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Many TMD patients with coexisting tinriitus find TMD therapy improves or resolves their tinnitus in conjunction with their TMD symptoms (Table I).
Some tinnitus characteristics, associations and clinical tests have been suggested as helpful in identifying which patients with coexisting TMD and tinnitus will obtain tinnitus improvement from TMD therapy. Through a questionnaire, Vernon ct al.19 attempted to separate tinnitus patients in an otolaryngology clinic into TMD and non-TMD groups. Rubinstein et apo divided tinnitus patients into TMD and non-TMD groups based on presence or absence of TMD symptoms and reported subjects in the TMD group had gradual tinnitus onset more often than in the non-TMD group. Clinical tests might further be able to identify TMD patients whose tinnitus would improve through therapy. This prospective study assessed TMD patients for tinnitus characteristics, tinnitus associations and clinical test results to determine if any variables would identify TMD patients whose tinnitus would improve or resolve with TMD therapy. Two hundred and sixty-seven TMD patients referred to a TMD specialty clinic, diagnosed with TMD, were asked if they had ringing or buzzing in their ear or head. The subjects were provided conservative TMD therapy in a manner thought to be most advantageous for their TMD disorder. The data was evaluated to determine which questions and tests were associated with improvement in tinnitus when significant TMD symptom improvement is obtained. Two hundred and sixty-seven TMD patients were evaluated, 101 reported coexisting tinnitus and 42 rated their tinnitus as moderate or severe. The subjects' tinnitus characteristics, tinnitus associations and clinical test results are summarized in Tables II, III and IV with subjects separated into groups according to their tinnitus change.
Only TMD patients who rated their tinnitus as moderate or severe were chosen for this study because it is thought that these patients would be more representative of patients consulting their physician for a tinnitus complaint rather than their dentist with a TMD complaint.
Tinnitus severity was the only characteristic (Table II) found significantly related to tinnitus outcome. Tinnitus pitch was not found to be significant (P = 0.613) nor was a trend noted for a relationship between the selected pitch range and tinnitus improvement through TMD therapy. Five of the eleven tinnitus associated questions (Table III) were significantly related to the subjects' outcome. Similar to our finding that a subject reporting normal hearing in the ipsilateral ear (Question 1) were significantly more likely to report tinnitus improvement, Erlandsson et al.18 also identified normal hearing or compensated hearing loss as a 'predictor for a subject's tinnitus improving from dental TMD therapies and biofeedback therapy. Among the clinical tests evaluated (Table IV), the investigator was only able to reproduce or intensify tinnitus for 22 of the 33 subjects (67%) who reported tinnitus improvement.
Maximum voluntary clenching was the only clinical test evaluated found significantly related to tinnitus outcome. In order to rule out a coexisting TMD problem, the author recommends the practitioner first observe for masticatory muscle or TMJ tenderness signs by applying two pounds of force to the extraoral masticatory muscles and one pound to the TMJs and intraoral muscles.5 This is a considerable amount of force. A valuable prediction would be if this exam was able to reproduce or intensify the patients' tinnitus, because all subjects reporting a positive tinnitus response to at least one of the clinical tests listed in Table IV, reported tinnitus improvement after TMD therapy.
The practitioner should be able to identify most TMD patients by observing for TMD signs in this manner and inquiring about TMD symptoms.
This study observed for a change in tinnitus among patients whose primary complaint was TMD symptoms who had concomitant tinnitus. Statistically significant questions and clinical tests were identified which may be helpful for patients with SIT and TMD in determining whether TMD conservative therapy should be considered in the evaluation and treatment or co-treatment of tinnitus.
Disclaimer: The opinions expressed in this article are those of the authors and are not to be construed as official or as reflecting the views of the United States Air Force or the Department of Defense. Door gebruik van een audiogram kan men een uitspraak doen over een eventuele gehoorbeschadiging.
Een verlies in de hoge tonen zal leiden tot het niet meer goed kunnen waarnemen van de voor spraak zo belangrijke medeklinkers (m, n, b, s, t etc.). The relationship between tinnitus pitch and the edge frequency of the audiogram in individuals with hearing impairment and tonal tinnitus. In onze praktijk hebben we de audiogrammen vergeleken van a€?oren met oorsuizena€?en a€?oren zonder oorsuizena€?. We will be provided with an authorization token (please note: passwords are not shared with us) and will sync your accounts for you. Models of tinnitus suggest roles for auditory, attention, and emotional networks in tinnitus perception.
