Characteristics of tinnitus with or without hearing loss: Clinical observations in Sicilian tinnitus patients

Auris Nasus Larynx 37 (2010) 685–693 www.elsevier.com/locate/anl

Characteristics of tinnitus with or without hearing loss: Clinical observations in Sicilian tinnitus patients Francesco Martines a,*, Daniela Bentivegna b, Enrico Martines b, Vincenzo Sciacca c, Gioacchino Martinciglio b a

Universita` degli Studi di Palermo, Dipartimento di Neuroscienze Cliniche (DINeC), Sezione di Otorinolaringoiatria, Via del Vespro 129, 90127 Palermo, Italy b Universita` degli Studi di Palermo, Dipartimento di Biotecnologie Mediche e Medicina Legale (DIBiMed.), Sezione di Audiologia, Via del Vespro 129, 90127 Palermo, Italy c Universita` degli Studi di Palermo, Dipartimento di Matematica e Applicazioni, Via Archirafi 34, 90123 Palermo, Italy Received 12 December 2009; accepted 25 March 2010 Available online 28 April 2010

Abstract Objective: To analyze the clinical characteristics of tinnitus both in normal hearing subjects and in patients with hearing loss. Methods: The study considered 312 tinnitus sufferers, 176 males and 136 females, ranging from 21 to 83 years of age, who were referred to the Audiology Section of the Department of Bio-technology of Palermo University. The following parameters were considered: age, sex, hearing threshold, tinnitus laterality, tinnitus duration, tinnitus measurements and subjective disturbance caused by tinnitus. The sample was divided into two groups: Group 1 (G1) subjects with normal hearing; Group 2 (G2) subjects with hearing loss. Results: Among the patients considered, 115 have normal hearing while 197 have a hearing deficit. There is a slight predominance of males respect to females that is more evidenced in G2 (61.42% of males vs. 38.58% of females). The highest percentage of tinnitus results in the decades 41–50 for G1 and >70 for G2 with a statistically significant difference between the two groups (P < 0.0001). The hearing impairment results in most cases of sensorineural type (74.62%) and limited to the high frequencies (58.50%), moreover the 72.10% of the patients with SNHL had a high-pitched tinnitus while the 88.37% of the patients high-frequency sensorineural hearing loss had a high-pitched tinnitus (P < 0.0001). As for the subjective discomfort, the catastrophic category resulted most representative among subjects with normal hearing with a statistically significant difference between the two groups but no significant correlation was found between the level of tinnitus intensity and the tinnitus annoyance confirming the possibility that tinnitus discomfort is elicited by a certain degree of psychological distress as anxiety, depression, irritability and phobias that do not allow the phenomenon of the ‘habituation’. Conclusion: This work, according to literature data, suggests that the hearing status and the elderly represent the principal tinnitus related factors; moreover tinnitus characteristics differ in the two groups for tinnitus pitch. There is, in fact, a statistically significant association between high-pitched tinnitus and high-frequency SNHL suggesting that the auditory pathway reorganization induced by hearing loss could be one of the main source of the tinnitus sensation. # 2010 Elsevier Ireland Ltd. All rights reserved. Keywords: Tinnitus; Normal hearing; Hearing loss

1. Introduction * Corresponding author at: Via Autonomia Siciliana, 70, 90143 Palermo, Italy. Tel.: +39 091545666; fax: +39 0916554271. E-mail addresses: [email protected] (F. Martines), [email protected] (D. Bentivegna), [email protected] (E. Martines), [email protected] (V. Sciacca), [email protected] (G. Martinciglio).

Tinnitus is an auditory phantom sensation, a ‘‘perception of a sound which results exclusively from activity within the nervous system without any corresponding mechanical, vibratory activity within the cochlea’’ with high prevalence rates in western societies [1–6].

