Keywords
hearing - tinnitus - hyperacusis - questionnaires
Palavras-chave
audição - zumbido - hiperacusia - questionários
Introduction
The tinnitus has become a common otological complaint. It is estimated that approximately
25 million Brazilians present such symptom[1].
A complete anamnesis about the installation of the symptom, description, localization,
nuisance caused, among others, is the first action in face of individuals complaining
of tinnitus[2]. The use of questionnaires is of great value for the assessment of the presence
and determination of the degree of severity of the tinnitus[3].
One of the oldest methods still in use to assess the tinnitus is the Acuphenometry[4].
The Tinnitus Handicap Inventory (THI) is a questionnaire that seeks to characterize and identify the tinnitus. It is succinct,
of easy application and interpretation and reliability for the clinical practice.
It addresses the interference of the tinnitus on the patient's quality of life: functional,
emotional and catastrophic reactions to tinnitus[5]. The THI was translated and validated to Brazilian Portuguese in 2005 by Ferreira et al[6].
Another complaint that has been found in bearers of tinnitus is the hyperacusis[7]
[8]
[9]
[10]. The hyperacusis is a tolerance reaction to environmental sounds, an exaggerated
or inappropriate response to sounds that do not cause nuisance to the general population.
Its prevalence varies from 9 to 15%, but this percentage is higher in people who present
tinnitus[8].
The decrease of noise tolerance is present when the individual reacts negatively to
the presence of a sound that would not evoke similar reactions in normal hearers.
Such reactions can be of discomfort, fear, nuisance, suffering and others[11]. The authors compare the reaction of discomfort of people with hyperacusis (usually
for weak sounds) to the reaction of normal individuals in the presence of a high intensity
sound.
The hyperacusis occurs in individuals with normal hearing[12]
[7]. Of the individuals with complaints of tinnitus, only 8 to 20% present normal hearing[13]
[12]
[7].
Method
This is a cross-sectional, descriptive, non-experimental, quantitative study of data
obtained from normal hearing volunteers who complained of hyperacusis and tinnitus.
To recruit subjects, the research was announced on the site of Universidade Federal
de Santa Maria (UFSM), local papers and radio stations.
The data collection occurred from May to July of 2010, at the Speech-Therapy Service
(STS) of UFSM. Participated on the research only individuals who agreed with the methodology
of the study, signing the Term of Free and Informed Consent (following Resolution
196/1996).
This study was attached to the Project “Research and database in auditory health”,
registered at the Ethics in Research Committee, under the number 0138.0.243.246-06.
Through anamnesis was investigated the existence of tinnitus and hyperacusis. Also,
it was researched the location (unilateral or bilateral) and the type of tinnitus
(if bass or treble). Were included on the study only normal hearing individuals who
presented complaints of hyperacusis and tinnitus.
Were considered normal hearing individuals only those that, on the Pure Tone Audiometry,
showed air thresholds not above 25 dB in every frequency[14], tympanogram type A[15] and presence of acoustic reflexes.
A visual inspection of the external auditory canal was conducted to discard the presence
of obstacles to the realization of PTA. That was performed by air at frequencies of
250, 500, 1000, 2000, 3000, 4000, 6000 and 8000 Hz and through bone transmission at
frequencies of 500, 1000, 2000, 3000 and 4000 Hz. The equipment used was the two channel
digital audiometer, brand Fonix, model FA-12, type 1 and earphones type TDH-39P, brand Telephonics.
The tympanometry and the the study of acoustic reflex were determined with the middle
ear analyzer of the brand Interacoustics AZ7, with phone TDH-39 and pad MX-41, with
probe-tone of 220 Hz at 70 dB NA for tympanometry, and calibration following the norm
ISO 389-1991.
The sample consisted of 25 individuals, with ages from 21 to 70 years, being 16 females
and 9 males.
To assess the tinnitus was used the Brazilian THI[6]. After completed, the points were summed, classifying the tinnitus in degrees: slight,
mild, moderate, severe and catastrophic[16].
