APPENDIX

95

PTM Flowchart

A

Tinnitus plus ALL of the 

below

 - Symptoms suggest neural

 origin of tinnitus (e.g., 

 tinnitus does not pulse with

 heartbeat)

 - No ear pain, drainage, or

 malodor

 - No vestibular symptoms 

 (e.g., no dizziness/vertigo)

 - No unexplained sudden

 hearing loss or facial palsy

Tinnitus plus ANY of

the below

 - Suicidal ideation

 - Obvious mental

 health problems

Tinnitus plus ANY of

the below

 - Physical trauma

 - Facial palsy

 - Sudden unexplained 

 hearing loss

Tinnitus plus ANY of

the below

 - Symptoms suggest 

 somatic origin of tinnitus

 (e.g., tinnitus that pulses 

 with heartbeat)

- Ear pain, drainage, or

 malodor

 - Vestibular symptoms

 (e.g., dizziness/vertigo)

Level 1 Triage

Triage Guidelines (for non-audiologists)

Refer to 

Mental Health or 

Emergency Care - 

report suicidal 

ideation

Refer to Audiology

(non-urgent referral)

Refer to ENT

(urgency determined by 

clinician; refer to audiologist 

for follow-up management)

Refer to Emergency 

Care or ENT 

(if unexplained sudden hearing

loss: Audiology referral prior to

ENT visit same day)

Level 5 Individualized Support

Level 4 Interdisciplinary Evaluation

Level 3 Group Education

Level 2 Audiologic Evaluation

Refer as necessary to

ENT, Mental Health,

or other specialist

if needed

if needed

if needed

if needed

if needed

Sound Tolerance

Evaluation &

Management

(STEM)

APPENDIX

97

Tinnitus Triage Guidelines

(My Patient Complains About Tinnitus—

What Should I Do?)

Tinnitus (“ringing in the ears”) is experienced by 

10 to 15% of the adult population. Of those, about 

one out of every five requires some degree of 

clinical intervention. When clinical intervention 

is required, often only some basic education is 

needed. However, some people with tinnitus have 

need for individualized care, or they have urgent 

medical issues. The following are general guidelines for triaging the patient who complains about 

tinnitus. Note that many symptoms that might be 

reported by patients are not included. For example, 

patients who report tinnitus may also report symptoms of head or neck injury/disease, or of TMJ disorder. These and other symptoms would indicate 

referral to appropriate specialists.

B

If the patient: Refer to:

1. 

•  Has physical trauma,facial palsy, or unexplained

sudden hearing loss

•  Has any other urgent medical condition

Emergency Care or Otolaryngology (If unexplained

sudden hearing loss—Audiology referral prior to

Otolaryngology visit same day)

(emergency referral)

2.

•  Has suicidal/homicidal ideations

•  Manifests obvious mental health problems

Emergency Care or Mental Health—report suicidal/

homicidal ideation

(may be emergency—if so, escort patient to Emergency

Care or Mental Health)

3.  Has ANY of the following:

• Symptoms suggest somatic origin of tinnitus

(example: tinnitus that pulses with heartbeat)

•  Ear pain, drainage, or malodor

•  Vestibular symptoms (example: dizziness/vertigo)

Otolaryngology

(urgency determined by clinician;refer to audiologist for

follow-up management)

4.  Has ALL of the following:

• Symptoms suggest neural origin of tinnitus (example:

tinnitus that does not pulse with heartbeat)

•  No ear pain, drainage, or malodor

•  No vestibular symptoms (example:no

dizziness/vertigo)

•  No unexplained sudden hearing loss or facial palsy

Audiology

APPENDIX

99

Overview of 

Objectives and Procedures of the 

Level 2 Audiologic Evaluation

C

Determine need for: Assessment procedures: Action needed:

1.  Referral for medical

examination

Standard clinical procedures Refer to otolaryngology

2.  Hearing aids or assistive

listening devices

Standard clinical procedures Fit devices as appropriate

3.  Level 3 Group

Education

Discuss with patient the responses to the

Tinnitus and Hearing Survey (primarily

Section A) (Appendix D). If the patient is

interested in attending a workshop that

focuses on managing problems listed in

section A then action is needed.

Schedule patient for group workshops

(after fitting of any instruments)

4.  Provision of Loudness

Tolerance Handout:

“What to DoWhen

Everyday Sounds Are

Too Loud” (Appendix E)

Review item 1 from Section C of

the Tinnitus and Hearing Survey

(Appendix  D). If the patient reports at

least a mild loudness tolerance problem,

then action is needed.

Provide a copy of the handout to the

patient with a brief explanation of its

purpose

5. Assessment for a

loudness tolerance

problem

Discuss with the patient the responses to

the Tinnitus and Hearing Survey (primarily

item 2 from Section C) (Appendix D).

If the patient reports that a loudness

tolerance problem would make it difficult

to attend a group education class, then

action is needed.

Schedule the patient for a Sound

Tolerance Evaluation and Management

(STEM) appointment. Suspend Level

3 of PTM until the sound tolerance

problem is resolved.

6.  Mental health screening Screening is done at Level 2 only if the

patient exhibits behaviors or makes

statements that would suggest the need

for mental health screening

Refer patient to a mental health

provider that is part of the “PTM or

tinnitus team,” or to primary care for

mental health screening

7.  Provision of self-help

education workbook:

How to Manage Your 

Tinnitus: A Step-by-Step 

Workbook

Patients who have problematic tinnitus

should be advised to attend Level 3 Group

Education.The workbook normally is

provided to patients at the start of the

first Level 3 workshop.

Issue a workbook at the end of

Level  2 only if the patient cannot or will 

not attend Level 3 Group Education. If

time permits, point out sections of the

workbook that are applicable to the

patient’s situation.

APPENDIX

101

Tinnitus and Hearing Survey

D

A. Tinnitus

Over the last week, tinnitus kept me from

sleeping.

Over the last week, tinnitus kept me from

concentrating on reading.

Over the last week, tinnitus kept me from

relaxing.

Over the last week, I couldn’t get my mind 

off of my tinnitus.

No,

not a 

 problem

Yes, a 

small

 problem

Yes, a 

moderate

 problem

Yes, a 

big

 problem

Yes, a very big

 problem

0 1 2 3 4 

0 1 2 3 4 

0 1 2 3 4 

0 1 2 3 4 

Grand 

Total

Total of each column

0 1 2 3 4 

0 1 2 3 4 

0 1 2 3 4 

0 1 2 3 4 

Grand Total

Total of each column

0 1 2 3 4 

0 1 2 3 4 

B. Hearing

Over the last week, I couldn’t understand what

others were saying in noisy or crowded places.

