Management of tinnitus in patients with presbyacusis
http://www.100md.com
《中华医药杂志》英文版
Department of Otorhinolaryngology, Diagnostic and Therapeutic Medical Centre 'Medicina', Kraków, Poland
Correspondence to Olaf Zagólski M.D., ul. Dunin-Wasowicza 20/II/9, 30-112 Kraków, Poland
E-mail: olafzag@poczta.onet.pl
[Abstract] Objective Sensorineural hearing loss in elderly patients (presbyacusis) relatively often coexists with annoying tinnitus, called presbytinnitus (PT). The purpose of this study was to evaluate the patient based outcome of fitting with hearing aids in patients with PT.Methods 33 subjects with PT aged 60~89 years were fitted with hearing aids and questioned about subjective hearing results. Assessment tools included comprehensive audiology and a subjective self-assessment survey of tinnitus characteristics. Results All patients had very good tolerance of the hearing aids. 28 of them declared to have had considerable reduction in PT intensity. Conclusions Fitting PT patients with hearing aids is usually effective. In patients with unilateral sensorineural hearing loss and tinnitus, fitting the impaired ear is sufficient. Individuals with bilateral complaints require bilateral fitting. Effectiveness of fitting in the discussed group of patients depended on speech discrimination scores prior to fitting. The improvement scores were higher in patients with more aggravated symptoms and did not depend on history of prolonged exposure to excessive noise.
[Key words] tinnitus； presbyacusis；presbytinnitus； elderly patients
INTRODUCTION
Sensorineural hearing loss in elderly patients (presbyacusis, PA) results from atrophy of hair cells in the organ of Corti, degeneration of nerve fibres in the cochlear ganglion and the cochlear nuclei, impaired blood supply of the spiral ligament and the vascular stripe, atrophy of the spiral ligament and rupture of the cochlear duct[1]. Many individual cases of PA do not separate into a specific type but have mixtures of these pathologic types[1]. About 11% patients with PA complain of annoying tinnitus[2~4], called ‘presbytinnitus' (PT)[2,5], reflecting cochleovestibular dysfunction[6], in many cases being a stable, high-pitched whistling[7]. PT is a significant interdisciplinary therapeutic problem[8]. The two types of PT are as follows: type I: PT develops as a primary initial complaint in association with a preexisting high-tone sensorineural hearing loss; type II: the PT history is long-standing, with a recent exacerbation, significant preexisting sensorineural hearing loss, subjective hearing loss, deterioration in speech discrimination and significant systemic complaints[2,5,6]. The management of PT is challenging. Statements that there is nothing that can be done are very inappropriate and should be avoided[9~12]. Tinnitus characteristics are assessed using detailed questionnaires[8]. Many elderly individuals suffering from PT have also different grades of hearing loss, therefore the aims of sound therapy obtained in normally hearing subjects by tinnitus generators can be accomplished by fitting individuals complaining of PT with hearing aids that amplify the level of background noise reducing the perception of PT[7,8].
The purpose of the study was to evaluate the patient based outcome of fitting individuals suffering from PT with hearing aids, in particular:
1.To assess impact of fitting on tinnitus management in the discussed group of patients.
2.To decide if the fitting should be unilateral or bilateral.
3.To determine prognostic factors of successful fitting.
MATERIALS AND METHODS
33 patients aged 60~89 years (mean=71, SD=6.3), 22 women and 11 men who had never been fitted with hearing aids before, were chosen for the study from a group of 121 elderly patients (aged 60 years or more) with PA or tinnitus. Subjects included in the study were exclusively those who suffered from tinnitus at least as much as from the hearing loss. Each individual had complete audiological examination. Patients with mixed hearing loss and hyperacusis were excluded from the study. In evaluation of tinnitus characteristics, each patient was asked to compare the tinnitus to a pure tone or noise in order to assess its pitch. The intensity of tinnitus was evaluated at the loudness level when the tone or noise stimulating the impaired ear masked the patient's tinnitus. Each patient was asked to fill in a questionnaire answering a set of questions concerning the history of the symptoms. The intensity of tinnitus and its impact on the subjects' life were evaluated along a scale ranging from 0 to 10 in a sound-proof room. All patients were subsequently fitted with hearing aids. The reduction of tinnitus intensity was calculated by subtracting the intensity score obtained after fitting from the score prior to fitting. 16 of the examined individuals gave a history of prolonged exposure to excessive noise. 5 individuals were diagnosed type I PT, the remaining 28 - type II PT. Results obtained in groups with tinnitus pitch below and from 2000 Hz, type of the PT, time of complaints below and from 5 years, positive and negative history of exposure to extensive noise (at least 5 years of exposure to noise at 90 dB or louder at least 3 hours a day), age below and from 70 years, subjective tinnitus intensity below and from 40 dB, with lowest hearing pure-tone threshold below and from 4000 Hz, and between groups of patients who had speech discrimination below and from 80% prior to fitting, were compared. To determine if there were significant differences between the improvement scores and the variables, an unpaired t-test was performed. Spearman's correlation coefficients were calculated to determine whether there were significant relationships between variables. All subjects signed an informed consent before being included in the study. The plan of the study was approved by the Local Ethical Committee. The tenets of the Helsinki declaration were followed.
