J Korean Med Sci.  2025 Feb;40(7):e93. 10.3346/jkms.2025.40.e93.

Consensus Statements on Tinnitus Assessment and Treatment Outcome Evaluation: A Delphi Study by the Korean Tinnitus Study Group

• Choo OS
• Park JM
• Park E
• Chang J
• Lee MY
• Lee HY
• Moon IS
• Song JJ
• Lee KY
• Song JJ
• Nam EC
• Park SN
• Shim HJ
• Rah YC
• Seo JH

• KMID: 2565185
• DOI: http://doi.org/10.3346/jkms.2025.40.e93

Abstract

Background
Tinnitus is a multifactorial condition with no universally accepted assessment guidelines. The Korean Tinnitus Study Group previously established consensus statements on the definition, classification, and diagnostic tests for tinnitus. As a continuation of this effort, this study aims to establish expert consensus on tinnitus assessment and treatment outcome evaluation, specifically tailored to the Korean clinical context.
Methods
A modified Delphi method involving 26 otology experts from across Korea was used. A two-round Delphi survey was conducted to evaluate statements related to tinnitus assessment before and after treatment. Statements were rated on a scale of 1 to 9 for the level of agreement. Consensus was defined as ≥ 70% agreement (score of 7–9) and ≤ 15% disagreement (score of 1–3). Statistical measures such as content validity ratio and Kendall’s coefficient of concordance (W) were calculated to assess agreement levels.
Results
Of the 46 assessment-related statements, 17 (37%) reached consensus, though overall pre-treatment assessments showed weak agreement (Kendall’s W = 0.319). Key areas of agreement included the use of the visual analogue scale, numeric rating scale, and validated questionnaires for pre-treatment evaluation. Five statements, such as the use of computed tomography, magnetic resonance imaging, and angiography for diagnosing pulsatile tinnitus, achieved over 90% agreement. For treatment outcome measurements, 8 of 12 statements (67%) reached a consensus, with moderate agreement (Kendall’s W = 0.513). Validated questionnaires and psychoacoustic tests were recommended for evaluating treatment effects within 12 weeks. While standardized imaging for pulsatile tinnitus and additional clinical tests were strongly recommended, full consensus was not achieved across all imaging modalities.
Conclusion
This study provides actionable recommendations for tinnitus assessment and treatment evaluation, emphasizing the use of standardized tools and individualized approaches based on patient needs. These findings offer a practical framework to enhance consistency and effectiveness in tinnitus management within Korean clinical settings.

Figure

• 

  Fig. 1 Process of the modified Delphi Study on tinnitus assessment.

• 

  Fig. 2 Responses of 11 multiple-choice questions related to clinical assessment and treatment outcomes measurements of tinnitus.VAS = Visual analogue scale, THI = Tinnitus Handicap Inventory, TFI = Tinnitus Functional Index, TQ = Tinnitus Questionnaire, THQ = Tinnitus Handicap Questionnaire, TRQ = Tinnitus Reaction Questionnaire, TSS = Tinnitus Severity Scale, BDI = Beck Depression Inventory, STAI = State-Trait Anxiety Inventory, PSQI = Pittsburgh Sleep Quality Index, BEPSI = Brief Encounter Psychosocial Instrument, EQ = Emotional Quotient, HADS = Hospital Anxiety and Depression Scale, BAI = Beck Anxiety Inventory, WHODAS = World Health Organization Disability Assessment Schedule, ISI = Insomnia Sleep Index, PHQ-9 = Patient Health Questionnaire-9, HRQoL = Health-related Quality of Life, PTA = Pure Tone Audiometry, SA = Speech Audiometry, LDL = Low-density Lipoprotein, DPOAE = Distortion Product Otoacoustic Emission, ABR = Auditory Brainstem Response, TEOAE = Transientevoked Otoacoustic Emission, ECoG = Electrocochleography, SOAE = Spontaneous Otoacoustic Emission, ASSR = Auditory Steady State Response, VEMP = Vestibular-evoked Myogenic Potential, CBC = Complete Blood Count, TFT = Thyroid Function Test, LFT = Liver Function Test, ECG = Electrocardiogram, TBCT = Temporal Bone Computed Tomography, MRA = Magnetic Resonance Angiography, CT = Computed Tomography, TCD = Transcranial Doppler, MRV = Magnetic Resonance Venography, RI = Residual Inhibition.

