■ There is considerable variability across patients in regard to their tinnitus and their ability to cope with its psychosocial consequences. Accordingly, the rehabilitative management of patients with tinnitus varies depending upon the impact it has on the individual’s HRQoL—creating a less than straightforward treatment approach.

Taking all of these issues into consideration, it is understandable that so many audiologists are reluctant to provide clinical management for this patient population in need of clinical services.

Tinnitus management, however, does fall within the scope of practice for audiologists (American Academy of Audiology, 2004; American Speech-Language-Hearing Association [ASHA], 2018). Furthermore, it is the audiologist who is best positioned to function as the primary health care provider on an interprofessional collaborative practice tinnitus management team. As audiologists, we have the necessary preparation: (a) knowledge of auditory disorders and their impact on auditory system function; (b) understanding of acoustic and psychoacoustic principles underlying tinnitus assessment (e.g., pitch and loudness matching) and intervention (e.g., sound therapy including tinnitus masking and habituation); (c) competency in using clinical instrumentation necessary to evaluate hearing and conduct the tinnitus psychoacoustic evaluation; (d) familiarization with self-assessment methodology used to quantify HRQoL; (e) expertise in selecting and fitting hearing aids (HAs), which remains a primary treatment method for providing tinnitus relief; (f) professional working relationship with physicians, psychologists, and other health care practitioners; and (g) patient-centered counseling skills that serve as the cornerstone for all contemporary audiologic rehabilitation programs (ASHA, 2018; Henry, 2004; Henry et al., 2005a).

The purpose of this chapter is to provide an overview of the management of patients with tinnitus using an interprofessional collaborative practice care path model that can be implemented in a busy clinical practice. The chapter begins by providing the basics such as definitions, epidemiologic factors, perceptual attributes, perceived severity, classification schemes, and the mechanisms of tinnitus generation and perception. The latter fundamental concepts are followed by a description of the evaluation process and treatment options, concluding with a discussion of the roles of other health care practitioners and alternative nonaudiologic treatment options for patients with tinnitus.

Underlying Principles of Tinnitus

Definitions

Tinnitus has been defined as the perception of sound in the absence of an external acoustic stimulus (Folmer, Griest, & Martin, 2001). Some have described it as a “phantom” auditory perception resulting from tinnitus-related neuronal activity within the auditory pathways (Jastreboff, 1990, 1995). It has been argued, however, that the use of the term phantom may not be helpful in a clinical context because it suggests that the perception is nonexistent (Noble & Tyler, 2007). Further, tinnitus should be recognized as a symptom of various causes and mechanisms but not as a disease in and of itself (Tunkel et al., 2014).

Some authors have defined tinnitus in terms of its temporal course (Coles, 1984; Dauman & Tyler, 1992; Davis, 1995; Hazell, 1995; Meikle, Creedon, & Griest, 2004). Most recently, the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) published clinical practice guidelines for tinnitus (Tunkel at al., 2014) and defined recent onset tinnitus as occurring less than 6 months in duration as reported by the patient, whereas persistent tinnitus has a duration of 6 months or greater.

Epidemiology

Obtaining a clear picture of the prevalence of tinnitus (i.e., number of individuals who experience tinnitus at a given time) is difficult because it has many forms and levels of severity, causing different studies to yield widely different outcomes (Møller, 2007). Furthermore, methodological techniques to gather prevalence data have varied using diverse sampling methods (e.g., questionnaires sent by mail or asked during an interview) and study populations (e.g., clinical samples having otologic pathologies or lack of differentiation between “normal” ear noises from “pathologic” tinnitus). In addition, such factors as general health status, degree of hearing loss, age, and noise exposure have not been well controlled, if at all, in most epidemiologic studies (Hoffman & Reed, 2004).

With an understanding of the aforementioned caveats, data estimate that at least some form of tinnitus occurs in approximately 25% of American adults (50 million people), and is a frequent occurrence in 8% (16 million people) of the adult population (Shargorodsky et al., 2010). Although most epidemiological studies are based on data from the U.S. (Hoffman & Reed, 2004; Sindhusake et al., 2003) and European countries (Krog, Engdahl, & Tambs, 2010; Quaranta, Assennato, & Sallustio, 1996), recent studies investigating the extent of tinnitus in other regions of the world are emerging, providing evidence that tinnitus is a significant global health burden (Khedr et al., 2010; Kim et al., 2015; Lasisi, Abiona, & Gureje, 2010; Michikawa et al., 2010; Xu et al., 2011).

