Perspectives of the ASHA Special Interest Groups

SIG 2, Vol. 2(Part 4), 2017, Copyright © 2017 American Speech-Language-Hearing Association

Pathophysiology of Tinnitus and Evidence-Based

Options for Tinnitus Management
James A. Henry
Veterans Affairs (VA) Rehabilitation Research & Development (RR&D) Service,
National Center for Rehabilitative Auditory Research, VA Portland Health Care System
Portland, OR
Department of Otolaryngology/Head & Neck Surgery, Oregon Health & Science University
Portland, OR
Disclosures
Financial: James Henry has no relevant financial interests to disclose.
Nonfinancial: James Henry has no relevant nonfinancial interests to disclose.

Abstract
Tinnitus is the perception of sound that has no source outside of the head – it is a “phantom”
sound. A great many people experience chronic tinnitus, which can be problematic to
different degrees. To date, no cure for tinnitus has been discovered in spite of worldwide
efforts from researchers studying the pathophysiological mechanisms of tinnitus. Until a
cure is discovered, individuals whose tinnitus is bothersome have evidence-based options
available. Tinnitus management is provided mainly by audiologists, otolaryngologists, and
mental health (MH) providers. The starting point for most patients is to receive an audiologic
evaluation. Audiologists can provide tinnitus counseling and fit hearing aids, both of which
can be beneficial for tinnitus management. Patients with symptoms of secondary tinnitus
(somatosounds) should be referred to an otolaryngologist for a medical examination. If
further tinnitus-specific services are needed for primary (idiopathic) tinnitus, then MH providers
can offer cognitive-behavioral therapy and audiologists can facilitate different approaches to
sound therapy. It is essential for all providers to follow evidence-based guidelines when
offering tinnitus management services.
Tinnitus, the perception of sound that has no source outside of the head, is most typically
associated with exposure to loud noise, which can also cause hearing loss (Axelsson & Barrenäs,
1992; Penner & Bilger, 1995). A positive correlation exists between degree of hearing loss and
prevalence of tinnitus—the likelihood of incurring tinnitus increases with increasing hearing loss
(Coles, 2000). In general, tinnitus can occur as the result of noise damage, blast exposure, head
and neck trauma or pathology, drugs or medications, and other medical conditions (e.g., acoustic
neuroma, cardiovascular and cerebrovascular disease, hyper- and hypothyroidism; Hoffman &
Reed, 2004; Meikle, 1997). Tinnitus is differentiated from transient ear noise, which has been
referred to as “spontaneous tinnitus” (Dobie, 2004; Henry, Zaugg, et al., 2010a). As either name
implies, a tonal sound emerges suddenly in one ear. The sound is typically accompanied by a
sense of ear fullness and loss of hearing sensitivity. These symptoms generally resolve within less
than a minute. Spontaneous tinnitus is a normal phenomenon that does not require clinical
services.
The present article focuses on clinical management of tinnitus. Pathophysiology of
tinnitus is discussed briefly with an emphasis on how understanding mechanisms of tinnitus
can lead toward therapies that treat the cause(s) of tinnitus rather than just the symptoms.
The primary purpose is to suggest a tinnitus management protocol based on systematic reviews
and research evidence that can help lead toward a standard of practice for tinnitus clinical
management.

