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Journal of Otology logoLink to Journal of Otology
. 2026 Feb 6;21(1):38–49. doi: 10.26599/JOTO.2026.9540051

Cross-sectional analysis of hearing loss, age and tinnitus severity in a web-recruited cohort of 610 subjects

María Cuesta 1, Pedro Cobo 1,*
PMCID: PMC12945662  PMID: 41766847

Abstract

Tinnitus

the hearing of a sound that has not been produced by any external or internal source, is a rather heterogeneous hearing disorder.

Background/Objectives

Hearing loss has been shown to be the main risk factor for tinnitus while emotional disorders are risk factors for developing intrusive or bothersome tinnitus. Moreover, aging has also been identified as another risk factor. The aim of this paper was to analyse the correlation between hearing loss, age and tinnitus severity in a cohort of 610 tinnitus sufferers.

Methods

Age, audiometric (hearing condition) and tinnitus (time duration and severity) data were assessed and analysed for all subjects just after recruiting (baseline). Furthermore, the average hearing loss (HL) curves of the participants for age groups were compared to these with the corresponding Age Related HL (ARHL).

Results

For most of the age groups, the measured HL curves exceeded in 10-20 dB those of the ARHL. The average age of tinnitus onset (age minus tinnitus duration) was found to be 44-46 years in both men and women. Weak correlation between audiometric feature and tinnitus distress was observed.

Conclusions

Hearing loss has been shown to be a clear risk factor for triggering tinnitus (86% of participants were hearing impaired). In this cohort, average measures of hearing loss showed, at most, weak associations with tinnitus-related distress, suggesting that non-audiological factors may play a predominant role.

Keywords: Tinnitus, Age, Hearing loss, Tinnitus-related distress

1. Introduction

Tinnitus has been defined as the perception of a sound for which there are no discernible external acoustic sources, that becomes a disorder when it is linked with emotional distress giving rise to, among other effects, behavioural changes and functional disability (De Ridder et al., 2021). Therefore, the simple conscious perception of tinnitus would be an auditory symptom which becomes an auditory disorder when it produces suffering in the subject.

Tinnitus is a rather heterogeneous auditory impairment (Cederroth et al., 2019) with multiple risk factors (McFerran et al., 2019; Waechter, 2021; Reisinger et al., 2023) and comorbidities (Mazurek et al., 2023). The main risk factors for tinnitus are hearing loss, aging, and emotional disorders (Genitsaridi et al., 2020). Between other comorbidities, stress, anxiety and depression are the most common (Brüggemann et al., 2016). Interaction between emotional states (anxiety and depression) and tinnitus severity in individuals before and after undergoing a four-month sound therapy intervention has been already explored in another article (Fernández-Ledesma et al., 2025) and is not considered here. Other factors, which may be as well involved in the development of tinnitus, such as high cholesterol, hypertension, and metabolic syndrome (Sacchetto et al., 2023), or glucose, haemoglobin A1c, and blood lipids (Molnár et al., 2025) were not addressed in this study. The strong link between tinnitus frequencies, intensities, and sensorineural hearing loss highlights the crucial role of hearing impairment in the development of tinnitus. In addition, tinnitus significantly affects the ability to understand speech (Mavrogeni et al., 2024, 2025). Whereas aging is cited as a risk factor for tinnitus, it is usually related to hearing loss (Al-Swiahb and Park, 2016; Reisinger et al., 2023). Since hearing loss increases with age, and hearing loss is a risk factor for tinnitus, it has been assumed that tinnitus increases with aging. Moreover, hearing loss may act as a cofounder between tinnitus and aging (Kim et al., 2015) or aging can constitute a risk factor for tinnitus by itself (Reisinger et al., 2023).

The relation between hearing loss and tinnitus is an intriguing matter, as many people with hearing loss do not develop tinnitus and many tinnitus subjects have an apparent normal hearing (measured as a conventional pure-tone audiometry). Linblad et al. reported that tinnitus occurs without concurrent self-reported hearing losses in about 1/3rd of all cases (Lindblad et al., 2014). (McFerran et al., 2019) referred that there are some patients, perhaps up to one in 10, who have tinnitus in association with normal pure-tone audiometry. Cuesta and Cobo (2023) found that 29% of a tinnitus cohort had normal hearing. Manche et al. (2016), on the other hand, noted that 95.6% of a sample of 3255 tinnitus subjects had associated with conductive or sensorineural hearing loss.

