Tinnitus

Fundación Canaria
para la Prevención
de la Sordera

Evaluation of Chronic Tinnitus Patients

F. Zenker and J.J. Barajas

Fundación Canaria para la Prevención de la Sordera, Santa Cruz de Tenerife, Spain

Abstract

Chronic tinnitus refers to prolonged suffering of a subjective sensation of noise with no known external origin. It is often a disturbing symptom which affects to the 6-20% of the population. It is usually associated with hearing losses of various origins, including Noise Induced Hearing Loss (NIHL). Psychological factors and coping mechanisms are more closely related to the degree of severity than the psychoacustic properties of the tinnitus. In an attempt to measure the effects of tinnitus, a few questionnaires have recently been introduced : the Tinnitus Questionnaire, designed to assess the dimensions of tinnitus complaint ; Tinnitus Handicap Questionnaire, measuring the effects of tinnitus, Tinnitus Severity Scale, measuring physical and psychological well-being, and Tinnitus Reaction Questionnaire designed to assess the psychological distress associated with tinnitus. The purpose of this study was firstly, to present preliminary data obtained with a Spanish adaptation of the Tinnitus Questionnaire ; and secondly, to study the complaints among three different groups of tinnitus sufferers (those with normal hearing, with hearing loss not induced by noise and with noise induced hearing loss).

Introduction

Tinnitus is defined as the perception of noise in the absence of any appropriate external stimulus [1]. It is usually associated with hearing losses of various origins [2], for example, tinnitus often accompanies a noise induced hearing loss (NIHL). Epidemiological studies have shown that up to the 17% of the population report having tinnitus, although only the 0.5% to the 1.6% are severely disabled to lead a normal life [3]. Among the hearing-impaired popula-tion, it has been estimated that the 67% suffer tinnitus, and of these, the 50% claim that tinni-tus is a problem so serious as impaired hearing, or more [4]. The frequency of tinnitus in NIHL was 35% of which 60% had pure-tone tinnitus and 40% had different types of broad band tinnitus [5].

From a psychological point of view several attempts have been made to assess tinnitus-related complaints. Standard instruments of clinical psychology and psychiatry like the Hop-kins Symptom Checklist [6], the Crown-Crisp Experimental Index [7] or the Minnesota Mul-tiphasic Personality Inventory [8] have been used. Generally, the results obtained from these procedures suggest that tinnitus, like other chronic conditions, may be associated with psy-chological distress, and particularly, with depression and anxiety [9]. Although, recent sudies have focused on the development of specific questionnaires which are directly related to dis-tress associated with chronic tinnitus. These attempts include the Tinnitus Effect Questionnaire [10], designed to asses the dimensions of Tinnitus complaint, Tinnitus Handicap Questionnaire [11], measuring the effects of tinnitus, Tinnitus Severity Scale [12], measuring physical and psychological well-being, and Tinnitus Reaction Questionnaire [13] designed to assess the psychological distress associated with tinnitus.

Taking into account these different approaches, the Tinnitus Questionnaire (TQ), de-veloped by Hallam et al. [10], has been used in several studies and it seems to be the most compenhensive assessment method of tinnitus related complaints [14-15]. Further, the TQ is the only instrument which provides a very broad description, with six scales derived from both, factor analysis and clinical evidence [15]. In the first version of the TQ developed by Jakes et al.[16] the authors found two general and three specific complaint factors labelled ‘emotional distress’ (effects of tinnitus on mood, family and social life) and ‘intrusiveness’ (how loud, unpleasant and distracting the noise were).Varimax rotation was used and all factors were orthogonal to each other. These results are consistent with the low relation between complaints and objective measures [16]. This lack of relationship may simply be indicative of the unreliability or invalidity of these objective measures [16]. Similar struc-ture was found in previous studies with different samples of subjects [14-15].

The present study was carried out with two principal aims. First ; to replicate the facto-rial structure of the TQ in a different and independent sample of tinnitus sufferers. Second; attempt to evaluate differences in the complaints due to tinnitus, assessed by the first version of the TQ developed by Jakes et. al in three different groups of chronic tinnitus sufferers , (a) subjects with normal hearing, (b) subjects with hearing loss not induced by noise (c) and sub-jects with noise induced hearing loss.

Method

Subjects and procedures

The subjects were 20 patients who attended an out-patient clinic suffering chronic tin-nitus. The characteristics of this sample was as follows ; mean age was 51.3 years (SD = 15.26), mean time since onset was 5.3 years (SD = 6.8), ranging from 1 to 33. 12 subjects (60%) had unilateral tinnitus. 55% of the sample (n = 11) were males. The age of the subjects ranged from 32 to 84 years (mean = 51.30 years). Subjects were asked, as part of a routine assessment, to complete a questionnaire concerning features of the tinnitus and other symp-toms. The scales used verbal descriptors of frequency or severity. Each scale had between 2 and 5 response categories.

