20Q: Tinnitus — Options for Clinical Evaluation and Treatment

From the Desk of Gus Mueller

Do you ever think about the fact that there are some things that we seem to know a lot about, yet we still don’t really understand? For example, let’s take what should be a simple one, behavioral differences between men and women. I’ve read the “Mars vs. Venus” book twice, and I’m still lost on that one. And how about eggs? Something we’ve been familiar with all our lives, and have been talking a lot about the past few months, but do we really know—did the egg come before or after the chicken? 

And then there is this thing called tinnitus, something we’ve been learning about since our first year of graduate studies, but we’re still not in 100% agreement if it should be pronounced TIN-it-tus or Tin-EYE-tus. It’s so elusive to pin down, that we have at least 20 different adjectives just to describe it. And the treatment for tinnitus? It’s anyone’s guess how many have been suggested over the years, with a new one popping up most every week on the Internet. Noted English otologist Joseph Toynbee’s untimely death in 1866 did prove that inhaling a combination of chloroform and prussic acid is not a treatment that should be advocated! But are there treatment strategies that really do work, and are evidenced-based?

So if you really want to know and understand the facts about tinnitus—”Who you gonna call?” The answer is simple. International expert James Henry, PhD. Jim tells us that his six years working on his doctorate under the tutelage of Mary Meikle and Jack Vernon ignited his passionate interest in tinnitus research. During his 35-year career, he was Principal or Co-Principal Investigator for 43 research grants, with total funding of $28 million. He has authored over 200 publications and five tinnitus-related books. His accomplishments have resulted in numerous awards, including the prestigious Jerger Career Award for Research in Audiology from the American Academy of Audiology. Dr. Henry recently retired, but remains active giving lectures and consulting.

Jim’s primary interest these days is writing books about tinnitus, hyperacusis, and hearing loss—all under the heading Ears Gone Wrong. The planned series of books is intended for the general public to be easily understood with practical information for addressing these auditory problems. The first book in this series—“The Tinnitus Book: Understanding Tinnitus and How to Find Relief” is now published and available here.

Dr. Henry not only has answers for the general public, but for us too—you’ll find many in his excellent informative and comprehensive 20Q article.

Gus Mueller, PhD
Contributing Editor

Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q

20Q: Tinnitus — Options for Clinical Evaluation and Treatment

Learning Outcomes 

After reading this article, professionals will be able to:

• Describe differences between primary tinnitus, secondary tinnitus, and somatosensory tinnitus, and describe when ear or head noise becomes a health condition requiring clinical services.
• Explain how to conduct an assessment using the Tinnitus and Hearing Survey to differentiate hearing problems from tinnitus problems.
• Describe evidence-based interventions for tinnitus.

James A. Henry

1. I keep seeing a lot of articles related to tinnitus, but really, is there anything new?

Before I answer that question, let’s first agree on some operational definitions. We of course all know “tinnitus” refers to the sensation of sound that has its source inside the head. But it’s not that simple.

For starters, there are two fundamental types of tinnitus: primary and secondary (Tunkel et al., 2014). These two types often go by different names, so I’ll defer to the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) for their definitions.(Tunkel et al., 2014) They define two major categories: primary tinnitus and secondary tinnitus.

If people “have tinnitus,” they almost always have primary tinnitus, which, for simplicity, can be thought of as “dysfunctional nerve activity in the brain that manifests itself as phantom sound.” More technically, the AAO-HNSF, in their tinnitus practice guideline, defines primary tinnitus as “idiopathic and may or may not be associated with sensorineural hearing loss. Although there is currently no cure for primary tinnitus, a wide range of therapies has been used and studied in attempts to provide symptomatic relief” (Tunkel et al., 2014) (p. 2). Primary tinnitus is often referred to as subjective tinnitus or sensorineural tinnitus.

Secondary tinnitus, again for simplicity, is “mechanical activity in the head or neck that produces acoustic signals that are detected via bone conduction.” The AAO-HNSF defines secondary tinnitus as “associated with a specific underlying cause (other than sensorineural hearing loss) or an identifiable organic condition. . . .Management of secondary tinnitus is targeted toward identification and treatment of the specific underlying condition” (p. 3). The AAO-HNSF emphasizes the importance of identifying “serious conditions that may cause tinnitus or accompany tinnitus” (p. 10). Secondary tinnitus is often referred to as objective tinnitus, somatic tinnitus, or somatosounds.

2. Somatosounds? Is that the same as somatosensory tinnitus?

No, but they could be related. Just like primary and secondary tinnitus, somatosensory tinnitus goes by different names and definitions. In essence, it is a subtype of primary tinnitus (Haider et al., 2017). It is not a form of secondary tinnitus although it may be associated with somatic disorders (Levine, 2004). Also referred to as “somatically modulated tinnitus,” it is a widespread phenomenon reported by about two-thirds of individuals who are examined for the condition (Levine, 2004; Ralli et al., 2017). It does not normally pose any medical concerns, unless an associated skeletal or muscular disorder requires treatment (Haider et al., 2017).

For those who experience somatosensory tinnitus, different physical (somatic) maneuvers modulate the psychoacoustic attributes of primary tinnitus to make it louder, softer, higher in pitch, lower in pitch, or even different with respect to its quality (timbre) (Ralli et al., 2017). The modulation is caused by pressure application to, or movement of, the head, neck, jaw, eyes, or even the arms, hands, and fingers. The most common tinnitus-modulating region is the temporomandibular joint (TMJ). The second most common region is the head and neck. Modulations have also been shown to result from certain kinds of electrical stimulation.