There are many kinds of hearing losses. Sensorineural and conductive hearing losses differ significantly in causes and prevalence. Hearing loss associated with aging is named Age Related Hearing Loss (ARHL) while hearing loss due to noise overexposure is called Noise Induced Hearing Loss (NIHL). Furthermore, other causes of hearing loss not related neither to aging nor to noise are those associated to otological diseases, such as Ménière´s disease, sudden sensorineural hearing loss (SHL), middle ear infection (otitis media), otosclerosis, etc.

There are two aspects of aging potentially related with hearing loss and tinnitus: prevalence and age of tinnitus onset. According to Eggermont (2014), there is a cubic-root dependence of tinnitus prevalence with hearing loss prevalence, with a higher prevalence for tinnitus at ages <45 years and a progressively reduced prevalence of tinnitus for older ages. Regarding the age of tinnitus onset and its relationship with the tinnitus distress (Schlee et al., 2011), this is an issue which remains still relatively indefinite. According to the most accepted hypothesis, the peak of tinnitus onset should be also at old ages.

Since objective measures of tinnitus are missed, clinicians rely on the subjective report of the participant to assess its loudness, pitch and severity (Langguth et al., 2011). Current subjective measures of tinnitus include psychoacoustic tests (pitch match, loudness, minimum masking level, or residual inhibition), rating scales (Visual Analog Scale (VAS)), and questionnaires (Tinnitus Handicap Inventory (THI), (Newman et al., 1998), Tinnitus Functional Index (TFI) (Henry et al., 2016), etc.). Is the presence of hearing loss a determining factor of tinnitus severity, or it is also influenced by other aspects? Although some studies found some correlation between hearing condition and tinnitus (Nicolas-Puel et al., 2002; Waechter, 2021), some others suggested that factors other than hearing loss should determine tinnitus annoyance (Eggermont, 2014), such as psychological third variables (Mazurek et al., 2023).

Thus, the aim of this paper is to further explore the relation between age (including tinnitus onset), hearing loss and tinnitus-related distress by analysing a sample of 610 voluntary participants.

2. Materials and Methods

2.1. Participants

A number of 610 tinnitus patients were recruited for this study through a call in our internet webpage (Clinical study on sound therapies of tinnitus (ITEFI CSIC)). It should be noted that this study is part of other where participants were subjected to a sound treatment with an Enriched Acoustic Environment (Cuesta and Cobo, 2024). Inclusion/exclusion criteria were applied to select those participants suitable for this therapy. However, for this cross-sectional study all recruited subjects older than 18 years and younger than 75 years, with non-pulsatile tinnitus were included. This includes subjects with unilateral/bilateral tinnitus and any type of otologic diagnosis (ototoxicity, Ménière’s disease, sudden hearing loss, chronic otitis, otosclerosis, vestibular schwannoma, etc.) and noise overexposure or trauma. Although the majority were Spanish (94%), there were also participants from other countries (6%). An Informed Consent Form was provided by all the subjects. The study was submitted to the Ethics Committee of CSIC which afforded its approval on 24/05/2022. The study was conducted in agreement with the Spanish Data Protection Law (RD1720/2007).

Participant’s data were collected through a Tinnitus Assessment Form which was first sent to them, together with the Informed Consent Form and the THI questionnaire. They were also asked to provide a recent pure-tone audiometry. Once the participants sent all this documentation by email, they were set a date for a videoconference, where this documentation was revised and confirmed.

2.2. Hearing levels

The hearing condition of the participants was assessed through their audiograms, which display their threshold hearing levels (HL) at eleven frequencies in the range 125 Hz - 8 kHz. Subjects provided their pure-tone audiograms measured in some external clinic. The maximum allowed interval between audiogram and study inclusion was one month. Some audiograms were measured only at octave frequencies between 125 Hz and 8 kHz (125, 250, 500, 1000, 2000, 4000 and 8000 Hz). In such a case, hearing thresholds at 750, 1500 and 3000 Hz were interpolated between the adjacent frequencies.

