The Impact of Tinnitus Severity on Work Functioning among U.S. Military Veterans with Tinnitus.

Tinnitus is highly prevalent among military Veterans. Severe tinnitus can be associated with negative impacts on daily life. Veterans with severe tinnitus may also have greater difficulties in functional roles, including work. However, few studies have explicitly explored this relationship. Traumatic brain injury (TBI), also prevalent among Veterans, is associated with tinnitus and can additionally impair work functioning. This quantitative investigation used a population-based survey to assess the relationship between tinnitus severity, measured using the Tinnitus Functional Index (TFI), and the impact of tinnitus on work, measured using a composite score from the Tinnitus History Questionnaire, among a stratified random sample of VA healthcare-using Veterans diagnosed with tinnitus, with and without comorbid TBI. Analyses were weighted to account for sampling design and Veteran non-response; multiple imputation was used to account for missing data. Results indicated that for every 1-point increase in TFI score, there was an average 8% increase in the odds of reporting a high level of impact on work functioning (OR: 1.08; 95% CI: 1.06, 1.11). Veterans with a comorbid TBI diagnosis, compared with those without, were more likely to have high tinnitus-related impact on work functioning (OR: 2.69, 95% CI: 1.85, 3.91), but the relationship between tinnitus severity and the impact of tinnitus on work functioning did not differ by TBI status. These data can help researchers and clinicians understand complex symptoms experienced by Veterans with tinnitus, with and without TBI, supporting the improved provision of clinical services to these patients.

History of Tinnitus Research at the VA National Center for Rehabilitative Auditory Research (NCRAR), 1997-2021: Studies and Key Findings.

The Veterans Affairs (VA) Rehabilitation Research & Development (RR&D) National Center for Rehabilitative Auditory Research (NCRAR) was first funded by the RR&D Service in 1997 and has been funded continuously since that time. The overall purpose of the NCRAR is to "improve the quality of life of Veterans and others with hearing and balance problems through clinical research, technology development, and education that leads to better patient care" ( www.ncrar.research.va.gov ). An important component of the research conducted at the NCRAR has been a focus on clinical and rehabilitative aspects of tinnitus. Multiple investigators have received grants to conduct tinnitus research and the present article provides an overview of this research from the NCRAR's inception through 2021.

Sound Tolerance Conditions (Hyperacusis, Misophonia, Noise Sensitivity, and Phonophobia): Definitions and Clinical Management.

Purpose: For some people, exposure to everyday sounds presents a significant problem. The purpose of this tutorial was to define and differentiate between the various sound tolerance conditions and to review some options for their clinical management. METHOD: We informally reviewed the literature regarding sound tolerance conditions. The terminology and definitions provided are mostly consistent with how these terms are defined. However, many inconsistencies are noted. Methods of assessment and treatment also differ, and different methodologies are briefly described. RESULTS: Hyperacusis describes physical discomfort or pain when any sound reaches a certain level of loudness that would be tolerable for most people. Misophonia refers to intense emotional reactions to certain sounds (often body sounds such as chewing and sniffing) that are not influenced by the perceived loudness of those sounds. Noise sensitivity refers to increased reactivity to sounds that may include general discomfort (annoyance or feeling overwhelmed) due to a perceived noisy environment, regardless of its loudness. Phonophobia, as addressed in the audiology profession, describes anticipatory fear of sound. Phonophobia is an emotional response such as anxiety and avoidance of sound due to the "fear" that sound(s) may occur that will cause a comorbid condition to get worse (e.g., tinnitus) or the sound itself will result in discomfort or pain. (Note that phonophobia is a term used by neurologists to describe "migraineur phonophobia"-a different condition not addressed herein.) Conclusions: The literature addresses sound tolerance conditions but reveals many inconsistencies, indicating lack of consensus in the field. When doing an assessment for decreased sound tolerance, it is important to define any terms used so that the patient and all health care professionals involved in the care of the patient are aligned with the goals of the treatment plan. Treatment generally involves gradual and systematic sound desensitization and counseling. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.20164130.

Factors affecting the implementation of evidence-based Progressive Tinnitus Management in Department of Veterans Affairs Medical Centers.

