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After summarizing the neurophysiological aspects of whiplash injury, the author proposes a guide for neurootological evaluation in relation to the pathophysiology of the injury.
The legal redress for bodily injury goes back to the very ancient concept of "an eye for an eye and a tooth for a tooth." It is really a kind of revenge fee for bodily damage. We suggest a guide for the neurootological approach to patients suffering from whiplash injury. Whiplash-associated disorders (WAD) should be distinguished from sprained neck, traumatic disk protrusion, and damage to cord and nerve roots. The so-called posterior cervical sympathetic syndrome of Barre is a disputed cause of vertigo arising from cervical lesions. Hinoki (first in 197 1 and then in detail in 1985) [2, 3] proposed a hypothesis in which the hypothalamus occupied a fundamental place to explain vertigo due to whiplash injury. Abnormal centripetal impulses arising from the injured cervical soft tissues may ascend along the spinoreticular tract to the brain stem. Furthermore, this tract changes neurons in the medulla oblongata, the pons, and the midbrain and terminates in the superior colliculus. The reticulospinal tract also originates in the brainstem reticular formation of both the medulla oblongata and the pons and is connected to the somatomotor cells in the ventral column. The cerebellum is, of course, involved in the development of this type of vertigo, as it is connected closely to the proprioceptors of the cervical and lumbar regions and to the brain stem (Fig.
Posture tests can be used to examine static or dynamic posturography (or both); several systems exist. As we have written in the report of the first meeting of the European Federation of Otorhinolaryngologic Societies [7], a great discordance exists not only between the members of the medical profession but between the rules and laws concerning disability throughout Europe.
Presented at the Twenty-Seventh International Congress of the Neurootological and Equilibriometric Society, Bad Kissingen, Germany, March 23-26,2000. How to cite this article Nicolas-puel C, Akbaraly T, Lloyd R, Berr C, Uziel A, Rebillard G, Puel J, et al. We undertook this prospective study with 555 patients attending a specialist tinnitus clinic at University Hospital, Montpellier, France, between 1998 and 2003.
The semiological analysis of tinnitus covered several parameters, and each patient completed a questionnaire. For spatial localization, patients were asked to describe their symptoms as being either left- or rightsided or as nonlateralized. Intensity was measured on a visual analog scale graded from 0 to 100, where 0 corresponded to an absence of tinnitus and 100 indicated the loudest tinnitus imaginable. We considered the length of history, age at presentation, intensity of the tinnitus, and any associated hearing loss as continuous variables. Table 1 details the population that was seen within a specialist tinnitus clinic (N = 555). Generally, patients were able to describe the circumstances in which they noticed the appearance of their tinnitus (Table 2). Analysis of the audiograms of the tinnitus patients showed a predominantly left-sided hearing loss, particularly in the higher frequencies (data not shown).
In this study, we focused on those patients who said that the onset of their tinnitus began after noise trauma. Whereas in the overall population patients showed a mainly left-sided high-frequency hearing loss ( > 4,000 Hz), patients in the noise trauma population had similar hearing loss in each ear (Fig. Our study, undertaken in the context of a specialist tinnitus clinic at the University Hospital, Montpellier, shows that tinnitus affects both genders equally. In contrast to other tinnitus patients, those with a history of noise trauma demonstrated similar hearing losses in each ear and showed no difference in side of lateralization or nonlateralization of their tinnitus.
In this study, almost all the patients who had a history of noise exposure said that their tinnitus was of a highpitched whistling frequency. In this study, we evaluated the intensity of tinnitus after noise trauma by using a visual analog scale. The vast majority of patients with noise trauma described their tinnitus as high-pitched and stable over time. This study shows that noise trauma appears to provoke a high-pitched whistling tinnitus that is stable over time, occurs in either ear, and usually appears in men who are, on average, younger than the general tinnitus population. The authors thank the Fond d'Aide a la Qualite des Soins de Ville Languedoc-Roussillon for his support in statistical analysis of the data.
INTRODUCTION: The general consensus on the roles of hearing loss in triggering tinnitus seems not applicable in patients with normal hearing thresholds. OBJECTIVE: To scrutinize auditory functioning in a sample of tinnitus subjects with normal hearing thresholds and non-tinnitus normally hearing control participants using transient evoked and distortion product otoacoustic emission (TEOAE and DPOAE) and Threshold Equalising Noise (TEN) test.
METHODS: Twenty-seven tinnitus adult patients with normal hearing thresholds and 27 normally hearing volunteers were tested with TEOAE, DPOAE and TEN test. CONCLUSION: These results suggest the possible existence of subtle auditory deficit in normally hearing tinnitus patients, which may be an early sign of diseases that are only diagnosed after the onset of hearing loss. Keywords: coustic neuroma, otoacoustic emissions, tinnitus, threshold equalising noise test. Tinnitus is defined as the perception of sound that results completely from activity within the nervous system without any corresponding mechanical, vibratory activity within the cochlea, and not related to external stimulation of any kind1. An increasing amount of epidemiology studies provide both self-reported data on tinnitus and hearing status which allows closer examination on the relationship between tinnitus and hearing status.
Although some studies have different theoretical assumptions and approaches, the significance of hearing loss in tinnitus generation is not questioned. Thus, several attempts have been made to explain pathophysiology mechanisms of tinnitus in patients with normal hearing ability particularly using otoacoustic emissions (OAEs). Several studies have revealed that TEOAEs and DPOAEs can be used as a tool to detect early hearing loss before it can be diagnosed by PTA13-15.
The contradict findings from previous research motivates researchers to find alternative theories to explain tinnitus mechanisms in tinnitus patients with normal hearing thresholds.
This study investigated 27 tinnitus subjects (42 tinnitus ears and 12 contralateral non-tinnitus ear) with normal hearing thresholds who were recruited from Welsh Hearing Institute, University Hospital of Wales. Full history taking and otoscopy examination were carried out at the beginning of the session. TEOAEs test was performed using unfiltered clicks of 80 µs duration presented in non-linear modes. The stimulus comprised of a pair of primary pure tones (f1 and f2) at a frequency ratio equal to 1.22. The basic principle of this test is to control for "off-frequency listening" from occurring by using a broad band noise (the threshold equalising noise).
This research has received the ethical approvals from the School of Applied Community and Health Studies (SACHS), University of Bristol Human Participants Ethics Committee and the South East Wales Research Ethics Committee. Initially, the left and right of DPOAE results were compared within the tinnitus and control groups. Then, the differences of overall mean DPOAE amplitude between tinnitus and control ear were compared. Various hypotheses have been put forward to explain tinnitus generation in normal hearing patients. Decreased TEOAE amplitudes were observed in 35.7% of the tinnitus subjects with normal hearing sensitivity. A statistically significant increase in DPOAE amplitude was observed in tinnitus ears at f2 frequency of 1414 Hz.
The fact that tinnitus patients with normal hearing have a significantly higher percentage of abnormal TEOAEs and a limited frequency of DPOAE than the controls may suggest that OHC dysfunction may be pivotal in tinnitus generation. In the current study, the percentage between abnormal TEOAE and DPOAE in both groups had no statistically significant difference.
