Level 2 Audiologic Evaluation

Tinnitus is a symptom of dysfunction within the 

auditory system, and usually is associated with 

some degree of hearing loss (Axelsson & Ringdahl, 

1989; A. Davis & Refaie, 2000; J. L. Henry & P. H. 

Wilson, 2001; Vernon, 1998). As stated in Chapter 

3, an audiologic examination should be the clinical 

starting point for all patients who complain of tinnitus, unless urgent medical services are required. 

In addition to the audiology testing, it is critical to 

determine how much of a patient’s complaint is due 

to a hearing problem and how much is due specifically to the tinnitus. A brief assessment should be 

performed to determine if intervention specific to 

tinnitus is warranted.

The objectives of the Level 2 Audiologic Evaluation are to determine the potential need for (a) a 

medical examination (usually from an otologist 

or otolaryngologist); (b) mental health screening 

(from a psychologist, psychiatrist, or other mental 

health provider); and/or (c) audiologic intervention 

(which can include intervention for hearing loss, 

tinnitus, and reduced tolerance to sound) (J. A. 

Henry et al., 2008b). (Appendix C provides an overview of objectives and procedures of the Level 2 

Audiologic Evaluation.)

The Level 2 evaluation includes a standard 

comprehensive hearing evaluation as well as written questionnaires to assess the patient’s perception 

of the relative impact of hearing and tinnitus problems. Patients who require amplification receive 

hearing aids, which can result in satisfactory management of reactions to tinnitus with minimal education and support. Any patient who experiences 

problematic tinnitus (even if they will receive hearing aids) is advised to participate in the Level 3 

Group Education workshops.

Tinnitus and Hearing Survey

As discussed in Chapter 3, patients who report 

problems with tinnitus may really be experiencing 

problems with hearing. The Tinnitus and Hearing 

Survey (THS; Appendix D) is a brief questionnaire 

designed specifically to assist patients and clinicians in determining how much of a patient’s 

reported problem is due to tinnitus and how much is 

due to hearing problems. The survey also contains 

two items that screen for sound tolerance problems.

5
40	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

The THS contains three sections. Section A 

includes four statements that address tinnitusspecific problems unrelated to hearing problems. 

Section B contains four statements that focus on common hearing problems. The Section B statements 

are phrased to minimize any perceived effects of 

tinnitus on hearing function. Higher scores for Section A indicate a tinnitus-specific problem, whereas 

higher scores for Section B indicate a hearing 

problem. Results of this survey, along with results 

of the hearing evaluation, provide the clinician 

with the information needed to differentiate tinnitus-specific problems from hearing problems. Section C asks patients if they have sound tolerance 

problems. Affirmative responses to Section C 

should be discussed with patients to determine the 

potential need to temporarily suspend the PTM 

protocol to focus on treating the sound tolerance 

problem.

After completing the THS, patients should 

understand that the problems listed in Section A 

are problems that can be addressed with tinnitus 

management. Section B problems can be addressed 

with intervention specific to hearing, regardless 

of the cause of the hearing problem. Section C 

addresses possible sound tolerance problems.

Patients who have tinnitus-specific problems 

should be advised to participate in Level 3 Group 

Education. Attending the Level 3 workshops will 

include provision of the self-help workbook (How to 

Manage Your Tinnitus: A Step-by-Step Workbook) (J. A. 

Henry et al., 2010a). Management options for hearingrelated problems include amplification, assistive listening devices, and auditory rehabilitation services. 

Management options for sound tolerance problems 

include a special sound tolerance handout (What to 

Do When Everyday Sounds Are Too Loud—Appendix E), sound desensitization procedures, and participation in the sound tolerance evaluation and 

management (STEM) protocol (for patients who 

would have difficulty participating in Level 3 Group 

Education because of reduced sound tolerance).

PTM Approach to Managing Sound 

Tolerance Problems

Tinnitus clinicians and researchers often report that 

a relatively high percentage of patients with tinnitus 

also suffer from hyperacusis. In reality, many or 

most patients who are identified as “hyperacusic” 

do not require intervention specific to sound tolerance. Treatment for reduced sound tolerance usually 

requires a program of systematic exposure to sound. 

The PTM sound therapy approach simultaneously 

addresses reduced sound tolerance. Therefore, 

sound therapy should be the starting point for PTM 

patients who have reduced sound tolerance and 

are able to participate in a program of sound-based 

tinnitus therapy. The key concern for audiologists 

is to determine if reduced sound tolerance will 

interfere with the intervention. Of course, it should 

be the patient’s decision to focus on addressing 

sound tolerance rather than tinnitus.

