Acta Oto-Laryngologica, 2005; 125: 1184
/1188

ORIGINAL ARTICLE

Validity and reliability study of three tinnitus self-assessment scales:

loudness, annoyance and change

H. PETER ZENNER1, HARRY DE MADDALENA2 & ILSE M. ZALAMAN1

Departments of 1Otolaryngology and 2Communication Disorders, University of Tübingen, Tübingen, Germany

Abstract
Conclusions. The three tinnitus self-rating scales described herein can be employed as part of ‘‘minimal datasets’’ to reflect
the patient’s current tinnitus status. These tests are simple and easy to use and can be completed by the patient alone. The
results are easy to interpret and provide a good foundation for an effective doctor
/patient dialogue. Objective. To investigate
the reliability and validity of three tinnitus self-rating scales: a six-point response scale for tinnitus loudness; an eight-point
response scale for tinnitus annoyance; and a six-point response scale for tinnitus change. Material and methods. The data for
273 patients participating in 2 separate studies were assessed in terms of their validity and reliability. We used criterion
validity to determine whether the scales had empirical associations with external criteria, in this case an already firmly
established tinnitus questionnaire. In addition we examined construct validity, i.e. its subcategories convergent and
discriminant validity, in order to find out how related or unrelated items or scales were. We tested the reliability and
repeatability of the scales using patients on our waiting list for tinnitus desensitization. Results. The test
/retest reliability
was 0.72 for tinnitus loudness and 0.62 for tinnitus annoyance. Calculations showed that all three scales correlated
positively with validated complex scales and thus we considered convergent validity to be adequate.

Keywords: Diagnosis, intrusiveness, tinnitus sensitization, treatment

Introduction minimum distortion, in choosing a term that most

Audiological psychoacoustic methods used to mea-
sure tinnitus impairment have been studied inten-
sively for many years. They demonstrate good
reliability and are easy to use. Most of these
measures are standardized and allow within- and
between-group comparisons as they measure objec-
tive impairment [1]. The treatment outcome for
chronic tinnitus, however, is based to a great extent
on self-assessment questionnaires and not psychoa-
coustic measures. Self-assessment measures do not
measure impairment but instead assess the degree of
personally experienced handicap and disability. No-
ble [2] states that ‘‘. . . no one can speak of personal
disabilities and handicaps better than the person
who suffers them; even if the form of account-
making is reduced to numbers on a scaled ques-
tionnaire, those numbers are still the result of
a person exercising discretion, hopefully with
closely matches their experience’’.
Some authors [3] suggest that tinnitus assessment
should comprise at least the following test batteries:
simple visual analogue scales (VASs) assessing the
loudness, annoyance and awareness of tinnitus
experienced, as well as prevention of sleep onset,
and/or tinnitus questionnaires assessing the follow-
ing parameters: quality of life, concentration, sleep
patterns, annoyance, emotional distress and tinnitus
masking. For example, Hallam et al. [4] and Goebel
and Hiller [5] developed tinnitus questionnaires
(TQs) which reliably quantify and differentiate
between the various tinnitus handicaps [5,6]. The
scales measure the following tinnitus parameters:
emotional distress; cognitive distress; psychosocial
distress; intrusiveness; hearing problems; sleep dis-
orders; and somatic distress. However, the loudness
and annoyance of tinnitus assessed by means of
VASs generally do not agree with psychoacoustic

Correspondence: H. Peter Zenner, MD, Department of Otolaryngology, University of Tübingen, Elfriede-Aulhorn-Strasse 5, 72076 Tübingen, Germany.
Tel: /49 7071 29 88001. Fax: /49 7071 29 5674. E-mail: zenner@uni-tuebingen.de

(Received 18 March 2005; accepted 6 July 2005)