RESULTS
22 patients compared intensity of their tinnitus to sounds at 40 dB and louder. In 21 subjects the tinnitus pitch was equal or higher than 2000 Hz. The awareness of tinnitus varied from 20% to 100% of the daytime. Tinnitus had considerable impact (5 and more points) on rest in 19, on sleep in 17 and on work in 4 individuals. 8 patients had speech discrimination scores below 80% in the verbal test performed prior to fitting. Tinnitus intensity decreased after fitting in 28 patients. 18 of them did not perceive tinnitus while wearing hearing aids. 22 subjects with bilateral complaints required bilateral fitting. 11 individuals with unilateral tinnitus were fitted with one hearing aid each. In 5 patients the tinnitus attenuated while wearing the fitting. All individuals with PT had pathological results of otoacoustic emissions (TEOAE reproduction scores below 70% at the frequency range 2 to 4 kHz).20 patients with bilateral tinnitus declared ‘shifting’ of the tinnitus towards the unfitted ear while wearing only one unit. Statistical significance of relationships between improvement scores and the tinnitus intensity prior to fitting, and improvement scores and speech discrimination scores prior to fitting was confirmed. Correlation was significant for the hearing loss at the tinnitus frequency and intensity of the tinnitus (Table 1).
Table 1 Conditions of Successful Tinnitus Management in the Examined Group
N.s. - no significance
DISCUSSION
Correlation between hearing threshold elevation scores at tinnitus frequency and tinnitus intensity (dB), together with the results of otoacoustic emissions, could confirm that the main defect causing both PA and PT sensory component was cochlear damage. The fact that in some patients in the discussed group the improvement was not satisfactory, or there was no improvement, could be explained by more complex aetiology of the complaints in those individuals. Degenerative changes might have involved not only the cochlea, which was confirmed in otoacustic emissions recordings, but also retrocochlear parts of the auditory pathway (low scores of speech discrimination, being a very sensitive test for pathologies of the central segments of the auditory pathway)[1]. Interference in speech discrimination was observed by Shulman particularly in type II PT[6]. In patients with subjectively louder tinnitus, areas of impaired hair cells are most probably wider than in individuals with minor complaints. Background noise supplied by the hearing aids influences greater amount of the hair cells, giving significantly greater improvement in those subjects than in patients with subjectively quieter tinnitus, which was observed in the discussed group of patients. Rosenhall[3] proved that a lifetime of exposure to noise is likely to have negative effects on the hearing, but the interaction between noise-induced hearing loss and age-related hearing loss is difficult to determine. The most commonly accepted assumption is a simple accumulating effects of noise and ageing on the hearing, particularly on cochlear pathology[3]. No difference between results obtained in subgroups of patients with positive and negative history of prolonged exposure to excessive noise may be explained by the fact that, like in PA, noise induced damage of the auditory pathway structures is observed most frequently within the cochlea[3]. Ueda[13] noted high pitch tinnitus (above 4000 Hz) both in PA and noise deafness. Therefore, if the main functional defect causing tinnitus is the organ of Corti dysfunction (pathological recordings of otoacoustic emissions, 100% speech discrimination), fitting the patient with hearing aids could be effective for PT.
CONCLUSIONS
The results of the study confirm effectiveness of fitting the majority of patients with presbytinnitus with hearing aids.
In patients with unilateral sensorineural hearing loss and tinnitus, fitting exclusively the impaired ear was effective. Individuals with bilateral complaints required bilateral fitting.
Effectiveness of fitting in the discussed group of patients depended on speech discrimination scores prior to fitting. The improvement scores were higher in patients with more intense tinnitus. The improvement scores and tinnitus characteristics did not correlate with history of prolonged exposure to excessive noise.