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 Pathophysiology of Tinnitus
What is currently known about neural mechanisms of tinnitus has been discovered
primarily through animal studies, imaging studies and psychoacoustic measures of tinnitus in
humans, and inferences derived from these studies integrated with our knowledge of auditory
neurophysiology (Shore, Roberts, & Langguth, 2016). Our understanding of tinnitus mechanisms
is further informed by studies of chronic pain that involves many of the compensatory changes in
the central nervous system that result from loss of peripheral input, which is similar to the changes
seen with tinnitus.
The American Academy of Otolaryngology/Head and Neck Surgery Foundation (AAO-HNSF)
Clinical Practice Guideline (CPG): Tinnitus defines two categories of tinnitus: primary and secondary
(Tunkel et al., 2014). Primary tinnitus is idiopathic and may or may not be associated with
age- or noise-related sensorineural hearing loss (SNHL). Secondary tinnitus is symptomatic of a
specific underlying cause (other than SNHL), which can be either an auditory system disorder
(e.g., cerumen impaction, otosclerosis, Meniere’s disease) or a non-auditory system disorder (e.g.,
intracranial hypertension or vascular anomalies causing pulsatile tinnitus). Suspected secondary
tinnitus would require a medical examination by an otolaryngologist (Henry, Zaugg, et al., 2010a).
The present article focuses on primary tinnitus.
The observation that tinnitus arises with problems of the inner ear initially suggested
a peripheral origin of tinnitus (Guitton, 2012). The persistence of tinnitus following transection
of the auditory nerve provided the first evidence that tinnitus could have a central origin (House
& Brackmann, 1981). It is now generally accepted that primary tinnitus does not arise from
increased activity of the cochlear nerve that might be driven by a damaged cochlea (Shore et al.,
2016). Rather, tinnitus appears to occur as a consequence of changes in the central auditory system
(CAS) when afferent input is reduced or lost from the cochlea. It thus appears that deafferentation
of the auditory nervous system is critical for the onset and maintenance of tinnitus.
Noise-induced tinnitus damages inner ear hair cells, resulting in reduced output through
the auditory nerve, plastic changes in the CAS, and eventually elevated spontaneous activity in
CAS structures. These structures are primarily auditory, but can involve non-auditory systems in
the maintenance and modulation of tinnitus (Shore et al., 2016). The plastic changes are critical
to this process, and involve alterations in the balance of excitatory and inhibitory neural activity.
More specifically, neural inhibition is reduced and excitation is increased. Numerous synaptic
mechanisms are involved in the development of these plastic changes.
Since direct study of the CAS is practically impossible in humans, it was necessary to
develop animal models to investigate the neural generators and manifestations of tinnitus. The
first animal models of tinnitus were developed in the 1980s, and numerous models have since
been developed and validated (Brozoski & Bauer, 2016). Animal models are useful for studying
both noise- and drug-induced tinnitus. The administration of a sufficient concentration of salicylate
always results in tinnitus, making salicylate-induced tinnitus a consistent and controllable model,
which has led to many important findings (Stolzberg, Salvi, & Allman, 2012). Salicylate-induced
tinnitus, however, has limited clinical relevance, which is also the case for all forms of drug-induced
tinnitus. Noise-induced tinnitus is clinically relevant, but not all animals (or humans) develop
tinnitus as a result of high levels of noise. Thus, animal models have inherent limitations. A further
limitation is that animals are incapable of describing the perception of tinnitus. Behavioral methods
are necessary to verify the presence of tinnitus.
Whereas the great majority of people with tinnitus also have hearing loss, 10–15% of these
individuals have normal auditory function based on standard audiologic testing (Barnea, Attias,
Gold, & Shahar, 1990; Schaette & McAlpine, 2011). It is possible that “hidden hearing loss” could
be responsible for such cases, which is caused by damage to the synapses connecting the inner

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 hair cells with auditory nerve fibers (Kujawa & Liberman, 2016). These synapses are highly
vulnerable to damage caused by noise exposure and normal effects of aging.
Several types of acoustic therapies have been devised with the aim of suppressing the
tinnitus beyond the stimulation period via putative neuroplastic mechanisms (Shore et al.,
2016). One approach is to “notch” the sound stimulus (usually music) to exclude energy close
to the tinnitus frequency with the intent to distribute lateral inhibition into the notched region,
suppressing tinnitus-related neural activity (Stein et al., 2016). Another method (acoustic
coordinated reset neuromodulation) presents short tones in a random varying sequence above
and below the tinnitus frequency, with the goal of reducing tinnitus-related neural hypersynchrony
(Hauptmann et al., 2015). Yet another approach uses a customized sound stimulation mimicking
the tinnitus perception during sleep to supposedly alter neurophysiological processing of
tinnitus during all hours, including wakeful hours when the device is not in use (Pedemonte,
Testa, Diaz, & Suarex-Bagnasco, 2014; Theodoroff et al., 2017). Each of these, and other sound
therapy techniques relies on accurately measuring the perceived tinnitus pitch (Hoare, Searchfield,
et al., 2014a).
It is clear that tinnitus is a pathology involving synaptic plasticity (Guitton, 2012). The
origin of tinnitus can occur either at the level of the synapses between inner hair cells and the
auditory nerve, within the auditory nerve itself, or from CAS structures. Long-term maintenance
of tinnitus is likely a function of a complex network of structures in the CAS and non-auditory
systems.