Somatosensory modulation of tinnitus is due to complex neural connections between the auditory system and somatosensory systems that have been extensively studied but are still not well understood (Ralli et al., 2017). “Somatic tinnitus could be a result of increased firing rates of specific sets of neurons that are excited by somatosensory inputs” (p. 936).

Some physicians and audiologists specialize in evaluating and treating somatosensory tinnitus. Clinical approaches to its management, however, are varied because of the lack of evidence-based guidelines (Haider et al., 2017). “Somatic disorders have been shown to play a central role in a large portion of patients with tinnitus and, when correctly identified and treated, can represent a valid therapeutic option” (Ralli et al., 2017) (p. 943). Treatment of TMJ disorders has been shown to improve or resolve tinnitus in the majority of those patients.

3. If people claim to “have tinnitus” doesn’t that mean that they all have basically the same experience?

Actually, no. As an example, we needed to identify participants in our ongoing longitudinal epidemiology study who “had tinnitus” (Henry et al., 2021). We discovered that claiming to have tinnitus can mean different things. We therefore created the Tinnitus Screener to distinguish between the different possible types of ear and head noises (Henry et al., 2016). The Tinnitus Screener is a one-page, six-item algorithm that takes about two minutes to complete. It is recommended for use if there is uncertainty what a person means when claiming to have tinnitus. (The Tinnitus Screener is available at this link: https://www.ncrar.research.va.gov/Documents/TinnitusScreener.pdf)

If a person says the tinnitus is always there and can be heard in any quiet environment, then there is no question that person has “constant” tinnitus and using the Tinnitus Screener would be superfluous. If the person is not sure if the tinnitus is constant, that’s when distinctions need to be made. Also, ear or head noise might not always be considered “tinnitus.” This is where labels and definitions really matter, and this is why we needed to develop the Tinnitus Screener. A person may have tinnitus but not have tinnitus.

4. Wait, what? How can a person “have tinnitus but not have tinnitus”?

Let me slightly rephrase your question: How can a person have tinnitus but not have primary tinnitus? This is important to understand, so let’s flesh it out.

Primary tinnitus is a health condition that requires medical services. Just the fact that a person has primary tinnitus means there is an 80% to 90% likelihood the person also has hearing loss (Kim et al., 2011). For that reason alone, these people should have a hearing evaluation (Henry, Piskosz, et al., 2019). Not all ear or head noises would be considered a “health condition” so we need to know when ear or head noise becomes a health condition, i.e., when does tinnitus become primary tinnitus?

The literature has provided various definitions for tinnitus. One of the most common definitions, which was suggested over 30 years ago, was “sound in the ears or head that lasts at least five minutes and occurs at least two times a week” (Dauman & Tyler, 1992). The five-minute criterion in this definition is to make sure the person isn’t referring to “transient ear noise”—a normal phenomenon experienced by almost everyone (sudden tone in one ear, which may be accompanied by a sense of ear fullness and hearing loss—all symptoms resolve within a few minutes). Transient ear noise has been referred to as “spontaneous tinnitus” (Dobie, 2004). If the only ear or head noise a person has experienced was spontaneous tinnitus, then that would be an example of a person having tinnitus but not having primary tinnitus.

Then there’s the person who is exposed to loud noise and experiences temporary tinnitus (typically along with temporary threshold shift—TTS). This would often be due to not wearing hearing protection when attending a rock concert or sports event, shooting guns, running a chainsaw or leaf blower, working with power tools or loud machinery, etc. Following the exposure, the person has tinnitus. If there is no further exposure, then the tinnitus typically resolves with a week or so—hence, the tinnitus was temporary. There are of course other causes of temporary tinnitus, most notably as a side effect of certain medications (prescription and non-prescription) (Altissimi et al., 2020). If the only ear or head noise a person has experienced was temporary tinnitus, then that would be another example of a person having tinnitus but not having primary tinnitus.

My research group settled on the definition of primary tinnitus as “sound in the ears or head that lasts at least five minutes and occurs at least once a week” (Henry et al., 2016; Henry et al., 2021). Our definition differs from the definition previously mentioned from over 30 years ago (Dauman & Tyler, 1992) only with respect to the number of times per week that tinnitus of at least five minutes duration is experienced. Rather than at least twice a week, we would argue that experiencing it at least once a week indicates the tinnitus has a regularity to it that would qualify it as a health condition, i.e., primary tinnitus.

5. Makes sense. What if a person’s tinnitus occurs less than weekly?

That is a valid question. We’re of course starting to split hairs because people may not know how often they experience tinnitus. We need a benchmark somewhere to determine if a person’s ear or head noise meets the criteria for being primary tinnitus. “Sound in the ears or head that lasts at least five minutes and occurs at least once a week” is a fairly arbitrary definition, but it helps to determine who needs medical services and who does not.

To answer the question, if a person experiences tinnitus lasting at least five minutes, but it occurs less than weekly, then we would place that person in the category of occasional tinnitus (Henry et al., 2016). If the tinnitus lasting at least five minutes is experienced at least weekly, but is not constant, then we would use the category intermittent tinnitus. Occasional tinnitus would not be considered a health condition, but intermittent tinnitus would be considered a health condition. We have previously published a guide for clinical recommendations that are based on temporal manifestations of tinnitus (Henry, McMillan, et al., 2019). A version of that guide is shown as Table 1.

