Sleep Quality in Patients with Tinnitus

Abstract

Objective

To analyze the association between sleep quality and chronic tinnitus.

Materials and Methods

The present is a prospective observational cross-sectional study in which convenience sampling (n = 51) was used to assess individuals with chronic tinnitus at a specialized outpatient clinic in a tertiary referral hospital. The data collection tools included a demographics questionnaire, a sleep quality questionnaire (the Mini Sleep Questionnaire), a questionnaire to assess the impact of tinnitus (Tinnitus Handicap Inventory), and pure-tone audiometry. The data was analyzed using the student's t-test or analysis of variance (ANOVA), the Mann-Whitney or Kruskal-Wallis's test, and the Pearson's Chi-squared or Fisher's exact test.

Results

There was a predominance of women and middle-aged adults with bilateral tinnitus and hearing loss. The scores on the Tinnitus Handicap Inventory revealed that the tinnitus had a moderate to catastrophic impact on quality of life. Most participants classified themselves as having severe sleep difficulties on the Mini Sleep Questionnaire. Furthermore, patients with higher scores on the Tinnitus Handicap Inventory tended to show poor quality sleep patterns on the Mini Sleep Questionnaire. Regarding the association between sex and the scores on the Tinnitus Handicap Inventory, more men were severely handicapped, whereas more women were catastrophically handicapped. There was also a significant association between age group and hearing loss.

Conclusion

The data analysis revealed a significant association between sleep quality and tinnitus in the sample.

 

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Keywords

tinnitus - sleep quality - quality of life

Introduction

Tinnitus is the perception of sound without external sound stimuli.[1] Although technically accurate, this classic definition does not address the complexity of patient experiences. There is a disparity between the definition and the clinical reality of tinnitus. A more comprehensive definition should include the patient's perception of cognitive and emotional aspects, as well as the impact on quality of life.[2] Some studies[3] [4] [5] have indicated that tinnitus impairs quality of life with unpleasant sounds and a range of coexisting symptoms, such as anxiety, depression, sleep disorders, hearing loss, and poor concentration and relaxation.

These symptoms transcend the purely sensory dimension and show that any definition of tinnitus should also include the negative impact on quality of life.[2] Regarding its etiology, tinnitus can be classified as primary or secondary. Primary tinnitus is generally considered idiopathic, with no direct link to a specific medical condition. It is often associated with sensorineural hearing loss. Secondary tinnitus usually has an identifiable cause, such as vascular and neuromuscular changes, or metabolic, otologic, toxicological or somatosensory disorders. Infectious conditions and head and neck injuries can also cause secondary tinnitus.[6] It is worth mentioning that hearing loss is also strongly associated with tinnitus.[4] [7]

The most recent study regarding the prevalence of tinnitus in Brazil[4] was conducted in 2021; using random sampling, a survey was conducted at at health centers, and the results revealed a prevalence of 31.6%. Using an epidemiological and cross-sectional approach, a population-based survey found that the prevalence was of 22% in the city of São Paulo in 2015.[8]

Persistent tinnitus can trigger a series of disturbances, among them frequent nighttime awakenings and poor sleep, daytime tiredness, stress, and impaired concentration.[5] [9] [10] Sleep plays essential neurobiological roles that are necessary for good physical and cognitive health, restored energy, a strong immune system, memory consolidation, and endocrine and metabolic regulation.[11] Sleep deprivation can result in long-term health problems, including cardiovascular diseases and metabolic disorders.[12] [13]

The specialized literature[14] recommends using questionnaires to evaluate chronic conditions to quantify psychological, emotional, and functional deficits. The Tinnitus Handicap Inventory (THI)[15] stands out as a widely used questionnaire to assess the impact of tinnitus on quality of life. It has already been translated into Brazilian Portuguese.[16] The Mini Sleep Questionnaire (MSQ) is used to assess sleep quality.[17]

Considering the scarcity of Brazilian studies and the reciprocal relationship between tinnitus and sleep quality, the present investigation seeks to fill a gap in the Brazilian literature and to provide insights to improve clinical care, as well as effective guidance for patients with this condition. Furthermore, in the literature consulted, we did not find articles that related the scores on the THI and on the MSQ. The joint analysis of the two questionnaires can help professionals provide better guidance to patients if a relationship is identified between the impacts of tinnitus and sleep quality. The use of the two instruments together can help guide patients who have tinnitus and who may report changes in their sleep. It is known that the treatment of patients with tinnitus begins with adequate guidance. If the hypothesis is that the greater the impact of tinnitus, the worse the quality of sleep is confirmed by the professional who works in this field, this will be an essential point in patient guidance. Furthermore, it is important that professionals working in the field of sleep can address questions about tinnitus more emphatically and make the necessary referrals for evaluations and specialized treatment.