ISSN 0001-6489 print/ISSN 1651-2551 online # 2005 Taylor & Francis
DOI: 10.1080/00016480510012282

measures [3,5,7]. Whereas most psychoacoustic
measures demonstrate that tinnitus matching is just
a few dB SPL above hearing threshold, the loudness
of tinnitus assessed by means of VASs is frequently
indicated to be intolerable. In their study of 1800
tinnitus patients, Meikle and Taylor-Walsh [7] dis-
covered that only 20% indicated a perceived tinnitus
loudness of
/6 dB above hearing threshold. Goebel
and Hiller [5] believe that tinnitus VAS scales have
low reliability and are unsuited for comparative
studies. If this is true then comparative VAS studies
in which tinnitus was investigated would be proble-
matic as it would not be possible for VAS-assessed
data to be replicated in terms of tinnitus loudness
and annoyance despite the use of careful designs as
an increase in these measures of
/100% is not
possible. Other objections towards VAS-based data
analyses expressed by the authors are founded on the
fact that it is supposedly extremely difficult to
understand why the same interventions lead to
different therapy outcomes in different patients
when the patients are grouped according to tinnitus
impairment measures.
In this study we investigated the reliability and
validity of three self-rating scales used in our
hospital. We used three separate Likert response
scales instead of VAS scales: a six-point scale for
tinnitus loudness; an eight-point scale for tinnitus
annoyance; and a six-point scale for tinnitus change
(Table I). We wanted to know whether these
psychometric scales were suited for the evaluation
of therapy outcome. The data of 273 patients
Table I. Response scales.
(a) Tinnitus loudness (six-point response scale).
Do you have tinnitus? If yes, where is it located? How loud is it?
Right ear Left ear Inside the head
Not audible k k
Barely audible k k
Moderately audible k k
Quite audible k k
Loud k k
Very loud k k
(b) Tinnitus annoyance (eight-point response scale).
How annoying has your tinnitus been within the last few days?
1. Not annoying 2. Hardly 3. Slightly 4. Moderately
annoying annoying annoying
(c) Tinnitus change after therapy (six-point response scale).
Compared with the beginning of therapy, my tinnitus is . . .
1. Gone k
2. Greatly improved k
3. Improved k
4. Unchanged k
5. Worse k
6. Worst k
Self-assessment of tinnitus 1185
participating in two separate studies were assessed
in terms of validity and reliability.
Instrument validation is necessary to determine
whether the newly constructed instruments measure
what they intend to measure. The validation proce-
dure comprises a number of steps. The objective is
to collect sufficient proof by providing enough
evidence which demonstrates that the measurement
reflects the patient’s experience accurately. Fayers
and Machin [8] are of the opinion that validity can
be divided into three major categories: content,
criterion and construct validity. We used criterion
validity to determine whether the scales have em-
pirical associations with external criteria, in this case
the already firmly established TQ of Goebel and
Hiller [5]. In addition we examined construct
validity, i.e. its subcategories convergent and dis-
criminant validity, in order to find out how related or
unrelated items or scales were.
Reliability and repeatability involve the random
variations occurring with measurements. We tested
reliability and repeatability on patients on our wait-
ing list for tinnitus desensitization therapy because
the status quo of the patients would not significantly
improve during that time. Should the results demon-
strate significant random variability within and
between patients then the instrument would not be
considered a reliable measuring tool. Moreover, low
reliability may also be an indicator or warning that
the instrument may be measuring something differ-
ent from what it should, i.e. the scales exhibit low
construct validity [8].
k
k
k
k
k
k
5. Annoying 6. Rather 7. Intensely 8. Extremely
annoying annoying annoying
1186 H. P. Zenner et al.
Material and methods
Patients
A total of 273 tinnitus patients (94 females, 179
males) from 2 neurootological outpatient centers
participated in this study. The mean duration of
tinnitus was ]/3 months. The localization of tinnitus
was as follows: right ear, n /76; left ear, n /69; and
bilaterally and within the head, n /128. The ages of
the patients ranged from 16 to 91 years (mean 50.8
years; median 53 years). All patients demonstrated
significant discrepancies between psychoacoustic
and psychometric measures in terms of loudness
which may be thought to indicate tinnitus sensitiza-
tion [9].
Study 1
To test for test
/retest reliability, 96 patients partici-
pated in a prospective investigation on chronic
tinnitus and were asked to provide information
about their tinnitus. At their first visit (t1) the
patients rated their tinnitus loudness and localization
on a six-point response scale (Table Ia) and their
tinnitus annoyance on an eight-point response scale
(Table Ib). The questions pertaining to tinnitus
annoyance referred to the last few days before the
clinic appointment.
Two weeks (t2) later the subjects received
the same rating scales by mail and were asked to
rate tinnitus loudness and annoyance once more
(Table Ia and Ib). These patients received no
tinnitus desensitization therapy between t1 and t2.
Study 2
The second study was designed to investigate the
convergent and discriminant validity of three scales:
tinnitus loudness, annoyance and change. The study
comprised 177 patients with chronic tinnitus. To
achieve tinnitus desensitization [10], patients re-
ceived professional cognitive therapy based on the
concepts of Kröner-Herwig et al. [11] and Delb et al.
[12]. The control group comprised 77 patients.
Patient data were assessed at t1 (first appointment)
and t2 (immediately after treatment). Control group
data were assessed at t1 (first appointment) and at t2
(endpoint of averaged waiting period based on mean
treatment time). All patients filled out a six-point
response scale on tinnitus loudness and an eight-
point response scale on tinnitus annoyance, as well
as the TQ of Goebel and Hiller [5]. At t2 every
patient also filled out an eight-point response scale
on tinnitus change in addition to the other two
scales.
Statistical analyses
Data analyses were performed using SAS version
8.0. The descriptive data used were frequencies,
means, medians and SDs (procedures FREQ,
MEAN and UNIVARITE). Product-moment rank
correlation coefficient computations were used to
assess retest reliability, as well as linear relations
between variables (procedure CORR). Mean com-
parisons were calculated using t -tests or the Wil-
coxon test (procedures TTEST and NPAR1WAY).
Results
Study 1
We only assessed data for patients who had tinnitus
at both t1 and t2 (n /67). The test
/retest reliabil-
ities for tinnitus loudness and annoyance were 0.72
and 0.62, respectively.
Study 2
There were no significant scale differences for the
two groups (Table II). This means that the two
groups did not differ significantly in terms of
evaluation criteria before treatment. After treatment
(t2) the TQ scores demonstrated significant differ-
ences in the desired direction, i.e. symptom im-
provement, between the treatment and control
groups in terms of the total score and the scores on
the subscales ‘‘emotional distress’’, ‘‘cognitive dis-
tress’’, ‘‘somatic distress’’ and ‘‘sleep disorders’’. The
scales ‘‘tinnitus loudness’’, ‘‘tinnitus annoyance’’ and
‘‘tinnitus change’’ also revealed significant positive
treatment effects (Table II) and therefore demon-
strated adequate discriminant validity. At t2 the
treatment group judged tinnitus loudness and an-
noyance as being significantly less bothersome than
the control group. The treatment group also demon-
strated significant differences (improvements) on the
eight-point response scale ‘‘tinnitus change’’. More-
over, calculations showed that all three scales
correlated positively with the TQ scales and thus
we considered convergent validity to be adequate
(Table III).
Discussion
We tested three simple tinnitus scales on two large
patient samples. Based on our findings we consider
the test validity of these scales to be adequate
(r /0.54
/0.66). The reliability for the tinnitus
loudness scale was also adequate (r /0.72) although
we would recommend that it should not be used in
isolation to document treatment outcome, only
together with other scales. The reason for this is
 Self-assessment of tinnitus 1187
Table II. Outcomes of the treatment and control groups. Mean (SD) scores recorded for the TQ assessment and the three rating scales.
t -tests were used for equal/unequal variances.

