surgical treatment. These may all of these patients should be evaluated by an
include hypertension, hyperthyroidism, carotid audiologist. The audiologist then can determine if a
blockage, glomus tumor, arteriovenous malforma- referral to otolaryngology or neurology is necessary.
tion, aneurisms, and so forth. Glomus tumors are
rare, but they are the most common tumor of the
middle ear and second most common of the tem-
Administer Tinnitus Problem
poral bone (second to vestibular schwannoma)
Checklist (optional procedure)
(Moffat & Hardy, 1989). Any mention of tumors to
patients can cause alarm and anxiety. It therefore is
important to assure patients that these tumors are To conclude the Level 2 Audiologic Evaluation, it
rare, and if they occur they usually are benign. is important to review results of the Tinnitus and
Nonpulsatile somatosounds include patulous Hearing Survey, Tinnitus Handicap Inventory, Hear-
eustachian tube, palatal myoclonus, and tensor tym- ing Handicap Inventory, and hearing assessment.
Level 2 Audiologic Evaluation 45

The patient should understand that problems listed instruments should not be an option for patients
in Section A of the Tinnitus and Hearing Survey until they have learned about and implemented
are specific to tinnitus and are addressed in Level different strategies of using sound for tinnitus man-
3 Group Education, and that problems in Section agement as addressed in Level 3 Group Education.
B are addressed by an audiologist and are not cov- The knowledge and experience of using sound to
ered in Level 3 Group Education. manage tinnitus gained during Level 3 allows
If the patient has a tinnitus-specific problem, patients to make informed decisions about using
and if time permits, then the Tinnitus Problem noise generators and combination instruments.
Checklist (Appendix H) can be helpful. Use of the Many patients can learn how to self-manage their
checklist is the starting point for teaching a patient tinnitus without having to use special ear-level
how to use sound to manage tinnitus, as described instruments. If instrument use is warranted, then
in the self-help workbook (How to Manage Your Tin- the proper use of these devices requires multiple
nitus: A Step-by-Step Workbook) (J. A. Henry et al., appointments with an audiologist who understands
2010a). Using the checklist provides structure to their use within the context of PTM.
talk to patients about any problems they experi- Although we generally recommend fitting
ence that are caused by the tinnitus. The checklist only hearing aids at Level 2, recent developments
also gives the patient information that is useful to need to be considered. In the past, combination
understanding how the workbook can be used, instruments included amplification features that
which is an advantage to patients who receive a were limited relative to hearing aids. Patients who
copy of the workbook. were fitted with combination instruments often did
not receive amplification that optimally addressed
their hearing loss. That situation has changed with
the recent introduction of new combination instru-
Hearing Aid Evaluation
ments from a number of hearing aid companies.
(if warranted)
These combination instruments do not sacrifice
hearing aid features so patients can be fitted with
Most patients with tinnitus have some degree of these devices as high-quality hearing aids. When
hearing loss and hearing aids sometimes can ade- fitting such combination instruments at Level2, it
quately ameliorate both their hearing and tinni- might be preferable to not use the noise feature of
tus problems (Surr et al., 1999, 1985). All patients the devices until the patient has attended a Level 3
should be advised of the potential for hearing aids workshopto ensure that the patient fully under-
to alleviate tinnitus as a secondary benefit. In some stands the different uses of therapeutic sound
instances, hearing aids can be used primarily for before actually using it with these devices.
managing tinnitus with improved hearing as a sec-
ondary benefit (J. A. Henry et al., 2008b; J. A. Henry,
Zaugg, et al., 2005a; Searchfield, 2005). Patients with Hearing Loss
The Flowchart for Assessment and Fitting of
Ear-Level Instruments (Appendix I) shows the clin- At Level 2, patients with hearing loss are provided
ical actions for PTM Levels 2 through 5with the amplification, assistive listening devices, and edu-
focus on ear-level instruments. The Level 2 Audio- cation in communication strategies as necessary to
logic Evaluation includes an assessment of candi- maximize their hearing function. Since impaired
dacy for hearing aids. If the patient is a hearing aid hearing may be the patients primary problem
candidate, then hearing aids are fitted as appropri- (often unknowingly prior to the hearing evalua-
ate. The preferred approach to providing patients tion), it is essential to optimize hearing function.
with ear-level instruments is to dispense only hear- Furthermore, patients who progress to Level 3
ing aids at Level 2 and not to provide ear-level Group Education require adequate hearing in
combination instruments or noise/sound genera- order for them to comprehend the presentation and
tors until after patients have completed Level 3 group discussion. Patients who receive hearing
Group Education. Noise generators and combination aids and/or assistive listening devices will receive
46 Progressive Tinnitus Management: Clinical Handbook for Audiologists

instruction in how to use these devices (along with degree of loss) to allow normal entry of
many other uses of sound and sound devices) for environmental sound (especially lowest
the management of tinnitus. frequency sounds that are not amplified
by the hearing aids) and to reduce the
sensation of occlusion. Both factors can
Patients With Normal Hearing contribute to reducing tinnitus perception.
n Hearing aids with feedback reduction
For Level 2 patients who have normal hearing and circuitry can facilitate the use of open-
problematic tinnitus, Level 3 Group Education is ear design hearing aids, or larger vent
recommended. In the group workshop, these patients diameters.
learn how to use sound (from many sources) to n Special noise suppression circuitry
manage their reactions to tinnitus. Some of these actually can be a detriment to patients
patients will acquire the skills needed for satisfactory with tinnitus, as noise suppression could
management and will not need further intervention. eliminate some background sound that
Others may require further help after completing might be helpful for these patients. What
Level 3, at which point they should be considered may be a goal for optimal hearing aid
for a Level 4 Interdisciplinary Evaluation that nor- performance may be at cross-purposes for
mally includes an evaluation for ear-level noise gen- tinnitus management. If a patient with
erators. Because of their personal experience using tinnitus has hearing aids with multiple
sound to manage tinnitus at Level 3, these patients memories, then a consideration is to
should be well prepared to participate fully in any program one of the memories to minimize
decision about using ear-level noise generators. noise reduction (as the tinnitus setting)
with the microphone set to omnidirectional,
Use of Hearing Aids With PTM and adjusted to minimize the reduction of
background sound. Some hearing aids
For audiologists, the provision of hearing aids is a offer music settings, or other settings
routine service with an established skill set. Audi- that minimize use of algorithms to
ologists are trained and experienced in the selec- eliminate nonspeech sounds.
tion and fitting of hearing aids for the purpose of n Some hearing aids offer sound generator
improving hearing. If hearing aids are incorporated settings that can be activated/repro-
into management for tinnitus, then the audiologist grammed after Level 3 Group Education
essentially has the training necessary to perform is provided if amplification alone does not
this service (J. A. Henry, Zaugg, et al., 2005a). The ameloriate effects of tinnitus.
method of PTM makes full use of these existing n Reduced levels of internal noise also can
skills to apply them directly to addressing tinnitus. be detrimental to tinnitus management.
There are, however, special considerations for the In older hearing aids, the floor noise of
use of hearing aids with these patients (Appendix J). hearing aids often was helpful for
tinnitus patients.

Hearing Aids for Managing

Reactions to Tinnitus Benefits of Amplification for Patients
With Tinnitus
Special considerations are important with respect to
using hearing aids for tinnitus management (these Beneficial effects on tinnitus from the use of ampli-
points are summarized briefly in Appendix J): fication may be due to:

n The ear canal should be left open as n Amelioration of communicative

much as possible (or venting should be difficulties caused by hearing loss but
maximalas appropriate for slope and attributed to tinnitus
Level 2 Audiologic Evaluation 47

n Alleviation of stress associated with mental health issues should be performed (unless
difficult listening situations the patient already is diagnosed with a mental
n Increase in ambient sound that can reduce health condition[s] and currently is receiving care
the effects of tinnitus (typically, ambient accordingly). Mental health screening also can be
sound makes tinnitus less noticeable) done at any stage of PTM at the clinicians discre-
n Stimulation of impaired portions of the tion. If possible, such screening ideally is conducted
auditory system that often are deprived by a mental health or primary care provider. In
of sound. most medical centers, primary care offers compe-
tent and efficient mental health screening services.
Thus, it usually is preferable to refer patients who
are suspected of mental health conditions to pri-
Refer for Mental Health
mary care for screening. However, different facili-
Screening (if indicated)
ties may handle mental health screening differently
so it is important to determine the procedures
Certain mental health disorders are known to be used at each facility. If screening is not available
associated with the presence and severity of tin- elsewhere, it can be useful for an audiologist to
nitus. Clinical depression and anxiety often affect use specific questionnaires to screen for the more
patients who experience the most problematic common comorbid conditions of sleep problems,
tinnitus (Dobie, 2003; Halford & Anderson, 1991; PTSD, anxiety problems, and symptoms of depres-
Kirsch et al., 1989). In addition, some patients suf- sion (see Chapter 8).
fer from post-traumatic stress disorder (PTSD).
PTSD is suspected if the patient reports having
been exposed to a trauma and subsequently expe-
Refer for Assessment of Sleep
rienced nightmares, flashbacks, exaggerated startle
Disorder (if indicated)
responses, or excessive anxiety or fear. The trau-
matic event does not need to be recent for a patient
to experience PTSD. Sleep disorders are the most common problem
Although depression, anxiety, and PTSD com- reported by patients who are bothered by tinni-
monly are associated with tinnitus, many other tus (Axelsson & Ringdahl, 1989; Jakes et al., 1985;
mental health disorders also may present along with Meikle et al., 2004; Tyler & Baker, 1983). Patients
tinnitus. These can include substance abuse (opi- with sleep disorders also tend to report the most
ates, amphetamines, sedatives, cocaine, marijuana, severe tinnitus (Erlandsson, Hallberg, & Axelsson,
hallucinogens, alcohol, etc.), bipolar disorder, psy- 1992; Folmer & Griest, 2000; Meikle, Vernon, &
chotic disorders, attention-deficit/hyperactivity Johnson, 1984; Scott, Lindberg, Melin, & Lyttkens,
disorder, panic, phobias, and obsessive-compulsive 1990). These patients may need specialized treat-
disorder (J. A. Henry et al., 2008b). All of these con- ment from a physician, mental health professional,
ditions, and others, present in clinical settings in and/or sleep disorders clinician.
varying degrees. It is important to not limit screen- It is important to question a patient about
ing and referral to only mental health conditions details of a reported sleep disorder to determine
that have known or suspected interactions with tin- if referral is needed. In some cases a sleep disorder
nitus. Failure to refer patients for possible mental can be related to a serious medical condition. It also
health conditions reduces the likelihood of achiev- is important to distinguish between insomnia and
ing the desired outcomes from any tinnitus inter- sleep apnea. Insomnia is a problem with initiat-
vention. The concern for so many potential mental ing or maintaining sleep, which typically does not
health disorders in patients with tinnitus can present have serious medical effects. Sleep apnea is a con-
a conundrum for audiologists, which speaks to the dition whereby breathing during sleep is disrupted
need for a psychologist to be on the tinnitus team. and can have serious health effects such as stroke.
If indicated by a patients comments or behav- Patients who report snoring, morning headaches,
ior during the Level 2 evaluation, screening for gasping or choking upon waking, or those who
48 Progressive Tinnitus Management: Clinical Handbook for Audiologists

have a bed partner who reports the presence of The only way to know if a medication allevi-
these indications of sleep apnea, should be referred ates tinnitus is through trial-and-error (e.g., some
to primary care for assessment. antidepressants can cause or exacerbate tinnitus as
a side effect). This generally is what is done by phy-
sicians who attempt to use medications to treat tin-
Managing Sleep Disorder nitus. It is better for patients if they can be helped
with counseling and the proper use of sound rather
If a patients sleep disorder is a direct consequence than receiving medications that can have harmful
of the tinnitus, then effective tinnitus management side effects or result in dependency/addiction.
may resolve the sleep problem. This requires the
appropriate use of sound in the sleep environment.
In most cases, this should be attempted prior to
Self-Help Workbook
referring the patient out for insomnia treatment. The
use of sound is harmless and inexpensive, whereas
insomnia treatment can involve medications, side The self-help workbook (How to Manage Your Tin-
effects, and significant costs. Strategies for improv- nitus: A Step-by-Step Workbook) (J. A. Henry et al.,
ing sleep when tinnitus is a problem are explained 2010a) can be given to patients either at the end of
in the Level 3 workshops, and are included in the the Level 2 Audiologic Evaluation, or at the begin-
self-help workbook (J. A. Henry etal., 2010a). ning of Level 3 Group Education. It generally is
preferable to withhold provision of the workbook
until the patient shows up for the first Level 3
workshopfor a number of reasons: (a) Anticipat-
Prescription Drugs and Tinnitus
ing receiving the workbook increases the likelihood
that patients will participate in Level 3. Attending
No prescription drug has been developed specifi- the workshops increases the likelihood that patients
cally for tinnitus. However, some antidepressant will learn and benefit from the self-help informa-
or anxiolitic medications such as amitryptiline or tion. Also, increasing the group size can improve
lorazepam may reduce symptoms. These drugs the likelihood of meaningful interactions amongst
most commonly are used to address coexisting group members. (b) Many patients believe that
sleep disorders and mental health disorderspri- reducing the loudness of their tinnitus is the only
marily depression and anxiety (Dobie, 2004a; J. A. way to feel better and may be disillusioned by the
Henry, Zaugg, et al., 2005a; Robinson, Viirre, & workbook since it does not offer that option. These
Stein, 2004). These studies conclude that medical patients may not even attempt to implement the
management of sleep and mental health problems ideas contained in the workbook and thus may
can be a helpful component of an overall approach only be able to benefit from the workbook if guided
to managing reactions to tinnitus. through it by a clinician (and in a group setting
Certain medications can trigger or exacerbate sometimes it may be other group members who are
tinnitus, including aspirin, NSAIDS, loop diuret- best able to influence a patient that the ideas in the
ics, and quinine. Normally, fairly high doses are workbook can be helpful). (c) Providing the work-
required to cause tinnitus effects, and the effects book as a patient is leaving the clinic decreases the
usually are temporary. Drugs used to treat mental likelihood that the patient and clinician will dis-
health and sleep conditions also may trigger or exac- cuss the concepts. Discussion fosters interest and
erbate tinnitus. Patients have reported exacerbation learning, and is more likely to lead to the patient
of tinnitus due to alcohol and caffeine. Ototoxicity making behavioral changes that will reduce reac-
from aminoglycosides and platinum-containing tions to tinnitus and increase quality of life.
chemotherapeutic drugs are well-known causes of We recommend offering to provide patients
hearing loss and tinnitus, and these effects often are with their own copy of the workbook when they
irreversible (Fausti et al., 1995; Rachel et al., 2002). come to the first Level 3 workshop. Patients also
Level 2 Audiologic Evaluation 49

should be told about the 13-minute tinnitus video tinnitus should be assessed by an audiologist who
that they can view online (http://www.ncrar can determine what services are needed, including: This video (a) medical exam; (b) mental health screening; and
was professionally produced by VA Employee Edu- (c) audiologic intervention for hearing loss, tinni-
cation System and provides basic information that tus, and/or hyperacusis.
can help to increase interest in learning the con- The Level 2 Audiologic Evaluation consists
cepts that are taught in the workbook and Level mainly of a conventional audiologic assessment.
3 workshops. The DVD with the 13-minute video Because the patient reports tinnitus, a brief assess-
is available from the NCRAR (or from any of the ment of tinnitus impact is performed. The primary
authors of this handbook) and can be used in the tool for assessing tinnitus impact is the Tinnitus and
clinic to show to patients. Most patients find the Hearing Survey (THS). Results of the THS should
video to be entertaining and informative. be discussed with the patient to determine if tinnitus-
specific intervention is appropriate. In addition to
the THS, it is recommended to administer the Tinni-
tus Handicap Inventory (THI) and Hearing Handi-
cap Inventory for the Elderlyscreening version
(HHIE-S). Results of the THI serve as a statistically
The great majority of patients who report tinnitus validated baseline for assessing outcomes of the tin-
also have some degree of hearing loss. The essen- nitus intervention. Results of the HHIE-S facilitate
tial first step in providing clinical services for these interpretation of the THS and THI, and serve as a
patients normally is to assess their hearing func- statistically validated baseline for assessing out-
tion. Using the triage guidelines described in the comes of clinical services specific to hearing loss.
previous chapter, these patients may require a Combined, these three questionnaires provide useful
medical and/or a mental health examination. At data for documenting a patients complaints and for
a minimum, however, all patients who report determining clinical services that may be needed.

Sound Tolerance Evaluation and

Management (STEM)

As described in the previous chapter, the Tinnitus and sound help with the tinnitus, but it also can help to
Hearing Survey (Appendix D) includes two items increase tolerance to sound (Formby, Sherlock, &
in Section C that screen for reduced sound tolerance. Gold, 2002). If the patient indicates on the second
The first item determines if a patient perceives that item of Section C that he or she would not be com-
he or she has a loudness tolerance problem, and, if fortable attending Level 3 Group Education, then
so, how much of a problem. If a problem is reported, that should alert the clinician to discuss sound tol-
then the second item is used to determine if the erance with the patient and consider scheduling a
patient would experience difficulty attending the special appointment to evaluate the sound tolerance
Level 3 workshops due to the sound/loudness toler- problem. As mentioned above, some patients may
ance problem. If the patient reports a sound tolerance just wish to focus on their sound tolerance problem.
problem, but can attend the workshops to address
a tinnitus problem, then the patient normally should
attend the group sessions. Some patients, however,
What Is STEM?
may express a strong desire to focus on their sound
tolerance problem rather than the tinnitus, and those
wishes should be honored even if the patient is The sound tolerance evaluation and management
capable of participating in the Level 3 workshops. (STEM) protocol is an adjunct program primarily
During the Level 3 workshops, patients learn for patients who have a sound tolerance problem
how to use therapeutic sound in various ways for that precludes them from participating in the PTM
managing reactions to tinnitus. All of the sugges- protocol. These patients are identified at the Level2
tions for using sound to manage tinnitus also are Audiologic Evaluation as requiring the special STEM
relevant for managing a sound tolerance problem. program (see Chapter 5). Their progress through
That is, if the patient follows the suggestions for PTM is suspended temporarily until they complete
using therapeutic sound, then not only can the the STEM program. Sound-based intervention that
52 Progressive Tinnitus Management: Clinical Handbook for Audiologists

patients receive through the STEM program also dixE), the essence of treatment for a sound tol-
may resolve their tinnitus problem, in which case erance problem is the systematic use of sound to
they may not need to resume the PTM program decrease sensitivity to sound. Although there are
(see PTM FlowchartAppendix A). As a general different manifestations of a sound tolerance prob-
rule, however, any patients with problems specific to lem (as described in Chapter 1), a generic approach
tinnitus should be advised to participate in Level 3 to treatment usually is adequate. The treatment
Group Education. involves increasing ambient levels of sound (with
The STEM evaluation appointment can include the possible use of ear-level instruments) as well
three components: administering the Sound Toler- as increasing activities involving active listening to
ance Interview (STI), testing loudness discomfort sounds that the patient finds enjoyable. This com-
levels (LDLs), and trial use of ear-level instruments. bined approach thus includes: (a) passive listening
Only the STI is essential for the evaluation, that is, procedures, which address general hypersensitiv-
it is essential to conduct an in-depth interview to ity to sound, and (b) active listening procedures,
fully understand the nature and severity of the which address the emotional components of a
problem, and to develop an appropriate manage- sound tolerance problem. Procedures for address-
ment plan. The STI also provides data that can be ing these different components individually are
used as a baseline to evaluate progress over time. available using the method of tinnitus retraining
All patients who participate in STEM should therapy (TRT) (J. A. Henry, Trune, Robb, & P. J. Jas-
receive counseling for reduced sound tolerance. treboff, 2007a, 2007b; P. J. Jastreboff & Hazell, 2004).
A counseling protocol is provided in the patient These TRT procedures can be used if the clinician
counseling book (Progressive Tinnitus Management: has familiarity with the procedures.
Counseling Guide) (J. A. Henry et al., 2010b). Counseling for reduced sound tolerance is
provided in a structured format using the patient
counseling book (Progressive Tinnitus Manage-
ment: Counseling Guide) (J. A. Henry et al., 2010b),
Sound Tolerance Interview
which contains a special section for this purpose.
The counseling book functions like a flip chart to
The six-question Sound Tolerance Interview (STI) facilitate the one-on-one counseling. The content
(Appendix K) fits within the framework of PTM of the counseling corresponds closely with the
and serves to guide the STEM evaluation proce- patient handout What to Do When Everyday
dures. The interview starts with a series of questions Sounds Are Too Loud (Appendix E). The hand-
(embedded in Question 1) to determine if the use out normally is provided to patients at the Level 2
of hearing aids contributes to the patients reported Audiologic Evaluation if they report any degree of
sound tolerance problem. Questions 2 through 5 a sound tolerance problem. The counseling leads to
are used to obtain details concerning the kinds of an explanation of the Sound Tolerance Worksheet
sounds and activities that are problematic, and the (Appendix L). Patients learn how to complete this
degree of the problem in each case. Question 6 is special worksheet to develop customized plans for
intended to determine if the patient overprotects self-managing their sound tolerance problem using
his or her ears through the use of hearing protec- therapeutic sound.
tion. (Overuse of hearing protection can sustain or
exacerbate a sound tolerance problem.)
Testing Loudness Discomfort
Levels (optional procedure)
Treatment for Reduced
Sound Tolerance
Testing loudness discomfort levels (LDLs) is less impor-
tant than information obtained from the Sound Tolerance
As explained in the patient handout What to Do Interview. At the audiologists discretion, LDLs can
When Everyday Sounds Are Too Loud (Appen- be tested for patients who go through the STEM
Sound Tolerance Evaluation and Management (STEM) 53

program, but LDL testing is not normally recom- inconsistent when providing repeated LDLs within
mended. Although this is a debatable point, we a test session. Some providers therefore measure
consider LDL testing to be nonessential even when each LDL twice. This is done by first obtaining the
a patient has a severe problem with reduced sound LDLs in each ear, then repeating the entire set of
tolerance because: (a) testing LDLs can cause dis- measurements.
comfort and anxiety in patients; (b) the validity of
LDLs as a measure of loudness tolerance in daily Instructions to Patients
life has not been established; and (c) the results of
LDL testing do not normally guide intervention Loudness discomfort levels can vary considerably
procedures. depending on the test instructions given to the
If a patient has reduced tolerance to sound, patient, and on the patients interpretation of the
it is our position that the best indicator for estab- instructions. It is essential to read standardized
lishing the degree of a sound tolerance problem, scripted instructions verbatim and to ask patients to
and to monitor progress during treatment, is the repeat back the task as they understand it. Patients
patients subjective reportwhich is facilitated are instructed, You will listen to different tones. Each
through administration of a structured interview tone will be made slightly louder in steps. Tell me when
with the STI (see Appendix K). Results of the inter- the loudness of the tone would be ok for 3 seconds, but
view define the problem and indicate the course would not be OK for more than 3 seconds. The objec-
of action that should be taken, regardless of the tive is to identify the level for each frequency at
results of LDL testing. Some audiologists choose to which any further increase would cause discomfort.
do LDL testing, which is acceptable as long as the
patient is comfortable with the procedures. LDL Audiometric Procedures
procedures are described further below.
Testing in each ear should start at 1000 Hz, with
successive frequencies ordered from lowest to
Definition of LDL highest. The first tone is presented at the approxi-
mate most comfortable level (usually 60 dB HL is
The threshold level of discomfort for a sound appropriate to start). Each tone is presented for 1 to
defines that sounds LDL. The LDL should reflect 2 seconds, and successive tones are raised in 5 dB
the level just below physical discomfort and not steps until the LDL is reported. At each new fre-
just fear that the sound is going to become too quency, the starting level should be about 20 dB
loud (a common manifestation of phonophobia). below the previous frequencys LDL.
Clinical LDL testing can be done using pure tones, As LDL testing is probably the patients least
speech stimuli, and narrow and broadband noise. favorite procedure, it is important to perform the
Using pure tones, LDLs can be obtained at various testing as rapidly as possible (without compro-
audiometric frequencies, establishing the upper mising the measures). If two sets of measures are
limit of the auditory dynamic range for each fre- obtained, only the second set should be reported.
quency tested. Sounds would be tolerated comfort- Reliability of responding also should be noted.
ably anywhere within the dynamic range.

