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Tinnitus is the most prevalent service-connected disability awarded to Veterans. However, clinical protocols for management of tinnitus have been inconsistent across Department of Veterans Affairs (VA) medical centers. A study was funded to develop and pilot test a protocol to provide tinnitus services consistently across VA audiology clinics. 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. Five hierarchical levels of care were defined and labeled the Progressive Audiologic Tinnitus Management (PATM) model. The model facilitates access to medical services for tinnitus and includes detailed protocols for evaluation, education, and counseling of patients. Patients at each level of care have the option to "progress" to the next level of PATM if further services are required. Clinical procedures were defined for each level and materials were produced for audiologists and patients. The PATM model was then piloted with clinical patients at the James A. Haley Veterans' Hospital (JAHVH) in Tampa, Florida. Throughout the pilot study, feedback from patients and clinicians was carefully noted. 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. This finding supports a clinical model that offers stepped-care ("progressive") levels of care until tinnitus management is achieved by the patient.

The Department of Veterans Affairs (VA) considers tinnitus a disability. Veterans can claim tinnitus as a "service-connected" disability if the tinnitus is thought to be connected to military service. The VA adjudicates each claim and determines whether reasonable evidence exists to support it. Currently, determining the presence of tinnitus is based on subjective reporting-objective measures do not exist. The aim of this study was to develop and document a test for detecting the presence/absence of tinnitus with high confidence. Using our computer-automated, self-guided tinnitus evaluation system, we conducted three phases of testing to compare psychoacoustic measures of tinnitus between participants with versus without tinnitus. Phase 1 measures included loudness match, pitch match, minimum masking level, residual inhibition, Békésy, and forced-choice double staircase. Phases 2 and 3 measures were chosen based on results of the previous phase. The number of tests and time of testing decreased during each successive phase. Differences were seen between groups; most notably, higher low-frequency loudness matches and higher median pitch matches were observed for participants with tinnitus. Results of this study suggest that further efforts can produce a defined psychoacoustic test battery for identifying the presence/absence of tinnitus.

Tinnitus, or "ringing in the ears," affects 10%-15% of adults; cases can be problematic and require lifelong management. Many people who have experienced traumatic brain injury (TBI) also experience tinnitus. We developed Progressive Tinnitus Management (PTM), which uses education and counseling to help patients learn how to self-manage their reactions to tinnitus. We adapted PTM by delivering the intervention via telephone and by adding cognitive-behavioral therapy. A pilot study was conducted to evaluate the feasibility and potential efficacy of this approach for individuals with and without TBI. Participants with clinically significant tinnitus were recruited into three groups: probable symptomatic mild TBI (n = 15), moderate to severe TBI (n = 9), and no symptomatic TBI (n = 12). Participants received telephone counseling (six sessions over 6 months) by an audiologist and a psychologist. Questionnaires were completed at baseline, 12 weeks, and 24 weeks. All groups showed trends reflecting improvement in self-perceived functional limitations due to tinnitus. A follow-up randomized clinical study is underway.

Chronic tinnitus is experienced by 10%-15% of the population, of which only about 20% require clinical intervention. People requiring intervention have different levels of need, ranging from the provision of basic information to long-term, individualized treatment. We address this clinical need by outlining a five-level "progressive intervention" approach to the management of tinnitus that would provide a systematic framework for treatment by audiologists. At each level, patients must be appropriately referred-usually to otolaryngology, psychology, and/or psychiatry. Level 1 is an interview method of screening for determining if the person requires clinical intervention (and addressing basic questions). Level 2 is the provision of structured group educational counseling. If the screening determines that care is urgently required or if further help is needed following the group session(s), a tinnitus intake assessment (Level 3) should be performed. The intake assessment, which includes educational counseling, can often meet a patient's needs. If not, then a program of continuing treatment (Level 4) would be indicated. If significant benefit were not achieved through consistent treatment over 1-2 years, longer-term treatment (Level 5) would be indicated, which could include alternate or multiple treatment modalities. At all levels, the goal is to minimize the impact of tinnitus on the patient's life as efficiently as possible.