www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Auditory
attention
in
individuals
with
tinnitus
夽
Daviany
Oliveira
Lima
a,
Aline
Menezes
Guedes
Dias
de
Araújo
b,
Fátima
Cristina
Alves
Branco-Barreiro
c,
Cláudia
da
Silva
Carneiro
b,
Larissa
Nadjara
Alves
Almeida
d,
Marine
Raquel
Diniz
da
Rosa
e,f,∗aUniversidadeFederaldaParaíba(UFPB),ProgramaAssociadodePós-graduac¸aoemFonoaudiologia,JoãoPessoa,PB,Brazil bUniversidadeFederaldaParaíba(UFPB),DepartamentodeFonoaudiologia,JoãoPessoa,PB,Brazil
cUniversidadeFederaldeSãoPaulo(Unifesp),EscolaPaulistadeMedicina(EPM),DepartamentodeFonoaudiologia,SãoPaulo,
SP,Brazil
dUniversidadeFederaldaParaíba(UFPB),ModelosdeDecisãoemSaúde,JoãoPessoa,PB,Brazil
eUniversidadeFederaldaParaíba(UFPB),DepartamentodeFonoaudiologia,ProgramaAssociadodePós-graduac¸aoem
Fonoaudiologia,JoãoPessoa,PB,Brazil
fGrupodeEstudosePesquisasemAudic¸ão,EquilíbrioeZumbido(GEPAEZ),JoãoPessoa,PB,Brazil
Received23March2018;accepted7January2019 Availableonline8March2019
KEYWORDS Hearing; Auditoryperception; Tinnitus; Auditoryattention Abstract
Introduction:Tinnitus ischaracterizedby thepresence ofasoundintheabsence of exter-nalsoundstimulus.Inindividualswithnormalaudiometry,itmaybeassociatedwithauditory attentiondifficulty,especiallyinthosewhoreporthightinnitusannoyance.
Objective: Toinvestigateauditoryattentionabilityinindividualswithtinnituscomplaint.
Methods:Cross-sectionalanalyticalobservationalstudy.Weevaluated30volunteerswith nor-malhearing(upto25dBHL):15withtinnitus(testgroup)and15withnocomplaints(control group), agedbetween18-40years.Thevolunteersansweredthetinnitushandicapinventory questionnaireandavisualanaloguescale.Subsequently,abasicaudiologicalevaluation (mea-toscopy, tonaland vocalaudiometry,and imittanciometry)andpsychoacoustic measures of tinnitus (loudnessandpitch)wereperformed.Toevaluateauditoryattention,thefollowing testswereperformed:auditorycognitiveevokedpotential(P300),centralauditoryprocessing tests(dichoticdigitstestandspeech-in-noisetest)andsustainedauditoryattentionabilitytest.
Results:Inthetinnitushandicapinventory,individualswithtinnitushadameanscoreof37.78 (±27.05),characterizedasmoderatedegree.Inthedichoticdigitstest(binauralseparation), adifferencewasobservedbetweenthegroupsinbothears.Moreover,therewasadifference inthespeech-in-noisetestinbothears(RE:p=0.044;LE:p=0.019),inP300(p=0.049)and intotalsustainedauditoryattentionabilitytest(p=0.032).Also,thereisanegative correla-tionbetweensustainedauditoryattentionabilitytest,decreaseinattentivenessandbinaural integration(RE:p=0.044;LE:p=0.048).
夽 Pleasecitethisarticleas:LimaDO,AraújoAM,Branco-BarreiroFC,CarneiroCS,AlmeidaLN,RosaMR.Auditoryattentioninindividuals withtinnitus.BrazJOtorhinolaryngol.2020;86:461---7.
∗Correspondingauthor.
E-mail:mrdrosa@yahoo.com.br(M.R.Rosa).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2019.01.011
1808-8694/©2019Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Conclusions:Individualswithtinnitushadapoorerperformancecomparedtothecontrolgroup regardingauditoryattentionability.Therefore,itisinferredthattinnitusisassociatedwith poorperformance inselectiveand sustained auditory attentioninthe assessed volunteers. Theseaspectsshouldbeconsideredforthemanagementofpatientswithtinnitus.
© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Audic¸ão;
Percepc¸ãoauditiva; Zumbido;
Atenc¸ãoauditiva
Atenc¸ãoauditivaemindivíduoscomzumbido
Resumo
Introduc¸ão: Ozumbidocaracteriza-sepelapresenc¸adesomnaausênciadeestímulosonoro externo.Emindivíduoscomaudiometrianormalpodeestarassociadoàdificuldadenaatenc¸ão auditiva,principalmentenaquelesquereferemaltoincômododozumbido.
Objetivo:Investigarahabilidadedeatenc¸ãoauditivaemindivíduoscomqueixadezumbido.
