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Author: admin | 10.11.2015 | Category: Ginkgo Biloba Tinnitus

Tinnitus is a common hearing affliction where the patient experiences a sound that is frequently described as a ringing in the ears.  Learn more about tinnitus by reviewing the questions and answers below, or visit our hearing clinic in Kelowna. 9.     I heard that a certain diet might help to reduce the tinnitus?  Are chocolate and wine bad for tinnitus? It is the conscious experience of a sound that originates in the head or ears.  It is frequently described as a ringing, buzzing, humming, hissing, sound of escaping steam, etc.
Disco Tinnitus is the temporary tinnitus due to exposure to loud noise.  It frequently affects teenagers and adults participating nightclubs and loud concerts. No, it does not mean you will lose your hearing.  Tinnitus may co-exist with hearing loss but it does not necessarily cause the tinnitus.
There is no direct correlation of alcohol, caffeine, and nicotine influencing the prevalence of tinnitus.  A low salt diet helps to reduce the symptoms of Meniere’s disease but does not reduce or enhance tinnitus. Avoid the quietness – turn on the radio, fan, TV.  Having some sounds in the environment reduces the contrast between your tinnitus and quietness and makes tinnitus less noticeable.
Hearing aids generally will help to cope with tinnitus more effectively if you have a hearing loss.  Being able to hear better can take the strain off listening.
How to cite this article Passi S, Ralli G, Capparelli E, Mammone A, Scacciatelli D, Cianfrone G.
The main objective of this study was to determine reliability, validity, and reproducibility of the Italian version of the Tinnitus Handicap Inventory (THI) self-administered questionnaire aimed at evaluating the impact of tinnitus on the quality of life of subjects affected by this symptom.
Over time, different authors have made various attempts at defining and classifying tinnitus; however, that none of their proposals has proved to be exhaustively descriptive suggests the great level of complexity of the pathogenesis and phenomenology associated with tinnitus.
One of the first definitions was coined by Itard (1774-1838), who described tinnitus as "an extremely irksome discomfort, which leads to a profound sadness in affected individuals." He advised several therapeutic approaches to gain relief, among which was the use of environmental noise [1,2]. Our opinion is that no single theory, model, or hypothesis will be exhaustive in all the affected patients [21]. Tinnitus may be continuous or intermittent and it can be localized at the ear level, bilaterally or unilaterally, or at various points in the head [24]. Therefore, because the tinnitus symptom is not always associated with a specific and easily detectable pathogenic factor and varies greatly in both qualitative and quantitative terms, it escapes instrumental evaluation. Further studies showed that the level of distress is not related to type, assumed cause, or features (such as pitch and loudness) of tinnitus [30-32]. In the course of the last two decades, several selfadministration questionnaires for the investigation of the disabling aspects of tinnitus have been reported in the literature [37,38], using various evaluation systems and presenting different features. On the occasion of the Fourth International Tinnitus Seminar in Bordeaux in 1991, Halford and Anderson [42] introduced the Subjective Tinnitus Severity Scale (STSS), composed of 16 items and a single factor evaluating severity of tinnitus in terms of intrusiveness and interference with sleep, relaxing capacity, and distress level. The two instruments discussed in the following paragraphs focus mainly on psychological reactions to tinnitus, a further confirmation of a trend in the most recent literature that takes into account tinnitus-coping strategies more than symptom severity. Normally, the tinnitus sufferer turns, in the first place, to specialists, such as an otolaryngologist or an audiologist.
One of the criticisms leveled at the THI in the past was that, compared with other self-assessment scales (Tinnitus Questionnaire [TQ], THQ, TRQ), its factorial structure had not been validated [52-54]. The THI has been adopted as either a primary outcome measure or in association with other evaluation scales and has been used in double-blind trials with a control group to assess the effect of pharmacological treatments administered to tinnitus sufferers. In light of our Italian clinical experience, we chose to evaluate reliability, validity, and psychometric properties of the THI, for we believe that among all tests described in this study, its questions are the most easily understood and provide an exhaustive framework for tinnitus impact on the sufferers' everyday life and function. It is interesting to note that item 24, relating to the effect of stress on tinnitus, turns out to be the least correlated to the total score of the scale.
High total scores are always suggestive of high scores in the catastrophic scale, in support of the findings of McCombe et al. These definitions based on grading are very useful in clinical practice and help doctors to quickly identify the most appropriate therapeutic choices. Recent studies have indicated that the pathophysiological basis for tinnitus may be abnormal activity in the auditory areas of the brain rather than aberrant activity in the periphery. Tinnitus is the sensation of hearing a sound when no external auditory stimulus is present [1]. A variety of tinnitus treatments have been tried, but hearing aids, maskers, drugs, and surgical interventions thus far have not been shown to be very effective [10, 11].
In general, antidepressants appear to work best for those who are depressed or anxious, who have more severe tinnitus, or who are treated for a longer time with an adequate dose of medication [13]. Recent studies have suggested that the pathophysiological basis for chronic tinnitus is neural activity in the brain rather than aberrant activity in the peripheral auditory system [17-22]. These theories suggest that overactive feedback loops in the brainstem-thalamus-auditory cortex may be the underlying mechanism of this problem.
Furthermore, the perception of tinnitus has been observed to be enhanced when the person perceiving the subjective noise "attends" to it and associates it with unpleasant emotions [28]. This model for the etiology of tinnitus suggests that, though tinnitus may be triggered by events in the periphery, the mechanisms that cause tinnitus to be a persistent and annoying condition are in the brain [32,33]. Given this theoretical background, we have approached the problem of tinnitus treatment by using customized sound-more specifically, a replica of the subjective tinnitus experience-to reduce the overactive sound-processing circuits.
After completion of pilot study 1, we implemented a more formalized and longer-duration protocol. We selected subjects between the ages of 20 and 60 years if they exhibited "primary tinnitus" as defined by Dr. In study 2, prior to recording of the EEG and eventrelated potentials (ERP), subjects had bilateral audiograms using adult routine clinical procedures with appropriate level of contralateral masking as needed.
Study 2 subjects underwent an otoscopic examination, tympanogram, and ipsilateral acoustic reflex screening. The perceptual experience of tinnitus was characterized in both studies using a successive approximation technique. Auditory stimulation in both studies consisted of sine waves generated by a function generator (Goldstar FG2002C; LG Precision, Seoul, South Korea). Audiograms were taken from 7 of the tinnitus subjects and 13 of the control subjects in study 1. Most subjects indicated changes in their tinnitus perceptions very soon after beginning CST, in one case even after trying out the habituation sound for only a few minutes in the laboratory.
In four of the five subjects who completed the 3 weeks of CST, hearing threshold at the frequency closest to the subject's tinnitus pitch improved by 10 dB or more (Fig.
The EEG recording procedure required the determination of hearing thresholds prior to each session. In study 1, we assessed the short-term effects of habituation on the electrophysiology by recording the N100 component from tinnitus and control subjects before and after 1 hour of CST. In study 2, comparison of the N100 responses (slope) before and after 3 weeks of CST showed a decrease in the intensity dependence in response to the 4-kHz tinnitus frequency tones (Fig.
Recent studies indicate that an altered afferent input to the auditory pathway may be the initiator of a complex sequence of events resulting in the generation of tinnitus at the central level of the auditory nervous system [17]. The hearing loss observed at the tinnitus frequencies raises the possibility that the stronger intensity dependence observed in the responses of tinnitus subjects to tinnitus frequency tones may have been caused by recruitment (abnormal loudness growth) rather than tinnitus. The observed changed intensity dependence of the auditory N100 response in tinnitus subjects in the present studies and in previously published findings [19,27,50- 52] indicate that tinnitus is accompanied by a reorganization of the tonotopic map in the auditory cortex. Our studies on the effectiveness of CST were conducted without a placebo treatment and were not blinded. Possible conflict of interest: Authors are shareholders in Tinnitus Otosound Products, LLC, a company developing diagnostic and treatment methods for tinnitus. Good hearing is essential to fully exploring and enjoying life!  Your sense of hearing is a precious gift that allows you to interact with others and enjoy the sounds of the world each day. Our mission  is to promote better hearing and improve the quality of your life.  We realize that good hearing can enrich your life, boost your self esteem and give you confidence. Our advanced expertise allows us to meet your hearing needs.  As a truly independent, non-manufacturer-owned hearing clinic in Kelowna, we’re dedicated to providing excellent service with the highest ethical standards. We invite you to visit our hearing clinic in Kelowna  located at the Guisachan Village Mall in Kelowna, British Columbia.
This study evaluated the interference of tinnitus on the quality of life for noiseexposed workers enrolled in a hearing conservation program. Most tinnitus research has focused on effective treatments and the mechanisms of the cause, detection, and perception of tinnitus.