Table 1. Different categories of ear (and/or head) noise and tinnitus. Ear noise becomes tinnitus when the sound lasts at least 5 minutes and is experienced at least weekly. Note that these categories refer to primary tinnitus and not to secondary tinnitus. This table was adapted from the document “Tinnitus: Guidance for DoD Primary Care Providers” developed by the Tinnitus Working Group, consisting of researchers and clinicians from the U.S Departments of Defense and Veterans Affairs.

6. When does tinnitus become “chronic”?

In medicine, as you are probably aware, a short-term condition is considered “acute,” while a long-term condition is “chronic.” The AAO-HNSF prefers the terms “recent onset” and “persistent” (Tunkel et al., 2014). Recent-onset tinnitus has been experienced for less than 6 months, while persistent tinnitus has been experienced for at least 6 months.

7. Are we done with operational definitions?

There are of course more, but I’ll just mention two more that are essential. We discussed when tinnitus becomes primary tinnitus. We need to make that distinction, imperfect as it is, to know if a person requires medical services or not (Henry, McMillan, et al., 2019). If so, then the person should at least see an audiologist for a hearing evaluation and tinnitus assessment. And yes, we’ve mentioned a lot of different definitions—I’ve provided a brief summary in Table 2.

8. What do you suggest I use for a tinnitus assessment?

That’s where these last operational definitions come in. Let’s consider the typical person with tinnitus who shows up for an audiologic evaluation. It is first essential to determine if the patient might have secondary tinnitus and would therefore need to be examined by an otolaryngologist. [Note: referral criteria have previously been described in detail (Henry, McMillan, et al., 2019; Henry, Zaugg, Myers, Kendall, et al., 2010); it should further be noted that the AAO-HNSF recommends a physical examination for any patient with “presumed primary tinnitus” (Tunkel et al., 2014).]

The patient will of course receive a thorough audiologic evaluation. In addition, it is necessary to determine if the patient’s tinnitus is bothersome or non-bothersome. Operationally, we need to differentiate bothersome from non-bothersome tinnitus to know if tinnitus-specific intervention is warranted. That takes us back to the AAO-HNSF guideline (Tunkel et al., 2014).

The AAO-HNSF defines bothersome tinnitus as primary tinnitus that (1) causes anxiety and distress; (2) affects quality of life; and/or (3) is enough of a concern as to cause a person to seek help for dealing with reactions to the phantom sound (Tunkel et al., 2014). They define non-bothersome tinnitus as primary tinnitus that does not cause anxiety or distress, does not affect quality of life, and is not enough of a concern to seek help.

The AAO-HNSF guideline points out that people whose tinnitus is still bothersome after the first 6 months require special consideration for services (Tunkel et al., 2014). They state, “tinnitus symptoms of 6 months or longer are less likely to improve spontaneously” (p. 13). They further state the need to “distinguish patients with bothersome tinnitus of recent onset from those with persistent symptoms (≥6 months) to prioritize intervention and facilitate discussions about natural history and follow-up care” (p. 17).

Table 2. Tinnitus definitions. These definitions are based primarily on recommendations from the AAO-HNSF and from auditory researchers at the VA RR&D National Center for Rehabilitative Auditory Research (NCRAR).

It might seem logical to administer a tinnitus questionnaire and just see if the score reaches a certain threshold to determine whether a person’s tinnitus is bothersome or not. Many tinnitus questionnaires have been validated for intake assessment (Newman et al., 2014; Theodoroff, 2021). They do a good job except for the concern that many people who have both hearing loss and tinnitus blame their tinnitus for their hearing problem (Ratnayake et al., 2009). When they respond to questions on a tinnitus questionnaire, they may be responding more with respect to their hearing problem than to a tinnitus problem. When that happens, the questionnaire score is inflated artificially, indicating the tinnitus is more of a problem than it really is.

When my research group started conducting tinnitus clinical trials, we needed participants who had bothersome tinnitus. It was often the case that we would screen them over the telephone and they seemed to be likely candidates because their tinnitus was reported to be a significant problem. We invited them into the lab for a full assessment, which revealed that their main problem was their difficulty hearing, which they thought was caused by the tinnitus. Their tinnitus was not enough of a problem to warrant receiving intervention so they were sent home after we spent hours conducting the evaluation.

As a result of our experiences with candidates not qualifying for our trials because they were blaming their tinnitus for their hearing problems, we developed the Tinnitus and Hearing Survey (THS) (Henry et al., 2015). (The THS along with detailed instructions concerning its use can be accessed at this link: https://www.ncrar.research.va.gov/Documents/THS.pdf) The THS contains 10 items on a single page and can be completed in about two minutes. The information derived from the THS, along with the tinnitus history and audiologic evaluation, is usually sufficient to know if the person has bothersome tinnitus and would be appropriate to receive tinnitus-specific intervention.

9. How does the Tinnitus and Hearing Survey work?

The THS has three sections: Tinnitus, Hearing, and Sound Tolerance. The Tinnitus section and the Hearing section each contain four statements about possible tinnitus problems and hearing problems, respectively. People with tinnitus are asked to rate each potential problem as “not a problem,” “small problem,” “moderate problem,” “big problem,” or “very big problem”—with a respective score of 0, 1, 2, 3, and 4. The total score for each section can range from 0 to 16.