REFERENCES
1. Schuknecht HF, Gacek MR. Cochlear pathology in presbycusis. Ann Otol Rhinol Laryngol,1993, 102: 1-16.
2. Podoshin L, Ben-David J, Teszler CB. Pediatric and Geriatric Tinnitus. Int Tinnitus J,1997, 3: 101-103.
3. Rosenhall U. The influence of ageing on noise-induced hearing loss. Noise Health,2003, 20: 47-53.
4. Nagel D, Drexel MK. Epidemiologic studies of tinnitus aurium. Auris Nasus Larynx,1989, 16,Suppl 1: 23-31.
5. Claussen CF, Kirtane MV. Randomisierte Doppelblindstudie zur Wirkung von Extractum Ginkgo biloba bei Schwindel und Gangunsicherheit deslteren Menschen. In CF Claussen (ed), Presbyvertigo, Presbyataxie, Presbytinnitus. Berlin: Springer Verlag, 1985，103-115.
6. Shulman A. Specific Etiologies of Tinnitus. The aging process. In A Shulman, Tinnitus Diagnosis and Treatment (2nd ed), Philadelphia: Lea & Febiger, 1991，382-387.
7. Nicolas-Puel C, Faulconbridge RL, Guitton M, et al. Characteristics of tinnitus and etiology of associated hearing loss: a study of 123 patients. Int Tinnitus J, 2002,8: 37-44.
8. Oliveira CA, Venosa A, Araujo MF. Tinnitus program at Brasilia University Medical School. Int Tinnitus J, 1999, 5: 141-3.
9. Szymiec E, D?browski P, Banaszewski J, et al. The problem of tinnitus in patients with presbyacusis. Otolaryngol Pol,2002,56: 357-60.
10. Henry JA, Jastreboff MM, Jastreboff PJ, et al. Assessment of patients for treatment with tinnitus retraining therapy. J Am Acad Audiol, 2002, 13: 523-44.
11. Shulman A. Tinnitology, Tinnitogenesis, Nuclear Medicine, and Tinnitus Patients. Int Tinnitus J, 1998,4: 102-108.
12. Ueda S. Treatment of tinnitus with intravenous lidocaine. Nippon Jibiinkoka Gakkai Kaiho, 1992, 95: 1389-97.
13. Ueda S, Asoh S, Watanabe Y. Factors influencing the pitch and loudness of tinnitus. Nippon Jibiinkoka Gakkai Kaiho,1992,95: 1735-43.
14. Rosenhall U, Karlsson AK. Tinnitus in old age. Scand Audiol, 1991,20: 165-71.
(Editor Jaque)(Olaf Zagólski)
Correspondence to Olaf Zagólski M.D., ul. Dunin-Wasowicza 20/II/9, 30-112 Kraków, Poland
E-mail: olafzag@poczta.onet.pl
[Abstract] Objective Sensorineural hearing loss in elderly patients (presbyacusis) relatively often coexists with annoying tinnitus, called presbytinnitus (PT). The purpose of this study was to evaluate the patient based outcome of fitting with hearing aids in patients with PT.Methods 33 subjects with PT aged 60~89 years were fitted with hearing aids and questioned about subjective hearing results. Assessment tools included comprehensive audiology and a subjective self-assessment survey of tinnitus characteristics. Results All patients had very good tolerance of the hearing aids. 28 of them declared to have had considerable reduction in PT intensity. Conclusions Fitting PT patients with hearing aids is usually effective. In patients with unilateral sensorineural hearing loss and tinnitus, fitting the impaired ear is sufficient. Individuals with bilateral complaints require bilateral fitting. Effectiveness of fitting in the discussed group of patients depended on speech discrimination scores prior to fitting. The improvement scores were higher in patients with more aggravated symptoms and did not depend on history of prolonged exposure to excessive noise.
[Key words] tinnitus； presbyacusis；presbytinnitus； elderly patients
INTRODUCTION
Sensorineural hearing loss in elderly patients (presbyacusis, PA) results from atrophy of hair cells in the organ of Corti, degeneration of nerve fibres in the cochlear ganglion and the cochlear nuclei, impaired blood supply of the spiral ligament and the vascular stripe, atrophy of the spiral ligament and rupture of the cochlear duct[1]. Many individual cases of PA do not separate into a specific type but have mixtures of these pathologic types[1]. About 11% patients with PA complain of annoying tinnitus[2~4], called ‘presbytinnitus' (PT)[2,5], reflecting cochleovestibular dysfunction[6], in many cases being a stable, high-pitched whistling[7]. PT is a significant interdisciplinary therapeutic problem[8]. The two types of PT are as follows: type I: PT develops as a primary initial complaint in association with a preexisting high-tone sensorineural hearing loss; type II: the PT history is long-standing, with a recent exacerbation, significant preexisting sensorineural hearing loss, subjective hearing loss, deterioration in speech discrimination and significant systemic complaints[2,5,6]. The management of PT is challenging. Statements that there is nothing that can be done are very inappropriate and should be avoided[9~12]. Tinnitus characteristics are assessed using detailed questionnaires[8]. Many elderly individuals suffering from PT have also different grades of hearing loss, therefore the aims of sound therapy obtained in normally hearing subjects by tinnitus generators can be accomplished by fitting individuals complaining of PT with hearing aids that amplify the level of background noise reducing the perception of PT[7,8].
