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Author: admin, 13.02.2015. Category: Is There A Cure For Tinnitus

Tinnitus is derived from the latin term for "ringing" and is typically explained as hearing a ringing or some other sound inside of the head. Tinnitus can be a symptom of many different conditions including neurological damage, ear infections, head trauma and noise damage, both work place, recreational and more and more frequently by listening to loud music etc. Hearing based tinnitus can be when the tiny cilia send sounds into the brain even when no sounds are present. Over the past 20 years working in both hearing clinics and hospital settings we have seen a large number of clients suffering with tinnitus, just like our favourite actor Mr. In this time we have fit hearing aids on many different patients who have been suffering from tinnitus. Approximately 4 of the 8 people had anywhere from an hour to up to 72 hours of relief after they removed their hearing aids too. While wearing hearing aids most patients stop hearing the ringing inside of their head caused by Tinnitus! Clearly Hearing is dedicated to improving the quality of lives of people living with hearing loss by offering access to high quality hearing aids at the lowest possible prices.
Tinnitus may result in some kind of internal whooshing, ringing, hissing, humming, and whistling, roaring, clicking or buzzing sound. You will notice that a person suffering from tinnitus complaints of hearing a ringing or buzzing sound. A person with tinnitus will notice several mouth related problems, such as chronic toothaches, jaw muscle pain, tongue sores, muscular tension, as well as tooth enamel erosion.
In some cases people suffering from tinnitus experience noise while in particular postures. In a few cases, cysts or tumors in the inner and middle section of the ear may develop that can lead to this hearing problem. Severe ear pain along with loud noise may result in an ear infection or a partial or complete hearing loss and if the noise is accompanied by dizziness then it may be a sign of some kind of neurological problem. An individual can put a few drops of  mineral oil in both the ears to reduce ear wax and to deal with the problem of ringing in the ears.
An individual can extract fresh onion juice and put the same in both the ears to treat the problem of ringing in the ears.
Putting warm clove oil in one ear at a time can also provide relief from the problem of ringing in the ears.
Practice of yoga and meditation on a regular basis can help an individual in reducing the mental pressure and therefore obtaining relief from the problem of ringing in the ears. Frequent use of garlic oil as an ear drop can also help in curing the symptoms of ringing in the ears.
Intake of dried fruits and nuts can increase blood circulation to the ears and help in the treatment of ringing in the ears.
INTRODUCTION: The general consensus on the roles of hearing loss in triggering tinnitus seems not applicable in patients with normal hearing thresholds.
OBJECTIVE: To scrutinize auditory functioning in a sample of tinnitus subjects with normal hearing thresholds and non-tinnitus normally hearing control participants using transient evoked and distortion product otoacoustic emission (TEOAE and DPOAE) and Threshold Equalising Noise (TEN) test.
METHODS: Twenty-seven tinnitus adult patients with normal hearing thresholds and 27 normally hearing volunteers were tested with TEOAE, DPOAE and TEN test.
CONCLUSION: These results suggest the possible existence of subtle auditory deficit in normally hearing tinnitus patients, which may be an early sign of diseases that are only diagnosed after the onset of hearing loss. Keywords: coustic neuroma, otoacoustic emissions, tinnitus, threshold equalising noise test. Tinnitus is defined as the perception of sound that results completely from activity within the nervous system without any corresponding mechanical, vibratory activity within the cochlea, and not related to external stimulation of any kind1.
An increasing amount of epidemiology studies provide both self-reported data on tinnitus and hearing status which allows closer examination on the relationship between tinnitus and hearing status. Although some studies have different theoretical assumptions and approaches, the significance of hearing loss in tinnitus generation is not questioned. Thus, several attempts have been made to explain pathophysiology mechanisms of tinnitus in patients with normal hearing ability particularly using otoacoustic emissions (OAEs). Several studies have revealed that TEOAEs and DPOAEs can be used as a tool to detect early hearing loss before it can be diagnosed by PTA13-15. The contradict findings from previous research motivates researchers to find alternative theories to explain tinnitus mechanisms in tinnitus patients with normal hearing thresholds. This study investigated 27 tinnitus subjects (42 tinnitus ears and 12 contralateral non-tinnitus ear) with normal hearing thresholds who were recruited from Welsh Hearing Institute, University Hospital of Wales.
