Clinical pathways are flow charts that outline, in general order, the events that represent appropriate diagnosis and/or treatment for a given disease, condition, or set of symptoms. They can provide clinicians with an overview of a diagnostic and/or treatment process and guide more detailed decision-making. In audiology, such clinical pathways have been used, for example, to describe the diagnosis and treatment of vestibular disorders1 and the auditory rehabilitation process.2
In this article, we propose the Tinnitus Clinical Pathway, shown in Figure 1. Clinical pathways do not include the details of diagnosis or treatment, and so we have not included such details here. Instead, we have identified and placed in order the typical flow of tests, procedures, management options, and decisions involved in treating patients with tinnitus.
Figure 1 represents tests, procedures, and management options with boxes or rectangles, while decision points are represented with diamonds. Thus, an audiologist can quickly see a recommended order of events. Events that occur earlier in the diagnostic and treatment process appear earlier in the figure. The process begins with the initial patient contact, and then moves on to diagnosis, referral considerations, and treatment options. The pathway ends with monitoring of clinical outcomes.
INITIAL CONTACT AND EVALUATION
The box labeled Initial Contact represents the first opportunity for clinic personnel to interact with a patient and make low-level logistical decisions regarding the evaluation. The first contact may be with the audiologist, but it may also be a telephone call from the patient to the receptionist or other staff member. The most fundamental decision is whether a patient belongs in the clinic's tinnitus pathway, or in another clinical pathway. The diamond labeled Tinnitus Major Problem indicates this decision point.
Successful initial contacts are those that place patients in the appropriate clinical pathway, indicated by the boxes Audiologic Evaluation and Audiologic/Tinnitus Evaluation. Patients who require a tinnitus evaluation must be scheduled for an evaluation of at least 2 hours with an audiologist specializing in tinnitus evaluation and management.3 While the components of the evaluation are determined by the audiologist, they should include, at a minimum, case history, audiologic evaluation, and tinnitus evaluation.
Each evaluation should begin with a history designed to obtain important information and to begin the process of gaining patient respect and trust. The audiologic, otologic, and general health information obtained should be sufficient for the audiologist to follow Food and Drug Administration (FDA) hearing aid fitting referral guidelines.
Information gathered on tinnitus may include subjective judgments of tinnitus pitch, loudness, annoyance, and interference with daily life, as well as subjective hyperacusis and noise exacerbation or “kindling.”3 Additionally, the patient should be screened for depression and suicide risk. Tools such as the Tinnitus Reaction Questionnaire4 contain items that can help audiologists screen patients.
An audiologic/tinnitus evaluation follows the case history. We recommend beginning otoscopy and temporomandibular joint (TMJ) evaluation with a case history. Training in conducting a physical examination for TMJ syndrome is available in some facilities from medical or dental staff. Patients who complain of dizziness or vertigo may also be evaluated on office balance tests.
The audiologic test battery may include, but need not be limited to, measurement of otoacoustic emissions, pure-tone and speech thresholds, word recognition in quiet, and uncomfortable loudness levels (ULL), as well as aural acoustic immittance testing, including reflex threshold and decay measurement. For patients with hyperacusis, acoustic reflex evaluation may be omitted. Auditory brainstem response, electrocochleography, and electronystagmography tests may be conducted at the audiologist's discretion.
Finally, the tinnitus evaluation battery may include tinnitus pitch and loudness matching, determination of the tinnitus minimum masking level, and testing for residual inhibition. For a more complete review of evaluation options, see Henry et al.3
COUNSELING AND REFERRAL
After the evaluation is complete, the audiologist must counsel patients who have tinnitus regarding its possible causes, treatment options, and prognosis. The audiologist must also make referral decisions at this point.
A medical referral is one possibility, as indicated by the diamond labeled Concerning Audiometrics/History and the Medical Evaluation box. A second referral possibility is indicated by the diamond labeled Mental Health Concerns and by the Mental Health Evaluation box. These options appear side by side in the figure to indicate that they should be considered at roughly the same time. As indicated in Figure 1, patients may be returned to the tinnitus treatment pathway when they are cleared by the referral source.
TO TREAT OR NOT TO TREAT
The next decision point on the pathway is indicated by the diamond labeled Patient Desires Treatment. Not all patients want tinnitus treatment. Some are satisfied with initial counseling, while others are unwilling to attend several appointments or wear a prosthetic device. Patients who do not wish treatment are dismissed after outcomes are measured and a follow-up schedule is recommended. This is indicated by the Measure Outcomes and Recommend Follow-up Schedule box.
