Level 4 Interdisciplinary Evaluation

Most patients can satisfactorily self-manage their 

reactions to tinnitus after participating in Level 3 

Group Education. Patients who need more support and education than is available at Level 3 can 

progress to the Level 4 Interdisciplinary Evaluation, which normally includes evaluations by an 

audiologist and a mental health provider who is 

trained to conduct psychological assessments.

The main purpose of the Level 4 Interdisciplinary Evaluation is to determine if individualized 

clinical services are needed to address tinnitusspecific problems. If these services are needed, then 

patients progress to Level 5 Individualized Support. Level 5 involves primarily one-on-one counseling from an audiologist (using the counseling 

book Progressive Tinnitus Management: Counseling 

Guide; J. A. Henry et al., 2010b) and/or a mental 

health provider. The audiologic counseling information essentially is the same as what is covered 

during the Level 3 workshops. However, the individualized format of the Level 5 counseling allows 

more personalized interaction and support than 

can be provided during Level 3. Level 5 intervention offered by a mental health provider includes 

further enhancement of skills for coping with tinnitus (taught during Level 3) such as additional 

relaxation techniques, attention control, and planning for “flare-ups.”

The audiologic assessment that is conducted 

as part of the Level 4 Interdisciplinary Evaluation involves conducting a structured interview 

and can include, as optional procedures, a tinnitus 

psychoacoustic assessment and/or evaluation for 

use of sound therapy devices. Administration of 

the Tinnitus and Hearing Survey (see Appendix D) 

in conjunction with the Tinnitus Interview (Appendix R) is the primary means of determining if 

one-on-one individualized support is appropriate. If so, then the audiologist and patient begin to 

formulate a management plan. Special procedures are used to evaluate and select ear-level 

devices for tinnitus management, including hearing aids, noise/sound generators, and combination 

instruments.

Mental Health Assessment

Systematic progression through the different levels 

of PTM effectively ensures that patients reaching 

the Level 4 Interdisciplinary Evaluation have a 

8
68	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

severe tinnitus problem that warrants an in-depth 

evaluation to determine if individualized support 

is appropriate. Due to the severity of their distress 

from tinnitus, these patients also are more likely to 

have comorbid mental health conditions or sleep 

disorders that would require an interdisciplinary 

approach to intervention. Screening for mental health 

conditions and sleep disorders therefore is conducted 

routinely by a mental health provider as part of the 

Level 4 evaluation (unless the patient was recently 

evaluated/diagnosed by a mental health professional and currently is receiving care accordingly).

If a mental health provider is included in 

the facility’s “tinnitus team,” then that individual 

should conduct the mental health assessment. Full 

assessment of mental health symptoms should be 

conducted by someone qualified to do such an 

evaluation such as a psychologist or psychiatrist. 

If a mental health provider is not part of the team, 

then the patient should be referred to primary care 

for a mental health assessment (or referred as dictated by the facility’s referral procedures). Finally, 

as discussed next, a nonmental health provider can 

conduct mental health screening in certain situations. However, those situations should be rare, as 

timely and collaborative mental health services are 

available within most health care organizations.

Mental Health Screening by Nonmental 

Health Clinicians

It is best for mental health screening to be performed by a psychologist or other mental health 

care provider who is familiar with the effects of 

hearing loss and tinnitus. If such a provider is 

unavailable, then basic screening for these symptoms can be conducted by any clinician who has 

been properly trained to use screening tools and 

who has resources for responding to their outcomes. In instances where audiologists (or other 

nonmental health care providers) are performing 

screening for referral to mental health, collaborations with mental health are essential to allow for 

immediate referrals and follow-up as warranted. 

Hospitals and outpatient clinics vary in the types 

and availability of mental health clinicians. When 

appropriate mental health care providers are 

unavailable, primary care providers often can be 

helpful as many have training and experience with 

screening for sleep and mental health problems.