0385-8146/$ – see front matter # 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2010.03.008

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Epidemiological studies showed that about one-third of the population experiences tinnitus at least once in their life and about 1–5% develop serious psychosocial complications; in Italy an epidemiological study based on questions to general population upon auditory dysfunctions evidenced a tinnitus prevalence percentage in 14.5% (8% in normal hearing subjects, 30.5% in presence of auditory dysfunctions) [7] while Girard et al. found a prevalence percentage of 5.2% in 41,631 Canadians [8]. It was estimated that in Germany 1.5 million have problems with tinnitus and 800,000 suffer so severely that they are in continuous medical treatment [9]. The presence of tinnitus progressively increases with increasing age (12% after 60 years of age; 5% in the 20–30 age group), and this is not so much correlated to senescence itself as to the frequent concomitant hearing loss (HL). The tinnitus prevalence in fact increases to 70–85% of the hearing-impaired population [2–6,10–13]. In most cases, despite any appropriate medical examination, the origin of tinnitus is unknown but it is well documented in literature that tinnitus and hearing deficit are often related phenomena. Tinnitus can be also due to other inner ear dysfunctions associated with sudden hearing loss or acoustic trauma, or part of otological and neurological diseases such as Me´nie`re’s disease, acoustic neuroma or severe head injury. Other aetiological factors have emerged from the larger epidemiological studies of tinnitus prevalence and actually they were considered as potential causes of tinnitus and/or co-factors. These factors include conditions such as vascular disease, diabetes, hypertension, autoimmune disorders, and degenerative neural disorders [14,15]. Although tinnitus is commonly associated with hearing loss, other tinnitus cases with normal hearing constitute an important group, but the studies performed up to now on this topic are restricted to hearing tests without considering the tinnitus characteristics [16–19]. A broad consensus within the neuroscience of tinnitus holds that this audiological condition is triggered by central deafferentation, mostly due to cochlear damage. Recently Weisz [20], based on the presence of a deafferentation also in tinnitus subjects with audiometrically normal thresholds, argues that it may be a primitive sign of diseases that are only diagnosed after the onset of hearing loss. Riga et al. [21] suggest that patients with normal hearing acuity who have acute tinnitus seem to have a less effective functioning of the cochlea efferent system. Even if in the last years there was a great consensus among the studies with respect to tinnitus suffered, the knowledge both on tinnitus onset and history, clinical presentation and audiological characteristics is still incomplete. The aim of this study was to focus on patients suffering from tinnitus who were referred to the Audiology Section of Palermo University in order to analyze either the clinical characteristics of tinnitus symptoms both in normal hearing

subjects and in patients with hearing loss and compare the tinnitus features observed in the two conditions, normal hearing and hearing loss.

2. Materials and methods The study was conducted by the Audiology Section of the Department of Bio-technology of Palermo University on 312 subjects, 176 males and 136 females, ranging from 21 to 83 years of age, which suffered from tinnitus. After the personal data all the patients underwent to a careful general medical history to identify tinnitus related pathologies and other health diseases. The subjects with psychotic disorders as schizophrenia and mental retardation were excluded from this study; it followed an ENT specialist history and an otological examination. As to the analysis of data collected, the following parameters were considered: age, sex, subjective judgment of tinnitus intensity (0–5 dB, 5 dB, 10 dB, 15 dB, and >15 dB), tinnitus laterality (unilateral or bilateral), tinnitus duration (acute: 3 months, subacute: 3–12 months, and chronic: >12 months), tinnitus measurements, subjective disturbance caused by tinnitus, normal hearing or associated hearing loss. As to age, patients were divided into six groups: from 21 to 30, 31 to 40, 41 to 50, 51 to 60, 61 to 70 and >70. The audio/vestibular system was studied through laminar audiometry (considering the frequencies 0.5–1– 2–3–4–8 kHz), tympanometry with stapedius reflex, auditory brain stem responses, nystagmography and Vestibular Evoked Miogenic Potentials. If necessary, to identify the cause of tinnitus others specific exams were performed; in particular laboratory studies including hematocrit, blood chemistries, thyroid studies and lipid battery; USG Doppler to value blood flow disturbance in vertebral and basilar artery; middle/inner ear CT study and, suspecting an acoustic neuroma or neurovascular conflict a MRI/Angio CT. The sample was divided into two groups: Group 1 (G1) subjects with normal hearing; Group 2 (G2) subjects with hearing loss. Audiometric threshold was considered as the pure tone average for the frequencies 0.5–1–2–4–8 kHz and divided in: normal hearing (<20 dB); light hearing loss (21–40 dB); moderate hearing loss (41–70 dB); severe hearing loss (71– 90 dB); profound hearing loss (>90 dB). Hearing loss was also divided into three categories: conductive hearing loss; sensorineural hearing loss (high frequency including 4 kHz and 8 kHz; low frequency limited to 250–500 Hz; flat curve) and mixed loss. The audiological measurement of tinnitus included pitch masking (high-middle or low-pitched) was determined matching the frequency of the tinnitus with a variety of stimuli and loudness matching, estimating the loudness of tinnitus with a pure tone or noise; the difference between the