In the field of tinnitus, however, only two studies reported the application of TEN(HL) test in tinnitus patients with normal hearing24,25.
Based on systematic review, no research on the application of TEN test in detecting acoustic neuroma has been published.
No published data was found on the application of a TEN test in detecting acoustic neuroma. This study showed that subtle cochlear problem may exist in tinnitus patients before it is significantly appeared in the audiogram. Thanks to University Hospital of Wales, UK for providing the facilities to conduct this research.
This study was supported by the University of Bristol, UK and Ministry of Higher Education (MOHE) Malaysia and Universiti Kebangsaan Malaysia (UKM) as parts of the first author's PhD research.
Paper submitted to the ITJ-SGP (Publishing Management System) on February 17, 2014; and accepted on February 20, 2014.
METHODS: This is a descriptive, cross sectional study of students of the college of medicine, University of Lagos, Nigeria from January to April 2012. Tinnitus is an abnormal perception of sound in the absence of an external mechanical or electrical stimulation1. The objectives of this study are to determine the prevalence of the use of ear phone and subjective tinnitus among the students, and the relationship between the occurrence of tinnitus and use of ear phones in these students. This is a descriptive, cross sectional study of students of the college of medicine, University of Lagos, Nigeria aged 16-35 years; from January to April 2012. Participants (203 males, 185 females) were recruited by stratified random sampling from 14 student hostel blocks. The use of ear phones in this study had a prevalence rate of 95.6%, which is high (Table 2).
This study showed that the most common type of earphone used was insert type - "in the ear" (Table 3); as also found in UK13 and Korea14. A significant difference in prolonged MP3 user listening patterns was found between respondents who had experienced tinnitus and those who had no tinnitus in USA among 28 university students18. Paper submitted to the ITJ-SGP (Publishing Management System) on August 15, 2013; and accepted on September 15, 2013. How to cite this article Olsen US, Lello E, Nagaraj VS, Reimer A, Ibertsson T, Brannstrom J.
OBJECTIVE: The aim of the present study was to examine whether perceived tinnitus severity changes over time, and if so what factors contribute to this change. DESIGN: A modified Swedish version of tinnitus severity questionnaire (MS-TSQ) was used to examine changes in tinnitus severity over a period of time. STUDY SAMPLE: The MS-TSQ questionnaire was completed by 455 subjects visiting an Ear, Nose and Throat (ENT) clinic in Sweden as part of baseline assessment (Sb). CONCLUSIONS: Results provide valuable framework for understanding the factors that affect tinnitus severity over a period of time.
Keywords: duration, hearing loss, modified swedish tinnitus severity questionnaire, psychological treatment, tinnitus severity. Subjective tinnitus is defined as the perceived sensation of sounds by individuals in the absence of any external physical stimulus1. Various factors can trigger the severity of tinnitus such as emotional stress, psychological factors and other physical or mental illnesses.
Many theories and models have been proposed to explain the etiology of tinnitus in individuals with hearing loss and in normal hearing6-8. Previous research has shown that psychoacoustic measurements of tinnitus do not always correlate with how tinnitus affects a person17. There are few studies on how tinnitus severity changes over time and it has been observed that many subjects report to health clinics with questions about the course of tinnitus severity. The subjects sample consisted of a consecutive series of 455 adult subjects who were self-referred to an ENT clinic in Lund, Sweden. The Modified Swedish version of Tinnitus Severity Questionnaire (MS-TSQ) developed by Axelsson and Schenkmanis24 (see Appendix 1 for English version of the questionnaire) was used in the present study. Pearson's correlation coefficient (rho) was used to examine associations between age, improvement, and PTA's.
A one-way ANOVA test was administered to assess significant differences, if any, in age, PTAs (low and high) and improvement in the MS-TSQ scores between the three subject groups. Results indicated that subjects with NH scored the least and subjects with USNHL scored the highest on the baseline MS-TSQ assessment.
Independent-Sample t-test was used to test if there were significant gender and psychological treatment differences in age, PTAs, MS-TSQ baseline, follow-up and difference score.
The purpose of this study was to explore the association between self-reported tinnitus severity and duration between baseline and follow-up assessment, degree of hearing loss, subject groups, age, gender and psychological treatment.
The present study assessed tinnitus severity performance obtained through questionnaires and calculated baseline scores (Sb), follow-up scores (Sf) and difference scores (Sd).
The results of the preset study are in agreement with some of the earlier studies, which conclude that the severity of the tinnitus decreases over time.
Results related to hearing thresholds and tinnitus scores indicated a significant difference in PTAlow between USNHL and NIHL in the right ear. Various studies have been carried out to investigate the effect of psychological treatment on the severity of tinnitus20,21. The present study investigated whether perceived tinnitus severity changes over time, and if so what factors contribute to this change.
Paper submitted to the ITJ-SGP (Publishing Management System) on June 10, 2014; and accepted on September 22, 2014. WAD can be associated with central nervous system lesions, such as postconcussion syndrome. Barre [1] proposed that cervical lesions might irritate the sympathetic vertebral plexus and result in a decreased blood flow to the labyrinth, owing to constriction of the internal auditory artery.
According to Hinoki [2], patients with whiplash injury present with a hypertonicity of the soft supporting tissues of the neck, owing to the overexcitation of the cervical proprioceptors. Among the ascending pathways from the cervical and lumbar proprioceptors to the brainstem, the spinoreticular tract seems to be the most important, as most of its fibers ascend along the lateral fasciculus and the anterior column and terminate in the reticular formation of both the medulla oblongata and the pons. Generally accepted is that the reticular formation of these parts of the brain and of Deiter's nucleus and the superior colliculus are active in both ocular and spinal reflexes related to body equilibrium. As previously mentioned, this tract is thought to have a close relationship with the spinoreticular tract. Anatomical pathways possibly involved in neurootological aspects of whiplash-associated disorders. Such a study would consist of saccadic tests - measures of accuracy, hypermetry, hypometry, latency, amplitude, duration, and peak velocity. A spontaneous nystagmus test would include analysis of eyes open in several directions of gaze and eyes closed and evaluated via electronystagmography (ENG) or videonystagmography (VNG). Gait tests, among others, are effective in vegetative disturbance analysis and in testing corticoequilibrium. Such testing would include tonal audiometry, suprathreshold and speech audiometry, and tests for malingering. Characteristics of Tinnitus in a Population of 555 Patients: Specificities of Tinnitus Induced by Noise Trauma. In this study, we compared tinnitus that appeared to be induced by noise trauma with that perceived to start in other circumstances in a population of 555 patients attending the specialist tinnitus clinic at the University Hospital in Montpellier, France. To do this, we compared tinnitus induced by noise trauma with that induced in other circumstances; we studied a population of 555 patients seen in a specialist tinnitus clinic at University Hospital, Montpellier.
In regard to variability over time, certain patients described their tinnitus either as stable over time or as fluctuating (usually louder at bedtime and on awakening). After otoscopy, audiometry was undertaken for each ear (air conduction, bone conduction, and speech audiometry). We analyzed the description of the sound of the tinnitus, its spatial localization, and the variability of the intensity as noncontinuous variables. We asked the patients to classify their tinnitus with regard to spatial localization and frequency, intensity, variability with time, and duration (Table 4). Pure-tone audiograms in subjects with a history of noise trauma (NT) and those with other ear pathology.