Instruments

A Spanish version of the TQ was used in our study. The questionnaire was translated from the original by a psychologist and an ENT surgeon independently, both fluent in English and Spanish and were familiarised with Tinnitus. The original and the translated versions were reviewed by a professional translator. The final version of the TQ was considered to have a satisfactory linguistic equivalence with the original English questionnarie.

Statistical Procedures

To explore which questions of the TQ commonly cluster together into distinguishable dimensions of tinnitus-related complaints, the 52 items of the instrument were subjected to a principal components factor analysis. An eigenvalue of 1 was set as the criterion for the num-ber of factors to be extracted and the factors were subjected to varimax rotation. In order to find significant differences between the three different groups non-parametric tests were used.

Results

A factorial analysis was performed using principal factoring with interaction, and the results were subjected to varimax rotation. The rotated results were: ten factors with eigenvalues greater than 1, extracted from each analysis, accounting for over 80 % of the variance. As in previous reports, Tinnitus com-plaint report was found to be multifactorial, factors were orthogonal, that means that subject’s position on one factor does not predict his position on any other factors. There are 2 factors related to general complaints about tinnitus, which were named similarlly to those obtained by Jakes et al. [16], ‘Distress due to tinnitus’ and ‘Intrusiveness of tinnitus’. Three other tinnitus complaint factors were named ‘Hearing Loss’, ‘Tinnitus Evolution’ and ‘Interference of Tin-nitus’. Other factors were also obtained which were not clearly ascribed to any tinnitus specific complaint. The 5 most important factors are briefly described below, in order of extraction. Fac-tor 1 (‘Interference due to Tinnitus’), explaining 20,7% of the variance, is loaded by items concerning how tinnitus can interfere over different situations as watching TV, reading, lis-tening to music or concentration. Factor 2 (‘Distress due to Tinnitus’) accounts for 12,7% of the variance, is loaded by items measuring effects of tinnitus on mood, how awareness and distracting affects the subject. Factor 3 (‘Intrusiveness of Tinnitus’) explaining 9,7% of the variance is loaded highly by items that measure how unpleasant and how it may result into an inability to cope with it. It also includes other items that measure the effects of tinnitus over family, social life and work. Factor 4 (‘Hearing Loss’) it explains the 8,8% of the variance and it loaded by items related to audition and not by any tinnitus complaint variables. Factor 5 (7,7% of variance) is related to how tinnitus has been getting worse over time and other audi-ological items as how noise-exacerbated tinnitus.

In order to find significant statistic differences in tinnitus complaint behaviour between the groups, we carried out a comparison of the score obtained in the 10 factors reported with the present questionnaire. No significant differences were obtained between the groups on 9 out of 10 factors of the TQ. Significant differences were found only between the NH and NIHL groups[Chi2(2)=7,24 pó0,0267]in factor 10. This difference may be ascribe to the high loading value of item 34 related to noisy job situa-tions.

Discussion

In order to assist the clinician to identify the nature and severity of complaints about tinnitus, several questionnaires have been developed. The Tinnitus Questionnaire (TQ), from Hallam et all. [15], is an instrument which provides a broad description from both factor analysis and clinical evidence. The factorial structure of this test has been replicated in different studies by Hiller et al.[10]. In this prileminary study we have carried out a replication of the first version of the TQ developed by Jakes et al. [16] in order to determine the factorial structure in a dif-ferent independent population. In addition, we have compared the results obtained by the three groups of tinnitus patients with different audiological characteristics. This study reproduced the same three main dimensions of tinnitus complaint obtained by previous studies [10-14-15-16] ; although some minor differences were found in the item composition of factors. The first main dimension has a great relation with emotional distress and appears to be composed of items indicating anxious or depressed mood and associated thoughts. The other two main dimensions reflect a stable pattern of auditory perceptual diffi-culties. As in previous studies, it can be stated that items indicative of emotional distress are relatively independent of items indicating difficulties of sensory and perceptual nature. The most interesting finding is that the sleep disturbance found in previous studies associated to chronic tinnitus suffers [10-14-15-16] has been found as a minor relative problem in our sub-jects.

This report failured to show significant differences in the questionnaire score obtained between tinnitus subject with normal hearing, with hearing loss not induced by noise and with noise induced hearing loss. Emotional distress and perceptual auditory difficulties are found as a common complaint of all tinnitus sufferers.

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