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hearing threshold and the sensation level was considered tinnitus loudness (0–5 dB, 5 dB, 10 dB, 15 dB, and >15 dB above the hearing threshold). To value the perceived severity of tinnitus and its impact on life Tinnitus Handicap Inventory (THI – Newman e coll.) was made. This tool is a 25-item survey that is composed of three subscales: a functional subscale (12 items), an emotional subscale (8 items) and a catastrophic response subscale (5 items) which address role and physical functioning, psychological distress, desperation and loss of control, respectively. Each item has 3 potential answers with ‘‘yes’’ assigned 4 points, ‘‘sometimes’’ 2 points, and ‘‘no’’ 0 points. This leads to a total score ranging from 0 indicating no tinnitus handicap and 100 the worst patients’ annoyance. Classically it grades five categories of tinnitus severity: slight corresponding to a score 0–16; mild (18–36); moderate (38–56); severe (58–76); catastrophic (78–100) [22]. The statistical analysis was performed using the Matlab1 computer programme.

3. Results 312 patients took part to the study, 176 (56.41%) males and 136 (43.59%) females, aged between 21 and 83 with a mean age of 54.86. Among the 312 patients with tinnitus considered, 115 (36.86%) have normal hearing (G1), while 197 (63.14%) have a hearing deficit (G2). The mean age resulted respectively 43.30 for G1 and 61.60 for G2. The highest percentage of tinnitus results in the decades 41–50 for G1 (28/115 corresponding to 24.35%) and >70 for G2 (72/197 corresponding to 36.55%) with a statistically significant difference between the two groups (P < 0.0001). As to sex, the group of normal hearing subjects comprised 55 males (47.83%) and 60 (52.17%) females. The group of patients with tinnitus and associated hearing loss comprised 121 males (61.42%) and 76 females (38.58%). The slight predominance of males compared to females was clearer in G2 (P = 0.011) in which the male gender represented a strong factor related to tinnitus. In 30.77% of cases, it was not possible to correlate the tinnitus with a known etiology; tinnitus was associated with presbiacucis in 47 cases (15.06%), chronic noise exposition in 27 cases (8.65%), acoustic trauma in 12 cases (3.85%), sudden hearing loss in 6 cases (1.92%), middle ear pathology in 35 cases (11.22%), degenerative cochlear disease as Meniere´ and chemotherapeutic toxicity in 26 cases (8.33%). Moreover it was diagnosed in 47 cases a coexisting Eustachian tube dysfunction and a temporomandibular Joint Syndrome in 5 cases. The hearing loss accompanies tinnitus symptoms in 63.14% of patients (G2); the hearing loss was identified as conductive hearing loss in 10.66% of cases, as sensorineural hearing loss in 74.62% of cases and as mixed type in 14.72% of cases. Of 147 patients with sensorineural hearing loss in