Evidence-Based Practice
Evidence-based research should guide the clinical management of tinnitus. Randomized
controlled trials (RCTs) that are properly conducted are the most important source for providing
such evidence (Keech, Gebski, & Pike, 2007). Recently, evidence-based guidelines for tinnitus
management became available from the AAO-HNSF (Tunkel et al., 2014). Developing their guidelines
relied on searching the peer-reviewed literature and identifying relevant RCTs.
The AAO-HNSF guidelines recommended the following procedures: (a) case history and
physical exam by an otolaryngologist; (b) comprehensive audiologic exam if the tinnitus is
“persistent” (i.e., present for at least six months), unilateral, or accompanied by hearing difficulties;
(c) determine if the tinnitus is bothersome or nonbothersome. If patients have persistent, bothersome
tinnitus, the CPG: Tinnitus recommended: (a) provide information about realistic treatment options;
(b) perform a hearing aid evaluation as appropriate; and (c) suggest Cognitive-Behavioral Therapy
(CBT) if intervention is needed.
It is noteworthy that, of all the different therapies currently available for tinnitus
management, the guidelines recommended only CBT as an evidence-based intervention. Sound-
based therapy was relegated to the “optional” category. Although the potential value of sound-
based therapy (of which there are many types) was acknowledged, it was not recommended due
to the relative paucity of RCTs verifying its clinical effectiveness. Hearing aids and combination
instruments (amplification and sound generator combined in a single unit) were also mentioned
as possibly helpful. At the time the CPG: Tinnitus was published, however, no RCTs had been
conducted focusing on hearing aids and combination instruments for this purpose—hence, they
were not recommended.

Hearing Aids and Combination Instruments for Tinnitus Management

Hearing aids have been used for tinnitus management since the 1940s (Shekhawat,
Searchfield, & Stinear, 2013). Since 1976, ear-level sound generators have been used as a
clinical tool to provide tinnitus masking (Vernon, 1976). Vernon pioneered the use of combination
instruments in the early 1980s (Vernon, 1982). All major hearing aid manufacturers now produce

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 combination instruments that combine state-of-the-art hearing aids with some type of acoustic
signal intended to mitigate effects of tinnitus.
Three RCTs have been recently completed evaluating the efficacy of combination instruments
relative to hearing aids for reducing effects of tinnitus (dos Santos et al., 2014; Henry, Frederick,
Sell, Griest, & Abrams, 2015; Henry, McMillan, et al., 2017). Participants wore combination
instruments (from a different manufacturer for each study) either with the sound generator
activated (combination instrument group) or deactivated (hearing aid group). For one of the
studies (Henry, McMillan, et al., 2017), a third group wore deep-fit, extended-wear hearing aids
and thus participants in that study were randomized into one of three groups. Primary outcomes
for each study were assessed using a tinnitus outcome questionnaire at baseline and following
treatment. dos Santos et al. (2014) used the Tinnitus Handicap Inventory (Newman, Jacobson,
& Spitzer, 1996) and the Henry et al. 2015; Henry, Thielman, et al., 2017) studies used the
Tinnitus Functional Index (TFI; Meikle et al., 2012). Results of all three RCTs were comparable—
both hearing aids and combination instruments resulted in a significant reduction in tinnitus
functional effects, although the difference in outcomes between groups was not statistically
significant. These three studies were consistent in demonstrating the efficacy of both hearing
aids and combination instruments for tinnitus management, although no additional benefit was
demonstrated for use of an integrated sound generator. These findings were not available when the
Cochrane Review evaluating the use of hearing aids for tinnitus management (Hoare, Edmondson-
Jones, et al., 2014b) and the AAO-HNSF CPG: Tinnitus (Tunkel et al., 2014) were in preparation.
A caveat should be noted concerning these three RCTs. All participants had both hearing
loss and bothersome tinnitus. People will often respond to questions about effects of tinnitus
with respect to their hearing loss (Ratnayake, Jayarajan, & Bartlett, 2009). For some of the
participants, baseline to post-treatment improvement on a tinnitus outcome questionnaire would
have resulted from improved hearing. Hearing loss therefore confounded the results of these
studies, and it is impossible to know how much of the improvement, in effects of tinnitus, was
actually a reduction in hearing difficulties.