The purpose of the study was to evaluate the patient based outcome of fitting individuals suffering from PT with hearing aids, in particular:
1.To assess impact of fitting on tinnitus management in the discussed group of patients.
2.To decide if the fitting should be unilateral or bilateral.
3.To determine prognostic factors of successful fitting.
MATERIALS AND METHODS
33 patients aged 60~89 years (mean=71, SD=6.3), 22 women and 11 men who had never been fitted with hearing aids before, were chosen for the study from a group of 121 elderly patients (aged 60 years or more) with PA or tinnitus. Subjects included in the study were exclusively those who suffered from tinnitus at least as much as from the hearing loss. Each individual had complete audiological examination. Patients with mixed hearing loss and hyperacusis were excluded from the study. In evaluation of tinnitus characteristics, each patient was asked to compare the tinnitus to a pure tone or noise in order to assess its pitch. The intensity of tinnitus was evaluated at the loudness level when the tone or noise stimulating the impaired ear masked the patient's tinnitus. Each patient was asked to fill in a questionnaire answering a set of questions concerning the history of the symptoms. The intensity of tinnitus and its impact on the subjects' life were evaluated along a scale ranging from 0 to 10 in a sound-proof room. All patients were subsequently fitted with hearing aids. The reduction of tinnitus intensity was calculated by subtracting the intensity score obtained after fitting from the score prior to fitting. 16 of the examined individuals gave a history of prolonged exposure to excessive noise. 5 individuals were diagnosed type I PT, the remaining 28 - type II PT. Results obtained in groups with tinnitus pitch below and from 2000 Hz, type of the PT, time of complaints below and from 5 years, positive and negative history of exposure to extensive noise (at least 5 years of exposure to noise at 90 dB or louder at least 3 hours a day), age below and from 70 years, subjective tinnitus intensity below and from 40 dB, with lowest hearing pure-tone threshold below and from 4000 Hz, and between groups of patients who had speech discrimination below and from 80% prior to fitting, were compared. To determine if there were significant differences between the improvement scores and the variables, an unpaired t-test was performed. Spearman's correlation coefficients were calculated to determine whether there were significant relationships between variables. All subjects signed an informed consent before being included in the study. The plan of the study was approved by the Local Ethical Committee. The tenets of the Helsinki declaration were followed.
RESULTS
22 patients compared intensity of their tinnitus to sounds at 40 dB and louder. In 21 subjects the tinnitus pitch was equal or higher than 2000 Hz. The awareness of tinnitus varied from 20% to 100% of the daytime. Tinnitus had considerable impact (5 and more points) on rest in 19, on sleep in 17 and on work in 4 individuals. 8 patients had speech discrimination scores below 80% in the verbal test performed prior to fitting. Tinnitus intensity decreased after fitting in 28 patients. 18 of them did not perceive tinnitus while wearing hearing aids. 22 subjects with bilateral complaints required bilateral fitting. 11 individuals with unilateral tinnitus were fitted with one hearing aid each. In 5 patients the tinnitus attenuated while wearing the fitting. All individuals with PT had pathological results of otoacoustic emissions (TEOAE reproduction scores below 70% at the frequency range 2 to 4 kHz).20 patients with bilateral tinnitus declared ‘shifting’ of the tinnitus towards the unfitted ear while wearing only one unit. Statistical significance of relationships between improvement scores and the tinnitus intensity prior to fitting, and improvement scores and speech discrimination scores prior to fitting was confirmed. Correlation was significant for the hearing loss at the tinnitus frequency and intensity of the tinnitus (Table 1).