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58.50% the hearing loss was limited to high frequencies; in the 11.56% to low frequencies; in 29.93% to a flat loss. As to audiometric threshold observed in G2 it was revealed: light hearing loss in 58.88% of cases, moderate hearing loss in 22.34% of cases, severe hearing loss in 15.74% of cases and profound hearing loss in 3.05% of cases. Tinnitus (Table 1) was referred as unilateral in 187 patients (59.93%) (in the right ear in 44.39% of cases, in the left ear in 55.61% of cases); bilateral in 74 patients (23.71%), and ‘‘in the head’’ in 51 cases (16.35%). In G1 tinnitus was referred as unilateral in 61.73% of cases (in the right ear in 53.53% of cases, in the left ear in 46.47% of cases), bilateral in 21.74% of cases, and in the head in 16.52% of cases; in G2 tinnitus was referred unilateral in 58.88% of cases (in the right ear in 38.80%, in the left ear in 61.20%), bilateral in 24.87% of cases and in the head in 16.24% of cases. Even if there was a slight predominance of unilateral tinnitus, it was not statistically significant (r = 0.543; P = 0.458). As to tinnitus duration, it was presented in acute form in 95 patients corresponding to 30.45% (38.26% for G1; 25.89% for G2), subacute in 42.63% for a total of 133 cases (35.65% for G1; 46.70% for G2) and chronic in 84 subjects with a percentage rate of 26.92% (26.09% for G1; 27.41% for G2). The difference between the tinnitus duration reported by the two groups was not statistically significant (P = 0.839). In most cases (209/312), patients reported their tinnitus as a pure tone in 66.99% (63.48% for G1; 69.03% for G2); in relation to narrow-band in 27.88% corresponding to 87 subjects (32.15% for G1; 25.38% for G2); finally the tinnitus is not identifiable in 16 patients, 5.13% of the total cases (4.35% for G1; 5.58% for G2). The statistical analysis did not evidence differences between the subjective judgment of tinnitus reported by the two groups (P = 0.208); however tinnitus as pure tone resulted a strong factors either for G1 and G2 (r = 0.984). The tinnitus’s frequency, measured by the pitch-matching test, was calibrated to high frequencies (4 kHz, 6 kHz, and 8 kHz) in 172 cases corresponding to 55.13% (44.35% for G1; 61.42% for G2), to middle frequencies (1 kHz, 2 kHz, and 3 kHz) in 56 patients, 17.95% of cases (9.56% for G1; 22.84% for G2), to low frequencies (125 Hz, 250 Hz, and 500 Hz) in 68 subjects with a percentage rate of 21.79% (37.39% for G1; 12.69% for G2) while the tinnitus hue was variable and not identifiable in 5.13% of cases (8.69% for G1; 3.04% for G2). From the statistical analysis showed a significant difference between the two groups (P < 0.0001). The 72.10% of the patients with sensorineural hearing loss had a high-pitched tinnitus while the 88.37% of the patients with high-frequency sensorineural hearing loss had a high-pitched tinnitus (Table 2 and Fig. 1). The loudness of tinnitus, as estimated by acufenometry, was: 0–5 dB above the hearing threshold in 44 patients corresponding to 14.1% (14.78% for G1; 13.70% for G2); 5 dB above the hearing threshold in 28.21% of cases for a

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Table 1 Tinnitus characteristics for G1 and G2. Factors

Tinnitus populations Normal hearing

Sex Male Female

Hearing loss

N

(%)

N

(%)

55 60

(47.83) (52.17)

121 76

(61.42) (38.58)

x2 = 5.458; P = 0.011

x2 = 91.175; P < 0.0001 r = 0.887; P = 0.0184

Age 21–30 31–40 41–50 51–60 61–70 >70

21 26 28 21 14 5

(18.26) (22.61) (24.35) (18.26) (12.17) (4.35)

5 11 16 39 54 72

(2.54) (5.58) (8.12) (19.80) (27.41) (36.55) x2 = 4.319; P = 0.096 r = 0.543; P = 0.458

Tinnitus localization Unilateral right Unilateral left Bilateral Head

38 33 25 19

(33.04) (28.69) (21.74) (16.52)