Reference

1. De Ridder D, Vanneste S, Song JJ, Adhia D. Tinnitus and the triple network model: a perspective. Clin Exp Otorhinolaryngol. 2022; 15(3):205–212. PMID: 35835548.

2. Choo OS, Kim H, Lee SJ, Kim SY, Lee KY, Lee HY, et al. Consensus statements on the definition, classification, and diagnostic tests for tinnitus: a Delphi study conducted by the Korean Tinnitus Study Group. J Korean Med Sci. 2024; 39(5):e49. PMID: 38317449.

3. Bauer CA. Tinnitus. N Engl J Med. 2018; 378(13):1224–1231. PMID: 29601255.

4. Shargorodsky J, Curhan GC, Farwell WR. Prevalence and characteristics of tinnitus among US adults. Am J Med. 2010; 123(8):711–718. PMID: 20670725.

5. Degeest S, Corthals P, Vinck B, Keppler H. Prevalence and characteristics of tinnitus after leisure noise exposure in young adults. Noise Health. 2014; 16(68):26–33. PMID: 24583677.

6. Pattyn T, Van Den Eede F, Vanneste S, Cassiers L, Veltman DJ, Van De Heyning P, et al. Tinnitus and anxiety disorders: a review. Hear Res. 2016; 333:255–265. PMID: 26342399.

7. Bhatt JM, Bhattacharyya N, Lin HW. Relationships between tinnitus and the prevalence of anxiety and depression. Laryngoscope. 2017; 127(2):466–469. PMID: 27301552.

8. Zeman F, Koller M, Langguth B, Landgrebe M. Tinnitus Research Initiative Database Study Group. Which tinnitus-related aspects are relevant for quality of life and depression: results from a large international multicentre sample. Health Qual Life Outcomes. 2014; 12(1):7. PMID: 24422941.

9. Henry JA, Dennis KC, Schechter MA. General review of tinnitus: prevalence, mechanisms, effects, and management. J Speech Lang Hear Res. 2005; 48(5):1204–1235. PMID: 16411806.

10. Eggermont JJ, Roberts LE. The neuroscience of tinnitus: understanding abnormal and normal auditory perception. Front Syst Neurosci. 2012; 6:53. PMID: 22798948.

11. Noreña AJ. An integrative model of tinnitus based on a central gain controlling neural sensitivity. Neurosci Biobehav Rev. 2011; 35(5):1089–1109. PMID: 21094182.

12. Henry JA. “Measurement” of tinnitus. Otol Neurotol. 2016; 37(8):e276–e285. PMID: 27518136.

13. Rabau S, Cox T, Punte AK, Waelkens B, Gilles A, Wouters K, et al. Changes over time of psychoacoustic outcome measurements are not a substitute for subjective outcome measurements in acute tinnitus. Eur Arch Otorhinolaryngol. 2015; 272(3):573–581. PMID: 24395086.

14. Genitsaridi E, Hoare DJ, Kypraios T, Hall DA. A review and a framework of variables for defining and characterizing tinnitus subphenotypes. Brain Sci. 2020; 10(12):938. PMID: 33291859.

15. Liu Y, Niu H, Zhu J, Zhao P, Yin H, Ding H, et al. Morphological neuroimaging biomarkers for tinnitus: evidence obtained by applying machine learning. Neural Plast. 2019; 2019:1712342. PMID: 31915431.

16. Adams B, Sereda M, Casey A, Byrom P, Stockdale D, Hoare DJ. A Delphi survey to determine a definition and description of hyperacusis by clinician consensus. Int J Audiol. 2021; 60(8):607–613. PMID: 33305628.

17. Ogawa K, Sato H, Takahashi M, Wada T, Naito Y, Kawase T, et al. Clinical practice guidelines for diagnosis and treatment of chronic tinnitus in Japan. Auris Nasus Larynx. 2020; 47(1):1–6. PMID: 31606294.

