In the context of tinnitus
and hyperacusis rehabilitation, all patients should undergo thorough medical
evaluation by their physician and ENT specialist prior to be referred for
tinnitus and/or hyperacusis rehabilitation. The psycho-audiological assessment
methods used in the process of tinnitus and/or hyperacusis rehabilitation
comprise (1) modified version of the pure tone audiometry, (2) modified version
of Uncomfortable Loudness Levels (ULLs) test, (3) tinnitus and hyperacusis
psychometric tools, (4) insomnia assessment, (5) psychometric tools for
screening of the psychological disorders.
Pure Tone Audiometry
Pure tone audiogram should
be measured using the procedure recommended by the British Society of Audiology
(BSA 2011a), but
with some modifications proposed by Aazh and Moore (2017b)to avoid any discomfort for patients who experiment tinnitus, hyperacusis,
misophonia or any type of noise sensitivity. The startingpresentation level at 0.25, 0.5, 2, 3, 4, 6,
and 8 kHz should be equal to the measured audiometric threshold at the
adjacent frequency (e.g., if the threshold at 1 kHz is 20 dB HL, the starting
level for measuring the threshold at 2 kHz should be 20 dB HL, instead of 50 dB
HL as recommended by the BSA).
Uncomfortable Loudness Levels (ULLs)
ULLs should be measured
following the BSA recommended procedure (BSA 2011b), but
with the modifications proposed by Aazh and Moore (2017b),
to avoid any discomfort. The starting presentation level should be equal to the
measured audiometric threshold at the test frequency. In addition, levels above 80 dB HL are not used. If the ULL is not
reached at 80 dB HL, the ULL at the test frequency is recorded as 85 dB HL.
Diagnosis f hyperacusis
When the average ULL at
0.25, 0.5, 1, 2, 4 and 8 kHz for the ear with the lower average ULL, which is
called ULLmin, was ≤77 dB HL, hyperacusis was deemed to be present (Aazh & Moore 2017a).
survey conducted by Dr. Aazh’s tinnitus team showed that 35% of patients who
sought help for tinnitus and/or hyperacusis (373/1067) had hyperacusis based on
ULLmin diagnostic criteria.
Diagnosis of Severe
hyperacusis should be diagnosed when a ULL of 30 dB HL or less is measured for
at least one of frequency from 0.25, 0.5, 1, 2, 3, 4, 6, and 8 kHz, for at
least one ear (Aazh & Moore 2018). Recent survey
conducted by Dr. Aazh’s tinnitus team showed that 4% of patients who sought
help for tinnitus and/or hyperacusis (48/1067) had severe hyperacusis. Read
Dr.Aazh’s pioneering study published in the Journal of the American Academy of
Audiology on Prevalence and Characteristics of Patients with Severe
The questionnaires listed below should be applied
before the start of the treatment and at the end of the last session. Patients
should complete these without involvement of their audiologist.
Handicap Inventory (THI; Newman et al. 1996)
The THI has 25 items, and response choices are "no" (0
points), "sometimes" (2 points) and "yes" (4 points). The
overall score ranges from 0 to 100. Scores from 0–16 indicate no handicap,
scores from 18–36 indicate mild handicap, scores from 38–56 indicate moderate
handicap, and scores from 58–100 indicate severe handicap (Newman et al. 1996).
Questionnaire (HQ; Khalfa et al. 2002)
The HQ comprises 14
items and the response choices are "no" (0 points), "yes, a
little" (1 point), "yes, quite a lot" (2 points), and "yes,
a lot" (3 points). The overall score ranges from 0 to 42. Scores of 22 or
more should be taken as indicating the presence of hyperacusis handicap (Aazh & Moore 2017a).
Severity Index (ISI; Bastien et al. 2001)
ISI comprises seven items that assess the severity of sleep difficulties and
their effect on the patient’s life. Each item is rated on a scale from 0 to 4
and the total score ranges from 0 to 28. Scores from 0-7 indicate no clinically
significant insomnia, scores from 8-14 indicate slight insomnia, scores from
15-21 indicate moderate insomnia, and scores from 22-28 indicate severe
insomnia (Bastien et al. 2001).
Analogue Scale (VAS; Maxwell 1978) of tinnitus
loudness, annoyance and effect on life.
VAS scores are ratings
on a scale from 0 to 10. The VAS score for the loudness of tinnitus is assessed
by asking the patient to rate the loudness of tinnitus during their waking
hours over the last months. The VAS score for annoyance induced by the tinnitus
is assessed by asking the patient to rate their subjective perception of
annoyance on average during the last month. The VAS score for the impact of
tinnitus on their life is assessed by asking the patient to rate the effect of
tinnitus on their life during the last month.
(6) Generalized Anxiety Disorder questionnaire (GAD-7; Spitzer
et al. 2006).
a 7-item questionnaire for assessment of anxiety symptoms. Patients are asked
how often during the last 2 weeks they had been bothered by each symptom.
Response options are not at all (0), several days (1), more than half the days
(2), and nearly every day (3). The total score ranges from 0 to 21. The recommended cut-off score for generalized
anxiety in the UK mental health system is a score of 8 or above (IAPT 2011).
Health Questionnaire (PHQ-9; Kroenke
et al. 2001).
a 9-item questionnaire for assessment of depression. The total score ranges
from 0 to 27. The recommended cut-off for caseness for depression in the UK
mental health system is a score of 10 or above
Aazh, H., &
Moore, B. C. J. (2017a). Factors related to Uncomfortable Loudness Levels for
patients seen in a tinnitus and hyperacusis clinic. International Journal of Audiology 56, 793-800.
Aazh, H., & Moore, B. C. J. (2017b). Incidence of discomfort
during pure-tone audiometry and measurement of uncomfortable loudness levels
among People seeking help for tinnitus and/or hyperacusis American
Journal of Audiolgy, 26, 226-232.
Aazh, H., & Moore, B. C. J. (2018). Prevalence and
characteristics of patients with severe hyperacusis among patients seen in a
tinnitus and hyperacusis clinic Journal of American Academy of Audiology,
Bastien, C. H., Vallieres, A., & Morin, C. M. (2001). Validation
of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med, 2, 297-307.
BSA (2011a). Pure-tone
air-conduction and bone-conduction threshold audiometry with and without masking:
Recommended Procedure. Reading, UK: British Society of Audiology.
BSA (2011b). Recommended
Procedure: Determination of uncomfortable loudness levels. Reading, UK:
British Society of Audiology
IAPT (2011). The IAPT Data Handbook: Guidance on recording and
monitoring outcomes to support local evidence-based practice In D. o. Health
(Ed.), UK: IAPT National Programme Team
Khalfa, S., Dubal, S., Veuillet, E., et al. (2002). Psychometric
normalization of a hyperacusis questionnaire. ORL J Otorhinolaryngol Relat Spec, 64, 436-42.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The
PHQ-9: validity of a brief depression severity measure. J Gen Intern Med, 16,
Maxwell, C. (1978). Sensitivity and accuracy of the visual analogue
scale: a psycho-physical classroom experiment. Br J Clin Pharmacol, 6,
Newman, C. W., Jacobson, G. P., & Spitzer, J. B. (1996).
Development of the Tinnitus Handicap Inventory. Arch Otolaryngol Head Neck Surg, 122, 143-8.
Spitzer, R. L., Kroenke, K., Williams, J. B., et al. (2006). A brief
measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med, 166, 1092-7.