45 71 49 32

(22.84) (36.04) (24.87) (16.24) x2 = 5.777; P = 0.839 r = 0.250; P = 0.839

Tinnitus duration Acute Subacute Chronic

44 41 30

(38.26) (35.65) (26.09)

51 92 54

(25.89) (46.70) (27.41) x2 = 1.753; P = 0.208 r = 0.984; P = 0.114

Subjective judgment of tinnitus Pure tone Narrow-band Undetermined

73 37 5

(63.48) (32.17) (4.35)

136 50 11

(69.03) (25.38) (5.58) x2 = 35.819; P < 0.0001 r = 0.663; P = 0.338

Tinnitus pitch High-pitched Middle-pitched Low-pitched Undetermined

51 11 43 10

(44.35) (9.56) (37.39) (8.69)

121 45 25 6

(61.42) (22.84) (12.69) (3.04) x2 = 13.072; P = 0.009 r = 0.859; P = 0.028

Tinnitus loudness 0–5 dB 5 dB 10 dB 15 dB >15 Undetermined

17 38 35 22 2 1

(14.78) (33.04) (30.43) (19.13) (1.74) (0.87)

27 50 83 22 2 13

(13.70) (25.38) (42.13) (11.17) (1.01) (6.60) x2 = 8.431; P = 0.031 r = 0.896; P = 0.039

THI Slight Mild Moderate Severe Catastrophic

21 36 30 15 13

(18.26) (31.30) (26.09) (13.04) (11.30)

total of 88 subjects (33.04% for G1; 25.38% for G2); 10 dB above the hearing threshold in 118 cases with a percentage rate of 37.8% (30.43% for G1; 42.13% for G2); 15 dB above the hearing threshold in 44 patients, 14.1% of the total (19.13% for G1; 11.17% for G2);

38 66 49 37 7

(19.29) (33.50) (24.87) (18.78) (3.55)

above 15 dB in 1.28% of cases (1.74% for G1; 1.01% for G2); in 4.48% of cases, 1 case for G1 corresponding to 0.87% and 13 cases for G2 corresponding to 6.60%, it was no able to identify the tinnitus’s loudness (P = 0.009) (Fig. 2).

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Table 2 Tinnitus subjects and SNHL: distribution according to type of SNHL and tinnitus pitch. Tinnitus pitch

High-pitched Middle-pitched Low-pitched Undetermined Total

Sensorineural hearing loss (SNHL)

Total

High frequencies (HF) N

Low frequencies (LF) N

Flat N

N

76 7 2 1 86

– 6 10 1 17

30 9 5 – 44

106 22 17 2 147

SNHL: x2 = 66.1230, f.d. = 6, P < 0.0001; HF vs. LF + Flat: x2 = 29.4, f.d. = 3, P < 0.0001.

Fig. 1. Distribution of tinnitus pitch among populations; G1 + G2: x2 = 35.819, f.d. = 3, P < 0.0001; r = 0.663, P = 0.338; G2: x2 = 21.06, f.d. = 3, P < 0.0001; r = 0.988, P = 0.012; SNHL: x2 = 29.4, f.d. = 3, P < 0.0001; r = 0.996, P < 0.0001.

Fig. 2. Distribution according to tinnitus Loudness (a); ANOVA test (b); correlation index r = 0.8598; P = 0.0281. Mean: normal hearing 8.35 dB  4.5582; hearing loss 8.24 dB  4.0174; confidence interval (CI) = 0.95; P = 0.24.

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Fig. 3. Distribution according to Tinnitus Handicap Inventory (a); ANOVA test (b); correlation index r = 0.896; P = 0.039; mean – normal hearing: slight 12.19  2.35; mild 28.11  3.9697; moderate 46.13  4.0999; severe 69.2  4.6475; catastrophic 87.38  4.5375; mean – hearing loss: slight 9.26  2.728; mild 26.72  4.754; moderate 46.24  5.3484; severe 68.37  3.9675; catastrophic 86  3.8297; confidence interval (CI) = 0.95; P = 0.