Over the last week, I couldn’t understand what 

people were saying on TV or in movies.

Over the last week, I couldn’t understand

people with soft voices.

Over the last week, I couldn’t understand what 

was being said in group conversations.

C. Sound Tolerance

Over the last week, everyday sounds were too

loud for me.*

If you responded 1, 2, 3 or 4 to the statement

above:

Being in a meeting with 5 to 10 people

would be too loud for me.*

*If sounds are too loud for you when wearing hearing aids, please tell your audiologist. 

APPENDIX

103

What to Do When Everyday 

Sounds Are Too Loud

(Not related to using hearing aids)

E

Bill Smith is bothered by everyday sounds. (This problem is sometimes called hyperacusis.) Kitchen sounds 

and the vacuum cleaner are too loud for him. He is bothered by road noise when he drives. It seems like everything at church is too loud. What should Bill do? Believe 

it or not, being around more sound can make things better! And, staying away from sound can make his problem worse! What??? He should add more sound??? 

Keep reading and we’ll explain . . . 

There are three things you can do if everyday 

sounds are too loud for you.

1. Keep yourself surrounded with sound that is 

comfortable for you.

2. Listen to sounds that you enjoy as often as you 

can.

3. Only wear hearing protection when you really 

need to.

1. Keep yourself surrounded with sound 

that is comfortable for you.

Why should I keep myself surrounded with 

sound? Let’s start by thinking about your eyes and 

how they adjust to light. Imagine sitting in a dark 

movie theater and then going outside into the daylight. Everything seems brighter to you than it does 

to people who were not sitting in the dark. Your 

eyes had adjusted to the dark and now they have 

to readjust to the daylight.

Your ears adjust to sound like your eyes adjust 

to light. If you stay away from sound, your ears will 

slowly adjust to the quiet. After a while, everyday 

sounds will seem louder and harder to tolerate. 

Avoiding sound will only make the problem worse.

If you keep yourself surrounded with sound, 

your ears will readjust. It will slowly become easier 

for you to tolerate everyday sounds. You should 

only use sounds that are comfortable for you. It 

usually takes at least a few weeks of being around 

sound for this change to happen.

How do I keep myself surrounded with sound? 

You can use any sound that is not annoying (the 

sound can be either neutral or pleasant). Here are 

some ideas:

n Listen to music at a comfortable level.

n Listen to radio shows.

n Play recordings of nature sounds.

n Keep a fan running.

n Use a tabletop water fountain.

Another choice: Some people wear small instruments in their ears that make a “shhh” sound. 

These instruments are called in-the-ear noise generators or maskers. Your audiologist can tell you more 

about them.

2. Listen to sounds that you enjoy as often 

as you can.

Why should I listen to sounds that I enjoy as 

often as I can? We just talked about the problem 

of everyday sounds being too loud (hyperacusis). 

Many people also have another problem: they just 

don’t like certain sounds, but not because they are too 

loud. (This problem is sometimes called misophonia.) 

If you don’t like certain sounds, you should make a 

point of listening to sounds that you enjoy. Spending time enjoying sound can help you get better at 

tolerating everyday sounds that you don’t like. 
	104 Progressive Tinnitus Management:  Clinical Handbook for Audiologists

3. Only wear hearing protection when you 

really need to.

Why should I use ear protection only when 

I really need to? When everyday sounds seem 

too loud, some people start using ear protection 

all the time. Remember that avoiding sound will 

make the problem worse. Only use ear protection 

when sounds are dangerously loud or uncomfortably loud. As soon as the sound around you is at a 

safe and comfortable level, take the ear protection 

off. The goal is to wear ear protection only when 

needed.

Use earplugs or earmuffs only when:

n sounds around you are uncomfortably 

loud

n you are around dangerously loud sounds 

like:

n lawn mowers

n loud concerts

n power tools

n guns

n etc.

Is there any research?

Yes. In 2002 Formby, Sherlock, and Gold1 studied 

sound tolerance.

n There were two groups of people:

1. One group wore earplugs for 2 weeks.

2. The other group wore in-the-ear sound 

generators (“maskers”) that make a 

“shhh” sound.

n After 2 weeks:

n The people who wore earplugs could 

tolerate less sound than before.

n The people who wore sound generators 

could tolerate more sound than before.

n This study showed that:

n Adding sound makes it easier to 

tolerate sound.

n Staying in quiet makes it harder to 

tolerate sound.

Bottom line

If everyday sounds bother you:

n Surrounding yourself with comfortable 

sound will help.

n Avoiding sound will make the problem 

worse.

How long does it take?

It can take weeks or months for your ears to adjust.

Talk to your audiologist if you have any questions.

1

“Adaptive Calibration of Chronic Auditory Gain: Interim Findings,” by C. Formby, L. P. Sherlock, & S. L. Gold, 2002, In 

Proceedings of the VIIth International Tinnitus Seminar (pp. 165–169) by R. Patuzzi (Ed.), Crawley, Australia: University of 

Western Australia.
105

Tinnitus Handicap Inventory

Instructions: The purpose of this questionnaire is to identify problems your tinnitus may be causing you. 

Check Yes, Sometimes, or No for each question. Do not skip a question. 

Yes 

(4)

Sometimes 

(2)

No 

(0)

1F Because of your tinnitus, is it difficult for you to concentrate?  ̃  ̃  ̃

2F Does the loudness of your tinnitus make it difficult for you to hear people?  ̃  ̃  ̃

3E Does your tinnitus make you angry?  ̃  ̃  ̃

4F Does your tinnitus make you feel confused?  ̃  ̃  ̃

5C Because of your tinnitus, do you feel desperate?  ̃  ̃  ̃

6E Do you complain a great deal about your tinnitus?  ̃  ̃  ̃

7F Because of your tinnitus, do you have trouble falling to sleep at night?  ̃  ̃  ̃

8C Do you feel as though you cannot escape your tinnitus?  ̃  ̃  ̃

9F Does your tinnitus interfere with your ability to enjoy social activities (such

as going out to dinner, to the movies)?