The characteristics of tinnitus can be described in a multitude of ways: intermittency, perceived location, quality descriptors, loudness magnitude ratings, loudness and/or pitch fluctuations, and number of sounds comprising the tinnitus, to name a few. Meikle and colleagues created an extensive database containing information about the perceptual attributes of tinnitus reported by 1,630 patients with clinically significant tinnitus (Meikle et al., 2004). The reader is encouraged to visit the Tinnitus Archive™ (2nd edition) website http://www.tinnitusarchive.org, created initially by Meikle and colleagues (2004) and currently maintained by the Oregon Hearing Research Center.

Classification Schemes

Tinnitus is often categorized as being either subjective (i.e., heard only by the patient) or objective (i.e., produced by an internal source that can be heard by another person). It has been argued (Dobie, 2004b; Hazell, 1995), however, that the latter term is inappropriate in that some internally generated acoustic sounds may not be heard by anyone except the patient. Accordingly, the term somatosound (“body sound”) has been proposed (Dobie, 2004b) as more suitable than the term objective for all sounds with internal acoustic sources whether or not they are audible to an external listener. The etiology of somatosounds may include such conditions as vascular pulsations, patulous Eustachian tubes, palatal or intratympanic myoclonus, and jugular outflow syndrome (Perry & Gantz, 2000).

The site of generation has also been proposed as a classification scheme, similar to hearing loss categorization. In this manner, the terms middle ear/conductive, sensorineural, or central tinnitus (Tyler & Babin, 1986; Zenner & Pfister, 1999) are used to describe tinnitus. Further, sensorineural tinnitus has been subclassified into four types based on involvement of the outer hair cells, inner hair cells, auditory nerve, and microvascular or osmotic endolymphatic mechanisms (Zenner, 1998). Although the latter classification scheme further delineates the potential tinnitus generator site, it most likely lacks clinical utility.

Using a broad classification scheme, the AAO-HNS (Tunkel et al., 2014) categorized tinnitus as being either primary or secondary. Primary tinnitus may be idiopathic in nature and may or may not be associated with sensorineural hearing loss. In contrast, secondary tinnitus is associated with a specific underlying cause (other than sensorineural hearing loss) or identifiable from organic auditory (e.g., otosclerosis, Meniere’s disease, vestibular schwannoma) or nonauditory (e.g., myoclonus, intracranial hypertension) conditions.

On the other hand, Tyler and Baker (1983) proposed that tinnitus be described as a function of associated HRQoL problems. Using the data obtained from 72 members of a tinnitus self-help group completing the Tinnitus Problem Questionnaire (TPQ), problems were assigned to one of four general categories: effects on hearing, effects on lifestyle, effects on general health, and emotional problems. Table 22–1 displays the 15 highest ranked tinnitus-related difficulties associated within each of the four general categories.

Using a cluster analysis statistical technique, Tyler and colleagues (2008) derived subgroups of tinnitus patients based on a number of variables involving different data collection mechanisms: outcome on questionnaires including the Tinnitus Handicap Questionnaire (Kuk, Tyler, Russell, & Jordan, 1990), Tinnitus Activities Questionnaire (Tyler et al., 2006), and portions of the Tinnitus Intake Questionnaire (Stouffer & Tyler, 1990); biographical factors; and psychoacoustic tinnitus measures including pitch and loudness matching. The rationale for developing tinnitus subgroup classifications is that they might provide insight into the underlying mechanisms of tinnitus and be helpful in determining a specific intervention approach or combination of approaches. Based on their preliminary attempt to classify patients with tinnitus using cluster analyses they proposed four major subgroups:

Our preference for classifying tinnitus, especially within the context of audiologic rehabilitation, is based on a biopsychosocial model. The World Health Organization’s International Classification of Functioning, Disability, and Health (WHO-ICF) (2004) provides a conceptual framework for developing a tinnitus classification taxonomy (Henry et al., 2005; Manchaiah et al., 2018; Newman & Sandridge, 2004; Ramkumar & Rangasayee, 2010; Tyler, 1993, 2000). In short, the ICF addresses functioning and disability related to a health condition affecting an individual’s activities and participation in everyday life within the context of environmental and personal factors. Table 22–2 summarizes the individual domains of the WHO-IFC schema describing how these categories pertain to tinnitus and their application in the assessment process.