The objective of the current study was to analyze the association between sleep quality and chronic tinnitus.

 

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Materials and Methods

The present cross-sectional study followed university guidelines and regulatory standards for research involving human beings (Resolution no. 466/12 of the Brazilian National Health Council). The institutional Ethics in Research Committee approved this project (under reference no. 6.674.413).

Using convenience sampling, research was conducted from October 2022 to December 2023. We included individuals who self-reported chronic tinnitus (that is, lasting for more than 6 months) and discomfort at a specialized outpatient clinic in a tertiary referral hospital. Patients 18 years of age or older who had chronic tinnitus were included. After being informed about the voluntary nature of the study, the objectives, the methods, and the risks and benefits, willing participants signed a Free and Informed Consent Form.

Data collection tools included questionnaires addressing age, sex, tinnitus characteristics and duration (in years), and perception of the tinnitus source (unilateral, bilateral or centered in the head). The THI aims to assess the repercussion and impact of tinnitus on an individual's quality of life by quantifying psychological, emotional, and functional deficits. There are 25 questions and the total score ranges from 0 to 100. The higher the score, the more intense the level of discomfort. The THI scores are organized into 5 categories: slight or no handicap (0–16%), mild handicap (18–36%), moderate handicap (38–56%), severe handicap (58–76%), and catastrophic handicap (78–100%).[15]

To assess sleep quality, we used the MSQ, which contains ten questions that comprehensively assess multiple aspects of sleep patterns, as well as the frequency at which these aspects are disturbed. The total MSQ score ranges from 0 to 60 to evaluate sleep pattern and quality. The resulting score is organized into different categories: very good sleep quality (0–9 points), good sleep quality (10–24 points), mild sleep difficulties (25–27 points), moderate sleep difficulties (28–30 points), and severe sleep difficulties (> 30 points).[17]

Hearing levels were also assessed through pure tone audiometry. Modulated pure tone (warble) was used to test frequencies from 250 Hz to 8,000 Hz in each ear. This step enabled us to analyze air-conduction thresholds by identifying the lowest sound intensity perceived by the patient for each frequency (in decibels, dB). These tests were performed in a soundproof booth using an AC40 audiometer (Interacoustics A/S) and TDH-39 headphones (Interacoustics A/S). Depending on the configurations of each audiogram, the World Health Organization (WHO) hearing loss classification (2020)[18] was used to diagnose and refer patients for specific treatment within the hospital.

Regarding the statistical analysis, participants were identified by number to maintain confidentiality, and all the data collected was saved in a Microsoft Office Excel spreadsheet (Microsoft Corp.). After tabulation, the database was exported into the IBM SPSS Statistics for Windows (IBM Corp.) software, version 21.0. The level of significance was set at 5% (p < 0.05). Quantitative variables were expressed as mean and standard deviation or median and interquartile range values. Categorical variables were expressed through absolute and relative frequencies. To compare means, we used the student's t-test or analysis of variance (ANOVA), complemented by the Tukey's range test. In cases of asymmetry, the Mann-Whitney or Kruskal-Wallis tests were used. To compare proportions, Pearson's Chi-squared or Fisher's exact tests were used.

 

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Results

The sample consisted of 51 participants, 68.6% of whom were women. Their ages ranged from 19 to 83 (mean: 57.2 ± 14.0) years. The median time of tinnitus perception was of 5 years, and 29.4% of the participants reported in the anamnesis that tinnitus negatively affected their sleep ([Table 1]).

Table 1 Characteristics of the study sample.

Variables	n = 51
Mean age (years)	57.2 ± 14.0
Sex – n (%)
Female	35 (68.6)
Male	16 (31.4)
Report of tinnitus interference on sleep	15 (9.4)
Tinnitus duration (years) – median (P25–P75)	5 (3–15)
Perception of tinnitus source – n (%)
One ear	21 (41.2)
Both ears	28 (54.9)
Centered in the head	2 (3.9)
Hearing loss – n (%)
None	7 (13.7)
Unilateral	10 (19.6)
Bilateral	34 (66.7)

Abbreviations: P25, 25th percentile; P75, 75th percentile.

An analysis of THI scores showed that the median was of 48 points. Moreover, the largest percentage of participants reported moderate (25.5%) or catastrophic (25.5%) handicap due to tinnitus. The mean total MSQ score was of 39.1 ± 10.3 points and most participants had severe sleep difficulties ([Table 2]).