For the analysis and characterization of hyperacusis, a questionnaire was developed,
based on publication by Aita[7] and Gonçalves, Tochetto and Gambini
[17]. The questionnaire addressed aspects such as: sounds considered uncomfortable (police
siren, bell, slamming door, music in normal and loud volume, etc.), difficulty to
understand speech in noise, situations that cause discomfort, sensations on the presence
of uncomfortable sounds (fear, tension, annoyance, necessity to go away from the sound,
tinnitus, etc), use of ear plugs and for how long tolerates these sounds (less than
1 minute, from 1 to 5, from 5 to 10, or more than 10 minutes).
The individuals underwent acuphenometry. In this study, only the pitch (sensation of sound frequency) of the tinnitus was researched. According to the type
of tinnitus reported by the patient, it was presented a pure tone ore a narrow band
noise, or else a broadband noise (white noise), to the ear contralateral to the tinnitus, thus determining its pitch.
In order to verify if there was compatibility between the pitch reported by the patient
and the one found in acuphenometry, the narrow band noise and the pure tone above
1 KHz were classified as treble pitch and below 1KHz as bass. The broadband noise,
once covers a wide range of frequencies, was considered to be compatible with either
reported pich, treble or bass.
The data were tabled and analyzed descriptively and statistically using the U test
of Mann-Whitney and Kruskal-Wallis test. The degree of significance adopted was 5%
(p < 0.05).
Results
The analyzed sample consisted of 64% female and 36% male individuals.
From the 25 analyzed individuals, the most common location of the tinnitus was bilateral
(84%). Of the 16% who reported unilateral tinnitus, the right ear was predominant
(75%) over the left ear (25%). Concerning the pitch of the tinnitus, 80% of the individuals reported it as treble.
The results of the degree of tinnitus according to the THI, considering the totality
of the subjects studied, are shown in [Figure 1]. The distribution of degrees of tinnitus in relation to gender is in [Table 1].
Table 1.
Degrees of severity of tinnitus (THI) according to gender.
|
Degrees of Tinnitus
|
Male
|
Female
|
|
Slight
|
2
|
3
|
|
Mild
|
7
|
4
|
|
Moderate
|
0
|
6
|
|
Severe
|
0
|
2
|
|
Catastrophic
|
0
|
1
|
|
N
|
9
|
16
|
U test of Mann-Whitney (p=0,04*).
Figure 1. Distribution of the degrees of severity of tinnitus according to THI in all evaluated
individuals.
[Table 2] shows the sounds considered uncomfortable, according to the hyperacusis questionnaire.
Table 2.
Uncomfortable sounds according to questionaire applied.
|
Uncomfortable sounds
|
n° of mentions (n=25)
|
|
Loud music
|
20
|
|
Horn
|
17
|
|
People talking loudly
|
17
|
|
Traffic noise
|
16
|
|
Door slamming
|
16
|
|
Sudden and loud noise
|
15
|
|
Sink dripping
|
13
|
|
Restaurant noise
|
11
|
|
Door bell
|
11
|
|
Police siren
|
11
|
|
Plane
|
9
|
|
Plastic bag noise
|
7
|
|
Blender
|
7
|
|
Phone ringing
|
6
|
|
Others
|
25
|
Note: Individuals reported more than one reaction.
We considered “other sounds” those with less than five mentions: car started (4),
loud laughter (3), fridge noise (3), sound of music at regular volume (2), motorcycle
noise (2), alarm clock (2), clapping (1), key noises (1), repetitive noises (1), crying
child (1), shower noise (1), television at regular volume (1), tableware scraping
on the plate (1), rockets (1) and microphone interference (1).
Still regarding the hyperacusis questionnaire used, 68% of the individuals reported
difficulty in understanding speech in noise. Regarding the situations that cause discomfort,
eight answers were obtained. The absence of situations that elicit the discomfort
was the most mentioned, followed by “at the end of the day” and “when I'm stressed”.
[Table 3] shows the reactions to uncomfortable sounds, according to the hyperacusis questionnaire.
Table 3.
Reactions to uncomfortable sounds, according to hyperacusis questionnaire.
|
Reactions to sounds
|
n° de mentions (n = 25)
|
|
Irritation
|
21
|
|
Anxiety
|
14
|
|
Necessity to get away from the sound
|
13
|
|
Tinnitus
|
11
|
|
Tension
|
11
|
|
Disorientation
|
8
|
|
Aggressiveness
|
5
|
|
Headache
|
4
|
|
Pain
|
2
|
|
Dizziness
|
2
|
|
Others
|
4
|
Note: Individuals reported more than one reaction.