In addition to its medical and audiological aspects, the psychosocial consequences of tinnitus can be of significance and have also been investigated.
Tinnitus is a common complaint among noise-exposed workers, and in some countries it is even recognized as a work-related condition for compensation purposes. The objective of our study is to evaluate the impact of tinnitus on the quality of life of workers who are exposed to noise and enrolled in a corporate hearing conservation program. We enrolled participants from a meat-packing facility in the state of Rio Grande do Sul, Brazil.
We administered a questionnaire to all the employees of the company (N = 372) at the beginning of the training sessions of their hearing conservation program.
To assess the workers' hearing status, we performed otoscopy and pure-tone audiometry, according to the requirements of the Brazilian legislation [10]. We administered to the 52 participants the Brazilian version of the Tinnitus Handicap Inventory (THI) questionnaire, elaborated by Newman et al. We calculated Pearson coefficients of linear correlation and tested their significances via the Student's t -test and Fisher's exact test, using a significance level of 5%. Eighty-two workers (22%) of the total population of 372 workers in the studied company reported tinnitus in the first interview of this study. Company records also indicated that 15% of the participants who were exposed to noise were also exposed to other hazards. The results of the relationship between tinnitus and the three THI scales are presented in Figure 2. Table 2 displays the correlations between the functional, emotional, and catastrophic scales and medical history. Table 3 presents the correlations of the THI results with the health problems described by the participants (n = 52). We separated the participants into two groups: The first was composed of 37 participants with normal hearing (71%), and the second included 6 participants (12%) with a bilateral high-frequency notch. Twenty-two percent of the noise-exposed participants complained of tinnitus, a finding comparable to rates of 25% reported by Sahley and Nodar [14] and 15.5% reported by Zimmermann [15]. Seventy-one percent of the participants with tinnitus complaints presented normal audiometric results, which suggests that tinnitus can be an early indicator of auditory risk from exposure to noise.
The application of the Brazilian version of the THI was both easy and expedient, as indicated by Newman et al. In Table 2, we found significant results involving the functional scale results with the use of prescription drugs and the catastrophic scale results with consumption of coffee.
Concerning the degree of severity of tinnitus, 44% presented degree 1 or "slight" tinnitus according to the classification by McCombe et al. We observed a significant correlation between tinnitus severity and exposure to noise and chemical pollutants, predominantly CO. We observed a significant correlation between the duration of noise exposure and the emotional scale for the participants with high-frequency notches, suggesting an extra-auditory effect of noise.
The results of this study demonstrated that the prevalence of tinnitus was high (22%) in this population, despite the fact that study participants were young individuals who had a short duration of noise exposure.
The Brazilian version of the THI proved to be an easy instrument to use for evaluating the impact of tinnitus on the quality of life of noise-exposed workers. How to cite this article Mahmoudian S, Shahmiri E, Rouzbahani M, Jafari Z, Keyhani MR, Rahimi F, Mahmoudian G, et al. Tinnitus is a debilitating condition that is widespread yet difficult to successfully diagnose and treat.
Regarding to McFadden (1982), Tinnitus is the "conscious experience of a sound that originates in an involuntary manner in the head of its owner or may appear to him to be so"1.
Some underlying causes were defined for tinnitus, including otological diseases, tumors, ototoxicity, acoustic trauma, noise-induced and psychological disturbances. Since almost the majority of tinnitus questionnaires for assessing individual's reaction to tinnitus are in English language and there is still no standardized and valid questionnaire in Persian, the provision of a Persian version of these questionnaires according to the culture of Iranian society is inevitable. The first aim of the current study was to investigate the linguistic validity of the Persian Version of the THI as a measure of tinnitus-related reactions in three dimensions 95 International Tinnitus Journal, Vol. The present study consists of translation and standardization of the original version of THI [25] into Persian version (Linguistic validation) then the reliability of the Persian version of THI has been identified.
In the first step according to the IQOLA protocol26, THI questionnaire was translated by two native speakers of Persian, bilingual in English and Persian, separately translated the original instrument into Farsi (Persian) language (translator 1 and 2).
At the second step of linguistic validation, we used two other translators (5 and 6) with high level of proficiency in Persian and English languages. Before the THI-P can be administered to assess the effects of tinnitus, its test-retest stability must be determined.
The degree of hearing loss is defined as the severity of the hearing loss measured by audiometry.
Patients were asked to complete the THI-P questionnaire as part of the initial assessment at the tinnitus center. All analyses were performed using statistical package for social science (SPSS) version 16. Student t-test was used to test for differences between THI scores and its subscales and gender, hearing impairments and tinnitus laterality. From the 25 items of THI-US version translated to Persian version of THI, thirteen items (52%) including 2, 3, 7, 8, 9, 10, 11, 15, 16, 20, 21 and 22 as an easy translation, six items (24%) including 6, 12, 14, 17, 18 and 19 as a relatively easy translation and finally other six items including 4, 5, 13, 23, 24 and 25 as a difficult translation were evaluated by translators.
The tinnitus characteristics of the 112 subjects attending the tinnitus center to consult about tinnitus management have been summarized in Table 1. The frequency distribution of tinnitus subjects who answered the various items in the THI-P questionnaire has been outlined in Table 3.
The correlation of age and total THI-P score was calculated by Pearson's product and for calculating the effect of sex and total THI-P score we applied independent student t-test.
Pearson product-moment correlations were calculated between the first and second administrations of the THI-P among the tinnitus subjects to assess the strength of the relationship between tests and retest (Figure 2). We assessed the percentages of "Yes", "Sometimes" and "No" answers and then we calculated the reproducibility (internal consistency reliability) of items in THI-P using the Cronbach's-alpha coefficient. In recent years, the need to assess and consider the consequences of diseases as well as distressing symptoms has been specifically considered in all special facilities of medical and rehabilitation. Hence, as a first step, standardization and validation of appropriate tools such as psychometric questionnaires are very important in order to evaluate disease or monitor treatment outcomes.
One of our ultimate goals for validating the Persian version of THI and for conducting current study was to develop a standard self-report tinnitus instrument, appropriate to the Persian's culture so that it could be administered as a criterion measure in clinical and research approaches available to clinicians and other researchers who are involved in different aspects of tinnitus subjects. It is widely agreed that in addition to desirable translation to validate an assessment tool, we should also use the terms adapted for socio-cultural setting of the population which will serve. The translation quality was assessed by translator 3 and 4 using a VAS criterion (from desirable up to absolute undesirable score).
In order to determine the divergent or discriminate validity of THI-P, we used the effects of three factors including hearing impairment, gender and age of the tinnitus subjects on the questionnaire scores. Regarding to other studies, in order to identify validity of THI questionnaires (German, Brazilian, Danish versions), authors administered the correlation between items in translated THI with the other standardized questionnaires (convergent validity structure)33. The most important specifications of one assessing instrument are always including repeatability, consistency and validity of obtained scores.
The other part of consistency was related to the correlation between test-retest which was evaluated by Pearson correlation coefficient. In this study, with omitting any of the THI-P items, the acquired score of Cronbach's alpha coefficient as calculated by the total score of Cronbach's alpha coefficient was very close (r = 0.943). In conclusion, this study demonstrated that the Persian version of THI (THI-P) is a valid and reproducible tool to assess the psychological complaints of tinnitus sufferers. We find that THI-P in structural and practical point of view is compatible with the original English version of THI. In this era, the determination of both objective and subjective effects of clinical intervention is critical, because clinicians using outcome measures could make decision about patient's status and the effective treatment. 191% of all subjects reported a reduction in Tinnitus disturbance of at least 40% , with an average improvement of 65%. Also, 80% of subjects reported that the level of their Tinnitus disturbance reduced so much as not to be any more significant.
The treatment was reported as being pleasant and easy to use by a high proportion of trial subjects. Sharon Sandridge, PhD, director, Audiology Clinical Services, Head and Neck Institute, at Cleveland Clinic, presented the data of a recent multi-site US study which evaluated 45 patients with varying forms of tinnitus.
The study, based on the Tinnitus Handicap Questionnaire, reported Tinnitus disturbance decreased by 44% following the 6 month treatment. 91% of all subjects reported a reduction in Tinnitusthis will be written under clinical evidence.. Download a copy of the Tinnitus Reaction Questionnaire (TRQ) and see what your score is now.
Tinnitus may co-exist with hearing loss but hearing loss may not be the cause of tinnitus.  Tinnitus is frequently associated with some diseases in the ear, such as otosclerosis, ear infections, and Meniere’s disease. A relaxed body can cope with tinnitus more effectively.  Tinnitus is usually not a sign of a serious, ongoing medical condition. The THI Questionnaire: Psychometric Data for Reliability and Validity of the Italian Version.
