Abstract
Background
Chronic tinnitus has a lot impact on the quality of life of person by affecting his/ her physical health, occupational health and social relations. It can lead to sleep interference, cognitive difficulties, lack of concentration, anxiety, frustration, anger and depression. The present study showed the severity and impact of tinnitus on quality of life of subjects with or without hearing loss using tinnitus functional index (TFI).
Methods
Subjects with history of tinnitus with or without hearing loss including informed consent, otoscopy, pure tone audiometry (PTA) were done. Grading of tinnitus was done by using tinnitus functional index score.
Results
The mean age of participants were 50.20 ± 4.2 years and male to female ratio were found to be 1.05:1. On PTA, 122 participants had hearing loss and 28 had no hearing loss. 49 patients had mild TFI score, 85 had moderate TFI score and 16 had severe hearing loss. The difference in the severity of tinnitus using TFI between normal hearing and sensorineural hearing loss individual was statistically significant. On the other hand, the severity of tinnitus and degree of hearing loss were also found to be statistically significant with p value < 0.0001 chi. Sq = 77.39. This shows that with increase in increase in hearing loss there is increase in TFI sore.
Conclusion
Tinnitus has a negative impact on the quality of life like pshycological, emotional and physical effects. The effects of tinnitus is more in those with co-existing hearing loss.
Keywords: Tinnitus, Tinnitus functional Index, Hearing loss
Introduction
Tinnitus or ringing in the ears is defined as the perception of sound such as buzzing, whistling or ringing in one or both ears or inside the head in the absence of any external stimulus (Haller, 2003) [1]. Tinnitus affects approximately 15 – 20% of overall population and affects daily activities of 25% of this population [2]. The severity of tinnitus varies from individual to individual, it may be slightly unnoticeable to an unbearable noise. There may be another complaints associated with tinnitus such as hearing loss, vertigo and headache [3].
The mechanism behind the tinnitus can be abnormal afferent excitation at cochlear level (glutamate neuroexcitotoxicity, calcium channel dysfunction, modulation of NMDA and non NMDA), efferent dysfunction (reduction of GABA effect), alteration of spontaneous activity and stress psychological disorders [4, 5]. In tinnitus, there is an abnormal processing of signal generated in auditory system, beginning at sensory level of cochlear nucleus in higher cells [6].
Tinnitus can be classified into two types subjective and objective. In subjective, tinnitus is perceived by the patient only i.e. the origin of this type of tinnitus may be in external ear, middle ear, inner ear or central nervous system disorders. On the contrary, in objective tinnitus sound can be heard by examiner as well as patient as it occurs due to muscle spasms or myoclonus of palatal muscles or those of middle ear (stapedial, tensor tympani) or these sounds comes from blood vessels in conditions of increased or turbulent flow (atherosclerosis), or abnormal vessels (in tumors or vascular malformations) or temporomandibular joints [7].
Tinnitus is most commonly associated with SHNL, which may be noise induced or presbycusis [8]. But it has been seen that approximately 10% of patient with a primary tinnitus have normal hearing thresholds. Chronic tinnitus has a lot of negative impact on the quality of life of person by affecting his/ her physical health, occupational health and social relations. It can lead to sleep interference, cognitive difficulties, lack of concentration and even negative reaction including anxiety, frustration, anger and depression [9]. Despite the availability of a wide diversity of treatment modalities used for the treatment of tinnitus, there is lack of a standardized tool for outcome measures [10].
Tinnitus severity is commonly assessed using psychosomatic measurements like tinnitus matching and tinnitus residual inhibition tests along with various self-reporting questionnaires like Tinnitus Handicap Inventory (THI) (Newman, Sandridge and Jacobson 1998) [11], Tinnitus Reaction Questionnaire (TRQ) (Wilson et al.1991) [12], Tinnitus Handicap Questionnaire (THQ) (Kuk et al., 1990) [13] etc. These questions are an essential tool in tinnitus severity and treatment outcome. Tinnitus Functional Index questionnaire is a reliable measure of tinnitus severity as well as responsiveness to treatment. Therefore, the aim of present study was to compare the severity of tinnitus in patients with or without hearing loss using TFI and to find the negative impact of tinnitus on quality of life such as physical, mental and psychological behavior of the person.
