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How to cite this article Der C, Alzerreca E, Martin JTS, Roman L, Zamorano I, Malhue J, Aliaga P, et al. INTRODUCTION: The psycho-emotional assessment is of utmost importance for evaluation of patients with tinnitus. OBJECTIVES: We propose a linguistic validation of the THI, in order to obtain reliable answers in our country. MATERIALS AND METHODS: We performed a translation of the original English questionnaire and assessed its feasibility by applying it in a group of patients with tinnitus. CONCLUSIONS: The adapted version of the THI shows satisfactory levels of internal consistency for the assessment of disability caused by tinnitus. Its intensity is variable, from almost imperceptible to intolerable and intrusive, significantly compromising patient's quality of life (QOL) and even leading to suicidal ideation4. The clinical characterization of tinnitus allows defining groups which try to orientate different etiologies and helps to establish conduct. For the measurement of the psychological impact and the disability of tinnitus, the test known as Tinnitus Handicap Inventory (THI, Newman & Jacobson, 1967). This test consists of 25 questions easily understood by the patients with three answers for every question: "yes", "sometimes", or "not". The THI is subdivided in three subscales, first, Functional scale, named by Newman consisted of 11 items, including the area of mental function (for example. The second subscale is the Emotional scale composed by 9 items that include affective answers provoked by the tinnitus, as anger, frustration, irritability and depression (for Example.
The THI is translated into several languages and adapted or validated according to the language and the idiosyncrasy of every country in numerous publications.
We realized a prospective study and analysis for statistical validation of a quality test of life and its psychological impact. Finally we realized a Pearson's coefficient of correlation between the result of the total score of THI-CL and each of his subscales by the age of the patient and we used the statistical program JMP 9 Version. With regard to the answers of each one of 25 items in the questionnaire THI-CL, the percentage of answers "yes" changed between a range of 4-70%; for the response "sometimes" this percentage changed between 5-45 % and for the response "not", this variation was between 20-84 % (Table 2).
The great individual variability for the degree of interference in the daily life and the disability that the tinnitus provokes, determines an imperious need to use questionnaires that value the impact produced by this one. Of alternative or complementary form, multiple instruments of measurement have been in use, as the visual analogous scale (VAS) who, in response to a precise question, codes in a scale from 0 to 10 the magnitude of a criterion as the intensity of perception of the tinnitus or the level of induced inconvenience17. From the publication of the THI, numerous translations and validations to different languages have arisen as response to the need of make an objective evaluation in these patients of the level of psychological affectation that they show. One of the characteristics that do the THI one of the most worldwide applied questionnaires in the patients' evaluation with tinnitus is his easy accomplishment correction and interpretation, demonstrating in different international studies a great facility of reproduction for the evaluation of tinnitus after a treatment14,15.
The easy reproduction and reliability in the evaluation of the psychological impact of the tinnitus, has done of the THI an important questionnaire in the patients' study with tinnitus submitted to a therapeutic intervention. The application of the THI questionnaire has spread to other areas of the audiology, as the evaluation of the adjustment to auditory prostheses in patients with hypoacusia and tinnitus, where it is possible to quantify the degree of satisfaction and response of the patient to his treatment21. The adapted version of the THI to our population presents a suitable equivalence with the original version in English, with satisfactory levels of internal consistency and easy reproduction, so that it is possible to use it in the Chilean population for the evaluation of the disability generated by tinnitus.
This validation supposes an important help on having generated a tool to know the impact of this symptom in the quality of life of our patients, and providing criteria to measure the evolutionary control of the therapeutic interventions.
Institution: Surgery Department, ENT Unit, Clinica Alemana de Santiago, Facultad de Medicina Clinica Alemana, Universidad del Desarrollo, Santiago, Chile.
Paper submitted to the ITJ-SGP (Publishing Management System) on July 12, 2013; and accepted on August 12, 2013.
How to cite this article Mendes RCCG, Ribas A, Macedo IP, Buschle M, Ataide AL, Pereira R, Kochen AP, et al. Several studies have shown that cochlear implants may reduce or even eliminate tinnitus in patients with bilateral profound hearing loss. Keywords: cochlear implants, deafness, language and hearing sciences, speech, speech perception, tinnitus. Tinnitus means perceiving a sound that is not being generated in the environment at that time.
Considered one of the most common symptoms of profound sensorineural hearing loss, tinnitus can significantly affect the quality of life of individuals2.