In [Table 3], “other reactions”were those with only one mention each: shock, a wish to cry, fear
and panic.
As for the use of earplugs, 88% reported not to use them. There was a predominance
of 5 to 10 minutes of tolerance time to the sounds considered uncomfortable.
The frequencies most commonly found in the acuphenometry were the treble, especially
6 and 8 KHz. [Table 4] shows the results of the analysis by ear, between the referred pitch at anamnesis and the one found in the acuphenometry. It was not possible to apply
statistical tests on these findings.
Table 4.
Relation between pitch reported by patient and the one found in the acuphenometry.
|
Pitch - anamnesis
|
|
Pitch - acuphenometry
|
|
Treble
|
Bass
|
White noise
|
Total
|
|
Treble
|
25 (86%)
|
0 (0%)
|
4 (14%)
|
29 (100%)
|
|
Bass
|
6(67%)
|
0 (0%)
|
3 (33%)
|
9(100%)
|
Nine subjects reported tinnitus of bass pitch, though such finding was not verified by acuphenometry. That is to say that this
individuals identified a treble sound (pure tone or narrow band noise) or white noise
instead of the referred bass.
Discussion
The assossiation between tinnitus and hyperacusis is frequently found in literature:
63%[8]
[10], 66,7%[7] and 90%[9]. However, we did not find studies that investigate subjects with these two concomitant
complaints. Therefore, the obtained data were compared to studies made only with people
with hyperacusis and only with bearers of tinnitus.
This study found greater representation of female individuals (64%). Women are more
affected both by hyperacusis (61%)[8], and by tinnitus (67,3%)[18], (52,1%).
However, there is controversy in literature about the influence of gender in the prevalence
of tinnitus[19]. We believe that the higher percentage of women found is due to the fact that they
are more available to seek medical care[20], since the female gender prevails in the search for health services[21].
It was observed the prevalence of subjects afflicted by tinnitus of bilateral location
(84%). Similar findings, though with smaller percentages, were found by other studies[17]
[19]. For their turn, Fernandes and Santos
[22] found only 20% of the sample reporting bilateral tinnitus.
In this study, the unilateral affection of the right ear was more reported than the
left. The study of Martines et al.
[23] goes to meet this finding. But in article by Fernandez and Santos
[22], the unilateral affection of the left ear was the most common (65%).
The most found pitch, both in anamnesis as in acuphenometry ([Table 4]), was the treble, especially at frequencies of 6 and 8 KHz. Literature also shows
treble pitch tinnitus as the most reported by patients with tinnitus[22]
[23]
[24]. As in this study, Menezes and Santos Filha
[4] relate higher occurrence of treble tinnitus at the same frequencies.
The most commom degree of tinnitus was mild (44%) ([Figure 1]), which agrees with the findings of Martines et al.
[23] and Paglialonga et al.
[25], because they found the same degree in normal hearing individuals. On the other
hand, Pinto, Sanchez & Tomita
[19] obtained higher percentage of the slight degree and Savastano
[26] of the moderate degree, using the same assessment instrument. The low scores found
can be explained, since in about 80% of the cases the tinnitus does not cause discomfort
for the patient[1]
[27].
Savastano
[26] found association of slight and mild degrees of tinnitus to individuals who had
hearing loss, and moderate to catastrophic degrees associated to individuals without
hearing loss, which was not verified in this study. According to this author, a greater
degree of hearing loss does not correlate to greater nuisance with the tinnitus.
According to THI, the degree of tinnitus was statistically higher in women ([Table 1]). This finding can be explained by the greater prevalence of affective disorders,
such as anxiety and depression, in women[19], since they are frequently described and associated to a greater nuisance to tinnitus[28].
On the contrary, Pinto, Sanchez & Tomita
[19] did not find statistically significant correlation between gender and the nuisance
caused by tinnitus, according to THI. These authors refer to depression as a possible
indirect influence of gender, showing incidence twice as high in females as in males[29].