Almost all (98.8%) of these patients said that their tinnitus was of a whistling type (see Table 4). Correlation between the intensity of tinnitus and the hearing loss in those with a history of noise trauma (NT).
In general, the patients seen tended to have a high-pitched hearing loss that is more marked on the left. The majority of tinnitus cases were linked to sound trauma after a concert, an evening at a nightclub, listening to a personal stereo, or using do-it-yourself power tools, in which one would expect both ears to have similar noise exposure. Statistical analysis showed a significant correlation between noise trauma and whistling tinnitus. With this instrument, we significantly correlated the intensity of the tinnitus with the degree of hearing loss between 2,000 and 8,000 Hz.
If the age and gender are accounted for by the source of the noise trauma (concerts, discos, hunting, do-it-yourself tools), the descriptive aspects of tinnitus are strongly correlated with hearing loss as demonstrated by pure-tone audiometry. Measurement of subtle auditory deficit in tinnitus patients with normal audiometric thresholds using evoked otoacoustic emissions and threshold equalizing noise tests. The absence of hearing loss on the audiogram in this group of patients poses a serious challenge to the cochlear theories in explaining tinnitus generation in this group of patients.
For many years, progress towards finding the effective treatments for tinnitus was hindered by vague understanding of its underlying pathologic mechanisms. The association between hearing loss and tinnitus has been well documented in the previous literature2-4. Some studies found a correlation between severity of tinnitus and degree of hearing loss3,8 while others found no such correlation9.
On the other hand, clinical observations have shown that 8 to 10 per cent of tinnitus patients had normal audiometric thresholds12.
It is hypothesised that outer hair cells damage results in stereocilia decoupling from the tectorial membrane, thus causing them to depolarise and subsequently resulting in tinnitus perception1.
An association of tinnitus with the changes in amplitude of TEOAEs and DPOAEs has been reported.
One study by Weisz et al.24 proposed that subtle auditory abnormality may also arise from the inner hair cells (IHCs) dysfunction. The subjects who were attending the Institute from January to December 2010, were identified by an audiology physician and audiologists based in this hospital. Then, all subjects underwent basic audiological tests which include pure tone audiometry and tympanometry.
Off-frequency listening occurs when the presented stimulus is being picked up by other parts of the cochlea instead of the targeted frequency area of the cochlea. From the analysis, the parameters of the TEOAEs for tinnitus ears are not significantly different from the control ears.
Since no statistically significant difference was observed between both ears, further statistical analyses were performed using combined data from both sides together. Distribution of the number of test frequencies with abnormal DPOAE in tinnitus and control ears. Based on the chi-square analysis, tinnitus ears have a statistically significant higher percentage of abnormal DPOAEs at some frequencies, mainly at 2000 and 4000 Hz regions (Table 4).
For example, it has been postulated that the different level of functionality between OHCs and IHCs (the Jastreboff's discordant dysfunction theory) can generate an unbalanced stimulation of dorsal cochlear nucleus's cells which produces abnormal neural activity.
Abnormal DPOAE amplitudes were also found in this group, particularly at high frequency regions, but in a slightly lower percentage than the TEOAE. For example, in Shiomi et al.19, the mean amplitudes of the DPOAE were significantly decreased in tinnitus patients with normal hearing than in normally hearing controls. One possible explanation for this finding is that it may be due to OHCs hypersensitivity, as reported in some previous research.
Abnormal TEOAEs and DPOAE in the tinnitus patients also imply that they may have subtle cochlear damage that is not yet appearing on the audiogram. This finding might suggest that both tests were sensitive to detect minor OHCs dysfunction.
Unexpectedly, the use of a TEN test in the current study has led us to find an acoustic neuroma in a patient. Sincere thanks to Ministry of Higher Education (MOHE), Malaysia, Universiti Kebangsaan Malaysia (UKM) and University of Bristol for providing sponsorship to pursue this PhD study. Program Audiologi, Pusat Pengajian Sains Rehabilitasi, Fakulti Sains Kesihatan - Universiti Kebangsaan Malaysia - Kuala Lumpur - AC - Malaysia. Subjective tinnitus and its association with use of ear phones among students of the College of Medicine, University of Lagos, Nigeria.
A total of 388 willing participants (203 males, 185 females) were recruited by stratified random sampling from the 14 student hostel blocks. More than 90% of the ear phone users had duration of ear phone use of duration of 3 to 6 years. It is a common symptom in otological pathologies suggesting an abnormality in perception which may be subjective or objective.
The prevalence of tinnitus increases directly in persons with high frequency hearing loss; although, the association between severity of tinnitus and degree of hearing loss is very weak1.
However, there is biological variability such that individuals are not affected equally by the same level of noise exposure7. Young adults from anecdotal sources, are fond of noise exposure arising from social exposure, especially use of ear phones for prolonged hours. With increasing media exposure by young people like undergraduates, more time is spent on listening to devices for entertainment: radios, televisions, iPods, laptops and others13. The calculated sample size was three hundred and eighty eight using the Fisher16 formula at a prevalence rate of 30%4,5 with degree of accuracy of 0.05 and non response rate of 20%.
Inclusion criteria were being resident in medical students' hostel, with no active ear disease and giving informed consent.


This finding lies within the limits of global prevalence of tinnitus among adult population of 10% to 33%3,4. This finding agrees with a study in Korea, where 94.3% of adolescents were found to use personal music players14.
It could be because of better appearance and cheaper price of the insert type of ear phones. This was not so in this study as most participants used ear phones and at similar durations. Loud noise may arise from recreational activity or pleasure, like using music players regularly. Nevertheless, the prevalence of subjective tinnitus of 20.6% among the students was within limits of global prevalence of tinnitus. El Dib RP, Silva EM, Morais JF, Trevisani VF, Prevalence of high frequency hearing loss consistent with noise exposure among people working with sound systems and general population in Brazil: a cross-sectional study.
Department of Ear, Nose and Throat - College of Medicine University of Lagos, Nigeria - Lagos - Nigeria. Factors affecting severity of tinnitus - a follow-up study of tinnitus subjects at an Ear Nose Throat clinic in Sweden.
The same questionnaire was completed during follow-up assessment (Sf) by 174 of these subjects to examine changes in tinnitus severity, if any. The sounds associated with tinnitus have been described as ringing, hissing, humming, whistling, etc2. It has been shown that many factors might affect the severity of tinnitus such as hearing loss, depression, anxiety and insomnia4.
A variety of assessment techniques have been designed that reports subjects' tinnitus severity through questionnaires and interviews18,19. These techniques range from providing psychological treatments20,21 to wearing tinnitus maskers6,22 for subjects with tinnitus. For the baseline assessment, subjects were selected from a consecutive sample of 455 adult subjects that visited the clinic between the years 2000 and 2008. The questionnaire covers topics such as quality of life, concentration and effect on sleep quality. Descriptive data including mean, standard deviation (SD) and significance levels (p) are presented in Table 3.