The majority of studies investigating tinnitus processing have approached it from a neuroanatomical or physiology tradition (Roberts et al., 2010) often using pain as an analogy (Moller, 2000).
The multi-dimensional nature of tinnitus is well demonstrated by the incongruence between self-report of tinnitus magnitude and psychoacoustic intensity matches (Baskill and Coles, 1999).
Sound therapy is aimed at facilitating the process of habituation of both tinnitus-induced reaction and tinnitus perception by decreasing the difference between tinnitus-related neuronal activity and background neuronal activity. Adaptation level theory is a longstanding psychoacoustic theory commonly used to explain and quantify the differences in signal and background described by Jastreboff above.
Helson (1964) postulated that the adaptation level was a weighted product of three components (external and internal): (1) Focal stimuli, (2) background or contextual stimuli, and (3) residuals. Where A is the adaptation level, X is the geometric mean of the focal stimuli, B is the background stimuli, and R are residuals (memory, arousal, and personality). The processes involved in tinnitus perception are likely to be similar to the analysis of complex sounds (Zenner et al., 2006). Tinnitus is unusual in that its internal representation conflicts with our sensory expectations and ability to generalize to experience. The mechanisms underpinning interaction of sound with tinnitus (Principle 3) are not well understood. The level of sound in the environment affects tinnitus perception (Heller and Bergman, 1953) this observation is important for understanding the role of ALT in the psychoacoustics of tinnitus. If these findings are applied to tinnitus some of the variability between psychoacoustic loudness matches and magnitude estimations may be explained. The residual component of Helson’s theory consists of psychological and individual factors that can influence perception. Increasing evidence points toward the role of attention in tinnitus perception (Cuny et al., 2004).
Like ASA and streaming (Griffiths and Warren, 2004; Snyder and Alain, 2007), tinnitus is probably the result of complex interactions at multiple levels of the auditory system. Adaptation level theory is a psychophysical theory and does not attempt to ascribe a physiological mechanism to change in tinnitus, but it can accommodate many existing models. Alongside differing theoretical basis one of the most obvious differences in the use of sound in these therapies is the level used.
The most effective level (mixing point) governed by these five factors was proposed to occur at approximately 30 dB SL (Jastreboff, 1999b). The fact that adaptation level is a weighted mean of external and internal stimuli implies that the influence of one class of stimuli may be counteracted by sufficient emphasis on other classes of stimuli. The uncertainty surrounding ideal therapeutic sound parameters are not solely limited to intensity. 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. Forty TMD patients rating their tinnitus as moderate or severe, were asked questions and participated in clinical tests. A study summarizing the symptoms of a group of 164 patients with TMD symptoms, reported the two most common words patients used to describe the quality of their pain were pressure (48%) and dull (27%), but throbbing (26%), sharp (18%), burning (16%) and heavy (14%) were also frequently used.5 The location of the pain also greatly varies.
Many of these patients complained of masticatory fatigue (40%), stiffness (20%), swelling (12%), and weakness (18%) in spite of no observable cranial nerve deficit. Erlandsson et al.18 suggested TMD patients with normal hearing, low tinnitus intensity and fluctuations in tinnitus intensity would obtain tinnitus improvement from TMD therapy.
Significantly more subjects in the TMD group reported tinnitus alterations from jaw movement, pain in the ipsilateral ear, fullness in the ipsilateral ear and more than one tinnitus sound. This study suggests gradual tinnitus onset may be another predictor for tinnitus improvement from TMD therapy. Shulman1 speculated if tinnitus patients can intensify their tinnitus by clenching their teeth, TMD is contributing to their tinnitus.
Maximum Voluntary Clenching, Subjects were asked to bite on their posterior teeth as hard as they could for one minute but stop if they developed intolerable pain.
Jaw Movements, Subjects were asked to maximally move their mandible to the right, left, and forward and open.
Pressure Applied to Ipsilateral TMJ, The ipsilateral TMJ was palpated on the lateral pole and posterior aspect with the mouth wide open, using one pound of force for one to two seconds. Statistical comparisons between the three groups was completed by Analysis of Variance (ANOVA) with Fisher's LSD Multiple Comparison post-hoc test for age.