In-Clinic Trial Use of

Measuring Tonal LDLs
Ear-Level Instruments
(Please refer to Loudness Discomfort LevelsClini-
(optional procedure)
cal GuideAppendix M.) If tonal LDLs are tested,
then they should be obtained minimally at octave After the sound tolerance evaluation, which includes
frequencies between 1 and 8 kHz. LDL testing may administering the STI (Appendix K) and possi-
be performed at additional frequencies and with bly LDL testing (Appendix M), it then is decided
other types of auditory stimuli. Patients often are if the patient should be evaluated for ear-level
54 Progressive Tinnitus Management: Clinical Handbook for Audiologists

instruments. This decision depends largely on the each stock device to patients and allowing them
extent of the problem, which should be clear after to direct the process of adjusting the sound levels.
the evaluation. This process might take more or less time depend-
Although ear-level instruments might pro- ing on individual patient characteristics.
vide the optimal treatment for a sound tolerance
problem, they may not be necessary. Often, sound
enrichment using a variety of sound sources can
Definitions: Hyperacusis,
provide an adequate acoustic-desensitization pro-
Misophonia, Phonophobia,
tocol. The clinician should weigh the pros and cons
of ear-level instruments for each patient and decide,
Loudness Recruitment
along with the patient, if these devices might be the
best choice for treatment. If so, then in-clinic trial Definitions for these terms were provided in Chap-
use of ear-level instruments should be performed. ter 1. They are reviewed briefly here. Hyperacusis is
The in-clinic trial can be conducted either before or a physical condition of discomfort or pain caused by
after the counseling, whichever is most appropri- sound (J. A. Henry, Zaugg, et al., 2005a). The effect
ate for the patient. is restricted primarily to the auditory pathways.
Misophonia means literally dislike of sound,
implying that emotions somehow are involved
When Are Ear-Level Instruments in the reaction to sound (M. M. Jastreboff & P. J.
Indicated? Jastreboff, 2002). Misophonic reactions would be
learned responses, thus the same sound might be
The decision to use ear-level instruments with a bothersome in some situations and not in others.
patient who has hyperacusis is based primarily on Phonophobia is a subcategory of misophonia, and
two factors: (a) the patients sound tolerance condi- specifically is a fear response caused by sound (P. J.
tion must be reasonably severe to justify the use of Jastreboff & M. M. Jastreboff, 2000).
these instruments; and (b) the patient must be moti- Any or all of these conditions might apply to a
vated to use the instruments. If either of these factors patient who complains of loudness tolerance prob-
does not apply, then the patient should be counseled lems. None of these conditions should be confused
appropriately to use sound desensitization proce- with loudness recruitment, which is abnormally
dures without the use of ear-level instruments. rapid growth in the perception of loudness (Ver-
non, 1976). Recruitment usually is a symptom of
cochlear or sensorineural hearing loss.
Conducting the In-Clinic Trial For purposes of PTM, any condition of reduced
sound tolerance (hyperacusis, misophonia, phono-
The purpose of the in-clinic trial is to provide phobia) is referred to as hyperacusis. The STEM
patients with the experience of wearing and listen- program does not make a distinction between these
ing to sound-generating devicesto help them different conditions with respect to the counseling
decide if using ear-level instruments is desirable. and sound desensitization procedures. The treatment
The sound should be described as a soothing procedures are designed to address both physical
shower sound and not in negative terms such as and emotional aspects of reduced sound tolerance.
noise or static. It is possible that some patients will
not be comfortable listening to the sound, but that
even just wearing the instruments might be appro-
priate for the first phase of treatment (i.e., some
patients need to just wear the instruments turned
off for a period of time before they can start lis- We have conducted screenings and evaluations
tening to the sound emitted from the instruments). of thousands of patients with tinnitus in multiple
Conducting the trial simply is a matter of fitting clinics as part of our clinical studies. It has been
Sound Tolerance Evaluation and Management (STEM) 55

our experience that many of these patients report phonia. Very few patients have pure hyperacusis
a sound tolerance problem, but that a very small or pure misophonia (see Chapter 1), thus a com-
number actually experience a severe problem bined approach usually is appropriate. For these
warranting special evaluation and treatment pro- patients, special consideration should be given
cedures. If patients do have a severe hyperacusis to collaborating with mental health clinicians to
problem (or if they just want treatment for reduced address potential psychological components of
sound tolerance), then the STEM protocol should the problem. Behavioral interventions have been
address their needs. The STEM protocol is imple- shown to be highly effective in decreasing patients
mented before the flow of PTM services continues, responses to intense fear. Such interventions have
that is, these patients should be treated separately been well described in the CBT literature (Hofmann
and then worked back into PTM as warranted by & Smits, 2008). Thus, psychological interventions
tinnitus-specific complaints. such as CBT may be used to help patients system-
With the STEM protocol, all patients with a atically modify their fear responses, habituate to
severe sound tolerance problem are assumed to everyday sounds, and achieve a greater sense of
have some combination of hyperacusis and miso- well-being and control.

Level 3 Group Education

Chronic tinnitus usually is a permanent condi- shops because of their emphasis on interaction
tion. In most cases tinnitus cannot be quieted, but and participation. The standard protocol consists
patients can learn to manage their reactions to it. of five weekly workshopstwo presented by an
These reactions may need to be managed for a audiologist and three by a psychologist (or other
lifetime. Clinical intervention with PTM focuses qualified mental health provider). With respect to
on educating patients to become self-sufficient in ordering the weekly workshops, it is recommended
managing their reactions to tinnitus. that the first and third workshops be those led by
This chapter provides a description of PTM the audiologist, and the second, fourth, and fifth be
Level 3 Group Education. Level 3 is the first level those led by the psychologist.
within the clinical hierarchy of PTM for which The audiologist instructs patients in how sound
intervention specific to tinnitus is the primary pur- can be used in different ways to manage reactions
pose of patient visits to the clinic. During Level 2, to tinnitus, and directs them through the process of
the main focus is to evaluate and manage hearing developing individualized action plans using the
problems, with a very brief assessment of tinnitus Sound Plan Worksheet (Appendix N). The three
impact. (Fitting hearing aids at Level 2 to assist in workshops conducted by a psychologist provide
the management of a hearing problem sometimes instruction for patients to learn how to use specific
also results in a reduction in the impact of tinnitus, coping skills to manage their reactions to tinnitus.
but this is not the primary purpose of fitting hear- It should be noted that group education is not
ing aids at Level 2.) Intervention provided specifi- an appropriate venue for some patients, who may
cally for tinnitus during Level 2 is ancillary, such as be unwilling to attend a group session or who may
answering questions and providing patients with just require one-on-one intervention. Furthermore,
educational materials. if a patient has a cognitive impairment or other
Level 3 Group Education consists of a series medical or mental health condition that would dis-
of patient-education classes that are termed work- rupt learning in a group education format, then the
58 Progressive Tinnitus Management: Clinical Handbook for Audiologists

information from the groups can be discussed with nized that effective management of chronic pain
the patient and his or her significant other on an depends much more on patients own efforts and
individual basis. expectations than on their passively receiving a
treatment. In essence, biomedical solutions are being
supplanted by educational approaches that focus
on supporting long-term rehabilitation.
Self-Help Workbook
As patients become more actively involved in
decisions affecting their clinical care, they naturally
In Chapters 3 and 5 we described the patient experience a greater sense of commitment to par-
self-help workbook How to Manage Your Tinnitus: A ticipate in the management process. This results in
Step-by-Step Workbook (J. A. Henry et al., 2010a). The a shift of responsibility from the health-care pro-
workbook is fairly comprehensive in that it provides fessional to the individual for the day-to-day man-
a great deal of information to guide patients in agement of their condition (S. Newman, Mulligan,
learning how to self-manage their reactions to tin- & Steed, 2001) (p. 1). Accomplishing this shift of
nitus. We have recommended that patients who responsibility requires working with patients to
participate in Level 3 Group Education receive a copy help them: (a) understand their condition; (b) par-
of the workbook when they attend their first work- ticipate in decisions regarding their management
shop. In Chapter 5, we described reasons for waiting plan; (c) develop and follow the plan; and (d) mon-
until Level 3 to provide the workbook. In general, it itor success of their self-management efforts and
will be more effective for patients when used in con- revise the plan as needed. The clinician and patient
junction with their participation in the workshops. should maintain a therapeutic relationship, with
contacts occurring either on an as needed or peri-
odic basis (i.e., regular follow-ups). This overall
approach appropriately is termed collaborative
Collaborative Self-Management

As explained in Chapter 3, when referring to inter-

vention for chronic tinnitus, we do not use the
Educating Patients to Use
word treatment, which can imply that a provider
Therapeutic Sound
performs some procedure (or administers a drug)
that is intended to quiet the tinnitus of a patient
who passively receives the procedure. We instead The use of therapeutic sound for tinnitus manage-
adhere to the notion that intervention should pri- ment is well supported clinically and by clinical
marily involve educating the patient about manag- research (J. A. Henry et al., 2008c). Evidence for
ing reactions to tinnitus. Different strategies often are sound-based tinnitus management has been reported
needed to manage reactions to tinnitus that occur for tinnitus masking (Folmer & Carroll, 2006; Hazell
in different situations. Patients need to learn these et al., 1985; Schleuning et al., 1980; Stephens &
strategies so they can manage any life experience Corcoran, 1985), tinnitus retraining therapy (Bart-
disrupted by the symptom. This learning should nik et al., 2001; Berry et al., 2002; Herraiz et al., 2005;
take place with a compassionate and knowledge- Herraiz et al., 2007), and neuromonics tinnitus
able clinician who provides the education. treatment (P. B. Davis et al., 2007). In addition, hearing
The PTM approach to self-management is aids are well known to provide benefit for patients
modeled closely after clinical methodologies recently with tinnitus (Del Bo & Ambrosetti, 2007; Folmer &
developed for chronic pain management (Blyth, Carroll, 2006; Saltzman & Ersner, 1947; Surr et al.,
March, Nicholas, & Cousins, 2005). In the past, 1999; Surr et al., 1985; Trotter & Donaldson, 2008).
urgent pain relief depended on treatments such as We completed two prospective clinical tri-
opioid drugs or invasive surgeries. It now is recog- als that involved fitting hearing aids, ear-level
Level 3 Group Education 59

noise generators, or combination instruments to First Workshop (With Audiologist)

most of the subjects (see First Study and Third
Study in Chapter 2). All cohorts, regardless of the The goal for session one is for all group participants
specific intervention involved, showed significant to use the Sound Plan Worksheet (see Appendix N)
improvement (to varying degrees). Folmer and to develop an individualized sound plan for
Carroll (2006) evaluated long-term outcomes in managing their most bothersome tinnitus situa-
OHSU Tinnitus Clinic patients. Three groups of tion. It is essential that participants learn how to
50 patients each were evaluated who: (a) used ear- use the worksheet to organize their efforts for using
level noise generators; (b) used hearing aids; and therapeutic sound.
(c) did not use ear-level devices. Although signifi- The focus of education with PTM is to pro-
cant improvement was observed for all patients, vide patients with practical, how-to information.
those who used ear-level devices experienced sig- The group sessions thus are task-oriented so the
nificantly better outcomes than those who did not time must be spent teaching the participants what
use devices. to do to manage their reactions to tinnitus. Cover-
An abundance of studies and clinical tech- ing all of the structured material during each ses-
niques support the use of therapeutic sound to sion requires up to an hour and a half. Keeping
manage tinnitus. It is important to note, however, these groups on-task can be challenging. There is
that no one method has been shown to be superior a natural tendency for patients to want to share
over the others. With PTM, patients are not limited their experiences and thoughts about tinnitus, and
to a single method or a particular device. Rather, the they have limited opportunity to do that during the
approach is to provide patients with the knowledge sessions. Also, any discussion about tinnitus inevi-
and skills to use sound and sound devices in adap- tably leads to many questions. For these reasons,
tive ways to manage any life situation disrupted by participants are asked to refrain from asking ques-
tinnitus. This is accomplished by teaching patients tions and discussing topics unrelated to the work-
the different ways that sound can be used to man- shop until the end of the session. Discussion and
age reactions to tinnitus, and helping them develop questions relevant to the topics being presented are
and implement custom sound-based management encouraged.
plans that address their unique needs.
Review the Tinnitus and Hearing Survey

Prior to enrollment in group education, each par-

Workshops Conducted by an
ticipant should have filled out the Tinnitus and
Hearing Survey (THS; Appendix D). As described
in Chapter 5, the THS is designed to assist patients
As mentioned above, Level 3 Group Education and clinicians in understanding how much of a
ideally consists of two workshops facilitated by patients problem is due to tinnitus and how much
an audiologist and three by a mental health pro- is due to hearing problems. It is critical for partici-
vider. A PowerPoint presentation (Managing Your pants to have used the THS to determine candi-
Tinnitus: What to Do and How to Do It) is given dur- dacy for enrollment in Level 3 Group Education. In
ing each workshop (the two PowerPoint presenta- Chapter 5, a list of requirements was provided that
tions made by audiologists are provided on the CD should be used to ensure that a patients participa-
that is included with this handbook). The leader tion in Level 3 is appropriate.
makes the presentations, facilitates discussion, and If group participants do not bring their com-
addresses any questions or concerns. The focus of pleted THS to the session, then they should com-
the two Level 3 classes facilitated by an audiologist plete one at the start of the session. The THS is then
is to assist patients in learning how to self-manage reviewed during the sessionthe concepts are
their reactions to tinnitus using therapeutic sound discussed and participants are asked to share their
in adaptive ways.
60 Progressive Tinnitus Management: Clinical Handbook for Audiologists

responses on the THS. This is done to ensure that Three Types of Sound
all participants understand that the purpose of the
classes is to address tinnitus-specific problems and To complete the Sound Plan Worksheet, partici-
that problems related to hearing are not addressed pants must learn about the three types of sound
during the workshops. (soothing, interesting, and background) that can
be used to manage reactions to tinnitus. The three
Sound Plan Worksheet types of sound have been described in detail else-
where (J. A. Henry et al., 2008c), and are reviewed
Use of the Sound Plan Worksheet (see AppendixN) briefly below.
facilitates the process of identifying sounds and
sound-generating devices that are expected to be
Soothing Sound. Soothing sound is any sound
effective in managing specific tinnitus-problem sit-
that provides an immediate sense of relief from
uations. The worksheet is used throughout the first
stress or tension that is caused by tinnitus. The use
session with the objective for each participant to
of soothing sound has its roots in the method of
develop a sound plan that will be used until the
tinnitus masking, which originally was described
second session to manage the participants most
by Vernon (1976). The method of tinnitus mask-
bothersome tinnitus situation. After participants
ing continues to be used, and relies on the use of
have gained experience and confidence with the
ear-level maskers that generate broadband noise
process and the concepts of developing sound
(Schechter & J. A. Henry, 2002). The use of sound
plans, then additional bothersome tinnitus situations
with tinnitus masking is intended to provide an
can be addressed and more complicated and sophis-
immediate sense of reliefnot to mask tinnitus,
ticated technology can be incorporated. Participants
as the name would seem to imply.
are encouraged to use the worksheet on a regular
Soothing sound for tinnitus management is
basis to refine and improve their sound plans.
not restricted to the use of ear-level maskers and
Creating a sound plan to address one problem
broadband noise. Any sound that produces a sense
situation involves four small tasks (No. 1 to 4 on the
of relief (or that the patient considers soothing)
Sound Plan Worksheet) that likely can be accom-
can be used as soothing sound. When using sooth-
plished successfully by patients: (1) identify a situ-
ing sound, it is important that patients focus on
ation when tinnitus is problematic; (2) determine
obtaining a sense of relief from stress and tension
which strategy (or strategies) for using sound will
rather than focusing on how much their tinnitus is
be implemented in that situation; (3) determine a
masked. We therefore decided to abandon use of
specific sound that will be used with each strategy;
the term masking altogether. Whether or not the
and (4) determine a specific device for presenting
tinnitus is masked is completely irrelevant to the
each sound. The plan is used for at least one week
use of soothing sound.
and then evaluated for its effectiveness (No. 5 on
the worksheet).
Group participants are instructed to identify, Interesting Sound. Interesting sound is used to
using the Tinnitus Problem Checklist (see Appen- actively divert attention away from the tinnitus.
dix H), the life situation in which their tinnitus is The use of interesting sound for tinnitus manage-
the most bothersome. To increase the likelihood ment has not been a part of any formal method of
that the initial sound plan will be implemented therapy for tinnitus. However, distraction is a con-
successfully, they then create a sound plan to man- cept that is used for pain management, and the use
age just that one situation using sounds and sound of interesting sound follows the basic pain model
devices that are readily accessible. In this way, par- (M. H. Johnson, 2005). In essence, using interesting
ticipants are empowered in creating a sound plan sound to manage reactions to tinnitus is intended
that can be implemented with minimal effort and to shift the patients attention away from the tin-
usually at no cost to address their most bothersome nitus and onto some other sound. Patients thus
tinnitus situation. learn to actively listen to sounds that they find
Level 3 Group Education 61

interesting or entertaining, which accomplishes the and daunting to accomplish. Patients certainly are
distraction objective. encouraged to learn more about the TRT concepts
if they are interested.
Background Sound. Some patients do not experi-
ence a satisfactory sense of relief from sound and Demonstrating the Three Types of Sound
so may be tempted to abandon its use altogether. It
is important that patients understand that even if Specific activities were developed to give group
sound does not provide immediate relief (or if it is participants the opportunity to experience each of
not interesting), it still can be very effective in man- the three types of sound. Visual scales are provided
aging reactions to tinnitus by reducing the contrast to enhance understanding of the activities (J.A.
between tinnitus and the acoustic environment, Henry et al., 2008c). The visual scales are demon-
thereby making it easier for the brain to let the tin- strated to participants during the first session so
nitus go unnoticed. that they can appreciate their utility. Participants
The candle in a dark room analogy is used learn that they can use the tools on their own to
to demonstrate the concept behind background evaluate the effectiveness of different sounds for
sound (as shown on the video that is provided ongoing tinnitus management.
with this handbook). A burning candle in a dark The Relief Scale (Appendix O) was developed
room naturally attracts attention because of the as a tool for PTM patients to use to (a) learn how
high contrast between the flame and the dark sur- soothing sound is used to manage reactions to tin-
roundings. If the room is then lighted, the contrast nitus, and (b) identify sounds and evaluate their
is reduced causing the flame to attract less atten- ability to induce relief. Patients listen to the dem-
tioneven though it has not changed. This anal- onstration sound and then answer the question,
ogy helps patients to understand the purpose of How much relief do I feel? The six-point response
using background sound. scale ranges from no relief (no reduction in stress
The use of background sound for tinnitus or tension caused by tinnitus) to complete relief
management is derived from the method of tin- (elimination of stress or tension caused by tinni-
nitus retraining therapy (TRT) (P. J. Jastreboff & tus). Participants are asked to share their ratings
Hazell, 2004), which started as a clinical technique with the group.
in the late 1980s. The method continues to be used The Attention Scale (Appendix P) was devel-
and relies on the use of sound to promote habitu- oped for use during an activity in which patients
ation (decrease in responsiveness) to tinnitus reac- learn how interesting sound can divert attention
tions and perception. Patients with more severe away from tinnitus. The scale is used as a tool to
tinnitus are advised to use ear-level sound genera- help patients identify the kinds of sounds that most
tors (or combination instruments). These patients effectively shift their thoughts away from the tin-
are instructed to adjust the level of the broadband nitus. Patients are instructed to select any sound
noise to below the mixing point, that is, below or sound passage that they would expect to keep
the level at which their tinnitus sound starts to their attention. After listening to the sound for at
change (J. A. Henry, Trune, et al., 2007a). Many of least one minute, they estimate the percentage of
our patients and research participants had diffi- attention focused on the interesting sound ver-
culty adjusting the sound to the mixing point, and sus the tinnitus. A sound passage is played during
often seemed generally confused and sometimes the workshop to demonstrate interesting sound,
anxious about the mixing-point concept. The use and participants are asked to share their ratings on
of background sound is intended to accomplish the Attention Scale with the group.
essentially the same purpose as for TRT. However, The notion of reducing auditory contrast
we do not refer to the mixing point, habituation, between tinnitus and sound in the environment
or other terminology that is specific to TRT. In this can be demonstrated to participants using a visual
way, patients learn what to do but are not expected analog. Tinnitus in a quiet environment results in
to adhere to a protocol that can seem complicated high contrast. The addition of sound reduces the
62 Progressive Tinnitus Management: Clinical Handbook for Audiologists

contrast. Patients can hear this effect by first noticing

how their tinnitus sounds in quiet, and then adding Case Example
sound. The Tinnitus Contrast Activity (AppendixQ)
serves as a visual analog to facilitate demonstrating A case example demonstrates how patients
this effect. Patients use the Tinnitus Contrast Activ- use the Sound Plan Worksheet (please refer to
ity while listening to different sounds. Although Appendix N). Mr. Roberts most bothersome
each sound reduces contrast by a different amount, situation was being annoyed by his tinnitus
patients are taught that any amount of contrast while working in his quiet office (No. 1). As a
reduction can be beneficialprovided the sound is general strategy (No. 2), he thought that using
experienced at a comfortable level. One or more background sound might in general be help-
background sounds are demonstrated to the group, ful. The specific sound he would try would
and participants are asked to relate the concept be constant fan noise (No. 3) from a small fan
depicted by the analog to the effect that is achieved in his office (No. 4). He tried this plan for one
with the sound. week and determined that the plan was a
little helpful (No. 5). He then revised his plan
Sound Grid by adding soothing sound (No. 2). He liked
sounds of nature and decided to listen to beach
For each of the three types of sound (soothing, back- sounds (No. 3) using a CD and CD player that
ground, interesting), environmental sound, music, he already owned (No. 4). After trying a com-
and speech can be used. This results in nine possi- bination of fan noise and sounds of nature for
ble combinations, as shown by the sound grid (Fig- one week, he indicated that the plan helped
ure 71). Environmental sound includes any nature him a lot (No. 5). Mr. Roberts initial sound
sound (sounds of animals, weather, moving water, plan demonstrated limited success. Based on
etc.) or synthetic (manmade) sound (e.g., electric that experience, he revised his plan and the
fans and appliances, broadband masking noise, new plan worked well for him. He experi-
synthesized sounds). Music of all styles can be used, enced success using the worksheet to address
including music with and without lyrics. Speech of one particular problem situation, and he now
all varieties is appropriate to utilize, including lec- uses the worksheet as needed to develop plans
tures, sermons, talk radio, guided imagery, crowd to address other problem situations.
noise, one-on-one conversation, and so forth.