 ̃  ̃  ̃

10E Because of your tinnitus, do you feel frustrated?  ̃  ̃  ̃

11C Because of your tinnitus, do you feel that you have a terrible disease?  ̃  ̃  ̃

12F Does your tinnitus make it difficult for you to enjoy life?  ̃  ̃  ̃

13F Does your tinnitus interfere with your job or household responsibilities?  ̃  ̃  ̃

14F Because of your tinnitus, do you find that you are often irritable?  ̃  ̃  ̃

15F Because of your tinnitus, is it difficult for you to read?  ̃  ̃  ̃

16E Does your tinnitus make you upset?  ̃  ̃  ̃

17E Do you feel that your tinnitus problem has placed stress on your relationship

with members of your family and friends?

 ̃  ̃  ̃

18F Do you find it difficult to focus your attention away from your tinnitus and on

other things?

 ̃  ̃  ̃

19C Do you feel that you have no control over your tinnitus?  ̃  ̃  ̃

20F Because of your tinnitus, do you often feel tired?  ̃  ̃  ̃

21E Because of your tinnitus, do you feel depressed?  ̃  ̃  ̃

22E Does your tinnitus make you feel anxious?  ̃  ̃  ̃

23C Do you feel that you can no longer cope with your tinnitus?  ̃  ̃  ̃

F

APPENDIX

continues
106

Yes 

(4)

Sometimes 

(2)

No 

(0)

24F Does your tinnitus get worse when you are under stress?  ̃  ̃  ̃

25E Does your tinnitus make you feel insecure?  ̃  ̃  ̃

Total ____ ____ ____

F denotes an item on the functional subscale; E, an item on the emotional subscale; and C, an item on the catastrophic response

subscale.

From “Development of the Tinnitus Handicap Inventory,” by C. W. Newman, G. P. Jacobson, & J. B. Spitzer, 1996, Archives 

of Otolaryngology-Head and Neck Surgery, 122, 143–148. Reprinted with permission.

Appendix F continued
107

Tinnitus Handicap Inventory

Screening Version

Instructions: The purpose of this questionnaire is to identify problems your tinnitus may be causing you. 

Check Yes, Sometimes, or No for each question. Do not skip a question. 

Yes 

(4)

Sometimes 

(2)

No 

(0)

  1 Because of your tinnitus, is it difficult for you to concentrate?  ̃  ̃  ̃

  2 Do you complain a great deal regarding your tinnitus?  ̃  ̃  ̃

  3 Do you feel as though you cannot escape your tinnitus?  ̃  ̃  ̃

  4 Does your tinnitus make you feel confused?  ̃  ̃  ̃

  5 Because of your tinnitus, do you feel frustrated?  ̃  ̃  ̃

  6 Do you feel that you can no longer cope with your tinnitus?  ̃  ̃  ̃

  7 Does your tinnitus make it difficult for you to enjoy life?  ̃  ̃  ̃

  8 Does your tinnitus make you upset?  ̃  ̃  ̃

  9 Because of your tinnitus, do you have trouble falling asleep at night?  ̃  ̃  ̃

10 Because of your tinnitus, do you feel depressed?  ̃  ̃  ̃

Total ____ ____ ____

From “Development and Psychometric Adequacy of the Screening Version of the Tinnitus Handicap Inventory,” by C. W. 

Newman, S. A. Sandridge, & L. Bolek, 2008, Otology and Neurotology, 29(3), 276–281. Reprinted with permission.

APPENDIX

109

Hearing Handicap Inventory—E

Screening Version

Please answer the following questions based on your last two weeks.

Yes 

(4)

Sometimes 

(2)

No 

(0)

  1. Does a hearing problem cause you to feel embarrassed when you meet new

people?

 ̃  ̃  ̃

  2. Does a hearing problem cause you to feel frustrated when talking to

members of your family?

 ̃  ̃  ̃

  3. Do you have difficulty when someone speaks in a whisper?  ̃  ̃  ̃

  4. Do you feel handicapped by a hearing problem?  ̃  ̃  ̃

  5. Does a hearing problem cause you difficulty when visiting friends,relatives, or

neighbors?

 ̃  ̃  ̃

  6. Does a hearing problem cause you to attend religious services less often than

you would like?

 ̃  ̃  ̃

  7. Does a hearing problem cause you to have arguments with family members?  ̃  ̃  ̃

  8. Does a hearing problem cause you difficulty when listening to TV or radio?  ̃  ̃  ̃

  9. Do you feel that any difficulty with your hearing limits or hampers your

personal or social life?

 ̃  ̃  ̃

10. Does a hearing problem cause you difficulty when in a restaurant with relatives

or friends?

 ̃  ̃  ̃

Total ____ ____ ____

G

From “Identification of Elderly People with Hearing Problems,” by I. M. Ventry, & B. E. Weinstein, 1983, Asha, 25(7), 37–42. 

Reprinted with permission.

APPENDIX

111

Tinnitus Problem Checklist

1. My most bothersome tinnitus situation is:

 ̃ Falling asleep at night  ̃ Relaxing in my recliner

 ̃ Staying asleep at night  ̃ Napping during the day

 ̃ Waking up in the morning  ̃ Planning activities

 ̃ Reading  ̃ Driving

 ̃ Working at the computer  ̃ Other ________________________

Write your answer on #1 of the Sound Plan Worksheet. Copies of the worksheet can be found at the 

end of the self-help workbook.1

2. My second most bothersome tinnitus situation is:

 ̃ Falling asleep at night  ̃ Relaxing in my recliner

 ̃ Staying asleep at night  ̃ Napping during the day

 ̃ Waking up in the morning  ̃ Planning activities

 ̃ Reading  ̃ Driving

 ̃ Working at the computer  ̃ Other ________________________

Write your answer on #1 of a separate Sound Plan Worksheet.

3. My third most bothersome tinnitus situation is:

 ̃ Falling asleep at night  ̃ Relaxing in my recliner

 ̃ Staying asleep at night  ̃ Napping during the day

 ̃ Waking up in the morning  ̃ Planning activities

 ̃ Reading  ̃ Driving

 ̃ Working at the computer  ̃ Other ________________________

Write your answer on #1 of a separate Sound Plan Worksheet.

H

1

How to Manage Your Tinnitus: A Step-by-Step Workbook, by J. A. Henry, T. L. Zaugg, P. M. Myers, & C. M. Kendall, 2010, San 

Diego, CA: Plural Publishing, Inc. Reprinted with permission.