What’s unique about the THS is that any responses about tinnitus are specific to tinnitus and would not be confused with a hearing problem. Likewise, any responses about hearing are specific to hearing problems and would not be conflated with a tinnitus problem. The scores on these two sections give a reasonably accurate idea as to how much of a problem the person has—separately—with tinnitus and with hearing. No cut-off scores are used, but rather the total scores for each section are informative to discuss with the person what clinical services might be needed.

The third section of the THS is designed to screen for a sound tolerance problem. This would usually be hyperacusis, but can also be misophonia, noise sensitivity, and/or phonophobia [all explained in a previous publication (Henry, Theodoroff, et al., 2022)]. Hyperacusis and other sound tolerance conditions are commonly comorbid with tinnitus (Baguley & Hoare, 2018; Jastreboff & Jastreboff, 2000; Sherlock & Formby, 2005), so it is important to at least screen for them as part of the initial evaluation.

10. Is that all there is to a tinnitus assessment?

The typical patient who has likely primary tinnitus should have a medical history (focusing on tinnitus and hearing difficulties), audiologic evaluation, and complete the THS. That’s all that’s usually needed at this initial stage. The evaluation will determine if the patient needs to be referred, if hearing aids are indicated, if tinnitus intervention is warranted, and if a full assessment for sound tolerance should be conducted.

If the patient screens positive for a sound tolerance problem, then an in-depth evaluation can be done using either the interview form that is used with Tinnitus Retraining Therapy (Henry et al., 2003) or the Sound Tolerance Interview that was created for use with Progressive Tinnitus Management (Henry, Theodoroff, et al., 2022).

We do not normally recommend a tinnitus questionnaire as part of the initial assessment, for the reason discussed above that people often blame their tinnitus for their hearing problem resulting in an inflated score on the questionnaire. If this potential confusion can be ruled out for a person, then completing a tinnitus questionnaire can be helpful to “dig deeper” into how the person is affected by tinnitus.

A tinnitus questionnaire is thus considered optional at the initial appointment. One further point: If the patient has bothersome tinnitus and will be receiving tinnitus-specific intervention, then it is important to administer a tinnitus questionnaire that will serve as a baseline against which treatment outcomes can be assessed. The Tinnitus Functional Index, has been validated for being sensitive to treatment effects (i.e., for “responsiveness”) (Meikle et al., 2012). Other questionnaires may work equally well.

Some patients of course require a more comprehensive tinnitus evaluation than what has been outlined here. Those patients are relatively uncommon but they certainly do exist. It may be obvious from the start that they need a thorough evaluation, including possibly from a behavioral health provider. In most cases, however, a stepped-care approach is the most efficient method of assessing a patient and determining any needed services. Our approach for the average patient is to conduct the tinnitus and hearing evaluation as I have described, provide tinnitus-specific intervention if needed, then do a more comprehensive evaluation for patients who still require tinnitus services following the intervention.

11. You mention several useful questionnaires, but I know some audiologists who do some form of pitch-matching with their tinnitus patients. Not worth the effort?

Good question, and I’ll expand my answer to include the battery of tinnitus psychoacoustic tests that are often performed by audiologists.

Tinnitus pitch matching is typically done along with tinnitus loudness matching. These measures are obtained to determine what the tinnitus sounds like for an individual (Henry, 2016). It is usually necessary, however, to also do spectrum matching because tinnitus is most often perceived as a spectrum of sound.

Tinnitus psychoacoustic measures are also obtained to determine if and how external sound affects the auditory attributes of tinnitus (its loudness, pitch, and timbre/spectral composition). These measures include minimum masking level (MML) and residual inhibition (temporary suppression of tinnitus that often occurs after the appropriate auditory stimulation).

I have written extensively about tinnitus psychoacoustic measures and suggest two publications for the interested reader (Henry, 2016; Henry & Meikle, 2000). To briefly summarize some of our conclusions:

• Although these measures are routinely obtained by tinnitus researchers and audiologists, they do not objectively quantify the auditory attributes of tinnitus. Nor are they diagnostic, prognostic, responsive, or indicative of treatment needs.
• Tinnitus loudness matches and tinnitus loudness ratings generally do not correlate, and it is more useful clinically to obtain loudness ratings than loudness matches.
• Tinnitus pitch matches using pure tones are often unreliable (likely due to tinnitus sounding more spectral than tonal) and a single pitch match using pure tones should be considered an estimate that is within a 2- to 3-octave range. Averaging repeated pitch matches should more accurately identify the tinnitus center-frequency versus obtaining a single pitch match.
• Although changes in MML have been cited as providing evidence of benefit from treatment, use of MMLs in this manner can be misleading (MMLs are not indicators of emotional or functional effects of tinnitus).
• Using the standard test for residual inhibition, the effect occurs for 80% to 90% of people tested. Tinnitus usually returns to its normal level within about 1 minute. Residual inhibition has the potential to be a viable method of treatment if the parameters that optimize the effect could be identified (research is needed).
• Overall, tinnitus psychoacoustic assessment has little if any value for clinical utilization, other than for counseling purposes.

12. I’ve heard that some people malinger tinnitus, in hopes of receiving some sort of medical disability award. Is there an audiometric test to determine the authenticity, like we do the Stenger test for a unilateral loss?