PURPOSE: Progressive Tinnitus Management (PTM) is an evidence-based interdisciplinary stepped-care approach to improving quality of life for patients with tinnitus. PTM was endorsed by Department of Veterans Affairs (VA) Audiology leadership in 2009. Factors affecting implementation of PTM are unknown. We conducted a study to: 1) estimate levels of PTM program implementation in VA Audiology and Mental Health clinics across the country; and 2) identify barriers and facilitators to PTM implementation based on the experiences of VA audiologists and mental health providers. METHOD: We conducted an anonymous, web-based survey targeting Audiology and Mental Health leaders at 144 major VA facilities. Quantitative analyses summarized respondents' facility characteristics and levels of program implementation (full PTM, partial PTM, or no PTM). Qualitative analyses identified themes in factors influencing the implementation of PTM across VA sites. RESULTS: Surveys from 87 audiologists and 66 mental health clinicians revealed that few facilities offered full PTM; the majority offered partial or no PTM. Inductive analysis of the open-ended survey responses identified seven factors influencing implementation of PTM: 1) available resources, 2) service collaboration, 3) prioritization, 4) Veterans' preferences and needs, 5) clinician training, 6) awareness of (evidence-based) options, and 7) perceptions of scope of practice. CONCLUSION: Results suggest wide variation in services provided, a need for greater engagement of mental health providers in tinnitus care, and an interest among both audiologists and mental health providers in receiving tinnitus-related training. Future research should address barriers to PTM implementation, including methods to: 1) improve understanding among mental health providers of their potential role in tinnitus management; 2) enhance coordination of tinnitus-related care between health care disciplines; and 3) collect empirical data on Veterans' need for and interest in PTM, including delivery by telehealth modalities.

Health Care Utilization and Mental Health Diagnoses Among Veterans With Tinnitus.

Purpose Tinnitus is prevalent among military Veterans and may frequently co-occur with mental health disorders. This study examined health care utilization and mental health diagnoses among Veterans with and without tinnitus who receive Department of Veterans Affairs (VA) health care. Method We randomly sampled 10% of VA health care users for a 5-year period between 2011 and 2016. Tinnitus and other diagnoses were identified using International Classification of Diseases diagnosis codes; Veterans assigned 1 or more inpatient codes or 2 or more outpatient codes were considered to have the respective diagnosis. We examined demographics, military service, clinical characteristics, and health care utilization of Veterans with and without tinnitus diagnoses. Bivariable and multivariable logistic regression was used to estimate associations between tinnitus and mental health diagnoses of interest. Results Among 617,534 eligible Veterans, 3.8% met criteria for tinnitus diagnosis. Prevalence of tinnitus was associated with sex, age, race, marital status, and VA service connection status; additionally, hearing loss and traumatic brain injury were frequently codiagnosed with tinnitus. Veterans with tinnitus had higher annual health care utilization than those without. While controlling for potential confounders, tinnitus diagnoses were associated with mental health diagnoses, including anxiety, depression, and substance use disorders. Conclusion Findings suggest that Veterans who are diagnosed with tinnitus have more health care utilization and are more frequently diagnosed with mental health disorders than Veterans who are not diagnosed with tinnitus. This suggests a need for coordinated tinnitus and mental health care services for Veterans in the VA system of care.

Progressive Tinnitus Management at Two Veterans Affairs Medical Centers: Clinical Implementation With Modified Protocols.

Purpose This is a description of the clinical implementation and outcomes of progressive tinnitus management (PTM) at 2 Veterans Affairs (VA) medical centers: Both programs modified the protocol originally described by PTM developers. Method Modifications at both sites were classified according to an evidence-based framework set forth by Stirman, Miller, Toder, and Calloway (2013) . The Iowa City VA PTM program clinicians made 2 modifications and the Asheville, North Carolina, VA PTM program clinicians made 6 modifications to the standard PTM protocol. Pre-post outcome measures were analyzed for 20 veterans who completed the Iowa City program and for 200 veterans who completed the Asheville program. Results Veterans who completed the Iowa City program showed a statistically significant decrease in the average Tinnitus Handicap Inventory score ( Newman, Jacobson, & Spitzer, 1996 ). Veterans who completed the Asheville PTM program showed a statistically significant decrease in the average Tinnitus Functional Index (TFI) score. Outcomes in Asheville were compared to outcomes of a clinical trial of PTM conducted by the developers of PTM. The clinical work in Asheville resulted in a greater mean reduction on the TFI and a larger effect size using the TFI as compared to the results of the PTM clinical trial. Conclusions Clinician-directed modifications to PTM that are made to address the unique needs and circumstances of an individual clinic have potential to result in positive outcomes for patients. Clinicians providing care for patients with tinnitus using PTM who modify the protocol to meet the needs of their local setting are encouraged to collect and report the outcomes of their modifications to improve understanding of the impact of various types of modifications to PTM and other evidence-based practices.

Telephone-Based Progressive Tinnitus Management for Persons With and Without Traumatic Brain Injury: A Randomized Controlled Trial.

