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Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
Clinical Experiences in Tinnitus Management
Background
Although tinnitus cannot be cured, it can be successfully managed to greatly reduce
associated disturbance, annoyance and distress, thus improving the patient’s quality of life1.
Despite the availability of clinically proven management methods such as Tinnitus Retraining
Therapy2 (TRT) and Neuromonics3, many audiologists lack sufficient training in tinnitus
treatment, leaving them uncomfortable or unable to determine the most efficient and effective
treatment for specific tinnitus patients1. To facilitate this process, Progressive Tinnitus
Management (PTM) was introduced4, a five-level hierarchical process for the identification and
provision of the least intensive tinnitus management sufficient to provide the patient adequate
relief. To date, there have been few studies regarding the implementation of PTM on a large
scale. In one recent report5, 66% of subjects had their needs met by Level 2 actions and another
27% had their needs met by Level 3 actions. Another report by the same author6 utilized
individual sound-management counseling (Level 3 of PTM) combined with psychological
intervention to manage the tinnitus of patients with traumatic brain injury, but results were not
complete at the time.
We reviewed the records for all patients referred to the Audiology Clinic over a 14-
month period. Our goals were to compare various characteristics of subjects who were referred
for tinnitus services with those who were referred for hearing problems and to identify and
describe any differences in the characteristics between subjects referred for tinnitus services
who did or did not progress from one PTM level to the next.
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
After exclusion of duplicate referrals, no shows and subjects who provided invalid
behavioral test results, 2543 subjects were included in this review, 654 of whom (25.7%) were
referred for complaint of tinnitus. To compare various characteristics, the subjects were then
assigned to one of the four groups presented in Table 1 in order of need for increasingly
intensive tinnitus management.
Group Description N % of all subjects
% of tinnitus subjects
NonT: Non-tinnitus subjects 1889 74.3% --
T-GrpN: Tinnitus subjects whose needs were met by PTM Level 1, Triage, or Level 2, Audiologic Evaluation
546 25.7% 83.5%
T-GrpY-IndN Tinnitus subjects whose needs were met by
PTM Level 3, Group Education. 72 2.8% 11.0%
T-GrpY-IndY Tinnitus patients whose needs were met by PTM Level 5, Individualized Management.
36 1.4% 5.5%
Table 1. Description of four subject groups.
Subject Characteristics
Mean ages suggest that the tinnitus subjects were younger than the non-tinnitus
subjects as shown in Table 2. A Kruskal-Wallis One-Way ANOVA on Ranks revealed significant
differences among the ages for the four groups (H = 278.706, p < .001). Dunn’s pairwise follow-
up comparisons indicated that the NonT group’s median age was significantly greater than the
median age of each of the tinnitus groups (p < .05). The T-GrpN median age was significantly
greater than the T-GrpY-IndN group (p < .05) but it was not significantly different from the
median age of the T-GrpY-IndN group (p > .05)
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
Tinnitus Group Median Age Mean Age (SD)
Non-T 65.0 66.8 (13.1)
T-GrpN 60.0 56.9 (12.3)
T-GrpY-IndN 52.0 50.1 (12.3)
T-GrpY-IndY 58.0 54.1 (10.8)
Table 2. Median and mean ages for the four study groups.
Subjective hearing problems were evaluated using the Hearing Handicap Inventory for
the Elderly – Screening Version, or HHIES (REF). The HHIES is a widely used 10-item screening
measure of hearing handicap. Scores range from 0-40 and may be categorized as no significant
hearing handicap (scores 0-8), mild-moderate hearing handicap (scores 10-24) and severe
hearing handicap (scores 26-40). As shown in Table 3, the median and mean HHIES scores for
all subject groups were similar; although a Kruskal-Wallis One-Way ANOVA on Ranks suggested
there were significant differences among the different groups’ HHIES scores (H = 47.24,
p < .001). Dunn’s pairwise follow-up comparisons indicated none of the groups’ scores were
significantly different. Also shown in Table 3 are the percentage of HHIES scores within each
subject group comprising different score categories which demonstrates that nearly half of all
tinnitus subjects’ scores were within the severe hearing handicap range, while over a third of
their scores were in the mild-moderate hearing handicap range. This finding is surprising given
the significantly better hearing demonstrated by the tinnitus subjects.
