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If you have any questions, need additional information, or would like to schedule an appointment, call Toll Free 1-888-418-9200. Key words: auditory disorders, hearing disorders, outcome and process assessment (health care), pilot projects, Progressive Audiologic Tinnitus Management, tinnitus, tinnitus intervention, treatment outcome, VA audiology, Veterans.
Abbreviations: AHRQ = Agency for Healthcare Research and Quality, CBT = cognitive-behavioral therapy, HHI = Hearing Handicap Inventory, HHIE-S = Hearing Handicap Inventory for the Elderly–Screening version, IRB = institutional review board, JAHVH = James A.
Since 1995, we have conducted research focusing on different aspects of tinnitus clinical management. The objective of this study was to define and test a tinnitus-management protocol that could be administered in VA Audiology clinics with minimal impact on routine clinical activities. A thorough literature review was conducted with particular attention to the prior tinnitus clinical services offered for Veterans.
The American Speech-Language-Hearing Association includes tinnitus management in its scope of practice for audiologists [16], which is justified for many reasons [17–18].
Approximately 2 yr were spent developing the PATM clinical materials and online training modules (described in Appendixes 1 and 2, respectively; available online only).
Study participants were Veteran patients who complained of tinnitus to a provider at the JAHVH.
Physicians (Primary Care, Otolaryngology, and Psychiatry) and other healthcare providers at the JAHVH were informed of the study before its implementation. These three sources of recruitment were sufficient, and no recruitment advertisements were posted. Eligible patients who desired to participate in the study were randomized to receive either UC or PATM.
Upon arrival at the Audiology Clinic, patients first met with the RA or the Chief of Audiology Section (PJM), who collected the baseline questionnaires.
After audiologic testing, patients randomized to UC received a frequently asked questions handout on tinnitus education and brief counseling about the use of sound to manage tinnitus. During the audiologic assessment, all patients randomized to PATM received a self-help workbook that was developed to support PATM [19]. Questionnaires included the Hearing Handicap Inventory (HHI) for the Elderly–Screening Version (HHIE-S) [20], Tinnitus Handicap Inventory (THI) [21–22], and Tinnitus and Hearing Survey (THS) [23].
The HHI is a statistically validated questionnaire used to measure patients’ self-perceived hearing handicap. The THI is a statistically validated tinnitus questionnaire that provides an index score, ranging from 0 to 100, with higher scores reflecting greater self-perceived tinnitus handicap. The THS was developed to distinguish between self-perceived tinnitus problems and hearing problems, making it an efficient tool to determine whether intervention specific to tinnitus is needed [23]. The THI was the primary outcome measure, and patients in the PATM group were expected to have equal or better tinnitus management as reflected in the mean THI scores.
A clinical handbook was completed that consisted of detailed procedures, checklists, handouts, forms, and questionnaires needed to conduct each of the five hierarchical levels of PATM. After completing the online training course, audiologists responded anonymously to brief semistructured surveys about the training modules.
The results of this survey indicated that time to complete each varied by learner and by content from less than 30 min to more than 2 h (usually 31–60 min). The last question at the end of each module asked learners to identify any barriers they foresaw to completing the practices described in the module. Following self-referral or referral by a provider, 221 patients at the JAHVH Audiology Clinic with a complaint of tinnitus were contacted by telephone and recruited; 109 were randomized to UC and 112 to PATM. The randomization was successful in that patients in the PATM and UC groups were not significantly different in demographics (age, sex, race, education) or health variables (perceived health, mental health diagnoses, or tinnitus handicap) (Table). Lipoflavonoid for tinnitus are not a prescription drug but rather considered as a natural supplement. In some rare instances, lipoflavonoid for tinnitus may bring about allergic reactions that may necessitate medical attention.
Take lipoflavonoids for tinnitus as prescribed by your physician or as indicated on the product label. Prior to start taking lipoflavonoids for tinnitus, it is always wise to consult with your physician first. This causes the middle ear mechanism (ossicles) to vibrate and send those waves on to the inner ear and brain. However, clinical protocols for management of tinnitus have been inconsistent across Department of Veterans Affairs (VA) medical centers. Haley Veterans’ Hospital, PATM = Progressive Audiologic Tinnitus Management, RA = research assistant, THI = Tinnitus Handicap Inventory, THS = Tinnitus and Hearing Survey, UC = usual care, VA = Department of Veterans Affairs. Patients with a more severe problem with tinnitus are more likely to experience comorbid depression [3], anxiety [4–5], and posttraumatic stress disorder [6] than those with a less severe problem.