The latest international publications7,8 suggest that patients with unilateral hearing loss, or even severe hearing loss, presenting ipsilateral tinnitus with hearing loss, unresponsive to several treatments, may also benefit from electrical stimulation of the auditory nerve through the CI. The beneficial effect of a CI on tinnitus can be explained by acoustic masking, by electrical stimulation directly to the auditory nerve, and especially by the reorganization of the central auditory system and associative brain areas that occurs after activation of the implant.
The aim of this study was to describe the audiological results of a patient with asymmetric hearing loss with ipsilateral disabling tinnitus, who was underwent the CI procedure.
Throughout the ENT care, various treatments were performed without success, for the reduction or remission of tinnitus, which led the patient at the time to have suicidal thoughts. The patient underwent cochlear implant surgery to the right ear in an attempt to improve auditory acuity, but mainly as a last resort in tinnitus treatment.
Before the CI, results were compatible with profound hearing loss to the right ear and severe loss to the left.
After the CI, thresholds compatible with normal hearing on the right ear were observed, as shown in Figure 1.
We used the Glendonald Auditory Screening Procedure (GASP test)12 which classifies the category of hearing on a scale of zero to six, where zero means no detection of speech sounds and six means open-set speech recognition. The protocol for assessing tinnitus was applied at the following times: before surgery, 45 days after surgery (activation of CI), two months later, six months later and one year after CI surgery. The literature11 states that the CI is configured as an alternative treatment of deafness and constitutes a multifactorial process with proven effectiveness.
The Brazilian study17 indicates that the hearing assessment obtained six months after the first implant programming demonstrates that English-speaking patients get excellent results in tests of recognizing words and sentences in open presentation, regaining useful hearing. Despite these satisfactory and known findings by physicians and audiologists, the primary complaint by the subject, which is the focus of this study, was the tinnitus. Di Nardo et al.6 reported that the CI provides effective results in reducing the perception of tinnitus intensity. Statistically significant reduction in THI overall indices and sub-indices, pre and post CI, were demonstrated in scientific studies8,11 showing lower levels of discomfort and a decrease in the intensity of tinnitus as a result of direct electrical stimulation of the auditory nerve and reorganization of the central auditory pathways and cortical association areas, leading to the use of tinnitus as a criterion for choosing the ear to be implanted. The results related to the concentration (66%), emotional (100%), sleep (26%) and hearing (96%) obtained by preoperative TAQ converged at a rate of 72% indicating strong interference of tinnitus, especially in the emotional and hearing states of the patient.
Factor 3, life prospects, went from a preoperative score of 100% to 50% after activation of the CI, 25% after two months of use, 75% after six months and reduction to 25% after 1 year of CI use. The consulted study11 shows that the CI generates maximum benefit in remission buzz around seven months after the performed procedure.

The reduction in the intensity and degree of tinnitus annoyance confirms the improvement in the quality of life of individuals, a fact that must be considered in preoperative counseling of patients with tinnitus as candidates for cochlear implants. CI as a treatment for post-lingual profound hearing loss is highly effective, there is improvement seen in hearing thresholds in performance and perception of speech sounds, as in the case presented.
Although the literature describes the indication of CI for patients with tinnitus, the initiative is still not being widely accepted by physicians and speech-language pathologists, especially when hearing loss is unilateral or asymmetric. Paper submitted to the ITJ-SGP (Publishing Management System) on May 21, 2013; and accepted on June 21, 2013. The Tinnitus Handicap Inventory (THI), is the most known and validated test for this purpose. Statistical analysis included internal validity (Cronbach's alpha) and linear correlation tests (Pearson coefficient). It is a frequent reason for consultation and patients come to a wide range of professionals: otolaryngologists, neurologists, psychiatrists, psychologists, and others.
Other reasons include exposition to noises, traumas of head and neck, local inflammation and use of medicaments10.
In the first case, it will allow to measure the magnitude of the symptom, to know the effect of therapies, or to follow-up patients. Firstly tinnitometry, which involves the confrontation of frequency and intensity, the mask ability of tinnitus and the search for the residual inhibition and secondly and most important, psycho-emotional medicine12.
Has been accepted by the principal centers because of its reliability, safety and supported validity13,14.
It gives 4 points to "yes", 2 points to "sometimes", and 0 point to "not", and the sum of the total score goes from 0 to 10013,14. For Spanish-speaking population exists a Spanish version of Herraiz et al.15, translated from the English and adapted to the daily language of Spain.