Table 2 Scores on the Tinnitus Handicap Inventory (THI) and Mini Sleep Questionnaire (MSQ)

Variables	n = 51
Total THI score – median (P25–P75)	48 (26–84)
THI classification – n (%)
Slight or no handicap (0–16%)	9 (17.6)
Mild handicap (18–36%)	9 (17.6)
Moderate handicap (38–56%)	13 (25.5)
Severe handicap (58–76%)	7 (13.7)
Catastrophic handicap (78–100%)	13 (25.5)
Mean total MSQ score	39.1 ± 10.3
MSQ Classification – n (%)
Good sleep quality (10–24)	5 (9.8)
Mild sleep difficulties (25–27)	0 (0.0)
Moderate sleep difficulties (28–30)	6 (11.8)
Severe sleep difficulties (> 30)	40 (78.4)

Abbreviations: P25, 25th percentile; P75, 75th percentile.

There was a significant association involving the total THI and MSQ scores and severity. This suggests that individuals with higher THI scores tend to have poor sleep patterns ([Table 3]).

Table 3 Association of the Mini Sleep Questionnaire (MSQ) and the Tinnitus Handicap Inventory (THI) with tinnitus, sociodemographic data and hearing levels.

Variables	Good sleep quality	Moderate sleep difficulties	Severe sleep difficulties	p
Tinnitus duration (years) – median (P25–P75)	4 (3–25)	3 (2–11)	5.5 (3–15)	0.432
Perception of tinnitus source – n (%)				0.233
One ear	3 (60.0)	2 (33.3)	16 (40.0)
Both ears	1 (20.0)	4 (66.7)	23 (57.5)
Centered in the head	1 (20.0)	0 (0.0)	1 (2.5)
Age group – n (%)				0.563
Adult	2 (40.0)	3 (50.0)	25 (62.5)
Older adult	3 (60.0)	3 (50.0)	15 (37.5)
Total THI score – median (P25–P75)	12 (5–35)	39 (23.5–53.5)	56 (30–86)	0.009
THI classification – n (%)				0.074
Slight or no handicap (0–16%)	3 (60.0)	1 (16.7)	5 (12.5)
Mild handicap (18–36%)	2 (40.0)	1 (16.7)	6 (15.0)
Moderate handicap (38–56%)	0 (0.0)	3 (50.0)	10 (25.0)
Severe handicap (58–76%)	0 (0.0)	1 (16.7)	6 (15.0)
Catastrophic handicap (78–100%)	0 (0.0)	0 (0.0)	13 (32.5)
Hearing loss – n (%)				04.19
None	0 (0.0)	2 (33.3)	5 (12.5)
Unilateral	1 (20.0)	0 (0.0)	9 (22.5)
Bilateral	4 (80.0)	4 (66.7)	26 (65.0)

Abbreviations: P25, 25th percentile; P75, 75th percentile.

Regarding the association involving sex and the THI and MSQ scores, there were significant differences linked to a higher impact on quality of life. More men were impacted by severe handicap, whereas more women were affected by catastrophic handicap ([Table 4]).

Table 4 Association of sleep quality with sex and tinnitus.

Variables	Female	Male	p
Total THI score – median (P25–P75)	48 (28–86)	47 (13–69)	0.255
THI classification – n (%)			0.012
Slight or no handicap (0–16%)	4 (11.4)	5 (31.3)
Mild handicap (18–36%)	8 (22.9)	1 (6.3)
Moderate handicap (38–56%)	9 (25.7)	4 (25.0)
Severe handicap (58–76%)	2 (5.7)	5 (31.3)*
Catastrophic handicap (78–100%)	12 (34.3)*	1 (6.3)
Mean total MSQ score	40.9 ± 10.2	35.3 ± 9.8	0.072
MSQ classification – n (%)			0.334
Good sleep quality (10–24)	2 (5.7)	3 (18.8)
Mild sleep difficulties (25–27)	0 (0.0)	0 (0.0)
Moderate sleep difficulties (28–30)	4 (11.4)	2 (12.5)
Severe sleep difficulties (> 30)	29 (82.9)	11 (68.8)

Abbreviations: MSQ, Mini Sleep Questionnaire; P25, 25th percentile; P75, 75th percentile; THI, Tinnitus Handicap Inventory.

Notes: *Statistically significant association after the adjusted residuals test. The significance level was set at 5%.