Nonmental health clinicians must be cautious in dealing with any issues related to anxiety, 

depression, stress disorders, suicidality or suicidal 

thoughts, risky behavior, and so forth, because this is 

not their area of expertise. These clinicians must use

the mental health screening tools only to aid in 

making appropriate referrals, and cannot provide 

diagnostic interpretation of test scores. Some patients 

may feel uncomfortable with these types of questions, or that the questioning is inappropriate and 

intrusive. Therefore, it is important to ask for permission to explore these issues, for example, “If you 

don’t mind, I would like to ask you some questions 

about your mood and things that can affect your 

mood. Sometimes ringing in the ears is made worse 

when other conditions are present at the same time.”

Before formally screening for mental health 

conditions, it is helpful to start with the patient’s 

medical records and scan for comorbid conditions 

that previously have been identified. After reviewing the chart, there are several options for identifying a need for referral to a different discipline. 

Simple mental health screeners can be useful in 

determining if a referral to a mental health clinician 

is warranted. Screening instruments are available 

to screen for anxiety, depression, and PTSD—the 

mental health conditions that have been observed 

to co-occur most commonly in patients who complain of bothersome tinnitus. Each medical facility 

has its preferred mental health screening tools and 

protocols. It is best to contact a mental health clinician or primary care physician at your site in advance 

to learn which screening tools are recommended 

for use by audiologists. Some sites prefer to funnel 

all mental health screenings into one service where 

an intake appointment is made to determine the 

needs of all referred patients. In some settings, health 

services are centralized to primary care providers 

(PCPs). Thus, it might be necessary to refer a patient 

to a PCP when there is any suspicion of a mental 

health or sleep disorder. The PCP then assesses the 

appropriateness of referral to a mental health or 

sleep clinic. At many sites audiologists must take the 

lead in educating other professionals about PTM and 

the interdisciplinary nature of this methodology.
Level 4 Interdisciplinary Evaluation	 69

A basic mental health screening battery can be 

completed in about 10 to 15 minutes. The results 

can assist in determining the potential need to 

involve other disciplines in the patient’s clinical 

management. Further assessment of these conditions is performed by a mental health provider as 

indicated by results of the screening tests.

Anxiety and Depression

Screening for anxiety and depression can be performed using the Hospital Anxiety and Depression 

Scale (HADS—Appendix S) (Zigmond & Snaith, 

1983). This self-screening questionnaire consists 

of 14 questions—seven for anxiety and seven for 

depression. Patients should be instructed to complete this self-screening questionnaire by responding spontaneously to each item. The HADS has been 

used extensively in primary care settings (Wilkinson & Barczak, 1988).

Post-Traumatic Stress Disorder

The Primary Care PTSD screening tool (PC-PTSD) 

(Prins et al., 2004) is available to detect possible 

PTSD, and to initiate appropriate referral (Appendix T). The PC-PTSD was designed for use in 

primary care and other medical settings and currently is used widely to screen for PTSD in military 

veterans. The four-item instrument enables rapid 

screening with high sensitivity but low specificity. 

The PC-PTSD is effective for capturing patients 

who require further evaluation for possible PTSD 

(although patients can have active symptoms and 

screen negative).

Other Mental Health Conditions

The disorder-specific screening tools that are recommended (HADS and PC-PTSD) address mental 

health disorders that have been observed commonly to co-occur with tinnitus. Use of these tools, 

however, does not adequately address the range 

of other mental health problems that can exist in 

these patients (see Chapter 5). Another approach 

to screening for mental health problems is to use 

a symptom checklist, which often is included as 

part of general intake questionnaires in medical 

clinics. Use of a symptom checklist might reduce a 

patient’s perceived stigma of mental health problems. Systematic screening using screening tools 

or checklists can be helpful, but is not necessary to 

justify referring a patient to a provider of a different 

discipline. The reason for referral often is simply 

that the clinician perceives that there are problems 

outside his or her field of expertise.

Sleep Disorders

As discussed in Chapter 5, sleep disorders are the 

most common problem reported by patients seeking clinical services for tinnitus, especially those 

with the most severe tinnitus problem. A brief 

questionnaire is available to screen patients for 

sleep disorders: the Epworth Sleepiness Scale (ESS

—Appendix U) (Johns, 1991). The ESS is the most 

widely used standardized tool for assessing “sleepiness.” Completing the ESS provides an index score 

that can be compared to normative data. A score of 

10 or more on the ESS suggests that the patient is not 

getting adequate sleep (for any reason), and may 

need to be referred to a physician for an evaluation.