There was a significant difference in PTAhigh for right and left ears between genders, indicating lower hearing thresholds for females than males. Previous studies have indicated that tinnitus patients experience increased tolerance over time20,28,29.
Previous studies have reported no significant differences between subjects with high degree tinnitus and those with mild or moderate annoyance in terms of age, gender or follow-up duration30.
Furthermore, it has been shown that tinnitus annoyance may increase with increasing hearing loss. In the present study, we asked our subjects if they had received treatment from a psychologist.
A modified Swedish version of the tinnitus severity questionnaire was administered to assess changes of tinnitus severity.
Hence, our purpose is not to define a disability scale but to determine whether we believe that a common approach to the medicolegal problem is necessary. Although numerous clinical reports of Barre syndrome have been published, few objective data exist to support an association between episodic vertigo and cervical sympathetic dysfunction. The condition is caused by an excitation of sympathetic beta-receptors in the muscle spindles. However, some fibers of this tract ascend directly to the midbrain and are connected to Deiter's nucleus. Among the descending paths from the brainstem, the median longitudinal fasciculus is important in cases of vertigo, because this tract originates in the brain stem and is connected to both the oculomotor nuclei and the somatomotor cells in the ventral column. Thus, the median longitudinal fasciculus and the reticulospinal tract seem especially important in the development of disequilibrium because of whiplash injury.
A positional nystagmus test would assess with VNG a patient's assumption of sitting, lying, and lateral left and right decubitus positions. Evoked potentials are part of audiological assessment and entail brain stem evoked response audiometry, middle latency response audiometry, and cortical audiometry. Our proposal for a standard battery of tests will be the first step in the right direction. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Observations upon the mechanism of positional nystagmus of the so-called benign paroxysmal type.
Patients had consulted for persistent tinnitus for 7 years from the onset of their symptoms. Taking account of the sound level in discos and clubs and from personal stereos (especially when listened to through headphones), one can anticipate the advent of an entire new generation of tinnitus sufferers.
Also, they were asked for a description of the sound; most patients were able to describe their tinnitus as whistling or buzzing.
Complementary investigations, such as otoacoustic emissions, evoked auditory potentials, videonystagmography, computed tomography, and magnetic resonance imaging scans, were undertaken as necessary to help to diagnose any hearing loss. There was a broad age range of patients, from 11 to 91 years, with the average age at presentation in the clinic being 54 ± 15 years.
Tinnitus was often attributed to ear pathology (34.8%) or, in fewer cases, to another illness (10%).
Within this category were concerts (53%), discotheques (35%), and prolonged use of personal stereos, especially when listened to through headphones (12%). However, the degree of hearing loss was significantly lower than that in patients suffering from other ear pathology (Fig.
Graphs show the average hearing loss in dB (± standard error of the mean) measured in the right ear (R, circles) and the left ear (L, crosses).
Statistical analysis demonstrated a significant correlation between tinnitus precipitated by noise trauma and the perception of it as a whistling type.
In 79.5% of cases, patients described their whistling tinnitus as stable over time (see Table 4). The correlation between tinnitus intensity, as measured on a visual analog scale (white circles), and the hearing loss (black circles) gives a coefficient that becomes greater as the hearing loss becomes greater. From a descriptive point of view, the tinnitus described by the patients in this study was mainly whistling, was stable with time, and was perceived on the left side. This being the case, we propose two hypotheses: (1) Fluctuating tinnitus tends to stabilize after a certain length of time or (2) fluctuating tinnitus may disappear, whereas longstanding tinnitus is stable. Assessing tinnitus and prospective tinnitus therapeutics using a psychophysical animal model. Cisplatininduced hyperactivity in the dorsal cochlear nucleus and its relation to outer hair cell loss: Relevance to tinnitus. Only one patient was found with a positive TEN test result, who was confirmed by Magnetic Resonance Imaging to have acoustic neuroma on the affected ear. The last half of the twentieth century saw considerable advances in our understanding of tinnitus from both physiological and psychological perspectives. It has been generally accepted that any severe damage along the auditory system may lead to a certain degree of hearing loss, which is generally associated with tinnitus5,6. Moreover, the incidence of tinnitus in patients with sensorineural hearing loss varies widely across studies. These observations may have several indications, such as hearing loss is not necessary in tinnitus generation, pure tone audiogram does not always indicate auditory damage, tinnitus may be a primary symptom of diseases that are only diagnosed after the occurrence of hearing loss, or several mechanisms exist in a group of patients. The different functionality of outer and inner hair cells can also cause imbalanced activity in the dorsal cochlear nucleus which in turn causes changes at higher levels of the auditory system that may be perceived as tinnitus1. In some studies, lower amplitude of TEOAEs13,16 or DPOAEs13,17-19 have been observed in tinnitus patients compared to in non-tinnitus controls. All participants had no history or current external and middle ear problem, noise exposure and psychiatric problem. In this experiment, a 2f1 - f2 distortion product was used because of its established clinical value. This off frequency listening occurs when the targeted area of inner hair cells or neurons are not functioning well and is referred to as a dead region27. In this case (Subject RX), the TEN (HL) test revealed that dead regions might exist at 1.5, 3 and 4 kHz on the left ear (Table 7). Since all the subjects in this study had normal hearing, the decrease in the TEOAE and DPOAE finding may possibly be considered as the effect of cochlear dysfunction of the cochlear active mechanism, which is related to OAE generation. Frequency analysis also showed that a significant decrease in DPOAE amplitude was mainly at the f2 frequency of 4000 to 7000 kHz. Therefore, the hearing status of these patients should be monitored for possibility of developing hearing loss later in life. Previous research has clearly demonstrated that OAE may be used to reveal subclinical OHCs damage in audiometrically normal ears13-15. Apart from difficulty hearing in background noise, she did not have any other classical symptoms of acoustic neuroma such as balance problem or poor speech discrimination scores. Firstly, it implies that a TEN test may offer a quick, inexpensive and non-invasive method for retrocochlear screening. In their study, they found 7 out of 8 auditory neuropathy patients with abnormal TEN test results. The finding also supported the possible clinical advantage of the TEN test as a screening tool for retrocochlear problem. Risk factors for tinnitus in a population of older adults: the blue mountains hearing study.
Characteristics of tinnitus and etiology of associated hearing loss: a study of 123 patients. The more the worse: the grade of noise-induced hearing loss associates with the severity of tinnitus. Tinnitus with normal hearing sensitivity: extended high-frequency audiometry and auditory-nerve brain-stem-evoked responses.
The effect of the number of averaged responses on the measurement of transiently evoked otoacoustic emissions in newborns.
Dead regions in the cochlea: diagnosis, perceptual consequences, and implications for the fitting of hearing aids.
Transient and distortion product evoked oto-acoustic emissions in normal hearing patients with and without tinnitus.
DPOAE in estimation of the function of the cochlea in tinnitus patients with normal hearing. Tinnitus and 2f1-f2 distortion product otoacoustic emissions following salicylate overdose. Ten(HL)-test results and psychophysical tuning curves for subjects with auditory neuropathy.