APPENDIX

113

Flowchart for Assessment and 

Fitting of Ear-Level Instruments

Level 1 is the triage level and does not involve 

audiology services. The focus of this flowchart is 

to show how decisions normally are made regarding the evaluation and fitting of different ear-level 

instruments (hearing aids, noise generators, and 

combination instruments) that can be used for tinnitus management. As noted in Chapter 5, new 

models of combination instruments do not sacrifice hearing aid performance. These devices can be 

fitted at Level 2, but it is recommended that the 

sound/noise generator be turned off until after 

the patient has attended at least the first session of 

Level 3 Group Education. 

I

Level 5 Individualized Support

Level 2 Audiologic Evaluation

Level 3 Group Education

Level 4 Interdisciplinary Evaluation

Fit hearing aids

Further intervention needed?

Further intervention needed?

Further intervention needed?

Candidate for ear-level devices?

In-clinic trials of 

devices - fit as needed

Hearing aid candidate?

Intervention complete

Yes No

Yes No

Yes No

No

No

Yes

Yes

APPENDIX

115

Level 2 Audiologic Evaluation:

Special Considerations for Hearing Aids

1. Some patients are obvious hearing aid candidates. Fit them with hearing aids as you normally 

would, except try to incorporate the following hearing aid features that are important for tinnitus 

management:

A. Use open-ear fitting if possible (or maximum venting)

B. Use feedback reduction circuitry to enable most open fitting

C. Ensure that any feature for reducing circuit noise (e.g., expansion) can be disabled—internal/

floor noise can be desirable for tinnitus

D. Ensure that any feature for reducing environmental noise can be disabled

2. Some patients are borderline hearing aid candidates. Be more open to trying hearing aids with 

these patients than for patients who do not have a tinnitus problem. Explain to these patients 

that hearing aids can help with both hearing problems and tinnitus problems.

A. Consider hearing aids for borderline hearing aid candidates if:

1) Patient is motivated to try hearing aids for the purpose of improving communicative and 

other hearing problems

 AND/OR

2) Patient is motivated to try hearing aids for the purpose of amplifying environmental sound 

to reduce tinnitus intrusiveness

B. Incorporate the hearing aid features listed above that are important for tinnitus management.

J

APPENDIX

117

Sound Tolerance Interview

[Note to clinician: Use this interview only if the patient already has reported a sound tolerance problem.]

Instructions to patients: You told me that some sounds are too loud for you when they seem normal to 

other people around you. We refer to this as trouble tolerating sound. I am going to ask you some 

questions about trouble tolerating sound. When you answer the questions, think back to how you have 

been doing over the last week.

1. Do you wear hearing aids?

 ̃ No—go to Question 2

 ̃ Yes

(If YES) Are everyday sounds too loud when you are wearing your hearing aids?

 ̃ No

 ̃ Yes

(If YES) Are everyday sounds too loud when you are not wearing your hearing aids?

 ̃ No

 ̃ Yes

[Note to clinician: If the sound tolerance problem appears to be caused by sounds amplified by 

hearing aids, consider making compression, MPO, and/or other adjustments to the aids to improve 

comfort. If the patient is not bothered by sound when unaided, then it is possible that all that is 

needed is to adjust the hearing aids for comfort.]

2. How does trouble tolerating sound affect your life?

________________________________________________________________________________________

3. On a scale of 0 to 10, how much does trouble tolerating sound affect your life?

(“0” would be “not at all”; “10” would be “as much as you can imagine.”)

(not at all) 0 1 2 3 4 5 6 7 8 9 10 (as much as you 

can imagine)

4. What kinds of sounds are too loud for you?

[Clinician: check all categories that apply; circle any sounds that the patient identifies as a problem; 

write in any additional sounds mentioned by the patient.]

 ̃ Higher pitched sounds (squeals, squeaks, beeps, whistles, rings, ___________________________)

 ̃ Lower pitched sounds (bass from radio, next-door music, ___________________________)

K

continues
	 118 Progressive Tinnitus Management:  Clinical Handbook for Audiologists

 ̃ Traffic (warning) sounds (emergency vehicle sirens, car horns, backup beeper on truck/van, 

___________________________)

 ̃ Traffic (background) sounds (road noise, road construction, diesel engines, garbage trucks, 

___________________________)

 ̃ Sudden impact sounds (door slam, car backfiring, objects dropping on floor, dishes clattering, 

___________________________)

 ̃ Voices (television, radio, movies, children’s voices, dog barking, ___________________________)

 ̃ Other (describe ___________________________)

5. I’m going to read a list of activities. I want you to tell me how often trouble tolerating sound is a 

problem during these activities.

[Clinician: check avoids if the patient avoids any of these activities due to trouble tolerating sound; 

if an activity is avoided, you can check two boxes for that activity.]

Never Rarely Sometimes Often Always N/A Avoids

a. Concerts?  ̃  ̃  ̃  ̃  ̃  ̃  ̃

b. Shopping?  ̃  ̃  ̃  ̃  ̃  ̃  ̃

c. Movies?  ̃  ̃  ̃  ̃  ̃  ̃  ̃

d. Work? (select N/A if retired)  ̃  ̃  ̃  ̃  ̃  ̃  ̃

e.   Day-to-day responsibilities

outside of work?

 ̃  ̃  ̃  ̃  ̃  ̃  ̃

f. Going to restaurants?  ̃  ̃  ̃  ̃  ̃  ̃  ̃

g. Driving?  ̃  ̃  ̃  ̃  ̃  ̃  ̃

h.   Participating in or observing

sports events?

 ̃  ̃  ̃  ̃  ̃  ̃  ̃

i. Attending church?  ̃  ̃  ̃  ̃  ̃  ̃  ̃

j. Housekeeping activities?  ̃  ̃  ̃  ̃  ̃  ̃  ̃

k. Child care?  ̃  ̃  ̃  ̃  ̃  ̃  ̃

l. Social activities?  ̃  ̃  ̃  ̃  ̃  ̃  ̃

m. Anything else? _______________  ̃  ̃  ̃  ̃  ̃  ̃  ̃

6. Do you ever use earplugs or earmuffs?

 ̃ No → Interview is complete

 ̃ Yes

Appendix K continued
(If YES) What percentage of your awake time do you use earplugs or earmuffs? 