In addition to insomnia, there are many 

other categories of sleep disorders. These include 

difficulty initiating and maintaining sleep, and 

sleep-phase disorders. These disorders usually are 

behaviorally based, responsive to behavioral interventions, and do not necessarily require specialty 

care (although sleep-phase disorders are best evaluated by a sleep clinic).

More serious categories of sleep disorder 

include sleep apneas and sleep-disordered breathing, REM behavior disorders, and narcolepsy. 

These can be serious medical conditions (especially 

sleep-disordered breathing, which can increase 

the risk of stroke) that warrant medical treatment 

with medications or other devices. Screening for 

sleep apneas/sleep-disordered breathing usually 

includes questions about snoring, morning headaches, waking with gasping or choking, and asking 

if a bed partner notices any of these things. People with sleep apnea often spend sufficient time 

sleeping but still do not feel rested in the morning. 

Sleep apneas and sleep-disordered breathing, REM 
70	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

behavior disorders, and narcolepsy generally are 

very pronounced and are conditions that usually 

are not related to tinnitus. Tinnitus-related insomnia generally does not necessitate referral to a sleep 

clinic unless the patient also reports symptoms 

of sleep-disordered breathing (snoring, morning 

headaches, etc.).

If a sleep disorder is due primarily to the 

patient reacting to tinnitus when attempting to 

sleep, then implementing the strategies offered by 

PTM may be sufficient to restore normal sleep patterns (see Chapter 5—Managing Sleep Disorder). 

Therapeutic sound can be highly effective in the 

sleep environment. Patients should learn the different combinations of using sound to optimize the 

potential for therapeutic sound to be helpful. These 

patients also may benefit from learning basic information about sleep hygiene such as limiting daytime napping, keeping a regular sleep schedule, 

and other behaviors that encourage sleep. In the 

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

Appendix I provides three pages of “tips for getting better sleep.”

Re-Administer Written 

Questionnaires at Level 4

Every patient who attends the Level 4 Interdisciplinary Evaluation should have completed all testing that normally is done at the Level 2 Audiologic 

Evaluation. At the Level 2 appointment, patients 

completed the Tinnitus and Hearing Survey (see 

Appendix D), Tinnitus Handicap Inventory (see 

Appendix F), and Hearing Handicap Inventory 

(see Appendix G). Patients should complete each 

of these written questionnaires again at the Level 4 

appointment with the audiologist. Readministering these questionnaires enables a comparison of 

responses between the Level 2 and Level 4 appointments, which can reveal any longitudinal changes 

in a patient’s self-perception of hearing and/or 

tinnitus handicap. The information obtained from 

the written questionnaires comprises an important 

component of the Level 4 evaluation. The structured interview would be incomplete without this 

information.

Administer the Tinnitus Interview

Although the use of written tinnitus questionnaires 

is advocated for all tinnitus patients, these questionnaires are insufficient for patients who reach 

Level 4. A supplemental tinnitus-specific interview 

(Tinnitus Interview—see Appendix R), which facilitates face-to-face structured dialogue with the 

patient, is necessary to capture the information 

needed to make decisions for clinical services at 

this level and helps to build rapport between 

patient and clinician. The patient’s responses to the 

Tinnitus and Hearing Survey (THS) in conjunction 

with the Tinnitus Interview are the most important 

components of the audiologic portion of the Level 

4 Interdisciplinary Evaluation. The interview offers 

a uniform format for asking questions and for 

recording responses. It should be completed in 

about 45 minutes, although its time of administration can vary considerably depending mostly on 

the extent of the patient’s problems.

The Tinnitus Interview is designed to supplement the THS during Level 4—it is not a standalone interview. Results of the THS should first be 

reviewed with the patient, after which the interview can be administered if appropriate. Reviewing the THS results provides both the patient and 

clinician with a good understanding of the patient’s 

current perception of problems with tinnitus, hearing, and loudness tolerance. This discussion gives 

the clinician opportunity to explain to the patient 

the types of intervention available for each of these 

auditory problems.