A significant association was also found between the perceived source of the tinnitus and age groups. Similarly, a significant association was established between age groups and hearing loss ([Table 5]).

Table 5 Association of age with tinnitus, sleep quality and hearing level.

Variables	Adult	Older adult	p
Perception of tinnitus source – n (%)			0.017
One ear	9 (30.0)	12 (57.1)
Both ears	21 (70.0)	7 (33.3)
Centered in the head	0 (0.0)	2 (9.5)
Total THI score – median (P25–P75)	45 (35–78)	48 (15–85)	0.553
THI classification – n (%)			0.297
Slight or no handicap (0–16%)	3 (10.0)	6 (28.6)
Mild handicap (18–36%)	6 (20.0)	3 (14.3)
Moderate handicap (38–56%)	8 (26.7)	5 (23.8)
Severe handicap (58–76%)	6 (20.0)	1 (4.8)
Catastrophic handicap (78–100%)	7 (23.3)	6 (28.6)
Mean total MSQ score	39.6 ± 9.3	38.4 ± 11.9	0.683
MSQ classification – n (%)			0.563
Good sleep quality (10–24)	2 (6.7)	3 (14.3)
Moderate sleep difficulties (28–30)	3 (10.0)	3 (14.3)
Severe sleep difficulties (> 30)	25 (83.3)	15 (71.4)
Hearing loss – n (%)			0.040
None	5 (16.7)	2 (9.5)
Unilateral	9 (30.0)	1 (4.8)
Bilateral	16 (53.3)	18 (85.7)

Abbreviations: MSQ, Mini Sleep Questionnaire; P25, 25th percentile; P75, 75th percentile; THI, Tinnitus Handicap Inventory.

 

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Discussion

The relationship between tinnitus and sleep quality is a topic of great concern in the scientific community. However, Brazilian studies are scarce, and there are no recent articles in the international literature. As such, updates on the topic are necessary. We will present evidence that points to tinnitus as the cause of impaired quality of life, including negative emotional and social effects associated with sleep quality. In this context, the current study can contribute to the specialized literature that seeks to explore the reciprocal relationship between tinnitus and sleep quality.

The sample was mostly composed of women and middle-aged adults, with an average tinnitus duration of 5 years, bilateral perception of the tinnitus source, severe sleep difficulties, and bilateral hearing loss. Previous studies[4] [8] [19] corroborate the higher proportion of tinnitus among females. However, this relationship is complex due to the different ways men and women deal with the condition and seek health care.[20] Such differences may be shaped by cultural and regional factors, personal attitudes about health, and personal agency when dealing with tinnitus. This adds to the complexity of understanding this relationship.

Despite the initial expectations to find a predominance of older adults, the results showed a predominance of middle-aged individuals. This is different from other findings in the specialized literature[21] that have demonstrated a higher prevalence of tinnitus in older adults. However, another study[4] reported an average age of 59.24 years of its sample, which corroborates our results. This divergence may stem from several factors, including methodological variation, diversity between populations, and different criteria to define and measure tinnitus.

When questioned during the initial interview whether tinnitus negatively affected their sleep, approximately 1/3 of the participants answered “yes”. This value was lower than expected by the researchers, since a population study[22] showed that 35% of individuals had sleep problems, leading to the hypothesis that complaints about sleep problems would be more prevalent.

Analyses regarding hearing loss showed that 86.3% demonstrated some level of hearing impairment. This result reaffirms the frequent association between tinnitus and hearing loss reported in other studies.[4] [23] It also reinforces the validity of our data collection and the importance of assessing for hearing loss during the clinical treatment of tinnitus.

Regarding the analysis for the impact of the tinnitus, the THI is the most well-known and widely used instrument worldwide. A European study[24] used the THI to investigate the impact of tinnitus on 630 patients, and only 24.9% had a mild or moderate handicap. In the current study, the median total THI score was 48 points, and a greater number of participants had a moderate or catastrophic handicap. This indicates a convergence regarding the perception of the impact of tinnitus among different population samples. It reinforces the idea that tinnitus is not uniform in its expression; it can vary considerably in severity and impact on quality of life. Additionally, individual experiences and perceptions are diverse.