OBJECTIVES: This randomized controlled trial evaluated the efficacy of delivering coping skills education from Progressive Tinnitus Management (PTM) by telephone (Tele-PTM). The trial followed a previous pilot study that showed positive results for Tele-PTM. DESIGN: Participants included individuals with bothersome tinnitus (N = 205) located anywhere within the United States. A special emphasis was given to including individuals who had experienced one or more traumatic brain injuries (TBIs). Participants were randomized to either Tele-PTM intervention or 6-month wait-list control (WLC). The Tele-PTM intervention involved five telephone appointments-two led by an audiologist (teaching how to use therapeutic sound) and three by a psychologist (teaching coping skills derived from cognitive-behavioral therapy). It was hypothesized that Tele-PTM would be more effective than WLC in reducing functional effects of tinnitus as measured with the Tinnitus Functional Index. Additional outcome measures included the Self-Efficacy for Managing Reactions to Tinnitus questionnaire and the Hospital Anxiety and Depression Scale. The effect of Tele-PTM on outcomes was estimated using linear mixed models. RESULTS: Overall results showed convincingly that the Tele-PTM group had significantly better outcomes than the WLC group. These results were consistent across all outcome measures, indicating not only a reduction of tinnitus functional distress but also increased self-efficacy. Improvements in measures of anxiety and depression were also observed. Tele-PTM participants in all TBI categories showed significant improvement. CONCLUSIONS: Results provide strong support for use of Tele-PTM methodology for persons with bothersome tinnitus, regardless of whether the person also has TBI symptoms. The effect size for Tele-PTM was high for the primary outcome measure, the Tinnitus Functional Index, and all other outcome measures showed significant improvement. Combined with our previous pilot study, the Tele-PTM method is validated for potential nationwide provision of tinnitus services.

Randomized Controlled Trial of a Novel Device for Tinnitus Sound Therapy During Sleep.

PURPOSE: The aim of this study was to determine if a customized stimulus from the Otoharmonics Levo System reduces tinnitus perceptions and reactions for people with bothersome tinnitus. METHOD: Sixty participants were randomized to 1 of 3 groups that used sound therapy devices during sleep that differed in their acoustic stimulus: (a) tinnitus-matched (TM), (b) noise stimulus (NS), and (c) bedside sound generator (BSG). Outcome measures were the Tinnitus Functional Index (TFI), numeric rating scale of tinnitus loudness, and tinnitus loudness match. A Bayesian hierarchical model was fit to estimate the differences in treatment efficacy among groups. RESULTS: Average tinnitus reactions and perceptions improved across treatment groups. We are at least 87% certain that treatment with TM or NS reduces mean TFI compared to treatment with BSG, with an estimated relative efficacy of 4.5-5 points greater reduction. We are at least 95% certain that treatment with TM results in greater reduction in mean numeric rating scale (NRS) of tinnitus loudness compared to the other groups, with an estimated relative efficacy of about 0.75 points greater reduction. CONCLUSIONS: This study offers some support for greater average improvement in reactions to tinnitus with TM or NS devices compared to the BSG device. The TM group, compared to the BSG and NS groups, showed a greater reduction in ratings of tinnitus loudness on the NRS on average. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.5545759.

Randomized Controlled Trial in Clinical Settings to Evaluate Effectiveness of Coping Skills Education Used With Progressive Tinnitus Management.

Purpose: This randomized controlled trial evaluated, within clinical settings, the effectiveness of coping skills education that is provided with progressive tinnitus management (PTM). Method: At 2 Veterans Affairs medical centers, N = 300 veterans were randomized to either PTM intervention or 6-month wait-list control. The PTM intervention involved 5 group workshops: 2 led by an audiologist (teaching how to use sound as therapy) and 3 by a psychologist (teaching coping skills derived from cognitive behavioral therapy). It was hypothesized that PTM would be more effective than wait-list control in reducing functional effects of tinnitus and that there would be no differences in effectiveness between sites. Results: At both sites, a statistically significant improvement in mean Tinnitus Functional Index scores was seen at 6 months for the PTM group. Combined data across sites revealed a statistically significant improvement in Tinnitus Functional Index relative to wait-list control. The effect size for PTM using the Tinnitus Functional Index was 0.36 (small). Conclusions: Results suggest that PTM is effective at reducing tinnitus-related functional distress in clinical settings. Although effect sizes were small, they provide evidence of clinical effectiveness of PTM in the absence of stringent research-related inclusion criteria and with a relatively small number of sessions of cognitive behavioral therapy.

Subjective Reports of Trouble Tolerating Sound in Daily Life versus Loudness Discomfort Levels.