Progressive Tinnitus Management

Progressive tinnitus management (PTM) is a stepped care program for patients who report
tinnitus (Henry, Zaugg, et al., 2010b). Each clinical step involves assessment and/or intervention
to identify and address needs related to hearing loss, tinnitus, and reduced tolerance to sound
(hyperacusis). Table 1 shows the five PTM levels and an overview of procedures conducted at each
level. Throughout the various levels of PTM, as needs are identified, the patient and clinician
collaboratively decide on the next appropriate course of action. The degree of services received
by patients aligns with their individual needs.
Beyond the initial referral level (Level 1 Referral), the first PTM step (Level 2 Audiologic
Evaluation) is a standard audiologic evaluation with the addition of the 10-item Tinnitus and
Hearing Survey (THS) to assess the functional effects of tinnitus and to screen for hyperacusis
(Henry, Griest, et al., 2015). In relatively rare instances hyperacusis may need to be resolved
before hearing problems or tinnitus can be addressed. Patients who are hearing aid candidates
are fit with hearing aids or combination instruments to address their hearing loss, which often
mitigates bothersome tinnitus (Henry, Frederick, et al., 2015; Shekhawat et al., 2013). After any
hearing loss and hyperacusis needs have been addressed, patients who require assistance for
bothersome tinnitus are offered Level 3 Skills Education.

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 Table 1. The Five Levels of Progressive Tinnitus Management (PTM) and an Overview of Clinical
Procedures at Each Level.

PTM Level Procedures References

1 Referral • Guidelines for non-ear-specialists to refer any patient who • Henry, Zaugg,
complains of tinnitus et al., 2010a
• Referrals to Audiology, Otolaryngology, Mental Health,
Emergency Care
• Most referrals to Audiology
2 Audiologic • Routine audiologic assessment • Henry, Frederick,
Evaluation • Tinnitus and Hearing Survey et al., 2015
• Optional: Tinnitus Screener • Henry, Griest,
et al., 2015
• Henry, Griest,
Thielman, et al.,
• Hearing aids/combination instruments if warranted 2016, Henry,
• Brief tinnitus counseling if needed Griest, Austin,
• Tinnitus Functional Index if receiving Level 3 services et al., 2016
• Henry, McMillan,
et al., 2017
• Meikle, Henry,
et al., 2012
3 Skills Education • Self-management education provided in group or • Edmonds et al.,
one-on-one setting 2017
• Sound-based therapy skills taught by an audiologist • Henry, Thielman
• Cognitive-Behavioral Therapy skills taught by a mental et al., 2017
health provider • Henry, Zaugg,
et al., 2009
4 Interdisciplinary • Comprehensive evaluation by an audiologist • Henry, Zaugg,
Evaluation • Comprehensive evaluation by a psychologist et al., 2010b
• Audiologist, psychologist, and patient collaborately
decide if Level 5 is needed
5 Individualized Depending on outcome of Level 4: • Henry, Zaugg,
Support • Ongoing support for as long as necessary by an et al., 2010b
audiologist (sound-based therapy)
• Ongoing support for as long as necessary by a mental
health provider (Cognitive-Behavioral Therapy, Acceptance
and Commitment Therapy, Mindfulness)

Level 3 Skills Education is normally provided as five weekly meetings (in group or
individual settings)—two taught by an audiologist and three by a mental health (MH) provider
who has expertise in CBT as applied to tinnitus. During the meetings, patients learn different
strategies for using sound and CBT-based coping skills to improve their quality of life. The
intended outcomes of learning and using the skills that are taught include reduced distress
from tinnitus and improved confidence in the ability to self-manage tinnitus.
The relatively few patients who are still significantly bothered by their tinnitus following
Level 3 are advised to undergo a Level 4 Interdisciplinary Evaluation. Level 4 provides an in-depth
assessment conducted by an audiologist and a psychologist leading to an informed and collaborative
decision as to whether to initiate Level 5 Individualized Support. Level 5 involves personalized
and ongoing meetings with the audiologist and/or the psychologist to incorporate the skills taught
at Level 3 into daily life, with modifications as needed to meet the needs and interests of the
individual being served.