Material and Methods
This was a cross-sectional observational study conducted in the Department of ENT and Head and Neck Surgery, Government Medical College Jammu from June 2020 to April 2021 on 150 patients with primary complaint of tinnitus after approval by Institutional Ethical Committee.
Inclusion Criteria
Patients in the age range of 10–60 years with primary complaint of tinnitus for a duration of 3 months with or without hearing impairment were included in the study.
Exclusion Criteria
Hearing loss since childhood.
History of middle ear disease or ear surgery.
History of hypertension.
History of intake of antidepressants, aspirin use, ototoxic drugs.
Pregnancy.
Relevant history was taken in all patients including duration of tinnitus, laterality of tinnitus, any previous intervention and any history of hearing loss. All patients were subjected to general physical and systemic examination. Local examination including otoscopy, tunning fork tests was done on all patients. Pure tone audiometry was performed on all patients in an acoustically treated room. Audiometric details and hearing loss were graded according to WHO grading of hearing impairment.
Informed consent was taken and all subjects were administered TFI (TINNITUS FUNCTIONAL INDEX) developed by Meikle et al., 2012 [14] At the end of the questionnaire, the total score which ranged from 0- 25 for each respondent was calculated. The 25 TFI items were related over the maximum value of 10. The TFI score was calculated as percentage which provided the respondent’s overall score within 0–100 range (Table 1).
Table 1.
Tinnitus Functional Index
| TFI includes 25 questions and 8 subscales. The subscales are | |
|---|---|
| 1 | Intrusiveness contain 1- 3 questions, |
| 2 | Reduced sense of control contain questions 4–6, |
| 3 | Cognitive interference contain question 7–9, |
| 4 | Sleep disturbance contains items 10–12, |
| 5 | Auditory difficulty associated with tinnitus contain question 13- 15, |
| 6 | Interference with relaxation contain question 16 -18, |
| 7 | Interference with relaxation contain question 16 -18, |
| 8 | Reduced quality of life contain question 19–22, |
| 9 | Emotional disturbance contain question 23- 25 |
| INTRUSIVE: OVER THE PAST WEEK | |
| 10 | What percentage of your time awake were you consciously AWARE OF your tinnitus? |
| 11 | Never aware: 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%: always aware |
| 12 | How STRONG or LOUD was your tinnitus? |
| 13 | Not at all strong or loud: 0 1 2 3 4 5 6 7 8 9 10: Extremely strong or loud |
| 14 | What percentage of your time awake were you ANNOYED by your tinnitus? |
| 15 | None of the time: 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%:All of the time |
| SENSE OF CONTROL: Over the PAST WEEK | |
| 16 | Did you feel IN CONTROL in regard to your tinnitus? |
| 17 | Very much in control: 0 1 2 3 4 5 6 7 8 9 10: Never in control |
| 18 | How easy was it for you to COPE with your tinnitus? |
| 19 | Very easy to cope: 0 1 2 3 4 5 6 7 8 9 10: Impossible to cope |
| 20 | How easy was it for you to IGNORE your tinnitus? |
| 21 | Very easy to ignore: 0 1 2 3 4 5 6 7 8 9 10: Impossible to ignore |
| C0GNITIVE: Over the Past week | |
| 22 | Your ability to CONCENTRATE? |
| 23 | Did not interfere: 0 1 2 3 4 5 6 7 8 9 10: Completely interfered |
| 24 | Your ability to THINK CLEARLY? |
| 25 | Did not interfere: 0 1 2 3 4 5 6 7 8 9 10: Completely interfered |
