Level 1 Triage

This and the remaining chapters focus on describing detailed procedures for conducting PTM. The 

present chapter describes procedures for “triaging” patients when they complain of tinnitus at 

any clinic. Patients report tinnitus to healthcare 

providers in many different clinics—not just otolaryngology and audiology. Direct points of contact 

include primary care, psychology, psychiatry, neurology, and oncology. Providers in these (and other) 

departments may be unaware of clinical resources 

that are available when patients complain of tinnitus. Guidelines are needed so that clinicians can 

refer these patients to receive appropriate care.

A guide (Tinnitus Triage Guidelines—Appendix B) has been developed to provide to clinicians 

as a resource to know how to appropriately refer 

their patients who complain of tinnitus. The evidence for these guidelines is based on best practices for referring these patients (Harrop-Griffiths 

et al., 1987; J. A. Henry, Zaugg, et al., 2005a; J. L. 

Henry & P. H. Wilson, 2001; Wackym & Friedland, 

2004). Audiologists see patients in any of PTM Levels 2 to 5, and more comprehensive referral guidelines have been developed for audiologists to use 

in these levels (J. A. Henry et al., 2008b). Reactions 

to tinnitus often are best managed using an interdisciplinary approach, thus proper referral and 

inclusion of a psychologist and otolaryngologist 

on the “tinnitus team” (when possible) are critical 

components of PTM.

When a patient complains of tinnitus, the primary concerns are to determine (in order of decreasing priority) if the patient: (a) has a serious medical 

condition (physical or mental) requiring immediate medical attention; (b) experiences symptoms of 

a nonurgent medical condition indicating the need 

for a medical examination; (c) experiences symptoms of a nonurgent psychological condition indicating the need for mental health screening; and 

(d) has been referred or has none of the symptoms 

listed above, indicating the current need for an 

audiologic examination.

Tinnitus Triage Guidelines

The Tinnitus Triage Guidelines (Appendix B) can 

be used by providers as a quick guide for triaging 

patients who complain of tinnitus. Following these 

4
36	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

guidelines should result in appropriate care in most 

cases. It needs to be emphasized, however, that the 

guidelines are greatly simplified for clinical expediency. It goes without saying that clinicians must 

use their clinical judgment to determine the best 

course of action for each patient. Another caveat is 

that clinical services for tinnitus are far from being 

standardized. Clinicians who provide tinnitus services often use very different approaches. Patients 

who are referred should be advised to become well 

informed before agreeing to undergo any medical 

procedure or to enroll in any therapeutic program.

PTM Level 1 Triage shown in the PTM Flowchart (Appendix A) includes a large rectangular 

text box that lists the basic criteria for referring 

patients who complain of tinnitus. Depending on 

the patient’s symptoms and other diagnostic factors, there are four possible referrals (as indicated 

by the four columns in the text box), which are 

described below. The Tinnitus Triage Guidelines 

(Appendix B) is an information sheet that can be 

distributed to providers as a quick guide for triaging their patients who complain about tinnitus. The 

guidelines can be distributed to clinics that are 

likely to encounter these patients. The PTM Flowchart (Appendix A) can be printed on the back side 

of the guidelines (Appendix B) to provide a single 

sheet with the essential triage/referral information.

Emergency Triage—Urgent Care or 

Otolaryngology

Idiopathic sudden sensorineural hearing loss (ISSHL) 

or facial palsy indicates an urgent need to be seen 

by otolaryngology or urgent care. ISSHL has been 

defined as hearing loss of at least 20 dB across three 

adjacent audiometric test frequencies (Battaglia, 

Burchette, & Cueva, 2008). However, at the time 

of initial report, patients usually do not have the 

results of an audiogram. Thus, if the patient reports 

an unexplained decrease in hearing sensitivity, 

then ISSHL should be suspected. The loss typically 

occurs over the course of three days or less and has 

no clear precipitating cause.

Although the etiology of ISSHL is unknown, 

possible causes include labyrinthitis (viral or bacterial), vascular disruption, labyrinthine membrane 

ruptures, immune-mediated mechanisms, abnormal cellular stress responses within the cochlea, 

and ion transport problems of the stria vascularis 

(Merchant, Adams, & Nadol, 2005; Trune, 2004). If 

left untreated, the hearing loss will resolve partially 

or completely in at least 50% of these patients. This 

recovery rate may be improved with corticosteroid 

(glucocorticoid) treatments, particularly if delivered intratympanically (Hamid & Trune, 2008). 

Although recovery with glucocorticoids often is 

interpreted as an underlying cochlear inflammation etiology, numerous inner ear ion homeostasis 

mechanisms also are controlled by corticosteroids 

(Merchant et al., 2005; Trune, 2004). Thus, conclusions about etiology based on treatment response 

can be debated, although lack of recovery with glucocorticoids indicates that other treatment options 

should be pursued.