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 Two large-scale RCTs were completed evaluating the efficacy of PTM. The first was a two-
site study conducted at the Memphis, Tennessee, and West Haven, Connecticut Veterans Affairs
(VA) hospitals. The purpose was to evaluate the effectiveness of PTM Level 3 Skills Education
compared to Wait List Control (WLC; Henry, Thielman, et al., 2017). Three hundred military
Veterans (150 at each VA) with bothersome tinnitus who desired treatment were enrolled as
participants. The PTM intervention involved five group workshops, conducted as described
above. At both sites, a statistically significant improvement in mean TFI scores was seen at six
months for the PTM group relative to WLC. These results indicated the effectiveness of PTM at
reducing tinnitus-related functional distress when implemented in VA clinical settings.
The second RCT of PTM (described briefly in Henry, Griest, Thielman, et al., 2016; full
publication currently in review) followed a pilot study suggesting efficacy of telephone-based PTM
(Henry et al., 2012). For the RCT, telephone-based PTM Skills Education was evaluated for
efficacy compared to WLC. Participants (N=205) were enrolled from around the country and
included both Veterans and non-Veterans. The education protocol consisted of five telephone
sessions—three with a psychologist and two with an audiologist (to correspond with the five
sessions that are normally offered in-clinic) in addition to two follow-up calls. Outcomes were
assessed using the TFI as the primary outcome instrument. At six months, improvement on the
TFI was about 20 points greater for the tele-PTM group relative to WLC, and the improvement
was sustained for another six months.

Clinical Recommendations Based on Evidence to Date

The recent RCTs described above add to the evidence base for guiding tinnitus clinical
services. The two PTM studies focused on Level 3 Skills Education, while the two hearing aid
studies were consistent with how Level 2 Audiologic Evaluation is conducted. The interventions
tested in all four studies resulted in significant improvement for participants on average. The
greatest improvement was seen with the two hearing aid studies. As already mentioned, some
of the improvement using hearing aids and combination instruments would have been due to a
reduction in self-perceived hearing difficulties that had been attributed to the tinnitus. It is therefore
essential to first address any hearing needs prior to providing tinnitus-specific intervention.
Further, a tinnitus outcome questionnaire should not be administered to patients prior to
addressing hearing needs because the index score can be inflated if hearing difficulties are
thought to be caused by the tinnitus.
In line with the AAO-HNSF guidelines and these four recent RCTs, evidence-based
guidelines for tinnitus management can be recommended with specificity. Two clinical steps of
management will address the great majority of patients who complain of tinnitus. The first step
would be conducted entirely by an audiologist and is consistent with PTM Level 2 Audiologic
Evaluation. The second step would be conducted by both an audiologist and a MH provider, and
is consistent with PTM Level 3 Skills Education.
Audiologic Management
Because up to 90% of individuals with tinnitus also have hearing loss (Coles, 1995;
Dobie, 2004; Johnson, 1998; Schechter, Henry, Zaugg, & Fausti, 2002), it can be argued as
best practice to conduct an audiologic evaluation for any person reporting the presence of
tinnitus. Tinnitus must therefore be clearly defined with respect to its history of occurrence (see
Table 2) to know who should undergo an audiologic evaluation (Henry, Griest, Austin, et al., 2016).

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 Table 2. Types of Primary Tinnitus With Respect to Its History of Occurrence—Specifically How
Often Experienced and Its Duration When Experienced. Clinical Recommendations Are Shown for
Each Type.