PURPOSE: A retrospective analysis of tonal and speech loudness discomfort levels (LDLs) relative to a subjective report of sound tolerance (SRST) was performed to explore the relation between the 2 commonly used clinical measures. METHOD: Tonal LDLs and SRST were measured for 139 U.S. military veterans who were recruited into a study providing intervention for tinnitus. Spearman's rank correlation coefficients were computed to assess the relation between the tonal and speech LDLs and the SRST. RESULTS: Only weak correlations were found between tonal LDLs and SRST and between speech LDLs and SRST. CONCLUSION: If LDLs ratings of SRST measured the same phenomenon, the measures would be strongly negatively correlated. The weak correlations found between the measures suggest that LDLs do not accurately represent a patient's ability to tolerate sound in daily life.

Multisite Randomized Controlled Trial to Compare Two Methods of Tinnitus Intervention to Two Control Conditions.

OBJECTIVES: In this four-site clinical trial, we evaluated whether tinnitus masking (TM) and tinnitus retraining therapy (TRT) decreased tinnitus severity more than the two control groups: an attention-control group that received tinnitus educational counseling (and hearing aids if needed; TED), and a 6-month-wait-list control (WLC) group. The authors hypothesized that, over the first 6 months of treatment, TM and TRT would decrease tinnitus severity in Veterans relative to TED and WLC, and that TED would decrease tinnitus severity relative to WLC. The authors also hypothesized that, over 18 months of treatment, TM and TRT would decrease tinnitus severity relative to TED. Treatment effectiveness was hypothesized not to be different across the four sites. DESIGN: Across four Veterans affairs medical center sites, N = 148 qualifying Veterans who experienced sufficiently bothersome tinnitus were randomized into one of the four groups. The 115 Veterans assigned to TM (n = 42), TRT (n = 34), and TED (n = 39) were considered immediate-treatment subjects; they received comparable time and attention from audiologists. The 33 Veterans assigned to WLC were, after 6 months, randomized to receive delayed treatment in TM, TRT, or TED. Assessment of outcomes took place using the Tinnitus Handicap Inventory (THI) at 0, 3, 6, 12, and 18 months. RESULTS: Results of a repeated measures analysis of variance using an intention-to-treat approach showed that the tinnitus severity of Veterans receiving TM, TRT, and TED significantly decreased (p < 0.05) relative to Veterans in the WLC group at 3 months (effect sizes = 0.44, 0.52, and 0.27, respectively) and at 6 months (effect sizes = 0.52, 0.56, and 0.40, respectively). Analyses comparing effectiveness of TM, TRT, and TED over 18 months revealed that the three conditions were not significantly different, but that tinnitus severity in the combined groups significantly decreased (p < 0.01) from baseline to 3 months (5.6 THI points) and from 3 to 6 months (3.7 THI points). With respect to clinically significant change, about half of Veterans who received TM (55%), TRT (59%), or TED (46%) showed strong or modest improvement on the THI by 18 months. Without treatment, the WLC group did not show significant change. Treatment effectiveness did not differ by study site. CONCLUSIONS: Audiologists who provided interventions to Veterans with bothersome tinnitus in the regular clinic setting were able to significantly reduce tinnitus severity over 18 months using TM, TRT, and TED approaches. These results suggest that TM, TRT, and TED, when implemented as in this trial, will provide effectiveness that is relatively similar by 6 months and beyond.

Tinnitus Screener: Results From the First 100 Participants in an Epidemiology Study.

PURPOSE: In the Noise Outcomes in Servicemembers Epidemiology Study, Veterans recently separated from the military undergo comprehensive assessments to initiate long-term monitoring of their auditory function. We developed the Tinnitus Screener, a four-item algorithmic instrument that determines whether tinnitus is present and, if so, whether it is constant or intermittent, or whether only temporary tinnitus has been experienced. Predictive validity data are presented for the first 100 Noise Outcomes in Servicemembers Epidemiology Study participants. METHOD: The Tinnitus Screener was administered to participants by telephone. In lieu of a gold standard for determining tinnitus presence, the predictive validity of the tinnitus category assigned to participants on the basis of the Screener results was assessed when the participants attended audiologic testing. RESULTS: Of the 100 participants, 67 screened positive for intermittent or constant tinnitus. Three were categorized as "temporary" tinnitus only, and 30 were categorized as "no tinnitus." Tinnitus categorization was predictively valid with 96 of the 100 participants. CONCLUSIONS: These results provide preliminary evidence that the Screener may be suitable for quickly determining essential parameters of reported tinnitus. We have since revised the instrument to differentiate acute from chronic tinnitus and to identify occasional tinnitus. We are also obtaining measures that will enable assessment of its test-retest reliability.