The Average audiometric thresholds (AAT) for the left and right ears, defined as

2.2. 1

were calculated, where HL(fi) are the HL values at each frequency and Nf are the above cited frequencies. Additionally, the low-frequency average audiometric thresholds (AATLF) and high-frequency average audiometric thresholds (AATLF), defined as

2.2. 2
2.2. 3

were used. An algorithm, described in Cuesta and Cobo (Cuesta and Cobo, 2018), was used to categorize the participants hearing grade as Normal Hearing (NH) or Hearing Impaired (HI). Specifically,

If　any(HL(fi)>=35 dB

　or　AAT>=26 dB

　or　|AATHF-AATLF|>=20 dB

　the subject is Hearing Impaired (HI)

otherwise

　the subject has Normal Hearing (NH)

Although other variables, such as the pure-tone average (PTA) (the average HL values at 500, 1000, 2000 and 4000 Hz) are used to characterise the hearing condition, these are unable to detect hearing impairments below 500 Hz or above 4 kHz, such as a high-steep high-frequency hearing loss or a profound scotoma at 6 kHz. The proposed algorithm, however, is able to detect all types of hearing impairments.

This algorithm was applied to both ears. All participants with any of the two ears with hearing impairment was included in the HI subgroup. In other words, NH subjects must have normal hearing at both ears. For illustrative purposes, Figure 1 shows superimposed the audiograms of all the participants with NH.

Figure 1.

Figure 1

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Hearing loss (HL) curves of all subjects with normal hearing (NH).

Hearing losses can arise from noise overexposure (NIHL), aging (ARHL) or other otological diseases (Ménière´s disease, sudden HL, otitis, otosclerosis, etc.). The International Standard ISO (2017) provides the expected medians and statistical distributions of hearing thresholds between 125 Hz and 8 kHz by age and sex. Figure 2 exhibits such ARHL curves for ages 30, 40, 50, 60, 70 and 80 years. ARHL increase with age and are higher at high frequencies. Also, they are larger for males than for females. As an example, for 70 years, the ARHL at 8 kHz are roughly 10 dB larger for males than for females. The differences for 80 years at 8 kHz differ in almost 15 dB.

Figure 2.

Figure 2

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Median age related hearing loss (ARHL) curves for males/females and ages of 30, 40, 50, 60, 70 and 80 years.

It can be interesting to analyse the mean HL curves of the participants for age groups, and compare these with the corresponding ARHL. Following recommendations for epidemiological research (McCormack et al., 2016), ages will be grouped in five intervals: younger than 34, from 35 to 44, from 45 to 54, from 55 to 64, and older than 65.

2.3. Tinnitus characteristics

Age, tinnitus lateralization, tinnitus duration (TD) and suspected etiology were collected through a Tinnitus Assessment Form and further confirmed in the videoconference.

From Age and TD, the age of tinnitus onset (TO) was calculated as

2.3. 4

The tinnitus severity of participants was assessed using the THI (a version validated to Spanish (Herráiz et al., 2001). Although several subscales of the THI can be assessed (functional, emotional, catastrophic) only the total score has been used. According to this severity scale (McCombe et al., 1999), 56/610 (9%) of participants had tinnitus without handicap (THI≤16), 180/610 (30%) exhibited mild handicap (18≤THI≤36), 155/610 (25%) were troubled by moderate handicap (38≤THI≤56), 127/610 (21%) suffered of severe handicap (58≤THI≤76), and 92/610 (15%) showed catastrophic handicap (THI≥78). Other authors proposed to classify tinnitus-related distress in compensated and decompensated (Hiller et al., 1999; Biehl et al., 2020). We will use here the THI to define two groups: participants with mild-moderate tinnitus handicap (MMTH) (THI≤56) and those with severe-catastrophic tinnitus handicap (SCTH) (THI≥58).

2.4. Statistics

Descriptive statistics tools of Matlab (The Mathworks Inc, Natick, MA. USA) were used to analyse the data. Furthermore, correlational statistics was applied to examine possible interrelations between quantitative variables (Age, TO, AAT and THI). Significance level was set at p<0.05. The normal distribution condition of these variables was checked by painting normal distribution plots with the norm plot MATLAB function.

3. Results

3.1. Hearing losses

The mean, median and standard deviation (SD) age of all participants, as well as for sex and hearing condition are summarised in Table 1.

Table 1. Age and sex of this cohort.

Sex Hearing condition
All Male Female HI NH
N (%) 610 (100%) 387 (63%) 223 (37%) 522 (86%) 88 (14%)
Age (mean) 52.1 52.7 50.5 53.5 43.2
Age (SD) 10.9 10.2 12.0 10.4 10.2
Age (median) 52.0 53.0 50.5 53.0 44
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There were much more males (63%) than females (37%) and males were slightly older than females. The age difference between males and females (2.2 years) was not statistically significant at p<0.05. Participants with NH were, on average, 10.3 years younger than those with HI. This difference was statistically significant at p<0.05.