Shulman [1] defined tinnitus as "the aberrant perception of sound reported by a patient that is unrelated to an external source of stimulation," whereas Jastreboff [2] mainly referred to the most recent neurophysiological acquisitions regarding the auditory function and described tinnitus as "the perception of sound that results exclusively from activity within the nervous system without any corresponding mechanical, vibratory activity within the cochlea and not related to external stimulation of any kind" [3]. Among the various pathologies that may cause or accompany tinnitus are otitis media, otosclerosis, Meniere's disease, presbycusis, exposure to noise and ototoxic drugs, sudden deafness, head trauma, acoustic neuroma, meningitis, and temporomandibular joint disorders [6-10].
Tinnitus is a very frequent symptom among the population and, indeed, some epidemiological studies report that temporary tinnitus can be commonly perceived by individuals of any age [22,23]. It can manifest suddenly or gradually, and sufferers describe it in a broad variety of qualitative features, from hissing to tinkling, from buzzing to steaming, or as a pool of undefined sound components, all descriptions that, unfortunately, do not provide the clinician with helpful indications for therapy or pathogenesis. As a matter of fact, no currently available methods are able to ascertain the presence of tinnitus or its severity in audiological terms: hence the necessity of alternative assessment instruments ranging beyond the audiology area and focusing instead on the impact of tinnitus on affected subjects' activities of daily living [25].
To account for the differences between tinnitus sufferers and nonsufferers, many authors considered the cognitive factor, thus identifying cognitive reactions to tinnitus as crucial to the development of habituation [33-35].
Some of these were formulated by audiologists, some others by psychologists and multidisciplinary teams.
Such a change of focus is researchers' answer to the growing evidence that tinnitus responds more readily to a global and multidisciplinary approach than to medical treatments. Such specialists make a clinical evaluation of the auditory apparatus to exclude or detect the presence of pathological situations causing tinnitus. It should provide indications for a multidisciplinary therapeutic approach and also serve for the assessment of therapeutic outcomes. Such validation was later provided by a Danish working group [47] and by Baguley and Andersson [52], who defined it as a distress-specific monofactorial scale.
The THI was employed to evaluate the efficacy of baclofen, melatonin, and glycopyrrolate in the treatment of Meniere's disease and of Ginkgo biloba, botulinum toxin type A, gabapentin, and melatonin on tinnitus and, in the case of melatonin, on sleep [57-63].
The Centre is located at the University of Rome Sapienza, Department of Otorhinolaryngology, Audiology, and Phoniatrics, G. This indicates the extent to which stress is a fundamental element in determining the degree of distress, independent of severity of tinnitus.
National Research Council Working Group 89 Committee on Hearing, Bioacoustics, and Biomechanics.
The US Food and Drug Administration (FDA) has not approved any drugs for treatment of tinnitus, though some studies have focused on medications, including benzodiazepines [12] and antidepressants [13]. Though studies of newer medications are ongoing, the use of current drugs involves a substantial incidence of side effects that individuals wish to avoid or often find intolerable.
Functional imaging techniques have demonstrated a relationship between the intensity of tinnitus and the degree of reorganization of the primary auditory cortex.
Indeed, research from our own laboratory [27] has shown that the brain activity of tinnitus sufferers in response to sounds similar to their tinnitus is different from the response to other sounds or from the brain response to sounds of people without tinnitus. In this scenario, the person experiencing tinnitus is annoyed by the sound, thereby activating the limbic system. Subjects participated in this first experiment at different times, varying between 1 and 24 months. The THQ consists of 27 statements relating to the impact of tinnitus on an individual's life. We obtained pure-tone air and bone conduction hearing sensitivity thresholds for the standard audiometric frequencies of 250 Hz to 8 kHz in a double-walled sound suite meeting current American National Standards Institute standards for threshold air conduction and bone conduction testing. We obtained middle-ear measures using a currently calibrated, portable Grason-Stadler GS-17 acoustic immitance Middle Ear Analyzer (Grason Stadler Inc., Madison WI). Spectrogram of a typical tinnitus habituation stimulus, showing two closely spaced narrow-band noises centered at 2,800 Hz and 3,225 Hz and a very-narrow-band noise centered at 7,417 Hz that is almost 40 dB stronger than the first two. Data were recorded from 15 electrode sites mounted on an elastic cap and located over a variety of scalp sites (F3, Fz, F4, C3, Cz, C4, P3, Pz, P4, T3, T4, T5, T6, O1, and O2 according to the modified International 10-20 System). The intensity and duration of each stimulus were set by a specially designed programmable logarithmic amplifier that is controlled in real time by a stimulus presentation and data collection program running in ADAPT.
During study 2, they were required to wear their MPEG player and listen to the customized habituation sound for 6-8 hours daily as they went about their normal activities. One of the tinnitus subjects had mild hearing loss, and three had moderate hearing loss on the right ear, whereas five had mild hearing loss, and none had moderate hearing loss on the left ear at their tinnitus frequency.
Generally, they thought that their tinnitus was much more bearable when the habituation sound was present and that the tinnitus was less bothersome at other times.
Changes in four tinnitus subjects' hearing levels at the tinnitus frequency during habituation training. This provided records of the tinnitus subjects' hearing thresholds at their tinnitus frequency. For the tinnitus patients, the habituation sound was the one used in habituation training, and the stimuli used for recording the N100 component were 1,000-Hz tones and the tinnitus frequency tones.
N100 intensity dependence in response to A) tinnitus frequency (4000 Hz) and B) control frequency (1000 Hz). Responses to 4-Hz tinnitus frequency tones A) before versus after customized sound therapy and B) tinnitus versus control.
The results of our two studies indicate that CST aimed at this central dysfunction can reduce chronic tinnitus quickly and safely. However, the reduced intensity dependence observed in responses to 2,000-Hz tones, one octave below the tinnitus frequency, is opposite to the effect of recruitment and thus not attributed to it. The main correlate of this reorganization in our studies was the enhanced contrast between responses to tinnitus frequency and tones approximately one octave lower than the perceived tinnitus pitch. Using evidence-based knowledge, we accurately diagnose hearing dysfunctions and disorders in a compassionate, caring and respectful environment.  By providing information and effective solutions, we’ve assisted many customers  in their quest to improve their lives. Noise measurements, a questionnaire, a Brazilian version of the Tinnitus Handicap Inventory (THI), and pure-tone audiometry were conducted with 52 participants (mean age, 29 years) who suffered from tinnitus.
Among the risk factors for tinnitus, the most prominent are age, gender, various diseases (otological, metabolic, neurological, and vascular alterations and dental factors), hearing loss, and exposure to noise, ototoxic drugs, caffeine, nicotine, and alcohol [1-4]. Tinnitus can alter an individual's ability to function in professional, social, and leisure activities and in family relationships, hence affecting the quality of life [5,6]. In addition to being beneficial for clinical applications, the tinnitus questionnaires are valuable for understanding the relationship between personality and the psychopathology of tinnitus, its impact on the daily life of persons who suffer from tinnitus, the difficulties and the perception of social support in relation to the problem, and the incapacities and the difficulties produced by tinnitus that can seriously affect quality of life [7-9].
Occupational hearing loss prevention initiatives rarely focus on the prevention and management of tinnitus. The company employs 372 workers (120 female, 252 male) working in two fixed 8-hour and 48-minute shifts.
The questionnaire gathered information on demographics and occupational and medical histories for each worker.
We also used Spearman's rank correlations to examine the results of exposure information versus the outcome. Because of attrition, we were able to study only 52 workers (14% of total population of the plant). Of those, 62% were exposed to carbon monoxide (CO), 13% to CO and vibration, 12% to hydrochloric acid, and 13% to sodium hydroxide. We observed that of the 52 participants, 71% had normal audiometric results, whereas 12% presented a bilateral high-frequency notch and 17% presented audiometric configurations of hearing loss due to causes other than noise, such as unilateral losses and flat audiometric configuration.
Median of hearing thresholds for the groups with normal hearing (all thresholds 25 dB hearing level [HL]), hearing loss configurations suggestive of noise-induced hearing loss (NIHL), and hearing loss from various causes. The distribution of poorest scores across scales of the Tinnitus Handicap Inventory, in percent (n = 52).
We observed a significant correlation between headaches (p = .0458) and the duration of tinnitus. We did not include the remaining 9 individuals (17%), who displayed other audiometric configurations of hearing loss in the statistical analysis.
The prevalence of tinnitus complaints in male subjects was 16% and in female subjects was 9%, similar to what has been reported [16-18]. Schleuning [2] explained that caffeine and nicotine could aggravate tinnitus because they are stimulants and can induce the constriction of blood vessels. The participants of the study who had such combined exposure had a higher degree of tinnitus severity.