Full history taking and otoscopy examination were carried out at the beginning of the session. TEOAEs test was performed using unfiltered clicks of 80 µs duration presented in non-linear modes.
The stimulus comprised of a pair of primary pure tones (f1 and f2) at a frequency ratio equal to 1.22. The basic principle of this test is to control for "off-frequency listening" from occurring by using a broad band noise (the threshold equalising noise). This research has received the ethical approvals from the School of Applied Community and Health Studies (SACHS), University of Bristol Human Participants Ethics Committee and the South East Wales Research Ethics Committee. Initially, the left and right of DPOAE results were compared within the tinnitus and control groups.
Then, the differences of overall mean DPOAE amplitude between tinnitus and control ear were compared. Various hypotheses have been put forward to explain tinnitus generation in normal hearing patients. Decreased TEOAE amplitudes were observed in 35.7% of the tinnitus subjects with normal hearing sensitivity. A statistically significant increase in DPOAE amplitude was observed in tinnitus ears at f2 frequency of 1414 Hz.
The fact that tinnitus patients with normal hearing have a significantly higher percentage of abnormal TEOAEs and a limited frequency of DPOAE than the controls may suggest that OHC dysfunction may be pivotal in tinnitus generation. In the current study, the percentage between abnormal TEOAE and DPOAE in both groups had no statistically significant difference.
In the field of tinnitus, however, only two studies reported the application of TEN(HL) test in tinnitus patients with normal hearing24,25. Based on systematic review, no research on the application of TEN test in detecting acoustic neuroma has been published. No published data was found on the application of a TEN test in detecting acoustic neuroma. This study showed that subtle cochlear problem may exist in tinnitus patients before it is significantly appeared in the audiogram.
Thanks to University Hospital of Wales, UK for providing the facilities to conduct this research. This study was supported by the University of Bristol, UK and Ministry of Higher Education (MOHE) Malaysia and Universiti Kebangsaan Malaysia (UKM) as parts of the first author's PhD research. Paper submitted to the ITJ-SGP (Publishing Management System) on February 17, 2014; and accepted on February 20, 2014.
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. These were primarily clients who had both a sensorineural , or nerve based, hearing loss as well as tinnitus.
The disease can arise either in the outer section of the ear, the inner section of the ear, middle section of the ear or in the brain. For example an affected person may hear sounds while lying on the bed or while sitting or sometimes even while turning the head. Even though, this type of cyst is very rare and only occurs in only some cases, but it is better to consult the doctor as soon as you develop such things. The person because of the noise cannot concentrate on any work and as a result goes into a depression. If a person experiences such kind of symptoms must rush immediately to a doctor before it’s too late.
You accept that you are following any advice at your own risk and will properly research or consult healthcare professional. It is essential to put the juice in one ear at a time and remove it after 10 – 15 minutes. Putting a few drops of this oil into the ear before going to bed can provide effective results. Measurement of subtle auditory deficit in tinnitus patients with normal audiometric thresholds using evoked otoacoustic emissions and threshold equalizing noise tests. The absence of hearing loss on the audiogram in this group of patients poses a serious challenge to the cochlear theories in explaining tinnitus generation in this group of patients. For many years, progress towards finding the effective treatments for tinnitus was hindered by vague understanding of its underlying pathologic mechanisms. The association between hearing loss and tinnitus has been well documented in the previous literature2-4. Some studies found a correlation between severity of tinnitus and degree of hearing loss3,8 while others found no such correlation9. On the other hand, clinical observations have shown that 8 to 10 per cent of tinnitus patients had normal audiometric thresholds12.