Figure 3 shows the hearing levels of male and female subjects. The confidence intervals are displayed by the shaded areas around the mean hearing levels. Above 2 kHz, participants had greater hearing losses, whilst below 2 kHz, hearing losses were lower for males than for females, mainly in the left ear. The mean hearing levels for NH and HI subjects are shown in Figure 4. The averaged hearing losses for participants with NH are lower than 20 dB for all frequencies.

Figure 3.

Figure 3

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Average hearing loss (HL) curves of the 610 tinnitus subjects by sex.

Figure 4.

Figure 4

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Average hearing loss (HL) curves of the tinnitus subjects hearing impaired (HI) and with normal hearing (NH).

Figures 5-9 display the mean HL curves (averaged for both ears) for males/females and for the age groups above mentioned. In these curves, the corresponding ISO 7029-2017 curves at the central age of the interval have been superimposed for comparison. The number of subjects in each age group are summarised in Table 2.

Figure 5.

Figure 5

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Average hearing loss (HL) of the tinnitus subjects younger than 35 years with the corresponding median age related hearing loss (ARHL) of ISO 7029 at 30 years superimposed.

Figure 9.

Figure 9

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Average hearing loss (HL) of the tinnitus subjects older than 65 years with the corresponding median age related hearing loss (ARHL) of ISO 7029 at 70 years superimposed.

Table 2. Number and percentages of males and females in each age group.

Age ≤34 35≤Age≤44 45≤Age≤54 55≤Age≤64 Age≥65
N all 36 (6%) 108 (18%) 216 (35%) 176 (29%) 74 (12%)
N males 15 (42%) 71 (66%) 134 (62%) 120 (68%) 47 (64%)
N females 21 (58%) 37 (34%) 82 (38%) 56 (32%) 27 (36%)
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Figure 6.

Figure 6

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Average hearing loss (HL) of the tinnitus subjects with age between 35 and 44 years with the corresponding median age related hearing loss (ARHL) of ISO 7029 at 40 years superimposed.

Figure 7.

Figure 7

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Average hearing loss (HL) of the tinnitus subjects with age between 45 and 54 years with the corresponding median age related hearing loss (ARHL) of ISO 7029 at 50 years superimposed.

In the age group below 34 years, the number of males is slightly lower than or equal to the minimum sample size (21) required for statistical power with effect size of 0.5, α=0.1 and β=0.9. The confidence intervals around the HL curves in Figures 5-9 reflects also the larger deviations for participants in the first (Figure 5) and last (Figure 9) age groups. HL of males are higher than HL of females in all age groups, in concordance with Figure 2.

To complement the information in Figures 5-9, Table 3 summarises the mean differences between cohort thresholds and ISO 7029 medians for each age group. These mean differences have been averaged for all frequencies. Mean differences range between 11.0 and 22.6 dB, with larger differences for females than for males, due to the fact median ISO 7020 are smaller for females than for males (see Figure 2).

Table 3. Mean differences (in dB) between the cohort thresholds and ISO 7029 medians for each age group.

Age ≤34 35≤Age≤44 45≤Age≤54 55≤Age≤64 Age≥65
Males Mean 12.8 17.5 17.8 16.5 11.0
SD 15.4 16.8 16.7 18.4 16.3
Females Mean 15.9 22.6 19.1 16.1 17.8
SD 14.5 22.5 19.3 17.2 18.4
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3.2. Tinnitus characteristics

Table 4 summarises the mean, median and standard deviation ages of participants for each tinnitus distress condition and their tinnitus lateralization. Subjects with MMTH (THI≤56) were, on average, 4.9 years older than subjects with SCTH (THI≥78). 326 of 610 participants (54%) had bilateral tinnitus. 179 of 610 (29%) subjects perceive their tinnitus in the left ear, and 105 of 610 (17%) perceive it in the right ear. Age differences among subjects with different tinnitus lateralization were not statistically significant.

Table 4. Age (in years) for each tinnitus distress condition and tinnitus lateralization of this cohort.