Using the Tinnitus and Hearing 

Survey to Determine Candidacy for 

Level 3 Group Education

Section A of the THS is used to assist in determining 

if a patient should attend Level 3 Group Education. 

Following the steps below can help to ensure that 

patients do not attend the Level 3 workshops with 

the misconception that they will learn to manage 

a hearing-in-noise problem (which patients often 

believe is the result of the tinnitus blocking sounds 

they are trying to hear.)

n Explain that group education focuses on 

finding ways to manage tinnitus-related 

problems—the workshops do not focus 

on hearing-related problems.

n Confirm that the patient is interested 

in attending workshops that address 

tinnitus-related problems.

n Ensure that the patient understands that 

participating in Level 3 Group Education 

does not preclude receiving concurrent 

services for managing hearing problems.

n Ensure that the patient does not have a 

sound tolerance problem to such a degree 

that it would be difficult to participate in 

the Level 3 workshops.

If the above requirements are met, then the patient 

likely is a candidate for Level 3 Group Education.
Level 2 Audiologic Evaluation	 41

Patient Example: Linda

Using the THS, a patient (Linda) provides a low 

score for Section A (tinnitus section) and a high 

score for Section B (hearing section), but reports 

a severe tinnitus problem. The Level 2 Audiologic 

Evaluation reveals that Linda has noise induced, 

high frequency, sensorineural hearing loss. Linda 

states that the problems listed in Section B are 

those that she finds most irritating and upsetting, and she believes those problems are caused 

by the tinnitus. After explaining the objectives of 

Level 3 Group Education, the audiologist helps her 

to recognize that she probably would not benefit 

from a class that focuses on Section A problems. 

She understands that audiologic management is 

needed to address the Section B problems. She is 

happy to receive the self-help workbook (How to 

Manage Your Tinnitus: A Step-by-Step Workbook) to 

learn more about her tinnitus.

Using the Tinnitus and Hearing Survey 

to Determine Need for Intervention for 

Reduced Sound Tolerance

Section C of the THS is used to assist in determining 

if a patient needs intervention for reduced sound 

tolerance. Following the steps below can help to 

ensure that reduced sound tolerance is addressed 

when needed.

Section C, Item 1

Any patient who reports a sound tolerance problem (of any degree) should receive the sound tolerance handout (What to Do When Everyday Sounds 

Are Too Loud—Appendix E).

Section C, Item 2

If a patient reports that a sound tolerance problem 

would make it difficult to attend the Level 3 workshops, this should be thoroughly discussed to ascertain that the patient would indeed have difficulty 

attending a group workshop specifically because 

of a sound tolerance problem (and not because of 

some other reason such as social anxiety, transportation problems, severe hearing loss, etc.). If sound 

tolerance is such a problem that the patient cannot continue with the normal PTM protocol, then a 

separate protocol should be undertaken to address 

the sound tolerance problem. The STEM protocol (Chapter 6) was developed for this purpose. 

Once the sound tolerance problem is sufficiently 

resolved, then the patient can re-enter the PTM 

protocol if necessary to address any tinnitus problems. Normally, reentry into PTM would involve 

the patient attending the Level 3 workshops (see 

Appendix A).

Tinnitus Handicap Inventory

Standardized tinnitus questionnaires are used 

to obtain a global index score of a patient’s perceived tinnitus severity, and many questionnaires 

are available for this purpose (C. W. Newman & 

Sandridge, 2004). A tinnitus-severity index score 

from a tinnitus questionnaire, however, should not 

be relied on as the sole indicator of the degree to 

which tinnitus affects a patient’s life (as explained 

in the next section).

A tinnitus questionnaire provides a standardized baseline of the patient’s perceived problem 

due to tinnitus, and it is essential to acquire this 

baseline prior to any testing or counseling. We recommend using the Tinnitus Handicap Inventory 

(THI—Appendix F) (C. W. Newman et al., 1996) 

for this purpose because it is one of the most widely 

used and best documented of the tinnitus questionnaires that currently are available. For management with PTM, the THI can serve as the primary 

outcome instrument. Patients should complete the 

THI to assess outcomes at intervals (e.g., every 

3 months) during ongoing intervention, and prior 

to terminating intervention.

The THI contains 25 statements, and response 

choices are “no” (0 points), “sometimes” (2 points), 

and “yes” (4 points). The index score ranges from 0 to 

100. Handicap severity can be categorized based on 

the THI index score as follows (Handscomb, 2006):

n Severe (58–100)

n Moderate (38–56)

n Mild (18–36)

n No handicap (0–16)
42	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

A change in the total index score of at least 20 points 

has been reported to indicate a statistically and 

clinically significant change in self-perceived tinnitus handicap (C. W. Newman & Sandridge, 2004).