| 26 | Your ability to FOCUS ATTENTION on other things besides your tinnitus? |
| 27 | Did not interfere: 0 1 2 3 4 5 6 7 8 9 10: Completely interfered |
| SLEEP: Over the Past week | |
| 28 | How often did your tinnitus make it difficult to FALL ASLEEP or STAY ASLEEP? |
| 29 | Never had difficulty: 0 1 2 3 4 5 6 7 8 9 10: Always had difficulty |
| 30 | How often did your tinnitus cause you difficulty in getting AS MUCH SLEEP as you needed? |
| 31 | Never had difficulty: 0 1 2 3 4 5 6 7 8 9 10: Always had difficulty |
| 32 | How much of the time did your tinnitus keep you from SLEEPING as DEEPLY or as PEACEFULLY as you would have liked? |
| 33 | None of the time: 0 1 2 3 4 5 6 7 8 9 10: All of the time |
| AUDITORY: Over the PAST WEEK | |
| 34 | Your ability to HEAR CLEARLY? |
| 35 | Did not Interfere: 0 1 2 3 4 5 6 7 8 9 10: Completely interfere |
| 36 | Your ability to UNDERSTAND PEOPLE who are talking? |
| 37 | Did not Interfere: 0 1 2 3 4 5 6 7 8 9 10: Completely interfere |
| 38 | Your ability to FOLLOW CONVERSATIONS in a group or at meetings? |
| 39 | Did not Interfere: 0 1 2 3 4 5 6 7 8 9 10: Completely interfere |
| Interference: Over the PAST WEEK, how much hasyour tinnitus interfered with… | |
| 40 | Your QUIET RESTING ACTIVITIES? |
| 41 | Did not Interfere: 0 1 2 3 4 5 6 7 8 9 10: Completely interfere |
| 42 | Your ability to RELAX? |
| 43 | Did not Interfere: 0 1 2 3 4 5 6 7 8 9 10: Completely interfere |
| 44 | Your ability to enjoy “PEACE AND QUIET”? |
| 45 | Did not Interfere: 0 1 2 3 4 5 6 7 8 9 10: Completely interfere |
| QUALITY OF LIFE Over the PAST WEEK, how much hasyour tinnitus interfered with… | |
| 46 | Your enjoyment of SOCIAL ACTIVITIES? |
| 47 | Did not Interfere: 0 1 2 3 4 5 6 7 8 9 10: Completely interfere |
| 48 | Your ENJOYMENT OF LIFE? |
| 49 | Did not Interfere: 0 1 2 3 4 5 6 7 8 9 10: Completely interfere |
| 50 | Your RELATIONSHIPS with family, friends and other people? |
| 51 | Did not Interfere: 0 1 2 3 4 5 6 7 8 9 10: Completely interfere |
| 52 | How often did your tinnitus cause you to have difficulty performing your WORK OR OTHER TASKS, such as home maintenance, school work, or caring for children or others? |
| 53 | Never had difficulty: 0 1 2 3 4 5 6 7 8 9 10: Always had difficulty |
| EMOTIONAL: Over the PAST WEEK | |
| 54 | How ANXIOUS or WORRIED has your tinnitus made you feel? |
| 55 | Not at all anxious or Worried: 0 1 2 3 4 5 6 7 8 9 10: Extremely anxious or worried |
| 56 | How BOTHERED or UPSET have you been because of your tinnitus? |
| 57 | Not at all bothered or Upset: 0 1 2 3 4 5 6 7 8 9 10: Extremely bothered or upset |
| 58 | How DEPRESSED were you because of your tinnitus? |
| 59 | Not at all depressed: 0 1 2 3 4 5 6 7 8 9 10: Extremely depressed |
The severity of tinnitus was placed in three categories on the basis of total score (Henry et al., 2015) [15].
Mild (< 25).
Moderate (25 – 50).
Severe (> 50).
Results
A total of 150 patients with primary complaint of tinnitus participated in the study. As shown on Table 1, the age range was between 14—74 years with a mean age of 50.20 ± 0.4.2 years. The highest number of participants were found in age > 50 years (36.7%) followed by age group 20–30 years (23.3%) and 40 – 50 years with (18.7%). Out of 150 patients 77 (51.3%) were males and 73 (48.6%) were females, with male to female ratio of about 1.05:1. Out of 150 participants, 85(56.7%) had unilateral tinnitus localization and 65(43.3%) with bilateral tinnitus localization (Table 2).
Table 2.