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
Group N Median HHIES
Mean HHIES (SD)
% No Significant Handicap
% Mild-Moderate Handicap
% Severe Handicap
% Some degree of Handicap
Non-T 1065 28.0 26.9 (12.2) 7.8% 30.3% 61.8% 92.1%
T-GrpN 361 24.0 22.3 (11.6) 18.6% 33.8% 47.6% 81.4%
T-GrpY-IndN 52 23.0 23.2 (10.4) 10.5% 44.2% 46.2% 90.4%
T-GrpY-IndY 21 24.0 21.5 (12.4) 19.0% 33.3% 47.6% 80.9%
Table 3. HHIES findings for four subject groups.
The prevalence of diagnoses often associated with tinnitus, such as mental health
disorders9,10,11,12,13, traumatic brain injury (TBI)14, migraine/headache15,16, dizziness17 and
substance abuse18 also was examined. Figure 1 shows that as the need for more intensive
tinnitus management increased the prevalence of mental health disorders, TBI and headaches
increased.
Figure 1. Percentage of subjects with specific medical diagnoses in each group
The prevalence of mental health diagnoses among the subject groups was substantial
and increased as more intensive tinnitus management strategies were required. As shown in
0
10
20
30
40
50
60
70
80
90
Mental Health TBI Headache Dizziness Substance Abuse
% o
f Su
bje
cts
Percentage of Subjects with Specific Medical Diagnoses in Each Group
Non-T
T-GrpN
T-GrpY-IndN
T-GrpY-IndY
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
Figure 2, the percentage of subjects with 1, 2 and 3 or more mental health diagnoses also
increased as more intensive tinnitus management strategies were required.
Figure 2. The percentage of subjects with specific numbers
of mental health diagnoses in each subject group.
To further evaluate this trend, a Kruskal-Wallis One-Way ANOVA on Ranks revealed
significant differences among the number of mental health diagnoses for the four groups (H =
74.190, p < .001). Dunn’s pairwise follow-up comparisons indicated that the non-tinnitus group
had significantly fewer MH diagnoses than each of the three tinnitus groups (p < .05), but that
there was no difference in MH diagnoses between the two tinnitus groups who attended group
education (p > .05). The median and mean number of MH diagnoses for each subject group are
presented in Table 4.
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
1 MH Diagnosis 2 MH Diagnoses 3+ MH Diagnoses
% o
f Su
bje
cts
Mental Health Diagnoses in Each Subject Group
Non-Tinnitus
T-GrpN
T-GrpY-IndN
T-GrpY-IndY
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
Subject Group Median Number of MH Diagnoses
Mean Number of MH Diagnoses (SD)
NonT 0.00 0.47 (0.78)
T-GrpN 0.00 0.63 (0.93)
T-GrpY-IndN 1.00 0.92 (0.95)
T-GrpY-IndY 1.00 1.16 (0.95)
Table 4. Median and mean number of MH diagnoses in four subject groups.
PTM Level 1: Triage
Triage was “developed for non-audiologist health care providers who encounter
patients complaining of tinnitus. The guidelines are consistent with accepted clinical practices”
(Henry et al, 2010). Appropriate referrals then are made based on symptoms and other
diagnostic factors. If Triage was not performed by a non-audiologist provider, the audiologist
should determine if a patient requires tinnitus services through the standard case history and
screening measures of perceived tinnitus severity and tinnitus-related distress. An example of
the tinnitus section of a standard case history is shown in Figure 3. The audiologist can provide
follow-up inquiries for further details regarding any tinnitus reports.
Figure 3. Example of standard case history section inquiring about tinnitus.
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
Neither the perceived sound of the tinnitus nor the ear(s) in which the tinnitus was
heard were captured for the subjects. However, Figure 4 reveals the percentage of subjects in
each tinnitus group who reported the severity of their tinnitus was mild, moderate or severe. A
Kruskal-Wallis One-Way ANOVA on Ranks revealed significant differences among the severity
categories reported by the subjects in the three tinnitus groups (H = 60.451, p < .001). Dunn’s
pairwise follow-up comparisons indicated that there were significantly more “severe” tinnitus
ratings among the tinnitus subjects in the group that required individualized management (T-
GrpY-IndY) than among the subjects in the other two groups (p < .05).