Group 1 reported their tinnitus was resolved, Group 2 had significant tinnitus improvement and Group 3 had no tinnitus improvement in spite of having significant TMD improvement. The only variables found to have a significant difference between Groups 1 and 2 were Question 5 and maximum voluntary clenching; between Groups 2 and 3 were Question 4 and maximum voluntary clenching. Most TMD patients are between the ages of 20 and 40 years old while most tinnitus patients are between 40 and 80 years old.2,26 It appears the etiology of the tinnitus for our younger patients tended to be from TMD while older patients tended more often to be from another cause.
Subjects rating their tinnitus as moderate were significantly more likely to report tinnitus improvement than if they rated it as severe. This corroborates a similar finding by Vernon et al.19 in which they found no significant difference in tinnitus pitch between their TMD and non-TMD groups of tinnitus patients.
Subjects reporting "yes" to Questions 1, 3, 4, or 5, or "no" to Question 11 were significantly more likely to report tinnitus improvement. Questions 3 and 4 attempt to identify whether the subject had a temporal relationship between tinnitus and TMD. Interestingly, all subjects who had no change in their tinnitus did not have a positive clinical test. It was the test most frequently able to elicit a positive tinnitus response, occurring for 17 of the 33 subjects (52%) who had tinnitus improvement.
It is not uncommon for the author to observe his residents reluctant to apply this amount of force and unable to elicit masticatory muscle or TMJ tenderness in a TMD patient.
But only 67 percent of the subjects who reported tinnitus improvement had a positive tinnitus response to one of these tests. Many TMD patients with coexlstmg tinnitus find TMD therapy improves or resolves their tinnitus in conjunction with their TMD symptoms.
The statistically significant questions identified with tinnitus outcome improvement in this study may help practitioners identify which TMD patients may obtain tinnitus improvement with TMD conservative treatment.
Their tinnitus was reproduced or intensified from one minute of maximum voluntary clenching on their posterior teeth.
The authors speculate these findings may be generalizable to patients whose primary complaint is tinnitus and have coexisting TMD.
National Institutes of Health Technology Assessment Conference Statement: Management oftemporomandibular disorders. Schiffman E, Haley D, Baker C, Lindgren B: Diagnostic criteria for screening headache patients for temporomandibular disorders.
Kelly HT, Goodfellow OJ: Vertigo attributable to dental and temporomandibular joint causes. Gelb H, Calderone JP, Gross SM, Kantor ME: The role of the dentist and the otolaryngologist in evaluation tem poromandibular joint symptoms. Bernstein JM, Mohl ND, Spiller H: Temporomandibular joint dysfunction masquerading as disease of the ear, nose and throat. Kerstein RB: Treatment of myofascial pain dysfunction syndrome with occlusal therapy to reduce lengthy disclusion time - A recall study. Vernon J, Griest S, Press L: Attributes of tinnitus that may predict temporomandibular joint dysfunction. Rubinstein B, Erlandsson SI: A stomatognathic analysis of patients with disabling tinnitus and craniomandibular disorders (CMD). Rubinstein B, Axelsson A, Carlsson GE: Prevalence of signs and symptoms of craniomandibular disorders in tinnitus patients. Wright EF, Schiffman EL: Treatment alternatives for patients with masticatory myofascial pain. Het audiogram is een grafische voorstelling van de absolute gehoordrempel van een persoon als functie van de frequentie.


This means that you will not need to remember your user name and password in the future and you will be able to login with the account you choose to sync, with the click of a button. This page doesn't support Internet Explorer 6, 7 and 8.Please upgrade your browser or activate Google Chrome Frame to improve your experience. A model of tinnitus audibility based on Helson’s (1964) adaptation level theory (ALT) is hypothesized to explain the relationship between tinnitus audibility, personality, memory, and attention. An additional approach is to consider tinnitus from a psychoacoustical perspective (Penner and Bilger, 1995) in which audibility is governed by context, memory, attention, and personality (Welch and Dawes, 2008). A person who suffers from tinnitus may report it as sounding very loud, but match it to a low-intensity external sound (Jakes et al., 1986). Since all our senses work on the basis of differences between signals and background, and not on its absolute value, by decreasing the difference between the tinnitus signal and the background neuronal activity it is easier for the central nervous system to filter out or block tinnitus-related activity. The weighting coefficients p, q, and r determine the relative contributions to adaptation level.