Type of Characteristics Clinical Recommendations

Primary
Tinnitus

Spontaneous • Transient ear noise that occurs • Normal phenomenon experienced

randomly and spontaneously in
one ear
• Typically accompanied by sense
of ear fullness and hearing loss
• Symptoms usually resolve within
2–3 minutes
Temporary • Follows exposure to loud sound or
certain medications or solvents
• Often accompanies temporary
threshold shift (TTS) and can be a
warning sign that TTS has occurred
• Can last 1 or more days following
exposure
Occasional • Lasts at least 5 minutes
• Occurs, on average, every few weeks
or every few months
Intermittent • Lasts at least 5 minutes
• Occurs, on average, every day, or
every week
Constant • Can always be perceived in a quiet
environment
by almost everyone
• No clinical services required
• Indicates damage to inner ear
• Educate about hearing conservation
• Monitor symptoms as appropriate
• Educate about hearing conservation
• Monitor symptoms as appropriate
• Conduct routine audiologic exam
• Conduct brief tinnitus assessment
• Provide tinnitus
intervention if needed
• Conduct routine audiologic exam
• Conduct brief tinnitus assessment
• Provide tinnitus intervention
if needed

As already mentioned, transient ear noise (spontaneous tinnitus) is a normal phenomenon

of the auditory system and does not require clinical services. Some people have experienced
“temporary tinnitus,” which would be associated with an event causing exposure to dangerously
loud sound (Keppler, Dhooge, & Vinck 2015) or to the ingestion of ototoxic drugs (Dille et al.,
2010). In the case of noise exposure, temporary tinnitus indicates that auditory damage has
occurred, and can be a warning sign that the person has experienced a temporary threshold
shift that could lead to permanent threshold shift with further exposure (Dobie, 2001). Individuals
seeking clinical services should at least be counseled about the effects of loud noise and other
ototoxins. They should also be monitored for any increase in symptoms.
Some people report “occasional” tinnitus, which would refer to tinnitus lasting at least
five minutes, that is experienced, on average, every few weeks or every few months (Henry, Griest,
Austin, et al., 2016). As for temporary tinnitus, individuals seeking services for occasional
tinnitus should be counseled about the potential effects of ototoxins and monitored for any
increase in symptoms.
Individuals experiencing “intermittent” or “constant” tinnitus should receive an audiologic
evaluation. Intermittent tinnitus would be tinnitus lasting five minutes or longer and appearing,

