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PTM Flowchart APPENDIX A PTM Flowchart Level 5 Individualized Support if needed Refer as necessary to Level 4 Interdisciplinary Evaluation ENT, Mental Health, if needed or other specialist Level 3 Group Education if needed Sound Tolerance if needed Evaluation & Level 2 Audiologic Evaluation Management if needed (STEM) Refer to Audiology Refer to ENT Refer to Emergency Refer to (non-urgent referral) (urgency determined by Care or ENT Mental Health or clinician; refer to audiologist (if unexplained sudden hearing Emergency Care - for follow-up management) loss: Audiology referral prior to report suicidal ENT visit same day) ideation Tinnitus plus ALL of the Tinnitus plus ANY of below the below - Symptoms suggest neural - Symptoms suggest Tinnitus plus ANY of Tinnitus plus ANY of origin of tinnitus (e.g., somatic origin of tinnitus the below the below tinnitus does not pulse with (e.g., tinnitus that pulses - Physical trauma - Suicidal ideation heartbeat) with heartbeat) - Facial palsy - Obvious mental - No ear pain, drainage, or - Ear pain, drainage, or - Sudden unexplained health problems malodor malodor hearing loss - No vestibular symptoms - Vestibular symptoms (e.g., no dizziness/vertigo) (e.g., dizziness/vertigo) - No unexplained sudden hearing loss or facial palsy Triage Guidelines (for non-audiologists) Level 1 Triage 95 APPENDIX B Tinnitus Triage Guidelines (My Patient Complains About Tinnitus— What Should I Do?) Tinnitus (“ringing in the ears”) is experienced by lines for triaging the patient who complains about 10 to 15% of the adult population. Of those, about tinnitus. Note that many symptoms that might be one out of every five requires some degree of reported by patients are not included. For example, clinical intervention. When clinical intervention patients who report tinnitus may also report symp- is required, often only some basic education is toms of head or neck injury/disease, or of TMJ dis- needed. However, some people with tinnitus have order. These and other symptoms would indicate need for individualized care, or they have urgent referral to appropriate specialists. medical issues. The following are general guide- If the patient: Refer to: 1. Emergency Care or Otolaryngology (If unexplained • Has physical trauma, facial palsy, or unexplained sudden hearing loss—Audiology referral prior to sudden hearing loss Otolaryngology visit same day) • Has any other urgent medical condition (emergency referral) 2. Emergency Care or Mental Health—report suicidal/ • Has suicidal/homicidal ideations homicidal ideation • Manifests obvious mental health problems (may be emergency—if so, escort patient to Emergency Care or Mental Health) 3. Has ANY of the following: Otolaryngology • Symptoms suggest somatic origin of tinnitus (urgency determined by clinician; refer to audiologist for (example: tinnitus that pulses with heartbeat) follow-up management) • Ear pain, drainage, or malodor • Vestibular symptoms (example: dizziness/vertigo) 4. Has ALL of the following: Audiology • Symptoms suggest neural origin of tinnitus (example: tinnitus that does not pulse with heartbeat) • No ear pain, drainage, or malodor • No vestibular symptoms (example: no dizziness/vertigo) • No unexplained sudden hearing loss or facial palsy 97 APPENDIX C Overview of Objectives and Procedures of the Level 2 Audiologic Evaluation Determine need for: Assessment procedures: Action needed: 1. Referral for medical Standard clinical procedures Refer to otolaryngology examination 2. Hearing aids or assistive Standard clinical procedures Fit devices as appropriate listening devices 3. Level 3 Group Discuss with patient the responses to the Schedule patient for group workshops Education Tinnitus and Hearing Survey (primarily (after fitting of any instruments) Section A) (Appendix D). If the patient is interested in attending a workshop that focuses on managing problems listed in section A then action is needed. 4. Provision of Loudness Review item 1 from Section C of Provide a copy of the handout to the Tolerance Handout: the Tinnitus and Hearing Survey patient with a brief explanation of its “What to Do When (Appendix D). If the patient reports at purpose Everyday Sounds Are least a mild loudness tolerance problem, Too Loud” (Appendix E) then action is needed. 5. Assessment for a Discuss with the patient the responses to Schedule the patient for a Sound loudness tolerance the Tinnitus and Hearing Survey (primarily Tolerance Evaluation and Management problem item 2 from Section C) (Appendix D). (STEM) appointment. Suspend Level If the patient reports that a loudness 3 of PTM until the sound tolerance tolerance problem would make it difficult problem is resolved. to attend a group education class, then action is needed. 