Moreover, a negative impact of tinnitus on the subjects' quality of life could de detected. The 22% tinnitus rate among workers, most of whom nonetheless had normal hearing, suggests a need to address tinnitus in occupational hearing loss prevention initiatives. Rick Davis and Robert Randolph (National Institute for Occupational Safety and Health, USA) and Alberto Behar (University of Toronto, Canada) provided helpful critiques of the manuscript. Persian language version of the "Tinnitus Handicap Inventory": translation, standardization, validity and reliability. This symptom is a debilitating condition that is widespread yet difficult to successfully diagnose and treat. For some patients with tinnitus this sensation does not interfere with their daily activities and for others it is disabling and restricts their work, sleep, and social activities10,11.
Numerous studies using various open-ended or self-report structured questionnaires have been conducted. For this reason we perform according to the International Quality of Life Assessment protocol (IQOLA) approved by WHO in 1991. Craig Newman, author of the original questionnaire of THI, has permitted us to develop and use the Tinnitus Handicap Inventory in Persian Language Version. They were asked, if needed, to mention a list of possible translations for some words, sentences and phrases. On the other hand, the words and items on the level of reading ability of 14 years old or less were noticed for linguistic validation of THI-P.
All subjects gave written informed consent in accord with the declaration of Helsinki before examinations. So, in retest after one week from filling the first THI-P, the questionnaire was filled again by the same patients.
Descriptive statistics, including frequency distributions, means and standard deviation were computed for each item of THI-P. Multiple linear regression analysis was used to study the effect of gender, hearing loss and the tinnitus laterality on the overall THI score as well as the functional, emotional and catastrophic subscales.
In this study, the research method and the role of subjects were explained clearly and completely. The translation clarity exception in one item (item 17) which was evaluated as relatively desirable, in the other 24 items (96%) of THI-P was evaluated as desirable. Most of tinnitus subjects (72.7%) perceived one type of tinnitus sound, while others complained of sensation of more than one type of sound on different occasions. Scatter plots illustration the relationship between the THI-P score and the age in all subscales. As shown in Figure 2, the scatter plot indicates the correlation between the first (test) and second (retest) administration of the THI-P and their subscales on tinnitus subjects. Scatter plots illustration the correlation between the first (test) and second (retest) administration of the THI-P and their subscales. Researches in many different countries around the world in this area indicate the global emphasis on the importance of these assessments.
This symptom is as a common problem which can affect several aspects of patients' life including: going to sleep, understanding speech, depression, irritation, concentration and worse on awakening. To acquire this expressed goal, it was necessary to translate and standardize the original version of THI and then to evaluate the test-retest reliability of the THI-P.
The measure of difficulty of Persian translation of THI was evaluated by translator 1 and 2 using a visual analogue scale from easy up to difficult (VAS; 100 mm total length). The measure of this criterion administers three measures including clarity scores, common language and identifies conceptual equivalence.
Both convergent and discriminate validity methods were used for identifying validity of original English version of THI19. In current research the reliability of THI-P was evaluated from two 102 International Tinnitus Journal, Vol. We obtained 0.96 in Persian THI version, consistent with significant correlation in retest. The findings showed that none of the items of the Persian version of the questionnaire need to be removed. Also, THI-P could be administered as a standard measuring instrument for patients and clinicians all over Iran. Henceforth, THI-P could be used for both clinical and research purposes by different professionals like audiologists, otolaryngologists, psychiatrists and could be also used for monitoring, treatment and rehabilitative effects on the life's quality of tinnitus sufferers. ENT and Head & Neck Research Center, Hazrat Rasoul Akram Hospital, Tehran University of Medical Sciences (TUMS), Tehran, Iran. Department of Audiology, School of Rehabilitation Sciences, Tehran University of Medical Sciences (TUMS). Department of Biometry, School of Rehabilitation Sciences, Tehran University of Medical Sciences (TUMS). The device comes with 4 different musical tracks fully personalized depending on individual’s hearing level and tinnitus. In addition, there are more than 200 medications listing tinnitus as a potential side effect.  However, there is small percentage of normal hearing people have tinnitus. All subjects reported as their main problem a tinnitus that had persisted for at least 6 months.
In our view, the most exhaustive definition, including the numerous aspects of this symptom, is McFadden's: "Tinnitus is the conscious experience of a sound that originates in the head or neck, and without voluntary origin obvious to that person" [3]. Recent hypotheses refer to sensorineural hearing loss of autoimmune and neuroendocrine origin and metabolic disease.
The reported prevalence of continuous tinnitus is 6-30%, of which only a portion (0.5-2%) of the population turns out to be significantly affected. Even from a quantitative viewpoint, descriptions given by tinnitus sufferers do not provide useful clinical correlates, as numerous factors can affect the patients, such as environmental noise and the level of attention that the subject pays to the symptom. In this regard, the observations of Tyler and Baker [25] of 72 patients-members of a tinnitus self-help group-are a starting point for the formulation of some specific tests. In addition, a psychological predisposition that was hypothesized can affect tinnitus-coping abilities.
In 1990, Sweetow and Levy [40] introduced the Tinnitus Severity Scale (TSS), with 15 items and five relevant factors: symptom intrusiveness, distress, hearing loss, sleep disorders, and drug use. The widely known Tinnitus Reaction Questionnaire (TRQ), proposed by Wilson et al [45], is made up of 26 items investigating four factors: general distress, level of interference in work performance, severe distress, and avoidance strategies.
As previously stated, specialists who normally see tinnitus sufferers know well that the symptom's severity is not directly related to the triggering pathology or to psychoacoustic characteristics of the symptom. Specifically, 11 items are included in the functional scale, 9 in the emotional scale, and 5 in the catastrophic scale.
These authors found the reliability of the test-retest to be high and reported a high validity correlating with other distressmeasuring scales, specifically the TQ, as shown by Baguley et al. The use of the THI in association with other instruments, such as the Tinnitus Coping Style Questionnaire, has been reported in assessing the efficacy of low-power laser on tinnitus [64]. Its validity was confirmed as an outcome-measuring instrument determining the efficacy of tinnitus retraining therapy as compared to acoustical masking [68]. The first version of the questionnaire (the alpha version) constituted 45 items, some based on interviews with patients and others adapted from both the Hearing Handicap Inventory for the Elderly and the Dizziness Handicap Inventory and others based on the symptomatic categories defined by Tyler and Baker [25]. Specifically, the THI devotes 11 items to the functional scale, 9 to the emotional scale, and 5 to the catastrophic scale. These properties provide clinicians or health operators with an instrument that completes the audiology diagnosis, thus indicating the necessity for involving other professionals who are not directly related to audiology, such as psychologists and neuropsychiatrists. In that interesting and very useful study, the authors provide a characterization of the type of impact that tinnitus causes in connection with the subject's ratings.
Development of tinnitus-related neuronal hyperactivity through homeostatitic plasticity after hearing loss: A computational model. Etanercept therapy for immune-mediated cochleovestibular disorders: A multicenter, open-label, pilot study. Sudden hearing loss as a first complication of long-standing Type 1 diabetes mellitus: A case report. The inner hair cell synaptic complex: Physiology, pharmacology and new therapeutic strategies. Increases in spontaneous neural activity in the hamster dorsal cochlear nucleus following cisplatin treatment: A possible basis for cisplatin-induced tinnitus.
Cisplatininduced hyperactivity in the dorsal nucleus and its relations to outer hair cell loss: relevance to tinnitus.
Elevated fusiform cell activity in the dorsal nucleus of chinchillas with psychophysical evidence of tinnitus. In vivo optical imaging of toneevoked activity in the dorsal cochlear nucleus with a voltage sensitive dye.
Evidence of decreased GABAergic influence on temporal integration in the inferior colliculus following acute noise exposure: A study of evoked potentials in the rats. Lateralized tinnitus studied with functional magnetic resonance imaging: Abnormal inferior colliculus activation. The perceived severity of tinnitus: Some observations concerning a large population of tinnitus patients. Psychological characteristics of individuals high and low in their ability to cope with tinnitus. Psychological dimensions in patients with disabling tinnitus and craniomandibular disorders. Tinnitus Reaction Questionnaire: Psychometric properties of a measure of distress associated with tinnitus. Brazilian Portuguese language version of the Tinnitus Handicap Inventory: Validity and reproducibility.
Validation of the German-version Tinnitus Handicap Inventory (THI) Psychiatr Prax 34(1):140-142, 2007.
Ginkgo biloba does not benefit patients with tinnitus: A randomized placebocontrolled double-blind trial and meta-analysis of randomized trials.
An investigation of the audiological handicap associated with unilateral sudden sensorineural hearing loss.
Patient-based outcomes in patients with primary tinnitus undergoing tinnitus retraining therapy. However, such reorganization can be reversed through training-induced changes in the response pattern of cortical neurons. However, tinnitus sensations can be constant, loud, and annoying to the point that the sufferer is emotionally affected by this sensation. Finally, psychotherapy for tinnitus does help some, but it is aimed at mitigating the psychological effects of the problem rather than the sound itself. This suggests that aberrant activity exists in the sound-processing circuits for sounds that the tinnitus sufferer hears.
