Clinical Experiences in Tinnitus Management Backgroundstevebentonaud.weebly.com/uploads/6/8/1/9/6819039/clinical_experi… · T-GrpN 60.0 56.9 (12.3) T-GrpY-IndN 52.0 50.1 (12.3)

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.



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)



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.



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



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



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.



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



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



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)



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



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



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.



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)



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



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.



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).



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



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)



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

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60

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100

110

Me

an T

hre

sho

lds

(dB

HL)

Frequency (Hz)

.25k .5k 1k 2k 3k 4k 6k 8k



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



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.



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 %



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



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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