18. Keeney S, Hasson F, McKenna HP. A critical review of the Delphi technique as a research methodology for nursing. Int J Nurs Stud. 2001; 38(2):195–200. PMID: 11223060.

19. Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, et al. GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol. 2011; 64(4):395–400. PMID: 21194891.

20. von der Gracht HA. Consensus measurement in Delphi studies review and implications for future quality assurance. Technol Forecast Soc Change. 2012; 79(8):1525–1536.

21. Raj-Koziak D, Gos E, Swierniak W, Rajchel JJ, Karpiesz L, Niedzialek I, et al. Visual analogue scales as a tool for initial assessment of tinnitus severity: psychometric evaluation in a clinical population. Audiol Neurootol. 2018; 23(4):229–237. PMID: 30439712.

22. Langguth B, Goodey R, Azevedo A, Bjorne A, Cacace A, Crocetti A, et al. Consensus for tinnitus patient assessment and treatment outcome measurement: tinnitus Research Initiative meeting, Regensburg, July 2006. Prog Brain Res. 2007; 166:525–536. PMID: 17956816.

23. Meikle M, Taylor-Walsh E. Characteristics of tinnitus and related observations in over 1800 tinnitus clinic patients. J Laryngol Otol Suppl. 1984; 98:17–21.

24. Rizzardo R, Savastano M, Maron MB, Mangialaio M, Salvadori L. Psychological distress in patients with tinnitus. J Otolaryngol. 1998; 27(1):21–25. PMID: 9511115.

25. Dobie RA, Sakai CS, Sullivan MD, Katon WJ, Russo J. Antidepressant treatment of tinnitus patients: report of a randomized clinical trial and clinical prediction of benefit. Am J Otol. 1993; 14(1):18–23. PMID: 8424470.

26. Megwalu UC, Finnell JE, Piccirillo JF. The effects of melatonin on tinnitus and sleep. Otolaryngol Head Neck Surg. 2006; 134(2):210–213. PMID: 16455366.

27. Kim HJ, Lee HJ, An SY, Sim S, Park B, Kim SW, et al. Analysis of the prevalence and associated risk factors of tinnitus in adults. PLoS One. 2015; 10(5):e0127578. PMID: 26020239.

28. Moon KR, Park S, Jung Y, Lee A, Lee JH. Effects of anxiety sensitivity and hearing loss on tinnitus symptom severity. Psychiatry Investig. 2018; 15(1):34–40.

29. Ooms E, Meganck R, Vanheule S, Vinck B, Watelet JB, Dhooge I. Tinnitus severity and the relation to depressive symptoms: a critical study. Otolaryngol Head Neck Surg. 2011; 145(2):276–281. PMID: 21493268.

30. Schaette R, Kempter R. Predicting tinnitus pitch from patients’ audiograms with a computational model for the development of neuronal hyperactivity. J Neurophysiol. 2009; 101(6):3042–3052. PMID: 19357344.

31. König O, Schaette R, Kempter R, Gross M. Course of hearing loss and occurrence of tinnitus. Hear Res. 2006; 221(1-2):59–64. PMID: 16962270.

32. Moore BC, Vinay , Sandhya . The relationship between tinnitus pitch and the edge frequency of the audiogram in individuals with hearing impairment and tonal tinnitus. Hear Res. 2010; 261(1-2):51–56. PMID: 20103482.

33. Schecklmann M, Vielsmeier V, Steffens T, Landgrebe M, Langguth B, Kleinjung T. Relationship between audiometric slope and tinnitus pitch in tinnitus patients: insights into the mechanisms of tinnitus generation. PLoS One. 2012; 7(4):e34878. PMID: 22529949.

34. Ochi K, Ohashi T, Kenmochi M. Hearing impairment and tinnitus pitch in patients with unilateral tinnitus: comparison of sudden hearing loss and chronic tinnitus. Laryngoscope. 2003; 113(3):427–431. PMID: 12616191.