Age and sex distribution, tinnitus localization, associated hearing loss and TFI score among participants
| Variable | Frequency | Percentage |
|---|---|---|
| Age (years) | ||
| 10-20 | 6 | 4 |
| 20-30 | 35 | 23.3 |
| 30-40 | 26 | 17.3 |
| 40-50 | 28 | 18.7 |
| >50 | 55 | 36.7 |
| Total | 150 | 100 |
| MEAN ±SD = 50.20±4.2 YEARS | ||
| RANGE : 14-74 YEARS | ||
| Sex | Frequency | Percentage |
| Male | 77 | 51.3 |
| Female | 73 | 48.7 |
| Total | 150 | 100 |
| Male:Female Ratio = 1.05:1 | ||
| Tinnitus Localisation | Frequency | Percentage |
| Unilateral | 85 | 56.7 |
| Bilateral | 65 | 43.3 |
| Ratio = 1.31:1 | ||
| History of Self Reported Hearing Impairment | Frequency | Percentage |
| Present | 83 | 53.3 |
| Absent | 67 | 44.7 |
| Type of Hearing Loss (n=122) | Frequency | Percentage |
| SNHL | 85 | 69.7 |
| Mixed | 37 | 30.3 |
| Hearing Impairment on Pta | Frequency | Percentage |
| Present | 122 | 81.3 |
| Absent | 28 | 18.7 |
| TFI Score | Frequency | Percentage |
| Mild <25 | 49 | 32.67 |
| Moderate 25-50 | 85 | 56.67 |
| Severe >50 | 16 | 10.67 |
Hearing impairment was an associated symptom among 83(53.3%) participants with 25(16.7%) on right side while 23(15.3%) on left side and 35(23.3%) participants on both sides. On PTA, 122 participants (81.3%) had hearing impairment. 85(69.7%) had SNHL, 67(30.3%) had mixed hearing loss (Fig. 1). In 28 subjects (18.7%) normal hearing was found. 49 (32.67%) subjects had mild tinnitus i.e. TFI score < 25, 85 (56.67%) had moderate tinnitus (TFI 25–50). Severe tinnitus (TFI > 50) was seen in 16 subjects (10.67%) (Table 2).
Fig. 1.
Type Of Hearing Loss
It was further found that subjects with normal hearing i.e. 78.57% had mild severity of tinnitus according to TFI and 22.13% patients had moderate severity and none had severe degree of hearing loss. In contrast, subjects with sensorineural hearing loss majority had moderate severity of tinnitus i.e.; 64.75% and about 13.12% patients were found to have severe tinnitus. The difference in the severity of tinnitus between normal hearing and in individual with sensorineural hearing loss was statistically significant (Table 3 and Fig. 2). Thus, we can say that there is a correlation between presence of hearing loss and TFI score.
Table 3.
Tinnitus severity on the basis of TFI in normal hearing and snhl groups
| Severity of tinnitus according to TFI | Normal hearing (Nr) n(%) | Snhl group n(%) | Significance | |
|---|---|---|---|---|
| Chi. sq. (x2)value | p value | |||
| Mild < 25 | 22(78.57) | 27(22.13) | 33.83 | < 0.001 |
| Moderate (25–50) | 6(21.43) | 79(64.75) | 17.29 | < 0.001 |
| Severe > 50 | 0 | 16(13.12) | 4.80 | 0.043 |
| Total | 28(100) | 122(100) | ||
Fig. 2.
Tinnitus severity and degree of hearing loss
Table 4 and Fig. 3 shows that correlation between severity of tinnitus (on the basis of TFI score) and degree of hearing loss. In subjects with mild hearing loss, 14.8% had mild, 9.8% had moderate and none had severe degree of tinnitus. On the contrary, in subjects with severe and profound hearing loss, majority had moderate to severe degree of tinnitus and difference between them were statistically significant with p value < 0.001, chi. Sq. = 77.39 that is in these participants it was seen that with the increase in hearing loss there is increase in TFI score.
Table 4.
Relationship between tinnitus severity (TFI questionnaire) and degree of hearing loss
| TFI Score | ||||
|---|---|---|---|---|
| Degree of hearing loss | Mild n(%) | Moderate n(%) | Severe n(%) | P Value |
| Mild | 18(14.8) | 12(9.8) | 0 | Chi. Sq. (χ82) = 77.39 P < 0.001 |
| Moderate | 10(8.2) | 20(16.3) | 1(0.8) | |
| Mod-severe | 2(1.6) | 17(13.9) | 0 | |
| Severe | 1(0.8) | 14(11.4) | 9(7.37) | |
| Profound | 0 | 6(4.9) | 12(9.8) | |
Fig. 3.
