14Stepped Care and Severity Stratification

FWhy match intensity to severity

Most people who notice tinnitus are not greatly bothered by it; a minority are profoundly distressed. Offering everyone the same intensive specialist programme would overwhelm services and over-medicalise the majority, while offering everyone only reassurance would abandon the severely affected. The solution endorsed across guidelines is stratified, stepped care: assess impact first, then deliver the lightest effective intervention, escalating only when needed [2014].

This rests on a key observation — tinnitus impact does not track its acoustic properties. A faint tinnitus can be catastrophic to one person and an intense one barely noticed by another. So we stratify on measured distress and functional impact, not on pitch, loudness match or audiogram [2013].

TScreening and triage tools

Stratification needs a yardstick. Two validated patient-reported measures dominate. The Tinnitus Handicap Inventory (THI) bands impact from slight (0–16) through mild, moderate and severe to catastrophic (78–100). The Tinnitus Functional Index (TFI) was designed to be responsive to change across eight domains (intrusiveness, sleep, emotion, cognition and more), making it well suited to tracking progress over time [2012].

These instruments do two jobs: at first contact they triage a patient into a care tier, and at review they quantify whether the chosen step is working. A common practice is to add a brief mood screen (such as the HADS) because comorbid anxiety and depression both worsen tinnitus distress and change the management plan.

CThe Dutch / ESIT stepped-care model

The landmark evidence for stepped care is the Dutch randomised trial by Cima and colleagues. Patients were allocated either to usual ENT/audiology care or to a specialised, stepped programme: a lower-intensity first step of education and audiological care for all, followed by a more intensive multidisciplinary CBT-based step for those with greater distress. The specialised stepped programme produced superior quality of life and reductions in tinnitus severity, and was cost-effective [2012].

This model was generalised in the European guideline, which frames tinnitus care as tiers: education and self-help for low impact; structured audiological and psychological therapy for moderate impact; and intensive multidisciplinary care for severe or refractory cases [2019].

CWhen to escalate and refer

Escalation is driven by two triggers: severity at presentation and failure to improve. A patient presenting with a high THI/TFI, marked sleep disruption, or comorbid depression should enter a higher tier from the outset rather than starting at the bottom. A patient who starts in a low tier but whose scores do not fall on review (typically at 6–12 weeks) is stepped up [2019].

Certain findings bypass the ladder entirely and demand prompt specialist referral: pulsatile or unilateral tinnitus, associated neurological signs, sudden hearing loss, or any expression of suicidal ideation. The stepped model is a default for the common bothersome case, not a substitute for clinical red-flag vigilance [2014].