 ̃ 5%  ̃ 30%  ̃ 55%  ̃ 80%

 ̃ 10%  ̃ 35%  ̃ 60%  ̃ 85%

 ̃ 15%  ̃ 40%  ̃ 65%  ̃ 90%

 ̃ 20%  ̃ 45%  ̃ 70%  ̃ 95%

 ̃ 25%  ̃ 50%  ̃ 75%  ̃ 100%

(If YES) Do you ever use earplugs or earmuffs in fairly quiet situations? 

 ̃ No  ̃ Yes

[Note to clinician: Some patients have difficulty understanding the point of this question. Another way 

to phrase it is: “Do you ever use earplugs or earmuffs because sounds are too loud for you when they seem 

normal to other people around you?” The concern is that people with sound tolerance problems may wear 

hearing protection in fairly quiet situations out of fear that they will encounter an uncomfortably 

loud sound. That behavior would be considered overprotecting ears, and is likely to cause the sound 

tolerance problem to worsen. These patients need to understand that use of hearing protection can 

lead to greater sensitivity to sound, thus exacerbating their sound tolerance problem.]

[Clinician: does patient overprotect ears due to problems with sound tolerance?]

 ̃ No  ̃ Yes

Sound Tolerance Evaluation and Management:  Sound Tolerance Interview 119

Adapted with permission from: Tinnitus Retraining Therapy: Clinical Guidelines, by J. A. Henry, D. R. Trune, M. J. A. Robb, 

& P. J. Jastreboff, 2007, San Diego, CA: Plural Publishing, Inc.

APPENDIX

121

Sound Tolerance Worksheet

L
122

1. When and where

will I do this? Things I 

can do

2. How will I do this? 3. Comments 4. Am I doing 

better?

Surroundmyself with comfortablesoundListen tosounds IenjoyUse earplugsor earmuffsonly whenneeded

After 1 month:After 2 months:After 3 months:
APPENDIX

123

Loudness Discomfort Levels—

Clinical Guide

M

1. Definitions

A. Hyperacusis: significantly reduced 

tolerance to sound that is restricted to 

auditory pathways

B. Misophonia: dislike of sound due to 

emotional reactions caused by sound

C. Phonophobia: specific case of misophonia 

when fear of sound is involved

D. Loudness recruitment: abnormally rapid 

growth of loudness caused by loss of outer 

hair cells

E. LDL: threshold level of physical (not 

emotional) discomfort for a sound

2. LDL testing

A. General guidelines

1. Patient must understand instructions to 

ensure proper response

2. Test at octave frequencies between 

1 and 8 kHz

3. Test each ear separately

4. Order testing from lowest to highest 

frequency

5. Present tones for 1–2 seconds each

6. Obtain LDLs twice within a session 

(test each ear, then repeat all testing)

7. Record only the second set of LDLs

B. Specific procedures

1. Instruct: “You will listen to different tones. 

Each tone will be made slightly louder in 

steps. Tell me when the loudness of the tone 

would be OK for 3 seconds, but would not 

be OK for more than 3 seconds.”

2. Present 1-kHz tone at approximate 

MCL (50–60 dB HL)

3. Raise level in 5-dB steps until patient 

signals that LDL has been reached

4. Starting levels at remaining frequencies 

should be about 20 dB below previous 

frequency’s LDL

5. When each ear has been tested once:

– Repeat instructions to patient

– Obtain second set of measures

– Record second set of measures

APPENDIX

125

Sound Plan Worksheet

N
126

1. Write down one bothersome tinnitus situation

Not at all A little Moderately Very much Extremely

Not at all A little Moderately Very much Extremely

Not at all A little Moderately Very much Extremely

Interestingsound

TINNITUS

Talk

Radio!

Audio

Books!

2. Check oneor more of the three ways to use sound to manage the situation

6. CommentsWhen you find something that workswell (or not so well)please comment.You do not need towait 1 week to write your comments.

3. Write down the sounds that you willtry

4. Write down the devices you will use

Backgroundsound

 Sound Other her Sound Other So ther Sound Other Soun ther Sound Other Sound  Other Sound Other Soun Other Sound Other Sou d Other Sound Oth ound Othe

TINNITUS

Soothingsound

TINNITUS

Soft breezes

Soothing voice

Babbling brook

Relaxing music

Running water

Ocean waves

5. Use your soundplan over the nextweek. How helpfulwas each sound afterusing it for 1 week?
APPENDIX

127

Relief Scale

O
128

Instructions:

1. Choose a sound that you think will be soothing. A soothing sound will give you a sense of relief from 

stress or tension caused by tinnitus. (Tracks 9–14 on the CD in the back of the self-help workbook1

have sounds that are soothing to many people.)

2. Adjust the volume of the sound until you find the level that is most soothing to you. 

3. Answer the question “When I listen to this sound, how much relief from stress and tension do 

I feel?”

1

How to Manage Your Tinnitus: A Step-by-Step Workbook, by J. A. Henry, T. L. Zaugg, P. M. Myers, & C. M. Kendall, 2010, San 

Diego, CA: Plural Publishing, Inc. Reprinted with permission.

0

No

relief

1

Slight

relief

2

Mild

relief

3

Moderate

relief

4

Nearly

complete

relief

5

Complete

relief

Write down the sound that you

listened to How much relief did the sound give you?

 0 1 2 3 4 5

 0 1 2 3 4 5

 0 1 2 3 4 5

 0 1 2 3 4 5

 0 1 2 3 4 5

 0 1 2 3 4 5

 0 1 2 3 4 5

 0 1 2 3 4 5

 0 1 2 3 4 5

 0 1 2 3 4 5

 0 1 2 3 4 5

 0 1 2 3 4 5

Relief Scale
APPENDIX

129

Attention Scale

P
130

Instructions:

1. Choose a sound that you think will keep your attention. (Tracks 15–19 on the CD in the back of the 

self-help workbook1 have sounds that are interesting to many people.)

2. Listen to the sound for at least 1 minute.

3. Choose the percent of attention focused on the sound while listening to it.

1

How to Manage Your Tinnitus: A Step-by-Step Workbook, by J. A. Henry, T. L. Zaugg, P. M. Myers, & C. M. Kendall, 2010, San 

Diego, CA: Plural Publishing, Inc. Reprinted with permission.

Attention focused on:

0% of attention focused on Other Sound

25% of attention focused on Other Sound

50% of attention focused on Other Sound

75% of attention focused on Other Sound

100% of attention focused on Other Sound

Tinnitus Other Sound

Write down the sound that you How much of your attention was focused

listened to on the “Other Sound”?