Tinnitus is perceived as a distinct auditory object (Principle 1) patients report specific tinnitus sounds and seek to identify their source (Feldmann, 1992).
True sounds can cover (mask) each other by reducing probability of detection, interfere with different identifying features (example pitch), or disruption of meaning (Kidd et al., 2002).
Unlike true sounds tinnitus does not have a source that can be seen, touched or correlated to other sensory input (Feldmann, 1992). Most psychoacoustic evaluations are undertaken in the very quiet environment of sound treated audiological booths, quite unlike the normal soundscape of the individual with tinnitus. The experimental condition and simple addition of a comparison sound can bias the adaptation level.
Memories of sound, past experience, arousal level, and personality will have a strong or negligible effect on tinnitus depending on the individual residuals influencing factors such as an individual’s signal detection criterion (Welch and Dawes, 2008). In ALT, attention has an important role in determining focus and possibly weighting of different components to the adaptation level. There are many potential mechanisms which could account for a changed audibility of tinnitus over different timescales including habituation (Jastreboff, 1999a), reversal of cortical reorganization (Okamoto et al., 2010), and gain related processes (Norena, 2011). The first sound therapy approaches attempted to relieve tinnitus by totally, or more often partially, masking the tinnitus. Although the use of sound at the tinnitus mixing point, as described by Jastreboff (1999b), has found wide acceptance clinically, there is limited evidence at this point that it is superior (or not) to other sound levels. According to ALT the level of sound is not the only consideration for tinnitus magnitude reduction; attention, arousal, personality, and other factors such as memory are critical components to the detection and audibility of tinnitus. 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).
Upon completion of TMD therapy, 21, 12, 7 and 0 reported thfir tinnitus was resolved significantly improved, unchanged and worse, respectively. It was speculated that these features may also predict which TMD patients with coexisting tinnitus would obtain tinnitus improvement through TMD therapy. Shulman1 speculated that patients with SIT would also report a history of gradual tinnitus onset. Rubinstein et al.21 observed audiology clinic patients who reported tinnitus alteration when pressure was applied to the ipsilateral TMJ, load was applied to the ipsilateral TMJ and resistance applied against mouth opening or protruding. Subjects were asked to open slightly (approximately 3 mm), The palm of one hand exerted cranially directed force on the inferior border of the mandible while the palm of the other hand supported the cranium.
Subjects were instructed to open while approximately one pound of finger pressure resisted their opening. Subjects were instructed to protrude their mandible while approximately one pound of finger pressure resisted their movement. Comparisons between the groups on each question was analyzed by Pearson's Chi-square Statistic with Yates Correction and Fisher's Exact Test as appropriate. Fisher's LSD Multiple Comparison post-hoc test revealed the significant difference was between Groups 1 and 3 and between Groups 2 and 3. The authors speculate pure tone audiometric assessment to identify the frequency spectrum of a patient's tinnitus would not be productive for identifying patients with coexisting TMD and tinnitus, who would obtain tinnitus improvement through TMD therapy.
Practitioners should be aware that maximum voluntary clenchine; often causes a TMD patient's pain to intensify,27 Therefore, the subjects in this study were instructed to bite on their posterior teeth as hard as possible for one minute but stop if they developed intolerable pain. Some patients do not interpret the pressure or dull quality as "pain," but only consider it an uncomfortable feeling that they have become used to having. Consequently, the authors recommend practitioners consider TMD in their differential diagnosis for nonotologic otalgia.
The authors recommend additional research be conducted evaluating the questions and clinical tests listed above with patients whose primary complaint is tinnitus and have concomitant TMD.
Orhan Ozturan, Inonu Universitesi, Malatya, Turkey, for the critical insight he provided him in the design of this study.
In het audiogram naast de tekst is met een blauwe banaan weergegeven bij welke frequenties en met welke intensiteit 'normale' spraak zich voordoet. This theory attempts to describe how tinnitus audibility or detectability might change with experience and context. The process that the auditory system uses to identify and differentiate auditory objects has become known as auditory scene analysis (ASA; Bregman, 1990). It is also known that the common report of tinnitus is far more frequent than complaints of tinnitus effects on quality of life (Gopinath et al., 2010). The adaptation level is an anchor or reference point for sensory magnitude and discrimination (Helson, 1964; Coren and Ward, 1989). We suggest that contributions of residuals, focal, and background stimuli need to be considered in judgment of tinnitus, along with the role of attention in emphasizing each elements importance.