Figure4. The percentage of subjects in each tinnitus group who
reported the severity of their tinnitus was mild, moderate or severe.
Figure 5 reveals the percentage of subjects in each tinnitus group who reported being
aware of their tinnitus specified percentages of waking hours. A Kruskal-Wallis One-Way
ANOVA on Ranks revealed significant differences among the awareness categories for the three
tinnitus groups (H = 31.079, p < .001). Dunn’s pairwise follow-up comparisons indicated that
there were significantly more “100%” tinnitus awareness ratings among subjects in each of the
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Mild Moderate Severe
% o
f Su
bje
cts
Tinnitus Severity Category
Tinnitus Severity Categoreis for 3 Subject Groups
T-GrpN
T-GrpY-IndN
T-GrpY-IndY
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
two tinnitus groups who required Group Education than among subjects in the group who did
not (p < .05).
Figure 5. the percentage of subjects in each tinnitus group who reported
being aware of their tinnitus specified percentages of waking hours
We postulated that both tinnitus awareness percentage and perceived tinnitus severity
may be related, so a simple correlation was completed between these values for the 554
subjects for whom both were available. A significant, moderately strong positive correlation
was identified (r = .50,p < .001): the more often a subject was aware of the tinnitus, the more
severe the tinnitus would be perceived.
To further explore the relationships between tinnitus awareness, perceived tinnitus
severity and tinnitus group, a multiple linear regression was performed with Tinnitus Group as
the dependent factor and tinnitus awareness category and perceived tinnitus severity category
as the two independent factors. The regression is shown in Figure 6; however the statistical
software indicated that both of the independent variables were not necessary: perceived
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
0-10% 11-25% 26-50% 51-75% 76-99% 100%
% o
f Su
bje
cts
Tinnitus Awareness (% of Waking Hours)
T-GrpN
T-GrpY-IndN
T-GrpY-IndY
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
tinnitus severity appeared to account for the ability to predict in which Tinnitus Group the
subject would be (p < .05).
Figure 6. Multiple linear regression equation: Tinnitus Group was the dependent factor and tinnitus awareness category and perceived tinnitus severity category were the two independent factors.
Various screening measures of perceived tinnitus severity and tinnitus-related distress
were available in this group of subjects and are described below.
According to McCombe et al (1999), the 1-5 Tinnitus Grade Scale (1-5 Grade) was
developed to categorize expected type and degree of tinnitus-related distress a patient may be
expected to experience based on score ranges on the Tinnitus Handicap Inventory (REF).
Specifically, the five grades and associated THI score ranges were:
Grade 1: No significant tinnitus-related distress. THI = 0-16. I only notice my
tinnitus in quiet environments. It does not interfere with my sleep or with my
daily activities. I'm not really troubled by my tinnitus.
Grade 2: Mild tinnitus-related distress. THI = 18-36. My tinnitus is easily covered
up by background sounds and easily forgotten during activities. It may rarely
interfere with my sleep but it does not interfere with my activities or quality of
life.
Grade 3:Moderate tinnitus-related distress. THI = 38-56. I hear my tinnitus even
in the presence of background sounds, but it doesn't interfere with my daily
Tinnitus Group = 0.598 + (0.0409 * Tinnitus Awareness Category) + (0.234 * Perceived Severity Category)
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
activities. My tinnitus is not quite as noticeable when I'm focused on other
activities. My tinnitus occasionally interferes with my sleep and occasionally
interferes with quiet activities.
Grade 4: Severe tinnitus related distress. THI = 58-76. I hear my tinnitus almost
always. It is rarely if ever covered up by background sounds. My tinnitus
regularly interferes with my sleep and can interfere with my ability to carry out
normal daily activities.
Grade 5: Catastrophic tinnitus-related distress. 78-100.My tinnitus is always
disturbing. It is a dominating problem that reduces my overall quality of life.