It is hypothesised that outer hair cells damage results in stereocilia decoupling from the tectorial membrane, thus causing them to depolarise and subsequently resulting in tinnitus perception1.
An association of tinnitus with the changes in amplitude of TEOAEs and DPOAEs has been reported. One study by Weisz et al.24 proposed that subtle auditory abnormality may also arise from the inner hair cells (IHCs) dysfunction. The subjects who were attending the Institute from January to December 2010, were identified by an audiology physician and audiologists based in this hospital.
Then, all subjects underwent basic audiological tests which include pure tone audiometry and tympanometry.
Off-frequency listening occurs when the presented stimulus is being picked up by other parts of the cochlea instead of the targeted frequency area of the cochlea. From the analysis, the parameters of the TEOAEs for tinnitus ears are not significantly different from the control ears. Since no statistically significant difference was observed between both ears, further statistical analyses were performed using combined data from both sides together.
Distribution of the number of test frequencies with abnormal DPOAE in tinnitus and control ears. Based on the chi-square analysis, tinnitus ears have a statistically significant higher percentage of abnormal DPOAEs at some frequencies, mainly at 2000 and 4000 Hz regions (Table 4).
For example, it has been postulated that the different level of functionality between OHCs and IHCs (the Jastreboff's discordant dysfunction theory) can generate an unbalanced stimulation of dorsal cochlear nucleus's cells which produces abnormal neural activity.
Abnormal DPOAE amplitudes were also found in this group, particularly at high frequency regions, but in a slightly lower percentage than the TEOAE. For example, in Shiomi et al.19, the mean amplitudes of the DPOAE were significantly decreased in tinnitus patients with normal hearing than in normally hearing controls.
One possible explanation for this finding is that it may be due to OHCs hypersensitivity, as reported in some previous research.


Abnormal TEOAEs and DPOAE in the tinnitus patients also imply that they may have subtle cochlear damage that is not yet appearing on the audiogram. This finding might suggest that both tests were sensitive to detect minor OHCs dysfunction.
Unexpectedly, the use of a TEN test in the current study has led us to find an acoustic neuroma in a patient. Sincere thanks to Ministry of Higher Education (MOHE), Malaysia, Universiti Kebangsaan Malaysia (UKM) and University of Bristol for providing sponsorship to pursue this PhD study. Program Audiologi, Pusat Pengajian Sains Rehabilitasi, Fakulti Sains Kesihatan - Universiti Kebangsaan Malaysia - Kuala Lumpur - AC - Malaysia.
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 sound can be either perceived in one of the ears or in both the ears or even sometimes in the head. The ear cyst or tumor creates pressure and affects the blood flow creating a strange sound. It is important to avoid consumption of salt, caffeine and alcohol to deal with the problem of ringing in the ears. Regular use of this remedy helps in ensuring proper sleep and providing relief from the problem of ringing in the ears. Only one patient was found with a positive TEN test result, who was confirmed by Magnetic Resonance Imaging to have acoustic neuroma on the affected ear. The last half of the twentieth century saw considerable advances in our understanding of tinnitus from both physiological and psychological perspectives. It has been generally accepted that any severe damage along the auditory system may lead to a certain degree of hearing loss, which is generally associated with tinnitus5,6.
Moreover, the incidence of tinnitus in patients with sensorineural hearing loss varies widely across studies.
These observations may have several indications, such as hearing loss is not necessary in tinnitus generation, pure tone audiogram does not always indicate auditory damage, tinnitus may be a primary symptom of diseases that are only diagnosed after the occurrence of hearing loss, or several mechanisms exist in a group of patients.
The different functionality of outer and inner hair cells can also cause imbalanced activity in the dorsal cochlear nucleus which in turn causes changes at higher levels of the auditory system that may be perceived as tinnitus1. In some studies, lower amplitude of TEOAEs13,16 or DPOAEs13,17-19 have been observed in tinnitus patients compared to in non-tinnitus controls. All participants had no history or current external and middle ear problem, noise exposure and psychiatric problem. In this experiment, a 2f1 - f2 distortion product was used because of its established clinical value. This off frequency listening occurs when the targeted area of inner hair cells or neurons are not functioning well and is referred to as a dead region27. In this case (Subject RX), the TEN (HL) test revealed that dead regions might exist at 1.5, 3 and 4 kHz on the left ear (Table 7).
