Clinical Experience with Progressive Tinnitus Management (PTM) Paper presented at the annual meeting of the American Academy of Audiology

Steven L. Benton, Au.D.

San Diego, CA (April 2010)

Background

Although tinnitus cannot be cured, it can be successfully managed to greatly reduce associated

disturbance, annoyance and distress, thus improving patients’ quality of life1. Despite the availability of

clinically proven management methods such as Tinnitus Retraining Therapy2 (TRT) and Neuromonics3,

many audiologists lack sufficient training in tinnitus treatment, leaving them uncomfortable or unable

to determine the most efficient and effective treatment for specific tinnitus patients1. To facilitate this

process, Progressive Tinnitus Management (PTM) was introduced4, a five-level hierarchical process for

the identification and provision of the least intensive tinnitus management sufficient to provide the

patient adequate relief. To date, there have been few studies regarding the implementation of PTM on

a large scale. In one recent report5, 66% of subjects had their needs met by Level 2 actions and another

27% had their needs met by Level 3 actions. Another report by the same author6 utilized individual

sound-management counseling (Level 3 of PTM) combined with psychological intervention to manage

the tinnitus of patients with traumatic brain injury, but results were not complete at the time.

The Current Study

We reviewed the records for all patients referred to the Audiology Clinic between October 1, 2008, and

November 30, 2009 (14 months). Goals were:

1. To compare various characteristics of subjects who are referred for tinnitus services with those

who are referred for hearing problems; and

2. To Identify and describe any differences in the characteristics between subjects referred for

tinnitus services who do or do not progress from one PTM level to the next.

After exclusion of duplicate referrals, no shows and subjects who provided invalid behavioral test

results, 2543 subjects were included in this review, 654 of whom (25.7%) were referred for complaint

of tinnitus. Subjects were then assigned to one of four groups, presented here in order of increasing

need for tinnitus management.

NonT: Non-tinnitus subjects.

N = 1889. 74.3% of all subjects.

T-GrpN: Tinnitus subjects not referred to Tinnitus Group Education.

N = 546. 25.7% of all subjects

T-GrpY-IndN

Tinnitus subjects referred to Group Education who did not

continue on to Individualized Management.

N = 72. 2.8% of all subjects

T-GrpY-IndY

Tinnitus patients referred to Group Education who did

continue on to Individualized Management.

N = 36. 1.4% of all subjects.

PTM Level 1 - Triage

The Tinnitus Severity Index, or TSI7 is a statistically validated 12-item questionnaire used at the Atlanta

VA to determine if patients may require tinnitus-specific services. TSI scores range from 12-60, and

scores of 36 or higher are consistent with significant tinnitus distress: these subjects may benefit from

more intensive services. Table 1 shows the mean TSI scores and standard deviations for the three

tinnitus groups. These findings suggest that the TSI is sensitive to increasing levels of tinnitus distress

and may differentiate among patients requiring less or more intensive levels of treatment.

Tinnitus Group Mean TSI S.D.

T-GrpN 34.69 10.25

T-GrpY-IndN 43.14 7.02

T-GrpY-IndY 49.70 7.20

Table 1. TSI scores for the tinnitus subject groups.

Tinnitus Group Mean Age (Yrs.) S.D.

Non-T 66.75 13.06

T-GrpN 56.86 12.33

T-GrpY-IndN 50.14 12.28

T-GrpY-IndY 54.06 10.84

Table 2 reveals that the tinnitus subjects were younger than non-tinnitus subjects.

Figure 1 further defines each group by providing the percentage

of subjects within defined age groups for each group of subjects.

0

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10

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25

30

35

40

45

<30 30-39 40-49 50-59 60-69 70-79 80-89

% o

f Su

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Non-T

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T-GrpY-IndN

T-GrpY-IndY

PTM Level 2 - Audiological Evalaution

Binaural values for 3-frequency average (.5, 1 & 2 kHz; 3Hz), four-frequency average (1, 2, 3 & 4 kHz;

4Hz), high-frequency average (4, 6 & 8 kHz; HF3) and slope (HF3 – 3Hz = SLOPE) were calculated using

common weighting values: [ (5 x poorer ear) + (better ear) / 6) ]8.

Figure 2 shows that tinnitus subjects demonstrate less hearing loss than non-tinnitus subjects.

Hearing aid use among subjects also was examined. Not surprisingly, hearing aid use was substantially

greater among non-tinnitus patients (65.8%) than among tinnitus subjects (46.0%). Among tinnitus

subjects, aid use was greatest among those subjects who exited PTM after Audiological Evaluation

(48.1%) than among those who proceeded to Tinnitus Group Education (39.1%).

126 tinnitus subjects (19.3% of all tinnitus subjects) required referral to Tinnitus Group Education after

completion of all actions related to Audiological Evaluation.

0

10

20

30

40

50

60

70

80

90

100

3Hz 4Hz HF3 Slope

dB

HL

Non-T

T-GrpN

T-GrpY-IndN

T-GrpY-IndY

PTM Level 3 - Group Education

The value of Tinnitus Group Education in reducing perceived tinnitus severity may depend on the

length of the program and its content: longer programs that include educational and/or cognitive

components demonstrate some success, although benefits may disappear over time19,20,21.

At the Atlanta VA Medical Center, timeliness of and access to services is a high priority, and multi-

session education activities were not possible. As a result, the author22 implemented a modified Group

Education activity in a single 2-hour session instead of two separate sessions. He previously found that

when utilizing the recommended PTM workbook materials21, Group Education failed to demonstrate a

significant positive impact on the participants' perceived tinnitus severity. Despite the absence of

significant positive impact, 100% of attendees provided positive program evaluations.