A feedback mechanism under control of the limbic system is assumed to give rise to an increased generation of tinnitus-related activity [29,30]. These studies support the idea that tinnitusrelated neuronal activity is confined to certain isofrequency regions of the auditory cortex.
We describe two studies: an initial pilot study (study 1) and one with a more formalized protocol (study 2). We first required tinnitus subjects to complete the Tinnitus Handicap Questionnaire (THQ) [44], and subsequently we audiometrically evaluated all subjects and recorded their EEGs.
Susan Gold, MS, CCC-A, of the University of Maryland Medical Center, Tinnitus and Hyperacusis Clinic.
It contains three subscales relating to mental health, hearing, and attitude toward tinnitus [44].
We used a Macio MA-41 portable audiometer (Maico Diagnostics, Eden Prairie MN) with a current calibration sticker for the pure-tone testing. In response to the subjects' statements, sounds were synthesized using highprecision, general-purpose sound synthesis software. Auditory stimuli of five different intensities were presented through insert earphones (Eartone 3A transducers with Earl link foam eartips; Cabot Safety Co, Indianapolis IN).
The intensity of the habituation sound was set by the individual so that the tinnitus perception was slightly louder than the habituation sound. The hearing tests in study 2 (Table 1) showed mostly normal hearing in both tinnitus and control subjects at 1 kHz and 2 kHz. For CST to be effective, the stimulus has to be audible but must not be so loud as to mask the tinnitus itself. However, in one case, a 10-dB improvement in one ear was offset by a 10-dB decrement in the other ear. For control subjects, the stimuli used for recording the N100 component were 1,000-Hz and 4,000-Hz tones.
Note that tinnitus subjects showed slightly higher slopes to their tinnitus tones than to the controls' 1,000-Hz tone, both before and after habituation. Furthermore, the intensity dependence of the control 2-kHz tones (approximately one octave below the tinnitus frequency) was also significantly decreased in tinnitus subjects. This tinnitus suppression may reflect aspects of "residual inhibition" (RI), though distinct mechanisms may be involved as well. Rather, we attribute this effect on intensity dependence to lateral inhibition caused by the tinnitus-related activity in auditory cortex.
After 3 weeks of CST, the intensity dependence of responses to tinnitus frequency tones was decreased, rendering the responses to tinnitus frequency tones more similar to responses from normal subjects to tones in the same frequency range. However, to conceive of a placebo condition that is truly blinded is difficult, because CST subjects have to undergo the sound-matching process to create their own habituation stimulus. Transient reduction of tinnitus intensity is marked by concomitant reductions of delta band power.
Changes in spontaneous neural activity immediately after an acoustic trauma: Implications for neural correlates of tinnitus.
Tinnitus sensitization: Sensory and psychophysiological aspects of a new pathway of acquired centralization of chronic tinnitus. Tinnitus dyssynchrony-synchrony theory: A translational concept for diagnosis and treatment. Dynamical properties of a plastic neural network model for tinnitus therapy and inhibition of oscillation using noise stimulus. Experimental-neuromodeling framework for understanding auditory object processing: Integrating data across multiple scales. ADAPT (Analog Data Acquisition and Processing Tools)-a software system for PC-compatible computers, designed to be used in neuro- and psychophysiological experiments, and for analysis and monitoring of various parameters of human spontaneous and event related brain potentials. Residual inhibition functions in relation to tinnitus spectra and auditory threshold shift. THI results indicated that tinnitus had the greatest influence in the functional scale (54%). We used the overall result to identify the degree of severity of tinnitus for each individual and for completing an analysis of the total scores by scales. Of all noise-exposed female workers in the plant, 11 (9%) reported having experienced tinnitus, and 41 (16%) of the noise-exposed male workers reported the condition.
Spearman's rank correlation coefficient results indicated a significant correlation between noise levels and how often workers experience tinnitus (p = .01). We also observed a significant correlation between the duration of noise and the functional scale (p = .039). It is important to notice that the average age of the population of our study (29.2 years) is younger than in other studies, which reported results from groups whose mean ages varied from 40 to 50 years and who had a short duration of noise exposure (average, 7 years)[18-21] . According to that author, doctors believe that 50% of patients with complaints of tinnitus improve significantly when they stop smoking or reduce caffeine intake. In recent decades, studies have demonstrated that simultaneous chronic exposure to CO and noise represents a potential risk to hearing, but reports of tinnitus exist only for cases of intense poisoning from CO [24].
This supports the inclusion of tinnitus prevention initiatives alongside workplace hearing loss prevention initiatives because of shared causal factors.
Information on tinnitus prevention and treatment could have a measurable, positive impact on a person's quality of life.
The authors thank all those who participated in the study for their time, interest, and cooperation. Guidelines for the grading of tinnitus severity: The results of a working group commissioned by the British Association of Otolaryngologists.
Objectives: The aim of current study was to compose and validate a Persian version of the Tinnitus Handicap Inventory (THI-P).
The prevalence of chronic tinnitus in the general population is estimated between 5-15% and causes to develop serious psychosocial complications in 1% to 3%1. It is reported that tinnitus can be severe enough to cause significant discomfort in one's daily life12. Finding the effects of tinnitus on the quality of life and assessing the individual's reaction to tinnitus are very important. The aim of IQOLA is to translate and provide health questionnaires with high validity and reliability for using in different countries by their formal language26. This version is both simple to administer and interpret and also a powerful psychometric tool. After that, each of the expert translators were asked about the difficulties of the translations and they were attributed a score according to the 100 point visual analogue scale (VAS). Afterward, the pooled back translation was compared and formed by translators and then an agreement was obtained for one English version of THI questionnaire for finding the coherency with original version.
Therefore the formulated initial Persian version of the instrument was attended by 24 (10 female and 14 male) high school students in Tehran.
The Cronbach's Coefficient Alpha test (where values>0.70 indicate a satisfactory internal consistency) was used to test for the evaluating internal stability of the THI-P29, and Pearson correlation coefficient was calculated between the total score of the THI-P and the scores of its subscales, age and pure tone average (PTA).
The common language score of THI-P was assessed as desirable in all 25 items (100%) and also the conceptual equivalence for three items (4, 10, 16) undesirable response (12%), for two items (23 and 14) in a relatively desirable level (8%), and the other items were desirable response (80%).
The type of sound reported by most tinnitus subjects was subjectively described as high-pitch tone, matched by external stimuli (described by 52.3% of subjects).
Table 2 summarized the mean air conduction thresholds across frequencies of 500-4000 Hz for left and right ears. As shown in Figure 1, the total score of THI-P and its subscales were not correlated with the age of tinnitus subjects.
Total score of the THI-P and its associated subscales are very close to corresponding values in the original THI-US (Table 6). In Iran, in order to converge and coordinate with the ongoing research at the international level concerning the evaluation of consequences of diseases, impairments, handicaps, treatments and rehabilitation, we should create a new movement. Sense of the various problems among the subject sufferer from tinnitus and understanding the impact of tinnitus on their quality of life are of the uttermost importance. Translation of the original questionnaire of THI in Persian language in overall was easy due to its simple sentences, whereas, the translators in six items acknowledged difficult translation (items of 4, 5, 13, 23, 24 and 25). The translation clarity in 24 items of THI-P was evaluated desirable and only one item (item 17) evaluated as relatively desirable. Majority of epidemiological tinnitus studies have reported a positive relationship between tinnitus and hearing loss4,34-35. This valid tool allows us to quantify how much tinnitus impacts the life's quality of these individuals.
Functional brain abnormalities localized in 55 chronic tinnitus patients: fusion of SPECT coincidence imaging and MRI. Prevalence of tinnitus and hearing thresholds of a non-noise-exposed population with and without tinnitus. Assessment of psychopathological aspects and psychiatric comorbidities in patients affected by tinnitus. Psychologic profile of tinnitus patients using the SCL-90-R and tinnitus handicap inventory.
Psychological profile and somatic complaints between help-seeking and non-help-seeking tinnitus subjects. Tinnitus reaction questionnaire: psychometric properties of a measure of distress associated with tinnitus.
Developmental and Psychometric Adequacy of the Screening Version of the Tinnitus Handicap Inventory.
Psychometric Adequacy of the Tinnitus Handicap Inventory (THI) for Evaluating Treatment Outcome.