ISSHL has been referred to as an “otologic 

emergency” (Goodhill & Harris, 1979). Failure to 

refer a patient with ISSHL for same-day ENT or 

urgent care can jeopardize the patient’s chances of 

recovering hearing function. The time course from 

the onset of symptoms until the initiation of corticosteroid therapy can be a factor in the chances of 

recovery—the more expediently these patients are 

seen, the better their prognosis (Jeyakumar, Francis, & Doerr, 2006).

Triage Patient to Mental Health

Some patients require mental health assessment, 

either because of obvious manifestations of mental 

health problems or because of expressed suicidal 

or homicidal ideation. If there is a question about 

the patient’s mental health, then screening tools are 

available to assist in determining the need for referral (J. A. Henry et al., 2008b). Some patients experience extreme anxiety or depression in reaction to 

tinnitus and should be referred to a mental health 

provider the same day symptoms are reported—

although this would not be an emergency referral. 

Suicidal or homicidal ideation warrants special 

attention, and referral guidelines are available for 

these patients (G. K. Brown, Henriques, Sosdjan, & 

Beck, 2004; Hawton, 2001; Kessler, Borges, & Walters, 1999).
Level 1 Triage	 37

In preparation for possible referrals, it is best to 

establish a relationship with local emergency mental health providers, such as the nearest emergency 

room, in-house security personnel, or on-call mental health providers. Many sites now have a suicide 

coordinator. Such mental health providers possess 

the skills and resources for assessing and responding to a patient’s risk of suicide or violence.

Triage Patient to Otolaryngology

Health care providers should refer patients to otolaryngology if certain symptoms coexist with the 

tinnitus. Patients require a medical examination 

and a hearing assessment if their symptoms suggest 

a somatic origin of tinnitus (e.g., pulsatile tinnitus), 

or if there is ear pain, drainage, or malodor. (Please 

see Chapters 1 and 5 for information about somatosounds.) Vestibular symptoms also require referral 

to otolaryngology. The urgency of these referrals is 

determined by the clinician. Referral to audiology 

also is indicated in these cases—ideally, patients 

should see an audiologist first so that audiologic 

test results are available to the otolaryngologist.

Triage Patient to Audiology

Patients complaining of tinnitus should be referred 

to audiology if symptoms suggest that a medical 

examination is not necessary. These patients require 

a hearing assessment by an audiologist in addition 

to a brief assessment of the severity of the tinnitus 

(see Chapter 5) (J. A. Henry et al., 2008b). Triaging patients to audiology requires: (a) symptoms 

suggest a neurophysiologic (not somatic) origin 

of tinnitus; (b) no ear pain, drainage, or malodor; 

(c) no vestibular symptoms; (d) no physical trauma, 

facial palsy, or ISSHL; and (e) no obvious mental 

health symptoms or suicidal ideation.

It is important to refer patients to audiologists 

who have expertise in tinnitus management. These 

audiologists have the ability to implement several 

different options for intervention, including use 

of ear-level devices (hearing aids, “maskers,” and 

combination instruments), educational therapies, 

and specific sound-based methods of intervention. 

These audiologists also generally work within a network of providers who specialize in tinnitus. Access 

to such a network is important to the patient.

It commonly is reported that many patients 

with tinnitus also suffer from a loudness tolerance 

problem (usually referred to generically as “hyperacusis”—see Chapter 1 for related definitions). In 

reality, most patients suspected as “hyperacusic” 

do not require intervention specific to loudness 

tolerance. Treatment for the condition generally 

requires a program of systematic exposure to sound, 

which is accomplished when implementing sound 

therapy for tinnitus. For patients with a severe 

hyperacusis problem, specific therapeutic programs 

are available (J. A. Henry, Trune, et al., 2007a). 

Chapter 6 describes the program that is used with 

PTM for patients who have a severe loudness tolerance problem.

Summary

Patients complain of tinnitus in many different clinics. However, most providers do not know what to 

tell these patients, nor do they know how to refer 

them most appropriately. Normally, a referral to 

audiology is appropriate. However, there are symptoms that suggest urgent or other care is required. 

We have explained those symptoms and provided 

the Tinnitus Triage Guidelines (Appendix B), which 

can be distributed to any clinic that would be the 

point of contact for patients who complain about 

tinnitus. These guidelines are appropriate for the 

majority of patients who complain of tinnitus, but 

they do not address all patients. It was noted above 

that the clinician is the final arbiter of any decision 

to refer a patient.

Different methods for managing reactions to 

tinnitus can be beneficial to patients when offered 

by qualified tinnitus specialists. Thus, it is essential 

to inform patients who complain of tinnitus that 

good services are available, but that they must be 

careful to obtain services only from qualified practitioners. Due to the subjective nature of tinnitus, a 

great many tinnitus “therapies” have been developed 

that have no scientific basis. Patients bothered by 

tinnitus have been known to try “just about anything” 
38	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

in an effort to obtain relief. It is unfortunate that this 

condition is vulnerable to questionable practices. 

Medical providers of all disciplines thus have the 

responsibility of providing accurate and positive 

information to these patients and referring them 

appropriately for any needed services.