According to McCombe et al, “the majority of people suffering tinnitus should fall into
Grades 2 and 3… Grade 4 should be uncommon… [and] Grade 5 should be extremely rare.
Associated psychological pathology is likely to be found.”
The 0-10 Tinnitus Problem Scale (1-10 Scale) was suggested by Abrams (2011), on which
patients are asked to rate the magnitude of their tinnitus as a problem using a scale of 0-10,
where 0 means “my tinnitus is not a problem at all” and 10 means “my tinnitus is the biggest
problem imaginable.” According to Abrams (2011), ratings of 7 or higher are consistent with
significant tinnitus-related distress.
The Tinnitus Severity Index, or TSI, was developed by Meikle et al (1995) as a brief,
statistically validated 12-item screening measure of tinnitus-related distress. TSI scores range
from 12-57, and scores of 36 or higher are consistent with severe tinnitus-related distress that
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
may warrant specific management. TSI scores obtained by interview format were available for
240 tinnitus subjects. Because patients often confuse tinnitus with hearing problems, interview
format allows the audiologist to maintain a focus on issues related to tinnitus, not perceived
hearing problems. Table 5 shows the mean TSI scores and standard deviations for the three
tinnitus groups. A Kuskal-Wallis One-Way ANOVA on Ranks revealed significant differences
among the scores for each tinnitus group (H = 52.737, p < .0010) and Dunn’s pairwise follow-up
comparisons revealed that the median score for T-GrpN was significantly lower than that of
both T-GrpY-IndN and T-GrpY-IndY (p < .05). Furthermore, Spearman’s Rank-Order Correlation
revealed a moderately strong correlation ( = .51, p < .001). These findings indicate that that
the TSI is sensitive to increasing levels of tinnitus distress and may differentiate among patients
requiring less or more intensive levels of treatment.
Tinnitus Group
N Median TSI
Score Mean TSI Score (SD)
T-GrpN 119 34.0 34.7 (10.3)
T-GrpY-IndN 71 42.0 43.1 (7.0)
T-GrpY-IndY 50 46.0 49.7 (7.2)
Table 5. TSI scores for three groups of tinnitus subjects.
TSI scores, 1-5 Grade Scale ratings and 0-10 Problem Scale ratings were available for 89
subjects. We created two subject groups (“High Scores” and “Low Scores”) each for both 1-5
Grade Scale ratings (Low = 1-3; High = 4-5) and 0-10 Problem Scale ratings (Low = 0-6, High = 7-
10). Using TSI scores as the gold standard, we utilized t-tests and Mann-Whitney Rank-Sum
tests to evaluate the validity of our arbitrarily assigned cutoff scores. For subjects divided into
Low and High Tinnitus Grade Scale ratings, significant differences (p < .05) observed between
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
groups on 1-5 Grade Scale ratings , 0-10 Problem Scale ratings and TSI Scores. For subjects
divided into Low and High 0-10 Problem Scale ratings, significant differences (p < .05) were
observed only between groups on the 0-10 Problem Scale ratings and TSI Scores. Cohen’s d for
all significant differences were very large. Table 6 reveals the mean 1-5 Grade Scale ratings, the
mean 0-10 Problem Scale ratings and the mean TSI scores for the Low and High subject groups.
1-5 Grade Scale Mean 1-5
Grade (SD)
p value and
Cohen’s d
Mean 0-10 Problem
(SD)
p value and
Cohen’s d
Mean TSI
(SD)
p value and
Cohen’s d
LOW (Grade = 1, 2, 3)
2.93 (0.26) p < .05
d = 4.02
5.50 (1.91) p < .05
d = 1.48
37.71 (7.63)
p > .05 HIGH (Grade = 4,
5) 4.54
(0.50) 7.93 (1.31)
45.70 (7.14)
0-10 Problem Scale
Mean 1-5 Grade (SD)
p value and
Cohen’s d
Mean 0-10 Problem
(SD)
p value and
Cohen’s d
Mean TSI
(SD)
p value and
Cohen’s d
LOW (Problem = 0-6)
2.88 (0.64)
p > .05
5.50 (1.04) p < .05
d = 2.94
37.67 (4.06) p < .05
d = 1.44 HIGH (Problem = 7-10)
4.28 (0.79)
8.24 (8.24) 46.03 (7.15)
Table 6. Mean 1-5 Grade Scale ratings, mean 0-10 Problem Scale ratings and mean TSI scores for the Low and High subject groups.