There is dearth of research on the level and nature of usage of PSPs in the youths and the effects of such pleasure sounds on the ear in our environment.
Ethical approval was obtained from the ethics committee of Lagos University Teaching Hospital (LUTH). A study on tinnitus in the elderly in Nigeria5 showed a higher prevalence rate of 41.9% in those aged 80 + years. A population based survey of 18-25 year olds in Nottingham (UK) found a lower prevalence rate of earphone usage of 43.6%13.
Tinnitus was commonest among users of both "in the ear" and head set types of ear phones (32.5%) but there was no statically significant difference in the prevalence rate of tinnitus among the various usage groups (Table 3). Some researchers have found that prolonged exposure to loud pleasure sound over a long period causes hearing related symptoms like hyperacusis, tinnitus and dullness of hearing15,21-23.
The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Latent cochlear damage in personal stereo users: a study based on click-evoked otoacoustic emissions. Epidemiological evaluation of hearing damage related to strongly amplified music (personal cassette players, discotheques, rock concerts)--high-definition audiometric survey on 1364 subjects.
Estimating adolescent risk for hearing loss based on data from a large school-based survey.
Survey of college students' MP3 listening: Habits, safety issues, attitudes, and education. The difference in scores obtained from the two assessments was calculated and was termed as difference scores (Sd).
A previous study by Stouffer et al.5 analyzed the factors responsible for the reduction or enhancement of tinnitus severity on 528 subjects with tinnitus. Most neurophysiologic evidence for tinnitus points to changes in the auditory system in individuals having hearing loss following noise exposure9,10 and over-representation in the cortical tonotopic organization at frequencies having normal hearing thresholds11. These assessment techniques quantify the impact of tinnitus on subjects' everyday life based on baseline and follow-up assessment scores. Forti et al.23 investigated the effect of tinnitus retraining therapy on 45 subjects having idiopathic tinnitus for at least 6 months.
A modified Swedish version of the Tinnitus Severity Questionnaire (MS-TSQ) developed by Axelsson and Schenkmanis24 was used to measure the baseline and follow-up scores for assessment of tinnitus severity in the present study. During this initial visit a medical and audiological examination was performed on all subjects to identify any underlying ear diseases. The MS-TSQ which was used in this study for both baseline and follow up assessment also contains 10 items.
A one-way analysis of variance (ANOVA) was used to examine any significant differences between the groups with different diagnoses regarding age, PTAs, Sb, Sf, and Sd scores. No significant differences were observed among the three groups in the follow-up MS-TSQ score. The effect of psychological intervention on the reduction of tinnitus severity has been shown to be positive. It has been shown that females seem to be at a greater risk for reporting significant tinnitus than males28. In terms of gender differences, it was found that females were less annoyed by tinnitus than males30. Changes in spontaneous neural activity in the dorsal cochlear nucleus following exposure to intense sound: relation to threshold shift. Elevated fusiform cell activity in the dorsal cochlear nucleus of chinchillas with psychophysical evidence of tinnitus.
Changes in spontaneous neural activity immediately after an acoustic trauma: implications for neural correlates of tinnitus.
The relationship between tinnitus pitch and the edge frequency of the audiogram in individuals with hearing impairment and tonal tinnitus. Prevalence and 5-year incidence of tinnitus among older adults: the epidemiology of hearing loss study.
When tinnitus loudness and annoyance are discrepant: audiological characteristics and psychological profile. This referee is the expert: He or she must be neutral and must detail the extent of the lesions. Because intracranial circulation is autoregulated independently of cervical sympathetic control, lesions in the vertebrosympathetic plexus are unlikely to produce focal constriction of the vasculature to the inner ear.
Hinoki [2] has demonstrated the development of granular vesicles at the end of unmyelinated nerve fibers near motor nerve endings of these spindles. The hypothalamus also must play an important role in producing vertigo due to whiplash injury, as most of Hinoki's patients [3] who had vertigo after whiplash injury had various autonomic symptoms, such as lacrimation, abnormal sweating, and palpitation.
Positional nystagmus mainly would involve Hallpike and Rose [4,5] positions with or without VNG.
For further information on the subject, we recommend particularly a book, Whiplash Injuries: Diagnosis and Treatment, written by several members of our society.
Meeting of the First European Conference of the European Society of Otorhinolaryngology, Paris.
Among these tinnitus patients, 17% described their tinnitus as starting after excessive noise exposure. Depending on the variables under analysis, a Student's t-test or chisquared testing was undertaken. In 15.9% of cases, the tinnitus appeared in association with psychological problems, such as emotional trauma, depression, or episodes of stress or anxiety.
Next most prevalent was firearm use (16.2%), the majority related to hunting or shooting as a leisure activity. The intensity of tinnitus perception was significantly correlated with the degree of hearing loss measured between 2,000 and 8,000 Hz. Note that the greatest correlation coefficients occur in the highest frequencies of hearing loss. Although not statistically significant, this latter finding is in accordance with other studies showing that hearing loss and tinnitus are generally more noticeable on the left side [8].
This link correlates with an earlier study on a smaller population showing that a whistling type of tinnitus was correlated with a high-frequency hearing loss and that a buzzing type of tinnitus was correlated with a low-frequency hearing loss [7]. These results agreed with our previous study of 58 patients [7], which showed that the intensity of stable whistling tinnitus is perceived as increasingly strong as the highfrequency loss is more marked. Only a longitudinal study of tinnitus patients will allow us to clarify these hypotheses further.
However, this attempt at categorizing patients' tinnitus as a function of both the etiology and the semiology allows us to evaluate better the medical and psychological treatment of these tinnitus patients. More commonly, various studies have shown that sensorineural hearing loss plays an important role in tinnitus generation. Therefore, the absence of hearing loss on the audiogram in this group poses a serious challenge to the aforementioned theories in explaining tinnitus generation in tinnitus patients with normal hearing. In the study, they investigated the inner hair cells functions in 11 chronic tinnitus patients with normal hearing thresholds using Threshold Equalising Noise (TEN) test and found 8 of them with possible inner hair cells problems. The results were presented as a distortion-product audiogram i.e the amplitude of the 2f1 - f2 DPOAE was plotted against the f2 from 1000 to 6169 Hz.
The broad band noise is designed to produce almost equal masked thresholds over a wide frequency range, for listeners with normal hearing and hearing impairment but without dead regions28. The abnormal TEOAEs in the tinnitus group were present for 1 and 4 kHz mostly, while in the control group, the abnormalities were mostly at 4 kHz. A t-test revealed that with regard to mean amplitude of TEOAE for tinnitus ears, there were no statistically significant differences for all frequencies tested (p > 0.05). Later, the mean amplitude of DPOAE for tinnitus and control ears against the corresponding f2 was compared.
From 20 tinnitus patients with abnormal OAEs, 13 of them exhibit either failed TEOAE or DPOAE results. According to this theory, discordant dysfunction can occur without affecting the audiometric hearing thresholds when the OHCs are partially damaged and where the IHCs are intact. Stated differently, abnormal or poor OAE results may be the indicator of subtle cochlear damage before the abnormality affects hearing sensitivity and appears on the audiogram. Thus, the similar findings indicate that DPOAE measurement can offer a frequency specific measurement for the detection of subtle localised cochlear damage even before affecting pure tone thresholds34.