A 10-question screening version of the THI 

(THI-S—see Appendix F) also can be used (C. W. 

Newman, Sandridge, & Bolek, 2008). The THI-S 

includes 10 of the same questions as the full-length 

THI and usually takes less than two minutes to complete. Comparison of the THI-S to the THI revealed 

a high correlation (r = 0.90). An index score of at 

least 6 points (out of a possible 40 points) on the 

THI-S was established as a fence for recommending follow-up. A change of more than 10 points is 

considered a significant clinical difference.

How Do the Tinnitus Handicap Inventory 

and Tinnitus and Hearing Survey Differ?

The THI and THS are used to accomplish different 

objectives, and each is important for PTM.

The THI is a statistically validated and widely 

recognized tool for assessing self-perceived tinnitus 

handicap, making it appropriate for standardized 

assessment of outcomes of clinical intervention. 

A patient’s index score from any tinnitus questionnaire, including the THI, is vulnerable to influence 

from hearing problems and cannot be relied on as 

the sole indicator of candidacy for Level 3 Group 

Education.

The THS is not a validated outcome instrument, and therefore should not be used as a primary measure of outcome of intervention. The 

THS was designed to differentiate tinnitus-specific 

versus hearing-specific problems, which is helpful 

for determining if a patient should attend Level 3 

Group Education. The THS can be used informally 

to monitor relative progress alleviating tinnitus 

problems versus hearing problems.

Hearing Handicap Inventory

The Hearing Handicap Inventory (HHI) is a selfadministered questionnaire that assesses selfperceived handicap imposed by hearing loss. Use of 

the HHI is recommended as a standard assessment 

tool for all patients undergoing Level 2 Audiologic 

Evaluation. Results of the HHI provide additional 

information to better understand how much of a 

patient’s complaints about tinnitus may be attributable to hearing handicap, which contributes to a 

more accurate interpretation of patients’ responses 

to the THI and THS.

Four versions of the HHI can be used. The 

Hearing Handicap Inventory for the Elderly (HHIE) 

is intended for patients age 65 and older (Ventry 

& Weinstein, 1982). The Hearing Handicap Inventory for Adults (HHIA) is intended for patients less 

than 65 years of age (C. W. Newman, Weinstein, 

Jacobson, & Hug, 1990). Both the HHIE and HHIA 

are 25-item self-assessment scales that include two 

subscales (emotional and social/situational). The 

HHIA differs from the HHIE only in that it includes 

questions about occupational effects of hearing 

loss. The screening versions of the HHIE (HHIE-S) 

and the HHIA (HHIA-S) each include 10 items and 

can be completed in 5 minutes or less (Lichtenstein, 

Bess, Logan, & Burger, 1990; Ventry & Weinstein, 

1983). The HHIE-S can be used with all patients 

and is recommended for routine use at the Level 2 

Audiologic Evaluation (Appendix G).

Assessment of Auditory Function

A standard audiologic evaluation provides the 

information necessary to determine need for referral for medical evaluation and to determine candidacy for audiologic hearing intervention. This is 

routine practice for audiologists, but some of the 

procedures warrant special considerations when 

patients present with tinnitus.

Otoscopy is performed routinely prior to placing earphones for audiometric testing. Even a small 

amount of cerumen on the tympanic membrane can 

create a mass effect resulting in a high frequency 

conductive hearing loss and tinnitus (Schechter & 

J. A. Henry, 2002). Therefore, it is important to consider this possibility when performing otoscopy.

Pulsed tones often are recommended for use 

when evaluating pure-tone thresholds in patients 

with tinnitus (Douek & Reid, 1968; Fulton & Lloyd, 

1975; Green, 1972; Yantis, 1994). Investigations, 

however, have revealed that hearing thresholds 
Level 2 Audiologic Evaluation	 43

generally are the same whether tones are presented 

in the pulsed or continuous mode (J. A. Henry & 

Meikle, 1999; Hochberg & Waltzman, 1972; Mineau 

& Schlauch, 1997). It is acceptable to use either 

pulsed or continuous tones for threshold testing, 

although the use of pulsed tones may assist some 

patients in distinguishing between the tones and 

the tinnitus, especially when the tinnitus pitch is 

close to the test frequency.

Some patients with tinnitus have trouble tolerating louder sounds, and some report that loud 

sounds make their tinnitus louder. It is important 

to use caution when conducting suprathreshold 

audiometric testing. The following guidelines can 

be helpful:

n Use the softest effective masking sounds 

during traditional audiometry (the need 

for masking can be reduced by using 

insert earphones that increase interaural 

attenuation).

n Use conservative levels of sound during 

word recognition testing.

n Approach reflex threshold and decay 

testing with particular caution as some 

patients have trouble tolerating the 

sounds used in these tests. In no instance 

should pure tones be delivered above 

105 dB HL. Speech stimuli should not be 

delivered above 100 dB HL.

