A critical analysis of tinnitus measuring methods

Revista Brasileira de Otorrinolaringologia

Azevedo, Andréia Aparecida de¹  Siqueira, Adriana Gomes de¹  Faculdade de Medicina de Valença¹  Universidade Federal do Rio de Janeiro¹  Figueiredo, Ricardo Rodrigues¹  Oliveira, Patrícia Mello de¹ 

关键词: scales;    measurement;    tinnitus.;   

DOI  :  10.1590/S0034-72992007000300019

学科分类：医学（综合）

来源: Associacao Brasileira de Otorrinolaringologia e Cirurgia Cervicofacial

【 摘 要 】

Tinnitus may be defined as a hearing sensation that does not come from outside, seeming to come from one or both ears, or even from the head, without a precise source location1. It is, in fact, a symptom, and not a disease, and according to varied studies, it affects between 14 and 32% of the population, and it may be disabling in up to 5% of the cases2. It may even be a sequela of different pathological processes which are no longer active2.Among the many classifications proposed for tinnitus, the one most accepted today classifies tinnitus into Auditory (caused by alterations in the ear, auditory pathways and auditory cortex) and Para-auditory (caused by vascular and muscle structures near the ear and auditory pathways) 2.Tinnitus physiopathology has yet many gaps of knowledge to be filled, and it is believed that in many cases it is multifactorial2. Among the major theories proposed, we list excitotoxicity2-4, lesions in the efferent system2,5, tectorial membrane collapse6, correlation with pain7 and the activation of psychosomatic and autonomic loops8. It is possible that, in the future, a theoretical model becomes part of these theories.Besides the difficulties brought about by the lack of understanding in physiopathology, there is also some difficulty in measuring tinnitus and, consequently, in assessing therapeutic results9. We still lack a consensus on the ideal methodology to measure tinnitus. It may be extremely subjective and influenced by environmental and psychosomatic factors. Many treatment results with medication and other means of treatment are disputed by the tinnitus measuring criteria employed10,11.In the present paper we intend to carry out a critical analysis of the main methods used today to measure tinnitus.AcuphenometryIt means " to measure acuphens" (tinnitus). This is one of the oldest methods and one of the least employed today. It encompasses a set of audiologic techniques used to try find in tonal audiometry a pure tone similar to the patientÂ’s tinnitus6.According to some authors, it could also be useful in the topo-diagnosis of dysacousia, starting from the idea that conductive dysacousia would generate tinnitus of lower frequencies ("water fall", "ocean waves"); and sensorineural dysacousia would generate higher frequency tinnitus ("cicada", "whistle", "cricket"). Mixed dysacousia would have a varied behavior, generating low or high tinnitus2,6.Acuphenometry is highly dependent on the patientÂ’s intellectual capacity and concentration, including certain skills to perceive sounds of different frequencies. It may work exceptionally well with musicians. It is also greatly examiner-dependent. In cases of unilateral tinnitus, the test is easier, since it compares the tinnitus with the sounds made to the contralateral ear. In bilateral cases, the attempts are gradual and successive, giving the ear higher and lower tones until it comes to one sound that more closely resembles the patientÂ’s tinnitus. Sound masking is necessary in most of the cases6. Most studies classify most of the tinnitus in the higher frequencies, notably between 6 and 8 kHz6.Acuphenometry has the major advantage of allowing for tinnitus monitoring, thus, treatment monitoring; and it also aids in the topo-diagnosis of auditory lesions. However, there are some disadvantages. First, tonal audiometry tries to correlate pure tones and tinnitus, which in many cases is multitonal. Moreover, few patients are able to provide an accurate correlation of their tinnitus with pure tones, even with experienced examiners. Acuphenometry is highly important in the treatment by masking, which is today increasingly less used. In our opinion, for acuphenometry, the cons outweigh the pros in this method.Analogue and Visual Scale (AVS)This is the scale that has been more frequently used in Brazilian tinnitus studies10,12-14. Actually, it is a visual graph used to determine the level of disturbance or discomfort caused by tinnitus, in a scale from 1 to 10. Intensity and discomfort are the most valued items.As the examiner asks the patient to determine in a 1 to 10 scale, how much the tinnitus bothers him/her, without a visual aid (as shown in figure 1), there may be score variations that the patient may attribute to different things, according to the variables related to psychosomatic and intellectual factors. The use of an image produces a visual reinforcement that may be remembered by the patient him/herself.  