Mechanisms and Models

The precise origins of tinnitus and associated mechanisms involved in the generation of tinnitus are not well-understood. Based on current research findings, it seems most likely that multiple mechanisms (including the auditory periphery, central auditory nervous system, and nonauditory sensory and motor systems) are involved in the generation of tinnitus, either simultaneously or interactively (Baguley, 2002; Bartels, Staal, & Albers, 2007; Georgiewa et al., 2006; Henry, Roberts, Caspary, Theodoroff, & Salvi, 2014; Kaltenbach, 2011). In general, there is agreement that the mechanisms of tinnitus involve deprivation of input or abnormal input from the peripheral auditory system to the central auditory nervous system. Reduced neural activity from the cochlea (e.g., due to noise exposure or ototoxicity) may result in increased spontaneous neural activity (hyperactivity) in the central auditory nervous system (Salvi, Lockwood, & Burkard, 2000) possibly due to a reduction in inhibitory influences (Kaltenbach et al., 2002; Kaltenbach, Zhang, & Zacharek, 2004). Accordingly, tinnitus is currently viewed as a systemic problem arising from imbalances in the excitatory and inhibitory inputs to auditory neurons occurring at multiple levels of the auditory system (Kaltenbach, 2011). Because of neural plasticity, changes in neural input may result in structural and/or functional changes in the central pathways (e.g., cortical and tonotopic reorganization), thus causing the perception of tinnitus (Eggermont & Roberts, 2004; Kaltenbach, 2000; Lockwood et al., 1998; Noreña, 2011; Roberts et al., 2010).

As is evident, there is no single convergence of view regarding tinnitus mechanisms. In fact, several models, theories, and hypotheses of tinnitus have been proposed, based on anatomic sites, physiologic mechanisms, and psychologic influences. Figure 22–1 provides a summary of current models and mechanisms of tinnitus involving the cochlea, auditory nerve, and central auditory nervous system. Note that the figure includes both potential anatomic and physiologic sites of tinnitus generation as well as general psychological models of tinnitus development.

The next section of this chapter describes an approach designed to assist in clinical decision making targeted at promoting tinnitus relief and empowering the patient. Empowerment is a critical factor in the rehabilitation process in that it not only improves patient satisfaction with care, but also increases compliance with and adherence to the treatment plan (Greenhalgh & Meadows, 1999). Figure 22–2 illustrates a model that can guide the clinician in the management of patients with tinnitus. It is a multistep interprofessional collaborative care path process allowing patients to be referred to several health care service providers and be discharged at various points within the clinical pathway. In general, care paths foster value-based, patient-centered treatment plans that provide a schema of sequenced actions necessary to achieve best practice outcomes (Schrijvers, van Hoorn, & Huiskes, 2012). The presentation of the Tinnitus Management Clinic (TMC) model used at the Cleveland Clinic will provide the framework for discussion of an interprofessional collaborative management approach.

TMC Clinical Path Entry

Patients with tinnitus can be referred to the TMC from any health care specialist (e.g., primary care physician, gerontologist). The initial step before a patient is scheduled into the TMC is an evaluation by both an audiologist and otolaryngologist. The importance of each service is described below.

Results from the comprehensive audiologic evaluation (i.e., pure-tone and speech audiometry, immittance measurements, and otoacoustic emissions) provide information about the severity and type of hearing loss, audiometric configuration, and functional integrity of the auditory system. The latter clinical data are critical to the medical diagnosis of any ear disease that may underlie the tinnitus symptoms. It is important to note, however, that many patients who have tinnitus also experience some degree of hyperacusis (i.e., hypersensitivity to sound). Thus, the clinician must be aware that the administration of specific tests in the audiologic battery, such as acoustic reflex threshold determination and reflex decay testing, may need to be abandoned to prevent patient discomfort due to loudness intolerance. (Authors’ note: The reader is referred to Fagelson and Baguley [2018] and a two-part review article appearing in the American Journal of Audiology [Pienkowski et al., 2014; Tyler et al., 2014] for a complete discussion of hyperacusis and sound intolerance mechanisms, diagnosis, and treatment.)

It would be prudent to incorporate a tool to screen for clinically significant tinnitus into every audiologic evaluation, not just when evaluating patients who are referred with tinnitus as their chief complaint. A quick and easy method to screen for clinically significant tinnitus is shown in Figure 22–3. Using this flowchart, the patient responds to each question guiding the clinician toward follow-up treatment recommendations. For example, if a patient indicates that his or her tinnitus is “not a problem” or a “small problem,” the provision of some basic counseling within the context of the audiologic evaluation may be sufficient. This minimal level of counseling might include information about the causes of tinnitus and hearing loss, hearing loss prevention, some strategies to manage his or her reactions to tinnitus, and the need to maintain a sound-enriched environment. For many patients, this brief counseling is sufficient and negates the need to return for further intensive tinnitus treatment. Also, consider directing the patient to the Tinnitus First Aid Kit website (http://www.tinnituskit.com), which was developed by the Ida Institute to provide some essential information about tinnitus and how to manage it effectively. In contrast, if a patient indicates that his or her tinnitus is chronic and causing him or her at least moderate problems, referral to further tinnitus management may be warranted.