If it is confirmed that the patient has a tinnitusspecific problem and is interested in tinnitus-specific 

intervention, then the next step is to conduct the 

Tinnitus Interview. It should be noted that the Tinnitus Interview does not cover information that 

most likely was discussed during the case history 

performed during the Level 2 Audiologic Evaluation. The case history normally would obtain a 

description of the tinnitus (loudness, pitch, timbre, 

perceived location, symmetry/asymmetry, constancy versus intermittency, and so on) and the circumstances of its onset. It may be helpful to review 

the case history before administering the Tinnitus 

Interview. However, it is important not to focus on 

what the tinnitus sounds like since the purpose of 
Level 4 Interdisciplinary Evaluation	 71

intervention is to assist the patient in learning how 

to manage reactions to tinnitus—not to attempt to 

change the sound of the tinnitus.

Question 1: Does the loudness of your 

tinnitus change on its own?

Tinnitus loudness may seem to change due to:

n Exposure to certain sounds

n Eating certain foods

n Being under extreme stress

n Being sleep deprived

n New medications or changes in dosage

n Changes in daily acoustic environment.

The patient’s answer to this question should not 

reflect these types of events. The purpose of the 

question is to determine whether the tinnitus fluctuates in loudness on its own, and if so, how often. 

“On its own” thus refers to naturally occurring 

changes in tinnitus loudness, that is, there is no 

external factor that precipitates the change.

Spontaneous changes in loudness can be associated with the tinnitus being more or less bothersome, that is, when the tinnitus is louder it tends to 

be more intrusive and annoying; when it is softer it 

might not be noticed as much. With PTM, patients 

are taught how to manage situations when their 

tinnitus is bothersome. With spontaneous changes 

in tinnitus loudness, these bothersome situations 

might be contingent on the loudness of the tinnitus.

Question 2: Do sounds ever change the 

loudness of your tinnitus? What kinds of 

sounds make your tinnitus louder? 

When sound makes your tinnitus louder, 

how long does the change last?

Patients occasionally report that exposure to certain sounds causes an increase in the loudness of 

their tinnitus (P. J. Jastreboff & Hazell, 2004). Dangerously loud sounds would be expected to cause 

this effect. One of the response options is “very 

loud sounds.” If this is the patient’s response, 

then exacerbation of tinnitus by sound most likely 

would be a normal effect and the patient should 

be counseled regarding hearing conservation. The 

intent of the question, however, is whether sounds 

at nondamaging levels cause the tinnitus to increase in loudness. If this is experienced, then the 

effect usually lasts minutes or hours. Of most concern is whether the effect lasts until at least the 

next day.

It may be helpful for patients who experience 

a prolonged tinnitus-exacerbation effect due to 

sound to carry earplugs so as to remain prepared 

for unavoidable situations that could trigger the 

exacerbation. Custom-fit high-fidelity/musicians 

earplugs usually are considered comfortable and 

they minimize distortion of sound. Patients must 

be cautioned, however, to avoid overuse of earplugs 

that could further increase their sensitivity to sound 

(Formby et al., 2002). Patients who experience prolonged exacerbation of tinnitus from sound also 

may require intervention for hyperacusis (see 

Chapter 6).

Question 3: How does your tinnitus 

affect you (not including trouble hearing 

or understanding speech)?

This question supplements the questions from Section A of the THS, which mentions specific life situations that commonly are affected by tinnitus. It is 

important to ask this open-ended question so that 

patients identify, without any prompting, the most 

bothersome aspects of their tinnitus. As always, it 

is important to ensure that patients do not confuse 

their tinnitus complaints with “trouble hearing or 

understanding speech.” A patient’s answer to Question 3 should indicate the primary complaint(s) that 

will be targeted by the intervention.

Question 4: Please tell me about 

everything you tried for your tinnitus 

prior to PTM. For each effort, what were 

you hoping would happen, and what 

actually did happen?

This question includes a note to the clinician, which 

helps to clarify the intent of asking the question:
72	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Clinician: Sometimes a pattern will emerge showing 

that the patient has made repeated (unsuccessful) 

attempts to make the tinnitus quieter, resulting in 

frustration and distress. If this is the case, try to ensure 

that the patient begins to see this pattern more clearly.

The discussion elicited by this question is useful 

to both the clinician and patient as they identify 

everything the patient has attempted for tinnitus 

management and the effectiveness of each effort. 