AVSÂ’s main advantage, besides the visual reinforcement and response standardization, is its very simplicity; such factor may be decisive in intellectually challenged patients. Nonetheless, this same simplicity may be seen as a disadvantage of this method, since it may induce a superficial and variable problem in assessment, and so, ideally, it must be associated with other methods. We believe that for the Brazilian population, this is still the most applicable assessment method.Tinnitus Handicap Inventory (THI)Increasingly, methods that measure not only the direct effects of a disease, but also the effects such disease has on the patientsÂ’ lives have been used15,16. In 1996, Newman, Jacobson and Spitzer published an article about the development of the Tinnitus Handicap Inventory, through the observation and criticism of other methods such as the Tinnitus Handicap/Support Questionnaire, Tinnitus Effect Questionnaire, Tinnitus Severity Questionnaire and Tinnitus Reaction Questionnaire15. According to the authors, their main goal was to create a method with the following characteristics:•Summarized, adequate to daily clinical practice;•easy deployment and interpretation;•approaching different tinnitus impacts on the patientÂ’s life quality;•validity and reliability.Clinical data from tinnitus patients and data from other scales were used in developing the THI. Three major items are assessed by the THI, and they are15:•tinnitus-related function reactions, such as difficulty to concentrate and anti-social behavior;•tinnitus-related emotional reactions, such as anger, frustration, irritability and depression;•tinnitus-related catastrophic reactions, such as despair, hopelessness, fear of "severe disease", loss of control and incapacity to cooperate.Below are the original THI questionnaire (Chart 1), and its interpretation (Chart 2):In our view, in relation to the authorsÂ’ initial proposal, the THI is more complex than the AVS; however still usable in the daily clinical practice. For the Brazilian Population, it may not be of easy application in many situations. As to the tinnitus aspect items used, its validity and reliability leads us to believe it is a valid method is more complex than AVS; however still applicable in routine clinical practice. For the Brazilian population, it may be hard to apply in many situations. As to the items used to approach the numerous aspects related to tinnitus, validity and reliability, we believe it is the most valid method.Hospital Anxiety and Depression Scale (HADS)According to the authors, this scale can be summarized and is of easy use. Its main goal is to separate the psychological aspects from those purely somatic. HADS is made up of 14 items (each with scales from 0 to 3), each subdivided in 11 subscales of 11 items each, assessing aspects related to anxiety and depression18.In our opinion, this scale, besides being relatively complex, evaluates only the tinnitus psychosomatic aspects, thus being incomplete.Tinnitus Disturbance Simplified Scale Analysis (TDSSA)Seeking a simplified method to quantify tinnitus, prioritizing aspects related to the patientÂ’s daily life that is affected by the tinnitus, we developed this scale in 2004.Our proposal considers individual characteristics and occasional psychological alterations found in patients with tinnitus19. It stems from the clinical observation of outpatient ward patients and those patients who participated in the 1st PAZ (Tinnitus Self-Help Program), held in Volta Redonda, in 20024. In this program, we held talks by otorhinolaryngologists, hearing therapists and physical therapists, also patient integration with reports from their individual experiences regarding their tinnitus, based on other similar groups, including the GAPZ (Tinnitus PatientsÂ’ Support Group), pioneer in Brazil, at the Federal University of São Paulo2.The scale classifies the degree of discomfort caused by tinnitus from 0 to 10, according to the following characteristics19:(1) Tinnitus perceivable only in silent environments, not interfering with sleep patterns;(2) Tinnitus perceivable only in silent environments, makes the patient, at least occasionally, to have trouble falling asleep, does not lead the patient to seek medical help in order to get prescriptions for sleeping pills;(3) The same situation above mentioned, but here the patient seeks medical help to get prescriptions for sleep inducing medication;(4) Tinnitus perceivable during the day, easily masked by environmental noise;(5) Tinnitus perceivable during the day makes the patient avoid silent environments;(6) Tinnitus perceivable during the day, causing emotional instability/irritability;(7) Tinnitus interferes with professional, schooling and/or domestic activities, reducing performance in general;(8) Tinnitus causing reclusion and anti-social behavior (isolation, aggressiveness, etc.);(9) Tinnitus causing hospital admittance for psychiatric reasons;(10) Tinnitus makes the patient consider drastic actions, such as inflicting deafness, cutting the ear off and suicide.In type 2 tinnitus, the symptom draws the patientÂ’s attention, however, often times he/she does not seek medical help. Starting on type 3, patients usually seek medical care. From type 5 on, associated psychological alterations become increasingly more important. In the extreme

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