Previous research on the relationship between tinnitus and sleep disorders[25] found that, when compared with the control group, 77% of the participants presented longer delays before falling asleep, early morning awakenings, awakenings in the middle of the night, morning fatigue, and chronic fatigue. A more recent study[26] used a different questionnaire, the Pittsburgh Sleep Quality Index, to collect information on sleep disorders. The authors[26] reported that 70.8% of patients, in a predominantly female sample, experienced sleeping difficulties. When relating these data to our results, there was a convergence in evidence. The mean total MSQ score was of 39.1 ± 10.3 points, indicating severe sleep difficulties and a predominance of female participants. Although the cited studies used different methodologies, this convergence in results reinforces the validity and relevance of the association. It also highlights the need to continue exploring this relationship to improve clinical intervention strategies. This finding can be attributed to several factors, including the intrinsic link between tinnitus and sleep disorders, and the reciprocal interaction between these two phenomena.

Recent research has shown that the greater the degree of severity and impact caused by tinnitus, the more sensitive the individual is affected by it. Emotional and health problems, such as anxiety and sleep disorders, can occur.[5] [27] We found a significant association involving the total THI score and the MSQ sleep classification categories, suggesting that individuals with higher THI scores and more severe tinnitus tend to have more impaired sleep patterns. This relationship is evident in the moderate and catastrophic handicap categories, in which tinnitus severity was associated with worse sleep quality. One study[5] analyzed the frequency of THI responses and reported a greater prevalence in the mild handicap category, followed by the moderate category. However, other studies[28] showed a higher frequency of severe and catastrophic handicaps. This data highlights the importance of considering tinnitus severity when evaluating the sleep patterns of affected individuals. Patients who suffer more from tinnitus require specific interventions, including guidance concerning sleep.

It is important to point out that, during the anamnesis, 29.4% of the participants reported sleep problems. However, when the MSQ was applied, we found that 90.2% presented a moderate or severe sleep disorder, emphasizing the need to investigate sleep in such patients using validated assessment tools. Thus, the MSQ has proven to be a valid instrument to identify sleep problems that affect patients with tinnitus; it is easy and quick to apply, and it can be used in the routine clinical practice to identify individuals who have changes in sleep quality and then refer them to specialized professionals.

It is also worth noting that, of the 51 participants in the survey, 27 (52.9%) reported that the nighttime period worsens tinnitus, which can lead to insomnia. There were no reports of daytime sleepiness.

The present study revealed findings similar to those of previous analyses[8] that showed greater tinnitus discomfort among women. The limited analysis of the association between sex and the subjectivity of tinnitus raises the possibility that women, due to greater attention and sensitivity to health changes, may perceive tinnitus more intensely.

Regarding the THI classification and sex, there was a difference in the severe and catastrophic handicap scores. There was an association between the male sex and severe handicap, and between the female sex and catastrophic handicap. This finding was unexpected and absent from the literature consulted. Although the total MSQ score associated with sex suggests a trend (p = 0.072), it did not demonstrate statistical significance. The pattern did not differ between the sexes. New and more robust studies on the relationship between sex and the impact of tinnitus are needed. The number of participants may have also influenced the results.

Regarding adults and older adults, there were no differences in terms of the values of the total scores or the THI and MSQ categories. Age may not have been a determining factor in the perception of tinnitus or sleep quality. Therefore, it is possible that other factors, such as individual characteristics and health history, play more prominent roles in these issues than the simple distinction between adults and older adults.

There was an association between age groups and the distribution of the results regarding the perception of the source of tinnitus. A greater number of adult participants reported bilateral tinnitus. At a different tertiary referral hospital, another study[29] reported the opposite result: no such association was found. These differences in findings suggest the need for further investigation into possible determinants. Additionally, there was a significant association between bilateral hearing loss and age group, which was expected. Aging is commonly associated with presbycusis, and is characterized by bilateral, symmetrical, and progressive hearing loss.[30]

Finally, the limitations to the current study include its cross-sectional design. In the future, larger samples and longitudinal approaches may help us better understand the dynamics between tinnitus and sleep. Including objective sleep measures is also recommended for a more comprehensive grasp of this complex and multifaceted relationship. Subjective assessments can still serve an important complementary role. The use of polysomnography is also suggested for future studies, enabling an objective analysis of the association between tinnitus and sleep quality.

The results show the benefit of a collaborative and interdisciplinary approach to assessing and treating patients with tinnitus. Future global guidelines, as well as integrative approaches to patients and sleep hygiene, must consider the unique aspects of each individual.

 

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Conclusion

Data analysis revealed that there was an association between sleep quality and tinnitus: most patients presented severe sleep difficulties and reported a catastrophic impact on their quality of life.

 

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Conflict of Interests

The authors have no conflict of interests to declare.

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Publikationsverlauf

Eingereicht: 13. August 2024

Angenommen: 10. April 2025

Artikel online veröffentlicht:
07. Juli 2025