In the process, it may become evident that the 

patient made repeated attempts to quiet the tinnitus and that each unsuccessful effort compounded 

the distress. The clinician should help the patient 

recognize if this has been the pattern of previous 

attempts to manage tinnitus. If so, then the clinician should clarify that the goal of intervention with 

PTM never is to change the tinnitus, and to explain 

the rationale for this approach. Throughout the 

course of PTM a patient might unintentionally slip 

back into the pattern of trying to change the tinnitus; if the clinician understands the patient’s history 

of attempts to change the tinnitus and the results of 

those attempts, then the clinician can gently remind 

the patient of that unsatisfactory history.

Question 5: Please tell me about the 

sounds you have used to manage your 

reactions to tinnitus since starting PTM. 

For each sound you tried, what were you 

hoping would happen, and what actually 

did happen?

As for Question 4, this question includes a note to 

the clinician to clarify the question’s intent:

Clinician: if the patient has the Sound Plan Worksheets that were used during Level 3, these can be 

used to guide this interaction. It also is important 

to reinforce the idea that with PTM the goal is not 

to change the tinnitus, but rather to change how 

one feels.

The intent of this question is to determine the 

patient’s impressions regarding his or her experiences using therapeutic sound with PTM. It is helpful if any Sound Plan Worksheets (see Appendix N) 

used by the patient are available for discussion. The 

clinician should note any misunderstandings or 

unrealistic expectations regarding the use of sound 

and reinstruct the patient as necessary to ensure 

that expectations are realistic. It also is helpful for 

the clinician to identify any successes experienced 

by the patient so that they can be pointed out and 

built upon if the patient continues with PTM.

Question 6: If we decide to move ahead 

with one-on-one support, then we will be 

making plans for using sound to manage 

your reactions to tinnitus. It will be 

helpful to have a list of sound-producing 

devices that you have available to you. 

Which of the following devices do you own?

As for Questions 4 and 5, a note to the clinician is 

included to clarify the question’s intent:

Clinician: For each type of device listed below that 

the patient owns, provide additional details. For 

instance, if patients report they own a radio, ask: 

how many radios, if any of them are portable, and if 

not portable where it is located. For each device the 

patient owns, ask how it currently is being used relative to tinnitus management.

Patients sometimes overlook sources of sound that 

they already own that can be used to manage their 

reactions to tinnitus. Answering this question creates a fairly detailed list of all of these resources 

available to the patient. The list can be referred to 

whenever a Sound Plan Worksheet is created or 

modified. All of the items on the list should be those 

that the patient already owns or has access to. Creating this list also can lead to discussion concerning 

other types of sound-producing devices that might 

be helpful for future sound plans.

Psychoacoustic 

Assessment of Tinnitus

Psychoacoustic assessment of tinnitus generally is 

not recommended within the framework of PTM. 
Level 4 Interdisciplinary Evaluation	 73

This may seem surprising, so the rationale for this 

recommendation is provided below.

A tinnitus psychoacoustic assessment typically includes tinnitus loudness and pitch matching, finding the minimum masking level (MML) 

using broadband noise (BBN), and testing for 

residual inhibition (RI). Tinnitus loudness and 

pitch matching involves procedures designed to 

identify a pure tone or band of noise that matches 

as closely as possible the pitch and loudness of the 

tinnitus. MML testing consists of finding the level 

of BBN required to completely cover, or mask the 

tinnitus. RI refers to the phenomenon that tinnitus 

can be temporarily reduced or terminated following certain acoustic stimulation.

When these tests are performed, patients are 

asked to attend closely to their tinnitus and to the 

effects of different sounds on the tinnitus. Asking 

patients to pay close attention to the sound of their 

tinnitus is at cross purposes with the therapeutic 

goals of PTM. With PTM, patients are required to 

attend to how they feel, rather than to the sound 

of their tinnitus. Making the transition to attending to how they feel and their reactions to tinnitus 

rather than to the sound of tinnitus is difficult for 

many patients, but very important. It is important because patients usually cannot satisfactorily 

change the sound of their tinnitus, but they usually 

can change how they feel. Furthermore, for PTM, 

results of tinnitus psychoacoustic testing generally are not helpful for diagnostic purposes, for 

guiding intervention, or for assessing outcomes of 

intervention.