Tinnitus may be considered the focal or stimulus of interest, while background noises are competitive stimuli. Tinnitus is recognized as comprising a combination of frequency, intensity, and temporal patterns that enable the individual to differentiate between tinnitus’ auditory signature against other sounds (Principle 2) so successful is the auditory system at this task probably aided by attention (see discussion on weighting factors) and Gestalt-like grouping [similar to figure-ground in visual perception (Qiu and Von Der Heydt, 2005)] that masking may not be achievable (Feldmann, 1971). This conflict with the environment and memory of true sound characteristics may trigger adaptive tuning (Grossberg et al., 2004), attention, and inhibitory mechanisms that would normally sub-serve a role in improving sound source identification, consequently further driving attention to the tinnitus perception. Tinnitus sufferers will report, and magnitude estimations support, tinnitus as a loud intrusive sound, however, psychoacoustical tinnitus loudness matches are low, rarely greater than 20 dB above threshold (Penner, 1986). In magnitude estimations tinnitus is usually compared to the quiet environment of the consultation room or research laboratory. Alertness and orientation effects are likely to affect the perception of loudness (Stallen, 2008). The perception of tinnitus in therapeutic sound is, perhaps, analogous to hearing sounds of interest in background noise. 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. The subjects' ages, questions results and clinical test results were statistically evaluated for an association with their tinnitus change.
Additionally, palpation of the deep masseter, medial pterygoid, lateral pterygoid and sternocleidomastoid muscles have been reported to reproduce or intensify a patient's tinnitus.22 Since TMD therapy heIps resolve TMJ and masticatory muscle tenderness, positive clinical tests that reproduce or intensify a patient's tinnitus might predict patients who would have tinnitus improvement from TMD therapy.
Participants were asked about their tinnitus characteristics and associated questions (Tables II and III). The palmar surface of the index finger palpated these areas using one to two pounds of force for one to two seconds. Of the 40 subjects completing this study, 21, 12, 7 and 0 reported their tinnitus was resolved, significantly improved, unchanged and worse, respectively. Similarly, Bushl5 found patients rating their tinnitus as severe were less likely to report tinnitus improvement from TMD therapy. Other tests that frequently elicited a positive tinnitus response were palpation of the posterior digastric muscle (36%) and masseter muscle (33%), and loading of the ipsilateral TMJ (33%).
Therefore, the author palpates very lightly at first, gradually increases the force up to these limits but stops as soon as tenderness is noted.


Deze drempel wordt bepaald bij verschillende frequenties: 125, 250, 500, 1000, 2000, 4000 en 8000 Hz.
Sommige theorieen van het ontstaan van tinnitus geven aan dat de dip in het audiogram is gerelateerd met de grenstheorie. The basis of ALT and potential role of auditory scene analysis in tinnitus perception are discussed. In this paper we introduce an empirically testable model of tinnitus audibility based on Helson’s (1964) adaptation level theory (ALT) and we discuss potential roles for ASA in differentiating tinnitus from ongoing auditory activity, consistent with previous models describing pattern recognition roles in tinnitus perception (Jastreboff, 1990).
The strength of a stimulus is compared to the central point of reference (the adaptation level), sensations below the ALT are less, above greater, the larger the distance between the adaptation level and stimulus the stronger it is (Broadbent and Ladefoged, 1960; Lauterbach, 1979). In the following discussion we suggest how these three components interact to create the tinnitus percept. Attempts to explain the difference between the sufferers rating of tinnitus magnitude and loudness match to external sounds have centered on loudness recruitment (Penner, 1986). Loudness matches using an external matching sound are not compared to the absence of sound, but instead to a new adaptation level which incorporates the test stimulus with the existing reference point of tinnitus. The detection and maintenance of tinnitus in the sensory and cognitive domains will interact with individual differences in health, coping, acceptance, motivation, and personality to determine magnitude of response (Helson, 1964; Revelle, 1995). The sound levels in different environments (busy office, quiet bedroom, and party) can increase or decrease audibility of tinnitus in a manner predicted by ALT. Following detection tinnitus may become a problem due to multiple overlapping networks one of which is a distress network (consisting of the anterior cingulate cortex, amygdale, and anterior insular) with memory mechanisms playing a role in awareness of tinnitus and reinforcement of distress (De Ridder et al., 2011).