The high percentage of TEOAE abnormality at 4 kHz for the control ears may suggest that the hearing status of these participants also needs to be monitored. Nonetheless, only the difference between numbers of abnormal TEOAE in tinnitus and control ears reached a statistically significant level. The former study suggested that tinnitus generation in their group of participants may be due to the effect of deafferentation of the neuron. Secondly, tinnitus patients may have a serious problem that triggers the tinnitus perception despite having normal hearing thresholds and normal OAE test results.
Patients with auditory neuropathy are known to have problems with transmission of the auditory signal to the brain, thus abnormal TEN test results in this group of patients were assumed to be due to the neuron dysfunction.
However, more research needs to be carried out in this area in order to support the current finding. For forty three percent of tinnitus sufferers, there is no known cause for their suffering - idiopathic3.
Otoscopy in such a person usually reveals a normal tympanic membrane (unless the patient has had previous middle-ear disease) and the audiogram will often show a dip at around 4-6 kHz in the early stages5.
However; with increasing noise levels above 90 dB SPL a greater proportion of any exposed population will exhibit pathological changes7. This study on tinnitus in students will help to explain any association between recreational noise exposure and tinnitus in our environment.
Aside from the dissimilarity in age of both sample population, this difference could also be attributed to health conditions not found in this study population such as hypertension.
This could be because that study was community based for all ages of randomly selected 5850 households in Nottingham area. Researchers have found "in the ear" type of ear phones to be more hazardous than the head set type10-12.
Previous literature has shown that tinnitus can have a significant impact on the quality of life in terms of altered psychosocial functions. Studies on the effect of noise exposure and tinnitus12 have shown that exposure to occupational noise gave increased odds for tinnitus in subjects with hearing loss.
Axelsson and Ringdahl10 administered a tinnitus questionnaire on a large population of randomly selected adults. Results indicated that the percentage of individuals with tinnitus who reported the disappearance of difficulties in different activities such as concentration, sleep, relaxation, work and social relations improved after the end of therapy.


All subjects underwent audiological and medical examinations to identify any abnormality in the ear condition.
In terms of baseline audiometric assessment, two pure tone averages (PTAs) were calculated - one for the low frequencies (PTAlow consisting of 0.5, 1 and 2 kHz) and the other for high (PTAhigh consisting of 3, 4 and 6 kHz) frequencies. The MS-TSQ items are identical to those of the original TSQ, but the number of response alternatives differs. A post-hoc analysis was conducted using Bonferroni correction to know if significant differences existed between groups. In terms of the improvement in the MS-TSQ scores, the USNHL group obtained significantly lower scores than the NIHL group.
The method of obtaining the responses through questionnaires sent out by mail has generally been shown to obtain a low response rate. A study by Nondahl et al.28 assessed tinnitus severity of subjects with five years in between. The results of the present study observed that females had a higher Sb and Sd scores than males. It is possible that the subjects may only have had a conversation or may have had further follow-up sessions with a psychologist, but those subjects who answered 'yes' in the questionnaire did receive psychological intervention. Also, psychological intervention had an influence on the improvement in tinnitus annoyance in subjects with tinnitus. The vestibuloocular reflex study also would cover head-shaking nystagmus, rotatory tests with ENG or VNG, and caloric analysis according to Dix and Hallpike [4], with ENG and VNG, including the measure of the ocular fixation index as described first by Demanez [6].
The patients who had a history of noise trauma had a symmetrical hearing loss, and no difference was seen in lateralization of tinnitus perception. Approximately 7% of the adult population judge their tinnitus to be sufficiently severe to warrant consulting a doctor [2]. We used chi-squared testing to study any associations between two variables in a class, ANOVA testing to study variables in the same class and continuous variables, and Pearson correlation coefficients to compare two continuous variables.
This difference may be explained by the age difference between the two groups, as the patients exposed to noise trauma were, on average, 10 years younger. In addition, in patients with no history of noise exposure, the hearing loss is significantly greater in the left ear than in the right, at frequencies greater than 4,000 Hz (asterisk). In whichever age group, hearing loss is less obvious in those patients with a history of noise trauma (white symbols) than in those without (black symbols).
It is not easy to compare our results using a visual analog scale with those studies wherein patients are asked to evaluate the frequency and intensity of their tinnitus with an external sound, usually a pure tone generated by an audiometer [12,13]. In addition, such a step allows us to better define those populations that are similar to the experimental models of tinnitus and on which therapeutic strategies are being developed [14-20].
Evidence showed a higher incidence of tinnitus patients with sensorineural hearing loss compared with conductive hearing loss7. In addition, not all individuals with hearing loss experience tinnitus, and not all tinnitus patients have hearing loss. While the theories seem cannot fit in this minority group, evidence obtained from this group may have huge implication for a better tinnitus mechanisms understanding as well as assist in developing and shaping tinnitus management. The studies reported that tinnitus subjects were found to have increased TEOAEs20,21 or DPOAEs22,23 compared with non-tinnitus counterparts.
Thabet25 attempted to replicated the earlier study by investigating 20 normally hearing unilateral tinnitus patients with TEN test and TEOAE.
The presence of DP amplitude was accepted as valid when the signal to + 2 SD noise floor ratio exceeded 3 dB and the absolute DPOAE amplitude was at least - 10 dB SPL at each individual f2. Table 2 shows the normal and abnormal TEOAEs at each frequency tested in both the tinnitus and control group.
Generally, an independent t-test showed no statistically significant differences observed between tinnitus and control ears at all frequencies except for frequency 1414, 4757, 5187 and 6169 Hz (Table 5). Meanwhile, from 16 control ears with abnormal OAEs, 10 ears exhibit either failed TEOAE or DPOAE results. The ABR showed absent wave V at 70 dBnHL in the left ear and normal ABR waveforms in the right ear, which were correlated with the TEN test results, suggesting of abnormal neural function. Therefore, in this current study, we sought to determine whether the measurement of TEOAE and DPOAE may reveal subtle cochlear abnormality in tinnitus patients with normal audiometric thresholds. Although the difference between numbers of abnormal DPOAE in tinnitus and control ears failed to reach a significant level, mean amplitude of tinnitus ears at frequency region of 2000 and 4000 Hz were statistically significantly lower than the control ears. They suggested that it could be the result of reduced afferent input to the central auditory system due to cochlear lesion, thus resulting in a decreased OHC efferent activity and ultimately leading to OHC hypersensitivity.
TEOAE measurement stimulates the whole basilar membrane of the cochlear, which means it gives more global information. Furthermore, dead regions normally exist in those who have hearing thresholds of 60 dB HL and above28.