Table 7 presents the percentage of normal-hearing tinnitus subjects with scores on
various measures of tinnitus-related distress falling in the significant and non-significant
distress categories. The majority of tinnitus subjects experience significant tinnitus-related
distress regardless of the specific measure that is used for documentation.
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
Score 1-5 Grade
Scale 0-10 Problem
Scale TSI Score
Consistent with NO Significant Tinnitus-Related
Distress 37% 29% 26%
Consistent with Significant Tinnitus-Related Distress
63% 71% 74%
Table 7. Percentage of normal-hearing tinnitus subjects with scores on various measures of tinnitus-related distress falling in the non-significant and significant distress categories.
To further explore the relationships between the independent variables 0-10 Problem
Scale rating and 1-5 Tinnitus Grade Scale rating and the dependent variable, TSI Score, a linear
regression was performed with TSI Score as the dependent factor and1-5 Grade Scale rating
and 0-10 Problem Scale rating as the two independent factors. The regression is shown in
Figure 7 (r = 0.547); however the statistical software indicated that both of the independent
variables were not necessary: The 0-10 Problem Scale Rating appeared to account for the ability
to predict the TSI Score (p < .05). As a result of these analyses, our clinic now exclusively utilizes
the 0-10 Problem Scale for tinnitus triage with a score of 7 or higher indicating significant
tinnitus-related distress.
Figure 7. Multiple linear regression equation: Tinnitus Group was the dependent factor and tinnitus awareness category and perceived tinnitus severity category were the two independent factors.
PTM Level 2: Audiologic Assessment
Audiological Assessment allows the audiologist and patient to further determine
whether tinnitus and/or other medical issues require intervention1. Hearing aids, if indicated,
TSI Score = 13.283 + (3.118 * 1-5 Grade Scale Rating) + (2.216 * 0-10 Problem Scale Rating)
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
and assistive devices, such as bedside sound generators, are provided as part of Audiologic
Assessment (the use of assistive devices is covered in a different paper). Patient education,
specifically demystification, is emphasized. Demystification is defined as detailed counseling
focusing both on the patient's primary tinnitus concerns and on information to correct common
misperceptions and negative thoughts about tinnitus. Demystification often is sufficient to
reduce limbic and autonomic system engagement and can reduce tinnitus disturbance to
acceptable levels. Hearing aid use among subjects also was examined.
Subjects in each group differed by degree of hearing loss. Four-frequency averages (1, 2,
3 & 4 kHz) were calculated for each ear, and then a single binaural value was calculated using
common weighting values: ((5 x poorer ear) + (better ear)) / 6) ]8.
Table 8 shows that tinnitus subjects demonstrated less hearing loss than non-tinnitus
subjects.
Tinnitus Group Median
4-Freq Avg. Mean 4-Freq
Avg. (SD)
Non-T 60.8 49.2 (20.4)
T-GrpN 29.6 31.3 (17.2)
T-GrpY-IndN 20.2 22.2 (12.8)
T-GrpY-IndY 24.0 27.7 (13.6)
Table 8. Median and mean four-frequency average for the four study groups.
A Kruskal-Wallis One-Way ANOVA on Ranks revealed significant differences among the
four-frequency averages for the four groups (H = 977.609, p < .001). Dunn’s pairwise follow-up
comparisons indicated that the NonT group’s median four-frequency average was significantly
Tinnitus Group Mean Age S.D.
Non-T 66.75 13.06
T-GrpN 56.86 12.33
T-GrpY-IndN 50.14 12.28
T-GrpY-IndY 54.06 10.84
Tinnitus Group Mean Age S.D.
Non-T 66.75 13.06
T-GrpN 56.86 12.33
T-GrpY-IndN 50.14 12.28
T-GrpY-IndY 54.06 10.84
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
greater than the that of each of the three tinnitus groups (p < .05). There were no significant
differences in median four-frequency averages among the three tinnitus groups.