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 on average, multiple times a day, or on a daily or weekly basis. Constant tinnitus would be
described as tinnitus that can always be perceived when in a quiet environment.
The audiologic evaluation of patients with intermittent or constant tinnitus would
normally be limited to routine audiologic testing (including a case history) plus the THS (Henry,
Griest, et al., 2015). The THS has been tested and validated for differentiating hearing problems
from tinnitus problems, which addresses the concern that many patients with both of these
complaints often blame the tinnitus for the hearing difficulties. The THS is a 10-item instrument
that can be completed by a patient in about two minutes (ideally in the waiting area, and then
reviewed by the audiologist). Two of the items on the THS screen for a sound tolerance problem
(hyperacusis), which may require specialized services (Henry, Zaugg, et al., 2010b).
The combined results of the audiologic evaluation and the THS will usually yield sufficient
data to make an informed decision as to whether further services are needed. Audiologists are
trained to detect signs of secondary tinnitus and to refer patients to an ear specialist if secondary
tinnitus is suspected (Henry, Zaugg, et al., 2010a).
If the patient is a hearing aid candidate, then a hearing aid evaluation is performed and
the patient is advised if hearing aids would be needed to address a hearing problem. If the patient’s
tinnitus is bothersome, then criteria for recommending hearing aids would be more liberal (i.e.,
patients may be “marginal” hearing aid candidates and hearing aids might be recommended
primarily to mitigate the bothersome tinnitus). Even patients who are not hearing aid candidates
may receive benefit with hearing aids, using a very low level of amplification (which would reduce
the contrast between their tinnitus and the ambient sound). Although combination instruments
have not been shown to result in greater benefit than hearing aids, the built-in sound generator
provides an option for sound therapy should it be desired by the patient.
All patients with bothersome tinnitus should be counseled briefly by the audiologist to
learn some minimal skills for tinnitus self-management. For the two hearing aid RCTs described
above (Henry, Frederick, et al., 2015; Henry, McMillan, et al., 2017), brief tinnitus counseling
involved explaining pages 31–64 in the PTM flip chart counseling book (Henry, Zaugg, et al.,
2010c). If ear-level devices are not dispensed, then the counseling should be worked in during
the assessment appointment if possible. If not, then a follow-up appointment can be scheduled
to provide the counseling. For patients receiving ear-level devices, the counseling should be
conducted during the fitting appointment.
Patients with bothersome tinnitus should be reassessed with the THS four to eight weeks
following the counseling. For those receiving ear-level devices, this can be accomplished during
the routine follow-up appointment to determine if the devices and counseling have sufficiently
resolved the tinnitus problem. For those who do not receive devices, the follow-up THS assessment
can be conducted over the telephone.
If the follow-up THS assessment indicates that the bothersome tinnitus is sufficiently
mitigated, then tinnitus management is complete. If tinnitus is still a problem, then the patient
should be asked if tinnitus-specific intervention is desired that would address the types of tinnitus
problems described in the THS. If not, then tinnitus management is complete. If tinnitus-specific
intervention is to be received, then a tinnitus outcome questionnaire should be administered. The
TFI is suggested for this purpose because it has been validated for being sensitive to outcomes of
treatment (Meikle et al., 2012). The TFI index score becomes the baseline for assessing outcomes
following the intervention.
Self-Management Skills Education
For patients receiving ear-level devices, the audiologic management protocol described
above can be expected to obtain results comparable to those described above for the three RCTs
that compared hearing aids to combination instruments for tinnitus management (dos Santos
et al., 2014; Henry, Frederick, et al., 2015; Henry, McMillan, et al., 2017). Some patients will
require further services to address their tinnitus problem, and it is recommended that these
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 patients enroll in a program that teaches tinnitus self-management skills (Henry, Zaugg, et al.,
2009). These patients, especially those with persistent tinnitus, are likely to have tinnitus for a
lifetime, and they are best served if they possess self-management skills empowering them to
know what to do whenever their tinnitus is disruptive to their lives.
The PTM protocol for teaching tinnitus self-management skills has been fully described
and tested for efficacy in the two-site RCT described above (Henry, Thielman, et al., 2017).
Although this is the protocol that has been validated in an RCT, the number of sessions, and
what is taught during each session, can be varied within reason without expecting a decrement
in outcomes (Edmonds, Ribbe, Thielman, & Henry, 2017).
For example, the MH provider may wish to focus on mindfulness training or Acceptance
and commitment therapy (ACT) rather than CBT. CBT has the strongest evidence base for
tinnitus management, but evidence is accumulating for both mindfulness and ACT (e.g., Cole
et al., 2015; Westin et al., 2011).

Summary and Conclusion

The mechanisms of tinnitus generation and maintenance remain to be discovered. There
is no cure for tinnitus and the cure(s) will most likely rely on elucidating the underlying cause(s).
In the meantime, tinnitus can be managed through a proper assessment and intervention that
is based on research evidence. The AAO-HNSF CPG: Tinnitus is the most comprehensive guide for
the clinical management of tinnitus based on a systematic review. That review, however, was
completed in early 2013, and numerous RCTs have been completed since then. Four of those
RCTs have been described briefly above, and findings from those trials can be integrated with
the recommendations from the CPG: Tinnitus.
A specific protocol has been outlined that will address tinnitus problems for most
patients, (i.e., mitigating the problems to the degree that a normal life can be lived in spite of
experiencing tinnitus that is unremitting). The audiologic evaluation involves little more than
what an audiologist would normally do to evaluate a patient for hearing loss and to fit hearing
aids. Addition of the THS to the audiologic evaluation provides the information needed to
differentiate hearing problems from tinnitus-specific problems. The recommended protocol
has been tested and vetted and is relatively easy for audiologists to implement. For patients
requiring further services, education to learn self-management skills is recommended.
There is currently no proof that any one method works better than any other method
for tinnitus management. Any claims to the contrary are unsubstantiated and could cause a
person to commit to a therapy that may result in the needless spending of thousands of dollars.
At the least, all providers should adhere to the AAO-HNSF CPG: Tinnitus to ensure that patients
are receiving evidence-based clinical services.

References
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History:
Received July 24, 2017
Revised August 19, 2017
Accepted August 27, 2017
https://doi.org/10.1044/persp2.SIG2.157

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