Regards tinnitus annoyance and its impact on quality of life the THI identified five categories of tinnitus severity: slight grade was found in 59 subjects with a prevalence rate of 18.91% (18.26% for G1; 19.29% for G2); mild grade in 32.69% for a total of 102 cases (31.30% for G1; 33.50% for G2); moderate grade in 79 cases corresponding to 25.32% (26.09% for G1; 24.87% for G2); severe grade was reported by 52 cases, 16.67% of total subjects (13.04% for G1; 18.78% for G2) and catastrophic grade in 6.41% of cases corresponding to 20 patients (11.30% for G1; 3.55% for G2) (Fig. 3). The univariant analysis showed a significant statistical difference between two groups (P = 0.031).

4. Discussion Tinnitus is a multifactorial symptom, which can be induced by all types of hearing loss as well as by somatic and psychiatric disorders and pharmaceutical drugs. Axelsson [23] described different diseases which were accompanied by tinnitus and the main causes leading to tinnitus were suggested. He was able to identify the aetiology of tinnitus in 81% of tinnitus tested. In 26% of cases, Savastano [19] was

not able to correlate the tinnitus with a known etiology or anatomical site. In our study the percentage of undetermined aetiology resulted 30.77%; this high value is due to a high number of chronic tinnitus sufferers examined in which it is more difficult to identify an aetiological factor also for the presence of co-existing psychological disorders associated to tinnitus. As it is confirmed in the present study in which the male prevalence is 56.41%, usually there is a slight predominance of males compared to females (P = 0.011); this prevalence value is more evidenced in tinnitus/hearing loss group (G2) (61.42% of males vs. 38.58% of females), while in G1 the distribution of frequency between male and females is similar (47.83% of males vs. 52.17% of females); Johansson et al., Palmer et al., and Fabijanska et al. [24–26], all reported a minimally higher, but not statistically significant, prevalence for male than for female. One reason for this slight prevalence of men, above all in G2, could be that they are generally exposed more than females to industrial noise and it is well known that chronic noise exposure is the main cause of tinnitus and hearing loss [27]. The epidemiological data have generally supported a strong association of tinnitus with elderly; as it is well

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Table 3 Distribution according to tinnitus intensity and Tinnitus Handicap Inventory. THI (category)

Slight Mild Moderate Severe Catastrophic Total

Tinnitus population

G1 G2 G1 G2 G1 G2 G1 G2 G1 G2 G1 G2

Tinnitus intensity

Total

0–5 dB N

5 dB N

10 dB N

15 dB N

>15 dB N

Undetermined N

N

5 7 5 9 3 6 3 5 1 – 17 27

6 11 11 21 11 9 4 7 6 2 38 50

6 15 12 26 9 20 4 19 4 3 35 83

4 4 8 6 7 10 3 2 – – 22 22

– – – 1 – 1 – – 2 – 2 2

– 1 – 3 – 3 1 4 – 2 1 13

21 38 36 66 30 49 15 37 13 7 115 197

G1: x2 = 29.0385, f.d. = 20, P = 0.0195; G2: x2 = 20.3173, f.d. = 20, P = 0.0615.