A more formalized assessment of tinnitus severity can be accomplished using standardized screening tools. The 10-item Tinnitus Handicap Inventory-Screening Version (THI-S) (Newman, Sandridge, & Bolek, 2008), shown in Table 22–3, is a shortened version of the 25-item THI (Newman, Jacobson, & Spitzer, 1996) using the same questions and same scoring process. Patients indicate “yes” (4 points), “sometimes” (2 points), or “no” (0 points) for each question asked, yielding a possible total score ranging from 0–40 points, with higher scores representing greater perceived psychosocial problems as a consequence of tinnitus. The scores on the THI-S have been shown to be comparable (r = .90) to the full 25-item version of the THI and yielded adequate test-retest reliability (r = .81). Furthermore, a cutoff value of more than 6 points (out of a possible 40 points) was established as a fence for recommending follow up. Another option is the Tinnitus and Hearing Survey (THS) screening tool (Henry et al., 2015). This 10-item questionnaire is especially helpful to quickly differentiate between hearing difficulties (including sound tolerance issues) and bothersome tinnitus. The THI-S and THS are attractive screening tools to use in a busy clinical practice because they are brief (i.e., they take less than 2 minutes to complete) and easy to administer, score, and interpret.

The evaluation of tinnitus by a physician should include a thorough history, physical examination, and referral for appropriate diagnostic testing (e.g., imaging studies, bloodwork panels) geared toward identifying any underlying condition that may cause or contribute to the tinnitus (Shi, Robb, & Michaelides, 2014). Table 22–4 summarizes the main components of the medical evaluation of tinnitus.

The medical or surgical management of an underlying pathology may help to alleviate the symptom of tinnitus for some; however, for the majority of patients, the cause for the tinnitus cannot be identified, or if it is, it cannot be reversed (e.g., noise-induced hearing loss) or successfully treated. When this is the case, physicians need to encourage their patients to seek nonmedical treatments (e.g., sound therapy, cognitive behavioral therapy) and reassure them that help is available from other health care providers. Unfortunately, all too often patients are told to “learn to live with it.” The latter advice can lead to further distress and discourages the patient from seeking appropriate nonmedical services that offer tinnitus relief. On the other hand, the physician’s positive comments about the benefits of nonmedical treatments set the stage for successful management by the audiologist and other health care providers. Accordingly, our role as audiologists is to educate physicians regarding the benefits of nonmedical intervention so that they encourage patients to seek assistance from other knowledgeable providers.

Shared Medical Appointment

The next major component for patients in the care path is attendance at the Shared Medical Appointment (SMA). The goal of the SMA is to promote patient access and clinician productivity. As shown in Figure 22–2, the TMC is a 3-hour SMA divided into a 1.5-hour Group Education Session (GES), followed by a 1.5-hour Interprofessional Screening Assessments (ISA). TMC providers include an audiologist, dentist, neurologist, physical therapist, and psychologist.

Prior to attending the SMA, each patient is mailed information about the TMC and several questionnaires to be completed before arriving to the appointment. These include an in-depth tinnitus case history and standardized disease- and condition-specific questionnaires (i.e., THI [Newman et al., 1996; Newman, Sandridge, & Jacobson, 1998]; Tinnitus Functional Index [TFI] [Meikle et al., 2012]) and dimension-specific screening measures for anxiety (Generalized Anxiety Disorders-7 [GAD-7] [Spitzer, Kroenke, Williams, & Löwe, 2006], depression (Patient Health Questionnaire-9 [PHQ-9] [Kroenke, Spitzer, & Williams, 2001]), neck issues (Neck Disability Index [Vernon & Mior, 1991]), and dizziness (Dizziness Handicap Inventory [Jacobson & Newman, 1990]). Moreover, a Shared Medical Appointment Acknowledgment form is included. This form is signed by each patient prior to the GES acknowledging that he or she is choosing to participate in a group session where confidentiality may be lost. Following are descriptions of the activities comprising each component of the TMC.