Figure 71.Sound grid. This grid shows that there are three types of sound (sooth-
ing, background, interesting) that can be used to manage reactions to tinnitus. Each
type of sound can involve the use of environmental sound, music, and/or speech to
manage specific tinnitus-problem situations. A total of nine combinations of sound
are possible as indicated by the nine checkmarks.
Level 3 Group Education 63

Second Workshop (With Audiologist) sessions is flexible, however, and depends on the
purpose of the therapy. Beck (1995) explained that
At the end of the first workshop, group partici- Most straight-forward patients with depression
pants are asked to return for a follow-up workshop and anxiety disorders are treated for 4 to 14 ses-
two weeks later. Between workshops, their home- sions (p. 7). One controlled study has shown
work is to carry out and evaluate the effective- that a condensed version of CBT for tinnitus can be
ness of their initial sound plan. Participants should conducted in two sessions with no differences in
bring their worksheet developed at the first ses- disability reduction relative to a group that attended
sion to the second session. They are told that they 11 sessions (Kroner-Herwig, Frenzel, Fritsche,
can modify the plan during the second session to Schilkowsky, & Esser, 2003). Consistent with a pro-
improve its effectiveness. gressive approach to tinnitus management, patients
The objectives of the second workshop are for should receive less intervention at lower levels and
participants to: (a) share their experiences using more intervention at higher levels. Therefore only
their initial sound plan; (b) engage in collaborative certain components of CBT are taught at Level 3 so
problem solving (to address any problems imple- as to minimize the number of sessions that patients
menting their sound plans); and (c) improve their are expected to attend at this level of care.
sound plan or develop a new sound plan. In addi- We determined that three CBT sessions at
tion, new information is covered during the second Level3 would be necessary to cover the most
workshop, including descriptions of: (a)different important components of CBT (described below).
types of sound-producing devices; (b)ideas for Patients then have the option of attending addi-
using sound to improve sleep; (c) sound-based tional sessions if further CBT counseling is needed.
methods of tinnitus management and how they These additional sessions normally are offered to
relate to the sound grid (see Figure 71); and (d) patients following, and depending on the results
lifestyle factors that can affect tinnitus and hear- of the Level 4 Interdisciplinary Evaluation. In addi-
ing. Participants should attend both workshops to tion, the Level 3 protocol is flexible such that if mul-
maximize their benefit. Participants who attend tiple participants in the CBT workshops require
only the first workshop should receive follow-up additional intervention, then additional workshops
by telephone. can be addedwhich again is consistent with the
progressive approach.
Typically, in CBT when basic information about
the problem is provided, this is called psychoeduca-
Workshops Conducted by a
tion and usually is presented during the first session
of CBT. The last session of CBT typically includes
information about preventing the problem from
Mental health intervention can be an important recurring or getting worse. For example, when CBT
component of an overall approach to managing tin- is used to treat depression, during the last session
nitus for all patients. Patients who are bothered by patients normally are taught how to identify early
tinnitus can, in general, benefit from receiving men- signs of depression relapse (such as overeating) or how
tal health intervention to alter maladaptive reac- to prevent depression (such as exercising regularly).
tions to tinnitus and to aid in coping with tinnitus. Psychoeducation and planning for flare-ups and
Mental health intervention is particularly impor- exposure to loud noise during PTM is presented in
tant for patients with tinnitus who also experience the self-help workbook provided to each patient,
post-traumatic stress disorder (PTSD), depression, and thus, this information is not repeated during
anxiety, or other mental health problems. the Level 3 CBT workshops with the mental health
A major question in the development of CBT provider. Consequently, more than three sessions
for Level 3 was the number of sessions that should of CBT would create some redundancies using the
be conducted. Six to ten sessions of CBT are typical PTM structure. However, all information (basics
in many clinical settings. The actual number of CBT of CBT, psychoeducation, protecting hearing, and
64 Progressive Tinnitus Management: Clinical Handbook for Audiologists

flare-up planning) and the CBT skills addressing pants to focus first on their most bothersome tin-
stress reduction, attention diversion, and cognitive nitus problem. In the process, patients learn that
restructuring are reviewed if the patient progresses managing reactions to tinnitus involves using a
to Level 5 Individualized Support. combination of strategies that each are developed
Patient learning in all of the Level 3 work- and refined through trial and error. Learning to
shops is facilitated by use of the PTM self-help manage tinnitus is a process that should be con-
workbook (J. A. Henry, Zaugg, Myers, & Kendall, ducted systematicallyby learning the strategies,
2010a). Each of the CBT components taught dur- developing action plans, implementing the plans,
ing Level 3 is described in the workbook. After and revising the plans to improve outcomes.
each session, patients practice their new skills by After the group participants have gained expe-
using worksheets and activities in the workbook. rience and confidence with the process and the use
These worksheets and activities are intended to of CBT concepts to manage their reactions to tinni-
facilitate learning the new skills and recording tus, they can use any of the skills as tools to help
progress. When patients return for the next work- them cope with their tinnitus. They are encouraged
shop, they are asked to report their progress to the to use the Thoughts and Feelings Worksheet on a
group. Group education based on CBT, as opposed regular basis to refine and improve their use of
to individual CBT sessions, is efficient and allows these coping skills.
patients to apply skills to a variety of situations
and to develop a social network from which to
draw support. Essential CBT Components

The Level 3 workshops led by a mental health pro-

Changing Thoughts and vider focus on teaching three CBT techniques: stress
Feelings Worksheet reduction (relaxation), attention diversion (plan-
ning pleasant activities), and cognitive restructur-
During the CBT workshops the Changing Thoughts ing (changing thoughts). During the first CBT
and Feelings Worksheet is used, which is modeled session, the basic premise that how one thinks and
after and used simultaneously with the Sound acts influences ones feelings is described. Empha-
Plan Worksheet (see Appendix N). The Changing sis is placed on clarifying goals and tracking efforts.
Thoughts and Feelings Worksheet helps patients Later, patients learn techniques to assist them in
track their use of the three coping skills offered learning ways to modify thoughts and increase or
during the CBT portion of Level 3. The worksheets decrease behaviors that influence how they feel
are used throughout the sessions with the objec- about their tinnitus. Each of these coping skills can
tive for participants to develop personalized plans be helpful to patients who want to learn ways to
for managing their reactions to tinnitus in specific manage their reactions to tinnitus. These skills also
problem-situations. are applicable to many other chronic conditions
CBT group participants are instructed to such as anxiety, depression, and pain.
identify, using the Tinnitus Problem Checklist (see
Appendix H), the life situation in which their tin-
nitus is the most bothersome. This is the same CBT Session 1
task that is required when they use the Sound Plan
Worksheet during the workshops conducted by an Stress Reduction
audiologist. It is helpful if patients identify the same
tinnitus problem on their two different worksheets Many patients report that their tinnitus is exacer-
to learn how very different strategies can be used bated by stress. By reducing stress or managing
to address a single problem situation. The audiolo- reactions to stress, patients are able to reset the
gists and mental health providers who teach these bodys natural stress arousal system to a more
workshops should point this out and ask partici- relaxed and calm state. Practicing relaxation tech-
Level 3 Group Education 65

niques can modify ones response to stress and skill also is taught during the first session of Level3
can serve to distract attention from the tinnitus with the mental health provider. The skill typically
to other things. The goal of providing this skill is to is easy for patients to understand.
empower patients with a simple and easy way Group participants are instructed to examine
to relax when stressed. the impact of tinnitus on their activities, particu-
Relaxation techniques taught during the first larly on pleasant activities, and to learn ways to
session of Level 3 with the psychologist include increase their activities. They are provided a list of
controlled breathing and imagery. A video demon- types of activities (solitary, indoor, social, musical,
stration of these techniques (Deep Breathing and etc.) from which to develop ideas about the types
Imagery) is included on the DVD that is provided of activities they would enjoy. They then are asked
with the self-help workbook. The Deep Breath- to add one pleasant activity to their daily routine
ing exercise is a controlled breathing exercise that and rate how effective it was in diverting attention
helps patients focus on taking slow and rhythmic away from the tinnitus.
breaths. Controlled breathing encourages atten- Increasing activities helps to distract patients
tion to the mechanisms of the lungs and sounds of from their tinnitus and helps them to gain mean-
breathing, which releases tension and diverts atten- ingful experiences that typically result in a greater
tion from tinnitus. The Imagery exercise teaches sense of relatedness and connectedness to the
patients to imagine being somewhere calming and world. Also, patients may have become isolated
safe. Imagery is useful as a relaxation technique over the course of learning to cope with their tin-
when a pleasant or neutral image is envisioned nitus. Some patients will need encouragement to
during distress (J. L. Henry & Wilson, 2001). These become social again.
techniques also require practice, thus, patients are
asked to complete homework between sessions.
Instructions for both of these relaxation exer- CBT Sessions 2 and 3: Cognitive
cises are specific for patients with tinnitus. For Restructuring
example, patients are instructed not to practice
the relaxation exercises in silence. Patients are During the second and third CBT workshops, the
encouraged to use soothing sound such as calm- group participants are taught how their thoughts
ing music during the exercises. Furthermore, since and behaviors influence feelings via a step-by-step
many patients with tinnitus also have hearing loss, guide for evaluating thoughts, modifying thoughts,
instructions take into account the fact that some and developing healthy attitudes. These cognitive
patients may feel more comfortable not closing restructuring activities require two sessions to ade-
their eyes during the relaxation exercises. They are quately cover all the material.
instructed to focus on an object in the room or on
the open-captioning of the relaxation demonstra- CBT Session 2
tions on the video.
During the first of the two sessions on cognitive
Attention Diversion via Increasing restructuring, participants learn about healthy
Pleasant Activities attitudes and examining their own thoughts; this
sometimes is called mindfulness training. Mind-
There are many ways to divert attention from one fulness is a state of being consciously aware of ones
activity to another. Many patients stop doing the own thoughts and behaviors. Some patients tend to
things they like to do (pleasant activities) and tend use faulty logic when thinking about experiences.
to focus on required activities such as work and During this session, participants learn the
house chores. The goal of providing this coping 12 most common types of negative appraisals
skill is to help patients learn ways to divert atten- (also called thought errors): (1) overgeneralization,
tion away from the tinnitus and onto other things (2) all-or-none thinking, (3) filtering or selective
by increasing pleasant activities in their lives. This abstraction, (4) mind-reading, (5) magnification
66 Progressive Tinnitus Management: Clinical Handbook for Audiologists

or catastrophization, (6) minimization, (7) person- ary Evaluation. During the call, the clinician asks
alization, (8) jumping to conclusions or arbitrary about progress implementing the action plans,
inference, (9) emotional reasoning, (10) should discusses any problems encountered, and answers
statements, (11) labeling, and (12) blaming (Beck, questions. The clinician can use any of the written
1995). They are taught to be mindful by system- questionnaires that were administered previously
atically examining their thoughts so as to provide to assist in determining if a Level 4 appointment is
insight into which of these 12 negative appraisals warranted.
they may be using. They are asked to cite personal
examples for each of the 12 negative appraisals as
homework. As they do this exercise, thought pat-
terns or habits typically emerge, helping them
understand their own thought processes.
Any person who has tinnitus can benefit from
CBT Session 3 being educated concerning what to do about the
phantom sound. Many patients are interested only
During the second of the two sessions on cognitive in a cure for their tinnitus, and they may not realize
restructuring, the participants learn to systemati- the importance of learning good management tech-
cally modify or restructure their thoughts so as to niques. In general, clinical services for tinnitus are
create different, more desirable emotional reac- provided only to patients who are bothered by their
tions. Constructive approaches to stress, such as tinnitus. The majority of individuals who expe-
thinking of a stressful event as a challenge rather rience tinnitus are not bothered by the constant
than a threat, are presented. Negative attitudes and sound and they mainly need to learn and adhere
appraisals of situations often lead to negative emo- to good practices to avoid situations that can dam-
tions, which immediately are applied to individu- age their hearing. Those who are bothered by their
als unique problems and concerns. tinnitus need to learn methods to self-manage their
During this session, step-by-step instructions reactions to tinnitus. With PTM, these methods
are provided for changing negative appraisals to include education about using therapeutic sound
more constructive, positive appraisals. The group and effective coping techniques.
works through an example in their workbook of The goals of PTM are achieved through the
using the step-by-step process to address a negative process of collaborative self-management. Clinicians
thought about an event and come up with alterna- who provide PTM should consider themselves as a
tive, more constructive thoughts. The participants source of information and support that empowers
life situation in which their tinnitus is most bother- patients to manage any situation in which tinnitus
some as identified on the Tinnitus Problem Check- is problematic. As already discussed, collaborative
list (see Appendix H) is used during this exercise self-management is very different from the tradi-
to keep the CBT sessions aligned with the sessions tional treatment model, which involves patients
with the audiologist. passively undergoing some kind of therapeutic
procedure(s). The keys to collaborative self-man-
agement are the availability of appropriate edu-
cational materials and the means to provide the
Post-Workshop Follow-Up
education to patients efficiently and effectively. The
framework of PTM provides for a variety of modal-
Patients who attend the workshops should be ities through which patients can learn the essential
informed that they will receive a follow-up phone self-help information. Level 3 Group Education is
call approximately one month after the last work- sufficient for most patients who are bothered by
shop. The call is made by the audiologist or the tinnitus. If further services are required, then the
mental health provider who conducted the work- patient should be scheduled for a Level 4 Inter-
shops. The purpose of the call is to determine if the disciplinary Evaluation, which is described in the
patient will return for the Level 4 Interdisciplin- next chapter.

Level 4 Interdisciplinary Evaluation

Most patients can satisfactorily self-manage their relaxation techniques, attention control, and plan-
reactions to tinnitus after participating in Level 3 ning for flare-ups.
Group Education. Patients who need more sup- The audiologic assessment that is conducted
port and education than is available at Level 3 can as part of the Level 4 Interdisciplinary Evalua-
progress to the Level 4 Interdisciplinary Evalua- tion involves conducting a structured interview
tion, which normally includes evaluations by an and can include, as optional procedures, a tinnitus
audiologist and a mental health provider who is psychoacoustic assessment and/or evaluation for
trained to conduct psychological assessments. use of sound therapy devices. Administration of
The main purpose of the Level 4 Interdisci- the Tinnitus and Hearing Survey (see Appendix D)
plinary Evaluation is to determine if individualized in conjunction with the Tinnitus Interview (Appen-
clinical services are needed to address tinnitus- dix R) is the primary means of determining if
specific problems. If these services are needed, then one-on-one individualized support is appropri-
patients progress to Level 5 Individualized Sup- ate. If so, then the audiologist and patient begin to
port. Level 5 involves primarily one-on-one coun- formulate a management plan. Special proce-
seling from an audiologist (using the counseling dures are used to evaluate and select ear-level
book Progressive Tinnitus Management: Counseling devices for tinnitus management, including hear-
Guide; J. A. Henry et al., 2010b) and/or a mental ing aids, noise/sound generators, and combination
health provider. The audiologic counseling infor- instruments.
mation essentially is the same as what is covered
during the Level 3 workshops. However, the indi-
vidualized format of the Level 5 counseling allows
more personalized interaction and support than
Mental Health Assessment
can be provided during Level 3. Level 5 interven-
tion offered by a mental health provider includes Systematic progression through the different levels
further enhancement of skills for coping with tin- of PTM effectively ensures that patients reaching
nitus (taught during Level 3) such as additional the Level 4 Interdisciplinary Evaluation have a
68 Progressive Tinnitus Management: Clinical Handbook for Audiologists

severe tinnitus problem that warrants an in-depth unavailable, primary care providers often can be
evaluation to determine if individualized support helpful as many have training and experience with
is appropriate. Due to the severity of their distress screening for sleep and mental health problems.
from tinnitus, these patients also are more likely to Nonmental health clinicians must be cau-
have comorbid mental health conditions or sleep tious in dealing with any issues related to anxiety,
disorders that would require an interdisciplinary depression, stress disorders, suicidality or suicidal
approach to intervention. Screening for mental health thoughts, risky behavior, and so forth, because this is
conditions and sleep disorders therefore is conducted not their area of expertise. These clinicians must use
routinely by a mental health provider as part of the the mental health screening tools only to aid in
Level 4 evaluation (unless the patient was recently making appropriate referrals, and cannot provide
evaluated/diagnosed by a mental health profes- diagnostic interpretation of test scores. Some patients
sional and currently is receiving care accordingly). may feel uncomfortable with these types of ques-
If a mental health provider is included in tions, or that the questioning is inappropriate and
the facilitys tinnitus team, then that individual intrusive. Therefore, it is important to ask for permis-
should conduct the mental health assessment. Full sion to explore these issues, for example, If you
assessment of mental health symptoms should be dont mind, I would like to ask you some questions
conducted by someone qualified to do such an about your mood and things that can affect your
evaluation such as a psychologist or psychiatrist. mood. Sometimes ringing in the ears is made worse
If a mental health provider is not part of the team, when other conditions are present at the same time.
then the patient should be referred to primary care Before formally screening for mental health
for a mental health assessment (or referred as dic- conditions, it is helpful to start with the patients
tated by the facilitys referral procedures). Finally, medical records and scan for comorbid conditions
as discussed next, a nonmental health provider can that previously have been identified. After review-
conduct mental health screening in certain situa- ing the chart, there are several options for identi
tions. However, those situations should be rare, as fying a need for referral to a different discipline.
timely and collaborative mental health services are Simple mental health screeners can be useful in
available within most health care organizations. determining if a referral to a mental health clinician
is warranted. Screening instruments are available
to screen for anxiety, depression, and PTSDthe
Mental Health Screening by Nonmental mental health conditions that have been observed
Health Clinicians to co-occur most commonly in patients who com-
plain of bothersome tinnitus. Each medical facility
It is best for mental health screening to be per- has its preferred mental health screening tools and
formed by a psychologist or other mental health protocols. It is best to contact a mental health clini-
care provider who is familiar with the effects of cian or primary care physician at your site in advance
hearing loss and tinnitus. If such a provider is to learn which screening tools are recommended
unavailable, then basic screening for these symp- for use by audiologists. Some sites prefer to funnel
toms can be conducted by any clinician who has all mental health screenings into one service where
been properly trained to use screening tools and an intake appointment is made to determine the
who has resources for responding to their out- needs of all referred patients. In some settings, health
comes. In instances where audiologists (or other services are centralized to primary care providers
nonmental health care providers) are performing (PCPs). Thus, it might be necessary to refer a patient
screening for referral to mental health, collabora- to a PCP when there is any suspicion of a mental
tions with mental health are essential to allow for health or sleep disorder. The PCP then assesses the
immediate referrals and follow-up as warranted. appropriateness of referral to a mental health or
Hospitals and outpatient clinics vary in the types sleep clinic. At many sites audiologists must take the
and availability of mental health clinicians. When lead in educating other professionals about PTM and
appropriate mental health care providers are the interdisciplinary nature of this methodology.
Level 4 Interdisciplinary Evaluation 69

A basic mental health screening battery can be part of general intake questionnaires in medical
completed in about 10 to 15 minutes. The results clinics. Use of a symptom checklist might reduce a
can assist in determining the potential need to patients perceived stigma of mental health prob-
involve other disciplines in the patients clinical lems. Systematic screening using screening tools
management. Further assessment of these condi- or checklists can be helpful, but is not necessary to
tions is performed by a mental health provider as justify referring a patient to a provider of a different
indicated by results of the screening tests. discipline. The reason for referral often is simply
that the clinician perceives that there are problems
outside his or her field of expertise.
Anxiety and Depression