Tinnitus with normal hearing sensitivity: extended high-frequency audiometry and auditory nerve brain-stem-evoked responses. Validity of the Italian adaptation of the Tinnitus Handicap Inventory; focus on quality of life and psychological distress in tinnitus-sufferers. Brazilian Portuguese Language version of the "Tinnitus Handicap Inventory": Validity and Reproducibility. Impact of tinnitus as measured by the Tinnitus Handicap Inventory among tinnitus sufferers in Singapore. Of the 72 patients, 93% (67) reported consequent changes in their lifestyle, 56% (40) reported effects on their general health, and 70% (50) reported emotional difficulties [26-29]. House [36] stated, in this regard, that the perception of tinnitus could be determined by specific personality characteristics, a viewpoint shared by other authors as well. The TRQ is based primarily on data provided by Tyler and Baker [25] and on that from the aforementioned TEQ, THQ, and TSS.
Each item is made up of a statement that the subject can rate on a Likert scale with three alternative assessments: 0 (no), 2 (sometimes), and 4 (yes).
The THI was also the main instrument employed in the study of the effects of an acoustic prosthesis on tinnitus, which evaluated 34 patients affected by tinnitus and hyperacusis and using a hearing aid for the first time [65]. The THI beta version is the one currently being used and is the object of our work (Table 1).
Each item is made up of a statement that affected subjects can rate on a Likert scale with three gradations: 0 (no), 2 (sometimes), and 4 (yes). We also computed Pearson's product-moment correlations between the THI and the three subscales (Table 3). Each question is easily and precisely formulated and allows time for the responders to reflect on the actual impact of the symptom on their everyday life situations, unlike a standard interview. The scale that appears to be most independent of the others is the catastrophic scale; however, the low number of items in this scale should be taken into account. In Aran JM, Dauman R (eds), Tinnitus 91-Proceedings of the Fourth International Tinnitus Seminar. In Aran JM, Dauman R (eds), Tinnitus91- Proceedings of the Fourth International Tinnitus Seminar. We address this problem by using customized sounds that reproduce the subjective experience to reduce overactive auditory circuits. Chronic sound sensations of tinnitus affect approximately 17% of the general US population [1-3], or approximately 44 million people, and approximately 33% of the elderly [4]. In one study, tinnitus subjects with depression treated with nortriptyline had decreased depression levels, functional disability, and tinnitus loudness [15,16]. We have hypothesized that mechanisms of lateral inhibition in the auditory areas of the brain act to confine the activity, driving the tinnitus sound perception to regions representing specific frequencies in the central auditory cortex and increasing the contrast between tinnitus-related activity in these regions and spontaneous activity in adjacent regions.
The increased perception can then lead to increased annoyance, completing a positive feedback cycle that will render tinnitus persistent and annoying. Moreover, it has been shown that the changes in the size of the tonotopic map in the auditory cortex can be induced by training [35]. The rationale behind the use of white noise is to generate a decreased signal-to-noise ratio between the tinnitus-related neuronal activity and random background activity in the auditory system. Customized sound therapy (CST) involves an initial session with a sound specialist, during which a "customized" sound is created for each individual and closely mimics the subjective tinnitus. Primary-tinnitus subjects are those presenting to the otology clinic with a main complaint of tinnitus, regardless of type and degree of hearing sensitivity. The audiometer has standard Telephonic THD-39 earphones with MX-41-AR ear cushions (Audiometrics, Oceanside CA) and a standard Radioear B-71 bone vibrator (Radioear Corp., New Eagle PA). We obtained initial baseline auditory brainstem response and auditory middle latency responses for each subject using a currently calibrated and certified electrically safe Biologic Brain Atlas (Advanced Biologic Corp., Toronto, Quebec, Canada) evoked potential machine with ER-3 insert earphones. The tinnitus sound is synthesized according to the description provided by the subjects using the program "pcmusic" [46].
Experience from study 1 indicated that subjects had difficulty in distinguishing the continuous habituation sound from their tinnitus. At 4 kHz, four of eight tinnitus subjects had mild or moderate hearing loss in their right ear, and five of eight subjects had mild hearing loss in their left ear.
Therefore, the intensity settings that tinnitus subjects used on their noise generator gave an estimate of the loudness of the tinnitus.
Some subjects reported changes in the sound quality of their tinnitus, so that their habituation sound was no longer a match for their tinnitus perception. Nonetheless, they were carried out under defined conditions so that changes in the measurements reflected changes in hearing threshold. Both tinnitus and the recruitment due to hearing loss may have influenced the intensity dependence of the N100 response to tinnitus frequency tones.


RI is the temporary suppression of tinnitus that occurs after the offset of an appropriate masking stimulus [48,49]. The main difference between tinnitus sufferers and controls manifested itself in the response to tones one octave below the tinnitus frequency (2 kHz in our studies). Consequently, all study subjects will know whether they are being habituated to a sound mimicking their tinnitus or to a "placebo" sound.
Eighty-two individuals (22% of the total population) had experienced tinnitus and were invited to participate in the study. The equipment used was an Interacoustics audiometer, model AD 229, with TDH-39 earphones, calibrated according to ISO 8253.
The average age of the sample was 29.2 years, and the average duration of noise exposure was 7 years. Moreover, significant results were found for the degree of tinnitus and exposure to chemical pollutants (p = .02). The THI indicated that even the degree 1 "slight" tinnitus experienced by most of the participants who reported tinnitus nevertheless had an impact on their quality of life. For instance, lesions in the neck and the middle ear and sinusitis and headaches increase the risk of tinnitus from 28% to 35%. The findings underscore the need for noise control and other effective strategies to mitigate causal factors.
The use of an instrument designed to evaluate the impact of tinnitus on a person's life, such as the THI, can contribute to a greater understanding of the needs of a specific person or group (or both). Experiencia do hospital das clinicas da faculdade de medicina da Universidade de Sao Paulo. Materials and Methods: The linguistic validation of the original version of THI into Persian version (THI-P) included translation, back translation and data gathering. Epidemiological studies indicated that in developed countries such as Germany about 1.5 million people, in the United States about 10 million out of 40 million tinnitus sufferers and a similar ratio in the United Kingdom have been reported that were seriously affected by tinnitus2-4. Tinnitus symptoms have been linked to various psychological and psychosomatic disorders13-15. One of the most important methods in the assessment of the severity of tinnitus and its effects on the lifestyle of a patient is the use of psychometrical evaluations.
Finally, we formulated the initial Persian version of the instrument with proper and satisfactory translation.
The final version of THI-P was administered in all tinnitus subjects who were managed in our center between September 2009 and May 2010.
The score of "Yes", "No" and "Occasionally" were 4, 0 and 2, respectively in three subscales: emotional, functional and catastrophic.
All personal information in the questionnaire were confidential and only used in this research. The other descriptions of tinnitus included cricket, sizzling, hissing, humming and other sounds. Tinnitus is a subjective idiopathic symptom in which it is not detected by blood examination and CT scan or like this. In this regard, translator 1 and 2 were asked to provide a list of possible alternative translations for the replacement in relatively difficult and difficult items of THI-P.
The prevalence of tinnitus among normal hearing subjects has been reported between 7%-10%36-37. In any case, it is necessary to have an initial basic measurement backing up the clinical audiological evaluation and indicating the degree of tinnitus impact on the sufferers' quality of life.
Each of the instruments described are meant to evaluate the direct effects of tinnitus on hearing and on function in terms of disability level. The Tinnitus Handicap Inventory (THI) [46] is a questionnaire made up of 25 items divided into three subscales: functional, emotional, and catastrophic.
The score of each scale is the sum of the answers to the items that constitute the scale itself. The author stated that both questionnaires are easily used and can be completed quickly -in about 5-15 minutes for the TQ and 10 minutes for the THI-and that directions for operator's use are rather simple, though the THI shows some advantages in terms of reproducibility because it is not subject to copyright. It consists of 25 items, as a result of a selection made from the previous 45, item selection being unaffected by age, gender, and hearing level. For our purposes, we considered audiological data gathered by means of half-octave tonal liminal audiometry and impedanciometry. Subjects were told to read each question carefully and to answer by choosing one of the three possible answers-yes, no, and sometimes- without skipping any question. A Student's t-test for independent samples was used to detect differences between women and men regarding the perception of tinnitus distress (Table 4). Our choice is supported by the results of the test-retest performed on the questionnaire, which corroborated its validity and solidity as a measuring instrument. The results of two preliminary studies indicate that customized sound therapy (CST*) aimed at this central dysfunction reduces tinnitus quickly and safely.
Of this group, estimates project that some 10- 12 million individuals will experience tinnitus problems sufficiently serious to seek professional help [5,6]. Shulman and Goldstein [24] interpreted these as changes in the congruence or dyssynchrony in cortical regions in the auditory and frontal cortices. This leads to increased tinnitus perception and to what most tinnitus sufferers hear-a tone or group of tones, as opposed to cacophonous noise containing all frequencies. In short, individuals experiencing tinnitus unintentionally condition themselves to aggravate tinnitus through negative reinforcement. Taken together, these findings suggest that the observed tinnitus-related changes in the organization of the auditory cortex are the result of the involuntary learning process described earlier. This background activity is achieved by introducing a quasirandom, stimulus-related signal in all of the parallel, tonotopic channels of the auditory system. This is followed by a period of several weeks to months during which the individual listens to the customized sound for several hours every day while going about normal daily activities. On a separate day, subjects' tinnitus sound experiences were characterized and recorded on an MP3 sound player. Behavioral loudness discomfort levels (LDLs) were also recorded at each frequency in both ears using pulsed pure tones with a 200-msec duration and 50% duty cycle.
