Tech Topic | May 2016 Hearing Review
Hearing care professionals need to be able to recognize which tools in their tinnitus toolbox to utilize on a patient-by-patient basis, and be aware of research to help make navigation of this an easier process for both the clinician and the patient.
Since the inception of audiology in the 1950s, treatment and assessment have slowly become cornerstones of tinnitus patient care. Tinnitus management has been a major topic in audiology, especially in the past several years. Assessment, evaluation, and counseling tools are now available for hearing care professionals who would like to add tinnitus care to their practice. Hearing instrument manufacturers have addressed this need by adding tinnitus-specific features into their hearing instruments and even introduced new and innovative ways to treat tinnitus via smart phone applications.1 Tinnitus treatment options are abundant and online resources are increasingly available for people who would like to learn about their condition.
The American Tinnitus Association (ATA) estimates that 50 million people in the United States experience tinnitus to some degree.2,3 Approximately 16 million people seek medical attention for their tinnitus, and tinnitus affects the daily lives for up to 2 million patients.4 The overall increase in patient awareness has, in turn, brought more people into hearing care clinics to seek help.
Part I of the “Tinnitus Toolbox” is a comprehensive guide for hearing care professionals to successfully navigate a best practices assessment protocol for their patients presenting with tinnitus.
Common Tinnitus Care Challenges
While the assessment portion of patient care is an imperative part of quantifying and documenting a diagnosis of tinnitus, it is just as important to be able to provide well-rounded, scientifically based patient care post assessment. The hearing care professional also has to be able to communicate effectively with the patient, categorize the tinnitus and document it, and get a baseline to not only establish where the patient currently is, but also use the baseline to determine how effective treatment has been.5
Perhaps one of the challenging aspects of working with tinnitus patients is reimbursement. Reimbursement with the Current Procedural Terminology (CPT) code 92625 (Assessment of Tinnitus) has been available since 2005 and remains for the 2016 Medicare Physician Fee Schedule (2016 Medicare Fee Schedule for Audiologists).6 It should be noted that to use this code the provider must perform pitch matching, loudness matching, and maskability for both ears.3
However, outside of assessment, there is limited insurance reimbursement for many additional aspects of tinnitus care. For example, long-term treatment does not have a designated code; therefore, more comprehensive tinnitus management strategies, such as Tinnitus Retraining Therapy (TRT) and Cognitive Behavioral Therapy (CBT), may not be reimbursed by insurers. Both TRT and CBT require an extended timeline with regularly scheduled appointments that must be kept.7 For the audiologists who offer tinnitus services, this revenue challenge leaves them with the not uncommon quandary of providing uncompromised patient care while keeping in mind the financial implications and feasibility.8
A thorough case history and auditory pathway assessment should be completed prior to beginning a comprehensive tinnitus evaluation. This begins with a tinnitus intake interview and otoscopic examination. Medical referrals also need to be considered, especially if the patient exhibits any of the red flags of tinnitus, such as pulsatile tinnitus, auditory hallucinations, or depression, etc (Table 1).9,13 As with any patient, always utilize clinical judgment for referrals if any concerns arise regarding the patient’s well-being.
For the hearing evaluation component, it is often useful to obtain high frequency audiometry with inter-octaves and an increased resolution around the area of the suspected tinnitus (Figure 1). For example, you may test 1,500, 3,000 and 6,000 Hz and determine threshold utilizing 2 dB steps instead of 5 dB. This can be useful particularly for patients who have normal or symmetrical audiological pure-tone results between 250-8,000 Hz. Obtaining Most Comfortable Levels (MCLs) and Uncomfortable Loudness Level (UCLs) for pure-tones gives an indication of the patient’s residual dynamic range or an indication of hyperacusis. As with any patient undergoing audiological evaluation, speech recognition thresholds and word recognition scores should also be obtained.11
In addition to the audiogram, middle-ear status should be verified by performing tympanometry and high frequency Otoacoustic Emissions (OAEs), preferably including frequencies above 8,000 Hz. Specifically, Distortion Product Otoacoustic Emissions (DPOAEs) completed with 5 points per octave can be useful for patients with normal hearing thresholds, as hearing loss can often be detected via OAEs prior to seeing any pure tone shifts on the audiogram.14
Tinnitus & Other Questionnaires
Questionnaires can garner important information from the patient about their current tinnitus management, if any, as well as facilitate discussion by giving the provider a framework in which to begin counseling. Information from these questionnaires can also provide an initial baseline for how the patient is coping with their tinnitus prior to, during, and at the conclusion of their time with the clinician.15 While there are many different questionnaires available for tinnitus assessment, the two most commonly used are the Tinnitus Handicap Inventory (THI)15 and the Tinnitus Functional Index (TFI).16
Figure 2 provides an excerpt from the TFI. These two questionnaires not only give a variety of easy-to-score and comprehensive questions, but they have been validated in numerous studies as effective measures of tinnitus quantification.3 Both are brief, containing only 25 questions each, and when utilized in a baseline assessment, can be used as benchmarks for patient success post tinnitus management.
Hearing care professionals are naturally inclined to focus on the hearing aspect of tinnitus symptoms. However, it’s imperative to take a more universal approach to these patients and consider concomitant medical issues. For example, of all tinnitus patients, it is estimated that “approximately 35% have anxiety, 13-28% have depression, and 25% exhibit psychiatric disorder, all of which can contribute to the negative feedback loop, or vicious cycle,” that tinnitus can foster.13,17 So, while planning a thorough tinnitus evaluation, other types of validated, psychoanalytical questionnaires can be useful in determining if a referral needs to be made to a mental health professional. These can include the Beck Depression Survey, the Spuelberger State-Trait Anxiety Inventory, and the Primary Care PTSD survey.