Tinnitus severity Tinnitus lateralization
All MMTH SCTH Bilateral Left ear Right ear
N (%) 610 (100%) 394 (65%) 216 (35%) 326 (54%) 179 (29%) 105 (17%)
Age (mean) 52.1 53.5 49.4 52.4 51.1 52.9
Age (SD) 10.9 10.7 10.7 11.1 10.5 11.0
Age (median) 52.0 53.0 50.0 53.0 51.0 52.0
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Table 5 summarises the tinnitus onset age (TO) and the tinnitus severity (THI) for all participants, as well as for sex (male/female), hearing condition (HI/NH) and distress condition (MMTH/SCTH). All TO mean values are roughly in the range about 44-46 years, except for the NH and SCTH subgroups of participants, which are 39.9 and 43.4 years, respectively. Thus, 44-46 years emerge as the age range in which tinnitus onset most frequently occurred within this self-selected cohort. Concerning THI, females had mean THI values slightly higher than males. Subjects with HI had slightly higher THI than those with NH. As expected, subjects with SCTH had, on average, THI values 42.1 points higher than those with MMTH.

Table 5. Tinnitus onset age (TO) and tinnitus distress (THI) for all, males/females, HI/NH and MMTH/SCTH subgroups.

Sex Hearing condition Tinnitus severity
All Males Females HI NH MMTH SCTH
TO (years) Mean 44.4 44.2 44.8 45.8 39.9 45.0 43.4
SD 12.8 12.6 13.1 12.7 12.1 13.1 12.3
Median 45.0 45.0 44.7 46.7 40.8 45.3 43.7

THI		 Mean 48.2 47.7 49.0 48.7 46.6 33.3 75.4
SD 23.9 24.3 23.3 23.7 24.8 13.8 11.4
Median 46 46.0 48.0 48.0 42.0 34.0 74.0
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According to the participant responses, the predominant tinnitus etiology was HL (28%), followed by emotional disorders (traumatic stress, depression, anxiety, obsessive–compulsive disorder, etc.) (17%), overexposure to noise (13%), ear infection (7%), sudden HL (6%), somatosensory, including temporomandibular joint and cervical disorders (6%), Meniérè’s disease (4%), Eustachian tube dysfunction (3%), ear surgery (otosclerosis, cholesteatoma) (3%), head trauma (3%), and others (ototoxicity, Schwannoma disease, Chiari, hydrocephaly) (2%). The remaining 8% assigned their tinnitus an idiopathic origin.

3.3. Correlation between tinnitus (THI) and audiological (AAT) characteristics

Correlation analysis was carried out between all possible pair of variables AAT and THI. Both variables are considered normally distributed, without significant outliers, so that Pearson correlation analysis is applied. The correlation coefficient (r), [rl,ru] the lower and upper bounds for r, and the significant level (p) were calculated assuming a null hypothesis of variables not correlated at significance level of 0.05. Therefore, calculated p≤0.05 indicate a significant correlation between AAT and THI. The results are summarised in Table 6. As it can be seen, these variables had a significant but very weak correlation with THI for five cases: AAT with THI for HI and SCTH subjects, AATLF with THI for NH and HI participants, and AATHF with THI for SCTH participants. Although these associations are weak in magnitude, (all observed correlations were |r| < 0.2), they may still account for a small, but non-zero, proportion of variance in tinnitus distress, and this modest effect must be interpreted in the context of other, unmeasured factors (psychological, contextual, etc.).

Table 6. Correlation coefficients and significance levels (r, p) (above) and confidence intervals [rl ru] (below) of all the paired THI-AAT variables.

THI
All Males Females HI NH MMTH SCTH
AAT: Average Auditory Threshold; AATLF: Average Auditory Threshold at frequencies 125 Hz-2 kHz; AATHF: Average Auditory Threshold at frequencies 3 kHz-8 kHz; THI: Tinnitus Handicap Inventory; HI: Hearing Impaired; NH: Normal Hearing; MMTH: mild-moderate tinnitus handicap; SCTH: severe-catastrophic tinnitus handicap; * denotes statistical significance at p<0.05; ** denotes statistical significance at p<0.01.