Treatment group (n /100) Control group (n /77) p

TQ:
Total score
t1 30.4 (17.1) 31.3 (19.7) NS
t2 16.1 (11.6) 32.4 (21.4) B/0.0001a
Emotional distress
t1 8.6 (5.4) 8.8. (5.8) NS
t2 3.8 (3.4) 8.4 (6.2) B/0.0001a
Cognitive distress
t1 6.1 (3.7) 6.4 (4.2) NS
t2 2.7 (2.7) 6.9 (4.4) B/0.0001a
Emotional and cognitive distress
t1 14.7 (8.6) 14.8 (9.2) NS
t2 6.4 (5.7) 15.1 (10.0) B/0.0001a
Hearing disorders
t1 3.7 (3.5) 4.8 (4.5) NSa
t2 2.6 (2.8) 5.2 (4.3) NSa
Sleep disorders
t1 2.7 (2.9) 2.3 (2.6) NS
t2 1.4 (1.8) 2.6 (2.9) B/0.01a
Somatic distress
t1 1.3 (1.8) 1.8 (2.0) NS
t2 0.9 (1.4) 2.0 (2.1) B/0.0001a
Rating scales:
Tinnitus loudness
t1 3.0 (1.1) 2.8 (1.3) NS
t2 2.1 (1.3) 3.4 (1.4) B/0.0001
Tinnitus annoyance
t1 3.9 (1.6) 3.8 (1.7) NS
t2 1.9 (1.4) 3.7 (1.6) B/0.0001
Tinnitus change
t2 2.6 (0.9) 4.0 (1.3) B/0.0001a
a
Unequal variances.