35. Song Z, Wu Y, Tang D, Lu X, Qiao L, Wang J, et al. Tinnitus is associated with extended high-frequency hearing loss and hidden high-frequency damage in young patients. Otol Neurotol. 2021; 42(3):377–383. PMID: 33196532.

36. Vielsmeier V, Lehner A, Strutz J, Steffens T, Kreuzer PM, Schecklmann M, et al. The relevance of the high frequency audiometry in tinnitus patients with normal hearing in conventional pure-tone audiometry. Biomed Res Int. 2015; 2015:302515. PMID: 26583098.

37. Schaette R, McAlpine D. Tinnitus with a normal audiogram: physiological evidence for hidden hearing loss and computational model. J Neurosci. 2011; 31(38):13452–13457. PMID: 21940438.

38. Wang M, Ai Y, Han Y, Fan Z, Shi P, Wang H. Extended high-frequency audiometry in healthy adults with different age groups. J Otolaryngol Head Neck Surg. 2021; 50(1):52. PMID: 34446093.

39. De Ridder D, Heijneman K, Haarman B, van der Loo E. Tinnitus in vascular conflict of the eighth cranial nerve: a surgical pathophysiological approach to ABR changes. Prog Brain Res. 2007; 166:401–411. PMID: 17956805.

40. Bartnik G, Hawley M, Rogowski M, Raj-Koziak D, Fabijanska A, Formby C. [Distortion product otoacoustic emission levels and input/output-growth functions in normal-hearing individuals with tinnitus and/or hyperacusis]. Otolaryngol Pol. 2009; 63(2):171–181. PMID: 19681492.

41. Vernon JA, Meikle MB. Tinnitus: clinical measurement. Otolaryngol Clin North Am. 2003; 36(2):293–305. PMID: 12856298.

42. Henry JA, Flick CL, Gilbert A, Ellingson RM, Fausti SA. Comparison of manual and computer-automated procedures for tinnitus pitch-matching. J Rehabil Res Dev. 2004; 41(2):121–138. PMID: 15558367.

43. Meikle MB, Stewart BJ, Griest SE, Henry JA. Tinnitus outcomes assessment. Trends Amplif. 2008; 12(3):223–235. PMID: 18599500.

44. Henry JA, Meikle MB. Psychoacoustic measures of tinnitus. J Am Acad Audiol. 2000; 11(3):138–155. PMID: 10755810.

45. Tunkel DE, Bauer CA, Sun GH, Rosenfeld RM, Chandrasekhar SS, Cunningham ER Jr, et al. Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. 2014; 151(2):Suppl. S1–S40. PMID: 25273878.

46. Andersson G. Tinnitus loudness matchings in relation to annoyance and grading of severity. Auris Nasus Larynx. 2003; 30(2):129–133. PMID: 12753982.

47. Perez-Carpena P, Bibas A, Lopez-Escamez JA, Vardonikolaki K, Kikidis D. Systematic review of sound stimulation to elicit tinnitus residual inhibition. Prog Brain Res. 2021; 262:1–21. PMID: 33931174.

48. Hobson J, Chisholm E, El Refaie A. Sound therapy (masking) in the management of tinnitus in adults. Cochrane Database Syst Rev. 2012; 11(11):CD006371. PMID: 23152235.

49. Galazyuk AV, Longenecker RJ, Voytenko SV, Kristaponyte I, Nelson GL. Residual inhibition: from the putative mechanisms to potential tinnitus treatment. Hear Res. 2019; 375:1–13. PMID: 30822633.

50. Ralli M, Greco A, Turchetta R, Altissimi G, de Vincentiis M, Cianfrone G. Somatosensory tinnitus: current evidence and future perspectives. J Int Med Res. 2017; 45(3):933–947. PMID: 28553764.

51. Zeng FG. An active loudness model suggesting tinnitus as increased central noise and hyperacusis as increased nonlinear gain. Hear Res. 2013; 295:172–179. PMID: 22641191.

52. Roberts LE, Salvi R. Overview: hearing loss, tinnitus, hyperacusis, and the role of central gain. Neuroscience. 2019; 407:1–7. PMID: 30885639.