Assessment of Potential Need for 

Otolaryngology Exam

As the ideal, every patient complaining of tinnitus 

would be examined by an otolaryngologist or otologist (Perry & Gantz, 2000). However, this may not 

be practical or realistic in some settings. Audiologists sometimes are the only health care providers 

who evaluate patients with tinnitus complaints. 

Audiologists must be aware of symptoms and conditions that indicate the need for referral to otolaryngology, which include:

n Symptoms consistent with vestibular 

schwannoma or other retrocochlear 

pathology

n Symptoms consistent with Ménière’s 

disease

n Symptoms consistent with somatic 

origin (i.e., vascular, muscular, skeletal, 

respiratory, or TMJ) of tinnitus (see next 

section below)

n Ear pain, drainage, or malodor

n Vestibular symptoms

n New-onset tinnitus or hearing loss

n Progressive tinnitus (tinnitus that is 

perceived as changing in loudness, pitch, 

and/or timbre over time)

n Significant conductive loss of 

undetermined etiology

n Unilateral or grossly asymmetric hearing 

loss.

The most common type of tinnitus is associated 

with noise-induced hearing loss. These patients 

usually report that their tinnitus has been fairly 

stable for years. This common form of tinnitus cannot be corrected surgically, nor is it life threatening. 

Although a medical exam always is in the patient’s 

best interest, an otologic exam may be eliminated 

if all of the following conditions apply:

n All symptoms and conditions that indicate 

the need for referral to otolaryngology 

(listed above) have been ruled out.

n Patient reports a history of noise exposure 

and concurrent or subsequent onset of 

tinnitus.

n Tinnitus is symmetric and nonpulsatile.

n Audiogram is consistent with a diagnosis 

of symmetric sensorineural hearing loss.

Symptoms of Somatosounds

We briefly described somatic tinnitus (somatosounds) in Chapter 1. It is important for clinicians to 

realize that many sounds of the head and neck are 

normal (Hazell, 2003). When we swallow we hear a 

clicking sound. There is a great deal of blood pulsing through the head and neck at any given time—

causing constant loud pulsations (that we normally 

don’t perceive). The carotid artery passes within 

about 6mm of the cochlea, and we occasionally can 

hear sounds of the heart through this artery. Additional sounds are caused by joints and muscles, the 
44	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

eustachian tube, and air passing through the airways. Although all of these sounds are considered 

normal, they become abnormal when heard on a 

daily basis or when they cause distress.

Somatosounds generally can be categorized 

as pulsatile and nonpulsatile (Hazell, 1998b). Pulsatile somatounds include venous hums, vascular 

loops, and carotid transmissions. Venous hums are 

caused by turbulent blood flow through the jugular 

bulb, which is a protrusion into the mastoid cavity 

(close to the middle ear) of the internal jugular vein. 

A large amount of blood flows rapidly through the 

jugular vein, causing vibration of the vein walls 

that is perceived as a humming noise. This is easily 

evaluated by an otolaryngologist and is a benign 

condition. Vascular loops within the internal auditory canal can compress the auditory nerve (Nuttall 

et al., 2004). This compression can cause auditory 

nerve activity that may be perceived as sound, 

which may be pulsatile (Møller, 1995; Nuttall 

et al., 2004). Surgery can remediate tinnitus caused 

by vascular compression of the auditory nerve. 

Carotid transmissions refers to any transmission of 

sound to the cochlea from the carotid artery. This 

often is caused by stenosis of the carotid artery, but 

also can include transmission of heart murmurs 

(Hazell, 1998b; Lockwood et al., 2004).

There are many other potential causes of pulsatile tinnitus, which have been described (Lockwood 

et al., 2004; Sismanis, 1998, 2003, 2007). Although 

rare, life-threatening pathology may be associated 

with pulsatile tinnitus (Sismanis, 2007). It thus is 

critical to establish an appropriate diagnosis for 

these patients. In general, a patient with pulsatile 

tinnitus should be medically evaluated to rule out 

potential vascular or neurologic conditions that 

require medical or surgical treatment. These may 

include hypertension, hyperthyroidism, carotid 

blockage, glomus tumor, arteriovenous malformation, aneurisms, and so forth. Glomus tumors are 

rare, but they are the most common tumor of the 

middle ear and second most common of the temporal bone (second to vestibular schwannoma) 

(Moffat & Hardy, 1989). Any mention of tumors to 

patients can cause alarm and anxiety. It therefore is 

important to assure patients that these tumors are 

rare, and if they occur they usually are benign.