An argument sometimes made for performing these tests is that results of pitch matching 

can be useful when adjusting the frequency output of an ear-level sound generator. The hope is 

that providing more sound in the frequency range 

corresponding with the tinnitus pitch will result 

in improved masking of tinnitus. Such efforts are 

irrelevant and possibly counterproductive with 

respect to using therapeutic sound with PTM. For 

example, sound from an ear-level sound generator would be used either as background sound or 

soothing sound (see Chapter 7). If used as background sound, then achieving masking is of no 

consequence—the purpose of background sound 

is to reduce contrast between tinnitus and a quiet 

environment. If used as soothing sound, then the 

audiologist should adjust the frequency output of 

the sound generator to produce a soothing effect 

regardless of the effect on the tinnitus itself. Patients 

commonly report that some sounds are soothing 

or relaxing even if they have no effect on the tinnitus percept. Conversely, some patients report that 

sounds that mask their tinnitus are unacceptably 

loud, or are as unpleasant as the tinnitus itself. 

Therefore, for PTM, focusing on masking tinnitus by emphasizing sound in the frequency range 

that corresponds with the pitch match can hinder 

efforts to identify sounds that are soothing to the 

patient.

Another argument sometimes made is that 

results of MML testing can be useful in predicting 

which patients are likely to benefit from the use of 

ear-level noise/sound generators (alone or in combination with a hearing aid). The rationale behind 

this argument is that patients who require high 

levels of BBN to mask their tinnitus are more 

likely to require unacceptably high levels of sound 

from a sound generator to adequately mask their 

tinnitus. As explained above, masking tinnitus is 

not the goal of using sound with PTM. (Masking 

may occur, however, in the process of using sound 

for another therapeutic purpose.) With PTM, sound 

from an ear-level sound generator is used either 

as soothing sound or background sound—neither 

of which involves masking of tinnitus. Therefore, 

predicting that a patient is unlikely to benefit from 

the use of ear-level sound generators because 

of high MMLs may falsely lower expectations of 

benefit and could actually prevent a patient from 

discovering that using a sound generator can be 

helpful for providing soothing or background 

sound even if there is no effect on the sound of the 

tinnitus itself.

For these reasons tinnitus psychoacoustic testing is not recommended as part of the Level 4 Interdisciplinary Evaluation. However, PTM should be 

considered a framework within which flexibility 

is allowed (and even encouraged) to best meet 

the needs of individual clinical programs. Detailed 

instructions for tinnitus psychoacoustic testing 

have been published elsewhere (J. A. Henry, 2004; J. 

A. Henry, Zaugg, & Schechter, 2005a) for clinicians 

who wish to include it in their clinical protocol.
74	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

In-Clinic Trials of 

Ear-Level Instruments 

(optional procedures)

Patients who reach Level 4 have undergone a successive “filtering” process that provides reasonable assurance that their problem with tinnitus 

warrants individualized clinical attention. These 

patients generally require much more assistance 

than has been available to them up to this point. 

They also typically are motivated to try new strategies that might be helpful in managing their reactions to tinnitus.

At Level 4, all types of ear-level sound generators and combination instruments (and hearing 

aids) are viable options for intervention. (Please 

refer to the Flowchart for Assessment and Fitting of 

Ear-level Instruments—Appendix I). The normal 

protocol is to fit only hearing aids at Level 2. However, as noted in Chapter 5, new models of combination instruments provide full-feature hearing 

aids. These combination instruments can be fitted 

at Level 2, and, if so, then we would recommend 

that the noise generator portion be turned off until 

the patient has received the audiologic counseling 

that is provided at Level 3.

If results of the Tinnitus and Hearing Survey 

(see Appendix D), supplemented with the Tinnitus 

Interview (see Appendix R) suggest that a patient 

is a candidate for Level 5 Individualized Support 

from an audiologist, then—if the patient is amenable—it is appropriate to conduct in-clinic trials 

of ear-level instruments. It is important to perform 

in-clinic trials because it often is difficult to predict 

how a patient’s tinnitus (and reactions to tinnitus) 

will be affected by amplification, sound from an 

ear-level sound generator, or a combination of 

amplification plus sound generator. In-clinic trial 

use of ear-level instruments allows patients to make 

realistic, experience-based decisions about the 

potential effectiveness of the devices. It should 

be explained to patients that the purpose of the 

in-clinic trials is to evaluate the potential usefulness of the devices for ongoing management of 

reactions to tinnitus. Results of the trials are used to 

determine collaboratively if ear-level instruments 

will be provided before beginning Level 5 Individualized Support.