53. Cederroth CR, Lugo A, Edvall NK, Lazar A, Lopez-Escamez JA, Bulla J, et al. Association between hyperacusis and tinnitus. J Clin Med. 2020; 9(8):2412. PMID: 32731492.

54. Hébert S, Fournier P, Noreña A. The auditory sensitivity is increased in tinnitus ears. J Neurosci. 2013; 33(6):2356–2364. PMID: 23392665.

55. Abdalkader M, Nguyen TN, Norbash AM, Raz E, Shapiro M, Lenck S, et al. State of the art: venous causes of pulsatile tinnitus and diagnostic considerations guiding endovascular therapy. Radiology. 2021; 300(1):2–16. PMID: 34032509.

56. Sismanis A. Pulsatile tinnitus: contemporary assessment and management. Curr Opin Otolaryngol Head Neck Surg. 2011; 19(5):348–357. PMID: 22552697.

57. Morris PP, Black DF, Port J, Campeau N. Transverse sinus stenosis is the most sensitive MR imaging correlate of idiopathic intracranial hypertension. AJNR Am J Neuroradiol. 2017; 38(3):471–477. PMID: 28104635.

58. Narvid J, Do HM, Blevins NH, Fischbein NJ. CT angiography as a screening tool for dural arteriovenous fistula in patients with pulsatile tinnitus: feasibility and test characteristics. AJNR Am J Neuroradiol. 2011; 32(3):446–453. PMID: 21402614.

59. Kwon BJ, Han MH, Kang HS, Chang KH. Endovascular occlusion of direct carotid cavernous fistula with detachable balloons: usefulness of 3D angiography. Neuroradiology. 2005; 47(4):271–281. PMID: 15809860.

60. Park SN, Han JS, Mee Park J, Jin HJ, Joo HA, Park JT, et al. A novel water occlusion test for disorders causing pulsatile tinnitus: our experience in 32 patients. Clin Otolaryngol. 2020; 45(2):280–285. PMID: 31850655.

61. Sunwoo W, Lee DY, Lee JY, Lee M, Kang Y, Park MH, et al. Characteristics of tinnitus found in anemia patients and analysis of population-based survey. Auris Nasus Larynx. 2018; 45(6):1152–1158. PMID: 29706416.

62. Kim SY, Min C, Kim HJ, Choi HG. Low thyroid-stimulating hormone levels are associated with annoying tinnitus in adult women: Korea National Health and Nutrition Examination Surveys. Otol Neurotol. 2021; 42(4):e408–e415. PMID: 33710990.

63. Hall DA. Designing clinical trials for assessing the effectiveness of interventions for tinnitus. Trends Hear. 2017; 21:2331216517736689. PMID: 29076393.

64. Meikle MB, Vernon J, Johnson RM. The perceived severity of tinnitus. Some observations concerning a large population of tinnitus clinic patients. Otolaryngol Head Neck Surg. 1984; 92(6):689–696. PMID: 6440089.

65. Scott TE, Costich M, Fiorino EK, Paradise Black N. Using a modified Delphi methodology to identify essential telemedicine skills for pediatric residents. Acad Pediatr. 2023; 23(3):511–517. PMID: 36084799.

66. Henry JA, Roberts LE, Caspary DM, Theodoroff SM, Salvi RJ. Underlying mechanisms of tinnitus: review and clinical implications. J Am Acad Audiol. 2014; 25(1):5–22. PMID: 24622858.

67. Alshabory HF, Gabr TA, Kotait MA. Distortion product otoacoustic emissions (DPOAEs) in tinnitus patients. Int Arch Otorhinolaryngol. 2021; 26(1):e046–e057. PMID: 35096158.

68. Sanchez TG, Roberts LE. Total remission or persistence of tinnitus and decreased sound level tolerance in adolescents with normal audiograms: a follow-up study. Prog Brain Res. 2021; 260:253–268. PMID: 33637221.

69. Akins RB, Tolson H, Cole BR. Stability of response characteristics of a Delphi panel: application of bootstrap data expansion. BMC Med Res Methodol. 2005; 5(1):37. PMID: 16321161.