The ideal size for an educational group is eight to 12 members, with the session lasting approximately 1.5 to 2 hours in length (Childers & Couch, 1989). It is important to control the group size because a group that is too large or too small may inhibit individual participation and reduce opportunities for interaction. Spouses/significant others should be encouraged to attend the session so that they have a better understanding of the patient’s problems and are better prepared to provide emotional support. The meeting room should be quiet and inviting, with chairs arranged in a circle so that everyone feels a sense of equality with one another and the exchange of information among participants and providers is enhanced.

One way to convey the aforementioned information is through the use of a computerized, picture-based slideshow presentation. The presentation, incorporating a series of animated picture sequences and sound clips (e.g., simulated tinnitus sounds), serves to guide the flow of the counseling session, organizes complex information in a logical sequence, keeps group discussion focused, and provides visual and auditory interest to the patients. Figure 22–4 displays some examples of the pictures contained in the slide show presentation.

■ Contact information for the American Tinnitus Association (http://www.ata.org; 800-634-8978).

Interprofessional Screening Assessments (ISA)

Following the GES, each participant of the SMA meets individually with the providers for approximately 15 minutes. The purpose of this brief encounter is to determine if the patient would benefit from a scheduled individual appointment with the provider, at which time a more thorough evaluation would be conducted, resulting in appropriate follow-up recommendations and treatment plans. Following is a brief summary of the activities performed by each clinician during the ISA.

■ Audiologist: Reviews purposes of and demonstrates various sound therapy options to determine which form of sound therapy provides relief and which may be most acceptable to the patient over the long term. Observed reactions to the use of different broadband sounds and/or amplification help to gauge the patient’s motivation for pursuing device use.

■ Neurologist: Screens for potential jaw, neck, or cervical disorders and conducts a physical examination to determine if tinnitus is somatically modulable (see Figure 22–5 for physical screening maneuvers used with each patient) and potentially amenable to physical therapy intervention.

■ Physical therapist: Screens for biomechanical problems associated with neck, spine, or jaw injuries, strains resulting from occupational requirements (e.g., time spent at computer), and poor posture.

■ Psychologist: Reviews results from the PHQ-9 and GAD-7 to address depression and/or anxiety and introduces the concept of the mind-body connection. For patients not requiring formal follow-up psychological counseling, The Mindfulness and Acceptance Workbook for Anxiety (Forsyth & Eifert, 2016) is an excellent resource and recommended for self-help to overcome generalized anxiety, fear, and worry.

TMC Disposition and Case Staffing

Once the ISAs are completed and the patients are discharged, the team gathers to discuss each participant’s case history and the screening observations to develop an individualized treatment plan. A summary report is generated and mailed to each patient along with specific recommendations from each provider on the team (e.g., hearing devices, bite modification appliances, physical therapy, cognitive behavioral therapy). It is critical that the report is written without extensive medical/clinical jargon so that it can be understood by a wide range of patients.

Following the TMC, patients are mailed a survey to assess satisfaction with and benefit from the experience. Figure 22–6 summarizes selected responses from the survey. As illustrated, the bulk of participants (n = 100/103) reported that the SMA was beneficial and would recommend the TMC to friends experiencing tinnitus (n = 97/103). Further, the survey examined the value of attending the TMC using the willingness-to-pay (WTP) econometric. Knowing that the cost of the TMC was $300 (self-pay), the mean WTP was $287 (standard deviation [SD] = $164; range $0–$1,500), showing nominal equivalence between the cost of the TMC and average WTP. These findings suggest that the patients perceived value in attending the TMC.

Individual Tinnitus Evaluation

The next two sections will highlight the audiologic tinnitus evaluation and management components of the care path, respectively. Subsequently, an overview of the assessment and treatment options offered by the other providers on the team (i.e., dentistry, neurology, physical therapy, psychology) will be presented.

The tinnitus evaluation protocol should include the following areas of investigation: (a) an in-depth tinnitus case history; (b) assessment of tinnitus impairment; (c) evaluation of tinnitus activity limitations and participation restrictions; (d) selection of the most appropriate form of sound therapy for a given patient; and (e) determination of treatment outcome.

Case History

The intake case history provides information about the nature of the patient’s complaints that cannot be measured objectively and supports quantitative self-reported measures. In addition, spending time to obtain a detailed case history facilitates rapport and the development of the patient-audiologist relationship. For medicolegal cases, completion of the detailed history is especially critical because it supports the consistency and plausibility of the patient’s report, or the absence of true symptoms, as well as motivation for seeking treatment.