Three Categories of Patients at Level 4

Categorizing patients with respect to their candidacy for hearing aids is essential prior to the Level 

4 in-clinic trials of ear-level instruments. Different 

instruments are demonstrated depending on the 

patient’s category. Categories include: (a) obvious hearing aid candidate; (b) borderline hearing 

aid candidate; and (c) not a hearing aid candidate.

“Obvious hearing aid candidates” are patients 

who have hearing loss to such a degree that: 

(a) amplification would most likely ameliorate 

their communicative and other hearing problems; 

and (b) they are motivated to wear hearing aids. 

With PTM, hearing aids typically are fit at Level 2 

(see Appendix I). Therefore, at Level 4, most obvious hearing aid candidates will already be wearing 

hearing aids.

“Borderline hearing aid candidates” typically 

report “occasional hearing problems.” These patients 

tend to have mild to moderate sloping high-frequency sensorineural hearing loss. To be considered a borderline hearing aid candidate, patients 

must be motivated to wear hearing aids (for management of tinnitus and/or to improve hearing).

Which Ear-Level Instruments Should Be 

Demonstrated for Each Patient Category?

For “obvious” and “borderline” hearing aid candidates, in-clinic trials with hearing aids and combination instruments are conducted. (If the patient 

already is a hearing aid user, then an in-clinic trial 

using the patient’s current hearing aids should be 

performed.) Borderline hearing aid candidates also 

should be evaluated for noise generators.

For patients who are not hearing aid candidates, normally only in-clinic trials with noise 

generators should be conducted. However, some 

patients with essentially normal hearing will benefit from hearing aids that are optimized for patients 

with tinnitus (described later).
Level 4 Interdisciplinary Evaluation	 75

Special Forms to Guide In-Clinic Trials of 

Ear-Level Instruments

A series of four forms has been developed for use 

as guides to selecting ear-level instruments at the 

Level 4 Interdisciplinary Evaluation. These forms 

include:

n Guide to Trial Use of Ear-Level 

Instruments (Appendix V)

n In-Clinic Trial Use of Hearing Aids 

(Appendix W)

n In-Clinic Trial Use of Combination 

Instruments (Appendix X)

n In-Clinic Trial Use of Noise Generators 

(Appendix Y)

The first form (Guide to Trial Use of Ear-Level 

Instruments—Appendix V) gives an overview of 

which ear-level instruments should be tried in the 

clinic for patients who are:

n Obvious hearing aid candidates

n Borderline hearing aid candidates

n Not hearing aid candidates.

This form also contains a guide to discussing with 

patients results of the trials and collaboratively 

making decisions regarding the use of ear-level 

instruments during Level 5 Individualized Support. The other forms (In-Clinic Trial Use of Hearing 

Aids—Appendix W; In-Clinic Trial Use of Combination Instruments —Appendix X; In-Clinic Trial 

Use of Noise Generators—Appendix Y) provide 

detailed instructions for conducting the in-clinic 

trials. These forms also are used to record patient 

responses to each trial performed.

Clinic Inventory of Trial Ear-Level 

Instruments

A variety of ear-level instruments should be available to conduct in-clinic trials with patients. Because 

of potential sanitization concerns, in-the-ear (ITE) 

instruments are not recommended—only behindthe-ear (BTE) instruments with temporary disposable earmolds are used for in-clinic trial use. Certain 

supplies also should be on hand, such as temporary 

earmolds (in a variety of sizes with variable venting), vent plugs, and temporary feedback wraps.