A cursory review of current medications, while not imperative, can also give you some indication if the tinnitus is medically induced. However, all questions about medications and their interactions should be routed through the prescribing physician.13
After performing the comprehensive audiological assessment and obtaining the appropriate questionnaire results, the final piece of a tinnitus evaluation is quantifying the tinnitus through measures such as Pitch Matching, Loudness Matching, and Residual Inhibition. Characterizing the subjective symptoms improves communication between the clinician and the patient and provides a documented basis for treatment. A tinnitus evaluation is typically associated with tests such as pitch matching and minimum masking levels, and those measures are needed for reimbursement as noted above. While these measures are useful in understanding and documenting a patient’s tinnitus, a thorough hearing assessment and tinnitus questionnaires provide important additional information that can assist in a differential diagnosis. Numerous resources have been published regarding tinnitus assessment and subtests, including the American Academy of Audiology and the American Academy of Otolaryngology-Head & Neck Surgery’s guidelines for the assessment and treatment of tinnitus patients.9-12
Figure 3 shows a preview of the tinnitus tab for the MADSEN® Astera2 by Otometrics, which has all of the necessary components for a tinnitus evaluation built into the software. In this example, since only the right ear has been assessed, a-52 modifier to the CPT code would be needed if no further testing was performed.
After leaving the defined harbor of a tinnitus evaluation, navigating the sea of tinnitus treatment options can be overwhelming. Each patient has unique experiences, comorbidities, and even perceptions of their tinnitus that can further complicate the therapy process, even for the most skilled clinician.
While there are promises of medical and minimally invasive approaches, currently the hearing care professional needs to be able to recognize which tools in their tinnitus toolbox to utilize on a patient-by-patient basis, and be aware of current and upcoming research to help make navigation of this an easier process for both the clinician and the patient.
Martin WH. Tinnitus care: what should I know when starting to provide tinnitus care? November 24, 2014. Available at: http://www.audiologyonline.com/articles/tinnitus-care-what-should-i-13109
American Tinnitus Association. Understanding the facts. Available at: https://www.ata.org/understanding-facts
Sanchez C, Switalski W. Tinnitus patient management for today’s audiologists. Audiology Today. 2015;27(2), 14-21.
Dobie R. What is tinnitus? Available at: http://hearinghealthfoundation.org//index.php?pg=what_is_tinnitus
Switalski W, Sanchez C. Tinnitus assessment: The key to successful tinnitus patient management [white paper]. Available at: http://www.audiologysystems.com/education/hearing-assessment-resources
American Speech-Language-Hearing Association. 2016 Medicare Fee Schedule for Audiologists. November 10, 2015. Available at: http://www.asha.org/uploadedFiles/2016-Medicare-Physician-Fee-Schedule-Audiology.pdf ; February 24, 2016.
Cima RFF, Andersson G, Schmidt CJ, Henry JA. Cognitive-behavioral treatments for tinnitus: a review of the literature. J Am Acad Audiol. 2014;25:29-61.
Piskosz M. How to establish a successful tinnitus clinic. Hearing Review. 2013;20(5)[May]:16-22. Available at: https://hearingreview.com/2013/05/how-to-establish-a-successful-tinnitus-clinic2
American Academy of Audiology. Audiologic guidelines for the diagnosis & management of tinnitus patients. October 18, 2000. Available at: http://www.audiology.org/publications-resources/document-library/tinnitus
Tunkel DE, Bauer CA, Sun GH, et al. Clinical practice guideline: Tinnitus. Otolaryngol–Head Neck Surg. 2014;151(2S):S1–S40. Available at: http://oto.sagepub.com/content/151/2_suppl/S1.full.pdf+html
Henry JA, Zaugg TL, Schechter MA. Clinical guide for audiologic tinnitus management I: Assessment. Am J Audiol. 2005;14, 21-48.
Jastreboff PJ, Hazell JW. A neurophysiological approach to tinnitus: clinical implications. Brit J Audiol. 1993;27(1):7-17.
Shi Y. Robb MJA, Michaelides EM. Medical management of tinnitus: role of the physician. J Am Acad Audiol. 2014;25:23-28.
Littman TA, Magruder A, Strother DR. Monitoring and predicting ototoxic damage using distortion-product otoacoustic emissions: pediatric case study. J Am Acad Audiol. 1998;9:257-262.
Newman CW, Sandridge SA, Jacobson GP. Psychometric adequacy of the tinnitus handicap inventory (THI) for evaluating treatment outcome. J Am Acad Audiol. 1998;9:153-160.
Meikle MB1, Henry JA, Griest SE, et al. The tinnitus functional index: Development of a new clinical measure for chronic, intrusive tinnitus. Ear Hear. 2012; 33(2)[Mar-Apr]:153-76.
McKenna L, Andersson G. Changing reactions to tinnitus. Hearing Review. 2007;14(9)[Aug]:12-19. Available at: https://hearingreview.com/2007/08/changing-reactions-to-tinnitus
Correspondence can be addressed to Hearing Review or Dr Young at: [email protected]
Original citation for this article: Young B, Boorazanes M, Sanchez C. The Tinnitus Toolbox Guide to Support the Full Patient Journey, Part 1. Hearing Review. 2016;23(5):24.?