Hearing aid use among subjects also was examined. Given the greater degree of hearing
loss among non-tinnitus subjects, it is not surprising that hearing aid use was significantly
greater among non-tinnitus patients than among tinnitus subjects (65.8% vs. 46.0%,
respectively; X2 = 7.325, p = 0.007). Among tinnitus subjects, aid use was not significantly
different between T-GrpN subjects than among those who in the combined T-GrpY-IndN and T-
GrpY-IndY subjects (48.1% vs. 39.1%, respectively; X2 = 1.302, p = 0.254).
PTM Level 3: Group Education
The value of Tinnitus Group Education in reducing perceived tinnitus severity may
depend on the length of the program and its content: longer programs that include educational
and/or cognitive components demonstrate some success, although benefits may disappear
over time19,20,21. PTM Group Education consists of demystification and the provision of
knowledge, skills and tools for the use of sound to manage tinnitus.
At the Atlanta VA Medical Center, timeliness of and access to services is a high priority,
and multi-session education activities were not possible. As a result, the author22 implemented
a modified Group Education activity in a single 2-hour session instead of two separate sessions.
He previously found that when utilizing the recommended PTM workbook materials21, Group
Education failed to demonstrate a significant positive impact on the participants' perceived
tinnitus severity. Despite the absence of significant positive impact, 100% of attendees
provided positive program evaluations.
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
In the current group of tinnitus subjects, 126 were scheduled for Group Education, but
18 (14.3%) were no-shows despite reminder calls and letters; 108 subjects attended Group
Education.
The Tinnitus Reaction Questionnaire (TRQ)23 was completed using a paper/pencil format
with guidance from the instructor prior to the beginning of Group Education. TRQs then were
mailed to the attendees one month after the session as an outcome measure. The mail-out also
asked the simple yes/no question “Do you need further help for your tinnitus?” Failure to
return the outcome TRQ was interpreted as indicating that the subject required no further
tinnitus management. Figure 8 shows the mean pre- and post-Group Education TRQ scores for
49 subjects for whom both values were available. Tinnitus Group Education failed to
demonstrate a significant positive impact on perceived tinnitus severity for these subjects as
indicated by pre- and post-Group Education TRQ scores (t = 1.070, p = .287) and Total
Disturbance Values (U = 845.000, p = .561).
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
Figure 8. Mean pre- and Post-Group Education TRQ scores and Total Disturbance percentages. Statistical analyses revealed that there were no significant differences between the mean Pre-
and Post-Group Education TRQ scores and Total Disturbance percentages (p < .05).
Thirteen subjects reported on the outcome questionnaire that they did not desire
further tinnitus services. We compared the Pre- and Post-Group TRQ scores and Total
Disturbance percentages of these 13 subjects (T-GrpY-IndN) to those of the 36 subjects who
would proceed to PTM Level 5, Individualized Support, (T-GrpY-IndY) as shown in in Figure 9.
Statistical analyses revealed that only the Pre-Group TRQ scores were significantly different
between the two groups (p < .001): the mean TRQ score of subjects who did not desire further
tinnitus services was significantly lower than that of the subjects who would proceed to PTM
Level 5, Individualized Support. The Pre-Group Total Disturbance percentages, Post-Group TRQ
Scores and Post-Group Total Disturbance Percentages were not significantly different (p > .05).
0
10
20
30
40
50
60
70
80
90
100
Mean TRQ Score Mean Total Disturbance %
Pre-Group
Post-Group
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
Figure 9. Pre- and Post-Group TRQ scores and Total Disturbance percentages of 13
subjects who reported they did not desire further tinnitus services (T-GrpY-IndN) and 36 subjects who would proceed to PTM Level 5, Individualized Support, (T-GrpY-IndY).