Minimum Inventory of Ear-Level Instruments for 

In-Clinic Trial Use

The minimum inventory of ear-level instruments 

would be a single pair of BTE combination instruments (with disposable earmolds). If possible, the 

instruments should have an adjustable frequency 

response for both the amplifier and the noise generator. If trial instruments are limited to one set of 

BTE combination instruments, then these instruments can be used to demonstrate the potential 

benefit from:

Noise Generators Alone. BTE combination instruments can be used to demonstrate the benefit 

obtained from using ear-level noise generators (the 

hearing aid portion is turned off).

Hearing Aids Alone. BTE combination instruments can be used to demonstrate the benefit obtained from using hearing aids (the noise generator 

portion is turned off). The drawback is that the hearing aid portion of a combination instrument may 

be less flexible, less sophisticated, and have fewer 

features than a traditional hearing aid. Increasingly, new models of combination instruments do 

not sacrifice hearing aid features, so these potential 

drawbacks are becoming less of a concern.

Combined Noise Generator and Hearing Aid.

BTE combination instruments can be used to demonstrate the potential benefit from the simultaneous use of a noise generator and hearing aid (both 

are turned on at the same time).

Ideal Inventory of Ear-Level Instruments for 

In-Clinic Trial Use

The ideal inventory of stock ear-level instruments 

would include noise generators, combination 

instruments, and hearing aids. There should be a 

pair of each type of device to allow binaural trial 
76	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

fittings of each. If possible, more than one model/

make of noise generator and combination instrument should be available to demonstrate the different choices. Hearing aids that serve a wide fitting 

range should be on hand.

Personal listening devices and stationary 

devices such as tabletop sound conditioners, pillow 

speakers, and MP3 players loaded with interesting, 

soothing, and background sounds also should be 

available for patients to try as alternative therapeutic uses of sound if ear-level instruments are not 

advised or desired.

Maintaining Continuity Between Level 3 

Counseling and In-Clinic Trials

During the Level 3 Group Education workshops, 

patients learn about the three types of sound (soothing, background, interesting) that can be used to 

manage reactions to tinnitus (see Chapter 7). For 

the in-clinic trials to be most meaningful, patients 

need to be informed that the instruments can be 

used to provide an immediate sense of relief (soothing sound), to provide a background of sound 

to reduce the tinnitus/background contrast, and to 

improve access to interesting sound.

Need for Follow-Up If Patients Receive 

Ear-Level Instruments

Use of ear-level instruments for tinnitus requires 

ongoing support (Level 5 Individualized Support) 

from an audiologist, including continued development and assessment of strategies for using sound 

most effectively. This process is facilitated by using 

the Sound Plan Worksheet (see Appendix N), which 

should be reviewed at every appointment. Individualized support typically involves two to five 

visits over a period of up to 6 months. A patient 

who receives special ear-level devices during Level 

4 should attend at least two Level 5 appointments.

Fitting Appointment

If ear-level instruments were ordered for the patient, 

then they are fitted prior to the initial Level 5 

appointment. However, the fitting appointment 

can be combined with the initial Level 5 appointment (which makes for a very long appointment).

Summary of Ear-Level Instruments 

for PTM

Appropriate use of sound can be critically important for managing reactions to tinnitus. There are 

numerous options for using sound with ear-level 

instruments. Each option must be considered for 

the individual patient. A systematic approach 

is required to determine the best combination of 

instruments and sounds. The patient makes the 

final decision, and the clinician facilitates the decision making process and provides a selection of 

sounds and instruments.

Criteria for Patients to Progress 

to Level 5 Individualized Support

Following completion of the Level 4 Interdisciplinary Evaluation for a patient, ideally the psychologist, audiologist, and patient decide collaboratively 

if the patient will initiate Level 5 Individualized 

Support with the psychologist and/or audiologist. 

Patients must meet the following criteria to be considered for Level 5 Individualized Support:

n Levels 1 to 4 of PTM have not adequately 

addressed their tinnitus concerns.

n They have been evaluated and referred as 

appropriate for care in other clinics.

n They understand the nature of the PTM 

services available from the psychologist 

and audiologist (including device options 

and potential duration of intervention).

n They are motivated and capable of 

participating in the activities proposed by 

the psychologist and/or audiologist.

If Level 5 Individualized Support is initiated with 

both the psychologist and audiologist, it is best if the 

clinicians remain in regular contact regarding the 

patient’s progress within each of the disciplines.