Screening for anxiety and depression can be per-

formed using the Hospital Anxiety and Depression
Sleep Disorders
Scale (HADSAppendix S) (Zigmond & Snaith,
1983). This self-screening questionnaire consists As discussed in Chapter 5, sleep disorders are the
of 14 questionsseven for anxiety and seven for most common problem reported by patients seek-
depression. Patients should be instructed to com- ing clinical services for tinnitus, especially those
plete this self-screening questionnaire by respond- with the most severe tinnitus problem. A brief
ing spontaneously to each item. The HADS has been questionnaire is available to screen patients for
used extensively in primary care settings (Wilkin- sleep disorders: the Epworth Sleepiness Scale (ESS
son & Barczak, 1988). Appendix U) (Johns, 1991). The ESS is the most
widely used standardized tool for assessing sleep-
iness. Completing the ESS provides an index score
Post-Traumatic Stress Disorder that can be compared to normative data. A score of
10 or more on the ESS suggests that the patient is not
The Primary Care PTSD screening tool (PC-PTSD) getting adequate sleep (for any reason), and may
(Prins et al., 2004) is available to detect possible need to be referred to a physician for an evaluation.
PTSD, and to initiate appropriate referral (Appen- In addition to insomnia, there are many
dix T). The PC-PTSD was designed for use in other categories of sleep disorders. These include
primary care and other medical settings and cur- difficulty initiating and maintaining sleep, and
rently is used widely to screen for PTSD in military sleep-phase disorders. These disorders usually are
veterans. The four-item instrument enables rapid behaviorally based, responsive to behavioral inter-
screening with high sensitivity but low specificity. ventions, and do not necessarily require specialty
The PC-PTSD is effective for capturing patients care (although sleep-phase disorders are best eval-
who require further evaluation for possible PTSD uated by a sleep clinic).
(although patients can have active symptoms and More serious categories of sleep disorder
screen negative). include sleep apneas and sleep-disordered breath-
ing, REM behavior disorders, and narcolepsy.
Other Mental Health Conditions These can be serious medical conditions (especially
sleep-disordered breathing, which can increase
The disorder-specific screening tools that are rec- the risk of stroke) that warrant medical treatment
ommended (HADS and PC-PTSD) address mental with medications or other devices. Screening for
health disorders that have been observed com- sleep apneas/sleep-disordered breathing usually
monly to co-occur with tinnitus. Use of these tools, includes questions about snoring, morning head-
however, does not adequately address the range aches, waking with gasping or choking, and asking
of other mental health problems that can exist in if a bed partner notices any of these things. Peo-
these patients (see Chapter 5). Another approach ple with sleep apnea often spend sufficient time
to screening for mental health problems is to use sleeping but still do not feel rested in the morning.
a symptom checklist, which often is included as Sleep apneas and sleep-disordered breathing, REM
70 Progressive Tinnitus Management: Clinical Handbook for Audiologists

behavior disorders, and narcolepsy generally are

very pronounced and are conditions that usually
Administer the Tinnitus Interview
are not related to tinnitus. Tinnitus-related insom-
nia generally does not necessitate referral to a sleep Although the use of written tinnitus questionnaires
clinic unless the patient also reports symptoms is advocated for all tinnitus patients, these ques-
of sleep-disordered breathing (snoring, morning tionnaires are insufficient for patients who reach
headaches, etc.). Level 4. A supplemental tinnitus-specific interview
If a sleep disorder is due primarily to the (Tinnitus Interviewsee Appendix R), which facil-
patient reacting to tinnitus when attempting to itates face-to-face structured dialogue with the
sleep, then implementing the strategies offered by patient, is necessary to capture the information
PTM may be sufficient to restore normal sleep pat- needed to make decisions for clinical services at
terns (see Chapter 5Managing Sleep Disorder). this level and helps to build rapport between
Therapeutic sound can be highly effective in the patient and clinician. The patients responses to the
sleep environment. Patients should learn the dif- Tinnitus and Hearing Survey (THS) in conjunction
ferent combinations of using sound to optimize the with the Tinnitus Interview are the most important
potential for therapeutic sound to be helpful. These components of the audiologic portion of the Level
patients also may benefit from learning basic infor- 4 Interdisciplinary Evaluation. The interview offers
mation about sleep hygiene such as limiting day- a uniform format for asking questions and for
time napping, keeping a regular sleep schedule, recording responses. It should be completed in
and other behaviors that encourage sleep. In the about 45 minutes, although its time of administra-
PTM self-help workbook (J. A. Henry et al., 2010a) tion can vary considerably depending mostly on
Appendix I provides three pages of tips for get- the extent of the patients problems.
ting better sleep. The Tinnitus Interview is designed to supple-
ment the THS during Level 4it is not a stand-
alone interview. Results of the THS should first be
reviewed with the patient, after which the inter-
Re-Administer Written view can be administered if appropriate. Review-
Questionnaires at Level 4 ing the THS results provides both the patient and
clinician with a good understanding of the patients
current perception of problems with tinnitus, hear-
Every patient who attends the Level 4 Interdisci- ing, and loudness tolerance. This discussion gives
plinary Evaluation should have completed all test- the clinician opportunity to explain to the patient
ing that normally is done at the Level 2 Audiologic the types of intervention available for each of these
Evaluation. At the Level 2 appointment, patients auditory problems.
completed the Tinnitus and Hearing Survey (see If it is confirmed that the patient has a tinnitus-
Appendix D), Tinnitus Handicap Inventory (see specific problem and is interested in tinnitus-specific
Appendix F), and Hearing Handicap Inventory intervention, then the next step is to conduct the
(see Appendix G). Patients should complete each Tinnitus Interview. It should be noted that the Tin-
of these written questionnaires again at the Level4 nitus Interview does not cover information that
appointment with the audiologist. Readminister- most likely was discussed during the case history
ing these questionnaires enables a comparison of performed during the Level 2 Audiologic Evalua-
responses between the Level 2 and Level 4 appoint- tion. The case history normally would obtain a
ments, which can reveal any longitudinal changes description of the tinnitus (loudness, pitch, timbre,
in a patients self-perception of hearing and/or perceived location, symmetry/asymmetry, con-
tinnitus handicap. The information obtained from stancy versus intermittency, and so on) and the cir-
the written questionnaires comprises an important cumstances of its onset. It may be helpful to review
component of the Level 4 evaluation. The struc- the case history before administering the Tinnitus
tured interview would be incomplete without this Interview. However, it is important not to focus on
information. what the tinnitus sounds like since the purpose of
Level 4 Interdisciplinary Evaluation 71

intervention is to assist the patient in learning how would be a normal effect and the patient should
to manage reactions to tinnitusnot to attempt to be counseled regarding hearing conservation. The
change the sound of the tinnitus. intent of the question, however, is whether sounds
at nondamaging levels cause the tinnitus to in-
crease in loudness. If this is experienced, then the
Question 1: Does the loudness of your effect usually lasts minutes or hours. Of most con-
tinnitus change on its own? cern is whether the effect lasts until at least the
next day.
Tinnitus loudness may seem to change due to: It may be helpful for patients who experience
a prolonged tinnitus-exacerbation effect due to
n Exposure to certain sounds sound to carry earplugs so as to remain prepared
n Eating certain foods for unavoidable situations that could trigger the
n Being under extreme stress exacerbation. Custom-fit high-fidelity/musicians
n Being sleep deprived earplugs usually are considered comfortable and
n New medications or changes in dosage they minimize distortion of sound. Patients must
n Changes in daily acoustic environment. be cautioned, however, to avoid overuse of earplugs
that could further increase their sensitivity to sound
The patients answer to this question should not (Formby et al., 2002). Patients who experience pro-
reflect these types of events. The purpose of the longed exacerbation of tinnitus from sound also
question is to determine whether the tinnitus fluc- may require intervention for hyperacusis (see
tuates in loudness on its own, and if so, how often. Chapter 6).
On its own thus refers to naturally occurring
changes in tinnitus loudness, that is, there is no
external factor that precipitates the change. Question 3: How does your tinnitus
Spontaneous changes in loudness can be asso- affect you (not including trouble hearing
ciated with the tinnitus being more or less bother- or understanding speech)?
some, that is, when the tinnitus is louder it tends to
be more intrusive and annoying; when it is softer it This question supplements the questions from Sec-
might not be noticed as much. With PTM, patients tion A of the THS, which mentions specific life situ-
are taught how to manage situations when their ations that commonly are affected by tinnitus. It is
tinnitus is bothersome. With spontaneous changes important to ask this open-ended question so that
in tinnitus loudness, these bothersome situations patients identify, without any prompting, the most
might be contingent on the loudness of the tinnitus. bothersome aspects of their tinnitus. As always, it
is important to ensure that patients do not confuse
their tinnitus complaints with trouble hearing or
Question 2: Do sounds ever change the understanding speech. A patients answer to Ques-
loudness of your tinnitus? What kinds of tion 3 should indicate the primary complaint(s) that
sounds make your tinnitus louder? will be targeted by the intervention.
When sound makes your tinnitus louder,
how long does the change last?
Question 4: Please tell me about
Patients occasionally report that exposure to cer- everything you tried for your tinnitus
tain sounds causes an increase in the loudness of prior to PTM. For each effort, what were
their tinnitus (P. J. Jastreboff & Hazell, 2004). Dan- you hoping would happen, and what
gerously loud sounds would be expected to cause actually did happen?
this effect. One of the response options is very
loud sounds. If this is the patients response, This question includes a note to the clinician, which
then exacerbation of tinnitus by sound most likely helps to clarify the intent of asking the question:
72 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Clinician: Sometimes a pattern will emerge showing used by the patient are available for discussion. The
that the patient has made repeated (unsuccessful) clinician should note any misunderstandings or
attempts to make the tinnitus quieter, resulting in unrealistic expectations regarding the use of sound
frustration and distress. If this is the case, try to ensure and reinstruct the patient as necessary to ensure
that the patient begins to see this pattern more clearly. that expectations are realistic. It also is helpful for
the clinician to identify any successes experienced
The discussion elicited by this question is useful by the patient so that they can be pointed out and
to both the clinician and patient as they identify built upon if the patient continues with PTM.
everything the patient has attempted for tinnitus
management and the effectiveness of each effort.
In the process, it may become evident that the Question 6: If we decide to move ahead
patient made repeated attempts to quiet the tinni- with one-on-one support, then we will be
tus and that each unsuccessful effort compounded making plans for using sound to manage
the distress. The clinician should help the patient your reactions to tinnitus. It will be
recognize if this has been the pattern of previous helpful to have a list of sound-producing
attempts to manage tinnitus. If so, then the clini- devices that you have available to you.
cian should clarify that the goal of intervention with Which of the following devices do you own?
PTM never is to change the tinnitus, and to explain
the rationale for this approach. Throughout the As for Questions 4 and 5, a note to the clinician is
course of PTM a patient might unintentionally slip included to clarify the questions intent:
back into the pattern of trying to change the tinni-
tus; if the clinician understands the patients history Clinician: For each type of device listed below that
of attempts to change the tinnitus and the results of the patient owns, provide additional details. For
those attempts, then the clinician can gently remind instance, if patients report they own a radio, ask:
the patient of that unsatisfactory history. how many radios, if any of them are portable, and if
not portable where it is located. For each device the
patient owns, ask how it currently is being used rela-
Question 5: Please tell me about the tive to tinnitus management.
sounds you have used to manage your
reactions to tinnitus since starting PTM. Patients sometimes overlook sources of sound that
For each sound you tried, what were you they already own that can be used to manage their
hoping would happen, and what actually reactions to tinnitus. Answering this question cre-
did happen? ates a fairly detailed list of all of these resources
available to the patient. The list can be referred to
As for Question 4, this question includes a note to whenever a Sound Plan Worksheet is created or
the clinician to clarify the questions intent: modified. All of the items on the list should be those
that the patient already owns or has access to. Cre-
Clinician: if the patient has the Sound Plan Work- ating this list also can lead to discussion concerning
sheets that were used during Level 3, these can be other types of sound-producing devices that might
used to guide this interaction. It also is important be helpful for future sound plans.
to reinforce the idea that with PTM the goal is not
to change the tinnitus, but rather to change how
one feels. Psychoacoustic
Assessment of Tinnitus
The intent of this question is to determine the
patients impressions regarding his or her experi-
ences using therapeutic sound with PTM. It is help- Psychoacoustic assessment of tinnitus generally is
ful if any Sound Plan Worksheets (see Appendix N) not recommended within the framework of PTM.
Level 4 Interdisciplinary Evaluation 73

This may seem surprising, so the rationale for this environment. If used as soothing sound, then the
recommendation is provided below. audiologist should adjust the frequency output of
A tinnitus psychoacoustic assessment typi- the sound generator to produce a soothing effect
cally includes tinnitus loudness and pitch match- regardless of the effect on the tinnitus itself. Patients
ing, finding the minimum masking level (MML) commonly report that some sounds are soothing
using broadband noise (BBN), and testing for or relaxing even if they have no effect on the tinni-
residual inhibition (RI). Tinnitus loudness and tus percept. Conversely, some patients report that
pitch matching involves procedures designed to sounds that mask their tinnitus are unacceptably
identify a pure tone or band of noise that matches loud, or are as unpleasant as the tinnitus itself.
as closely as possible the pitch and loudness of the Therefore, for PTM, focusing on masking tinni-
tinnitus. MML testing consists of finding the level tus by emphasizing sound in the frequency range
of BBN required to completely cover, or mask the that corresponds with the pitch match can hinder
tinnitus. RI refers to the phenomenon that tinnitus efforts to identify sounds that are soothing to the
can be temporarily reduced or terminated follow- patient.
ing certain acoustic stimulation. Another argument sometimes made is that
When these tests are performed, patients are results of MML testing can be useful in predicting
asked to attend closely to their tinnitus and to the which patients are likely to benefit from the use of
effects of different sounds on the tinnitus. Asking ear-level noise/sound generators (alone or in com-
patients to pay close attention to the sound of their bination with a hearing aid). The rationale behind
tinnitus is at cross purposes with the therapeutic this argument is that patients who require high
goals of PTM. With PTM, patients are required to levels of BBN to mask their tinnitus are more
attend to how they feel, rather than to the sound likely to require unacceptably high levels of sound
of their tinnitus. Making the transition to attend- from a sound generator to adequately mask their
ing to how they feel and their reactions to tinnitus tinnitus. As explained above, masking tinnitus is
rather than to the sound of tinnitus is difficult for not the goal of using sound with PTM. (Masking
many patients, but very important. It is impor- may occur, however, in the process of using sound
tant because patients usually cannot satisfactorily for another therapeutic purpose.) With PTM, sound
change the sound of their tinnitus, but they usually from an ear-level sound generator is used either
can change how they feel. Furthermore, for PTM, as soothing sound or background soundneither
results of tinnitus psychoacoustic testing gener- of which involves masking of tinnitus. Therefore,
ally are not helpful for diagnostic purposes, for predicting that a patient is unlikely to benefit from
guiding intervention, or for assessing outcomes of the use of ear-level sound generators because
intervention. of high MMLs may falsely lower expectations of
An argument sometimes made for perform- benefit and could actually prevent a patient from
ing these tests is that results of pitch matching discovering that using a sound generator can be
can be useful when adjusting the frequency out- helpful for providing soothing or background
put of an ear-level sound generator. The hope is sound even if there is no effect on the sound of the
that providing more sound in the frequency range tinnitus itself.
corresponding with the tinnitus pitch will result For these reasons tinnitus psychoacoustic test-
in improved masking of tinnitus. Such efforts are ing is not recommended as part of the Level 4 Inter-
irrelevant and possibly counterproductive with disciplinary Evaluation. However, PTM should be
respect to using therapeutic sound with PTM. For considered a framework within which flexibility
example, sound from an ear-level sound genera- is allowed (and even encouraged) to best meet
tor would be used either as background sound or the needs of individual clinical programs. Detailed
soothing sound (see Chapter 7). If used as back- instructions for tinnitus psychoacoustic testing
ground sound, then achieving masking is of no have been published elsewhere (J. A. Henry, 2004; J.
consequencethe purpose of background sound A. Henry, Zaugg, & Schechter, 2005a) for clinicians
is to reduce contrast between tinnitus and a quiet who wish to include it in their clinical protocol.
74 Progressive Tinnitus Management: Clinical Handbook for Audiologists

will be provided before beginning Level 5 Individ-

In-Clinic Trials of ualized Support.
Ear-Level Instruments
(optional procedures)
Three Categories of Patients at Level 4
Patients who reach Level 4 have undergone a suc-
cessive filtering process that provides reason-
Categorizing patients with respect to their candi-
able assurance that their problem with tinnitus
dacy for hearing aids is essential prior to the Level
warrants individualized clinical attention. These
4 in-clinic trials of ear-level instruments. Different
patients generally require much more assistance
instruments are demonstrated depending on the
than has been available to them up to this point.
patients category. Categories include: (a) obvi-
They also typically are motivated to try new strate-
ous hearing aid candidate; (b) borderline hearing
gies that might be helpful in managing their reac-
aid candidate; and (c) not a hearing aid candidate.
tions to tinnitus.
Obvious hearing aid candidates are patients
At Level 4, all types of ear-level sound gen-
who have hearing loss to such a degree that:
erators and combination instruments (and hearing
(a)amplification would most likely ameliorate
aids) are viable options for intervention. (Please
their communicative and other hearing problems;
refer to the Flowchart for Assessment and Fitting of
and (b) they are motivated to wear hearing aids.
Ear-level InstrumentsAppendix I). The normal
With PTM, hearing aids typically are fit at Level 2
protocol is to fit only hearing aids at Level 2. How-
(see Appendix I). Therefore, at Level 4, most obvi-
ever, as noted in Chapter 5, new models of com-
ous hearing aid candidates will already be wearing
bination instruments provide full-feature hearing
hearing aids.
aids. These combination instruments can be fitted
Borderline hearing aid candidates typically
at Level 2, and, if so, then we would recommend
report occasional hearing problems. These patients
that the noise generator portion be turned off until
tend to have mild to moderate sloping high-fre-
the patient has received the audiologic counseling
quency sensorineural hearing loss. To be consid-
that is provided at Level 3.
ered a borderline hearing aid candidate, patients
If results of the Tinnitus and Hearing Survey
must be motivated to wear hearing aids (for man-
(see Appendix D), supplemented with the Tinnitus
agement of tinnitus and/or to improve hearing).
Interview (see Appendix R) suggest that a patient
is a candidate for Level 5 Individualized Support
from an audiologist, thenif the patient is amena- Which Ear-Level Instruments Should Be
bleit is appropriate to conduct in-clinic trials Demonstrated for Each Patient Category?
of ear-level instruments. It is important to perform
in-clinic trials because it often is difficult to predict For obvious and borderline hearing aid can-
how a patients tinnitus (and reactions to tinnitus) didates, in-clinic trials with hearing aids and com-
will be affected by amplification, sound from an bination instruments are conducted. (If the patient
ear-level sound generator, or a combination of already is a hearing aid user, then an in-clinic trial
amplification plus sound generator. In-clinic trial using the patients current hearing aids should be
use of ear-level instruments allows patients to make performed.) Borderline hearing aid candidates also
realistic, experience-based decisions about the should be evaluated for noise generators.
potential effectiveness of the devices. It should For patients who are not hearing aid candi-
be explained to patients that the purpose of the dates, normally only in-clinic trials with noise
in-clinic trials is to evaluate the potential useful- generators should be conducted. However, some
ness of the devices for ongoing management of patients with essentially normal hearing will bene-
reactions to tinnitus. Results of the trials are used to fit from hearing aids that are optimized for patients
determine collaboratively if ear-level instruments with tinnitus (described later).
Level 4 Interdisciplinary Evaluation 75

Special Forms to Guide In-Clinic Trials of able earmolds are used for in-clinic trial use. Certain
Ear-Level Instruments supplies also should be on hand, such as temporary
earmolds (in a variety of sizes with variable vent-
A series of four forms has been developed for use ing), vent plugs, and temporary feedback wraps.
as guides to selecting ear-level instruments at the
Level 4 Interdisciplinary Evaluation. These forms Minimum Inventory of Ear-Level Instruments for
include: In-Clinic Trial Use

n Guide to Trial Use of Ear-Level The minimum inventory of ear-level instruments

Instruments (Appendix V) would be a single pair of BTE combination instru-
n In-Clinic Trial Use of Hearing Aids ments (with disposable earmolds). If possible, the
(Appendix W) instruments should have an adjustable frequency
n In-Clinic Trial Use of Combination response for both the amplifier and the noise gen-
Instruments (Appendix X) erator. If trial instruments are limited to one set of
n In-Clinic Trial Use of Noise Generators BTE combination instruments, then these instru-
(Appendix Y) ments can be used to demonstrate the potential
benefit from:
The first form (Guide to Trial Use of Ear-Level
InstrumentsAppendix V) gives an overview of Noise Generators Alone. BTE combination instru-
which ear-level instruments should be tried in the ments can be used to demonstrate the benefit
clinic for patients who are: obtained from using ear-level noise generators (the
hearing aid portion is turned off).
n Obvious hearing aid candidates
n Borderline hearing aid candidates Hearing Aids Alone. BTE combination instru-
n Not hearing aid candidates. ments can be used to demonstrate the benefit ob-
tained from using hearing aids (the noise generator
This form also contains a guide to discussing with portion is turned off). The drawback is that the hear-
patients results of the trials and collaboratively ing aid portion of a combination instrument may
making decisions regarding the use of ear-level be less flexible, less sophisticated, and have fewer
instruments during Level 5 Individualized Sup- features than a traditional hearing aid. Increas-
port. The other forms (In-Clinic Trial Use of Hearing ingly, new models of combination instruments do
AidsAppendix W; In-Clinic Trial Use of Combi- not sacrifice hearing aid features, so these potential
nation Instruments Appendix X; In-Clinic Trial drawbacks are becoming less of a concern.
Use of Noise GeneratorsAppendix Y) provide
detailed instructions for conducting the in-clinic Combined Noise Generator and Hearing Aid.
trials. These forms also are used to record patient BTE combination instruments can be used to dem-
responses to each trial performed. onstrate the potential benefit from the simultane-
ous use of a noise generator and hearing aid (both
are turned on at the same time).
Clinic Inventory of Trial Ear-Level
Instruments Ideal Inventory of Ear-Level Instruments for
In-Clinic Trial Use
A variety of ear-level instruments should be avail-
able to conduct in-clinic trials with patients. Because The ideal inventory of stock ear-level instruments
of potential sanitization concerns, in-the-ear (ITE) would include noise generators, combination
instruments are not recommendedonly behind- instruments, and hearing aids. There should be a
the-ear (BTE) instruments with temporary dispos- pair of each type of device to allow binaural trial
76 Progressive Tinnitus Management: Clinical Handbook for Audiologists

fittings of each. If possible, more than one model/ appointment. However, the fitting appointment
make of noise generator and combination instru- can be combined with the initial Level 5 appoint-
ment should be available to demonstrate the differ- ment (which makes for a very long appointment).
ent choices. Hearing aids that serve a wide fitting
range should be on hand.
Personal listening devices and stationary Summary of Ear-Level Instruments
devices such as tabletop sound conditioners, pillow for PTM
speakers, and MP3 players loaded with interesting,
soothing, and background sounds also should be Appropriate use of sound can be critically impor-
available for patients to try as alternative therapeu- tant for managing reactions to tinnitus. There are
tic uses of sound if ear-level instruments are not numerous options for using sound with ear-level
advised or desired. instruments. Each option must be considered for
the individual patient. A systematic approach
is required to determine the best combination of
Maintaining Continuity Between Level 3 instruments and sounds. The patient makes the
Counseling and In-Clinic Trials final decision, and the clinician facilitates the deci-
sion making process and provides a selection of
During the Level 3 Group Education workshops, sounds and instruments.
patients learn about the three types of sound (sooth-
ing, background, interesting) that can be used to
manage reactions to tinnitus (see Chapter 7). For
the in-clinic trials to be most meaningful, patients Criteria for Patients to Progress
need to be informed that the instruments can be to Level 5 Individualized Support
used to provide an immediate sense of relief (sooth-
ing sound), to provide a background of sound Following completion of the Level 4 Interdisciplin-
to reduce the tinnitus/background contrast, and to ary Evaluation for a patient, ideally the psycholo-
improve access to interesting sound. gist, audiologist, and patient decide collaboratively
if the patient will initiate Level 5 Individualized
Need for Follow-Up If Patients Receive Support with the psychologist and/or audiologist.
Ear-Level Instruments Patients must meet the following criteria to be con-
sidered for Level 5 Individualized Support:
Use of ear-level instruments for tinnitus requires
n Levels 1 to 4 of PTM have not adequately
ongoing support (Level 5 Individualized Support)
from an audiologist, including continued develop- addressed their tinnitus concerns.
n They have been evaluated and referred as
ment and assessment of strategies for using sound
most effectively. This process is facilitated by using appropriate for care in other clinics.
n They understand the nature of the PTM
the Sound Plan Worksheet (see Appendix N), which
should be reviewed at every appointment. Indi- services available from the psychologist
vidualized support typically involves two to five and audiologist (including device options
visits over a period of up to 6 months. A patient and potential duration of intervention).
n They are motivated and capable of
who receives special ear-level devices during Level
4 should attend at least two Level 5 appointments. participating in the activities proposed by
the psychologist and/or audiologist.