We were funded with a grant to specifically address this question. The study was conducted to develop and document a test for detecting the presence/absence of tinnitus with high confidence (Henry et al., 2013). We compared psychoacoustic measures of tinnitus between participants with versus without tinnitus (those without tinnitus were instructed to respond “as if” they had tinnitus). Participants with tinnitus were seen to have higher-decibel low-frequency loudness matches (loudness matches were obtained at a range of test frequencies) and higher-frequency median pitch matches. These results were not sufficient to recommend such testing to detect malingering. It was concluded that further research is needed to produce a defined psychoacoustic test battery for this purpose.

13. Okay, thanks. Now back to my original question—is there anything new?

I wish I could say we’ve had a breakthrough in tinnitus treatment. But I can’t. There are certainly promising methods being researched but nothing has yet been proven to be any better than what has been available for years.

14. Okay, no breakthroughs, but is there anything new?

According to PubMed, in 2022 there were 520 peer-reviewed articles with “tinnitus” in the title. That alone would indicate that a lot is new in the field of tinnitus. So I guess the answer is technically “yes, a lot is new.” But I would have to qualify that statement by saying most of what is “new” is not really significant with respect to how we provide clinical services for our tinnitus patients.

We certainly understand tinnitus better and there is more and more interest in the topic. This is a far cry from the situation only 50 years ago when tinnitus was barely on the radar of most clinicians and researchers. There was some interest, and a few sporadic articles about tinnitus, but for the most part tinnitus was an unknown topic to both the lay and professional communities.

Back to PubMed, in 1972 there were only eight publications with “tinnitus” in the title. So, in 50 years, the number of yearly publications with tinnitus as a focus has increased from eight to 520. There is obviously a lot of interest and a lot of effort going into understanding tinnitus better and knowing what to do about it. That in itself is a huge change that is noteworthy.

15. How is it possible that there were 520 publications about tinnitus in the past year alone and yet nothing “really significant with respect to how we provide clinical services for our tinnitus patients”?

To reiterate, we know a great deal more than we did 50 years ago. We have many more clinical tools, and we have a much better idea as to neural activity in the brain that is associated with tinnitus. Many publications have contributed to this progress in our understanding and the availability of resources.

If we trace back over these past 50 years, some of the most significant innovations for clinical management of tinnitus started with Jack Vernon, PhD. He developed the “masking” method in the 1970s and started the first clinic in the world that was dedicated to providing tinnitus services (Vernon & Schleuning, 1978).

It is a common misconception that Vernon’s masking method is intended to completely mask (cover up) the tinnitus. That may have been his original intent, but he soon discovered that tinnitus did not have to be completely masked to provide a sense of relief (Vernon, 1982). The same effect (relief) could be achieved with partial masking, which ensured a comfortable level of the masking noise (Vernon et al., 1990). The method is still referred to as “masking,” but a more appropriate description might be “sound-based tinnitus relief” (Henry et al., 2004).

In the 1980s, a number of tinnitus interventions were in the early stages of development. They included Cognitive Behavioral Therapy (CBT) applied to tinnitus (Sweetow, 1985, 1986), Tinnitus Retraining Therapy (TRT) (Jastreboff, 1990), and Tinnitus Activities Treatment (TAT) (Bentler & Tyler, 1987). Each of these methods is now fully developed, well established, and can be considered an “evidence-based intervention for tinnitus.” In 2005 the basic concept underlying Progressive Tinnitus Management (PTM) was first published (Henry et al., 2005), and PTM is also now well established and evidence-based (Henry, Thielman, et al., 2019; Henry et al., 2017).

These four methods (CBT, TRT, TAT, and PTM) are those I would consider to have a sufficient degree of both clinical and research evidence to recommend their use with patients. It should be pointed out, however, that CBT stands out as having the “strongest research evidence” according to systematic reviews and clinical practice guidelines that have been published (Cima et al., 2019; Fuller et al., 2020; Fuller et al., 2017; Tunkel et al., 2014). I agree with their assessment but must point out that CBT is not proven to be superior to these other methods.

16. How do these four methods differ?

It would take a whole book to adequately answer this question. I’ll just cover some salient points of comparison with respect to the different methods’ affiliations, appropriate providers, evaluation procedures, and treatment techniques.

Affiliations

Three of the methods (TRT, TAT, PTM) are associated with certain individuals and their research groups. TRT was developed by Dr. Pawel Jastreboff and his group at the University of Maryland, College Park, Maryland (he later relocated to Emory University in Atlanta, Georgia). TAT was developed by Dr. Richard Tyler and his group at the University of Iowa in Iowa City, Iowa. PTM was developed by myself and my research colleagues at the Portland Veterans Affairs Medical Center in Portland, Oregon.

CBT was initially described as a treatment for tinnitus by Dr. Robert Sweetow at the University of California at San Francisco. CBT-for-tinnitus, however, was later described by numerous investigators and is currently not associated with any particular individual or group.

Providers

A basic distinction between methods is which disciplines are involved in providing the clinical services. As already mentioned, the AAO-HNSF recommends a physical examination by an ear-specialist physician (typically an otolaryngologist) for any patient with “presumed primary tinnitus” (Tunkel et al., 2014). Otherwise, for all methods of tinnitus management, proper referral is essential to address any comorbid conditions (Henry, McMillan, et al., 2019; Tyler et al., 2008). Anxiety, depression, post-traumatic stress disorder (PTSD), and insomnia may indicate the need to refer to a psychologist or a psychiatrist. Symptoms suggestive of secondary tinnitus indicate the need to refer to an ear-specialist physician.