6. Mental health screening Screening is done at Level 2 only if the Refer patient to a mental health patient exhibits behaviors or makes provider that is part of the “PTM or statements that would suggest the need tinnitus team,” or to primary care for for mental health screening mental health screening 7. Provision of self-help Patients who have problematic tinnitus Issue a workbook at the end of education workbook: should be advised to attend Level 3 Group Level 2 only if the patient cannot or will How to Manage Your Education. The workbook normally is not attend Level 3 Group Education. If Tinnitus: A Step-by-Step provided to patients at the start of the time permits, point out sections of the Workbook first Level 3 workshop. workbook that are applicable to the patient’s situation. 99 APPENDIX D Tinnitus and Hearing Survey big a g small m moderate bi very m not s, a s, a es, a es, a No, Ye Y problem Y Ye A. Tinnitus proble problem problem proble Over the last week, tinnitus kept me from 0 1 2 3 4 sleeping. Over the last week, tinnitus kept me from 0 1 2 3 4 concentrating on reading. otal Over the last week, tinnitus kept me from 0 1 2 3 4 T relaxing. Over the last week, I couldn’t get my mind 0 1 2 3 4 Grand off of my tinnitus. Total of each column B. Hearing Over the last week, I couldn’t understand what 0 1 2 3 4 others were saying in noisy or crowded places. Over the last week, I couldn’t understand what 0 1 2 3 4 people were saying on TV or in movies. l Over the last week, I couldn’t understand 0 1 2 3 4 ta To people with soft voices. Over the last week, I couldn’t understand what 0 1 2 3 4 Grand was being said in group conversations. Total of each column C. Sound Tolerance Over the last week, everyday sounds were too 0 1 2 3 4 loud for me.* If you responded 1, 2, 3 or 4 to the statement above: Being in a meeting with 5 to 10 people 0 1 2 3 4 would be too loud for me.* *If sounds are too loud for you when wearing hearing aids, please tell your audiologist. 101 APPENDIX E What to Do When Everyday Sounds Are Too Loud (Not related to using hearing aids) Bill Smith is bothered by everyday sounds. (This prob- If you keep yourself surrounded with sound, lem is sometimes called hyperacusis.) Kitchen sounds your ears will readjust. It will slowly become easier and the vacuum cleaner are too loud for him. He is both- for you to tolerate everyday sounds. You should ered by road noise when he drives. It seems like every- only use sounds that are comfortable for you. It thing at church is too loud. What should Bill do? Believe usually takes at least a few weeks of being around it or not, being around more sound can make things bet- sound for this change to happen. ter! And, staying away from sound can make his prob- How do I keep myself surrounded with sound? lem worse! What??? He should add more sound??? You can use any sound that is not annoying (the Keep reading and we’ll explain . sound can be either neutral or pleasant). Here are some ideas: There are three things you can do if everyday sounds are too loud for you. n Listen to music at a comfortable level. n Listen to radio shows. 1. Keep yourself surrounded with sound that is n Play recordings of nature sounds. comfortable for you. n Keep a fan running. 2. Listen to sounds that you enjoy as often as you n Use a tabletop water fountain. can. 3. Only wear hearing protection when you really Another choice: Some people wear small instru- need to. ments in their ears that make a “shhh” sound. These instruments are called in-the-ear noise genera- 1. Keep yourself surrounded with sound tors or maskers. Your audiologist can tell you more that is comfortable for you. about them. Why should I keep myself surrounded with sound? Let’s start by thinking about your eyes and 2. Listen to sounds that you enjoy as often how they adjust to light. Imagine sitting in a dark as you can. movie theater and then going outside into the day- Why should I listen to sounds that I enjoy as light. Everything seems brighter to you than it does often as I can? We just talked about the problem to people who were not sitting in the dark. Your of everyday sounds being too loud (hyperacusis). eyes had adjusted to the dark and now they have Many people also have another problem: they just to readjust to the daylight. don’t like certain sounds, but not because they are too Your ears adjust to sound like your eyes adjust loud. (This problem is sometimes called misophonia.) to light. If you stay away from sound, your ears will If you don’t like certain sounds, you should make a slowly adjust to the quiet.
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