In 1999, the team began a series of clinical trials to evaluate different methods of tinnitus management [9]. Weekly conferences were held with the study team as the model was developed, drawing on VA and external experts as needed. This work was guided by the modified PATM model, educational research, and VA guidelines about appropriate language levels and formatting. The study was conducted in compliance with VA policy and with approval from the University of South Florida Institutional Review Board (IRB).

All these audiologists had prior experience providing clinical tinnitus services, involving hearing aids, combination instruments (hearing aid and sound generator combined), and basic audiologic counseling (education about tinnitus and various problem-solving and coping strategies).
The research assistant (RA) called these patients to explain the study and ask whether they were interested in participating.
The clinic receptionist inquired whether they had tinnitus (unless they already mentioned it).
They were informed of study enrollment by the examining audiologist and asked whether they would like further information. Patients then met with an audiologist from the respective group (UC or PATM) to which they were randomized. Individualized tinnitus counseling was offered as an option to those patients requesting further services. They were told that if they desired further services after reading the workbook, they were welcome to attend two group workshops, separated by 2 wk and conducted by one of the three PATM audiologists.
These questionnaires were mailed to all eligible patients following the telephone screening and again 6 mo later. Different versions of the HHI are available to assess patients ?65 yr [24] and patients <65 yr [25].
A change in the index score of at least 20 points is reported to indicate a clinically significant improvement for individuals at the 95 percent confidence level [26]. Discussion of the THS results with the study subjects was the primary means of determining whether intervention for tinnitus should be offered.
Data were also analyzed to determine whether patients in each group were similar with respect to demographics, health status, and tinnitus severity at baseline.
A patient self-help workbook with a DVD and CD was also developed, as was an online training program for the PATM audiologists.
Questions addressed time to complete, utility of information conveyed, confidence of learner to perform the described practices, and perceived barriers to completing the described practices. All three PATM audiologists endorsed the course as useful to their practice and that the module content met their stated objectives. The purpose of the calls was to support audiologists’ work by answering questions they had and helping to address barriers they encountered.
Of these 221 patients, 20 randomized to UC and 20 randomized to PATM were excluded from participation because they did not show up, called to be removed, or had a serious health concern that might have interfered with participation.
The product is formulated basically to aid in the treatment or tinnitus or ringing in the ear that is brought about by Meniere’s disease. The kinds of reactions to take note of include hives, swelling of the throat, lips, tongue or face as well as difficulty in breathing. Refrain from using the product in are dosages or for a prolonged period of time than the suggested time span.
It is essential to have an assessment regarding any health condition that you may be suffering from more in particular if you are taking any kind of medicines.
Effects from medications, drugs or alcohol also play an important part in causing tinnitus. It’s a chain reaction. The electrical impulses in the cochlea are transmitted through the cochlear nerve to the auditory portion of the brain. A study was funded to develop and pilot test a protocol to provide tinnitus services consistently across VA audiology clinics.
The prevalence of tinnitus is increasing because of the increasing pervasiveness of toxic noise and other ear-damaging consequences of a highly technological society [7]. This work not only provided efficacy data but also identified procedures that were most efficient for clinical application.
For phase 1, a model of care was defined and the necessary materials to administer the protocol were developed. Concept depicted here is that pyramid contains entire population of people who experience chronic tinnitus. The audiologists were randomized by the study biostatistician to provide either PATM or usual care (UC) for tinnitus management. The providers received copies of referral guidelines that were developed for the pilot study (Tinnitus Triage Guidelines; see Appendix 1, available online only).
Patients reporting tinnitus were informed that a research study was open to enrollment and asked whether they would like further information. Patients in both groups underwent audiologic testing according to JAHVH’s usual clinical protocol. These patients also had the option of receiving sound therapy devices, including ear-level sound generators and combination instruments, and tabletop sound conditioners.
The questionnaires were used clinically to assess each patient’s auditory needs before and after receiving audiology services. To compare groups, a Student t-test was used for continuous variables and a chi-square test for categorical data.
The five levels of care and the materials developed for each level are described in Appendix 1 (available online only), and a description of the online training program is provided in Appendix 2 (available online only). Only one audiologist suggested for one module that there could be a time constraint problem. A total of 92 PATM patients and 89 UC patients completed questionnaires and attended the initial visit.