Nonpulsatile somatosounds include patulous 

eustachian tube, palatal myoclonus, and tensor tympani syndrome (Hazell, 1998b). A patulous eustachian tube remains open abnormally. This condition 

often is misdiagnosed as a blocked eustachian tube 

(Schuknecht, 1993). Symptoms can include a sense 

of ear fullness, respiratory noises, and autophony 

(abnormal loudness of one’s own voice). Palatonal 

myoclonus is caused by rapid contractions of the 

soft palate musculature (Hazell, 1998b; Lockwood 

et al., 2004). These contractions may be associated 

with contractions of other muscles in the head and 

neck. The contractions can cause the eustachian 

tube to open and close, giving the perception of 

an irregular clicking/snapping sound in one or 

both ears. Tensor tympani syndrome is caused by 

spasms of the tensor tympani muscle that produces 

a fluttering low frequency sound (Hazell, 1998b). 

The sound may be correlated with the sensation of 

an insect fluttering in the ear canal. This condition 

generally is benign but may be alleviated by sectioning of the tensor tympani muscle.

Somatically Modulated Tinnitus

Some patients report that movements or manipulations of the eyes, head, neck, jaw, or shoulder can 

cause changes in the loudness or pitch of their tinnitus. This phenomenon is referred to as “somatically 

modulated tinnitus.” It has been reported by some 

investigators that the phenomenon is much more 

prevalent than previously thought—with up to 80% 

of patients reporting that their tinnitus can be modulated somatically when asked the right questions 

(Levine, 2004). If a patient does report that movement of the head or neck can change the loudness 

or pitch of the tinnitus, then the question arises as 

to how to properly refer these patients. In general, 

all of these patients should be evaluated by an 

audiologist. The audiologist then can determine if a 

referral to otolaryngology or neurology is necessary.

Administer Tinnitus Problem 

Checklist (optional procedure)

To conclude the Level 2 Audiologic Evaluation, it 

is important to review results of the Tinnitus and 

Hearing Survey, Tinnitus Handicap Inventory, Hearing Handicap Inventory, and hearing assessment. 
Level 2 Audiologic Evaluation	 45

The patient should understand that problems listed 

in Section A of the Tinnitus and Hearing Survey 

are specific to tinnitus and are addressed in Level 

3 Group Education, and that problems in Section 

B are addressed by an audiologist and are not covered in Level 3 Group Education.

If the patient has a tinnitus-specific problem, 

and if time permits, then the Tinnitus Problem 

Checklist (Appendix H) can be helpful. Use of the 

checklist is the starting point for teaching a patient 

how to use sound to manage tinnitus, as described 

in the self-help workbook (How to Manage Your Tinnitus: A Step-by-Step Workbook) (J. A. Henry et al., 

2010a). Using the checklist provides structure to 

talk to patients about any problems they experience that are caused by the tinnitus. The checklist 

also gives the patient information that is useful to 

understanding how the workbook can be used, 

which is an advantage to patients who receive a 

copy of the workbook.

Hearing Aid Evaluation 

(if warranted)

Most patients with tinnitus have some degree of 

hearing loss and hearing aids sometimes can adequately ameliorate both their hearing and tinnitus problems (Surr et al., 1999, 1985). All patients 

should be advised of the potential for hearing aids 

to alleviate tinnitus as a secondary benefit. In some 

instances, hearing aids can be used primarily for 

managing tinnitus with improved hearing as a secondary benefit (J. A. Henry et al., 2008b; J. A. Henry, 

Zaugg, et al., 2005a; Searchfield, 2005).

The Flowchart for Assessment and Fitting of 

Ear-Level Instruments (Appendix I) shows the clinical actions for PTM Levels 2 through 5—with the 

focus on ear-level instruments. The Level 2 Audiologic Evaluation includes an assessment of candidacy for hearing aids. If the patient is a hearing aid 

candidate, then hearing aids are fitted as appropriate. The preferred approach to providing patients 

with ear-level instruments is to dispense only hearing aids at Level 2 and not to provide ear-level 

combination instruments or noise/sound generators until after patients have completed Level 3 

Group Education. Noise generators and combination 

instruments should not be an option for patients 

until they have learned about and implemented 

different strategies of using sound for tinnitus management as addressed in Level 3 Group Education. 

The knowledge and experience of using sound to 

manage tinnitus gained during Level 3 allows 

patients to make informed decisions about using 

noise generators and combination instruments. 

Many patients can learn how to self-manage their 

tinnitus without having to use special ear-level 

instruments. If instrument use is warranted, then 

the proper use of these devices requires multiple 

appointments with an audiologist who understands 

their use within the context of PTM.

