Audiologic Guidelines for the Diagnosis & Management of Tinnitus Patients
Revised October 18, 2000
Tinnitus refers to an auditory perception not produced by an external sound. It is commonly described as a "hissing, roaring, or ringing" and can range from high pitch to low pitch, consist of multiple tones, or sound like noise (having no tonal quality at all). It most often is constant, but can also be perceived as pulsed, or intermittent, and may begin suddenly, or may come on gradually. It can be sensed in one ear, both ears, or in the head. It has been estimated that as many as 40-50 million U.S. residents have experienced more than momentary tinnitus with as many as 2.5 million reporting feeling debilitated by the symptom. As many as 10-12 million individuals have sought help for the condition. Tinnitus may cause or be associated with a wide range of problems including sleep difficulties, fatigue, stress, trouble relaxing, difficulty concentrating, depression, and irritability. As a result it can affect one's quality of life including social interactions and work.
Scope of Practice
Audiologists are qualified to evaluate, diagnose, develop management strategies, and provide treatment and rehabilitation for tinnitus patients. In evaluating and managing tinnitus, it is helpful and worthwhile for audiologists to work with a multidisciplinary team approach.
Suggested Evaluation Guidelines
Prior to recommending or beginning any treatment for tinnitus, it is essential that a differential diagnosis be attempted. It is important to consider the entire person, not merely the audiogram and/or the characteristics of the tinnitus. There are many factors that can cause and affect tinnitus and its perception that will influence the management plan and outcome of any treatment.
The basic tinnitus evaluation (beyond the audiologic examination) should consist of the following measures:
Comprehensive case history including, but not limited to, questions regarding time of onset, course of progression, description, location, perceived cause, extent to which the patient is bothered, exacerbating factors (such as food, stress, lack of sleep, etc.), history of noise exposure, medications, familial history of hearing loss or tinnitus, effect on sleep, and effect on personal/social/occupational relationships.
- Loudness discomfort levels;
- Tinnitus pitch matching;
- Tinnitus loudness matching;
- Minimal masking level;
- Subjective questionnaires; There are several valid and reliable surveys designed to measure the disability and handicap associated with tinnitus.
- Professionals that specialize in the assessment and treatment of tinnitus also may find additional audiologic procedures useful for diagnosis and counseling.
Tinnitus Patient Management Procedures
Similar to the evaluation process, the treatment of patients with tinnitus is most likely to succeed when a multidisciplinary approach is employed. While it is true that at this time there is no cure for most cases of tinnitus, it is not true that "there is nothing that can be done about it". A number of treatment approaches that can be performed by audiologists have been described with various degrees of reported success. They are listed below (in alphabetical order) along with a brief description:
A trained professional counselor can be very helpful whenever the tinnitus becomes problematic. Counseling should be considered both as a primary approach, when appropriate, and as an adjunctive approach, to all treatment strategies. Counseling consists of gathering data through careful listening, making adjustments in one's strategies based on that knowledge, and conveying information. Thus, it serves both a diagnostic and therapeutic function.
- Cognitive Behavioral Therapy
One type of counseling that may be successful in helping people cope with tinnitus is cognitive behavioral modification therapy. This approach can help persons identify the way they react to their tinnitus and learn new responses, thereby minimizing the negative thoughts and behavior patterns that are associated with tinnitus.
- Habituation & Tinnitus Retraining Therapy
Tinnitus Retraining Therapy is a method developed to facilitate habituation to tinnitus. It combines sound enrichment therapy with directive counseling. Sound is employed to reduce the contrast between silence or ambient noise and the perception of the tinnitus. It may be in the form of environmental sounds, amplification, or broadband sound generating devices. A reduction of the perception of the tinnitus (but not complete obliteration of it) is considered essential to the process of habituation. Counseling and education serve to demystify tinnitus, providing the patient with an intellectual and emotional framework in which habituation can occur.
- Hearing Aids & Tinnitus Instruments
For individuals with hearing loss, environmental sounds may be inadequate in themselves to afford relief. However, amplifying them with the assistance of hearing aids may provide enough background stimuli to give tinnitus relief, while simultaneously enhancing the individual's listening and communication abilities. If hearing aids alone are inadequate, tinnitus instruments may be of help. Tinnitus instruments are devices that provide amplification, and add the option of an independently controlled broadband sound generator.
- Maskers & Home Masking Devices
Maskers are used to cover-up the tinnitus perception with a competitive signal that either partially or completely competes with or conceals the tinnitus. This can be achieved by a number of methods, ranging from environmental masking to ear-level worn sound generators. Also, there are commercially available recordings of a wide range of sounds that can provide complete or partial masking. In addition to their masking effect, these sounds may assist in relaxation.