PTM Levels 4 and 5: Multidisciplinary Evaluation and Individualized Support
“Systematic progression through the different levels of PTM effectively ensures that
patients reaching the Level 4 Interdisciplinary Evaluation have a severe tinnitus problem that
warrants an in-depth evaluation to determine if individualized support is appropriate (Henry et
al, YEAR ref #39).” Additionally, because of the severity of their tinnitus-related distress, PTM
Level 4 may include evaluation by a qualified mental health care specialist. Because mental
health services are beyond the scope of audiologists, this section will focus on Tinnitus
Evaluation. Reasons for measuring tinnitus include determining which patients are likely to
benefit from specific types of treatment, provision of treatment guidelines (e.g. spectrum
and/or loudness characteristics of broadband desensitization or masking sounds) and
determination if any treatment has had an effect24.
0
10
20
30
40
50
60
70
80
90
100
110
Pre TRQ Pre Tot Dist % Post TRQ Post Tot Dist %
T-GrpY-IndY
T-GrpY-IndN
(p < .001) (p >.05) (p > .05) (p > .05)
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
At the Atlanta VA, Tinnitus Evaluations are completed using the standardized methods
suggested by Neuromonics, including assessment of tinnitus quality (e.g., noise- or tone-like),
loudness, perceptual location (e.g., right or left ear, both ears, midline) and minimum masking
levels. Discomfort levels also are measured to assess loudness tolerance. Although 36 subjects
progressed to Individualized Management in the period under review, the Tinnitus Evaluation
measures presented below represent data from a total of 61 subjects.
Figure 10 presents the mean pure-tone thresholds for this group of 60 subjects. As
noted, the subjects generally had a mild sensorineural hearing loss in the higher frequencies.
Figure 10. Audiometric thresholds for 60 tinnitus subjects who participated in tinnitus evaluations.
-10
0
10
20
30
40
50
60
70
80
90
100
110
Me
an T
hre
sho
lds
(dB
HL)
Frequency (Hz)
.25k .5k 1k 2k 3k 4k 6k 8k
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
In this group of subjects, 45 (74%) had at least one mental health diagnosis, and 20 of
those subjects (44%) had two or more mental health diagnoses. Specific measures related to
these subjects’ tinnitus are presented in Table 9.
Ranking of Auditory Problems #1 #2 #3
Tinnitus 98.3% 1.7% 0.0%
Hearing Loss 1.7% 73.3% 25.0%
Loudness Tolerance 0.0% 25.0% 75.0%
Pitch
2 kHz & lower 3-4 kHz > 4 kHz
7% 33.9% 54.8%
Quality
Tone-Like Noise Like
29.0% 71.0%
Min. Masking Level (dB SL) Mean (S.D.)
14.9 (12.5)
Discomfort Levels (dB HL) .5 k 1k Hz 4 kHz Avg.
Right Ear 76.6 (22.8) 78.2 (18.4) 81.8 (23.9) 79.1 (19.8)
Left Ear 75.8 (20.4) 78.2 (18.2) 81.2 (20.4) 78.6 (17.9)
Loudness Tolerance
Normal (> 90 dB HL)
Decreased (71-90 dB HL)
Hyperacusis (< 70 dB HL)
Right Ear 30.7% 32.3% 37.1%
Left Ear 43.5% 24.2% 32.3%
Same Tolerance Both Ears Normal Decreased Hyperacusis
27.4% 22.6% 25.8%
Residual Inhibition
Could Not Test None Partial Complete
10.0% 15.0% 43.3% 21.7%
Table 9. Tinnitus evaluation findings in a group of 61 tinnitus subjects.
Neuromonics Tinnitus Treatment (NTT) is an FDA-approved tinnitus treatment that
utilizes a customized, binaural correlated acoustic signal embedded in pleasant music to
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
stimulate auditory pathways deprived by hearing loss, engage the limbic system in a positive
fashion and to allow intermittent tinnitus perception, thereby facilitating habituation to the
tinnitus3. In a study of NTT with 35 subjects who reported significant tinnitus disturbance, 91%
demonstrated a significant improvement in tinnitus disturbance as evidenced by at least a 40%
improvement in TRQ scores25. The average TRQ improvement for all subjects was 65%. Also at 6
months, 80% of the subjects' reported tinnitus disturbance was no long clinically significant.
At the Atlanta VA, individualized tinnitus management was completed utilizing NTT,
which provides a structured method for fitting the customized treatment device. As noted
earlier, although 36 subjects progressed to Individualized Management in the period under
review, the measures obtained at the delivery appointment shown in Table 10 represent data
from 61 Neuromonics patients.