The high intensity sounds were the uncomfortable sounds most mentioned by the individuals:
high volume music sounds, horn, people talking loudly, traffic noise, door slamming,
sudden and high sound, in this order ([Table 2]).
In study performed with musicians with hyperacusis, Gonçalves, Tochetto & Gambini
[17] also found, mainly, the high intensity souns to be discomforting: traffic noise,
door slamming, and high volume music. The sounds that started hyperacusis, in Aita's study[7], were: music, sounds of planes and motors in general. Sounds of telephone, doorbell,
sirens and slamming doors were also mentioned, but less frequently.
The difficulty to understand speech in noise mentioned (68%) may be deeply connected
to the mechanism of tinnitus and hyperacusis, through the Olivocochlear Medial System
(OMS); this system acts as a modulator to the activity of the external ciliated cells
(ECC) of the cochlea and, among other functions, acts in the recognition of auditory
stimuli in the presence of competitive noise[12].
We believe that in, people afflicted by tinnitus, occurs a loss of modulation of the
ECC, causing an abnormal auditory pathways activity, misinterpreted as a sound. In
hyperacusis, the ECC cease to perform their function of non-linear amplification,
beginning to amplify low and moderat intensity sounds[30]. Probably, a cortico-thalamic-olivary pathway is responsible for selective attention
and cochlear modulation, both important in the discrimination of speech in the presence
of noise[12].
Thus, a disorder of the OMS might cause the tinnitus, hyperacusis and difficulty to
recognize speech in noise, as demonstrated by Henning et al.
[31]. In the mentioned study, normal hearing individuals with complaints of tinnitus
and hyperacusis showed lower performance in the presence of noise, with statistically
significant difference, when compared to normal hearing individuals without auditory
complaints.
The most common reactions to sound were irritation, anxiety, necessity to get away
from the sound, tinnitus, tension and disorientation ([Table 3]). Aita
[7] found similar reactions: irritation, tinnitus, headache, hearing decrease, aggressiveness,
nausea and anguish. Gonçalves, Tochetto & Gambini
[17], on the other hand, reported tension, anxiety, necessity to get away from the sound,
anger, irritation and pain, being similar to this study, only with different number
of mentions.
Hypersensitivity can cause anxiety and even fear, occurring for specific sounds as
well as general sounds. This happens because the connections between the central auditory
system and the brain areas involved in anxiety and fear are closely connected[32].
Due to these reactions caused by uncomfortable sounds, 12% of the researched individuals
reported the use o earplugs. Valente et al.
[33] found constant use of earplugs in severe cases of hyperacusis, because even conversation
caused nuisance. According to Baguley
[32] the first reaction to the hyperacusis is to protect oneself with earplugs or other
such devices.
It is noteworthy that auditory overprotection is contraindicated, because it can raise
even more the central hearing gain and aggravate the hyperacusis[32]. In fact, the Tinnitus Retraining Therapy, sound therapy indicated to tinnitus and hyperacusis, is based on auditory desensitization,
which involves the gradual removal of earplugs[34].
Most of the subjects questioned reported 5 to 10 minutes of tolerance to sounds considered
uncomfortable. Aita
[7] found time lower than one houre.
In the acuphenometry ([Table 4]), the bass pitch reported by some subjects was not confirmed. Adding to the results found, Mor
[35] also found in acuphenometry prevalence of treble pitch, especially at frequencies of 6 to 8 KHz, in normal hearing individuals with complaints
of tinnitus.
The absence of relation between the pitch reported in the anamnesis and the one found in the acuphenometry may have occurred
due to patient's difficulty to compare and associate pure tones or noises to tinnitus,
apart from tinnitus being multitonal, in most cases[24].
Conclusion
Normal hearing individuals with complaints of tinnitus and hyperacusis show prevalence
of treble pitch tinnitus, located bilaterally and of mild degree. The degree of tinnitus was more
accentuated on females.
The high intensity sounds were considered the most uncomfortable. The most mentioned
reactions to these sounds were: irritation, anxiety and necessity to get away from
the sound. The difficulty to understand speech in the presence of noise was reported
by most of the individuals