Since all the subjects in this study had normal hearing, the decrease in the TEOAE and DPOAE finding may possibly be considered as the effect of cochlear dysfunction of the cochlear active mechanism, which is related to OAE generation.
Frequency analysis also showed that a significant decrease in DPOAE amplitude was mainly at the f2 frequency of 4000 to 7000 kHz.
Therefore, the hearing status of these patients should be monitored for possibility of developing hearing loss later in life. Previous research has clearly demonstrated that OAE may be used to reveal subclinical OHCs damage in audiometrically normal ears13-15. Apart from difficulty hearing in background noise, she did not have any other classical symptoms of acoustic neuroma such as balance problem or poor speech discrimination scores. Firstly, it implies that a TEN test may offer a quick, inexpensive and non-invasive method for retrocochlear screening.
In their study, they found 7 out of 8 auditory neuropathy patients with abnormal TEN test results. The finding also supported the possible clinical advantage of the TEN test as a screening tool for retrocochlear problem.
Risk factors for tinnitus in a population of older adults: the blue mountains hearing study.
Characteristics of tinnitus and etiology of associated hearing loss: a study of 123 patients. The more the worse: the grade of noise-induced hearing loss associates with the severity of tinnitus.
Tinnitus with normal hearing sensitivity: extended high-frequency audiometry and auditory-nerve brain-stem-evoked responses. The effect of the number of averaged responses on the measurement of transiently evoked otoacoustic emissions in newborns.
Dead regions in the cochlea: diagnosis, perceptual consequences, and implications for the fitting of hearing aids. Transient and distortion product evoked oto-acoustic emissions in normal hearing patients with and without tinnitus. DPOAE in estimation of the function of the cochlea in tinnitus patients with normal hearing. Tinnitus and 2f1-f2 distortion product otoacoustic emissions following salicylate overdose. Ten(HL)-test results and psychophysical tuning curves for subjects with auditory neuropathy.
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. Intake of garlic can also help in reducing the inflammation in the ears and increasing blood circulation. More commonly, various studies have shown that sensorineural hearing loss plays an important role in tinnitus generation.
Therefore, the absence of hearing loss on the audiogram in this group poses a serious challenge to the aforementioned theories in explaining tinnitus generation in tinnitus patients with normal hearing. In the study, they investigated the inner hair cells functions in 11 chronic tinnitus patients with normal hearing thresholds using Threshold Equalising Noise (TEN) test and found 8 of them with possible inner hair cells problems.
The results were presented as a distortion-product audiogram i.e the amplitude of the 2f1 - f2 DPOAE was plotted against the f2 from 1000 to 6169 Hz.
The broad band noise is designed to produce almost equal masked thresholds over a wide frequency range, for listeners with normal hearing and hearing impairment but without dead regions28.
The abnormal TEOAEs in the tinnitus group were present for 1 and 4 kHz mostly, while in the control group, the abnormalities were mostly at 4 kHz. A t-test revealed that with regard to mean amplitude of TEOAE for tinnitus ears, there were no statistically significant differences for all frequencies tested (p > 0.05). Later, the mean amplitude of DPOAE for tinnitus and control ears against the corresponding f2 was compared.
From 20 tinnitus patients with abnormal OAEs, 13 of them exhibit either failed TEOAE or DPOAE results.


According to this theory, discordant dysfunction can occur without affecting the audiometric hearing thresholds when the OHCs are partially damaged and where the IHCs are intact. Stated differently, abnormal or poor OAE results may be the indicator of subtle cochlear damage before the abnormality affects hearing sensitivity and appears on the audiogram.