When a patient opts not to be treated, we do not necessarily consider it a failure. The decision often indicates that the counseling provided has alleviated the patient's worries or that the distress caused by the tinnitus is not severe enough for the person to elect treatment or some combination of both. Of course, patients who do request treatment move on through the pathway.
Patients who desire treatment should be categorized by their treatment needs. Treatment options include tinnitus retraining therapy with the goal of habituation, and masking for more immediate relief. These goals can be accomplished using environmental sound enrichment/quiet avoidance,5 habituation noise devices, hearing aids, and combination hearing aid/habituation noise devices.3
Each audiologist must decide on his or her own treatment preferences. Typically, the goal in our clinic is habituation through quiet avoidance. We have chosen for our clinical pathway the diagnosis and treatment categories described by Jastreboff and Jastreboff.6 They are listed in the boxes labeled (0) No Device, (I) Noise Generators, (II) Hearing Aids, (III) Noise Generators, and (IV) Noise Generators.
Knowledgeable readers understand the differences in how noise generators are used in categories I, III, and IV. In category I, the intensity of the white noise may be set at the mixing point with the tinnitus. In category III, the white noise is set initially to just audible. For category IV, the intensity of the white noise is set initially below audibility. Further discussion of the use of white noise and amplification is beyond the scope of this article. Counseling appropriate to the category is assumed. Patients requiring a device must have ear impressions taken and be fitted as indicated by the box Impressions, Fitting, etc.
Cognitive behavioral therapy recommended
In addition to quiet avoidance and general counseling, we believe that cognitive behavioral therapy7 must be part of the treatment for every patient. This therapy may include identifying and challenging negative thoughts and discussing cognitive errors related to tinnitus. However, not all patients require a major emphasis on cognitive psychology therapy.
The audiologist must determine the appropriate major emphasis for each patient, as indicated by the diamond labeled Cognitive Behavioral Therapy Emphasis or Quiet Avoidance Emphasis and the boxes indicating the Quiet Avoidance and Cognitive Behavioral Therapy emphasis options. Counseling and treatment schedules must be individually set depending on the treatments implemented. As a general guide, we recommend Jastreboff's tinnitus retraining therapy follow-up schedule (appointments at 3 weeks, 6 weeks, 3 months, 6 months, 12 months, and 18 months).8 The box labeled Administer Treatment indicates the implementation of the treatment/follow-up schedule.
When treatment is finished, the audiologist must determine if further counseling is needed, as indicated by the diamond labeled Further Counseling Needed. This clinical judgment may require experience and training, the details of which are beyond the scope of this article.
If further counseling is unnecessary, the audiologist should measure outcomes and recommend a follow-up schedule, as indicated by the box labeled Monitor Final Outcomes & Set Final Monitoring Scheduled. If further counseling is needed, the audiologist should again consider if there are patient issues beyond the scope of audiologic practice. The Mental Health Issues diamond indicates this decision point.
Outcomes are measured for referred patients, as indicated by the box labeled Mental Health Evaluation, Monitor Outcomes, & Set Follow-up Schedule. Patients who need more counseling and treatment without a mental health referral may be followed within the clinical pathway, as indicated by the Administer Treatment box.
Treatment options may include any combination of imagery training, progressive muscle relaxation, and biofeedback to reduce reaction to tinnitus and stress and to give patients a means to control their reaction to tinnitus. When the process is completed, the audiologist measures final outcomes and recommends a monitoring schedule.
We recommend this Tinnitus Clinical Pathway to readers for their consideration. It has not been tested empirically.
The pathway represents a potential flow of tinnitus diagnostic, treatment, and management activities. It generally shows the activities in series, but parallel activity can occur at the audiologist's discretion. Audiologists can also alter components and the order of activities in accordance with their own clinical judgments and preferences and the needs of the patient. We recommend that final outcomes be measured routinely, and that the data be used to drive decisions regarding the clinic services.
When measuring outcomes, audiologists must consider how to define success. Sources of information on options for determining success and of treatment efficacy data include Henry et al.9 and Sheldrake et al.10
In closing, we must note that simply following this or any clinical pathway does not ensure success. Additional factors such as clinical judgments, decision criteria, test selection and administration, treatment choices, and counseling skills are all essential to positive outcomes.
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7. Jastreboff PJ, Hazell JWP: A neurophysiological approach to tinnitus: Clinical implications. Brit J Audiol
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9. Henry JA, Schechter MA, Nagler SM, Fausti S: Comparison of tinnitus masking and tinnitus retraining therapy. JAAA
10. Sheldrake JB, Hazell JWP, Graham RL: Results of tinnitus retraining therapy. Sixth International Tinnitus Seminar,