CBT is primarily in the domain of clinical psychologists. Some mental and behavioral health providers (clinical social workers, psychiatrists, professional counselors, advanced nurse practitioners) also have CBT expertise (Henry, Goodworth, et al., 2022). It is paradoxical that, although CBT has the strongest research evidence for tinnitus intervention, very few mental and behavioral health providers offer CBT specifically for tinnitus (Beukes et al., 2021; Schmidt et al., 2018). This scarcity of CBT-for-tinnitus providers has been addressed by authors who noted that audiologists are the most common point of contact for individuals seeking clinical services for tinnitus (Beukes et al., 2021; Henry, Goodworth, et al., 2022). It was suggested that audiologists should not perform CBT without proper training and supervision, but they could teach the behavioral strategies of CBT (relaxation and distraction techniques), which require much less training than learning to teach the cognitive strategies (constructively changing thoughts about tinnitus) (Henry, Goodworth, et al., 2022).

Treatment with TRT, TAT, and PTM is provided mostly by audiologists, but can be provided, at least partially, by mental and behavioral health providers, as listed previously for CBT. Of the approximately 75 AuD training programs in the U.S., a recent survey revealed that at least 32 (43%) provide training in tinnitus management (Henry, 2020). Most of the 32 programs reported that they provide training specifically in TRT, TAT, and PTM. Otherwise, audiologists have training in general counseling and many audiologists are well-versed in most aspects of tinnitus management.

PTM has five stepped-care levels and different clinicians are involved at the different levels. Level 1 is referral only, and applies to all clinicians who have patients reporting tinnitus. Level 2 is the audiologic evaluation and thus involves only an audiologist (unless referral is necessary). Levels 3 and 5 are the treatment levels, and both audiologists and mental/behavioral healthcare providers deliver the treatment. Level 4 is the higher-level comprehensive evaluation for patients whose tinnitus problems persist. Both an audiologist and a psychologist provide the Level 4 evaluation. (Psychologists are essential at this level because they are qualified to diagnose behavioral health conditions.)

Evaluation

Another basic distinction is how patients are clinically evaluated. CBT is a method of therapy only, i.e., there is no universally prescribed method of assessment for patients with tinnitus. Of course an initial evaluation is essential to determine if CBT would be appropriate for an individual and, if so, how the treatment should be tailored to address individual concerns. There is no one “right” way to perform an evaluation of patients being considered to receive CBT for their bothersome tinnitus. Certain measures, however, would be considered essential, as described by various authors (Andersson & Kaldo, 2006; Beukes et al., 2021; Cima et al., 2014; Fuller et al., 2020; Theodoroff et al., 2022).

As for CBT, TAT is described as a treatment protocol, i.e., it is therapy only. Dr. Tyler and his group who developed TAT, however, have published details about how to conduct a tinnitus evaluation, which is available in various publications (Mancini et al., 2022; Perreau et al., 2022; Tyler et al., 2006; Tyler et al., 2008). In addition to the audiologic assessment, a tinnitus assessment is conducted using the Tinnitus Primary Function Questionnaire (Tyler et al., 2014), which helps to determine how much of a problem patients have in each of four areas: sleep, concentration, thoughts and emotions, and hearing and communication (Perreau et al., 2022; Tyler et al., 2006). Based on the evaluation, patients are assigned to one of three categories: “distressed,” “concerned,” or “curious” (Mancini et al., 2022). Depending on the treatment plan, the tinnitus assessment can also involve measuring the psychoacoustic characteristics of tinnitus (pitch, loudness, and maskability) (Tyler et al., 2008).

TRT has a specific methodology for assessment of patients, which has been described in detail by Dr. Jastreboff and his group (Jastreboff, 2000; Jastreboff & Hazell, 2004; Jastreboff & Jastreboff, 2000). The primary purpose of the evaluation is to diagnose and distinguish between tinnitus, hearing loss, and decreased sound tolerance (Jastreboff & Jastreboff, 2000). It includes a medical evaluation, one-on-one interview using a structured interview form, audiologic evaluation, and loudness discomfort level (LDL) testing (Henry et al., 2002, 2003; Jastreboff & Hazell, 2004). Tinnitus psychoacoustic measures are obtained using “any generally accepted method” (Jastreboff & Hazell, 2004). Distortion product otoacoustic emissions (DPOAE) testing is considered “useful but not necessary.” The evaluation determines which of five categories is appropriate for the patient: category 0 (low degree of tinnitus life-impact and/or tinnitus is a new experience), category 1 (significant problem with tinnitus; no significant hearing loss; no decreased sound tolerance), category 2 (same as category 1 except also significant hearing difficulties), category 3 (hyperacusis is the primary complaint; may or may not have a significant problem with tinnitus; misophonia may be present), and category 4 (prolonged exacerbation of tinnitus and/or hyperacusis as a result of exposure to certain low-level sounds).