Although we generally recommend fitting 

only hearing aids at Level 2, recent developments 

need to be considered. In the past, combination 

instruments included amplification features that 

were limited relative to hearing aids. Patients who 

were fitted with combination instruments often did 

not receive amplification that optimally addressed 

their hearing loss. That situation has changed with 

the recent introduction of new combination instruments from a number of hearing aid companies. 

These combination instruments do not sacrifice 

hearing aid features so patients can be fitted with 

these devices as high-quality hearing aids. When 

fitting such combination instruments at Level 2, it 

might be preferable to not use the noise feature of 

the devices until the patient has attended a Level 3 

workshop—to ensure that the patient fully understands the different uses of therapeutic sound 

before actually using it with these devices.

Patients with Hearing Loss

At Level 2, patients with hearing loss are provided 

amplification, assistive listening devices, and education in communication strategies as necessary to 

maximize their hearing function. Since impaired 

hearing may be the patient’s primary problem 

(often unknowingly prior to the hearing evaluation), it is essential to optimize hearing function. 

Furthermore, patients who progress to Level 3 

Group Education require adequate hearing in 

order for them to comprehend the presentation and 

group discussion. Patients who receive hearing 

aids and/or assistive listening devices will receive 
46	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

instruction in how to use these devices (along with 

many other uses of sound and sound devices) for 

the management of tinnitus.

Patients With Normal Hearing

For Level 2 patients who have normal hearing and 

problematic tinnitus, Level 3 Group Education is 

recommended. In the group workshop, these patients 

learn how to use sound (from many sources) to 

manage their reactions to tinnitus. Some of these 

patients will acquire the skills needed for satisfactory 

management and will not need further intervention. 

Others may require further help after completing 

Level 3, at which point they should be considered 

for a Level 4 Interdisciplinary Evaluation that normally includes an evaluation for ear-level noise generators. Because of their personal experience using 

sound to manage tinnitus at Level 3, these patients 

should be well prepared to participate fully in any 

decision about using ear-level noise generators.

Use of Hearing Aids With PTM

For audiologists, the provision of hearing aids is a 

routine service with an established skill set. Audiologists are trained and experienced in the selection and fitting of hearing aids for the purpose of 

improving hearing. If hearing aids are incorporated 

into management for tinnitus, then the audiologist 

essentially has the training necessary to perform 

this service (J. A. Henry, Zaugg, et al., 2005a). The 

method of PTM makes full use of these existing 

skills to apply them directly to addressing tinnitus. 

There are, however, special considerations for the 

use of hearing aids with these patients (Appendix J).

Hearing Aids for Managing 

Reactions to Tinnitus

Special considerations are important with respect to 

using hearing aids for tinnitus management (these 

points are summarized briefly in Appendix J):

n The ear canal should be left open as 

much as possible (or venting should be 

maximal—as appropriate for slope and 

degree of loss) to allow normal entry of 

environmental sound (especially lowest 

frequency sounds that are not amplified 

by the hearing aids) and to reduce the 

sensation of occlusion. Both factors can 

contribute to reducing tinnitus perception.

n Hearing aids with feedback reduction 

circuitry can facilitate the use of openear design hearing aids, or larger vent 

diameters.

n Special noise suppression circuitry 

actually can be a detriment to patients 

with tinnitus, as noise suppression could 

eliminate some background sound that 

might be helpful for these patients. What 

may be a goal for optimal hearing aid 

performance may be at cross-purposes for 

tinnitus management. If a patient with 

tinnitus has hearing aids with multiple 

memories, then a consideration is to 

program one of the memories to minimize 

noise reduction (as the “tinnitus” setting) 

with the microphone set to omnidirectional, 

and adjusted to minimize the reduction of 

background sound. Some hearing aids 

offer “music” settings, or other settings 

that minimize use of algorithms to 

eliminate nonspeech sounds.

n Some hearing aids offer sound generator 

settings that can be activated/reprogrammed after Level 3 Group Education 

is provided if amplification alone does not 

ameloriate effects of tinnitus.

n Reduced levels of internal noise also can 

be detrimental to tinnitus management. 

In older hearing aids, the floor noise of 

hearing aids often was helpful for 

tinnitus patients.

Benefits of Amplification for Patients 

With Tinnitus

Beneficial effects on tinnitus from the use of amplification may be due to:

n Amelioration of communicative 

difficulties caused by hearing loss but 

attributed to tinnitus
Level 2 Audiologic Evaluation	 47

n Alleviation of stress associated with 

difficult listening situations

n Increase in ambient sound that can reduce 

the effects of tinnitus (typically, ambient 

sound makes tinnitus less noticeable)

n Stimulation of impaired portions of the 

auditory system that often are deprived 

of sound.