Fitting Appointment If Level 5 Individualized Support is initiated with

both the psychologist and audiologist, it is best if the
If ear-level instruments were ordered for the patient, clinicians remain in regular contact regarding the
then they are fitted prior to the initial Level 5 patients progress within each of the disciplines.

Level 5 Individualized Support

Individualized support is needed by relatively few

patients. Level 5 Individualized Support involves
Level 5 Standard Protocol for
use of the same principles of using sound and cop- Audiologists
ing techniques to manage tinnitus that are pre-
sented in Level 3 Group Education. However, at Level 5 Appointments
Level 5 some patients use ear-level noise/sound
generators or combination instruments, and the At each Level 5 appointment with an audiologist:
education and support is provided in a one-on-one (a) the functioning and proper use of ear-level
format with more intense and individualized assis- instruments is verified (if applicable); and (b) one-
tance. Also, Level 5 counseling is less structured on-one PTM counseling is conductedfocusing on
and allows for flexibility in what is covered dur- updating the Sound Plan Worksheet (see Appen-
ing the sessions. The individual counseling should dixN) to ensure that the patient is optimizing the
reinforce the Level 3 principles, but the clinician use of therapeutic sound to address tinnitus-problem
has latitude to modify or expand on the counsel- situations. If the clinician feels that it is necessary, the
ing information as needed. Level 5 intervention patients progress is evaluated, and current needs are
normally requires up to six months of repeated assessed using any of the questionnaires that were
appointments with an audiologist and/or a mental administered at the Level 4 evaluation, including
health provider. the Tinnitus Handicap Inventory (see Appendix F),
78 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Tinnitus and Hearing Survey (see Appendix D), Adherence to the Appointment Schedule
Hearing Handicap Inventory (see Appendix G), and
the Tinnitus Interview (see Appendix R). If the Tin- Adherence to the recommended schedule requires
nitus Interview is used, then it is best to select indi- motivation and commitment on the part of the
vidual questions that are relevant to the patients patient. Normally, only patients with the most
complaints rather than administering the entire problematic tinnitus are so inclined. Patients who
interview. Audiometric testing is repeated only if live at a distance may not be able to return to the
the patient reports a significant auditory change. clinic as often as advised. These patients should at
least be counseled via telephone, using the self-help
Schedule of Appointments workbook How to Manage Your Tinnitus: A Step-by-
Step Workbook (J. A. Henry et al., 2010a) as a general
Following the initial Level 5 appointment, return guide to implementing self-help strategies.
counseling appointments normally are scheduled
at 1, 2, 4, and 6 months. Six-Month Appointment
Why Are Return Appointments Important? The appointment at six months is the final appoint-
ment for most patients receiving Level 5 services.
Return appointments are an essential, but often If this is the final appointment, then the same pro-
neglected, aspect of ongoing management for patients cedures are conducted as for the standard protocol
who have a severe problem with tinnitus. It is that is recommended for all of the Level 5 appoint-
unreasonable to expect these patients to accomplish ments (see Level 5 Appointments above). In addition,
all management objectives without the guidance and the Tinnitus Handicap Inventory (see Appendix F)
support of a tinnitus specialist. Consequently, they and the Tinnitus and Hearing Survey (see Appen-
require repeated appointments on a prescribed sched- dix D) should be administered and results com-
ule until their problem is sufficiently resolved and/ pared to previous responses to evaluate the patients
or they are capable of performing self-management progress through all levels of PTM. If problems
effectively. were reported on the Tinnitus Interview (see Appen-
From a health education perspective, patients dix R), then it would be important to repeat any
need to return for repeated counseling because they pertinent questions from the interview.
recall only about half of the information, and some
of the health information is remembered incor-
rectly (Margolis, 2004; Shapiro, Boggs, Melamed, & Exceptions to the Level 5 Standard
Graham-Pole, 1992). It also has been reported that Protocol for Audiologists
patients immediately forget as much as 80% of the
information (Kessels, 2003).
Repeated appointments are required for all Final Appointment
Level 5 patients to ensure that they are using their The patients final Level 5 appointment may
ear-level devices properly and that they remember be earlier or later than six-months. Regardless
the key points of counseling (J. A. Henry, Trune of when the final appointment takes place, the
etal., 2007a; P. J. Jastreboff & Hazell, 2004). Return procedures described above for the six-month
visits also are necessary to ensure that patients are appointment should be performed during the final
(a) implementing their individualized sound plans appointment.
developed at previous visits, and modifying the
plans to optimize their efficacy; and (b) using the Making the Decision to End Intervention
specific coping skills that are taught by the men- Before or After Six Months
tal health provider. Compliance with a schedule of
periodic appointments optimizes the potential to The decision to end intervention should be made
achieve successful results. jointly between the clinician and patient. Ideally,
Level 5 Individualized Support 79

this decision would be corroborated by the patients Telephone Counseling

responses to outcome questions on the Tinnitus
Handicap Inventory (THI) (see Appendix F) and Patients may not be able to attend the recommended
Tinnitus and Hearing Survey (see Appendix D) series of return appointments because they live at
(although such corroboration is not essential). As a a distance or for other reasons. These patients can
reference, it has been reported that a 20-point be counseled adequately over the telephone if they
reduction in the THI index score reflects clinically have the self-help workbook (J. A. Henry et al.,
significant improvement (C. W. Newman & San- 2010a) to refer to during the counseling.
dridge, 2004). When intervention is complete,
patients should be advised to telephone the clini-
cian whenever questions or issues arise, and to Self-Help Workbook
request special appointments if needed.

At the initial Level 5 appointment, patients should

Extending Intervention Beyond Six Months be asked if they have a copy of the workbook (How
to Manage Your Tinnitus: A Step-by-Step Guide, J. A.
If the patient requires intervention beyond six Henry et al., 2010a), which normally is dispensed
months, then the progress made to this point at the beginning of Level 3 Group Education. If not,
should be reviewed with the patient along with then a new copy should be provided. The work-
discussion of the potential benefit of further inter- book should be reviewed with the patient and
vention. Multiple issues can be discussed as poten- portions of the workbook that are most applicable
tially contributing to a lack of sufficient progress: should be discussed. Patients should be aware that
the key PTM counseling principles are described
n The patients tinnitus problem was in the workbook, along with step-by-step instruc-
so severe that more time and support tions for developing plans to manage their tinnitus
are needed for the patient to be able to problem using both therapeutic sound and coping
adequately self-manage reactions to techniques. They should be encouraged to read the
tinnitus. workbook and adhere to its recommendations.
n Effective sound plans (using the Sound
Plan WorksheetAppendix N) have not
yet been identified.
n The patient (for any reason) has not PTM Level 5 Counseling
implemented the sound plan(s) from the
Sound Plan Worksheet. The education provided by audiologists to patients
n A psychological component has not been at all levels of PTM is designed primarily to help
properly managed through help from a patients develop, and experience success using,
mental health professional. self-management strategies that address the situ-
ations when their tinnitus is most problematic
Every possible contributing factor should (using the Sound Plan WorksheetAppendix N).
be explored, and referrals to other services may The main difference at Level 5 is the one-on-one
be indicated more strongly at this point. If, after setting that facilitates direct interaction between
thorough review with the patient, there is agree- patient and clinician. Some patients do better by
ment that further intervention may be helpful, then receiving ongoing individualized attention from a
Level 5 appointments can be extended beyond six caring and knowledgeable clinician. Some patients
months. It is critical for these patients to know also need the opportunity to resolve any questions
that further services are accessible and available or concerns about their tinnitus in a private setting
if needed. where they can express feelings and concerns that
80 Progressive Tinnitus Management: Clinical Handbook for Audiologists

they might not have been comfortable discussing

in a group setting.
Level 5 CBT
A patient counseling guide (Progressive Tinni-
tus Management: Counseling Guide, J. A. Henry The Level 4 Interdisciplinary Evaluation informs
et al., 2010b) is used during the Level 5 appoint- the intervention provided by a mental health pro-
ments. The counseling guide is used like a flip vider at Level 5. The mental health services at
chart, but laid flat on a table between clinician and Level5 involve a review of the CBT coping tech-
patient. When the book is open, one side faces the niques taught during Level 3 Group Education
clinician and the other side faces the patient. The (and included in the self-help workbook that is pro-
clinicians pages contain bulleted counseling vided to patients at Level 3) and an individualized
points, and the patients pages show simplified examination of patients unique achievements and
bulleted points and illustrative graphics. The coun- challenges so far during PTM. Further integrating
seling guide was designed to be used primarily by coping skills by attending to challenges patients
audiologists. A similar guide is in development that face when implementing the skills allows themes
will be intended primarily for use by mental health to emerge. Patients learn more about setting and
providers. achieving goals with behavioral modification by
The Level 5 patient counseling guide includes tracking their progress using clearly defined mea-
three sections: an introductory section, follow-up sures of change. For example, if a patient is hav-
section, and supplemental sound tolerance (hyper- ing difficulty managing stress, charting stress on
acusis) section. The first two sections correspond a scale from 0 to 10 is an effective way to quantify
with the Level 3 PowerPoint presentations (Manag- the patients response to stress and observe change
ing Your Tinnitus: What to Do and How to Do It) that as a result of modification in behavior. During
are included on the CD in the back of this hand- Level5, patients learn how to accept their indi-
book. Using the counseling guide, most patients vidual strengths and weaknesses while gaining a
at Level 5 will start with the follow-up section sense of control in the event that change is realistic
(because the material covered in the introductory and obtainable.
section was already covered during Level 3 Group In order to provide CBT, clinicians must be
Education). The introductory section normally is trained by another professional experienced in
used only with patients who have not completed this modality of psychotherapy. Mental health cli-
Level 3. The introductory section, however, serves nicians may or may not have received this train-
as a resource for fundamental PTM counseling ing, thus the involvement of mental health at this
information that can be accessed as needed during level will depend on the availability of CBT-trained
counseling sessions. mental health providers. A mental health provider
who is experienced in providing CBT is skilled
in explaining the process of CBT to patients, pos-
sesses skill in conceptualizing underlying themes
Demonstrating Personal Listening
that arise for individuals, and assists patients in
Devices and Stationary Devices
developing their skills to problem solve. Such cli-
nicians refer to themselves as psychotherapists,
Appropriate use of augmentative sound can be which is a title regulated by state licensing boards
very effective for helping to manage reactions to based on qualifications and training. A psychother-
tinnitus. Unless the various personal listening apist has received years of training and supervi-
devices and stationary devices are demonstrated sion on establishing a good working relationship
in the clinic, however, patients may not appreci- with patients (also known as rapport). Psychother-
ate their full value. There is no formal protocol for apists adhere to a code of ethics and guide patients
demonstrating these devicesthey simply should through the therapeutic intervention. Psychothera-
be available in the clinic and demonstrated as pists who specifically provide CBT understand the
appropriate during the Level 5 appointments. importance of behavioral and cognitive theories
Level 5 Individualized Support 81

of the intervention. They assist the patients in learn- combination instruments have been helpful, but
ing ways to evaluate and change their thoughts lately has been finding that he has to turn up
and behaviors. the noise generator higher and higher to com-
During Level 5 CBT, psychotherapists help pletely mask out the tinnitus. He also reports
patients understand their tinnitus as it relates to that once he has set the noise generator to a
the entire mind-body system. Often, tinnitus is high level, sometimes the tinnitus returns after
accompanied by symptoms of depression such as several minutes. He also feels like he is carry-
increased or decreased appetite, problems falling ing around his own portable noisy environment
or staying asleep, and decreased pleasure when and believes he cannot hear as well when the
doing activities that once were pleasurable, among noise is on.
other symptoms. By simultaneously addressing Sam needs to be reminded that the goal of
a patients reactions to tinnitus and depressive using sound is never to mask the tinnitus. The
symptoms, the patient recognizes the importance three types of sound (soothing, interesting, and
of addressing both the minds reactions to physical background) should be reviewed. It should be
symptoms, and the physical symptoms that might clarified that the sound generator portion of the
influence emotions. combination instrument can be used as soothing
Occasionally, patients place more empha- sound or background sound, neither of which
sis on the problem of tinnitus than on other more requires masking. It may also be helpful to point
difficult emotional problems, such as unresolved out that the hearing aid portion of the device can
trauma. Perhaps because tinnitus adds to frus- make it easier for him to understand interesting
tration that already exists for some patients who soundslike speech. It also can be explained
struggle when negative emotions arise or because that when hearing is the predominant need, he
tinnitus is something that can be described physi- can turn the noise to either a very soft level or
cally, learning ways to cope with tinnitus may be turn it off completely.
how patients prefer to begin looking at the way The audiologist should summarize the con-
they cope with stress, emotions, and problems in tents of the meeting with Sam and make it avail-
general. Nonetheless, several patients during one able to the psychologist providing Level 5
of our studies (see Chapter 2, Fifth Study) who support to ensure that the psychologist is aware
began using CBT to cope with tinnitus realized that of Sams difficulties with using sound.
their tinnitus was just one problem among many in
their lives. CBT for tinnitus for these particular
patients offers an introduction to positive thoughts,
behaviors, and attitudes in what might be per- Beyond Level 5
ceived as a less formidable environment than what
Individualized Support
would be required to address the other problems.
Such patients are then primed to use these cop-
ing skills in other areas of their lives. Level 5 CBT If a patient does not make satisfactory progress
gives patients the opportunity to start using the after about six months of Level 5 Individualized
skills of CBT on a concrete, diagnosable, physi- Support, then a different approach can be consid-
cal problem (tinnitus) from which they can apply ered. Options for extended intervention at Level 5
the skills to more global emotional problems and include further PTM audiologic counseling (modi-
behaviors. fied as necessary), further CBT counseling (includ-
ing the addition of different components of CBT
Case Study: Sam that may not have been covered to this point), tin-
nitus masking, tinnitus retraining therapy, and neu-
Sam has received ongoing Level 5 Individu- romonics tinnitus treatment. There is no definitive
alized Support fom an audiologist and psy- evidence that any one of these behavioral methods
chologist for three months. He reports that his is more effective than any other.
82 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Cognitive-Behavioral Therapy forth. Counseling is used with TM, but the use of
therapeutic sound to induce a sense of relief is the
The objectives of CBT are to identify negative primary mode of intervention. There is no training
behaviors, beliefs, and reactions in patients and to program available for TM. Clinicians must learn
assist them in substituting appropriate and posi- TM on their own or be trained by an individual
tive reactions (see Chapter 7). CBT initially was who has expertise in this method.
used as an effective treatment for depression and
anxiety. A standard CBT protocol as adapted for
tinnitus involves up to ten sessions. These sessions Tinnitus Retraining Therapy
can be conducted with individual patients or with
groups of patients. The method of tinnitus retraining therapy (TRT)
CBT normally is performed by mental health has two basic components: educational (direc-
providers. It can, however, be administered by tive) counseling and sound therapy (J. A. Henry,
other health care providers who have received the Trune, et al., 2007a, 2007b; P. J. Jastreboff & Hazell,
proper training. Training to conduct CBT for tin- 2004). Unlike TM, the use of therapeutic sound
nitus is not offered on any routine basis for non- with TRT is not meant to give a sense of relief (J. A.
mental health clinicians, but must be obtained from Henry, Schechter, et al., 2002). With TRT the patient
a professional who has this expertise. Books are should hear the tinnitus clearly, but with constant
available that describe CBT clinical procedures in sound in the background. The background sound
detail (J. L. Henry & P. H. Wilson, 1998, 2002). reduces the contrast between the tinnitus and the
quiet environment, thus making the tinnitus less
likely to attract attention (passive attention diver-
Tinnitus Masking sion). Patients are supposed to use sound in this
way every day to eventually achieve habituation,
The method of tinnitus masking (TM) became avail- that is, reduction or elimination of tinnitus reac-
able as a clinical technique in the late 1970s (Ver- tions and perception.
non, 1977). It was popular through the 1980s and Evaluation of patients for TRT results in their
continues to be used (Schechter & J. A. Henry, 2002). placement into one of five categories: 0, 1, 2, 3, and
The main objective of TM is to use broadband noise 4. Patients in all categories are counseled to enrich
to provide a sense of relief from tension or stress their sound environment at all times with soft,
caused by tinnitus. Because of the label masking, pleasant, or neutral background sound. Category
however, the main objective has commonly been 0 patients have tinnitus that is not severe enough
misunderstood to be to cover up or mask the tin- to warrant the use of ear-level devices, thus they
nitus (J. A. Henry, Schechter, et al., 2002). Maximiz- receive TRT counseling only. Category 1 patients
ing a sense of relief is accomplished with complete are severely bothered by their tinnitus, and ear-
masking for some people, partial masking for others, level instruments (sound generators, combination
and sometimes even with no masking effect (J. A. instruments, or hearing aids) are advised for use
Henry, Rheinsburg, & Zaugg, 2004). each day for at least one year. With respect to the
TM patients normally are fitted with ear-level PTM combinations of sound (see Figure 71), the
instruments (maskers) that present wide-band use of broadband noise with TRT is an example of
noise to the ears. Patients are instructed to adjust using environmental sound as background sound.
the noise to the level that provides the greatest Category 2 patients also have a severe tinnitus
sense of relief. With respect to the PTM combina- problem, but in addition they have hearing loss
tions of sound (see Figure 7-1), TM is an example of requiring amplification. These patients are fitted
using environmental sound as soothing sound. Patients with hearing aids or combination instruments,
also are advised to use various sound-producing and sound therapy is conducted as for Category 1
devices to achieve relief, including CDs, tabletop patients. Patients in Category 3 require primary man-
fountains, sound machines, sound pillows, and so agement for hyperacusis, which involves special
Level 5 Individualized Support 83

desensitization procedures using sound to increase noise is removed from the audio signal. Patients
tolerance levels (J. A. Henry, Trune, et al., 2007a, are instructed to gradually reduce the volume of
2007b). Category 4 refers to patients whose tinnitus the music. The objective of stage 2 is essentially the
is exacerbated by exposure to certain sounds. These same as for TRT: less awareness of, and less reac-
latter patients require judicious use of sound to sys- tion to, the tinnitus. The use of sound during stage
tematically reduce their reactions to sound. 2 of NTT is an example of using music as soothing
The originators of this method contend that sound, transitioning to using music as background
it is necessary to attend their training courses in sound (see Figure 71) prior to discontinuing daily
order to properly conduct TRT. However, books use of the device.
are available that describe TRT clinical procedures
in detail, and numerous clinicians who are trained
and experienced in conducting TRT may be avail-
able to provide training and clinical supervision.

All audiologists routinely encounter patients who

Neuromonics Tinnitus Treatment complain of tinnitus. Different methods of interven-
tion for tinnitus have been available to audiologists
Neuromonics tinnitus treatment (NTT) is unique for years. However, relatively few audiologists
among tinnitus therapies in that providers who have received adequate training in providing clini-
offer this technique work directly with a com- cal services for tinnitus. Audiologists need the skills
pany to receive all training, materials, therapeutic to evaluate patients and provide the needed level
devices, and support. After a provider has received of care. The method of PTM is a definable program
training, company representatives attend the pro- of care that is based primarily on goal-oriented
viders first appointments with patients to ensure counseling of various uses of sound for managing
that all clinical procedures are conducted accord- reactions to tinnitus, and the provision of specific
ing to the prescribed protocol. The method cannot coping skills fundamental to CBT.
be implemented without the companys endorse- Standardized clinical guidelines for managing
ment and support. reactions to tinnitus are unlikely to be established
Intervention with NTT involves six months in the near future for audiologists. Training in tin-
or more of using a proprietary, wearable listen- nitus clinical services is highly variable among
ing device 2 to 3 hours per day (P. B. Davis, 2006). audiology graduate programs (J. A. Henry, Zaugg,
The device is similar to an MP3 player and plays etal., 2005a). Any training that exists reflects biases,
baroque and new age music that is specially selected which is understandable because research does not
for having relaxation-inducing qualities. For each conclusively support any one form of management.
patient, the device is customized by the company There are four broad areas that require consensus to
so that the sound output is adjusted (equalized) for achieve standardization. These include: (a) defined
any hearing loss. The device is used to implement clinical procedures; (b) research evidence to sup-
desensitization to the tinnitus in two stages as the port clinical procedures; (c) audiology graduate
prescribed protocol. During the first two months training; and (d) patient educational programs.
of treatment (stage 1) wide-band noise (shower PTM establishes basic procedures that can be used
sound) is added to the music. The objective of by audiologists until more formal standardized
stage 1 is to attain a sense of relief and control over techniques are developed and validated.
the tinnitusgenerally to reduce anxiety. Relative The effectiveness of intervention with PTM
to the combinations of sound as described for PTM depends on the effectiveness of the education that
(see Figure 71), the use of sound during stage 1 of is provided to patients. It is essential that evidence-
NTT is an example of using a combination of music based methods of patient education are utilized.
and environmental sound as soothing sound. Dur- Previously, we have reviewed a variety of learn-
ing the next four months (stage 2) the wide-band ing theories that have particular relevance to PTM
84 Progressive Tinnitus Management: Clinical Handbook for Audiologists

(J. A. Henry, Zaugg, Myers, Kendall, et al., 2009). problem profile. This patient-centered approach
This review shows that PTM adheres to a num- has been shown to greatly enhance individual
ber of principles that have been demonstrated to motivation for making adaptive changes for
optimize effective patient learning of skills for self- improving health (Stewart et al., 2000). In PTM,
management of health. patients participate in the process of defining the
We recognize that counseling for facilitating problem and identifying specific behavior changes
health behavior change presents challenges that for managing the problem. Each patient becomes
can result in frustration for patients and clinicians an active participant in making decisions and
alike (Rollnick, Mason, & Butler, 1999). Behavioral ultimately is in charge of making lifestyle adjust-
changes do not come easily, especially when the ments to mitigate his or her own tinnitus prob-
target behaviors and their underlying cognitions lem. Understanding that the patient is an expert
are long-standing, sometimes even lifelong hab- in his or her own life circumstances, problems,
its. However, counseling with PTM is a patient- resources, and abilities is the key that enables this
centered method that addresses the uniqueness collaborative tinnitus self-management approach
of each patient and his or her particular tinnitus- to succeed.