Several published tinnitus case history questionnaires are available (Henry et al., 2005a; Henry, Jastreboff, Jastreboff, Schechter, & Fausti, 2002; Schechter & Henry, 2002). For example, the Iowa Tinnitus Questionnaire (Stouffer & Tyler, 1990) is a two-part history form. Part A, completed by the patient, focuses on the patient’s description of tinnitus, problems associated with tinnitus, and other aspects of tinnitus from the individual’s perspective. Part B, completed by the audiologist, consists of three questions regarding the primary diagnosis, patient’s primary complaint, and air-conduction thresholds for each ear at 1000 and 4000 Hz.

Many audiologists develop their own intake questionnaires. Table 22–5 summarizes the salient points that should be addressed during the history. In general, the history should include inquiry about: (a) descriptive attributes of the tinnitus; (b) specific behavioral, social, emotional, and interpersonal consequences of tinnitus; (c) factors that may increase or reduce tinnitus disturbance; (d) hearing, hearing loss, and sound tolerances issues; (e) previous tinnitus treatments; (f) prioritization of concerns (e.g., hearing loss, tinnitus sound tolerance problems); and (g) expectations about treatment.

Tinnitus Impairment

Tinnitus impairment (i.e., perceptual characteristics of the tinnitus) may be quantified using two general approaches: scaling techniques or psychoacoustic measurement. Scaling techniques for tinnitus typically involve the application of a direct estimation method. The latter approach is designed to elicit from the patient a direct quantitative estimate of the magnitude of a tinnitus attribute such as pitch and/or loudness. Figure 22–7A illustrates examples of direct estimation numeric rating scales. Using a numeric scale technique, Stouffer and Tyler (1990) indicated the average rating for subjective pitch estimates for their sample on a 10-point scale was 7.12 (SD = 2.3), with 65% of the subjects rating their pitch as 7 points or higher. Stouffer and Tyler further noted that the average loudness rating was 6.3 on the 10-point scale (SD = 2.3). An alternative approach is the visual analog scale (VAS) that often employs a line of fixed length, usually 100 mm, with anchors appropriate for the attribute being measured (Figure 22–7B). In a sample of patients with chronic tinnitus, Adamchic and colleagues (2012) demonstrated that the VAS has good test-retest reliability and convergent validity for measuring self-perceived tinnitus annoyance and loudness.

Psychoacoustic measurement techniques provide the researcher and clinician a method for quantifying the sensory and perceptual characteristics of the tinnitus experience. These procedures have a long history (Henry & Meikle, 2000), focusing on the development of specific techniques, test-retest reliability of the obtained data, and the extent to which different protocols might reflect differences among patient populations. In the clinical setting, psychoacoustic tinnitus measurements (Table 22–6) include pitch and loudness matching, minimum masking levels, residual inhibition, and loudness discomfort levels (used to quantify sound tolerance problems that often accompany tinnitus). The reader is referred to Henry and Meikle (2000) for a discussion on how to perform these measurements.

Tyler (2000) proposed several reasons for conducting the aforementioned measures, including: reassuring the patient that the tinnitus is real; demonstrating the acoustic characteristics of the tinnitus to the patient’s significant others; distinguishing different subcategories of tinnitus; determining potential treatment benefit and selecting specific treatment options; quantifying treatment outcome/effectiveness; and assisting in medicolegal issues. The clinical utility of pitch matching was suggested by Schaette, König, Horning, Gross, and Kempter (2010), who demonstrated that sound therapy was more effective when tinnitus was matched to frequencies less than 6000 Hz. Moreover, the Tinnitus Research Initiative consensus statement (Langguth et al., 2007) proposed that loudness matches and tinnitus maskability should be considered primary psychoacoustic outcome measures in tinnitus treatment clinical trials.

Although measurement protocols for assessing the psychoacoustic attributes of tinnitus are not currently standardized and may require specialized instrumentation (Henry et al., 2009; Henry, Rheinsburg, Owens, & Ellingson, 2006), methods using a diagnostic audiometer have been recommended (Henry, 2004; Henry et al., 2005a; Lentz, Walker, Short, & Skinner, 2017). Currently, a clinically available computer-based tinnitus assessment tool has been developed to measure psychoacoustic attributes of tinnitus (e.g., frequency, bandwidth, tempo, and slope; intensity threshold; maskability) more precisely than can be accomplished using a standard audiometer (Figure 22–8; Tinnometer Main Screen, courtesy of MedRx). The unit of measurement for each component for the psychoacoustic battery varies depending upon the stimulus parameter. For example, pitch (psychoacoustic correlate of frequency) is measured in hertz (Hz), and loudness (psychoacoustic correlate of intensity) has typically been measured in dB sensation level (SL; amount, expressed in dB, above the patient’s threshold).