Refer for Mental Health 

Screening (if indicated)

Certain mental health disorders are known to be 

associated with the presence and severity of tinnitus. Clinical depression and anxiety often affect 

patients who experience the most problematic 

tinnitus (Dobie, 2003; Halford & Anderson, 1991; 

Kirsch et al., 1989). In addition, some patients suffer from post-traumatic stress disorder (PTSD). 

PTSD is suspected if the patient reports having 

been exposed to a trauma and subsequently experienced nightmares, flashbacks, exaggerated startle 

responses, or excessive anxiety or fear. The traumatic event does not need to be recent for a patient 

to experience PTSD.

Although depression, anxiety, and PTSD commonly are associated with tinnitus, many other 

mental health disorders also may present along with 

tinnitus. These can include substance abuse (opiates, amphetamines, sedatives, cocaine, marijuana, 

hallucinogens, alcohol, etc.), bipolar disorder, psychotic disorders, attention-deficit/hyperactivity 

disorder, panic, phobias, and obsessive-compulsive 

disorder (J. A. Henry et al., 2008b). All of these conditions, and others, present in clinical settings in 

varying degrees. It is important to not limit screening and referral to only mental health conditions 

that have known or suspected interactions with tinnitus. Failure to refer patients for possible mental 

health conditions reduces the likelihood of achieving the desired outcomes from any tinnitus intervention. The concern for so many potential mental 

health disorders in patients with tinnitus can present 

a conundrum for audiologists, which speaks to the 

need for a psychologist to be on the “tinnitus team.”

If indicated by a patient’s comments or behavior during the Level 2 evaluation, screening for 

mental health issues should be performed (unless 

the patient already is diagnosed with a mental 

health condition[s] and currently is receiving care 

accordingly). Mental health screening also can be 

done at any stage of PTM at the clinician’s discretion. If possible, such screening ideally is conducted 

by a mental health or primary care provider. In 

most medical centers, primary care offers competent and efficient mental health screening services. 

Thus, it usually is preferable to refer patients who 

are suspected of mental health conditions to primary care for screening. However, different facilities may handle mental health screening differently 

so it is important to determine the procedures 

used at each facility. If screening is not available 

elsewhere, it can be useful for an audiologist to 

use specific questionnaires to screen for the more 

common comorbid conditions of sleep problems, 

PTSD, anxiety problems, and symptoms of depression (see Chapter 8).

Refer for Assessment of Sleep 

Disorder (if indicated)

Sleep disorders are the most common problem 

reported by patients who are bothered by tinnitus (Axelsson & Ringdahl, 1989; Jakes et al., 1985; 

Meikle et al., 2004; Tyler & Baker, 1983). Patients 

with sleep disorders also tend to report the most 

severe tinnitus (Erlandsson, Hallberg, & Axelsson, 

1992; Folmer & Griest, 2000; Meikle, Vernon, & 

Johnson, 1984; Scott, Lindberg, Melin, & Lyttkens, 

1990). These patients may need specialized treatment from a physician, mental health professional, 

and/or sleep disorders clinician.

It is important to question a patient about 

details of a reported sleep disorder to determine 

if referral is needed. In some cases a sleep disorder 

can be related to a serious medical condition. It also 

is important to distinguish between insomnia and 

sleep apnea. Insomnia is a problem with initiating or maintaining sleep, which typically does not 

have serious medical effects. Sleep apnea is a condition whereby breathing during sleep is disrupted 

and can have serious health effects such as stroke. 

Patients who report snoring, morning headaches, 

gasping or choking upon waking, or those who 
48	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

have a bed partner who reports the presence of 

these indications of sleep apnea, should be referred 

to primary care for assessment.

Managing Sleep Disorder

If a patient’s sleep disorder is a direct consequence 

of the tinnitus, then effective tinnitus management 

may resolve the sleep problem. This requires the 

appropriate use of sound in the sleep environment. 

In most cases, this should be attempted prior to 

referring the patient out for insomnia treatment. The 

use of sound is harmless and inexpensive, whereas 

insomnia treatment can involve medications, side 

effects, and significant costs. Strategies for improving sleep when tinnitus is a problem are explained 

in the Level 3 workshops, and are included in the 

self-help workbook (J. A. Henry et al., 2010a).

Prescription Drugs and Tinnitus

No prescription drug has been developed specifically for tinnitus. However, some antidepressant 

or anxiolitic medications such as amitryptiline or 

lorazepam may reduce symptoms. These drugs 

most commonly are used to address coexisting 

sleep disorders and mental health disorders—primarily depression and anxiety (Dobie, 2004a; J. A. 