AAT (dB)		 All (0.07,0.07)
[-0.006 0.15]
Males (0.06,0.23)
0.039 0.16]
Females (0.09,0.16)
[0.04 0.22]
HI (0.10,0.03*)
[0.01 0.19]
NH (-0.16,0.05)
[-0.32 0.003]
MMTH (0.06,0.20)
[-0.03 0.16]
SCTH (0.14,0.04*)
[0.003 0.26]




AATLF (dB)		 All (0.09,0.03*)
[0.007 0.16]
Males (0.07,0.15)
[0.02 0.17]
Females (0.10,0.14)
[-0.03 0.23]
HI (0.12,0.009**)
[0.03 0.21]
NH (-0.18,0.03*)
[-0.34 –0.02]
MMTH (0.08,0.13)
[-0.02 0.18]
SCTH (0.11,0.11)
[-0.03 0.24]



AATHF (dB)		 All (0.05,0.25)
0.03 0.13]
Males (0.04,0.45)
[-0.06 0.14]
Females (0.07,0.27)
[-0.06 0.2]
HI (0.05,0.27)
[-0.04 0.14]
NH (-0.10,0.24)
[-0.26 0.07]
MMTH (0.04,0.42)
[-0.06 0.14]
SCTH (0.14,0.04*)
[0.005 0.27]
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4. Discussion

The large sample size for this tinnitus cohort (N = 610) provides adequate power for descriptive analyses, subgroup comparisons and basic correlation analyses, and is larger than many earlier clinical series. The use averages of HL for all (AAT), low (AATLF) and high (AATHF) frequencies allow detection of non-standard audiometric patterns (e.g. steep high-frequency loss, high-frequency scotoma, etc.) that would be missed by conventional PTA (0.5–4 kHz). The use of an audiometric classification algorithm, explicitly designed to capture diverse audiometric configurations, is a methodological strength and adds reproducibility to the classification of Normal Hearing (NH) versus Hearing Impaired (HI) subjects. Furthermore, the systematic comparison of mean hearing thresholds with ISO 7029 age related hearing loss (ARHL) reference curves is an important and informative feature of the study, clearly illustrating the extent to which the cohort deviates from age-expected norms.

A percentage of people with tinnitus has normal hearing. This percentage varies in the literature from 10% (McFerran et al., 2019) to 33% (Lindblad et al., 2014). In our sample, 14% of participants had normal hearing. Although some of these could have high-frequency losses (Weisz et al., 2006) or could suffer of hidden hearing loss (HHL) (Liberman et al., 2016), both not assessed in this study, tinnitus can be also triggered by others auditory (Eustachian tube dysfunction) or non-auditory (temporomandibular joint disorders or other head and neck conditions (Michiels, 2023), stress (Mazurek et al., 2012, etc.,) sources which do not present with hearing loss.

We found that HL is higher in males than females, especially at frequencies above 2 kHz (Figure 2). However, females had slightly higher tinnitus-related distress than males (Table 4). Sharma et al. (2018) and Fioretti et al. (2020) reported similar results. Although many previous studies pointed to ARHL as an important risk factor for tinnitus (Schlee et al., 2011; Kim et al., 2015; Reisinger et al., 2023) our results reinforce the hypothesis that other hearing loss sources might be also considered as potential trigger of tinnitus. In other words, ARHL seems not to be the main source of hearing losses related to tinnitus. When averaged HL curves for different age groups are compared with the corresponding median ARHL provided by the ISO 7029-2017, we found that average HL curves in all age groups exceed in roughly 10-20 dB the corresponding median ARHL curves. Therefore, this reinforces the idea that the hearing losses of participants in our sample were not only age-related but due to something else. The HL curves of the younger group (Age<34 years) deserves a special mention. Younger individuals are being increasingly exposed to recreational noise including loud music exposure at concerts, nightclubs and via personal music players (Imam and Hannan, 2017). In our cohort, these participants showed hearing thresholds 12 dB above those corresponding to their age.

The traditional theory assumes that HL augments with age and tinnitus is mainly triggered by hearing loss. Osterloo et al. (2021) missed any dependency of age with tinnitus, despite the strong age-related character of hearing impairment. From our data stands out that the presence of tinnitus peaks at roughly 46 years, for HI subjects, and 40 for NH participants. This does not agree with the generally accepted impression that tinnitus prevalence peaks at 60-70 years (Schlee et al., 2011). We attribute this disagreement to that most authors claim that HL increases with age and tinnitus is (mainly) triggered by ARHL. But as it is demonstrated in Figures 4-8, other types of HL than ARHL, which are not age-dependent, also contribute to tinnitus. Schlee et al. (2011) reported also that the mean age of tinnitus onset of subjects with normal hearing (N=755) was 42.4 years. Given the close interrelation between tinnitus-related distress and emotional disorders, this peak could be associated with stress, anxiety and depression disorders. For instance, Gonçalves and Byrne (2012) described a marked peak of generalised anxiety disorder at 40-50 years.