Axelsson, A., & Barrenas, M. -L. (1992). Tinnitus in idiopathic sudden sensorineural hearing loss. Otol-
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PTM Flowchart

Level 5 Individualized Support

if needed

Refer as necessary to Level 4 Interdisciplinary Evaluation

ENT, Mental Health, if needed
or other specialist
Level 3 Group Education
if needed
Sound Tolerance
if needed
Evaluation &
Level 2 Audiologic Evaluation
if needed (STEM)

Refer to Audiology Refer to ENT Refer to Emergency Refer to

(non-urgent referral) (urgency determined by Care or ENT Mental Health or
clinician; refer to audiologist (if unexplained sudden hearing
for follow-up management)
Emergency Care -
loss: Audiology referral prior to
ENT visit same day)
report suicidal
Tinnitus plus ALL of the Tinnitus plus ANY of
below the below
- Symptoms suggest neural - Symptoms suggest Tinnitus plus ANY of Tinnitus plus ANY of
origin of tinnitus (e.g., somatic origin of tinnitus the below the below
tinnitus does not pulse with (e.g., tinnitus that pulses - Physical trauma - Suicidal ideation
heartbeat) with heartbeat) - Facial palsy - Obvious mental
- No ear pain, drainage, or - Ear pain, drainage, or - Sudden unexplained health problems
malodor malodor hearing loss
- No vestibular symptoms - Vestibular symptoms
(e.g., no dizziness/vertigo) (e.g., dizziness/vertigo)
- No unexplained sudden
hearing loss or facial palsy Triage Guidelines (for non-audiologists)

Level 1 Triage


Tinnitus Triage Guidelines
(My Patient Complains About Tinnitus
What Should I Do?)

Tinnitus (ringing in the ears) is experienced by lines for triaging the patient who complains about
10 to 15% of the adult population. Of those, about tinnitus. Note that many symptoms that might be
one out of every five requires some degree of reported by patients are not included. For example,
clinical intervention. When clinical intervention patients who report tinnitus may also report symp-
is required, often only some basic education is toms of head or neck injury/disease, or of TMJ dis-
needed. However, some people with tinnitus have order. These and other symptoms would indicate
need for individualized care, or they have urgent referral to appropriate specialists.
medical issues. The following are general guide-

If the patient: Refer to:

1. Emergency Care or Otolaryngology (If unexplained
Has physical trauma,facial palsy, or unexplained sudden hearing lossAudiology referral prior to
sudden hearing loss Otolaryngology visit same day)
Has any other urgent medical condition (emergency referral)
2. Emergency Care or Mental Healthreport suicidal/
Has suicidal/homicidal ideations homicidal ideation
Manifests obvious mental health problems (may be emergencyif so, escort patient to Emergency
Care or Mental Health)
3. Has ANY of the following: Otolaryngology
Symptoms suggest somatic origin of tinnitus (urgency determined by clinician; refer to audiologist for
(example: tinnitus that pulses with heartbeat) follow-up management)
Ear pain, drainage, or malodor
Vestibular symptoms (example: dizziness/vertigo)
4. Has ALL of the following: Audiology
Symptoms suggest neural origin of tinnitus (example:
tinnitus that does not pulse with heartbeat)
No ear pain, drainage, or malodor
No vestibular symptoms (example:no
No unexplained sudden hearing loss or facial palsy


Overview of
Objectives and Procedures of the
Level 2 Audiologic Evaluation

Determine need for: Assessment procedures: Action needed:

1. Referral for medical Standard clinical procedures Refer to otolaryngology
2. Hearing aids or assistive Standard clinical procedures Fit devices as appropriate
listening devices
3. Level 3 Group Discuss with patient the responses to the Schedule patient for group workshops
Education Tinnitus and Hearing Survey (primarily (after fitting of any instruments)
Section A) (Appendix D). If the patient is
interested in attending a workshop that
focuses on managing problems listed in
section A then action is needed.
4. Provision of Loudness Review item 1 from Section C of Provide a copy of the handout to the
Tolerance Handout: the Tinnitus and Hearing Survey patient with a brief explanation of its
What to Do When (Appendix D). If the patient reports at purpose
Everyday Sounds Are least a mild loudness tolerance problem,
Too Loud (Appendix E) then action is needed.
5. Assessment for a Discuss with the patient the responses to Schedule the patient for a Sound
loudness tolerance the Tinnitus and Hearing Survey (primarily Tolerance Evaluation and Management
problem item 2 from Section C) (Appendix D). (STEM) appointment. Suspend Level
If the patient reports that a loudness 3 of PTM until the sound tolerance
tolerance problem would make it difficult problem is resolved.
to attend a group education class, then
action is needed.
6. Mental health screening Screening is done at Level 2 only if the Refer patient to a mental health
patient exhibits behaviors or makes provider that is part of the PTM or
statements that would suggest the need tinnitus team, or to primary care for
for mental health screening mental health screening
7. Provision of self-help Patients who have problematic tinnitus Issue a workbook at the end of
education workbook: should be advised to attend Level 3 Group Level 2 only if the patient cannot or will
How to Manage Your Education. The workbook normally is not attend Level 3 Group Education. If
Tinnitus: A Step-by-Step provided to patients at the start of the time permits, point out sections of the
Workbook first Level 3 workshop. workbook that are applicable to the
patients situation.


Tinnitus and Hearing Survey


blem big
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pro smal

pro very
pro mod
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A. Tinnitus
Over the last week, tinnitus kept me from 0 1 2 3 4

Over the last week, tinnitus kept me from 0 1 2 3 4

concentrating on reading.

Grand Total
Over the last week, tinnitus kept me from 0 1 2 3 4

Over the last week, I couldnt get my mind 0 1 2 3 4

off of my tinnitus.

Total of each column

B. Hearing
Over the last week, I couldnt understand what 0 1 2 3 4
others were saying in noisy or crowded places.
Over the last week, I couldnt understand what 0 1 2 3 4
people were saying on TV or in movies.
Grand Total
Over the last week, I couldnt understand 0 1 2 3 4
people with soft voices.
Over the last week, I couldnt understand what 0 1 2 3 4
was being said in group conversations.

Total of each column

C. Sound Tolerance
Over the last week, everyday sounds were too 0 1 2 3 4
loud for me.*

If you responded 1, 2, 3 or 4 to the statement

Being in a meeting with 5 to 10 people 0 1 2 3 4
would be too loud for me.*
*If sounds are too loud for you when wearing hearing aids, please tell your audiologist.


What to Do When Everyday
Sounds Are Too Loud
(Not related to using hearing aids)

Bill Smith is bothered by everyday sounds. (This prob- If you keep yourself surrounded with sound,
lem is sometimes called hyperacusis.) Kitchen sounds your ears will readjust. It will slowly become easier
and the vacuum cleaner are too loud for him. He is both- for you to tolerate everyday sounds. You should
ered by road noise when he drives. It seems like every- only use sounds that are comfortable for you. It
thing at church is too loud. What should Bill do? Believe usually takes at least a few weeks of being around
it or not, being around more sound can make things bet- sound for this change to happen.
ter! And, staying away from sound can make his prob- How do I keep myself surrounded with sound?
lem worse! What??? He should add more sound??? You can use any sound that is not annoying (the
Keep reading and well explain . . . sound can be either neutral or pleasant). Here are
some ideas:
There are three things you can do if everyday
sounds are too loud for you. n Listen to music at a comfortable level.
n Listen to radio shows.
1. Keep yourself surrounded with sound that is n Play recordings of nature sounds.
comfortable for you. n Keep a fan running.
2. Listen to sounds that you enjoy as often as you n Use a tabletop water fountain.
3. Only wear hearing protection when you really Another choice: Some people wear small instru-
need to. ments in their ears that make a shhh sound.
These instruments are called in-the-ear noise genera-
1. Keep yourself surrounded with sound tors or maskers. Your audiologist can tell you more
that is comfortable for you. about them.
Why should I keep myself surrounded with
sound? Lets start by thinking about your eyes and 2. Listen to sounds that you enjoy as often
how they adjust to light. Imagine sitting in a dark as you can.
movie theater and then going outside into the day- Why should I listen to sounds that I enjoy as
light. Everything seems brighter to you than it does often as I can? We just talked about the problem
to people who were not sitting in the dark. Your of everyday sounds being too loud (hyperacusis).
eyes had adjusted to the dark and now they have Many people also have another problem: they just
to readjust to the daylight. dont like certain sounds, but not because they are too
Your ears adjust to sound like your eyes adjust loud. (This problem is sometimes called misophonia.)
to light. If you stay away from sound, your ears will If you dont like certain sounds, you should make a
slowly adjust to the quiet. After a while, everyday point of listening to sounds that you enjoy. Spend-
sounds will seem louder and harder to tolerate. ing time enjoying sound can help you get better at
Avoiding sound will only make the problem worse. tolerating everyday sounds that you dont like.

104 Progressive Tinnitus Management: Clinical Handbook for Audiologists

3. Only wear hearing protection when you n There were two groups of people:
really need to. 1. One group wore earplugs for 2 weeks.
Why should I use ear protection only when 2.The other group wore in-the-ear sound
I really need to? When everyday sounds seem generators (maskers) that make a
too loud, some people start using ear protection shhh sound.
all the time. Remember that avoiding sound will n After 2 weeks:
make the problem worse. Only use ear protection nThe people who wore earplugs could
when sounds are dangerously loud or uncomfort- tolerate less sound than before.
ably loud. As soon as the sound around you is at a nThe people who wore sound generators
safe and comfortable level, take the ear protection could tolerate more sound than before.
off. The goal is to wear ear protection only when n This study showed that:
needed. nAdding sound makes it easier to
Use earplugs or earmuffs only when: tolerate sound.
nStaying in quiet makes it harder to
n sounds around you are uncomfortably tolerate sound.
n you are around dangerously loud sounds Bottom line
like: If everyday sounds bother you:
n lawn mowers
n Surrounding yourself with comfortable
n loud concerts
sound will help.
n power tools
n Avoiding sound will make the problem
n guns
n etc.
How long does it take?
Is there any research? It can take weeks or months for your ears to adjust.
Yes. In 2002 Formby, Sherlock, and Gold1 studied
sound tolerance. Talk to your audiologist if you have any questions.

 Adaptive Calibration of Chronic Auditory Gain: Interim Findings, by C. Formby, L. P. Sherlock, & S. L. Gold, 2002, In

Proceedings of the VIIth International Tinnitus Seminar (pp. 165169) by R. Patuzzi (Ed.), Crawley, Australia: University of
Western Australia.

Tinnitus Handicap Inventory
Instructions: The purpose of this questionnaire is to identify problems your tinnitus may be causing you.
Check Yes, Sometimes, or No for each question. Do not skip a question.

Yes Sometimes No
(4) (2) (0)
1F Because of your tinnitus, is it difficult for you to concentrate?
2F Does the loudness of your tinnitus make it difficult for you to hear people?
3E Does your tinnitus make you angry?
4F Does your tinnitus make you feel confused?
5C Because of your tinnitus, do you feel desperate?
6E Do you complain a great deal about your tinnitus?
7F Because of your tinnitus, do you have trouble falling to sleep at night?
8C Do you feel as though you cannot escape your tinnitus?
9F Does your tinnitus interfere with your ability to enjoy social activities (such
as going out to dinner, to the movies)?
10E Because of your tinnitus, do you feel frustrated?
11C Because of your tinnitus, do you feel that you have a terrible disease?
12F Does your tinnitus make it difficult for you to enjoy life?
13F Does your tinnitus interfere with your job or household responsibilities?
14F Because of your tinnitus, do you find that you are often irritable?
15F Because of your tinnitus, is it difficult for you to read?
16E Does your tinnitus make you upset?
17E Do you feel that your tinnitus problem has placed stress on your relationship
with members of your family and friends?
18F Do you find it difficult to focus your attention away from your tinnitus and on
other things?
19C Do you feel that you have no control over your tinnitus?
20F Because of your tinnitus, do you often feel tired?
21E Because of your tinnitus, do you feel depressed?
22E Does your tinnitus make you feel anxious?
23C Do you feel that you can no longer cope with your tinnitus?

Appendix F continued

Yes Sometimes No
(4) (2) (0)

24F Does your tinnitus get worse when you are under stress?
25E Does your tinnitus make you feel insecure?
Total ____ ____ ____

F denotes an item on the functional subscale; E, an item on the emotional subscale; and C, an item on the catastrophic response

From Development of the Tinnitus Handicap Inventory, by C. W. Newman, G. P. Jacobson, & J. B. Spitzer, 1996, Archives
of Otolaryngology-Head and Neck Surgery, 122, 143148. Reprinted with permission.

Tinnitus Handicap Inventory
Screening Version

Instructions: The purpose of this questionnaire is to identify problems your tinnitus may be causing you.
Check Yes, Sometimes, or No for each question. Do not skip a question.

Yes Sometimes No
(4) (2) (0)
1 Because of your tinnitus, is it difficult for you to concentrate?
2 Do you complain a great deal regarding your tinnitus?
3 Do you feel as though you cannot escape your tinnitus?
4 Does your tinnitus make you feel confused?
5 Because of your tinnitus, do you feel frustrated?
6 Do you feel that you can no longer cope with your tinnitus?
7 Does your tinnitus make it difficult for you to enjoy life?
8 Does your tinnitus make you upset?
9 Because of your tinnitus, do you have trouble falling asleep at night?
10 Because of your tinnitus, do you feel depressed?
Total ____ ____ ____

From Development and Psychometric Adequacy of the Screening Version of the Tinnitus Handicap Inventory, by C. W.
Newman, S. A. Sandridge, & L. Bolek, 2008, Otology and Neurotology, 29(3), 276281. Reprinted with permission.


Hearing Handicap InventoryE
Screening Version

Please answer the following questions based on your last two weeks.

Yes Sometimes No
(4) (2) (0)
1. Does a hearing problem cause you to feel embarrassed when you meet new
2. Does a hearing problem cause you to feel frustrated when talking to
members of your family?
3. Do you have difficulty when someone speaks in a whisper?
4. Do you feel handicapped by a hearing problem?
5. Does a hearing problem cause you difficulty when visiting friends, relatives, or
6. Does a hearing problem cause you to attend religious services less often than
you would like?
7. Does a hearing problem cause you to have arguments with family members?
8. Does a hearing problem cause you difficulty when listening to TV or radio?
9. Do you feel that any difficulty with your hearing limits or hampers your
personal or social life?
10. Does a hearing problem cause you difficulty when in a restaurant with relatives
or friends?
Total ____ ____ ____

From Identification of Elderly People with Hearing Problems, by I. M. Ventry, & B. E. Weinstein, 1983, Asha, 25(7), 3742.
Reprinted with permission.


Tinnitus Problem Checklist
1. My most bothersome tinnitus situation is:
Falling asleep at night Relaxing in my recliner
Staying asleep at night Napping during the day
Waking up in the morning Planning activities
Reading Driving
Working at the computer Other ________________________
Write your answer on #1 of the Sound Plan Worksheet. Copies of the worksheet can be found at the
end of the self-help workbook.1

2. My second most bothersome tinnitus situation is:

Falling asleep at night Relaxing in my recliner
Staying asleep at night Napping during the day
Waking up in the morning Planning activities
Reading Driving
Working at the computer Other ________________________
Write your answer on #1 of a separate Sound Plan Worksheet.

3. My third most bothersome tinnitus situation is:

Falling asleep at night Relaxing in my recliner
Staying asleep at night Napping during the day
Waking up in the morning Planning activities
Reading Driving
Working at the computer Other ________________________
Write your answer on #1 of a separate Sound Plan Worksheet.

 ow to Manage Your Tinnitus: A Step-by-Step Workbook, by J. A. Henry, T. L. Zaugg, P. M. Myers, & C. M. Kendall, 2010, San

Diego, CA: Plural Publishing, Inc. Reprinted with permission.


Flowchart for Assessment and
Fitting of Ear-Level Instruments
Level 1 is the triage level and does not involve models of combination instruments do not sacri-
audiology services. The focus of this flowchart is fice hearing aid performance. These devices can be
to show how decisions normally are made regard- fitted at Level 2, but it is recommended that the
ing the evaluation and fitting of different ear-level sound/noise generator be turned off until after
instruments (hearing aids, noise generators, and the patient has attended at least the first session of
combination instruments) that can be used for tin- Level 3 Group Education.
nitus management. As noted in Chapter 5, new

Level 5 Individualized Support Intervention complete

Yes No
In-clinic trials of
devices - fit as needed Further intervention needed?

Yes No

Candidate for ear-level devices?

Level 4 Interdisciplinary Evaluation

Yes No

Further intervention needed?

Level 3 Group Education

Yes No

Fit hearing aids Further intervention needed?

Yes No

Hearing aid candidate?

Level 2 Audiologic Evaluation


Level 2 Audiologic Evaluation:
Special Considerations for Hearing Aids
1. Some patients are obvious hearing aid candidates. Fit them with hearing aids as you normally
would, except try to incorporate the following hearing aid features that are important for tinnitus
A. Use open-ear fitting if possible (or maximum venting)
B. Use feedback reduction circuitry to enable most open fitting
C. Ensure that any feature for reducing circuit noise (e.g., expansion) can be disabledinternal/
floor noise can be desirable for tinnitus
D. Ensure that any feature for reducing environmental noise can be disabled

2. Some patients are borderline hearing aid candidates. Be more open to trying hearing aids with
these patients than for patients who do not have a tinnitus problem. Explain to these patients
that hearing aids can help with both hearing problems and tinnitus problems.
A. Consider hearing aids for borderline hearing aid candidates if:
1)Patient is motivated to try hearing aids for the purpose of improving communicative and
other hearing problems
2)Patient is motivated to try hearing aids for the purpose of amplifying environmental sound
to reduce tinnitus intrusiveness
B. Incorporate the hearing aid features listed above that are important for tinnitus management.


Sound Tolerance Interview
[Note to clinician: Use this interview only if the patient already has reported a sound tolerance problem.]

Instructions to patients: You told me that some sounds are too loud for you when they seem normal to
other people around you. We refer to this as trouble tolerating sound. I am going to ask you some
questions about trouble tolerating sound. When you answer the questions, think back to how you have
been doing over the last week.

1. Do you wear hearing aids?

Nogo to Question 2
(If YES) Are everyday sounds too loud when you are wearing your hearing aids?
(If YES) Are everyday sounds too loud when you are not wearing your hearing aids?
[Note to clinician: If the sound tolerance problem appears to be caused by sounds amplified by
hearing aids, consider making compression, MPO, and/or other adjustments to the aids to improve
comfort. If the patient is not bothered by sound when unaided, then it is possible that all that is
needed is to adjust the hearing aids for comfort.]

2. How does trouble tolerating sound affect your life?


3. On a scale of 0 to 10, how much does trouble tolerating sound affect your life?
(0 would be not at all; 10 would be as much as you can imagine.)
(not at all) 0 1 2 3 4 5 6 7 8 9 10 (as much as you
can imagine)

4. What kinds of sounds are too loud for you?

[Clinician: check all categories that apply; circle any sounds that the patient identifies as a problem;
write in any additional sounds mentioned by the patient.]
Higher pitched sounds (squeals, squeaks, beeps, whistles, rings, ___________________________)
Lower pitched sounds (bass from radio, next-door music, ___________________________)

118 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Appendix K continued

Traffic (warning) sounds (emergency vehicle sirens, car horns, backup beeper on truck/van,

Traffic (background) sounds (road noise, road construction, diesel engines, garbage trucks,
Sudden impact sounds (door slam, car backfiring, objects dropping on floor, dishes clattering,
Voices (television, radio, movies, childrens voices, dog barking, ___________________________)
Other (describe ___________________________)

5. Im going to read a list of activities. I want you to tell me how often trouble tolerating sound is a
problem during these activities.
[Clinician: check avoids if the patient avoids any of these activities due to trouble tolerating sound;
if an activity is avoided, you can check two boxes for that activity.]

Never Rarely Sometimes Often Always N/A Avoids

a. Concerts?
b. Shopping?
c. Movies?
d. Work? (select N/A if retired)
e. Day-to-day responsibilities
outside of work?
f. Going to restaurants?
g. Driving?
h. Participating in or observing
sports events?
i. Attending church?
j. Housekeeping activities?
k. Child care?
l. Social activities?
m. Anything else? _______________

6. Do you ever use earplugs or earmuffs?

No Interview is complete
Sound Tolerance Evaluation and Management: Sound Tolerance Interview 119

(If YES) What percentage of your awake time do you use earplugs or earmuffs?
5% 30% 55% 80%
10% 35% 60% 85%
15% 40% 65% 90%
20% 45% 70% 95%
25% 50% 75% 100%
(If YES) Do you ever use earplugs or earmuffs in fairly quiet situations?
No Yes
[Note to clinician: Some patients have difficulty understanding the point of this question. Another way
to phrase it is: Do you ever use earplugs or earmuffs because sounds are too loud for you when they seem
normal to other people around you? The concern is that people with sound tolerance problems may wear
hearing protection in fairly quiet situations out of fear that they will encounter an uncomfortably
loud sound. That behavior would be considered overprotecting ears, and is likely to cause the sound
tolerance problem to worsen. These patients need to understand that use of hearing protection can
lead to greater sensitivity to sound, thus exacerbating their sound tolerance problem.]
[Clinician: does patient overprotect ears due to problems with sound tolerance?]
No Yes

Adapted with permission from: Tinnitus Retraining Therapy: Clinical Guidelines, by J. A. Henry, D. R. Trune, M. J. A. Robb,
& P. J. Jastreboff, 2007, San Diego, CA: Plural Publishing, Inc.