Auditory brainstem response and auditory middle-latency response two-channel recordings followed clinical recording and analysis parameters outlined in Ferraro's Laboratory Exercises in Auditory Evoked Potentials [45].
In an iterative process, the resulting sound was played back to the subjects, who responded with suggested adjustments, such as altering the pitch, number of components, balance, or quality of the synthetic sound. Within each series, 80 stimuli of different intensities, for a total of 400 stimuli, were presented in random order and at intervals varying randomly between 1 and 3 seconds. Hence, to help individuals compare the loudness of their tinnitus to that of the habituation sound, we instructed them to use the pulsed version of their customized sound. Conversely, only 2 of 12 control subjects had mild or moderate hearing loss in their left ear, and only 1 of 12 control subjects had moderate hearing loss in the right ear. Though most subjects did not keep a detailed log of the volume settings on their MP3 players, clearly the volume setting required for the habituation sound to be just audible over the subject's internal tinnitus perception decreased over time, in one case so much that the subject exhausted the available intensity settings and the stimulus had to be resynthesized at a lower intensity. When a new habituation sound mimicking the changed tinnitus perception was synthesized, the subjects reported the CST to be as effective as before.
The first threshold measured was set to 0 dB normalized hearing level (nHL), and all other measurements were plotted with reference to it. Because CST caused a lowering of the subjects' hearing thresholds at frequencies near their perceived tinnitus pitch, these results reflect an effect of CST, regardless of whether the observed change is caused by a decrease of tinnitus-related neuronal activity or decreased recruitment due to lowered hearing thresholds. Some participants in this study described immediate relief, effects on the THQ, and changes in hearing threshold within 3 weeks. The change in the EEG pattern induced by CST manifests in responses to the tinnitus frequency. However, to assess the efficacy of CST in a crossover trial with comparable therapies might be possible, as that study design would not require a placebo condition and blinding.
Twenty (24%) of the 82 were not able to participate because they lost their jobs before collection of data, 5 (6%) declined to participate saying that they no longer had symptoms of tinnitus, and 5 (6%) were on vacation at the time of data collection.
We performed puretone audiometry for all subjects at frequencies of 0.5, 1, 2, 3, 4, 6, and 8 kHz. The functional subscale, composed of 11 questions, evaluates the limitations that tinnitus induces in the mental, social, occupational, and physical areas.
Table 1 displays the findings pertaining to the health problems and auditory and medical histories described by the participants.
In the THI, tinnitus was shown to have the greatest relationship to the functional scale (54%), indicating that its impact is more noticeable in social, daily, and reading activities involving concentration, auditory acuity, attention, and rest. The analysis of the THI results along with the audiometric results indicated that a considerably greater number of significant correlations were verified in the group with altered hearing, which was expected because the two conditions-compromised hearing and tinnitus-are often associated. Information dissemination on the risks and prevention alternatives is of great importance, as is the management of tinnitus. Finally, it could be used in the design of appropriate strategies to manage tinnitus in the workplace. It is shown that 48% to 60% of patients with chronic or disabling tinnitus have major depressive disorder (MDD)16.
Such self-report questionnaires include the Tinnitus Questionnaire (TQ)18, Tinnitus Handicap Inventory (THI)19, Tinnitus Severity Scale (TSS)20, Tinnitus Handicap Questionnaire (THQ)21, Subjective Tinnitus Severity Scale22 and Tinnitus Reaction Questionnaire (TRQ)23. The THI is a 25-item self-report instrument which is divided into three subscales including functional, emotional and catastrophic reactions to tinnitus.
On the basis of these two translations and their VAS scores to each THI items, we formed the pooled version that was then reviewed by presence of translators for considering suggested replacing words and difficulty in translation. This questionnaire was used as an initial instrument for gathering data from tinnitus subjects at next steps. Each single item was read loudly and the participants were asked to follow the items on the given sheet. Age, gender, medical history and tinnitus characteristics were recorded as baseline information. In total, more than 92% of tinnitus subjects who attended the current study revealed high pitch tinnitus, matched by external stimuli (>3000 Hz). Independent Student t-tests did not demonstrate statistically difference between total THI-P score and those with or without hearing impairment, neither did those with unilateral or bilateral tinnitus (Table 4). The main problem with tinnitus is its subjective nature so that evaluation of this complaint always depends upon patient's words.
These alternative items were reviewed again by translator 3 and 4 in order to optimize quality of translation and finally revised for appropriate items. In conceptual equivalence of the translation, three items had undesirable response (4, 10 and 16) and two items had relatively desirable response.
The THI has been widely employed at an international level in clinical contexts, both to evaluate the subjective perception of handicap level and to measure the outcomes of treatments [47-51]. Perhaps this is the reason for the frequent choice of the THI by several work teams in recent years. We had the questionnaire translated a first time by a bilingual translator; since then, the translated test has been back-translated into the original language to guarantee that the author's scope was respected for each question. Participants described immediate relief, showed changes on the Tinnitus Handicap Questionnaire, and reported changes in hearing threshold within 3 weeks. Approximately 20% suffer to a degree that their quality of life and productivity are impaired [7]. Similarly, magnetoencephalography (MEG) studies [25] have reported increased gamma-band activity in a resting condition in individuals with tinnitus. Shulman [31] demonstrated the changes in cortical and limbic regions in tinnitus subjects as compared to controls and hypothesized a final common pathway for tinnitus. Because training-induced changes in the response pattern of cortical neurons can be reversed by habituation, we hypothesize that habituation will ameliorate tinnitus. TRT is available currently, but it is expensive, time-consuming, of long duration, and only incompletely effective.
Furthermore, subjects' tinnitus had to be present all the time with constant sound quality.
We instructed each subject to push the signal button when an increasing continuous pulsed pure tone reached a subjective loudness level that represented initial annoyance. The evoked potential recording protocols sequentially programmed into the Brain Atlas were the same for each subject. In response to these suggestions, we modified the sound description file and repeated the process until the subjects reported that the synthesized sound matched their subjective tinnitus experience well. The EEG was amplified by 10,000 and band-pass filtered between 0.01 and 100 Hz at 3 dB down. This facilitated the determination of the requisite intensity, at which point they could switch over to the continuous sound for the habituation itself.
After 1 hour of habituation, the hearing threshold at the tinnitus frequency was lowered by as much as 15 dB nHL. Observations from one subject indicate that most of the tinnitus relief is gained during the first 4-8 weeks of CST.
However, the contrast between responses to tinnitus frequency tones and tones one octave below the tinnitus frequency was not changed after 3 weeks of CST. Therefore, the final sample of the study consisted of 52 participants: 11 females (9% of the total of 120 noiseexposed female workers in the studied plant) and 41 males (16% of the total of 252 noise-exposed male workers in the studied plant). The emotional subscale, composed of 9 questions, includes affective answers for tinnitus (anger, frustration, irritability, and depression). All participants exposed to noise levels greater than 85 dB are required to use ear muffs, and information on their use and maintenance are given when workers are hired. The emotional scale was the second most affected and is related to manifestations of nervousness, frustration, irritation, depression, anxiety, insecurity, and difficulty in relationships with family and friends.
Estabelece diretrizes e parametros minimos para avaliacao e acompanhamento da audicao dos trabalhadores expostos a niveis de pressao sonora elevados.
In addition, tinnitus is a common symptom of the auditory system disorders that is usually associated with sensoryneural hearing loss6,7.
Asplund reported that among subjects with tinnitus poor sleep and frequent waking were more common in men and women17. In this regard the client was questioned in order to find out which activity or performance of the patient is affected by tinnitus. Analysis of the THI items suggested that this self-report instrument had excellent internal consistency reliability and adequate convergent and constructive validity28. It is worth to mention that in this step, for differentiation of the level of difficulty in translation, average scores less than 25 were considered as easy, more than 30 as difficult and between 25 and 30 as relatively easy.
Thus, items with undesirable translation were revised by translator 5 and 6 and revised by suggested replacing proper words, sentences and phrases.