Figure 8.

Figure 8

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Average hearing loss (HL) of the tinnitus subjects with age between 55 and 64 years with the corresponding median age related hearing loss (ARHL) of ISO 7029 at 60 years superimposed.

In a study examining tinnitus-related distress, researchers analysed total THI scores for both males and females (Mavrogeni et al., 2022). The results showed significantly higher total THI scores in females, which aligns with the findings of the current investigation. We found a weak correlation between AAT (a measure of hearing loss) and THI (a measure of tinnitus distress). Only the AAT with THI for HI subjects, AATLF with THI for NH and HI participants, and AATHF with THI for SCTH participants were statistically significant, but with very low correlation coefficients (Table 6). Therefore, these results still account for a small portion of the variance in distress, and that its contribution is limited. This is in line with the results of many authors (Eggermont, 2014; Pinto et al., 2015; Aazh and Salvi, 2019; Mores et al., 2019) but disagrees with some others. For instance, Waechter (2021) found a moderate correlation (p=0.01, r=0.42) between PTA (the average HL at frequencies 500 Hz - 4 kHz) and THI for N=38 tinnitus sufferers. Nicolas-Puel et al. (2002) reported also a significant (p<0.001) and positive moderate correlation (r=0.48) between AATHF and VAS in N=58 tinnitus patients. Therefore, our results confirm that, whereas HL is a clear risk variable for tinnitus triggering (86% of the participants in this study were hearing impaired), it is unimportant for the associated tinnitus-related distress.

4.1. Limitations

The main limitation of this study was the restriction of HL curves to the 125 Hz-8 kHz range. We are aware that some authors (Song et al., 2021; Jafari et al., 2022) claim that tinnitus is always triggered by some degree of cochlear mechanical dysfunction, which may occur at frequencies above 8 kHz and, therefore, are not observed by a conventional measurement of hearing. We will take this issue into consideration for future research.

Participants were asked to provide their audiograms measured in some external clinic, which can introduce substantial measurement variability and bias, as sound-treated booth, calibration and masking protocols can be different.

Main findings of this article, such as age of onset and the relative role of ARHL versus other types of hearing loss, should not be considered as population-based, as the web-recruitment method likely over-represent individuals with more intrusive symptoms, higher motivation for treatment or specific sociodemographic profiles. Therefore, the observed peak around 44–46 years should be considered as the age range in which tinnitus onset most frequently occurred within this self-selected cohort.

In this article, several bivariate correlations are examined across multiple subgroups (NH/HI, MMTH/SCTH, sex), all tested at α = 0.05, without any formal correction for multiple comparisons. In addition, no multivariable models were presented to adjust for potential confounders (e.g. age, sex, tinnitus duration, hearing status), which may affect the robustness and generalizability of individual p-values.

Finally, two further limitations of this study are the lack of analysis of the relationship between emotional states and tinnitus severity, and the absence of a formal classification of audiometric patterns. The first issue has been accomplished in a recent article (Fernández-Ledesma et al., 2025). The second is under current research.

5. Conclusions

The analysis of the tinnitus severity, HL and age in a 610 tinnitus participants sample, is reported. As expected, mean HL increased with age, was higher in males and at higher frequencies. In all age groups, the mean HL curves of the participants exceeded the corresponding ARHL curves by more than 20-30 dB. Noticeably, the average age of tinnitus onset was about 44-46 years in both men and women with hearing impaired. While hearing loss has been shown to be a clear risk factor for triggering tinnitus (86% of participants were hearing impaired), weak correlation between AAT and THI was observed suggesting that it may still account for a small portion of the variance in distress.

Acknowledgements

We are grateful to all subjects participating in this study.

Acknowledgments

Conflict of interest

The authors declare no conflict of interest.

Data availability

Not applicable.

Author contributions

Both authors contributed equally and have approved the final manuscript.

Ethical approval

The study was submitted to the Ethics Committee of CSIC which afforded its approval (protocol code 004/2022) on 24/05/2022. A written informed consent was obtained from participants. The study was conducted in compliance with the Declaration of Helsinki and in agreement with the Spanish Data Protection Law (RD1720/2007).

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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