Thus, the similar findings indicate that DPOAE measurement can offer a frequency specific measurement for the detection of subtle localised cochlear damage even before affecting pure tone thresholds34. The high percentage of TEOAE abnormality at 4 kHz for the control ears may suggest that the hearing status of these participants also needs to be monitored. Nonetheless, only the difference between numbers of abnormal TEOAE in tinnitus and control ears reached a statistically significant level.
The former study suggested that tinnitus generation in their group of participants may be due to the effect of deafferentation of the neuron.
Secondly, tinnitus patients may have a serious problem that triggers the tinnitus perception despite having normal hearing thresholds and normal OAE test results. Patients with auditory neuropathy are known to have problems with transmission of the auditory signal to the brain, thus abnormal TEN test results in this group of patients were assumed to be due to the neuron dysfunction. However, more research needs to be carried out in this area in order to support the current finding. 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. Evidence showed a higher incidence of tinnitus patients with sensorineural hearing loss compared with conductive hearing loss7. In addition, not all individuals with hearing loss experience tinnitus, and not all tinnitus patients have hearing loss. While the theories seem cannot fit in this minority group, evidence obtained from this group may have huge implication for a better tinnitus mechanisms understanding as well as assist in developing and shaping tinnitus management. The studies reported that tinnitus subjects were found to have increased TEOAEs20,21 or DPOAEs22,23 compared with non-tinnitus counterparts. Thabet25 attempted to replicated the earlier study by investigating 20 normally hearing unilateral tinnitus patients with TEN test and TEOAE.
The presence of DP amplitude was accepted as valid when the signal to + 2 SD noise floor ratio exceeded 3 dB and the absolute DPOAE amplitude was at least - 10 dB SPL at each individual f2.
Table 2 shows the normal and abnormal TEOAEs at each frequency tested in both the tinnitus and control group.
Generally, an independent t-test showed no statistically significant differences observed between tinnitus and control ears at all frequencies except for frequency 1414, 4757, 5187 and 6169 Hz (Table 5).
Meanwhile, from 16 control ears with abnormal OAEs, 10 ears exhibit either failed TEOAE or DPOAE results. The ABR showed absent wave V at 70 dBnHL in the left ear and normal ABR waveforms in the right ear, which were correlated with the TEN test results, suggesting of abnormal neural function.
Therefore, in this current study, we sought to determine whether the measurement of TEOAE and DPOAE may reveal subtle cochlear abnormality in tinnitus patients with normal audiometric thresholds. Although the difference between numbers of abnormal DPOAE in tinnitus and control ears failed to reach a significant level, mean amplitude of tinnitus ears at frequency region of 2000 and 4000 Hz were statistically significantly lower than the control ears. They suggested that it could be the result of reduced afferent input to the central auditory system due to cochlear lesion, thus resulting in a decreased OHC efferent activity and ultimately leading to OHC hypersensitivity. TEOAE measurement stimulates the whole basilar membrane of the cochlear, which means it gives more global information. Furthermore, dead regions normally exist in those who have hearing thresholds of 60 dB HL and above28. In other words, even though dead regions normally exist in patients with hearing loss of more than 55 dBHL, normal hearing people can also have a 'dead region' which may be due to retrocochlear abnormality.
Similarly, the abnormal result in Subject RX in the current study may also be because of the problem in neurons rather than in the inner hair cells. MRI revealed a large vestibular schwannoma in the left cerebello-pontine angle which was compressiong the brainstem and cisternal portion of the VIIIth cranial nerve.This study showed that subtle cochlear problem may exist in tinnitus patients before it is significantly appeared in the audiogram. 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. Jastreboff & Jastreboff11 reported that about 27% of totally deaf patients do not have tinnitus, whereas 20% of normal hearing people have tinnitus. This is because the results obtained from this special group may directly related to the tinnitus perception, but not to the concomitant hearing loss. The test was performed in a sound treated room where the ambient noise was maintained between 20 to 40 dB A. The difference between the two groups is highly significant at frequencies of 1, 1.5 and 2 kHz, but not at 3 and 4 kHz.