As reported in several studies for the original version (US), Italian, Turkish, Danish, Portuguese and Singapore translations of THI19,28,38-41, the Persian version of THI was not significantly different in the handicap scores between those with normal hearing and those with hearing impairment with regard to the degree of handicap severity. Eventually it became clear that internal consistency was high and the response of every item to the response of total items was matched. The main factor is relevant to the social and emotional spheres and to problems of sleep and rest. This scale refers to the reactions of people interacting daily with tinnitus sufferers; therefore, rather than assessing the sufferers themselves, it is an additional instrument for the evaluation of how relatives, friends, and colleagues support or interact with sufferers. The test has, indeed, been translated and validated into Danish, Spanish, Korean, Brazilian Portuguese, and German. According to Dobie [54] as well, both the TQ and the THI are likely to become common instruments for any work team involved in the diagnosis and treatment of tinnitus [55,56]. We also saw changes in the intensity dependence of the auditory N100 in tinnitus patients, supporting the idea that tinnitus reflects a reorganization of tonotopic maps in the auditory cortex. This translates to between 2% and 3% of the population whose lives are adversely affected by tinnitus [8,9]. Studies in experimental animals and humans have suggested that tinnitus is associated with a synchronized hyperactivity in the auditory cortex and proposed that the underlying pathophysiological mechanism is thalamocortical dysrhythmia.
More precise methods of habituation have been suggested by computational models of tinnitus [37-41]; for a review, see Husain, [42,43]. This external sound appears to calm the internal overactive circuits and is not associated with annoyance and anxiety.
Subjects were initially interviewed at the Otolaryngology Clinic to ensure that they met all exclusionary criteria. The LDL was repeated at each standard test frequency to determine whether the initial level was stable or adjusted upward. We required subjects to document the time during which the sound player was used and the intensity settings. Over several weeks of habituation training, we observed hearing thresholds at the tinnitus frequency to decrease by as much as 25 dB nHL.
After this initial period, apparently wearing the sound device regularly is unnecessary, and the experience with this one subject indicates that using the habituation sound occasionally as needed may be sufficient. Therefore, whether longer CST treatments can completely reverse the cortical reorganization associated with tinnitus remains to be seen. We also performed daily biological calibration checks on the audiometer immediately before testing subjects. Last, the catastrophic subscale is composed of 5 questions and examines the most severe reactions from tinnitus (desperation, loss of control, inability to face problems, inability to escape tinnitus, and fear of having a serious ailment)[12]. Walkthrough observations suggest that use of the hearing protection is high, but no information exists on the consistency of hearing protection use. The catastrophic scale demonstrated alterations related to desperation, intolerance to tinnitus, and loss of control in situations when experiencing tinnitus (see Fig. All participants complained of chronic unilateral or bilateral subjective idiopathic tinnitus lasting for at least 6 months before consulting about their tinnitus. An epidemiological study in Italy based on a tinnitus questionnaire demonstrated that the prevalence of tinnitus was 8% in normal hearing subjects while this amount rose up to 30.5% in the presence of auditory dysfunctions8. This agreed version of Persian THI translation was given to the two other translators who were expert to Persian philology (translator 3 and 4).
Finally, the results of the present investigation suggest that the THI-P was simple and clear, without losing its equivalence towards cultural issues. All values of item-total correlation coefficient are greater than 0.3 which also indicated high internal consistency in THI-P except item 19. The second factor refers to hearing capacity, and the third covers patients' opinions on tinnitus.
Considering the growing interest in tinnitus in Italy, our study objective was to work at the cultural adaptation of the questionnaire to the Italian language and to its validation.
Unfortunately, neither of the two questionnaires takes into consideration the presence of hyperacusis as an accessory phenomenon, though the relevant literature states that some 40% of tinnitus sufferers report this symptom as well. The final score obtained is directly proportional to the impact of tinnitus on the sufferer's life. Tinnitus is perceived even in the presence of environmental sound; however, daily activities are not impaired.
The main correlate of this reorganization was the enhanced contrast between responses to the perceived tinnitus pitch and tones approximately one octave lower. Estimates anticipate that the number of serious tinnitus cases will increase significantly over the next few years. Hence, decreased auditory stimulation results in decreased firing rate and decreased lateral inhibition.
These models explain how a decreased auditory input resulting from a peripheral hearing deficit can give rise to a specific tinnitus pitch.
One contained a pulsed version of the subjects' tinnitus sound (250-msec pulse duration, 50% duty cycle), and the other was a 180-sec-long continuous sound.
For stimulus presentation and data acquisition and analysis, the ADAPT scientific software [47] was used. In our study, factors such as gender, age, tobacco, and exposure to firearms were not significantly associated with tinnitus. Results: There was no significant difference between gender, age, hearing impairment and total score and subscales of THI-P. Therefore, the valid psychometrical evaluations such as THI can be administered as a robust instrument to objectify tinnitus distress, but additional measures might be needed in order to catch the dimensions of tinnitus-related problems. Inoverall the translation quality of THI-P was evaluated as desirable from both aspects of a careful translation and adapted to the socio-cultural setting.
After 3 weeks of CST, the intensity dependence to the tinnitus pitch decreased, making these responses more similar to those from normal subjects responding to tones in the same frequency. When the tinnitus sound itself is used as a habituation stimulus, Langner's model predicts that the tinnitus should disappear. Directive counseling would tend to draw the individual's attention to the tinnitus, whereas habituation is designed to draw attention away from the tinnitus. We recorded responses to pure-tone sounds at and below the tinnitus frequency before and after the 1-hour habituation treatment. Two subjects dropped out after reporting strange sounds from their MP3 player that seemed to make their tinnitus worse.
We then downloaded the digitized sound into a small portable digital sound playback device (MPEG-player). The underlying rationale for CST is to draw subjects' attention away from their tinnitus, and reports indicate that though subjects readily perceive their tinnitus and the habituation sound if they choose to, CST helps them to ignore their tinnitus. Coles [26], among several authors, reported that the worse the hearing is, the more probable is the occurrence of tinnitus. Pearson product-moment correlations revealed adequate test-retest reliability for the THI-P (r = 0.96). Also the valid questionnaires are valuable in the evaluation of results from before to after special treatment and its effect on the individual's quality of life. This model also assumes that the limbic system is a necessary component for stabilizing the tinnitus perception. In one case, the cause of the disturbing sounds was a defective MP3 player; in the other case, the disturbing sounds were caused by an artifact in the conversion of the digitized sound from the WAV to the MP3 file format.
The time needed for this successive approximation procedure varied, depending on the subjects' ability to describe their subjective experience of tinnitus and on their ability to characterize differences between the tinnitus they experience and the sounds being synthesized by the computer. Directive counseling in connection with CST might actually be counterproductive because it might remind subjects of the annoyance associated with untreated tinnitus and thereby draw their attention to their tinnitus rather than away from it. Therefore, the symptom of tinnitus has forced clinicians to attempt to establish protocols for accuracy of tinnitus diagnosis and treatment9. The Tinnitus Handicap Inventory (THI)25 has gained widespread acceptance as a self-report measure of tinnitus around the world. Therefore, these translators (3 and 4) for each question determined 3 scores on the basis of 100 point criteria. Therefore, the Persian translation of THI was not affected by hearing impairment, gender and age factors. On the basis of these models, we propose to use a frequency-specific or "custom-made" sound similar to an individual's tinnitus for habituation purposes. Halfway through the training period, we scheduled a second session to characterize the tinnitus sound to ensure that the stimulus still matched the subjects' tinnitus perception. In one case, data were excluded because the subject did not wear the MP3 player for the requisite time and was not present for the follow-up examination owing to scheduling conflicts. Because it produces effects after only a few weeks of treatment without involving directive counseling or requiring frequent regular visits to health care professionals, CST is expected to provide quick and lasting relief from tinnitus at relatively low cost. Approximately 20% of the patients with hearing loss present complaints of tinnitus, whereas 90% of those with severe tinnitus had hearing loss. In this VAS, zero point means absolutely improper quality and 100 means absolutely proper and satisfactory quality. After that, the subsequent processing was attended by audiologists from department and research center of otolaryngology of Tehran University of Medical Sciences (TUMS). We conjecture that using a customized sound and mimicking the tinnitus as closely as possible should be highly efficient in reducing the perception of tinnitus. After 3 weeks, all subjects underwent a second EEG and audiological assessment and a final clinical evaluation. Before beginning CST, we required subjects to confirm that the habituation sound matched their tinnitus during two or more sessions separated by at least a week. Further, though adding a replica of the annoying sound that tinnitus patients experience would appear to be even more annoying, the method of playing the replica at the same volume as the experienced sound minimizes any discomfort.
Criteria for decision making in improper quality of each translation items was the average score less than 90 (determined by translators 3 and 4). Adjustments to the stimulus were needed for some subjects after CST had progressed a few weeks. Accordingly, in this step, Persian version of the THI was obtained, which regarding to all translators 1 to 4, had satisfactory quality. It seemed clear that this was owing to changes in the characteristics of the tinnitus itself rather than a mismatch in the initial sounds.




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