In the current study, 126 subjects were scheduled for Group Education, but 18 (14.3%) were no-shows

despite reminder calls and letters; 108 subjects attended Group Education.

PTM Group Education consists of demystification and the provision of knowledge, skills and tools for

the use of sound to manage tinnitus. The Tinnitus Reaction Questionnaire (TRQ)23 was completed using

a paper/pencil format with guidance from the instructor prior to the beginning of Group Education.

TRQs then were mailed to the attendees one month after Group Ed as an outcome measure. Failure to

return the outcome TRQ was interpreted as indicating that the subject required no further tinnitus

management. Figure 4 shows the mean pre-Group Education TRQ scores and total tinnitus disturbance

(calculated as % of waking hours subject is aware of tinnitus x % of time subject is aware of the tinnitus

that it is disturbing) for the 108 subjects who attended Group Education and post-Group Education

values for the 36 (33.3%) who returned their outcome TRQs. (Failure to return the outcome TRQ was

interpreted as indicating the subject required no more intensive management.) Again, Group

Education failed to demonstrate a significant positive impact on perceived tinnitus severity for these

subjects. These 36 subjects then proceeded to Tinnitus Assessment.

Figure 4: Pre- and Post-Group Education TRQ Scores and Total Disturbance Scores

PTM Level 4 - Tinnitus Evaluation

Reasons for measuring tinnitus include determining which patients are likely to benefit from specific

types of treatment, provision of treatment guidelines (e.g. spectrum and/or loudness characteristics of

broadband desensitization or masking sounds) and determination if any treatment has had an effect24.

At the Atlanta VA, Tinnitus Evaluations are completed using the standardized methods suggested by

Neuromonics, including assessment of tinnitus quality (e.g., noise- or tone-like), loudness, perceptual

location (e.g., right or left ear, both ears, midline) and minimum masking levels. Discomfort levels also

are measured to assess loudness tolerance. The various assessment findings are shown at the top of

the next column.

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40

60

80

100

Pre TRQ Post TRQ Pre Tot Dist Post Tot Dist

Mea

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RQ

Sco

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Figure 4: Pre- and Post-Group Education TRQ Scores and Total Disturbance Scores

T-GrpY-IndN

T-GrpY-IndY

PTM Level 5 - Individualized Management

Neuromonics Tinnitus Treatment, an FDA-approved tinnitus treatment, utilizes a customized, binaural

correlated acoustic signal embedded in pleasant music to stimulate auditory pathways deprived by

hearing loss, engage the limbic system in a positive fashion and to allow intermittent tinnitus

perception, thereby facilitating habituation to the tinnitus3.

In a study of Neuromonics Tinnitus Treatment with 35 subjects who reported significant tinnitus

disturbance, 91% demonstrated a significant improvement in tinnitus disturbance as evidenced by at

least a 40% improvement in TRQ scores25. The average TRQ improvement for all subjects was 65%. Also

at 6 months, 80% of the subjects' reported tinnitus disturbance was no long clinically significant.

At the Atlanta VA, individualized tinnitus management was completed utilizing Neuromonics Tinnitus

Treatment (NTT), which provides a structured method for fitting the customized treatment device.

Although 35 subjects progressed to Individualized management in the period under review, the

measures obtained at the delivery appointment shown below represent data from 61 Neuromonics

patients.

Successful Neuromonics Tinnitus Treatment outcome is defined by a 40% reduction in TRQ score and a

reduction in tinnitus awareness and tinnitus disturbance. Figure 5 reveals the mean TRQ scores and

total disturbance percentage both before treatment and after 5-8 months of treatment. For the

subjects who thus far had reached this point in the treatment, the mean decrease in TRQ scores was

69.0% (S.D. = 19.7) and the mean reduction in total tinnitus disturbance was 72.4% (S.D. = 24.1).

Figure 5: Mean Pre- and Post-Treatment TRQ Scores and % Total Disturbance

Discussion and Conclusions

Progressive Tinnitus Management (PTM) offers a structured, effective means of assuring that patients

receive the precise level of tinnitus management they require. Of 2543 referrals, 25.7% were based

on tinnitus complaints and, through implementation of PTM processes, only 5.5 % of these required

individualized management.

PTM Level 1 – Triage. The TSI appears to be a valid tool for differentiating among tinnitus patients

requiring different levels of management. Mean TSI scores increased as the need for more intensive

treatment needs increased.

0

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60

80

100

TRQ Score % Total Disturbance

Mea

n T

RQ

Sco

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r %

To

t D

istu

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Post Treatment

PTM Level 2 – Audiological Evaluation. 79.5% of tinnitus subjects exited PTM after Audiological

Evaluation, primarily as a result of demystification and the provision of appropriate management

devices. Only 126 subjects (19.3% of all tinnitus referrals) found their needs could not be managed

with actions associated with Audiological Evaluation, and so they were referred to Group Education.

PTM Level 3 – Group Education. 108 subjects (16.5% of all tinnitus referrals) actually attended Group

Education. Group Education provides two important benefits: (1) tinnitus patients can share

experiences with others who have the same problems, and (2) it lays a firm foundation on which to

build successful Individualized Management. 36 subjects (5.5% of all tinnitus referrals) proceeded to

Tinnitus Assessment followed by Individualized Treatment.

PTM Levels 4 & 5 – Tinnitus Assessment and Individualized Management. Neuromonics Tinnitus

Treatment has proven to be a successful treatment for subjects whose needs could not be met with

less intensive management strategies.

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