Table 1 Conditions of Successful Tinnitus Management in the Examined Group
N.s. - no significance
DISCUSSION
Correlation between hearing threshold elevation scores at tinnitus frequency and tinnitus intensity (dB), together with the results of otoacoustic emissions, could confirm that the main defect causing both PA and PT sensory component was cochlear damage. The fact that in some patients in the discussed group the improvement was not satisfactory, or there was no improvement, could be explained by more complex aetiology of the complaints in those individuals. Degenerative changes might have involved not only the cochlea, which was confirmed in otoacustic emissions recordings, but also retrocochlear parts of the auditory pathway (low scores of speech discrimination, being a very sensitive test for pathologies of the central segments of the auditory pathway)[1]. Interference in speech discrimination was observed by Shulman particularly in type II PT[6]. In patients with subjectively louder tinnitus, areas of impaired hair cells are most probably wider than in individuals with minor complaints. Background noise supplied by the hearing aids influences greater amount of the hair cells, giving significantly greater improvement in those subjects than in patients with subjectively quieter tinnitus, which was observed in the discussed group of patients. Rosenhall[3] proved that a lifetime of exposure to noise is likely to have negative effects on the hearing, but the interaction between noise-induced hearing loss and age-related hearing loss is difficult to determine. The most commonly accepted assumption is a simple accumulating effects of noise and ageing on the hearing, particularly on cochlear pathology[3]. No difference between results obtained in subgroups of patients with positive and negative history of prolonged exposure to excessive noise may be explained by the fact that, like in PA, noise induced damage of the auditory pathway structures is observed most frequently within the cochlea[3]. Ueda[13] noted high pitch tinnitus (above 4000 Hz) both in PA and noise deafness. Therefore, if the main functional defect causing tinnitus is the organ of Corti dysfunction (pathological recordings of otoacoustic emissions, 100% speech discrimination), fitting the patient with hearing aids could be effective for PT.
CONCLUSIONS
The results of the study confirm effectiveness of fitting the majority of patients with presbytinnitus with hearing aids.
In patients with unilateral sensorineural hearing loss and tinnitus, fitting exclusively the impaired ear was effective. Individuals with bilateral complaints required bilateral fitting.
Effectiveness of fitting in the discussed group of patients depended on speech discrimination scores prior to fitting. The improvement scores were higher in patients with more intense tinnitus. The improvement scores and tinnitus characteristics did not correlate with history of prolonged exposure to excessive noise.
REFERENCES
1. Schuknecht HF, Gacek MR. Cochlear pathology in presbycusis. Ann Otol Rhinol Laryngol,1993, 102: 1-16.
2. Podoshin L, Ben-David J, Teszler CB. Pediatric and Geriatric Tinnitus. Int Tinnitus J,1997, 3: 101-103.
3. Rosenhall U. The influence of ageing on noise-induced hearing loss. Noise Health,2003, 20: 47-53.
4. Nagel D, Drexel MK. Epidemiologic studies of tinnitus aurium. Auris Nasus Larynx,1989, 16,Suppl 1: 23-31.
5. Claussen CF, Kirtane MV. Randomisierte Doppelblindstudie zur Wirkung von Extractum Ginkgo biloba bei Schwindel und Gangunsicherheit deslteren Menschen. In CF Claussen (ed), Presbyvertigo, Presbyataxie, Presbytinnitus. Berlin: Springer Verlag, 1985，103-115.
6. Shulman A. Specific Etiologies of Tinnitus. The aging process. In A Shulman, Tinnitus Diagnosis and Treatment (2nd ed), Philadelphia: Lea & Febiger, 1991，382-387.
7. Nicolas-Puel C, Faulconbridge RL, Guitton M, et al. Characteristics of tinnitus and etiology of associated hearing loss: a study of 123 patients. Int Tinnitus J, 2002,8: 37-44.
8. Oliveira CA, Venosa A, Araujo MF. Tinnitus program at Brasilia University Medical School. Int Tinnitus J, 1999, 5: 141-3.
9. Szymiec E, D?browski P, Banaszewski J, et al. The problem of tinnitus in patients with presbyacusis. Otolaryngol Pol,2002,56: 357-60.
10. Henry JA, Jastreboff MM, Jastreboff PJ, et al. Assessment of patients for treatment with tinnitus retraining therapy. J Am Acad Audiol, 2002, 13: 523-44.
11. Shulman A. Tinnitology, Tinnitogenesis, Nuclear Medicine, and Tinnitus Patients. Int Tinnitus J, 1998,4: 102-108.
12. Ueda S. Treatment of tinnitus with intravenous lidocaine. Nippon Jibiinkoka Gakkai Kaiho, 1992, 95: 1389-97.
13. Ueda S, Asoh S, Watanabe Y. Factors influencing the pitch and loudness of tinnitus. Nippon Jibiinkoka Gakkai Kaiho,1992,95: 1735-43.
14. Rosenhall U, Karlsson AK. Tinnitus in old age. Scand Audiol, 1991,20: 165-71.
(Editor Jaque)(Olaf Zagólski)