Tinnitus and hearing survey: a screening tool to differentiate bothersome tinnitus from hearing difficulties.

PURPOSE: Individuals complaining of tinnitus often attribute hearing problems to the tinnitus. In such cases some (or all) of their reported "tinnitus distress" may in fact be caused by trouble communicating due to hearing problems. We developed the Tinnitus and Hearing Survey (THS) as a tool to rapidly differentiate hearing problems from tinnitus problems. METHOD: For 2 of our research studies, we administered the THS twice (mean of 16.5 days between tests) to 67 participants who did not receive intervention. These data allow for measures of statistical validation of the THS. RESULTS: Reliability of the THS was good to excellent regarding internal consistency (α=.86-.94), test-retest reliability (r=.76-.83), and convergent validity between the Tinnitus Handicap Inventory (Newman, Jacobson, & Spitzer, 1996; Newman, Sandridge, & Jacobson, 1998) and the A (Tinnitus) subscale of the THS (r=.78). Factor analysis confirmed that the 2 subscales, A (Tinnitus) and B (Hearing), have strong internal structure, explaining 71.7% of the total variance, and low correlation with each other (r=.46), resulting in a small amount of shared variance (21%). CONCLUSION: These results provide evidence that the THS is statistically validated and reliable for use in assisting patients and clinicians in quickly (and collaboratively) determining whether intervention for tinnitus is appropriate.

Development of a progressive audiologic tinnitus management program for Veterans with tinnitus.

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.

Evaluating psychoacoustic measures for establishing presence of tinnitus.

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.

Pilot study to develop telehealth tinnitus management for persons with and without traumatic brain injury.

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.

Principles and application of educational counseling used in progressive audiologic tinnitus management.

Exposure to loud sounds is a common cause and exacerbater of tinnitus - a troubling auditory symptom that affects millions of people worldwide. Clinical research at the National Center for Rehabilitative Auditory Research has resulted in a clinical model of tinnitus management referred to as Progressive Audiologic Tinnitus Management (PATM). The model involves five hierarchical levels of management: Triage, Audiologic Evaluation, Group Education, Tinnitus Evaluation, and Individualized Management. Counseling by audiologists and, as needed, mental health providers, is a key component of PATM. This style of counseling focuses less on didactic informational counseling; instead, counseling is used for facilitating patients' learning to adjust to the disturbing auditory symptom by successfully employing tools from two powerful skillsets for self-management of chronic tinnitus - the therapeutic uses of sound and techniques from cognitive-behavioral psychology. This article provides an overview of the methods of counseling used with PATM and provides details concerning the overarching principles of collaborative adult learning that are believed to be most important in facilitating self-management by patients who complain of tinnitus.

Using therapeutic sound with progressive audiologic tinnitus management.

Management of tinnitus generally involves educational counseling, stress reduction, and/or the use of therapeutic sound. This article focuses on therapeutic sound, which can involve three objectives: (a) producing a sense of relief from tinnitus-associated stress (using soothing sound); (b) passively diverting attention away from tinnitus by reducing contrast between tinnitus and the acoustic environment (using background sound); and (c) actively diverting attention away from tinnitus (using interesting sound). Each of these goals can be accomplished using three different types of sound-broadly categorized as environmental sound, music, and speech-resulting in nine combinations of uses of sound and types of sound to manage tinnitus. The authors explain the uses and types of sound, how they can be combined, and how the different combinations are used with Progressive Audiologic Tinnitus Management. They also describe how sound is used with other sound-based methods of tinnitus management (Tinnitus Masking, Tinnitus Retraining Therapy, and Neuromonics).

The role of audiologic evaluation in progressive audiologic tinnitus management.

Progressive Audiologic Tinnitus Management (PATM) is based on the premise that tinnitus is managed most efficiently using a hierarchy of clinical services that address different levels of need. PATM includes five levels of management: (a) triage; (b) audiologic evaluation; (c) group education; (d) tinnitus evaluation; and (e) individualized management. This article provides an overview of PATM and focuses on the procedures that make up the Level 2 Audiologic Evaluation. The evaluation is conducted to assess the potential need for medical, audiologic (hearing loss, tinnitus, hyperacusis), and/or mental health services. The Tinnitus Handicap Inventory, Hearing Handicap Inventory, and Tinnitus and Hearing Survey are used to differentiate effects of tinnitus and hearing loss. If indicated, patients are interviewed with the Tinnitus-Impact Screening Interview. Patients requiring amplification receive hearing aids. Often, management of hearing loss at Level 2 addresses any problems that were attributed to the tinnitus, which obviates further tinnitus-specific intervention.