As specific aims we will try (1) to generate a test of auto application and easy correction in the clinical national services, (2) to obtain a reliable method for the measurement of results in the treatment of tinnitus in Chilean patients, (3) and to rely on an instrument that it should allow to measure the degree of psychological impact and disability generated by tinnitus. Translation of the original document in English "Tinnitus Handicap Inventory" of Newman and cols. Viability of the questionnaire: in the second phase, a group of ENT residents, of Spanish native language evaluated the questionnaire. Application of the questionnaire: a group of 60 patients with tinnitus was submitted to the questionnaire THI-CL in his final version, for evaluation of disability produced by the tinnitus. Statistical Analysis: We calculated the frequency of distribution, medians and standard diversion of every item of the questionnaire THI-CL. For it, the acufenometrics measurements do not contribute sufficient information to establish a category or degree of psycho-emotional severity that allows to certify the condition of a patient in a certain minute of his disease or treatment. Other authors have published experiences with questionnaires as the Beck's scale of depression, of frequent use in psychology, to estimate in an objective way the disability produced for tinnitus18. As is demonstrated in the original version and in the Danish and Italian validation, Chilean version of the THI does not seem to be affected by age and sex so much for the total score and for each of his sub scales, which contributes furthermore to his cultural validity19,20. Our experience was similar, achieving that the patients were answering entirely the questionnaire in all the cases, without difficult reports before the exposition of a question. Is considered to be significant, a difference bigger than 20 points between the initial pre-treatment questionnaire and the result post therapy in the follow-up14. However, there are not consistent references regarding ipsilateral tinnitus compared to unilateral profound hearing loss. It is a very frequent symptom, which may affect around 17% of the population in some countries. Several studies claim that the cochlear implant (CI) can diminish or even eliminate the perception of tinnitus in patients with bilateral profound hearing loss and that, although a risk of tinnitus perception that increases after implantation exists, it is very small3-6. With the support of these findings researchers suggest that tinnitus should be a selection criterion in choosing which ear to implant and that patients with severe unilateral hearing loss associated with severe tinnitus can be considered CI candidates9-11. The comparison between the responses obtained before and after the CI verify the benefits achieved with this therapy. The tests were conducted in a soundproof booth, with the Madsen Itera - GN Otometrics audiometer.
The test was applied prior to the CI, five months later, eight months later, and finally, after a year. This fact was borne out in this case report, where the pre and postsurgical audiometric tests showed improvement in tone thresholds with CI use. In this study, by applying the VAS, we observed a significant reduction in the intensity of tinnitus perception, and that after activation of the CI, the rating went from four to one after 60 days of using the device. In our study, after activation of the CI, there was a reduction in the THI total index (six) and sub-indices (functional 2, catastrophic 0, and emotional 4) to a score of one.
A total reduction of assessed scores on aspects of sleep and concentration with a reduction of greater than 20%, significant data regarding the emotional and hearing aspects, was observed after activation of the CI. In our study there was a significant reduction in the percentage of THQ (Table 3) after activation of the CI and the subsequent evaluations (two and six months of CI use) mainly in factors 1 and 2. In addition, it can be seen that the CI was critical to the reduction of tinnitus perception.
Speech, Language and Hearing Sciences - Universidade Tuiuti do Parana - Curitiba - PR - Brasil. Department of Otolaryngology - Hospital Infantil Pequeno Principe - Curitiba - PR - Brasil. Speech, Language and Hearing Sciences - Hospital Infantil Pequeno Principe - Curitiba - PR - Brasil.
In the UK up to 5% of the adult population is at least moderately annoying by tinnitus and in 1% severely affects its QOL2,5.
The subjective tinnitus cannot be perceived by another person, whereas the other can be identified by the examiner by means of auscultation or another method8. This score determines degrees of disability for tinnitus from slightly to severely impaired (Table 1). Due to the tinnitus, is it difficult to enjoy social activities as going out to eat or going to the cinema?), and the area of physical function (for Example.
The third scale is the Catastrophic scale composed by 5 items that reflect the desperation of the patient, disability to be able to escape of the problem, perception of having a critical illness, loss of the control and his disability to face the problem (for Example. This version differs from our language in vocabulary and does not correspond to the linguistic local culture, without exist up to the minute experiences published of his use in Chile. After possessing authorization of the author for the accomplishment of the project, we made a translation of the original questionnaire to the Spanish in independent form, for doctors of bilingual and Spanish native language. In a group activity, every article was read while the participants were following the reading in a printed material.

For the analysis of internal consistency of the test or reliability, we applied the test of Cronbach's Alpha Coefficient to the total score of the THI-CL questionnaire and every subscale.