The evaluation for PTM has been described in some detail above. Levels 2 and 4 are the assessment levels (Henry & Manning, 2019; Henry, Zaugg, Myers, & Kendall, 2010). Level 2 Audiologic Evaluation includes a medical history (focusing on tinnitus and hearing difficulties), audiologic evaluation, hearing aid evaluation (if appropriate), and completing the THS. Patients who screen positive on the THS for a sound tolerance problem are evaluated in-depth using the Sound Tolerance Interview (Henry, Theodoroff, et al., 2022). A tinnitus questionnaire is not normally recommended because of the concern that some people blame their tinnitus for their hearing problem, which can artificially inflate the score on the questionnaire. If such potential confusion is ruled out, the Tinnitus Functional Index can be helpful for a more in-depth assessment (Meikle et al., 2012). For patients who still require tinnitus services following intervention (Level 3 Skills Education), a comprehensive tinnitus evaluation (Level 4 Interdisciplinary Evaluation) is conducted by both an audiologist and a psychologist.

Treatment

Cognitive Behavioral Therapy. Treatment with CBT can utilize a number of different self-help techniques. As indicated by its name, CBT has “cognitive” and “behavioral” components of therapy. The cognitive component attempts to replace negative thoughts and beliefs with thoughts and beliefs that promote a more positive outlook on tinnitus. The behavioral component involves teaching different coping skills for managing effects of tinnitus. The counseling sessions can include different areas of focus, including cognitive restructuring, distraction activities, relaxation techniques, and education about the auditory system, improving sleep, and general health. It is not known if any one of these areas of focus provides the greatest benefit for tinnitus management (Cima et al., 2014; Fuller et al., 2020).

CBT has evolved as three “waves” over the decades (Hayes & Hofmann, 2017; Kahl et al., 2012). The first wave used behavioral therapies to change what people do to improve how they feel. The second wave added cognitive components to change how people think to improve how they feel. Second-wave CBT has been termed “traditional CBT” (Apolinario-Hagen et al., 2020). Third-wave CBT takes the counterintuitive approach that, rather than changing thoughts and feelings, we should become more accepting of ourselves the way we are (Kahl et al., 2012). Third-wave CBT includes mindfulness-based approaches and Acceptance and Commitment Therapy (ACT), which have been used to treat tinnitus (Cima et al., 2014; Hesser et al., 2012; Westin et al., 2011). A growing body of scientific literature supports third-wave CBT.

Tinnitus Retraining Therapy. The stated goal of TRT is to achieve habituation of reactions to tinnitus, which leads automatically to habituation of the awareness of tinnitus (Henry et al., 2007a, 2007b; Jastreboff & Hazell, 2004). When habituation takes place, the related nerve connections in the brain are “rewired” (or “retrained”—hence the name Tinnitus Retraining Therapy). The treatment involves specific protocols of counseling and sound therapy—both designed to optimize habituation.

The structured counseling, which is based on Jastreboff’s “neurophysiological model of tinnitus,” is the most important component of treatment. The neurophysiological model explains tinnitus with respect to what takes place in three regions of the brain: the auditory nervous system, the limbic system, and the sympathetic part of the autonomic nervous system. Patients are educated about how the three parts of the brain are involved when tinnitus is bothersome versus when it is non-bothersome.

Sound therapy supplements the counseling. All patients are advised to “enrich their sound environment 24/7.” Patients with more problematic tinnitus wear ear-level sound generators during the day to deliver broad-band noise directly to the ears. The level of the noise is adjusted very specifically to “just below the mixing point,” i.e., to just below the level at which the noise and the tinnitus blend, or “mix,” together. Modern hearing aids usually have a built-in sound generator and are generally preferable to wearable sound generators.

Tinnitus Activities Treatment. TAT over the years has consistently involved informational counseling, a focus on patients’ overall well-being, and teaching coping strategies (Tyler & Baker, 1983). The basic philosophy is to consider the whole patient when providing treatment. “Patient expectation nurturing” is the guiding principle to provide patients with a positive outlook (Tyler et al., 2001). The counseling is patient-centered and uses pictures that relate to areas of life most affected by the tinnitus (Perreau et al., 2022).

For curious patients, providing them with some basic information about tinnitus often “is sufficient to demystify tinnitus and relieve the individual’s anxiety” (Tyler et al., 2008) (p. 29). For concerned patients, the overall goal is to provide them with preliminary counseling to learn “some self-directed management strategies.” Distressed patients have more serious problems associated with their tinnitus. A structured treatment plan is developed based on relative concerns in each of the four problem areas: thoughts and emotions, sleep, concentration, and hearing and communication.

Full treatment with TAT has three overall components: counseling regarding tinnitus and associated problems, teaching coping strategies (including activities engagement), and sound therapy with partial masking, which is considered optional (Mancini et al., 2022; Tyler et al., 2008). For most patients, “partial masking sound therapy” is used along with the counseling (Tyler et al., 2006). Sound therapy is not used with all patients because of the potential for the added sound to interfere with hearing (Tyler & Baker, 1983).