In other words, even though dead regions normally exist in patients with hearing loss of more than 55 dBHL, normal hearing people can also have a 'dead region' which may be due to retrocochlear abnormality. Similarly, the abnormal result in Subject RX in the current study may also be because of the problem in neurons rather than in the inner hair cells. MRI revealed a large vestibular schwannoma in the left cerebello-pontine angle which was compressiong the brainstem and cisternal portion of the VIIIth cranial nerve.This study showed that subtle cochlear problem may exist in tinnitus patients before it is significantly appeared in the audiogram. Excessive loud sounds (noise) can arise from a variety of occupational and non occupational sources. It will also form a baseline data for further research in understanding tinnitus in young people in developing countries. In such cases, the subjects' response to tinnitus can produce annoyance, mood changes, fear, anxiety and depression - all of which are associated with tinnitus severity3. They also concluded that tinnitus severity increased as a function of number of years since onset. These subjects were mainly exposed to leisure-time noise and had frequent tinnitus but their thresholds were within normal limits. Studies have shown that tinnitus affects a person's well being and can lead to a range of associated problems. Audiological examination consisted of pure tone audiometry supplemented with Auditory Brainstem Response (ABR) and Magnetic Resonance Imaging (MRI) if required. An addition of a response alternative of 'not sure' was added to the already existing four response alternatives in the original TSQ version. Independent samples t-test was used to analyze gender differences and the effect of psychological treatment. No significant differences were observed in the MS-TSQ difference scores between NH and NIHL; and between NH and USNHL groups. Two-hundred and thirty-three patients reported significant tinnitus at the first examination, and 105 patients (45%) reported decreased annoyance during the follow-up assessment.
Also, no significant hearing threshold differences were observed between the groups who received psychological intervention versus those who did not.
The NIHL group showed the lowest Sd score and these scores were significantly lesser compared to USNHL group.
This subset of patients was mainly male and on average was 10 years younger than other tinnitus patients. When questioned, 5% of German adults stated that they had irritating tinnitus, 1% of adults considered themselves handicapped by their tinnitus, and 0.5% were unable to live a normal life [3].
All the data, whether in a table or in text, are expressed as the mean plus or minus the standard deviation. Tinnitus precipitated by use of machinery accounted for 11.6% (mainly such do-it-yourself tools as drills and grinders. To determine the influence of age on the hearing loss, we performed a stratified study on two groups of patients with demonstrable hearing loss, whether or not they had a history of noise trauma: those 40 years old and older and those younger than 40 years. Among those aged 40 years or younger, the difference is significant at 250, 500, 1,000, and 8,000 Hz, whereas in those older than 40, the difference is significant only in the lower frequencies (250, 500, and 1,000 Hz).
Leisure noise appeared to be the principal cause, especially amplified music, whether from a concert or a disco. In our study, the small number of patients who had been exposed to firearm noise did not permit significant study. In these cases, patients were able to perceive the external sound only if it were presented 5-15 dB above their auditory threshold, which poses a problem with interpretation. Jastreboff & Jastreboff11 reported that about 27% of totally deaf patients do not have tinnitus, whereas 20% of normal hearing people have tinnitus.
This is because the results obtained from this special group may directly related to the tinnitus perception, but not to the concomitant hearing loss. The test was performed in a sound treated room where the ambient noise was maintained between 20 to 40 dB A.
The difference between the two groups is highly significant at frequencies of 1, 1.5 and 2 kHz, but not at 3 and 4 kHz. The decrease in DPOAEs amplitude over a limited frequency range in DP-gram found in tinnitus patients with normal hearing may be a susceptible area representing minor cochlear pathology. Similarly, a more recent study by Sztuka et al.35 attributed the increase in DPOAE amplitude in tinnitus patients with normal hearing as a result of increased motility of the OHCs due to decreased neural activity in the auditory nerve.
Conversely, the number of abnormal DPOAE in tinnitus ears was not statistically significantly different from the controls. They found that outer hair cells damage (assessed by TEOAE) was more common in normally hearing tinnitus patients than inner hair cells damage. In this case, the positive TEN (HL) results may not be due to inner hair cells damage but maybe because of poor processing efficiency that is associated with neural problems due to compression of large vestibular schwannoma on the VIIIth nerve38. However, caution should be taken in interpreting the TEN test results as 10 dB-above-thresholds criteria is just a binary criteria that means passing or failing the TEN test, but does not mean dead or not dead. Occupational sources are factory machinery, generators, building sites and high-impact tools.
The results were displayed as tables and tests of association were done at p value of 0.05 for significance. Researchers in Australia20 also found no significant association between years of use or exposure from personal stereo players and self- reported tinnitus.
Studies have suggested that being exposed to excessive noise for longer periods of time, could lead to hearing loss and tinnitus, whereas a noise exposure over a short time period, could cause tinnitus as the only symptom. No significant correlation was observed between improvement in tinnitus scores and other variables of age, pure tone audiometry types or duration of follow-up. A study by Snow27 concluded that a questionnaire can be a good method to assess tinnitus severity. Of these 105 patients, 45 reported no tinnitus, and 60 reported that their tinnitus had shifted from significant to mild. In our study, the NH group had the lowest Sb score among the three groups, but had a higher Sd score than subjects with NIHL. In the present study baseline audiometric measurements indicate females had significantly lower hearing thresholds in the high frequencies. This finding indicates that hearing thresholds may not be the most important influencing factor on how the subjects experienced annoyance by their tinnitus, especially since the group receiving treatment had a significantly higher Sb score.
Further studies investigating the effects of the type and duration of psychological treatment on the tinnitus severity can be explored. In this population, the hearing loss is significantly less than that measured in the other patients, even allowing for their younger age. For more clarity, data plotted in the graphs are expressed as the mean plus or minus the standard error of the mean. Among those younger than 40, hearing loss at 250, 500, 1,000, and 8,000 Hz was significantly less in the patients with a history of noise trauma. Note the characteristic notch in the audiogram at 6,000 Hz in those younger patients with a history of noise trauma.
This would explain an average age of this group of tinnitus sufferers 10 years younger than that of the other tinnitus patients. For example, should tinnitus that has been measured at 10 dB above the auditory threshold be considered as low intensity (only 10 dB) or stronger than the hearing loss would suggest? It can be assumed that the role of sensorineural hearing loss as a tinnitus generator is complex and the mechanism of tinnitus may rely on the presence of other contributing factors such as damage to specific hair cells or the auditory nerve fibers. This appears to support the hypothesis that a reinforced mechanical distortion is generated by cochlear hyperactivity that can be the source of the tinnitus. DPOAE is more frequency specific and thus is expected to be more sensitive in detecting subclinical abnormality in cochlear function over TEOAE. Their finding supports the theory that outer hair cells abnormality may be an important factor in the tinnitus mechanism37.