0% 25% 50% 75% 100%

0% 25% 50% 75% 100%

0% 25% 50% 75% 100%

0% 25% 50% 75% 100%

0% 25% 50% 75% 100%

0% 25% 50% 75% 100%

0% 25% 50% 75% 100%

0% 25% 50% 75% 100%

0% 25% 50% 75% 100%

Attention Scale
APPENDIX

131

Tinnitus Contrast Activity

Q
132

Tinnitus Contrast Activity

1. Spend a few moments listening to your tinnitus in quiet.

2. Now turn on some background sound. The sound should be pleasant or neutral. (Tracks 20–23 on the 

CD in the back of the self-help workbook1 have sounds that are background sound to many people.)

3. Adjust the volume to a comfortable level.

4. Notice the reduced contrast. 

5. Reducing contrast makes it easier to ignore your tinnitus.

1

How to Manage Your Tinnitus: A Step-by-Step Workbook, by J. A. Henry, T. L. Zaugg, P. M. Myers, & C. M. Kendall, 2010, San 

Diego, CA: Plural Publishing, Inc. Reprinted with permission.

Write down the sound Write any comments you have about using

that you listened to this sound as background sound

Tinnitus Contrast Activity
APPENDIX

133

Level 4 Interdisciplinary 

Evaluation: Tinnitus Interview

Clinicians: This interview is intended to be administered immediately after administering the Tinnitus 

and Hearing Survey and thoroughly discussing the results with the patient. (Please note that this interview does not cover tinnitus-specific information that most likely was covered during the case history 

performed during the Level 2 Audiologic Evaluation. It may be helpful to review the case history before 

administering this interview.)

1. Does the loudness of your tinnitus change on its own?

 ̃ No → Go to #2

 ̃ Yes → How often does it change?

 ̃ Never

 ̃ Several times per month

 ̃ Several times per week

 ̃ Several times per day

 ̃ Several times per hour

2. Do sounds ever change the loudness of your tinnitus?

 ̃ No effect → Go to #3  ̃ Softer → Go to #3

 ̃ Louder

(if “LOUDER”) What kinds of sounds make your tinnitus louder? [Clinician: check all categories 

that apply; circle any sounds that the patient identifies as a problem; write in any additional 

sounds mentioned by the patient.]

 ̃ Very loud sounds/activities that would be expected to make the tinnitus louder (firing a gun, 

attending a concert, using power tools, ____________________) [Clinician: If this is the only 

response from the patient, then exacerbation of tinnitus by sound would be considered a 

normal effect.]

 ̃ Higher pitched sounds (squeals, squeaks, beeps, whistles, rings, ____________________)

 ̃ Lower pitched sounds (bass from radio, ____________________)

 ̃ Traffic (warning) sounds (emergency vehicle sirens, car horns, backup beeper on truck/van, 

____________________)

 ̃ Traffic (background) sounds (road noise, road construction, diesel engines, garbage trucks, 

____________________)

 ̃ Sudden impact sounds (door slam, car backfiring, objects dropping on floor, dishes clattering, 

____________________)

R

continues
	134 Progressive Tinnitus Management:  Clinical Handbook for Audiologists

 ̃ Voices (television, radio, movies, children’s voices, dog barking, ____________________)

 ̃ Other (describe) __________________________________________

When sound makes your tinnitus louder, how long does the change last?

 ̃ 1–2  ̃ Second(s)

 ̃ 3–4  ̃ Minute(s)

 ̃ 5–10  ̃ Hour(s)

 ̃ more than 10  ̃ Day(s)

3. How does your tinnitus affect you (not including trouble hearing or understanding speech)?

________________________________________________________________________________________

________________________________________________________________________________________

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? [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.]

What have you tried for 

tinnitus prior to PTM?

What were you hoping would 

happen? What actually did happen?

Appendix R continued
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? [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.]

What sounds have you used to 

manage reactions to tinnitus 

during PTM?

What were you hoping would 

happen? What actually did happen?

Level 4 Interdisciplinary Evaluation: Tinnitus Interview 135

continues
	136 Progressive Tinnitus Management:  Clinical Handbook for Audiologists

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? [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.]

Type of device

How many 

are available?

Are any 

portable?

If not portable, 

where is it located?

How is it being used with 

respect to tinnitus?

 ̃ Television

 ̃ Radio

 ̃ MP3 player

 ̃ CD player

 ̃ Satellite radio

 ̃  Table top sound

generator (“sound

spa”)

 ̃  Table top water

fountain

 ̃  Fan/air conditioner/

etc.

 ̃  Music channels on

cable or satellite TV

 ̃  Computer with

internet access (to

access radio stations,

podcasts, and other

sources of sound)

 ̃  Cell phone capable

of playing music

 ̃ Other

Appendix R continued
APPENDIX

137

Hospital Anxiety and 

Depression Scale (HADS)

S

Emotions play an important part in most illnesses. 

The more your health care providers know about your 

feelings the better they will be able to help you. 

This questionnaire is designed to help your 

health care providers know how you feel. Read 

each item and put a checkmark in the box next to 

the reply that best describes how you have been 

feeling in the past week. Ignore the numbers 

printed on the left side.

Don’t take too long thinking over your replies. 

Your first reaction to each item will probably be the 

most accurate response.

A I feel tense or “wound up”:

3  ̃ Most of the time

2  ̃ A lot of the time

1  ̃ From time to time, occasionally

0  ̃ Not at all

D I still enjoy the things I used to enjoy:

0  ̃ Definitely as much

1  ̃ Not quite so much

2  ̃ Only a little

3  ̃ Hardly at all

A I get a sort of frightened feeling as if 

something awful is about to happen:

3  ̃ Very definitely and quite badly

2  ̃ Yes, but not too badly

1  ̃ A little, but it doesn’t worry me

0  ̃ Not at all

D I can laugh and see the funny side of things:

0  ̃ As much as I always could

1  ̃ Not quite so much now

2  ̃ Definitely not so much now

3  ̃ Not at all

A Worrying thoughts go through my mind:

3  ̃ A great deal of the time

2  ̃ A lot of the time

1  ̃ From time to time, but not too often

0  ̃ Only occasionally

D I feel cheerful:

3  ̃ Not at all

2  ̃ Not often

1  ̃ Sometimes

0  ̃ Most of the time

A I can sit at ease and feel relaxed:

0  ̃ Definitely

1  ̃ Usually

2  ̃ Not often

3  ̃ Not at all

D I feel as if I am slowed down:

3  ̃ Nearly all the time

2  ̃ Very often

1  ̃ Sometimes

0  ̃ Not at all

A I get a sort of frightened feeling like 

“butterflies” in the stomach:

0  ̃ Not at all

1  ̃ Occasionally

2  ̃ Quite often

3  ̃ Very often

D I have lost interest in my appearance:

3  ̃ Definitely

2  ̃ I don’t take as much care as I should

1  ̃ I may not take quite as much care

0  ̃ I take just as much care as ever

continues
	138 Progressive Tinnitus Management:  Clinical Handbook for Audiologists

A I feel restless as if I have to be on the 

move:

3  ̃ Very much indeed

2  ̃ Quite a lot

1  ̃ Not very much

0  ̃ Not at all

D I look forward with enjoyment to things:

0  ̃ As much as I ever did

1  ̃ Rather less than I used to

2  ̃ Definitely less than I used to

3  ̃ Hardly at all

A I get sudden feelings of panic:

3  ̃ Very often indeed

2  ̃ Quite often

1  ̃ Not very often

0  ̃ Not at all

D I can enjoy a good book or radio or TV 

program:

0  ̃ Often

1  ̃ Sometimes

2  ̃ Not often

3  ̃ Very seldom

From “The Hospital Anxiety and Depression Scale,” by A. S. Zigmond, & R. P. Snaith, 1983, Acta Psychiatrica Scandinavica, 

67(6), 361–370. Reprinted with permission.

Totals Clinician: add the individual scores for the “A’s” (anxiety), and then for the “D’s” 

(depression). This is a screening tool only, it is not diagnostic.

0–7 normal

8–10 referral for further evaluation may be helpful

11–21 referral for further evaluation likely to be helpful

Appendix S continued
APPENDIX

139

The Primary Care PTSD Screen 

(PC-PTSD)

T

Description

The PC-PTSD is a four-item screen that was 

designed for use in primary care and other medical 

settings and currently is used to screen for PTSD in 

veterans at the VA. The screen includes an introductory sentence to cue respondents to traumatic 

events. The authors suggest that in most circumstances the results of the PC-PTSD should be considered “positive” if a patient answers “yes” to any 

three items. A cutoff score of 2 can be used to optimize sensitivity. Those screening positive should 

then be assessed with a structured interview for 

PTSD. The screen does not include a list of potentially traumatic events.

Scale

Instructions

In your life, have you ever had any experience that 

was so frightening, horrible, or upsetting that, in 

the past month, you: 

1. Have had nightmares about it or thought about 

it when you did not want to? YES / NO

2. Tried hard not to think about it or went out of 

your way to avoid situations that reminded 

you of it? YES / NO

3. Were constantly on guard, watchful, or easily 

startled? YES / NO

4. Felt numb or detached from others, activities, 

or your surroundings? YES / NO

Current research suggests that the results of the PCPTSD should be considered “positive” if a patient 

answers “yes” to any three items.

References

Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., 

Hugelshofer, D. S., Shaw-Hegwer, J., . . . Sheikh, J. I. 

(2003). The primary care PTSD screen (PC–PTSD): 

Development and operating characteristics. Primary Care Psychiatry, 9, 9–14

Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., 

Hugelshofer, D. S., Shaw-Hegwer, J., . . . Sheikh, J. I. 

(2004). The primary care PTSD screen (PC–PTSD): 

Corrigendum. Primary Care Psychiatry, 9, 151

Additional Reviews

Orsillo, S. M. (2001). Measures for acute stress disorder 

and posttraumatic stress disorder. In M. M. Antony 

& S. M. Orsillo (Eds.), Practitioner’s guide to empirically based measures of anxiety (pp. 255–307). New 

York, NY: KluwerAcademic/Plenum. PILOTS ID 

24368 (p. 299).

Norris, F. H., & Hamblen, J. L. (2004). Standardized 

self-report measures of civilian trauma and PTSD. In 

J. P. Wilson, T. M. Keane & T. Martin (Eds.), Assessing 

psychological trauma and PTSD (pp. 63–102). New 

York, NY: Guilford Press. PILOTS ID 18638 (p. 71).

APPENDIX

141

Epworth Sleepiness Scale

U

The Epworth Sleepiness Scale is used to determine 

the level of daytime sleepiness. A score of 10 or 

more is considered sleepy. A score of 18 or more is 

very sleepy. If you score 10 or more on this test, you 

should consider whether you are obtaining adequate sleep, need to improve your sleep hygiene 

and/or need to see a sleep specialist. These issues 

should be discussed with your personal physician.

Use the following scale to choose the most appropriate number for each situation:

0 = would never doze or sleep.

1 = slight chance of dozing or sleeping

2 = moderate chance of dozing or sleeping

3 = high chance of dozing or sleeping

Fill in your answers and see where you stand.

From: “A New Method For Measuring Daytime Sleepiness: The Epworth Sleepiness Scale,” by M. W. Johns, 1991, Sleep, 

14(6), 540–545. Copyright © 1990–1997 by MW Johns. Adapted with permission.

Situation

Chance of 

Dozing or 

Sleeping

1.  Sitting and reading _____

2. Watching TV _____

3.  Sitting inactive in a public place _____

4.  Being a passenger in a motor vehicle for

an hour or more _____

5.  Lying down in the afternoon _____

6.  Sitting and talking to someone _____

7.  Sitting quietly after lunch (no alcohol) _____

8.  Stopped for a few minutes in traffic while

driving _____

Total score (add the scores up)

(This is your Epworth score) _____

APPENDIX

143

Level 4 Interdisciplinary 

Evaluation: Guide to Trial Use of 

Ear-Level Instruments

1. If your patient is an obvious hearing aid candidate

follow the procedures outlined in the following 

forms (any order is acceptable):

1. In-Clinic Trial Use of Hearing Aids 

(Appendix W) AND

2. In-Clinic Trial Use of Combination 

Instruments (Appendix X)

Note: Whether or not the patient is 

currently wearing hearing aids, follow the 

procedures outlined in both forms.