Henry, Zaugg, et al., 2005a; Robinson, Viirre, & 

Stein, 2004). These studies conclude that medical 

management of sleep and mental health problems 

can be a helpful component of an overall approach 

to managing reactions to tinnitus.

Certain medications can trigger or exacerbate 

tinnitus, including aspirin, NSAIDS, loop diuretics, and quinine. Normally, fairly high doses are 

required to cause tinnitus effects, and the effects 

usually are temporary. Drugs used to treat mental 

health and sleep conditions also may trigger or exacerbate tinnitus. Patients have reported exacerbation 

of tinnitus due to alcohol and caffeine. Ototoxicity 

from aminoglycosides and platinum-containing 

chemotherapeutic drugs are well-known causes of 

hearing loss and tinnitus, and these effects often are 

irreversible (Fausti et al., 1995; Rachel et al., 2002).

The only way to know if a medication alleviates tinnitus is through trial-and-error (e.g., some 

antidepressants can cause or exacerbate tinnitus as 

a side effect). This generally is what is done by physicians who attempt to use medications to treat tinnitus. It is better for patients if they can be helped 

with counseling and the proper use of sound rather 

than receiving medications that can have harmful 

side effects or result in dependency/addiction.

Self-Help Workbook

The self-help workbook (How to Manage Your Tinnitus: A Step-by-Step Workbook) (J. A. Henry et al., 

2010a) can be given to patients either at the end of 

the Level 2 Audiologic Evaluation, or at the beginning of Level 3 Group Education. It generally is 

preferable to withhold provision of the workbook 

until the patient shows up for the first Level 3 

workshop—for a number of reasons: (a) Anticipating receiving the workbook increases the likelihood 

that patients will participate in Level 3. Attending 

the workshops increases the likelihood that patients 

will learn and benefit from the self-help information. Also, increasing the group size can improve 

the likelihood of meaningful interactions amongst 

group members. (b) Many patients believe that 

reducing the loudness of their tinnitus is the only 

way to feel better and may be disillusioned by the 

workbook since it does not offer that option. These 

patients may not even attempt to implement the 

ideas contained in the workbook and thus may 

only be able to benefit from the workbook if guided 

through it by a clinician (and in a group setting 

sometimes it may be other group members who are 

best able to influence a patient that the ideas in the 

workbook can be helpful). (c) Providing the workbook as a patient is leaving the clinic decreases the 

likelihood that the patient and clinician will discuss the concepts. Discussion fosters interest and 

learning, and is more likely to lead to the patient 

making behavioral changes that will reduce reactions to tinnitus and increase quality of life.

We recommend offering to provide patients 

with their own copy of the workbook when they 

come to the first Level 3 workshop. Patients also 
Level 2 Audiologic Evaluation	 49

should be told about the 13-minute tinnitus video 

that they can view online (http://www.ncrar

.re­search.va.gov/ForVets/Tinnitus.asx). This video 

was professionally produced by VA Employee Education System and provides basic information that 

can help to increase interest in learning the concepts that are taught in the workbook and Level 

3 workshops. The DVD with the 13-minute video 

is available from the NCRAR (or from any of the 

authors of this handbook) and can be used in the 

clinic to show to patients. Most patients find the 

video to be entertaining and informative.

Summary

The great majority of patients who report tinnitus 

also have some degree of hearing loss. The essential first step in providing clinical services for these 

patients normally is to assess their hearing function. Using the triage guidelines described in the 

previous chapter, these patients may require a 

medical and/or a mental health examination. At 

a minimum, however, all patients who report 

tinnitus should be assessed by an audiologist who 

can determine what services are needed, including: 

(a) medical exam; (b) mental health screening; and 

(c) audiologic intervention for hearing loss, tinnitus, and/or hyperacusis.

The Level 2 Audiologic Evaluation consists 

mainly of a conventional audiologic assessment. 

Because the patient reports tinnitus, a brief assessment of tinnitus impact is performed. The primary 

tool for assessing tinnitus impact is the Tinnitus and 

Hearing Survey (THS). Results of the THS should 

be discussed with the patient to determine if tinnitusspecific intervention is appropriate. In addition to 

the THS, it is recommended to administer the Tinnitus Handicap Inventory (THI) and Hearing Handicap Inventory for the Elderly—screening version 

(HHIE-S). Results of the THI serve as a statistically 

validated baseline for assessing outcomes of the tinnitus intervention. Results of the HHIE-S facilitate 

interpretation of the THS and THI, and serve as a 

statistically validated baseline for assessing outcomes of clinical services specific to hearing loss. 

Combined, these three questionnaires provide useful 

data for documenting a patient’s complaints and for 

determining clinical services that may be needed.