Starkey Research & Clinical Blog

The Tinnitus Handicap Inventory (THI): A quick and reliable method for measuring tinnitus outcomes

Newman, C.W., Sandridge, S.A. & Jacobson, G.P. (1998). Psychometric adequacy of the Tinnitus Handicap Inventory (THI) for evaluating treatment outcome. Journal of the American Academy of Audiology 9, 153-160.

This editorial discusses the clinical implications of an independent research study. This editorial does not represent the opinions of the original authors.

Tinnitus affects approximately 40-50 million people in the United States and an estimated 10-12 million people seek treatment for it (ATA, 2011; AAA, 2000). Though tinnitus has many potential causes, it often coincides with sensorineural hearing loss. In some cases medical or surgical treatment may be an option, but more often than not an individual with hearing loss and tinnitus will seek hearing aids. Therefore, clinical audiologists frequently encounter patients who suffer from tinnitus.

Because of the potentially disruptive effects of tinnitus on a patient’s ability to function and their sense of well-being, it is important for audiologists to include some estimation of tinnitus handicap in their overall clinical evaluation. Comprehensive diagnostic testing, including tinnitus pitch and loudness matching, should be supplemented with tinnitus self-report measures.  Self-report questionnaires elucidate the effect that the tinnitus has on the individual’s daily life. For instance, tinnitus can disrupt sleep and the ability to concentrate at work or in social interactions and can cause depression, irritability, frustration, stress and feelings of helplessness (Kochkin & Tyler, 1990). Examination of the emotional and social impact of tinnitus and how much it disturbs an individual’s daily activities is essential for determining the course of treatment.

There are a number of potential treatment approaches for tinnitus, including but not limited to: hearing aids, tinnitus maskers, combination hearing aid/masking devices, tinnitus retraining therapy, cognitive therapy, psychological counseling and stress management. Because any of these approaches may succeed with some patients and not others, it is essential to tailor the tinnitus rehabilitation program to each individual and to measure the efficacy of treatment to determine when a change in strategy is indicated.  Though a number of tinnitus questionnaires exist, many of them are limited in scope, difficult to score and interpret, or lack data to support their reliability and validity (Tyler, 1993). Tinnitus handicap questionnaires that are broad in scope and easy to administer and interpret are beneficial because clinicians are often working under time constraints. Test-retest reliability is particularly important if tinnitus self-report questionnaires are to be used to measure treatment outcomes.

The Tinnitus Handicap Inventory was developed as a brief, easily administered way to evaluate the disabling consequences of tinnitus (THI; Newman et al., 1996). It has potential for use in an initial evaluation of handicap or later as well as a way to measure treatment outcome. In the paper discussed here, Newman, Sandridge and Jacobson measured the test-retest reliability and repeatability of the THI, then used their findings to develop categories for the severity of perceived tinnitus handicap.

The THI is a 25-item questionnaire with items that are grouped into three subscales: functional, emotional and catastrophic responses.  The functional subscale items reflect the effect of tinnitus on mental, social, occupational and physical functioning. The emotional subscale items probe the individual’s emotional reactions to the tinnitus and the catastrophic response items address whether tinnitus makes the respondent feel desperate, trapped, hopeless or out of control.  A “yes” response is given 4 points, a “sometimes” response is given 2 points and a “no” response is given 0 points. The questionnaire yields scores for each subscale and a total score that ranges from 0 and 100, with high scores indicating a greater handicap.

Twenty-nine adult subjects, ranging in age from 23 to 87 years old, participated in the study. Subjects were patients at two outpatient Audiology clinics. All subjects presented with tinnitus as their primary complaint and most had gradually sloping, high-frequency, sensorineural hearing losses. The mean length of time that patients reported having tinnitus was 6 years and the mean length of time they had been “bothered” by the tinnitus was 3 years. Eleven participants reported unilateral tinnitus, whereas 18 reported bilateral tinnitus.  The participants reported, on average, that their tinnitus was present 90% of the time during waking hours.

Subjects completed the THI and a tinnitus case history questionnaire (modified from Stouffer and Tyler, 1990) following the scheduling of their initial appointment.  These forms were returned by mail prior to the visit. The second administration of the THI took place approximately 20 days later. This investigation was intended to measure test-retest reliability, which is the magnitude of agreement between two scores when the interval between them is short. The authors cited three reasons for this time frame. First, because many of the subjects were distressed by their tinnitus, they needed to be clinically evaluated and treated as soon as possible. Second, because tinnitus can fluctuate they wanted patients to make all of their judgments within a limited window of time. Third, the interval between initial clinical assessment and evaluation of treatment is often short. For instance, evaluation of the benefit of a tinnitus masker or hearing aid must be completed within the 30-day or 45-day trial period and one goal of the study was to assess the clinical value of the THI.