known, sensorineural hearing loss in elderly patients relatively often coexists with annoying tinnitus, termed presbytinnitus by Claussen et al. [28]. As reported by Henry et al. [29], Shulman [30], and Zagolski [31], presbytinnitus like presbyacusis is due to pathologic alterations of the auditory pathways, both peripheral and central which in tested population, was progressively more evidenced in seniors. Our study evidenced the highest percentage of total tinnitus population after the age of 70 followed by the decades 61–70 and 51–60 (P < 0.0001). In particular this increase in tinnitus prevalence in older patients is confirmed in the group of subjects with tinnitus and hearing loss (G2) supporting a significant age/hearing loss/tinnitus correlation of data literature [29–31]; among the subjects with normal hearing the highest tinnitus prevalence is evidenced in the decade 41–50 while the elderly population is little suffering. In this study, of a total number of 312 tinnitus sufferers, hearing loss was shown in 63.14% of cases with a high prevalence of sensorineural type (74.62%), supporting the actual theories that a reduction of effective functioning of the auditory afferent system represents the most common cause of tinnitus [32,33]. The sensorineural hearing loss was found, in most cases, limited to the high frequencies (58.50%) and of light-moderate degree (81.22%). These results were also referred by Satar [18], Savastano [19], and Henry [34]; also Nicolas-Puel et al. [27] reported in most cases of the 123 patients studied a high-frequency SNHL. The results of our study show a tinnitus as a pure tone in 66.99% (mean value of 63.48% for G1 and 69.03% for G2) and calibrated to high frequencies in 55.13% (mean value of 44.35% for G1 and 61.42% for G2); moreover the 72.10% of the patients with SNHL had a high-pitched tinnitus while the 88.37% of the patients high-frequency sensorineural hearing loss had a high-pitched tinnitus (x2 = 66.1230, f.d. = 6, P < 0.0001). These results seem to confirm data literature that there is a statistically significant association between high-pitched tinnitus and high-frequency SNHL, suggesting that the auditory pathway reorganization induced by hearing

loss could be one of the main source of the tinnitus sensation [12,35,36]. Fig. 1 shows the significant relationship, statistically significant, between the type of SNHL and the tinnitus pitch. The high percentage value of pure tone tinnitus and limited to high frequencies in normal hearing subjects (respectively 63.48% and 44.35%), similar to hearing loss patients, supports the literature theories that in normal hearing subjects tinnitus may arise from an alteration in the spontaneous activity along the tonotopic axis in the auditory pathway, mostly due to localized damage of outer hair cells (OHC) with intact inner hair cells (IHC), that in a standard audiological evaluation not exhibit a hearing loss [1,18,35,36]. More frequently the subjective judgment of tinnitus intensity was 10 dB above the hearing threshold (37.8%); this value suggests that most patients seek for specialist examination when the symptom is already disturbing (P = 0.009) [37,38]. Moreover there is a slight correlation between the level of tinnitus intensity and hearing threshold (r = 0.859; P = 0.028) (Fig. 2). The data of this work show that 23.08% of the total subjects, according to THI test, have sleep disturbances and difficulty in any daily activity; the difference as to the subjective discomfort reported by the two groups is statistically significant (P = 0.031). The results, in fact, underline that the catastrophic category is most representative among subjects with normal hearing (13 cases corresponding to 11.30% of G1 vs. 7 cases corresponding to 3.55% of G2) demonstrating the possibility that tinnitus discomfort is elicited by a certain degree of psychological distress and somatic attention that do not allow the phenomenon of the ‘habituation’. Moreover, no significant correlation was found between the level of tinnitus intensity measured by matching procedure and the tinnitus annoyance either in G1 or G2 (Table 3). As stated above, it may support the actual theory that the patient reaction to tinnitus cannot be classified as a

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simple function of its psychoacoustic aspects but rather as a complex interaction between acoustic phantom symptoms, somatic attention and depressive symptoms.

5. Conclusions Tinnitus is a distressing symptom, provoking an important decrease in the quality of life in 23.08% of tinnitus sufferers, based on self-report questionnaire, that is strongly correlated to many factors. This work, according to literature data, suggests that the hearing status and the elderly represent the principal tinnitus related factors. Tinnitus characteristics differ in the two groups for the age and tinnitus pitch. The correlation with age is particularly significant in the group of patients with hearing loss, which seems to cause an increase in the incidence of the tinnitus. In most cases tinnitus is high-pitched and it is associated to high-frequency hearing loss with a significant statistical correlation between the two variables. From the THI results the catastrophic category results most representative among subjects with normal hearing but there is no significant correlation between tinnitus intensity and tinnitus annoyance either in G1 and G2 confirming the possibility that tinnitus discomfort is elicited by a certain degree of psychological distress as anxiety, depression, irritability and phobias.

Conflict of interest The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.

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