Sound Tolerance Worksheet

1. When and where 2. How will I do this? 3. Comments 4. Am I doing
will I do this? better?
Things I
can do
After 1 month:

myself with

After 2 months:

Listen to
sounds I

After 3 months:

Use earplugs
or earmuffs
only when

Loudness Discomfort Levels
Clinical Guide
1. Definitions 5. Present tones for 12 seconds each
A. Hyperacusis: significantly reduced 6.Obtain LDLs twice within a session
tolerance to sound that is restricted to (test each ear, then repeat all testing)
auditory pathways 7. Record only the second set of LDLs
B. Misophonia: dislike of sound due to B. Specific procedures
emotional reactions caused by sound 1.Instruct: You will listen to different tones.
C. Phonophobia: specific case of misophonia Each tone will be made slightly louder in
when fear of sound is involved steps. Tell me when the loudness of the tone
D. Loudness recruitment: abnormally rapid would be OK for 3seconds, but would not
growth of loudness caused by loss of outer be OK for more than 3 seconds.
hair cells 2.Present 1-kHz tone at approximate
E. LDL: threshold level of physical (not MCL (5060 dB HL)
emotional) discomfort for a sound 3.Raise level in 5-dB steps until patient
2. LDL testing signals that LDL has been reached
A. General guidelines 4.Starting levels at remaining frequencies
1.Patient must understand instructions to should be about 20 dB below previous
ensure proper response frequencys LDL
2.Test at octave frequencies between 5. When each ear has been tested once:
1 and 8 kHz Repeat instructions to patient
3. Test each ear separately Obtain second set of measures
4.Order testing from lowest to highest Record second set of measures


Sound Plan Worksheet

1. Write down one bothersome tinnitus situation

2. Check one 3. Write down the 4. Write down the 5. Use your sound 6. Comments
or more of the sounds that you will devices you will use plan over the next When you find
three ways to try week. How helpful something that works
use sound to was each sound after well (or not so well)
manage the using it for 1 week? please comment.
situation You do not need to
wait 1 week to write

your comments.





lit l
e ry ely

Ex uch

Soft breezes
Soothing voice
Babbling brook
Relaxing music
Running water
Ocean waves







lit ll
ry ely


Ex uch

Sound Other
her Sound Other So
ther Sound Other Soun
ther Sound Other Sound
Other Sound Other Soun
Other Sound Other Sou
d Other Sound Oth
ound Othe






lit l
ry ely


Ex uch


Relief Scale

Relief Scale

1. Choose a sound that you think will be soothing. A soothing sound will give you a sense of relief from
stress or tension caused by tinnitus. (Tracks 914 on the CD in the back of the self-help workbook1
have sounds that are soothing to many people.)
2. Adjust the volume of the sound until you find the level that is most soothing to you.
3. Answer the question When I listen to this sound, how much relief from stress and tension do
I feel?

0 1 2 3 4 5
No Slight Mild Moderate Nearly Complete
relief relief relief relief complete relief

Write down the sound that you

listened to How much relief did the sound give you?
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5

 ow to Manage Your Tinnitus: A Step-by-Step Workbook, by J. A. Henry, T. L. Zaugg, P. M. Myers, & C. M. Kendall, 2010, San

Diego, CA: Plural Publishing, Inc. Reprinted with permission.


Attention Scale

Attention Scale

1. Choose a sound that you think will keep your attention. (Tracks 1519 on the CD in the back of the
self-help workbook1 have sounds that are interesting to many people.)
2. Listen to the sound for at least 1 minute.
3. Choose the percent of attention focused on the sound while listening to it.

Attention focused on:

Tinnitus Other Sound
0% of attention focused on Other Sound

25% of attention focused on Other Sound

50% of attention focused on Other Sound

75% of attention focused on Other Sound

100% of attention focused on Other Sound

Write down the sound that you How much of your attention was focused
listened to on the Other Sound?
0% 25% 50% 75% 100%
0% 25% 50% 75% 100%
0% 25% 50% 75% 100%
0% 25% 50% 75% 100%
0% 25% 50% 75% 100%
0% 25% 50% 75% 100%
0% 25% 50% 75% 100%
0% 25% 50% 75% 100%
0% 25% 50% 75% 100%

 ow to Manage Your Tinnitus: A Step-by-Step Workbook, by J. A. Henry, T. L. Zaugg, P. M. Myers, & C. M. Kendall, 2010, San

Diego, CA: Plural Publishing, Inc. Reprinted with permission.


Tinnitus Contrast Activity

Tinnitus Contrast Activity
Tinnitus Contrast Activity

1. Spend a few moments listening to your tinnitus in quiet.

2. Now turn on some background sound. The sound should be pleasant or neutral. (Tracks 2023 on the
CD in the back of the self-help workbook1 have sounds that are background sound to many people.)
3. Adjust the volume to a comfortable level.
4. Notice the reduced contrast.
5. Reducing contrast makes it easier to ignore your tinnitus.

Write down the sound Write any comments you have about using
that you listened to this sound as background sound

 ow to Manage Your Tinnitus: A Step-by-Step Workbook, by J. A. Henry, T. L. Zaugg, P. M. Myers, & C. M. Kendall, 2010, San

Diego, CA: Plural Publishing, Inc. Reprinted with permission.


Level 4 Interdisciplinary
Evaluation: Tinnitus Interview
Clinicians: This interview is intended to be administered immediately after administering the Tinnitus
and Hearing Survey and thoroughly discussing the results with the patient. (Please note that this inter-
view does not cover tinnitus-specific information that most likely was covered during the case history
performed during the Level 2 Audiologic Evaluation. It may be helpful to review the case history before
administering this interview.)

1. Does the loudness of your tinnitus change on its own?

No Go to #2
Yes How often does it change?
Several times per month
Several times per week
Several times per day
Several times per hour

2. Do sounds ever change the loudness of your tinnitus?

No effect Go to #3 Softer Go to #3

(if LOUDER) What kinds of sounds make your tinnitus louder? [Clinician: check all categories
that apply; circle any sounds that the patient identifies as a problem; write in any additional
sounds mentioned by the patient.]
Very loud sounds/activities that would be expected to make the tinnitus louder (firing a gun,

attending a concert, using power tools, ____________________) [Clinician: If this is the only
response from the patient, then exacerbation of tinnitus by sound would be considered a
normal effect.]
Higher pitched sounds (squeals, squeaks, beeps, whistles, rings, ____________________)
Lower pitched sounds (bass from radio, ____________________)
Traffic (warning) sounds (emergency vehicle sirens, car horns, backup beeper on truck/van,
Traffic (background) sounds (road noise, road construction, diesel engines, garbage trucks,
Sudden impact sounds (door slam, car backfiring, objects dropping on floor, dishes clattering,


134 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Appendix R continued

Voices (television, radio, movies, childrens voices, dog barking, ____________________)

Other (describe) __________________________________________
When sound makes your tinnitus louder, how long does the change last?
12 Second(s)
34 Minute(s)
510 Hour(s)
more than 10 Day(s)

3. How does your tinnitus affect you (not including trouble hearing or understanding speech)?



4. Please tell me about everything you tried for your tinnitus prior to PTM. For each effort, what were
you hoping would happen, and what actually did happen? [Clinician: Sometimes a pattern will
emerge showing that the patient has made repeated (unsuccessful) attempts to make the tinnitus
quieter, resulting in frustration and distress. If this is the case, try to ensure that the patient begins
to see this pattern more clearly.]

What have you tried for What were you hoping would
tinnitus prior to PTM? happen? What actually did happen?
Level 4 Interdisciplinary Evaluation:Tinnitus Interview 135

5. Please tell me about the sounds you have used to manage your reactions to tinnitus since starting
PTM. For each sound you tried, what were you hoping would happen, and what actually did
happen? [Clinician: if the patient has the Sound Plan Worksheets that were used during Level 3,
these can be used to guide this interaction. It also is important to reinforce the idea that with PTM
the goal is not to change the tinnitus, but rather to change how one feels.]

What sounds have you used to

manage reactions to tinnitus What were you hoping would
during PTM? happen? What actually did happen?

136 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Appendix R continued

6. If we decide to move ahead with one-on-one support, then we will be making plans for using
sound to manage your reactions to tinnitus. It will be helpful to have a list of sound producing
devices that you have available to you. Which of the following devices do you own? [Clinician:
For each type of device listed below that the patient owns, provide additional details. For instance,
if patients report they own a radio, ask: how many radios, if any of them are portable, and if not
portable, where it is located. For each device the patient owns, ask how it currently is being used
relative to tinnitus management.]

How many Are any If not portable, How is it being used with
Type of device are available? portable? where is it located? respect to tinnitus?


MP3 player

CD player

Satellite radio

Table top sound

generator (sound
Table top water
Fan/air conditioner/
Music channels on
cable or satellite TV
Computer with
internet access (to
access radio stations,
podcasts, and other
sources of sound)
Cell phone capable
of playing music

Hospital Anxiety and
Depression Scale (HADS)
Emotions play an important part in most illnesses. A Worrying thoughts go through my mind:
The more your health care providers know about your 3 A great deal of the time
feelings the better they will be able to help you. 2 A lot of the time
This questionnaire is designed to help your 1 From time to time, but not too often
health care providers know how you feel. Read
0 Only occasionally
each item and put a checkmark in the box next to
the reply that best describes how you have been D I feel cheerful:
feeling in the past week. Ignore the numbers
printed on the left side. 3 Not at all
Dont take too long thinking over your replies. 2 Not often
Your first reaction to each item will probably be the 1 Sometimes
most accurate response. 0 Most of the time

A I feel tense or wound up: A I can sit at ease and feel relaxed:
3 Most of the time 0 Definitely
2 A lot of the time 1 Usually
1 From time to time, occasionally 2 Not often
0 Not at all 3 Not at all

D I still enjoy the things I used to enjoy: D I feel as if I am slowed down:

0 Definitely as much 3 Nearly all the time
1 Not quite so much 2 Very often
2 Only a little 1 Sometimes
3 Hardly at all 0 Not at all

A I get a sort of frightened feeling as if A I get a sort of frightened feeling like

something awful is about to happen: butterflies in the stomach:
3 Very definitely and quite badly 0 Not at all
2 Yes, but not too badly 1 Occasionally
1 A little, but it doesnt worry me 2 Quite often
0 Not at all 3 Very often

D I can laugh and see the funny side of things: D I have lost interest in my appearance:
0 As much as I always could 3 Definitely
1 Not quite so much now 2 I dont take as much care as I should
2 Definitely not so much now 1 I may not take quite as much care
3 Not at all 0 I take just as much care as ever
138 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Appendix S continued

A I feel restless as if I have to be on the A I get sudden feelings of panic:

move: 3 Very often indeed
3 Very much indeed 2 Quite often
2 Quite a lot 1 Not very often
1 Not very much 0 Not at all
0 Not at all
D I can enjoy a good book or radio or TV
D I look forward with enjoyment to things: program:
0 As much as I ever did 0 Often
1 Rather less than I used to 1 Sometimes
2 Definitely less than I used to 2 Not often
3 Hardly at all 3 Very seldom

Totals Clinician: add the individual scores for the As (anxiety), and then for the Ds
(depression). This is a screening tool only, it is not diagnostic.

07 normal
810 referral for further evaluation may be helpful
1121 referral for further evaluation likely to be helpful

From The Hospital Anxiety and Depression Scale, by A. S. Zigmond, & R. P. Snaith, 1983, Acta Psychiatrica Scandinavica,
67(6), 361370. Reprinted with permission.

The Primary Care PTSD Screen
4. Felt numb or detached from others, activities,
Description or your surroundings? YES / NO

The PC-PTSD is a four-item screen that was Current research suggests that the results of the PC-
designed for use in primary care and other medical PTSD should be considered positive if a patient
settings and currently is used to screen for PTSD in answers yes to any three items.
veterans at the VA. The screen includes an intro-
ductory sentence to cue respondents to traumatic
events. The authors suggest that in most circum- References
stances the results of the PC-PTSD should be con-
sidered positive if a patient answers yes to any
Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P.,
three items. A cutoff score of 2 can be used to opti- Hugelshofer, D. S., Shaw-Hegwer, J., . . . Sheikh, J. I.
mize sensitivity. Those screening positive should (2003). The primary care PTSD screen (PCPTSD):
then be assessed with a structured interview for Development and operating characteristics. Pri-
PTSD. The screen does not include a list of poten- mary Care Psychiatry, 9, 914
tially traumatic events. Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P.,
Hugelshofer, D. S., Shaw-Hegwer, J., . . . Sheikh, J. I.
(2004). The primary care PTSD screen (PCPTSD):
Corrigendum. Primary Care Psychiatry, 9, 151

Instructions Additional Reviews

In your life, have you ever had any experience that
was so frightening, horrible, or upsetting that, in Orsillo, S. M. (2001). Measures for acute stress disorder
and posttraumatic stress disorder. In M. M. Antony
the past month, you:
& S. M. Orsillo (Eds.), Practitioners guide to empiri-
cally based measures of anxiety (pp. 255307). New
1. Have had nightmares about it or thought about
York, NY: KluwerAcademic/Plenum. PILOTS ID
it when you did not want to? YES / NO 24368 (p. 299).
2. Tried hard not to think about it or went out of Norris, F. H., & Hamblen, J. L. (2004). Standardized
your way to avoid situations that reminded self-report measures of civilian trauma and PTSD. In
you of it? YES / NO J. P. Wilson, T. M. Keane & T. Martin (Eds.), Assessing
3. Were constantly on guard, watchful, or easily psychological trauma and PTSD (pp. 63102). New
startled? YES / NO York, NY: Guilford Press. PILOTS ID 18638 (p. 71).


Epworth Sleepiness Scale
The Epworth Sleepiness Scale is used to determine Use the following scale to choose the most appro-
the level of daytime sleepiness. A score of 10 or priate number for each situation:
more is considered sleepy. A score of 18 or more is
0 = would never doze or sleep.
very sleepy. If you score 10 or more on this test, you
1 = slight chance of dozing or sleeping
should consider whether you are obtaining ade-
2 = moderate chance of dozing or sleeping
quate sleep, need to improve your sleep hygiene
3 = high chance of dozing or sleeping
and/or need to see a sleep specialist. These issues
should be discussed with your personal physician. Fill in your answers and see where you stand.

Chance of
Dozing or
Situation Sleeping
1. Sitting and reading _____
2.Watching TV _____
3. Sitting inactive in a public place _____
4. Being a passenger in a motor vehicle for
an hour or more _____
5. Lying down in the afternoon _____
6. Sitting and talking to someone _____
7. Sitting quietly after lunch (no alcohol) _____
8. Stopped for a few minutes in traffic while
driving _____

Total score (add the scores up)

(This is your Epworth score) _____

From: A New Method For Measuring Daytime Sleepiness: The Epworth Sleepiness Scale, by M. W. Johns, 1991, Sleep,
14(6), 540545. Copyright 19901997 by MW Johns. Adapted with permission.


Level 4 Interdisciplinary
Evaluation: Guide to Trial Use of
Ear-Level Instruments
1. If your patient is an obvious hearing aid candidate of Background Sound. Any or all of these
follow the procedures outlined in the following effects are useful for managing tinnitus. The
forms (any order is acceptable): patient must be aware of these effects and
1.In-Clinic Trial Use of Hearing Aids choose which effect(s) is most important
(Appendix W) AND to him/her in making the final decision.
2.In-Clinic Trial Use of Combination Use the following discussion points and
Instruments (Appendix X) questions to make a decision about which, if
Note: Whether or not the patient is any, instruments will be used during Level5.
currently wearing hearing aids, follow the Have the patients completed Sound Plan
procedures outlined in both forms. Worksheet(s) available to look at during this
2. If your patient is a borderline hearing aid candidate n Any instruments you use should not be
follow the procedures outlined in the following annoying at all
forms (any order is acceptable): n Ear-level instruments can provide Soothing
1.In-Clinic Trial Use of Hearing Aids Sound (but even if they dont they still can
(Appendix W) AND be useful for managing tinnitus)
2.In-Clinic Trial Use of Combination nDid any of the instruments give you a
Instruments (Appendix X) AND sense of relief from tinnitus?
3.In-Clinic Trial Use of Noise Generators nIf yes, which instruments gave you the

(Appendix Y) best sense of relief?

Note: Whether or not the patient is n Remember, any ear-level device can provide
currently wearing hearing aids, follow the a convenient source of Background Sound
procedures outlined in all three forms. throughout the daythis alone can be helpful
to manage tinnitus
3. If your patient is not a hearing aid candidate n (If hearing aids or combination instruments
follow the procedures outlined in the follow- were tried) Improving hearing can make it
ing form: easier to use Interesting Sound to manage
1.In-Clinic Trial Use of Noise Generators tinnitus
(Appendix Y) nWhich instruments gave you the best
hearing ability?
After trying all instruments, discuss the following nDo you think any of the instruments you
points: tried today would make it easier for you to
use Interesting Sound to manage tinnitus?
n [Clinician: Ear-level instruments can n Do you think any of the instruments you
improve hearing (which makes Interesting tried today could be helpful?
Sound more accessible), give a sense of nWhich instruments would you most
relief, and provide a convenient source likely use?


Level 4 Interdisciplinary Evaluation:
In-Clinic Trial Use of Hearing Aids
n Use one form for each type of hearing aid that is evaluated
n If the patient is already using hearing aids, perform the trial with his/her current hearing aids
n Goal: establish realistic, experience-based judgment about the effectiveness of hearing aids for
managing both hearing and tinnitus problems
n For each trial, escort patient through different acoustic environments
a) Quiet environment (e.g., waiting areanot a sound booth)
b) Mildly noisy environment (e.g., hallway)
c) Noisy environment (e.g., dining area)

Conducting the Trial

Adjust hearing aids to target gain using real-ear (adjust for comfort as needed)

Acoustic environment
Ask these questions: Quiet Mildly noisy Noisy Comments
Does the sound from the device(s) bother Yes No Yes No Yes No
you? [Clinician: if yes try to adjust
instruments to eliminate annoyance.]
With these instruments, is your hearing Same Same Same
the same, better, or worse than without Better Better Better
the instruments? Worse Worse Worse
With these instruments, how much relief 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5
do you feel from your tinnitus? [Clinician:
Use the Relief Scale below.]

Relief Scale

0 1 2 3 4 5
No Slight Mild Moderate Nearly Complete
relief relief relief relief complete relief


Level 4 Interdisciplinary
Evaluation: In-Clinic Trial Use of
Combination Instruments
n Use one form for each type of combination instrument that is evaluated
n Goal: establish realistic, experience-based judgment about the effectiveness of combination
instruments for managing both hearing and tinnitus problems
n For each trial, escort patient through different acoustic environments
a) Quiet environment (e.g., waiting areanot a sound booth)
b) Mildly noisy environment (e.g., hallway)
c) Noisy environment (e.g., dining area)

Conducting the Trial

First, adjust amplification portion of the combination instruments to target gain using real-ear
equipment (adjust for comfort as needed)
Second, adjust volume and frequency output of noise generator portion of the combination
instruments to attempt to maximize sense of relief from tinnitus

Acoustic environment
Ask these questions: Quiet Mildly noisy Noisy Comments
Does the sound from the device(s) bother Yes No Yes No Yes No
you? [Clinician: if yes try to adjust
instruments to eliminate annoyance.]
With these instruments, is your hearing Same Same Same
the same, better, or worse than without Better Better Better
the instruments? Worse Worse Worse
With these instruments, how much relief 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5
do you feel from your tinnitus? [Clinician:
Use the Relief Scale below.]

Relief Scale

0 1 2 3 4 5
No Slight Mild Moderate Nearly Complete
relief relief relief relief complete relief

Level 4 Interdisciplinary Evaluation:
In-Clinic Trial Use of Noise Generators
n Use one form for each type of noise/sound generator that is evaluated
n If the patient is already using hearing aids, have the patient complete the activity In-Clinic Trial Use
of Hearing Aids (Appendix W) to reflect performance with their current hearing aids.
n Goal: establish realistic, experience-based judgment about the effectiveness of sound generators for
managing tinnitus problems
n For each trial, escort patient through different acoustic environments
a) Quiet environment (e.g., waiting areanot a sound booth)
b) Mildly noisy environment (e.g., hallway)
c) Noisy environment (e.g., dining area)

Conducting the Trial

Adjust volume and frequency output of noise generator to attempt to maximize sense of relief from

Acoustic environment
Ask these questions: Quiet Mildly noisy Noisy Comments
Does the sound from the device(s) bother Yes No Yes No Yes No
you? [Clinician: if yes try to adjust
instruments to eliminate annoyance.]
With these instruments, is your hearing Same Same Same
the same, better, or worse than without Better Better Better
the instruments? Worse Worse Worse
With these instruments, how much relief 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5
do you feel from your tinnitus? [Clinician:
Use the Relief Scale below.]

Relief Scale

0 1 2 3 4 5
No Slight Mild Moderate Nearly Complete
relief relief relief relief complete relief

Descriptions of DVD and CD
A DVD and a CD are attached to the back cover of Video 2: Managing Your Tinnitus for
this handbook. The DVD contains four interactive group viewing, Session 2
videos. The first two videos model the education
that is provided to patients during the two sessions Length: 27:00
of PTM Level 3 Group Education that are conducted
by an audiologist. These two videos can be used This is the second in a series of two video programs
to accomplish two purposes: (1) All clinicians who designed to be watched by a group of people, and
plan to lead Level 3 Group Education should first features an interactive discussion of techniques to
watch the videos while assuming the role of the use for tinnitus management. Researchers James
patientthis will facilitate learning how to teach Henry, Ph.D. and Tara Zaugg, Au.D. begin by re-
the Level 3 sessions. (2) The videos can be shown to viewing important points from the first video ses-
groups of patients during the Level 3 Group Educa- sion, then discuss ideas for choosing listening de-
tion instead of using the PowerPoint presentations vices. This is followed by ideas for updating the
that are provided in the attached CD. The third and viewers sound plans, and a comparison of the dif-
fourth videos on the DVD provide demonstrations ferent sound-based methods of tinnitus manage-
of two relaxation techniquesdeep breathing and ment. Finally, the researchers discuss other things
imagery. These relaxation videos can be used to viewers can do to manage their tinnitus.
supplement the Level 3 Group Education.
The CD contains PowerPoint files that should Video 3: Managing Your Tinnitus,
be used for the Level 3 Group Education sessions Imagery Exercise
when conducting live presentations.
Length: 10:19
Tinnitus can cause stress and tension that prevents
Managing Your Tinnitus DVD clear thinking and optimum functioning. This brief
video guides the viewer through a powerful relaxation
technique known as Imagery. This exercise can be
Video 1: Managing Your Tinnitus for used any time to help the viewers get their mind off
group viewing, Session 1 their tinnitus and help them feel calm and relaxed.