Progressive Tinnitus Management. “Progressive” refers to stepped-care, meaning patients progress through increasingly higher levels of care depending on their individual need. Level 1 Referral is a description of referral guidelines for any healthcare provider who encounters patients complaining of tinnitus (Henry, McMillan, et al., 2019; Henry, Zaugg, Myers, Kendall, et al., 2010). The Level 2 Audiologic Evaluation includes a medical history and brief assessment of tinnitus using the Tinnitus and Hearing Survey (Henry et al., 2015). Level 3 Skills Education consists entirely of treatment for bothersome tinnitus. The treatment includes counseling (individually or in groups) by both an audiologist and a psychologist or other behavioral health provider. Patients develop individualized treatment plans (one specific to sound therapy and another specific to CBT) to address their “most bothersome tinnitus situation” (Henry, Zaugg, Myers, & Kendall (Schmidt), 2010; Henry, Zaugg, Myers, & Kendall, 2010). The great majority of patients have their needs met through the first three levels of PTM. If not, then they are advised to step up to the Level 4 Interdisciplinary Evaluation, which is conducted by both an audiologist and a psychologist (Henry, Zaugg, Myers, & Kendall, 2010). The evaluation is comprehensive to determine why tinnitus continues to be a problem and to suggest further treatment if needed, which would lead to Level 5 Individualized Support.

Level 5 patients are those whose tinnitus is the most severe and incalcitrant. They are also more inclined to have coexisting conditions such as anxiety, depression, PTSD, and insomnia. The same Level 3 skills may be taught in Level 5 but with greater individualized attention. Other forms of tinnitus therapy are options during Level 5, and can include any of the other treatments highlighted above (CBT, TRT, TAT) as well as Acceptance and Commitment Therapy (Westin et al., 2011), mindfulness-based stress reduction (Arif et al., 2017), and different forms of counseling and/or sound therapy (Henry & Quinn, 2020; Searchfield et al., 2011).

While these treatment strategies are all somewhat different between the four methods, there is a common objective. Because there is no cure for tinnitus, eliminating or reducing the sound of tinnitus is not normally an option. Treatment therefore focuses on eliminating or reducing the effects of tinnitus, which most generally involve problems sleeping, problems concentrating, and negative emotions such as stress, anxiety, PTSD, annoyance, and depression. These objectives are accomplished when patients do not (or minimally) react to or pay attention to their tinnitus. In a word, the end goal is habituation (Hallam et al., 1984). Whereas habituation is most commonly identified with TRT (Jastreboff & Hazell, 2004), it is, in reality, the ultimate goal of all methods of tinnitus treatment.

17. How do we know if the goal of treatment has been achieved with a patient?

We might ask, how do we identify the minimal level of change that would reflect actual benefit perceived by the patient? It was mentioned above that the Tinnitus Functional Index (TFI) has been validated for assessing outcomes of treatment (Meikle et al., 2012). The TFI’s developers suggested that a minimum reduction in the TFI score of 13 points was likely to reflect actual benefit perceived by the patient. The 13-point criterion can serve as a benchmark, but should not be relied upon by itself to positively identify meaningful improvement. In addition to obtaining a change score on the TFI (or on any tinnitus questionnaire) it is important to elicit from patients their subjective impressions as to whether they are doing better than before the treatment.

18. What about all the other methods of treatment for tinnitus?

I have ignored the myriad methods of treatment for tinnitus that have limited evidence in the literature. Some of these methods involve patients passively receiving treatment, i.e., a procedure is performed on the patient or a substance is ingested. Other methods involve patients learning self-care skills—to help them sleep better, concentrate better, and not react emotionally to their tinnitus.

Some methods have been tested in controlled trials and are considered “promising” (Cima et al., 2019; Fuller et al., 2017; Tunkel et al., 2014). Importantly, any method that cannot cause harm and does not involve significant cost should not be ruled out as potentially helpful. The research is just not sufficient to be dogmatic about any method of tinnitus management. I have stayed focused on the behavioral methods of treatment that are supported by research and by many years of clinical use.

19. You haven’t talked much about sound therapy, or what I’ve previously called “masking” (?)

Sound therapy refers to the use of any type of sound for the purpose of reducing the emotional and functional effects of tinnitus. Does sound therapy have research evidence showing its effectiveness? Yes and no. According to clinical practice guidelines, sound therapy is at best considered an “option” for treatment because of its lack of strong research support (Cima et al., 2019; Fuller et al., 2017; Tunkel et al., 2014). I have made the case elsewhere, however, that sound therapy has more evidence than it is given credit for in the scientific literature (Henry, Carlson, et al., 2022; Henry & Quinn, 2020). “We contend that the strict inclusion criteria for these reviews are counterproductive and have the effect of obscuring decades of evidence demonstrating the clinical effectiveness of sound therapies for tinnitus (Henry, Carlson, et al., 2022) (p. 2327).

20. Any final comments?

A major goal of research is to develop a safe and effective treatment that would make tinnitus go away, i.e., cure the condition. Fortunately, numerous options exist for patients to get the help they need to live a normal life unaffected, or only mildly affected, by their tinnitus. Although many patients think that is an unattainable goal, it has been accomplished by a great many people who felt the same way.

Patients should be advised to stay positive and adopt the expectation that tinnitus does not have the power to dominate their life. It is important to keep an open mind and try different approaches—even unusual ones. Patients should keep trying to find what works for them, which will most likely be different from what works for other people. It is the clinician’s role to guide them through this process.

For the decades I have been doing tinnitus research, I have seen many products and treatments for tinnitus that caused initial excitement but did not prove to be better than anything already available. This has happened repeatedly, and it continues today. This is not to say that some new product or treatment might not be shown to be superior to all others, but it is important to be skeptical of anything new until it has been proven to be beneficial (and cost-effective).

It has been my pleasure to share with you some of what I have learned over the years. My sincere desire is that this tutorial has provided you with information that can contribute to helpful answers and renewed hope to your patients.

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