- Self-help and Support/Education Groups
Some people find help, stay informed on the latest information, and share treatment experiences by talking to others with similar problems. These groups should be facilitated, or at least attended, by an audiologist or a psychologist (to prevent misinformation from being conveyed) and may include lectures from a variety of related disciplines.
- Stress Management
Stress can aggravate tinnitus, and tinnitus can be very stressful. There are many procedures that can be helpful in learning to manage stress. Biofeedback assisted relaxation is one technique that people can learn to control breathing, muscle tension and heart rate. Other methods of stress reduction include yoga, meditation, self-hypnosis, and exercise.
- There is no evidence to support the effectiveness of alternative treatments such as acupuncture, homeopathy, and herbal remedies such as ginkgo biloba.
Due to issues regarding scope of practice, areas of interest, and time constraints, many hearing health care facilities across the country cannot afford to offer comprehensive and extensive tinnitus evaluation and consultation. Therefore, it is highly recommended that health care providers advise tinnitus patients of other resources (such as the American Tinnitus Association) and/or refer them to appropriate professionals who have a special interest in tinnitus. Furthermore, because tinnitus may be symptomatic of a treatable disease, referrals to physicians and other health care professionals are commonly indicated. Included among the professionals who may provide valuable services are specialists in otolaryngology, psychiatry, psychology, relaxation therapy, dental (temperomandibular joint dysfunction), and neurology.
Further measurement of outcome using randomized clinical trials and investigations with appropriate placebo controls is needed for the tinnitus patient management procedures cited in this document. The use of valid and reliable questionnaires can be helpful in assessing treatment outcome. It is essential that conclusions regarding outcome not be finalized at the conclusion of the formal treatment. Long-term follow-up data are needed to determine whether treatment strategies are successful.
CPT Code Considerations
Although CPT codes exist for diagnostic audiologic procedures, CPT codes are lacking for components of the formal tinnitus evaluation beyond the audiologic assessment. There are, for example, no CPT codes for a tinnitus consultation, loudness discomfort levels, tinnitus pitch and loudness matching, minimal tinnitus masking levels, or high frequency audiometry. Likewise, specific CPT codes do not currently exist for tinnitus patient management procedures performed by audiologists, such as counseling, habituation and tinnitus retraining therapy. Lack of appropriate coding is an impediment to the comprehensive diagnosis and rehabilitation of the tinnitus patient, in view of the extensive time requirements necessary for these patients' assessment and treatment The availability of appropriate CPT codes with associated adequate reimbursement could potentially facilitate the delivery of clinical services by audiologists to tinnitus patients.
Andersson G, Lyttkens L, Larsen HC (1999) Distinguishing levels of tinnitus distress. Clin-Otolaryngol. 24(5): 404-10.
Baguley DM, Stoddart RL, Hodgson C (in press ) Convergent validity of the Tinnitus Handicap Inventory and the Tinnitus Questionnaire. Journal of Laryngology and Otology.
Burns EM (1984) A comparison of variability among measurements of subjective tinnitus and objective stimuli. Audiol 23:426-440.
Douek E, Reid J (1968) The diagnostic value of tinnitus pitch. J Laryngol Otol 82:1039-1042.
Goodwin PE, Johnson RM (1980b) The loudness of tinnitus. Acta Otolaryngol 90:353-359.
Hallam RS, Jakes SC, Chambers C, Hinchcliffe R (1985) A comparison of different methods for assessing the 'intensity' of tinnitus. Acta Otolaryngologica (Stockh) 99:501-508.
Henry JA, Flick CL, Gilbert AM, Ellingson RM, Fausti SA (1999) Reliability of tinnitus loudness matches under procedural variation. J Amer Acad Audiol 10:502-520.
Jakes SC, Hallam RC, Chambers CC, Hinchcliffe R (1986) Matched and self-reported loudness of tinnitus: methods and sources of error. Audiol 25:92-100.
Kuk FK, Tyler RS, Russell D, Jordan H (1990) The psychometric properties of a tinnitus handicap questionnaire. Ear and Hearing; 11,6, 434-444.
Newman CW, Jacobson GP, Spitzer JB (1996) Development of the tinnitus handicap inventory. Arch Otolaryngol Head Neck Surg; 122 : 143 - 148
Penner MJ. (1983). Variability in matches to subjective tinnitus. J Sp Hear Res 26:263-267.
Penner MJ. (1984). Equal-loudness contours using subjective tinnitus as the standard. J Sp Hear Res 27:274-279.