The decrease in DPOAEs amplitude over a limited frequency range in DP-gram found in tinnitus patients with normal hearing may be a susceptible area representing minor cochlear pathology.
Similarly, a more recent study by Sztuka et al.35 attributed the increase in DPOAE amplitude in tinnitus patients with normal hearing as a result of increased motility of the OHCs due to decreased neural activity in the auditory nerve. Conversely, the number of abnormal DPOAE in tinnitus ears was not statistically significantly different from the controls.
They found that outer hair cells damage (assessed by TEOAE) was more common in normally hearing tinnitus patients than inner hair cells damage.
In this case, the positive TEN (HL) results may not be due to inner hair cells damage but maybe because of poor processing efficiency that is associated with neural problems due to compression of large vestibular schwannoma on the VIIIth nerve38. However, caution should be taken in interpreting the TEN test results as 10 dB-above-thresholds criteria is just a binary criteria that means passing or failing the TEN test, but does not mean dead or not dead. 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. It can be assumed that the role of sensorineural hearing loss as a tinnitus generator is complex and the mechanism of tinnitus may rely on the presence of other contributing factors such as damage to specific hair cells or the auditory nerve fibers. This appears to support the hypothesis that a reinforced mechanical distortion is generated by cochlear hyperactivity that can be the source of the tinnitus. DPOAE is more frequency specific and thus is expected to be more sensitive in detecting subclinical abnormality in cochlear function over TEOAE. Their finding supports the theory that outer hair cells abnormality may be an important factor in the tinnitus mechanism37. For this reason, more research needs to be carried out on the clinical benefit of the TEN test before applying this method clinically.
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.
By contrast, in other cases, TEOAE and DPOAE results showed poor or absent emissions in tinnitus patients with sensorineural hearing loss, even in those ears with normal hearing16,19,36.
In this current study, the result may possibly be due to subtle cochlear abnormality also existing in non-tinnitus participants with normal hearing.
However, results from both studies may be more compelling if they included a retrocochlear test. 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. The TEN test appears to be a potential non-invasive and quick test of inner hair cells function.
The mean pure tone audiometric thresholds of tinnitus and control groups are shown in Table 1.
The tumour was compressing the brainstem and cisternal portion of the VIIIth cranial nerve. These variations can be explained by postulating that it is most likely to reflect different cochlear mechanisms underlying tinnitus generation due to different cochlear pathological changes in tinnitus ears37. The result of the current study is consistent with Thabet's study in which only one subject was found with a dead region, on the left ear. 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. Nonetheless, it is too early to make a conclusion based on the aforementioned two studies on tinnitus.
An independent t-test revealed that there was no significant difference in hearing thresholds between tinnitus patients and controls at all frequencies except at 6 and 8 kHz.
Thus, the variability of findings in this study may possibly be because of different mechanisms existing in the normally hearing tinnitus patients.
According to Jastreboff37 however, there are different levels of dysfunction from the OHC up to the higher auditory pathways. 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. At both these frequencies, tinnitus patients had significantly higher thresholds than control individuals.
He hypothesised that in some patients, though the level of dysfunction is undetectable by TEOAE, it may be sufficient to produce tinnitus. 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). Therefore, this study aimed to investigate subtle cochlear abnormality in tinnitus patients with normal hearing thresholds using evoked OAEs (TEOAEs and DPOAEs) and TEN test.
Contrarily, in some, the level of abnormality is detectable but not enough to trigger tinnitus. Criteria for decision making in improper quality of each translation items was the average score less than 90 (determined by translators 3 and 4).
Therefore, Jastreboff's hypothesis is a possible explanation as to why not all hearing loss patients present with tinnitus, and not all tinnitus patients present with hearing loss. Accordingly, in this step, Persian version of the THI was obtained, which regarding to all translators 1 to 4, had satisfactory quality.



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