It has been argued, however, that SL may not accurately reflect the patient’s perception of tinnitus loudness (Newman, Wharton, Shivapuja, & Jacobson, 1994; Tyler, Aran, & Dauman, 1992; Tyler & Conrad-Armes, 1983). Tyler (2000) advocates that the use of sones, the conventional psychoacoustic unit for measuring loudness, would be a more appropriate measure than dB SL. The following example illustrates this point. Figure 22–9 displays the loudness growth function for a patient with normal hearing at 1000 Hz and a moderate sensorineural hearing loss at the pitch-match frequency. The predicted growth in loudness in sones is based on the equation described by Tyler and Conrad-Armes (1983):

L = k(P – P₀)^0.6

where: L = loudness in sones

k = constant that depends on the unit of measurement (with P measured in micropascals, k = 0.01)

P = equal-loudness match in dB sound pressure level (SPL)

Note that, in Figure 22–9, SPL is converted into dB hearing level (HL) on the abscissa with loudness in sones on the ordinate. As can be seen, this patient’s threshold at 1000 Hz was 20 dB HL. Tinnitus was determined to have an equal loudness match of 34 dB HL, which was 14 dB SL and calculated to have a loudness judgment value of 0.88 sones. At the pitch-match frequency, however, this same patient had a threshold of 48 dB HL with an equal loudness match of 61 dB HL. The sensation levels for both frequencies were essentially equal, at 14 and 13 dB SL, respectively. Yet, when the sone value was calculated for the pitch-matched frequency, it was determined to be 5.68 sones—more than 5 times greater than the sone value at 1000 Hz. This case illustrates the appropriateness of estimating loudness with sones, rather than simply reporting SL (Newman et al., 1994).

Self-Reported Measures

The use of self-reported measures to assess the impact of tinnitus on the patient’s HRQoL is a critical component in the evaluation of activity limitation and participation restriction. In fact, the AAO-HNS tinnitus guidelines strongly recommend the use of self-reported measures to help distinguish patients with bothersome tinnitus from those with nonbothersome tinnitus (Tunkel et al., 2014). Newman and Sandridge (2004) outlined a number of reasons for inclusion of these measures in the evaluation process:

Over the years, several questionnaires have been developed. Table 22–7 summarizes some of the readily available questionnaires that evaluate a broad spectrum of activity limitation, participation restriction, cognitive reaction to tinnitus, and coping. As shown, for each questionnaire there is a short description of its content domains, scoring and interpretation, psychometric properties, and strengths and weaknesses as viewed by the current authors. The self-reported measures summarized in Table 22–7 are all quantitative in nature or score driven (i.e., responses can be summed and/or averaged, resulting in a total score or subscale scores).

In contrast, qualitative tinnitus questionnaires are not score driven, and provide the clinician with information that is more descriptive in nature. For example, the TPQ developed by Tyler and Baker (1983) employs an open-ended format. The patient is simply asked, “Please make a list of the difficulties that you have as a result of your tinnitus. List them in order of importance, starting with the biggest difficulties. Write down as many of them as you can.” The primary advantage of the open-ended approach (e.g., TPQ), in contrast to structured measures (e.g., THI; Tinnitus Reaction Questionnaire [TRQ] [Wilson, Henry, Bowen, & Haralambous, 1991]), is that they allow the patient to list their own specific tinnitus problems instead of limiting the patient to a fixed set of responses that may or may not be of relevance. This is similar to the benefits offered by the HA tool; namely, the Client-Oriented Scale of Improvement (COSI) (Dillon, James, & Ginis, 1997), where the patient reports his or her own specific hearing difficulties rather than select from among a closed-response list.

Maintaining diaries has been used as a technique for assessing the patterns of tinnitus complaints over time (e.g., changes in pitch, loudness, annoyance, sleep disturbance) and factors that may be associated with those changes (e.g., noise exposure, medication use, diet). Daily diaries have been helpful in designing cognitive behavioral therapy (CBT) sessions by identifying unhelpful and negative thought patterns (Hallam & McKenna, 2006; Henry & Wilson, 2001); however, diary/journal entries may also be counterproductive as they increase the patient’s attention to the tinnitus (i.e., self-checking behavior). Continued shifts in attention toward the tinnitus may not be advantageous for sound therapy treatments where the goal is to direct attention away from the tinnitus. Further, outcome assessment is limited by the lack of psychometric data regarding diary/journal validity, reliability, and responsiveness.