that the test
/retest scores for the tinnitus loudness
and annoyance scales (sample for Study 1) showed
significant variations within and between patients. It
could be that the measurements are detecting some-
thing different from what we intended to measure,
for example variations in mood states, which would
explain why the test validity of these scales was only
moderately adequate. Noble [2] believes that the
assessment of validity ‘‘. . . is a complex and never
ending task. Instead, the process of validation
consists of accruing more and more evidence that
the scales are sensible and behave in the manner that
is anticipated’’.
In many studies on tinnitus severity, the authors
neglect to investigate the differences in patients’
experience of tinnitus, which are immensely varied.
It has been our clinical experience that some patients
with tinnitus become extremely upset, while others
remain completely calm. Although the correlation
coefficients between tinnitus loudness, annoyance
and change were not as high as we expected and
hoped for they nevertheless point towards the covert

Table III. Rank correlations and p -values for the relationships between the variables tinnitus loudness, annoyance and change and the TQ.

TQ Tinnitus loudness Tinnitus annoyance Tinnitus change

Total score r/0.54; p B/0.0001 r/0.66; p B/0.0001 r/0.58; p B/0.0001

Emotional distress r/0.50; p B/0.0001 r/0.60; p B/0.0001 r/0.56; p B/0.0001
Cognitive distress r/0.51; p B/0.0001 r/0.57; p B/0.0001 r/0.56; p B/0.0001
Emotional and cognitive distress r/0.52; p B/0.0001 r/0.62; p B/0.0001 r/0.58; p B/0.0001
Hearing disorders r/0.35; p B/0.0001 r/0.42; p B/0.0001 r/0.42; p B/0.0001
Sleep disorders r/0.32; p B/0.0001 r/0.44; p B/0.0001 r/0.34; p B/0.0001
Somatic distress r/0.40; p B/0.0001 r/0.46; p B/0.0001 r/0.44; p B/0.0001
1188 H. P. Zenner et al.
Table IV. Minimal dataset for use in assessing degree of tinnitus sensitization.
Test
TQ
Tinnitus loudness (six-point response scale)
Tinnitus annoyance (eight-point response scale)
Tinnitus change (six-point response scale)
/ /included in minimal dataset; / /not included in minimal dataset; a/adequate; n.a. /not adequate; n.ass. /not assessed.
influence of emotional and cognitive factors on these
particular rating scales. Thus emotional distress
affects mood states and cognition influences how
people perceive tinnitus, i.e. positively or negatively.
Furthermore, the tinnitus change scale also seems to
indicate that tinnitus improvement correlates di-
rectly with emotional and cognitive disorders. These
factors were also described by Hallam et al. [4] and
our results would seem to be in agreement with
theirs. Our findings show that self-rating of tinnitus
loudness, annoyance and change is influenced by
emotional and cognitive factors. These results may
be helpful in explaining why subjectively experienced
loudness and tinnitus matching almost never corre-
late. The answer is simple: different phenomena are
being measured. According to these ideas, the rating
of subjective loudness is based more on emotional
and cognitive interpretations than on sensory judg-
ments.
Based on the neurophysiological tinnitus model
proposed by Zenner and Zalaman [9], cognitive
variables possess a central function in the sensitiza-
tion of tinnitus. Some of the following subjective
attributes (fears) of tinnitus tend to facilitate cogni-
tive sensitization of tinnitus [9,13]: (i) it is harmful;
(ii) it induces fear; (iii) it is unpredictable; (iv) it
induces loss of control; and (v) it induces physiolo-
gical and psychological stress. If the three tinnitus
scales described here are more likely to reflect
emotional and cognitive interpretations than sensory
judgments, then they may be suitable for estimating
tinnitus sensitization. Nevertheless, in practice these
three scales can be employed together with the TQ
as ‘‘minimal datasets’’ to reflect the patient’s current
tinnitus status (Table IV). These scales are simple
and easy to use and can be filled out by the patient
alone. The results are easy to interpret and provide a
Before therapy After therapy Validity Reliability
/ / a a
/ / a a
/ / a n.a.
/ / a n.ass.
good foundation for an effective doctor
/patient
dialogue.
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