It is said to contain a key ingredient called eriodictyol glycoside which improves the microcirculation in the inner ear canal.

This is because multivitamins are not anticipated to bring about any adverse side effects although there have been a few cases of non-serious side effects that have been reported including unpleasant aftertaste in the mouth, upset stomach and headache. Drawing on a series of prior VA and external research projects, a clinical model was formulated, supporting materials in multimedia were developed, and a pilot study was conducted. There are no guidelines governing the provision of tinnitus clinical services—leaving the sufferer with tinnitus at a clear disadvantage when seeking care. Phase 2 involved conducting a pilot study to examine the feasibility and potential efficacy of the new program. The program took into account the fact that most individuals with tinnitus do not require extensive intervention [2] (Figure 1). Majority of these people (lower part of pyramid) are not particularly bothered by their tinnitus. Typical progression for patients beyond level 1 Triage is level 2 (Audio-logic Evaluation), level 3 (Group Education), level 4 (Tinnitus Evaluation), and level 5 (Individualized Management). The three UC audiologists continued to provide their usual tinnitus services, while the three PATM audiologists completed the online training course to conduct PATM.
If so, the RA called them to explain the study and determine whether they were interested in participating. A Waiver of Documentation of Informed Consent was approved by the IRB because the clinical services provided in conjunction with the study were considered routine and customary care. Therefore, a high score on the THI could indicate the need for intervention for a hearing problem rather than for a tinnitus problem. Formative data included semistructured surveys for the audiologists about the online training experience, four interviews with the study audiologists as a group during the study, individual discussions between audiologists and the Chief of Audiology Section (PJM) on site throughout the study, and weekly conference calls with the study team for which detailed minutes were taken. Five hierarchical levels of care were defined and labeled the Progressive Audiologic Tinnitus Management (PATM) model. Although tinnitus is very prevalent among military Veterans (it is the most common service-connected disability), many Department of Veterans Affairs (VA) medical centers do not provide systematic clinical services for tinnitus [8].
We designed and conducted a fourth study (reported herein) to develop and pilot test Progressive Audiologic Tinnitus Management (PATM). Most of them require education, which can be administered efficiently and consistently through a structured group education process [10,14–15]. Many only want assurance that their tinnitus does not reflect some serious medical condition (middle of pyramid). Of note, the audiologists randomized to UC all had considerably more tinnitus-management training and experience than the audiologists randomized to PATM. The HHIE-S was chosen because it is short and contains no questions about employment, making it applicable to all patients regardless of employment status and age. For this reason, the THI could not be relied upon alone to determine the need for intervention specifically for tinnitus and was thus supplemented by the THS. Records were kept and data were collated and analyzed by the team implementation specialist (MWL) and reported to the team to identify barriers to care and issues encountered when using the new materials. Each PATM audiologist (n = 3) received 30–35 h in 3 h increments of release time from clinical duties to complete the online course. The model facilitates access to medical services for tinnitus and includes detailed protocols for evaluation, education, and counseling of patients. PATM was developed as a hierarchical model of providing clinical services for Veteran patients who complain of tinnitus [12]. A triaging protocol was also required to ensure that the tinnitus does not indicate the presence of a medical problem requiring surgery (a rarity) or some other serious medical condition. Relatively few have tinnitus that requires some degree of clinical intervention (toward top of pyramid). In fact, the great majority of patients who complain of tinnitus have their needs met at levels 2 and 3.Click Image to Enlarge. Plans were made to secure continuing education credits for providers who completed the modules. Each module, or chapter, stated objectives and then presented learning content that also contained comprehension questions throughout. Clinical procedures were defined for each level and materials were produced for audiologists and patients. The relatively few patients requiring further services could progress to receive an in-depth tinnitus evaluation (level 4) and individualized intervention as needed (level 5). Responses were analyzed and a detailed report was written by the implementation research specialist (MWL).
Appendix 1 (available online only) provides details of the PATM protocol and the clinical materials that were developed.
Training materials for audiologists, incorporation of the protocol into clinic activities, and patient outcomes were evaluated. The model was implemented within the JAHVH Audiology Clinic and to assist Veterans with tinnitus management. The most notable finding was how little tinnitus-specific intervention was required for the majority of patients.

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