Tinnitus Severity "Today" Average Better Worse
48.2% 14.8% 37.0%
Oasis Setting Mean (S.D.) Comfortable Volume 7.78 (1.97)
Minimum Volume 9.26 (3.17) Intermittent Interaction
Volume 6.72 (2.74)
High Interaction Volume 8.96 (2.12)
Results at Comfortable Volume Interaction Relief
Complete 29.6%
90.7%
22.2%
94.4% High 20.4% 24.1%
Moderate 40.7% 48.2%
Low 7.4% 9.3%
3.7% 5.6%
None 1.9% 1.9%
Table 10. NTT settings and subjective relief results in a group of 61 tinnitus subjects.
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
Figure 11 reveals the mean TRQ Scores and Total Disturbance Percentages both before
treatment and at 3, 5, 6, 7 and 8 months during treatment. As noted, the mean scores
demonstrated substantial declines throughout treatment.
Figure11. Mean TRQ Scores and Total Disturbance Percentages
both before treatment and at 3-8 months during treatment
Successful NTT outcome is defined by a 40% reduction in TRQ score and a reduction in
tinnitus awareness and tinnitus disturbance. As shown in Figure 12, for the subjects who had
completed treatment by 8 months, the mean decrease in TRQ Scores was 69.0% (S.D. = 19.7)
and the mean decrease in Total Disturbance Percentages was 72.4% (S.D. = 24.1). The Pre- and
Post- Treatment TRQ Scores and the Pre- and Post- Treatment Total Disturbance Percentages
were significantly different (p < .001). Furthermore, Cohen’s d confirmed that the differences
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pre-Tx 3 Mos 5 Mos 6 Mos 7 Mos 8 Mos
Mean TRQ Score
Mean Total Disturbance %
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
were also very large and clinically significant. (Please note that the Post-Treatment values
presented in Figure 12 differ from the values shown at 8 months in Figure 1 because not all
subjects completed Neuromonics Tinnitus Treatment by 8 months.)
Figure 12. Mean TRQ Scores and Total Disturbance Percentages
both before treatment and at 3-8 months during treatment
Conclusion
Progressive Tinnitus Management (PTM) offers a structured, effective means of assuring
that patients receive the precise level of tinnitus management they require. In a 14-month
period, after exclusion of duplicate referrals, no shows and subjects who provided invalid
behavioral test results, 2543 hearing test referrals were identified, 654 of whom (26%) were
referred for PRIMARY COMPLAINT OF TINNITUS
PTM Level 1 – Triage. The TSI appears to be a valid tool for differentiating among
tinnitus patients requiring different levels of management. Mean TSI scores increased as the
need for more intensive treatment needs increased.
0 10 20 30 40 50 60 70 80 90 100
Pre-Treatment Post Treatment
p < .001
d = 2.70
p < .001
d = 3.01
TRQ Score
% Total Disturbance
Steven L. Benton, Au.D. - 2010
Steven L. Benton, Au.D. - 2010
PTM Level 2 – Audiological Evaluation. 79.5% of tinnitus subjects exited PTM after
Audiological Evaluation, primarily as a result of demystification and the provision of appropriate
management devices. Only 126 subjects (19.3% of all tinnitus referrals) found their needs could
not be managed with actions associated with Audiological Evaluation, and so they were
referred to Group Education.
PTM Level 3 – Group Education. 108 subjects (16.5% of all tinnitus referrals) actually
attended Group Education. Group Education provides two important benefits: (1) tinnitus
patients can share experiences with others who have the same problems, and (2) it lays a firm
foundation on which to build successful Individualized Management. 36 subjects (5.5% of all
tinnitus referrals) proceeded to Tinnitus Assessment followed by Individualized Treatment.
PTM Levels 4 & 5 – Multidisciplinary Evaluation and Individualized Management.
Neuromonics Tinnitus Treatment has proven to be a successful treatment for subjects whose
needs could not be met with less intensive management strategies.
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Steven L. Benton, Au.D. - 2010
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