Results showed that the mean scores and standard deviations were comparable between the two THI administrations. Participants also maintained their relative standing on total and subscale scores from initial test to retest, as indicated by correlations ranging from .84 to .94. Repeatability was measured via calculation of difference scores and plots of their deviation from a difference score of zero. The THI was deemed to have acceptable repeatability because 95% of the difference scores fell within +/- 2 standard deviations from zero.  The repeatability measures allowed the investigators to determine how much of a difference in score would indicate a true difference in status for an individual patient. They found that the total THI scores on two separate administrations would have to differ by at least 20 points in order to be considered a true change. In other words, a clinician using the THI as a tool to measure treatment efficacy would have to see a decrease of at least 20 points to consider the treatment to be successful.

Following these analyses, quartiles were calculated from the mean total THI scores in order to assign scores to one of four handicap categories. On repeat administrations over time, movement from one category to another would indicate a change in tinnitus handicap status, either related to deterioration in the patient’s condition or an improvement based on treatment. The four handicap categories were as follows:

Quartile           Category                       Total THI Score

1st                   No handicap                       0-16

2nd                  Mild handicap                     18-36

3rd                   Moderate handicap              38-56

4th                   Severe handicap                 58-100

Self-reported scales are already widely used to illuminate a patient’s perceived hearing handicap and as a method of evaluating hearing aid fitting outcome or other aural rehabilitation efforts.  One of the primary goals of Newman, Sandridge and Jacobson’s study was to determine if the THI could be used as a clinical tool to evaluate tinnitus treatment outcomes. The reliability and repeatability of the THI suggests that it could be used in this way and it is a straightforward scale that is easy to administer and score. The authors suggest that the THI could be combined with other 25-item scales like the Hearing Handicap Inventory for Adults (HHIA, Newman et al., 1990) or Hearing Handicap Inventory for the Elderly (HHIE, Ventry & Weinstein, 1982) and the Dizziness Handicap Inventory (DHI, Jacobson & Newman, 1990) as a self-report inventory battery to evaluate initial handicap and efficacy of audiological and otological rehabilitation efforts. 

Tyler and Kochkin (1990) reported that 60% of tinnitus sufferers report benefit from the use of hearing aids and that 88% of hearing care professionals treat tinnitus with hearing aids.  Surr, et al. (1999) administered the THI before and six weeks after hearing aid fitting and reported that 90% of their participants demonstrated a significant reduction in THI scores. Because of the co-occurrence of tinnitus and sensorineural hearing loss, clinical audiologists frequently encounter tinnitus sufferers and may often be the first or only health professional to discuss tinnitus management options with the patient. It is important for audiologists to be familiar with tinnitus etiologies, evaluation techniques, treatment options and efficacy measures so they can provide proper guidance to their patients. Clinical appointments are often subject to time constraints, but the clinician is accountable for treatment outcomes, so brief but robust self-report inventories like the THI can be valuable clinical tools.

References

American Academy of Audiology (2000).  Audiologic guidelines for the evaluation and management of tinnitus.  AAA website, http://www.audiology.org/resources/documentlibrary/Pages/TinnitusGuidelines.aspx.

American Tinnitus Association (2011). As cited in Beck, D., Hearing aid amplification and tinnitus: 2011 overview. Hearing Journal 64 (6), 12-13.

Jacobson, G.P. & Newman, C.W. (1990). The development of the Dizziness Handicap Inventory. Archives of Otolaryngology Head and Neck Surgery 116, 424-427.

Kochkin, S. & Tyler, R.S. (2008). Tinnitus treatment and the effectiveness of hearing aids – hearing care professional perceptions. Hearing Review 15(13), 14-18.

Newman, C.W., Weinstein, B.E., Jacobson, G.P & Hug, G.A. (1990). The Hearing Handicap Inventory for Adults: psychometric adequacy and audiometric correlates. Ear and Hearing 11, 176-180.

Newman, C.W., Jacobson, G.P. & Spitzer, J.B. (1996). Development of the Tinnitus Handicap Inventory. Archives of Otolaryngology Head and Neck Surgery 122, 143-148.

Newman, C.W., Sandridge, S.A. & Jacobson, G.P. (1998). Psychometric adequacy of the Tinnitus Handicap Inventory (THI) for evaluating treatment outcome. Journal of the American Academy of Audiology 9, 153-160.

Stouffer, J.L. & Tyler, R.S. (1990). Characterization of tinnitus by tinnitus patients. Journal of Speech and Hearing Disorders 55, 439-453.

Surr, R.K., Kolb, J.A., Cord, M.T. & Garrus, N.P. (1999). Tinnitus handicap inventory (THI) as a hearing aid outcome measure. Journal of the American Academy of Audiology 10(9), 489-495.

Tyler, R.S. (1993). Tinnitus disability and handicap questionnaires. Seminars in Hearing 14, 377-384.

Ventry, I. & Weinstein, B. (1982). The Hearing Handicap Inventory for the Elderly: a new tool. Ear and Hearing 3, 128-134.