2. If your patient is a borderline hearing aid candidate

follow the procedures outlined in the following 

forms (any order is acceptable):

1. In-Clinic Trial Use of Hearing Aids 

(Appendix W) AND

2. In-Clinic Trial Use of Combination 

Instruments (Appendix X) AND

3. In-Clinic Trial Use of Noise Generators 

(Appendix Y)

Note: Whether or not the patient is 

currently wearing hearing aids, follow the 

procedures outlined in all three forms.

3. If your patient is not a hearing aid candidate

follow the procedures outlined in the following form:

1. In-Clinic Trial Use of Noise Generators 

(Appendix Y)

After trying all instruments, discuss the following 

points:

n [Clinician: Ear-level instruments can 

improve hearing (which makes Interesting 

Sound more accessible), give a sense of 

relief, and provide a convenient source 

of Background Sound. Any or all of these 

effects are useful for managing tinnitus. The 

patient must be aware of these effects and 

choose which effect(s) is most important 

to him/her in making the final decision. 

Use the following discussion points and 

questions to make a decision about which, if 

any, instruments will be used during Level 5. 

Have the patient’s completed Sound Plan 

Worksheet(s) available to look at during this 

discussion.]

n Any instruments you use should not be 

annoying at all

n Ear-level instruments can provide Soothing 

Sound (but even if they don’t they still can 

be useful for managing tinnitus)

n	 	Did any of the instruments give you a 

sense of relief from tinnitus?

n	 	If yes, which instruments gave you the 

best sense of relief?

n Remember, any ear-level device can provide 

a convenient source of Background Sound 

throughout the day—this alone can be helpful 

to manage tinnitus

n (If hearing aids or combination instruments 

were tried) Improving hearing can make it 

easier to use Interesting Sound to manage 

tinnitus

n	 	Which instruments gave you the best 

hearing ability?

n	 	Do you think any of the instruments you 

tried today would make it easier for you to 

use Interesting Sound to manage tinnitus?

n Do you think any of the instruments you 

tried today could be helpful?

n	 	Which instruments would you most 

likely use?

V

APPENDIX

145

Level 4 Interdisciplinary Evaluation:

In-Clinic Trial Use of Hearing Aids

W

0

No

relief

1

Slight

relief

2

Mild

relief

3

Moderate

relief

4

Nearly

complete

relief

5

Complete

relief

n Use one form for each type of hearing aid that is evaluated

n If the patient is already using hearing aids, perform the trial with his/her current hearing aids

n Goal: establish realistic, experience-based judgment about the effectiveness of hearing aids for 

managing both hearing and tinnitus problems

n For each trial, escort patient through different acoustic environments

a) Quiet environment (e.g., waiting area—not a sound booth)

b) Mildly noisy environment (e.g., hallway)

c) Noisy environment (e.g., dining area)

Conducting the Trial

 ̃ Adjust hearing aids to target gain using real-ear (adjust for comfort as needed) 

Acoustic environment

Ask these questions: Quiet Mildly noisy Noisy Comments

Does the sound from the device(s) bother 

you? [Clinician: if “yes” try to adjust

instruments to eliminate annoyance.]

Yes No Yes No Yes No

With these instruments, is your hearing 

the same, better, or worse than without 

the instruments?

Same

Better

Worse

Same

Better

Worse

Same

Better

Worse

With these instruments, how much relief 

do you feel from your tinnitus? [Clinician:

Use the Relief Scale below.]

0  1  2  3  4  5 0  1  2  3  4  5 0  1  2  3  4  5

Relief Scale

APPENDIX

147

0

No

relief

1

Slight

relief

2

Mild

relief

3

Moderate

relief

4

Nearly

complete

relief

5

Complete

relief

Level 4 Interdisciplinary 

Evaluation: In-Clinic Trial Use of 

Combination Instruments

n Use one form for each type of combination instrument that is evaluated

n Goal: establish realistic, experience-based judgment about the effectiveness of combination 

instruments for managing both hearing and tinnitus problems

n For each trial, escort patient through different acoustic environments

a) Quiet environment (e.g., waiting area—not a sound booth)

b) Mildly noisy environment (e.g., hallway)

c) Noisy environment (e.g., dining area)

Conducting the Trial

 ̃ First, adjust amplification portion of the combination instruments to target gain using real-ear 

equipment (adjust for comfort as needed) 

 ̃ Second, adjust volume and frequency output of noise generator portion of the combination 

instruments to attempt to maximize sense of relief from tinnitus 

Acoustic environment

Ask these questions: Quiet Mildly noisy Noisy Comments

Does the sound from the device(s) bother 

you? [Clinician: if “yes” try to adjust

instruments to eliminate annoyance.]

Yes No Yes No Yes No

With these instruments, is your hearing 

the same, better, or worse than without 

the instruments?

Same

Better

Worse

Same

Better

Worse

Same

Better

Worse

With these instruments, how much relief 

do you feel from your tinnitus? [Clinician:

Use the Relief Scale below.]

0  1  2  3  4  5 0  1  2  3  4  5 0  1  2  3  4  5

Relief Scale

X

APPENDIX

149

Level 4 Interdisciplinary Evaluation:

In-Clinic Trial Use of Noise Generators

n Use one form for each type of noise/sound generator that is evaluated

n If the patient is already using hearing aids, have the patient complete the activity In-Clinic Trial Use 

of Hearing Aids (Appendix W) to reflect performance with their current hearing aids.

n Goal: establish realistic, experience-based judgment about the effectiveness of sound generators for 

managing tinnitus problems

n For each trial, escort patient through different acoustic environments

a) Quiet environment (e.g., waiting area—not a sound booth)

b) Mildly noisy environment (e.g., hallway)

c) Noisy environment (e.g., dining area)

Conducting the Trial

 ̃ Adjust volume and frequency output of noise generator to attempt to maximize sense of relief from 

tinnitus.

Acoustic environment

Ask these questions: Quiet Mildly noisy Noisy Comments

Does the sound from the device(s) bother 

you? [Clinician: if “yes” try to adjust 

instruments to eliminate annoyance.]

Yes No Yes No Yes No

With these instruments, is your hearing 

the same, better, or worse than without 

the instruments?

Same

Better

Worse

Same

Better

Worse

Same

Better

Worse

With these instruments, how much relief 

do you feel from your tinnitus? [Clinician: 

Use the Relief Scale below.]

0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5

Relief Scale

Y

0

No

relief

1

Slight

relief

2

Mild

relief

3

Moderate

relief

4

Nearly

complete

relief

5

Complete

relief