Penner MJ. (1986a). Magnitude estimation and the "paradoxical" loudness of tinnitus. J Sp Hear Res 29:407-412.
Penner MJ, Bilger RC. (1992). Consistent within-session measures of tinnitus. J Sp Hear Res 35:694-700.
Tyler RS (1991). The psychophysical measurement of tinnitus. In J-M Aran & R Dauman (Eds.), Fourth International Tinnitus Seminar. Bordeaux, France: Kugler Publications.
Tinnitus Patient Management Procedures
Anderson G, Melin L, Hagnebo C, Scott B, Lindeberg P (1995) A review of psychological treatment approaches for patients suffering from tinnitus. Annals of Behavioral Medicine 17, 357-366.
Davies S, McKenna L, Hallam RS (1995) Relaxation and cognitive therapy: A controlled trial in chronic tinnitus. Psychology & Health 10, 129-144.
Dobie RA, Sakai CS, Sullivan, MD, Katon WJ, Russo J (1993). Antidepressant treatment of tinnitus patients: reports of randomized clinical trials and clinical prediction of benefit. American Journal of Otology, 14, 18-23.Hear-Res, 80(2): 216-32.
Erlandsson SI, Rubenstein B. Carlsson SC (1991) Tinnitus: evaluation of biofeedback and stomatognathic treatment. Br. J. Audiol 25: 151-161.
Gold SL, Gray WC, Jastreboff PJ (1995) Selection and fitting of noise generators and hearing aids for tinnitus patients. Proceedings of the Fifth International Tinnitus Seminar. Portland, Oregon 312-314.
Hallam RS, Jakes SC (1988) Cognitive variables in tinnitus annoyance. British Journal of Clinical Psychology, 27:213 - 222.
Hallam RS, Rachman S, Hinchcliffe R (1984) Psychological aspects of tinnitus . In Rachman S (ed) Contributions to Medical Psychology, 3, Pergamon Press, Oxford.
Hazell JWP (1999) The TRT method in practice. Proceedings of the Sixth International Tinnitus Seminar. Cambridge UK 92-98.
Jastreboff PJ, Hazell JW (1993) A neurophysiological approach to tinnitus: clinical implications. Br.J.Audiol, 27(1): 7-17.
Morgan D (1992) Tinnitus of TMJ origin: A preliminary report. The Journal of Craniomandibular Practice. 10 (2) 124-129.
Schleuning AJ, Johnson RM (1997) Use of masking for tinnitus. International Tinnitus J. 3 (1) 25-29.
Sheldrake JB. (1985). A clinical study of tinnitus maskers. Br J Audiol 19:65-146.
Surr RK, Montgomery AA, Mueller HG (1985) Effects of Amplification on Tinnitus among new hearing aid users. Ear and Hearing 6 (2) 71-75.
Sweetow RW (2000) Cognitive-Behavioral Modification in Tinnitus Handbook. Ed Tyler, R.S. Chapter 13, 297-312, Singular Press, San Diego, CA, 2000.
Sweetow RW (1986) Cognitive Aspects of Tinnitus Patient Management": Ear and Hearing. 7,6, 390-396.
Vernon J, Johnson R, Schleuning A, Mitchell C (1980) Masking and Tinnitus. Audiology and Hearing Education: 6, 5-9.
Wilson PH, Henry JL (1993) Psychological approaches in the management of tinnitus. Australian Journal of Otolaryngology 1, 296-302.
Wilson PH, Bowen M, Farag P (1992) Cognitive and relaxation techniques in the management of tinnitus. Tinnitus 91-Proceedings of the Fourth International Tinnitus Seminar, Amsterdam, New York: Kugler Publications.
Wright EF, Bifano SL (1997) The relationship between tinnitus and temporomandibular disorder (TMD) therapy. International Tinnitus J 3 (1) 55-61.
Young DW (2000) Biofeedback training in the Treatment of tinnitus. Chapter 12 In Tyler RS (ed ) Tinnitus Handbook, Singular, San Diego.
Andersson G, Lyttkens L (1999) A meta-analytic review of psychological treatments for tinnitus. Br J Audiol. 33(4): 201-10.
Dobie RA (1999) A review of randomized clinical trials in tinnitus. Laryngoscope. 109(8): 1202-1211.
Meikle MB (1997) Electronic access to tinnitus data: the Oregon Tinnitus Data Archive. Otolaryngol-Head and Neck Surg; 117:698-700.
Meikle MB, Johnson RM, Griest SE, Press LS, Charnell MG (1995) Oregon Tinnitus Data Archive 95
Task Force Committee Members
Robert Sweetow, chair
James Hall III.