Most clinicians believe that total masking, so that tinnitus is inaudible, is not achievable without conflicting with comfort, consequently lower levels of therapeutic sound have been advocated (Tyler, 2006). 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. The following were identified as significantly associated with tinnitus improvement when the patient reports: they are younger in age, their tinnitus is moderate rather than severe, their hearing is normal, their tinnitus began approximately when their TMD symptons began, their tinnitus is worse when their TMD symptoms are worse, their tinnitus is related to stress, their tinnitus is unrelated to loud noise and their tinnitus is reproduced or intensified from one minute of maximum voluntary clenching on their posterior teeth.
The pitch of their tinnitus was determined by asking the subject to select one of three categories which most accurately identified its range: below, within or above voice range. The sternocleidomastoid muscle was palpated between the thumb and index finger along its full length. Following successful conservative TMD therapy, subjects were asked if their tinnitus was resolved, significantly improved, unchanged or worse, during the two to six months they were followed. The proposed psychoacoustic model lends itself to incorporation into existing neurophysiological models of tinnitus perception. Tinnitus audibility is defined here as a stimulus dimension to which many variables contribute to tinnitus being heard.
The pioneering work of Heller and Bergman (1953) suggested that spontaneous auditory perceptions occur in a majority of people given an ideal signal detection context.
The use of the terms are often governed by the training of the author, for example, adaptation is often used in physiology to describe a change, possibly short-term, in the response of sensory systems following stimulation, habituation is a decrease in response after repeated stimulation, sensitization an increase in response with repeated stimulation. Judgments of tinnitus magnitude are hypothesized to change over time according to situation, attention, and psychological factors.
Loudness recruitment occurs in the presence of hearing loss and is an elevation in threshold without an increase in loudness discomfort levels; this results in a reduced dynamic range and more rapid growth of loudness (Penner, 1986).
The relationship between the stimulus (matching sound) and prevailing level (tinnitus) determines its perceived magnitude and quality. If tinnitus is seen as being behaviorally important (Jastreboff and Hazell, 2004) or perceived out of context, conflicting with reality (Feldmann, 1992) it will take on greater importance relative to other sounds. If there is a reduction in background sound levels or a change in focus there will be a greater weighting to tinnitus. Jastreboff (1999b) proposed an effectiveness function for sound levels to be used in the habituation-based Tinnitus Retraining Therapy (TRT). 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. These findings may help forecast which tinnitus patients with concomitant TMD may obtain tinnitus improvement through TMD therapy.
Subjects also participated in clinical tests (Table IV) to determine whether tests reproduced or intensified their tinnitus. Het gehoorverlies wordt uitgedrukt in het aantallen dB's verschil ten opzicht van de 0 lijn - de normaalhorende. It is hoped that the ALT hypothesis will allow for greater empirical investigation of factors influencing tinnitus perception, such as attention and tinnitus sound therapies. Perception of tinnitus-like sounds occurs in between 64% (Tucker et al., 2005) and 94% (Heller and Bergman, 1953) of people without tinnitus when listening in a silent environment. In many other fields adaptation is a general term indicating broad effects across all biological and social levels (Helson, 1964; Mazess, 1975), for example, affective adaptation involves psychological processes that reduce responses to emotional events (Wilson and Gilbert, 2008). The adaptation level is the combined effects of present and past experience and is the level to which comparisons are made (Helson, 1964; Della Bitta and Monroe, 1974).
Tinnitus masking is believed to be the result of central processing (Penner, 1987) as: (1) it does not always occur in a frequency specific manner, (2) masking sound presented to the ear opposite the perceived location of tinnitus can successfully mask tinnitus, and (3) tones may mask tinnitus described as a broadband sound (Feldmann, 1971).
Studies attempting to accommodate for recruitment in tinnitus loudness match have provided mixed results (Penner, 1986). The mere presence of a comparison stimulus alters the adaptation level, creating a new anchor point so that tinnitus is matched to an external matching sound at a level that is lower than anticipated. A loss of control over the environment, such as the uncontrollable experience of sounds that have no auditory source in the environment (tinnitus), may lead to learned helplessness including a reduction in coping behaviors (Overmier, 2002).