For this reason, more research needs to be carried out on the clinical benefit of the TEN test before applying this method clinically. Since only frequencies from 125 Hz to 8 kHz are measured in conventional pure-tone audiometry, it is possible that a person with normal hearing can have a hearing loss at frequencies higher than 8 kHz accompanied by tinnitus13,14. In relation to hearing thresholds, it was observed that, in subjects who had tinnitus always, 19% considered themselves as having normal hearing, 55% had some hearing loss, 19% had marked hearing loss and 3% were deaf. The study had the approval of the Ethical committee in the section of Logopedics, Phoniatrics and Audiology, Lund University. The subjects' responses were rated based on the global score obtained from the MS-TSQ questionnaire. We believe that the 'true' response rate in our study is much higher (around 59%) since 267 of the total 455 subjects initially responded to the questionnaires that were sent to them. For 341 patients who reported mild tinnitus at baseline, 40% reported that their tinnitus had not changed, compared to 55% of the 233 who had moderate tinnitus. The range of the duration between the baseline and follow-up visit varied from 1 year and 11 months to 9 years and 4 months and this factor might have had an effect on the audiometric thresholds during the follow-up phase. Statistical analysis showed a significant correlation between a history of exposure to noise trauma and the presence of a high-pitched "whistling" tinnitus. However, we observed no significant difference in hearing loss at 2,000, 4,000, and 6,000 Hz (see Fig. Other sources of noise trauma were firearm use and do-it-yourself power tools, which would explain the overwhelming male majority in this noise exposure subgroup. Eggermont and Roberts [11] demonstrated that the frequency of tinnitus is closely correlated to audiometric hearing loss. With tinnitus measurable in this way at 5-15 dB above the threshold, would one have to say that the intensity of tinnitus depends on hearing threshold and that a proportional relationship exists between tinnitus and hearing threshold? By contrast, in other cases, TEOAE and DPOAE results showed poor or absent emissions in tinnitus patients with sensorineural hearing loss, even in those ears with normal hearing16,19,36. In this current study, the result may possibly be due to subtle cochlear abnormality also existing in non-tinnitus participants with normal hearing. However, results from both studies may be more compelling if they included a retrocochlear test. It is shown that subjects with tinnitus have steeper maximum high-frequency slopes compared to the subjects without tinnitus. It has also been shown that cognitive behavioral therapies can improve a person's ability to cope with their tinnitus21.
Of the total 455 subjects, 267 subjects (response rate of around 59%) returned back the questionnaire. After exclusions based on subject category and responses to all items in the questionnaire, our study yielded a final response rate of around 38% (n = 174). Studies have shown that prevalence of tinnitus increases due to exposure to industrial and recreational noise1,6. The presence of whistling tinnitus was significantly correlated with high-frequency hearing loss.
In France, a study involving the population around Nice produced results similar to those of other countries with regard to the prevalence of tinnitus [4]. Finally, whatever the pathology responsible for the appearance of tinnitus, patients had suffered for an average of 7 years before being seen in the tinnitus clinic. In other words, the frequency spectrum of tinnitus is inversely proportional to auditory threshold. Only a study comparing the two types of tinnitus intensity evaluation (audiometric-based pitch matching and visual analog scale) will allow clear answers to those questions. The TEN test appears to be a potential non-invasive and quick test of inner hair cells function.
The mean pure tone audiometric thresholds of tinnitus and control groups are shown in Table 1.
The tumour was compressing the brainstem and cisternal portion of the VIIIth cranial nerve. These variations can be explained by postulating that it is most likely to reflect different cochlear mechanisms underlying tinnitus generation due to different cochlear pathological changes in tinnitus ears37.
The result of the current study is consistent with Thabet's study in which only one subject was found with a dead region, on the left ear. Studies have argued that the presence of tinnitus is related to the boundary in the audiogram between the frequency regions of normal or near-normal hearing and a region with a higher degree of hearing loss15,16.
A similar study by Andersson et al.20 observed that the severity of tinnitus reduced over time in all of their subjects, when psychological intervention was provided. In the MS-TSQ item 1 is provided with scores ranging from 2-8, item 2 from 1-4 and items 3-10 has scores ranging from 0-4. In the present study, no significant associations were found between Sd scores in the MS-TSQ and age, PTA, or duration.
It has been shown that NIHL results in an imbalance of spontaneous and sound-driven cochlear output across different frequencies.
The intensity of tinnitus, measured using a visual analog scale, appeared to be stronger than the measured hearing loss would suggest. A further French study focusing on the quality of life of 603 tinnitus sufferers showed clearly that in 26% of patients, tinnitus created difficulties in everyday life [5]. This may be related to the fact that this study was undertaken in a hospital setting, which tends to be a secondary or tertiary referral clinic for patients with tinnitus.
If this were the case, one would expect that the whistling tinnitus noticeable after noise trauma would have a spectrum predominating in high frequencies. However, the correlation between hearing loss and intensity of tinnitus that we measured in this study suggests that a visual analog scale is the tool of choice to help us to understand the incapacitating character of tinnitus associated with noise trauma.
Nonetheless, it is too early to make a conclusion based on the aforementioned two studies on tinnitus.
An independent t-test revealed that there was no significant difference in hearing thresholds between tinnitus patients and controls at all frequencies except at 6 and 8 kHz. Thus, the variability of findings in this study may possibly be because of different mechanisms existing in the normally hearing tinnitus patients.
According to Jastreboff37 however, there are different levels of dysfunction from the OHC up to the higher auditory pathways. These results indicate that both the degree of hearing loss and the shape of an audiogram were factors that could predict the occurrence of tinnitus. It was observed that females had a higher MS-TSQ Sb score and a lower MS-TSQ Sf score than males. The presence of tinnitus engenders notable modifications of behavior and a clear deterioration in quality of life. Among those who were 40 years old or older, hearing loss between 250 and 1,000 Hz was significantly greater in the patients who did not experience noise trauma, although we observed no significant difference at 2,000, 4,000, 6,000, and 8,000 Hz. At both these frequencies, tinnitus patients had significantly higher thresholds than control individuals. He hypothesised that in some patients, though the level of dysfunction is undetectable by TEOAE, it may be sufficient to produce tinnitus.
Subjects with a global score below 20 were classified to have mild tinnitus, while a global score above 30 was classified as severe. Hence, these pathophysiological changes might be responsible for observing lesser improvement in the tinnitus severity scores in subjects with NIHL.
Irritability, stress, anxiety, and deterioration in quality of sleep are frequently described both by tinnitus patients themselves and by their families [5]. These results show that whatever a patient's age, those with a history of noise trauma has less hearing loss than did those with other etiologies of hearing loss.
Therefore, this study aimed to investigate subtle cochlear abnormality in tinnitus patients with normal hearing thresholds using evoked OAEs (TEOAEs and DPOAEs) and TEN test.
Contrarily, in some, the level of abnormality is detectable but not enough to trigger tinnitus. Subjects with global scores between 20 and 30 were classified as having moderate tinnitus24.
Therefore, Jastreboff's hypothesis is a possible explanation as to why not all hearing loss patients present with tinnitus, and not all tinnitus patients present with hearing loss. The MS-TSQ was administered on all subjects in two stages - a baseline score (Sb) during the initial visit and a follow-up score (Sf) with varying duration of time after the baseline assessment. It has a deleterious effect on intrafamily relationships, especially because of the difficulty that relatives may have in understanding what the tinnitus sufferer is undergoing [6]. The change in the tinnitus severity was calculated as (Sb - Sf), termed as the difference scores (Sd). The duration between the baseline and follow-up assessment varied from 1 year 11 months to 9 years and 4 months.



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