Tinnitus severity in normal hearing group and hearing loss group on the basis of TFI
Discussion
Tinnitus is the ringing sensation in one or both ears. Tinnitus severity can be assessed by psychoacoustic measurement using tinnitus matching test, tinnitus residual inhibition test or self-reported questionnaires. The most common among them is Tinnitus Functional Index (TFI). TFI provides an important tool in terms of severity, diagnosis and treatment outcomes. The most important risk factor for the development of tinnitus is hearing loss and it is assumed that emergence of tinnitus is a reflection of brain mechanism that aims to compensate for the lack of auditory input [16]. Also, dynamics of stress associated with course of tinnitus over time, which leads to interplay between stress, tinnitus distress and tinnitus loudness [17].
TFI helps in assessing the complaints associated with tinnitus and scores according with complaint leads to categorization of severity of tinnitus as well as response to treatment related changes in the tinnitus. TFI helps in the measurement of severity of tinnitus and interventional outcomes. The health related quality of life questionnaire was administered to all participants. This was consistent with study conducted by Kennedy et al., who in another study concluded that quality of life effects by tinnitus differ from individuals to individuals but most commons were emotional effects, lifestyle, sleep disturbance and auditory effects [18]. In another study of Hallam et al., studied participants with tinnitus and stated that in many of them tinnitus interferes with concentration due to the presence of distracting sounds inside the head which can affect the cognitive process especially attention [19].
In this study, we concluded that with increase in age there is gradual increase in the frequency of tinnitus. The mean age of tinnitus patient was about 60 years and highest frequency found in age group of > 50 years. This was consistent with the study conducted by Sogebi et al., and Lasisi et al. [20, 21] The main reason for prevalence of tinnitus among middle aged were unlawful use of drugs, recreational and occupational noises.
In this study, we found that males and female ratio was about 1.05:1. In study conducted by Hoffman and Reed et al.; (2004), in which males were more likely to have reported chronic tinnitus compared with females [22], while study conducted by Marmut et al.; showed that higher number of female participants were present with tinnitus [23].
In our study, about 122 participants had hearing loss on pure tune audiometry (85 had SNHL and 37 had mixed hearing loss) on pure tone audiometry, while rest had no hearing loss. This shows a correlation between tinnitus and hearing loss i.e. hearing loss is more associated with patient experiencing tinnitus. Our study also showed that difference in severity of tinnitus with normal hearing and patient with hearing loss as statistically significant. This is consistent with study conducted by Wrzosek et al., which showed that hearing-impaired participants with tinnitus have higher scores than normal hearing subjects with tinnitus [24]. Another study by Mazurek et al., showed 83% patients had tinnitus associated with hearing loss [25]. Vernon et al., reported about 70% tinnitus patient had hearing loss and concluded that patients with higher degree of hearing loss had associated tinnitus [26]. Moderate hearing loss was found to be most commonly associated tinnitus from this study, which is comparable to study by Ayodele SO et al., mild to moderate hearing loss is most commonly associated with tinnitus and in profound hearing loss prevalence is less than 10% [27]. Another study by N Mahafza et al., 2020 through their study concluded that patients with tinnitus and SNHL has scored higher on auditory subscale of TFI than patient with normal hearing thresholds [28].
In this study we also noted that individual with higher degree of hearing loss had greater severity of tinnitus according to TFI score and this is consistent with the study conducted by Dziendziel B et al., which showed that with increase in severity of hearing loss, tinnitus severity was also increased [29]. Another study by Searchfield et al., had shown the same result that is with increase in severity of hearing loss there is an increase in severity of tinnitus [30]. In contrast, another study by Sarvastano et al., 2008 did not show any relation between tinnitus severity and degree of hearing loss [31].
Conclusion
Tinnitus has a significant negative impact on the quality of life causing cognitive interference, emotional distress and sleep disturbances. TFI is a useful tool to measure the patient’s perception of tinnitus severity and its impact on life. There is a statistically significant association between hearing loss as well as its degree and severity of tinnitus. Thus, effect of tinnitus on quality of life of an individual is more in those with co-existing hearing loss. Thus, TFI can be used to monitor the psychosocial effects of tinnitus and its response to management.
Footnotes
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