Assessment of self-efficacy (confidence individuals have in their abilities to perform specific tasks, goals, and behaviors) may play an important role in the overall evaluation of tinnitus patients’ ability to engage in and carry out a successful treatment plan. To this end, Smith and Fagelson (2011) created the 40-item Self-Efficacy for Tinnitus Management Questionnaire (SETMQ) that has been shown to have adequate internal consistency reliability, test-retest reliability, and construct validity. Specifically, the SETMQ was developed to determine the level of confidence patients with tinnitus believe they have in selected abilities (i.e., routine tinnitus management, emotional response to tinnitus, internal thoughts and interactions with others, tinnitus concepts, and use of devices) that will allow them to manage and control the negative consequences of tinnitus. This questionnaire provides a unique perspective by evaluating the patient’s belief system, potentially resulting in improved counseling strategies and better management outcomes.

A number of sound therapy devices (to be discussed later in the chapter) are available to provide relief from the annoying and bothersome consequences of tinnitus. These include assistive sound enrichment devices, HAs, ear-level SGs, combination units, and other personal listening devices. The overall objectives of sound therapy are to alter tinnitus perception and reduce the negative emotional reactions associated with bothersome tinnitus, thereby promoting clinical benefit in the form of tinnitus relief (Tunkel et al., 2014). Moreover, the rationale for using any device is to decrease the perception of the tinnitus, thus reducing the signal (tinnitus)-to-background noise ratio. That is, the goal is to reduce the contrast between the environment and the patient’s tinnitus percept. In this way, the brain interprets the tinnitus as less noticeable, and therefore, less annoying and troublesome. Henry, Zaugg, Myers, and Schechter (2008) propose that sounds can provide not only soothing relief from the tinnitus, but can also act as a distracter either through passive background sound or active interesting sound.

As shown on the bottom of Figure 22–2, the next step in the care path following evaluation is a discussion about appropriate intervention options with the patient. The focus of audiologic management is the provision of the selected sound therapy device which must be accompanied by ongoing and intensive counseling. It is critical to be cognizant that devices are merely a tool and only one component in the overall management of tinnitus. That is, audiologic rehabilitation should not simply revolve around the technology provided, but a treatment plan should be put into place ensuring that patients have a complete understanding regarding the underlying rationale for device application as well as other techniques to help reduce the consequences of tinnitus (e.g., mindfulness, importance of continued participation in activities; hearing loss prevention strategies; techniques for improving sleep). In this vein, the audiologic management of tinnitus cannot and should not be one size fits all. Although the following sections describe specific treatment approaches and techniques, it is critical to understand that intervention should be personalized and target patient-centered functional goals.

A variety of simple-to-use, inexpensive techniques and devices can be implemented to increase the level of background sound to decrease the tinnitus signal-to-noise ratio. The exposure to pleasant external sounds promotes relief, provides distraction, and decreases the patient’s awareness to tinnitus. Many patients find it beneficial, for example, to play the television or radio at home in the background. A number of other environmental enrichment devices are available and include: (a) tabletop sound machines that can generate different types of sounds (e.g., rain, wind, waterfall); (b) personal sound players that contain recordings of music and nature/environmental sounds and/or apps that can stream similar tinnitus relief-producing sounds; (c) tabletop water fountains; (d) fans; and (e) water purifiers (Folmer et al., 2006b). For patients with sleep disturbance, the sound generated by tabletop sound machines, personal sound players, and apps can be delivered (e.g., hardwired or streamed) effectively to commercially available pillows (e.g., Sound Pillow^® Sleep System) or headbands (e.g., SleepPhones^®) with integrated small, flat speakers designed for comfort.

Combination devices contain a HA circuit and a sound-producing circuit in the same instrument, allowing patients who have both hearing loss and tinnitus to use one device. Today’s combination devices have the flexibility of turning on or off the hearing aid microphone and have multiple program capabilities so that the devices can be used as HAs only, SGs only, or HA-SG combinations. A critical feature in the combination device is the ability to control the volume of the SG portion independent of the volume control of the HA, as the perception of the tinnitus fluctuates. Further, most commercially available devices have several built-in tinnitus relief sound options (e.g., broadband sounds, modulated sounds, fractals) contained within the same unit. Figure 22–10 displays examples of magnitude transfer functions of filters used for three broadband sound options (A) and modulation patterns that mimic rhythms of the ocean (B) in a commercially available combination device. Moreover, tinnitus relief apps downloaded to smartphones/tablets permit an almost endless range of sounds (e.g., broadband, environmental/nature sounds, music, layered and complex sounds) that can be directly streamed to the combination devices.

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