These measurements allow to quantify of a reproducible form, although subjective, the severity and the tolerance of a tinnitus. In the article of Newman, the authors justify the low value obtained by the limited number of questions that compose this scale (5 items). One of the limitations of the questionnaire happens when the initial score is minor to 20 points, situation in which statistically there has not corroborated a difference between both measurements14. Bases fisiopatologicas del tratamiento del tinnitus neurosensorial: Rol del sistema auditivo eferente.
Psychometric adequacy of the Tinnitus Handicap Inventory (THI) for evaluating treatment outcome. Evaluacion de la incapacidad provocada por el tinnitus: homologacion linguistica nacional del Tinnitus Handicap Inventory (THI).
Correlation analysis of the visual-analogue scale and the Tinnitus Handicap Inventory in tinnitus patients. Brazilian Portuguese Language version of the "Tinnitus Handicap Inventory": validity and reproducibility.
The aim of this paper is to describe audiological results of a patient with asymmetrical hearing loss with incapacitating ipsilateral tinnitus in the ear subjected to cochlear implant surgery. We do not know its prevalence in Brazil, but if we extrapolate the data from our international population, it is possible that some 28 million Brazilians have already had some form of tinnitus1. Chart 1 shows the comparison between the results where it can be verified that the patient progressed from category zero to six in the 12-month study. The patient went from category zero to six, where there is open-set recognition of words and phrases together.
The degree of discomfort, intolerance or failure often are not related to the intensity of tinnitus, says a consulted study1, but mood disorders (depression, dysthymia) and anxiety often present, exerting strong influences on the worsening of the tinnitus. After 180 days of use, the patient did not perceive any ringing with the CI turned on and noticed only mild tinnitus with the CI off. Influence of evoked compound action potential on speech perception in cochlear implant users. Incapacitating unilateral tinnitus in single-sided deafness treated by cochlear implantation.
Stimulation by cochlear implant in unilaterally deaf rats reverses the decrease of inhibitory transmission in the inferior colliculus. Techniques for assessing auditory speech perception and lipreading enhancement in young deaf children. Resultados auditivos com o implante coclear multicanal em pacientes submetidos a cirurgia no Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo. Likewise, we can distinguish the pulsatile tinnitus and the not-pulsatile; the first one is usually vascular, especially in unilateral tinnitus concordant with the patients' pulsations6. In 2006, Pena et al.16 proposed a linguistic homologation of this scale publishing a translation to the Spanish local language.
On the basis of these translations a questionnaire was made in Spanish who was checked and retro translated into the English for a professional certified translator. They should have answered to 2 questions for every article: what does deal you with this question? It was considered to be a criterion of incorporation, 18 year-old patients, with tinnitus subjectively diagnosed, unilateral or bilateral of more than 6 months of duration and refractory to treatment. Besides, calculation of the Cronbach's alpha coefficient was realized eliminating an item to the time of the questionnaire simultaneously, for determine the dependent variation of each item.
In our experience, a satisfactory result was obtained, without difference between the sub scales. With regard to this limitation, Newman et al.14, postulate that only the change of category of disability degree (Table 1), would allow to demonstrate an improvement later to the establishment of a treatment.
Audiological exams and responses to perception protocols for tinnitus before and after surgery were analyzed. Without a personal sound amplification device (PSAP) during the application of the GASP, the patient reported that he felt only a slight vibration in the right ear to the presented sound stimuli. In our study, the patient reported he had considered suicide due to the discomfort caused by tinnitus. Experiencia do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo. In children has been described in 6.5% of patients, although up to 34% refers tinnitus when directly questioning7.
Finally the coherence was compared between the version retro translated to English and the original version in English to obtain a definitive questionnaire. Was considered a criterion of exclusion the presence of neurological disease or have psico-organic damage.
The tests showed improvements in the hearing threshold on the side with the implant, improvements in speech perception and a significant reduction in tinnitus perception, which consequently led to an improvement in the patient's quality of life.
Shortly after activation of the CI he began to recognize open-set word and auditory performance, improving at each evaluation. These three axes: pulsatility, laterality and if it is objective or subjective can make a diagnostic approximation and orientate the clinician to a certain etiology.
The answers were taken in account by a group reviser composed by medical specialists in otolaryngology for final alterations to the questionnaire.
We didn't realize segregation on the basis of audiometric results or demographic variables.
Additional to this, we realized a Student's t-test for independent samples, to define if the total score of the THI-CL and each of his sub scales were presenting statistically significant differences between men and women.
In this manner we finished the confection of the questionnaire THI in his national version in Spanish. There was delivered an informed consent to every patient who should have been well-read and signed before the participation in the study and possess the approval of the Scientific Educational Department and Committee of Ethics of German Clinic of Santiago for the development of the investigation.

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