In an interesting addition to the classic Heller and Bergman (1953) experiment of listening for sound in quiet, Knobel and Sanchez (2008) manipulated attention while keeping background sound constant. Neurons in the auditory system require some form of adaptation system to cope with the dynamic range of sounds and changes in the environment over time (Dean et al., 2005, 2008). 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 chosen questions and clinical tests were based upon the suggestions derived from the literature and clinical experience.
Adaptation is a two-way process allowing both an increase or decrease in response (Helson, 1964). Henry and Meikle (1996) undertook monaural and binaural measures of loudness growth at both reference and tinnitus frequencies. Welch and Dawes (2008) found that, in a population sample of 32 year olds, those who experienced tinnitus were less close to others, less constrained, and more negatively emotional. 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 tinnitus frequency was rated as constant, daily (occurring every day but not constant), weekly (occurring every week but not every day) or monthly (occurring every month but not every week). The central auditory masking effect known as informational masking may, along with other mechanisms such as suppression (Jastreboff, 1999b), contribute to reducing tinnitus detectability in sound. It was concluded that personality traits biased tinnitus reporting and influenced tinnitus signal detection (Welch and Dawes, 2008).
Interpreting the results in an ALT framework the focus (X, tinnitus) and background (B, silence) were constant, as were residuals (R) for the given individual, but the weighting factors (p, q, and r; attention and arousal) varied. 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. Tinnitus duration was similarly rated as constant or lasting for hours, minutes or seconds.
Such a mechanism may also be responsible for reduced tinnitus complaint with long-term stimulation with low-level sound (Norena, 2011). In informational masking the signal may be represented, but detection is affected because of competition for limited processing capacity between signal and masker (Watson, 2005). Consequently much of the paradoxical loudness of tinnitus remains unexplained (Henry and Meikle, 1996).
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. Tinnitus loudness, alone, does not determine severity but a multi-dimensional concept of tinnitus audibility, expressed by ALT, may have ramifications for treatments that incorporate sound to reduce audibility or detection of tinnitus. For example, competing speech makes hearing conversation difficult because of the information it contains, as well as any masking from overlapping spectral characteristics. Change in tinnitus could be due to such alterations in the underlying distribution of neural activity or decrease in criteria set for detection (Welch and Dawes, 2008). Some of these mixing points were within the range of sounds that could theoretically result in stochastic resonance effects. 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. Informational masking is likely to be influenced by attention and could be considered a weighting factor for tinnitus audibility in our ALT model of tinnitus. Cognitive resources are needed to maintain distinction between target and distractor (Lavie, 2005); attention load on non-auditory activities is less likely to see emergence of tinnitus perceptions (Knobel and Sanchez, 2008).
According to Welch and Dawes (2008) theory the placement of signal detection criterion reflects the individual’s predisposition to detect a given level of activity.
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). Two people with the same injury related neural activity may or may not experience tinnitus on the basis of this signal detection criterion.
The lowest combined tinnitus and stimulus annoyance a simple embodiment of Jastreboff (principle 5) occurred at 34% of the range from threshold to MML. Criteria for decision making in improper quality of each translation items was the average score less than 90 (determined by translators 3 and 4).
It is a common clinical observation that tinnitus patients will say the tinnitus is not a problem when they are busy. The criterion may differ as a consequence of the person’s personality but may be adaptable if the individual is able to understand that this criterion is under an internal locus of control (Welch and Dawes, 2008). Accordingly, in this step, Persian version of the THI was obtained, which regarding to all translators 1 to 4, had satisfactory quality.
Involvement in non-tinnitus focused activities such as work, hobbies and exercise, may change how and if people react to the tinnitus percept.
It is possible that tinnitus sound therapy may exert its effects not only through changing the relative distributions of tinnitus and non-tinnitus auditory activity but also through an increase in detection criterion. Tinnitus counseling, psychological-based treatments, and simple attention training (Henry and Wilson, 2002) may reduce the weighting on residual factors, contributing positively to reductions in tinnitus magnitude. In any case, given the limited and conflicting evidence for the benefit of one intensity of therapeutic sound over another, it would appear reasonable to suggest that further studies are required to define the optimal relationship between tinnitus and sound level (Tyler, 2006). ALT may assist in quantifying appropriate therapeutic sound levels for a given individual from a psychoacoustic point of view.



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Comments to «Relationship between tinnitus and stress»

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