Length: 35:08 Video 4: Managing Your Tinnitus,

Deep Breathing Exercise
This is the first in a series of two video programs
designed to be watched by a group of people.
The two videos feature an interactive discussion Length: 12:48
of techniques for managing reactions to tinnitus. Tinnitus can cause stress and tension. Many
Researchers James Henry, Ph.D. and Tara Zaugg, people want their tinnitus to go away, or at least
Au.D. guide the viewers in developing a custom- to be quieted. Unfortunately, there is no safe and
ized sound plan to manage reactions to tinnitus. consistent way to quiet tinnitus, but there are
This first video corresponds with the first session many ways to feel better by using techniques to
of Level 3 Group Education (see Chapter 7). relieve stress and tension. One of these techniques

152 Progressive Tinnitus Management: Clinical Handbook for Audiologists

is called Deep Breathing, and this video provides tions Files to make the programs work prop-
a relaxing, guided exercise to help the viewer learn erly. The two PowerPoint files contain presen-
the techniques to help them get their mind off their tations titled Managing Your Tinnitus: What to
tinnitus so they can function more effectively. Do and How to Do ItSessions 1 and 2. The three
sound files are linked to the Session 1 Power-
Point file.
CD with PowerPoint Files: These presentations were created to guide
Managing Your Tinnitus: PTM Level 3 Group Education. Audiologists nor-
What to Do and How to Do It mally give the presentations, although they can
Sessions 1 and 2 be given by anyone who is proficient in the PTM
education. Further information can be found in
Chapter 7.
The CD contains two PowerPoint files, three
sound files, and a folder that contains Opera-

A Tinnitus Handicap Inventory (THI), 4142

Tinnitus Problem Checklist, 4445
Alcohol intake, 47, 48 Audiology, 24
Aminoglycoside antibiotics, 5 Individualized Support protocol, 7779
Amitryptiline, 48 patient education, 26
Amphetamine abuse, 47 triage to, 37
Antidepressants, 48 Auditory imagery, 4
Anxiety, 47, 48, 69
Anxiolitics, 48
Appendixes. See Forms
Aspirin, 5, 48 Bipolar disorder, 47
Assessment. See also Audiologic Evaluation;
Interdisciplinary Evaluation
mental health, 6770
psychoacoustic, 7273 Caffeine intake, 5, 48
Attention-deficit/hyperactivity disorder, 47 Case studies/patient examples
Attention Scale, 61, 129130 bilateral intermittent tinnitus, 3233
Audiologic Evaluation bothersome tinnitus, 33
auditory function assessment, 4243 CBT (cognitive-behavioral therapy), 81
and candidacy for Group Education, 40 hearing loss/tinnitus, 32
Ear-Level Instrument Assessment/Fitting Individualized Support, 81
Flowchart, 45, 113 phonophobia, 33
hearing aid evaluation, 4547 (See also Hearing PTSD, 33
aids main entry) sensorineural hearing loss, 41
Hearing Aid Special Considerations, 46, 115 CBT (cognitive-behavioral therapy)
Hearing Handicap Inventory, 42 case study, 81
and hyperacusis, 40, 41 clues for tinnitus management, 3
LDLs, 53 extended support option, 8182
and mental health referral, 47 Group Education, 6366 (See also Group Education
objectives overview, 39, 99 main entry)
otolaryngology exam need assessment, 43 Individualized Support, 8081, 82
otoscopy, 42 and individualized support level, 30
overview, 27, 49 and patient education, 25, 31
patient example: sensorineural hearing loss, 41 in PTM foundational research, 17, 1819
procedures overview, 39, 99 and STEM, 29, 55
pure-tone threshold evaluation, 4243 telephone-based, 18
sleep disorder referral assessment, 4748 CD/DVD: Managing Your Tinnitus, 151152
somatosounds assessment, 4344 Changing Thoughts and Feelings Worksheet, 64
suprathreshold audiometric testing, 43 Chemotherapy, 5, 48
THI (Tinnitus Handicap Inventory), 4142, 105 Chronic tinnitus, 2. See also Tinnitus
106, 107 Cisplatin, 5
THS (Tinnitus and Hearing Survey), 3941, 101 Clinical data of patients (tinnitus), 89

154 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Clinical trial candidacy, 1213 Sound Plan Worksheet, 125126

Cocaine abuse, 47 Sound Tolerance Interview, 117119
Cochlear cellular stress responses, 36 Sound Tolerance Worksheet, 121122
Cognitive-behavioral therapy (CBT). See CBT Tinnitus and Hearing Survey, 101
(cognitive-behavioral therapy) Tinnitus Contrast Activity, 62, 131132
Cognitive restructuring, 6566 Tinnitus Handicap Inventory, 105106
Combination Instrument In-Clinic Trial Use, 75, 147 Tinnitus Handicap Inventory: Screening Version,
Conductive tinnitus, 6, 7 107
Corticosteroids, 36 Tinnitus Interview: Interdisciplinary Evaluation,
Tinnitus Problem Checklist, 111
D Tinnitus Triage Guidelines, 97
Depression, 47, 69 What to Do When Everyday Sounds Are Too Loud
Diuretics, 5, 48 (without hearing aids), 103104
DVD/CD: Managing Your Tinnitus, 151152 Foundational research
assessment protocol development, 15
and ATM (audiologic tinnitus management),
E 14
and clinical trial candidacy, 1213
Ear-Level Instrument Assessment/Fitting Flowchart, educational component need, 14
45, 46, 70, 74, 113 efficacy: TM versus TRT, 1213
Ear-Level Instrument In-Clinic Trial Use, 145 efficacy: TM versus TRT, veterans, 1415
Ear-Level Instrument Trial Use Guide, 75, 143 group intervention, 1314
Ear noise, transient, defined, 12 and multidisciplinary team, 1718
Education. See Group Education overview, 12, 19
Epidemiology, 6 paths can differ for management, 12
Epworth Sleepiness Scale, 69, 141 and psychological concerns, 1718
Etiology of tinnitus, 6 and self-help workbook (PTM), 14, 17, 18
Evaluation. See Audiologic Evaluation sound attention diversion, 14
Examples. See Case studies/patient examples studies
first, 1213
second, 1314
F third, 1415
Forms fourth, 1517
Attention Scale, 129130 fifth, 1718
Audiologic Evaluation objectives/procedures TBI: veterans, 1718
overview, 99 and telephone-based administration, 17
Combination Instrument In-Clinic Trial Use, 147 and therapeutic sound, 14, 18
Ear-Level Instrument Assessment/Fitting veterans, 1418
Flowchart, 113
Ear-Level Instrument In-Clinic Trial Use, 145
Ear-Level Instrument Trial Use Guide, 75, 143
Epworth Sleepiness Scale, 141 Glucocorticoids, 36
Hearing Aid Special Considerations, 115 Group Education
Hospital Anxiety and Depression Scale (HADS), first session, 5963
137138 second session, 63
Loudness Discomfort LevelsClinical Guide, 123 attention diversion, 65
Noise Generator In-Clinic Trial Use, 149 Attention Scale, 61, 129130
Primary Care PTSD Screening Tool (PC-PTSD), audiologist-conducted workshops
139 and Attention Scale, 61
PTM Flowchart, 95 background sound type taught, 61
Relief Scale, 127128 demonstration of sound types, 6162
Index 155

individualized sound plan development, 59 HHIE-S (Hearing Handicap Inventory for the
interesting sound type taught, 6061 Elderly-Screening), 42, 109
and Relief Scale, 61 Hospital Anxiety and Depression Scale (HADS), 69,
soothing sound type taught, 60 137138
Sound Plan Worksheet, 57, 59, 60, 62, 64 How to Manage Your Tinnitus (J.A. Henry et al.), 27
sound types taught, 6061 28, 40, 45, 48, 58, 78. See also Patient self-help
THS (Tinnitus and Hearing Survey) review, workbook main entry
5960, 101 Hyperacusis, 33. See also Loudness recruitment;
Tinnitus Contrast Activity, 62 Misophonia; Phonophobia; Sound Tolerance
candidacy, 40 Interview (STI); STEM (sound tolerance
CBT (cognitive-behavioral therapy) evaluation and management)
essential componments, 64 defined, 9
overview, 6364 Loudness Discomfort LevelsClinical Guide, 123
Session 1, 6465 screening for, 27, 28
Session 2, 6566 Sound Tolerance Interview form, 117119
Session 3, 66 sound tolerance management approach, 40
Changing Thoughts and Feelings Worksheet, Sound Tolerance Worksheet, 52, 121122
64 therapy for, 10, 37, 52, 8283
cognitive restructuring, 6566 What to Do When Everyday Sounds Are Too Loud
collaborative self-management, 58, 66 (without hearing aids), 40, 41, 52, 103104
continuity with Interdisciplinary Evaluation, 76 Hypersensitivity to sound. See Hyperacusis
follow-up, 66
overview, 2829, 66
patient self-help workbook, 58
pleasant activities for diversion, 65 Idiopathic sudden sensorineural hearing loss
psychologist-conducted workshops (ISSHL), 36, 37
overview, 6366 Individualized Support
relaxation techniques, 65, 151 appointments process, 7779
Relief Scale, 61 audiologist standard protocol, 7779
sound grid use, 62 augmentative sound, 80
stress reduction, 6465 CBT (cognitive-behavioral therapy), 8081, 82
therapeutic sound use education, 5859 counseling, 7980
Tinnitus Contrast Activity, 131132 criteria for progress from Interdisciplinary
Tinnitus Problem Checklist, 6062, 64, 66 Evaluation, 76
extending intervention, 79
NTT (neuromonics tinnitus treatment) extended
H support, 83
Hallucinations (auditory/musical), 45 overview, 77, 8384
Hallucinogen abuse, 47 patient self-help workbook, 79
Health literacy, 26 personal listening devices, 80
Hearing aids Sound Plan Worksheet, 77, 79
needed for PTM, 4546 stationary sound devices, 80
and tinnitus, 4647 telephone counseling, 79
tinnitus management reaction, 46 THS (Tinnitus and Hearing Survey), 7778, 101
Hearing Aid Special Considerations, 46, 115 Tinnitus Handicap Inventory (THI), 7778
Hearing Handicap Inventory for the Elderly- Tinnitus Interview: Interdisciplinary Evaluation,
Screening (HHIE-S), 42, 109 78
Hearing loss, 7 TM (tinnitus masking) extended support, 82
case study, 32 TRT (tinnitus retraining therapy) extended
idiopathic sudden sensorineural hearing loss support, 8283
(ISSHL), 36, 37 Individualized support
sensorineural, 41 overview, 3031
156 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Insomnia, 47, 48, 69, 70 Loudness Discomfort Levelsclinical guide, 123

Interdisciplinary Evaluation Loudness discomfort levels (LDL), 10, 5253
anxiety screening, 69 Loudness recruitment. See also Hyperacusis
BTE (behind-the-ear) instrument in-clinic trials, defined, 910, 54
7576 treatment, 10
Combination Instrument In-Clinic Trial Use, 75,
continuity with Group Education, 76
criteria for progress to Individualized Support, 76 Managing Your Tinnitus, 59, 80, 151152
depression screening, 69 Managing Your Tinnitus (DVD/CD), 151152
Ear-Level Instrument Assessment/Fitting Marijuana use, 47
Flowchart, 70, 74, 113 Masking. See TM (tinnitus masking)
ear-level instrument follow-up, 76 Masking as term, 60. See also TM (tinnitus masking)
Ear-Level Instrument In-Clinic Trial Use, 7476, Medications
145 aminoglycoside antibiotics, 5
Ear-Level Instrument Trial Use Guide, 75, 143 amitryptiline, 48
forms for in-clinic ear-level trials, 75 antibiotics, 5
Hospital Anxiety and Depression Scale (HADS), antidepressants, 48
69, 137138 anxiolitic, 48
interview administration, 7072 aspirin, 5, 48
Noise Generator In-Clinic Trial Use, 75, 149 chemotherapy, 5, 48
noise generators for in-clinic trials, 75 cisplatin, 5
nonmental health clinician screening, 6869 corticosteroids, 36
overview, 2930, 67 diuretics, 5, 48
PC-PTSD (Primary Care PTSD) screening tool, 69 glucocorticoids, 36
psychoacoustic assessment, 7273 loop diuretics, 5, 48
PTSD (posttraumatic stress disorder), 69 lorazepam, 48
sleep disorders, 6970 NSAIDs (nonsteroidal antiinflammatory drugs),
Sound Plan Worksheet, 72, 76 5, 48
THS (Tinnitus and Hearing Survey), 70, 74, 101 quinine, 5, 48
Tinnitus Handicap Inventory (THI), 70, 105106, Mental health professionals
107 referral to, 47
Tinnitus Interview, 67, 70, 74, 78, 133136 on team, 2425
Intervention triage to, 2425
Group Education overview, 2627 (See also Misophonia. See also Hyperacusis
Education main entry; Group Education main in case history, 33
entry) defined, 9, 54
ISSHL (idiopathic sudden sensorineural hearing and evaluation, 28
loss), 36, 37 treatment, 10

Labyrinthine membrane ruptures, 36 Narcolepsy, 69, 70
Labyrinthitis, 36 NCRAR (National Center for Rehabilitative
LDL (loudness discomfort level). See loudness Auditory Research), 19, 22
discomfort levels (LDL) Neuro-otologology, 24
Level 1. See Triage main entry Noise Generator In-Clinic Trial Use, 75, 149
Level 2. See Audiologic Evaluation main entry Nonpulsatile tinnitus, 2, 43, 44
Level 3. See Individualized Support main entry Nonsteroidal antiinflammatory drugs (NSAIDs), 5
Level 4. See Interdisciplinary Evaluation main entry NSAIDs (nonsteroidal antiinflammatory drugs), 5,
Loop diuretics, 5, 48 48
Lorazepam, 48 NTT (neuromonics tinnitus treatment), 83
Index 157

O clinical service progressivity, 2223

collaborative self-management, 26, 58, 66
Obsessive-compulsive disorder, 47 efficiency of, 22
Opiate abuse, 47 five levels of, 22, 23
Otolaryngology, 24 flowchart, 26, 36, 41, 52, 95
referral to criteria, 4344 foundational research, 1119 (See also
triage to, 36, 37 Foundational research main entry for details)
Ototoxicity, 48 and hearing needed for participation, 4546
hierarchical approach, 22, 23
interdisciplinary approach, 2425
intervention (See Intervention main entry)
Panic episodes, 47 levels overview, 2630 (See also Triage,
Pathophysiology of tinnitus, 78 Audiologic Evaluation, Group Education,
Patient clinical data (tinnitus), 89 Interdisciplinary Evaluation, Individualized
Patient examples. See Case studies/patient examples Support main entries for details)
Patient self-help workbook mental health professionals on team, 2425
Group Education, 58 neuro-otologists on team, 24
Individualized Support, 79 otolaryngologists on team, 24
overview, 2728 overview, 2134, 3132
timing of distribution, 4849 and prosthetics, 25 (See also Prosthetics main
PC-PTSD (Primary Care PTSD) screening tool. entry)
See Primary Care PTSD Screening Tool PTSD (posttraumatic stress disorder), 24, 47 (See
(PC-PTSD) also PTSD (posttraumatic stress disorder)
Phobias, 47 main entry)
Phonophobia. See also Hyperacusis; Sound Tolerance reaction to tinnitus management, 2122
Interview (STI); STEM (sound tolerance sleep disturbances, 2526 (See also Sleep
evaluation and management) disturbances main entry)
in case study, 33 sound tolerance management approach, 40
defined, 9 PTSD (posttraumatic stress disorder), 24
and LDL, 53 case study, 33
Loudness Discomfort LevelsClinical Guide, 123 and psychologist group sessions, 63
Sound Tolerance Interview form, 117119 referral for, 47
Sound Tolerance Worksheet, 52, 121122 screening, 69
treatment, 10 Pulsatile tinnitus
What to Do When Everyday Sounds Are Too Loud Audiologic Evaluation, 4344
(without hearing aids), 40, 41, 52, 103104 causes, 44
Prevalence of tinnitus, 6 clinical presentation, 43
Primary Care PTSD Screening Tool (PC-PTSD), 69, defined, 2, 44
139 differential diagnosis, 24
Progressive Tinnitus Management: Counseling Guide site of, 24
(J.A. Henry et al.), 31, 52, 67, 79 and surgery, 44
Prosthetics, 25 and triage, 37
Psychotic disorders, 47
PTM (progressive tinnitus management)
assessment as starting point, 26 (See also
Audiologic Evaluation main entry; Quinine, 5, 48
Interdisciplinary Evaluation main entry; Triage
main entry)
audiologists on team, 24
basic premises, 2126 Relaxation techniques, 65, 151
and CBT (cognitive-behavioral therapy (See CBT Relief Scale, 61, 127128
(cognitive-behavioral therapy) main entry) REM behavior disorders, 69
158 Progressive Tinnitus Management: Clinical Handbook for Audiologists

S Tinnitus. See also Chronic tinnitus

amplification benefits, 4647
Sedative abuse, 47 associated auditory pathologies, 6, 7
Self-help workbook. See Patient self-help workbook criterion, 2
main entry delayed-onset, 6
Sensorineural tinnitus hallucinations (auditory/musical), 45
and noise exposure, 7 and hearing loss degree, 7
origin of, 3 neurological origin, 2
as phantom auditory perception, 3 neurophysiologic, 3 (See also Sensorineural
Sleep apnea, 47, 48, 69 tinnitus main entry)
Sleep disorders, 2526 nonpulsatile, 2 (See also under Tinnitus main entry)
management of, 48 objective, 3
referral for, 4748 onset, 56, 8
screening, 6970 pathophysiology, 78
Sleepiness Scale, Epworth, 69, 141 permanent versus temporary, 5
Somatosound and prescription medication, 48 (See also
Audiologic Evaluation, 4344 Medications main entry)
overview, 23 pulsatile, 2 (See also under Tinnitus main entry)
and triage, 37 recent-onset, 56
Sound hypersensitivity. See Hyperacusis risk factors, 67
Sound Plan Worksheet, 57, 59, 60, 62, 64, 72, 76, 77, sensorineural overview, 3 (See also Sensorineural
79, 125126 tinnitus main entry)
Sound Tolerance Interview form, 117119 somatic, 23
Sound Tolerance Interview (STI), 52, 53, 117119. See somatically modulated, 44
also STEM (sound tolerance evaluation and somatic versus neurophysiologic origin, 2
management) somatosound, 23 (See also Nonpulsatile tinnitus;
Sound Tolerance Worksheet, 52, 121122 Pulsatile tinnitus; Somatosounds; Tinnitus
STEM (sound tolerance evaluation and main entry)
management), 40. See also Hyperacusis; overview, 23 (See also Somatosound main entry)
Phonophobia symptoms, 2
described, 5152 types, 2
ear-level instrument trial use, 5354 sound types, patient reports, 89
hyperacusis/allied conditions definitions, 54 subjective, 4
overview, 28, 51, 5455 subjective versus objective, 34
Sound Tolerance Interview (STI), 52, 53, 117119 temporary versus permanent, 5
STI (Sound Tolerance Interview). See also Tinnitus and Hearing Survey, 101
Hyperacusis; Phonophobia; Sound Tolerance Tinnitus Contrast Activity, 62, 131132
Interview (STI) Tinnitus Handicap Inventory, 105106
Stria vascularis ion transport problems, 36 Tinnitus Handicap Inventory: Screening Version,
Substance abuse, 47 107
Tinnitus Interview: Interdisciplinary Evaluation,
67, 70, 74, 78
tinnitus neural signal defined, 2
TBI (traumatic brain injury), 6, 1718 Tinnitus Problem Checklist, 4445, 6062, 64, 66, 111
Telephone appointments/follow-up, 17, 18, 63, 66, triage guidelines, 3536, 37, 97 (See also Tinnitus
78, 79 Triage Guidelines under main entry Forms)
Therapeutic sound, 10, 12, 14, 17, 18, 25, 28, 30, 45, video Web site, 49
51, 52, 5859, 66, 70, 72, 73, 77, 79, 81, 82 Tinnitus and Hearing Survey (THS), 13, 25, 28,
THI (Tinnitus Handicap Inventory). See Tinnitus 3941, 44, 51, 5960, 67, 70, 74, 7778, 101. See
Handicap Inventory (THI) also Audiologic Evaluation; Interdisciplinary
THS (Tinnitus and Hearing Survey). See Tinnitus Evaluation
and Hearing Survey (THS) versus THI (Tinnitus Handicap Inventory), 4
Index 159

Tinnitus Contrast Activity, 62, 131132 to mental health, 3637

Tinnitus Handicap Inventory (THI), 4142, 70, to otolaryngology, 36, 37
7778, 79, 105106, 107. See also Audiologic overview, 27, 35, 3738
Evaluation; Individualized Support; to urgent care, 36
Interdisciplinary Evaluation TRT (tinnitus retraining therapy)
Tinnitus Interview: Interdisciplinary Evaluation, Individualized Support extended support, 8283
133136 overview, 8283
Tinnitus masking (TM). See TM (tinnitus masking) in PTM, 12, 61
Tinnitus Problem Checklist. See also Audiologic research, 12, 14
TM (tinnitus masking)
Individualized Support extended support, 82
overview, 82 Vascular disruption, 36
in PTM, 12 Veteran research, 1418. See also Primary Care
research, 12, 14 PTSD Screening Tool (PC-PTSD); PTSD
TMJ (temporomandibular joint), 2, 43 (posttraumatic stress disorder)
Transient ear noise defined, 12
Traumatic brain injury (TBI), 1617
to audiology, 37 What to Do When Everyday Sounds Are Too Loud
guidelines, 3536, 37 (See also Tinnitus Triage (without hearing aids), 40, 41, 52, 103104
Guidelines under main entry Forms) Workbook. See Patient self-help workbook main entry