Método: Pesquisadotipoobservacionalanalíticadecarátertransversal.Foramavaliados30 voluntárioscomaudic¸ãonormal(até25dBNA):15comzumbido(grupoteste)e15semaqueixa (grupocontrole),entre18e40anos.Osvoluntáriosresponderamoquestionáriodohandicap dozumbido---Tinnitus HandicapInventory---eaescalavisual analógica.Emseguida, fez-se aavaliac¸ãoaudiológicabásica (meatoscopia, audiometriatonal,vocal eimitanciometria)e medidaspsicoacústicasdozumbido(loudnessepitch).Paraavaliaraatenc¸ãoauditiva,foram usadosostestes:potencialevocadoauditivocognitivo(P300),processamentoauditivocentral (dicóticodedígitosedefalanoruído)eodeatenc¸ãoauditivasustentada.
Resultados: No Tinnitus Handicap Inventory, indivíduos com zumbido apresentaram escore médio de 37,78(±27,05); caracterizado por grau moderado. No teste dicótico de dígitos (separac¸ão binaural) percebeu-se diferenc¸a entreos grupos, nas duasorelhas. Além disso, houvediferenc¸anotestedefalanoruído,emambasasorelhas(OD:p=0,044;OE:p=0,019),no P300---(p=0,049)enotestedeatenc¸ãoauditivasustentadatotal(p=0,032).Alémdecorrelac¸ão negativaentreotestedeatenc¸ãoauditivasustentada,decréscimodevigilânciaeintegrac¸ão binaural(OD:p=0,044;OE:p=0,048).
Conclusão:Osindivíduoscomzumbidoapresentaramdesempenhoinferiorao grupocontrole nahabilidadedeatenc¸ãoauditiva.Portanto,infere-sequeozumbidoestáassociadoaobaixo desempenhonaatenc¸ãoauditivaseletivaesustentadanosvoluntáriospesquisados.Tais aspec-tosdevemserconsideradosparaomanejodopacientecomzumbido.
© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Tinnitusischaracterizedbytheperceptionofoneormore
sounds in theears or head in theabsence of an external
acousticsignal.1,2Itisasymptomthataffectsapproximately
10---15%oftheadultworldpopulation.InBrazil,itisbelieved
thatmorethan28 millionindividuals havetinnitus,which
makesitapublichealthproblem.3Anepidemiologicalstudy
carriedoutinthecity ofSãoPaulo showsthat 22%ofthe
populationhasthissymptom.4
Duetoitsmultifactorialetiology,tinnitusisconsidered
adifficult symptom to treat.1 Otological andneurological
problems,infectiousdiseases,medications,dentaland
psy-chologicaldisorderscancausetinnitus.5
Inapproximately80%ofcases,tinnitusismildand
inter-mittent,with no majorconsequences for the individual’s
life.However,whenthetinnitusmanifestationisprofound,
it can significantly impair quality of life, affecting sleep,
concentration,attention,emotionalbalanceandevensocial
interaction,preventingindividualsfromeffectively
perfor-mingactivitiesofdailyliving.6
Tinnitusmaybepresentinindividualswithnormal
audio-metryor hearing loss.7,8 When present in individualswith
normalaudiometry,thehighemotionalimplicationofsevere
tinnituscouldleadtoahigh levelofattentiondirectedto
the symptom, which can increase the inattention and/or
prevent habituation to it.9 Some authors report that in
patientswithhighlyannoyingtinnitus,theinterferencewith
activitiesthatdemandattentionishigher.10,11
Itis believed thatthe networksassociatedwith
atten-tion, memory, distress, and multisensory experience are
involvedwiththetinnitusperception.9Thisperceptioncan
playsa rolein attention, in the limbicsystem and in the
secondaryauditorycortex.11
A study has shown that selective attention in
indivi-dualswithtinnitusdiffersfromthatinnormalindividuals.12
However,anotherstudydidnotobserveanytinnitus
interfe-renceinselectiveattentionandtemporalresolutionabilities
usingauditoryprocessingtests(Speech-in-WhiteNoise-Test,
DichoticDigitsTestandGaps-in-NoiseTest).13
The literatureshowsahigheroccurrenceofalterations
in the long-latency auditory evoked potentials (LLAEP) in
individualscomplainingoftinnituswhencomparedto
indi-vidualswithout thecomplaint. Additionally, patients with
severe tinnitus fail to adequately habituate to the sound
stimulusintheLLAEP.9
Inclinicalpractice,somepatientscomplainingof
tinni-tus have reportedattention andconcentration difficulties
during activities of daily living. Based onthese problems
andthescarcityofstudiesrelatedtotinnitusandauditory
attention,itbecomesimportanttoverifywhetherthereis
an association between auditoryattention difficulties and
thetinnitussymptom.Moreover,theresultsobtainedinthe
presentstudycanprovidemeasuresforthecontroland
pre-ventionofthesealterationsandcanbeusedasthebasisfor
other studies, thus contributingtoimprove thequalityof
lifeofthesepatients.
Little is known about the electrophysiological
charac-teristics in patients withtinnitus, and evenless is known
abouttheinteractionsbetweenattentionmechanismsand
tinnitus.Therefore,doesthetinnitusinterferewiththe
per-formanceofteststhatevaluateauditoryskills?Considering
theabove,theaimofthisstudyistoinvestigatethe
audi-toryattentionabilityinindividualswithtinnituscomplaints
andtoverifywhetherthereisacorrelationwiththedegree
oftinnitusannoyance.
Method
This is a cross-sectional observational/descriptive study.
Thirtyvolunteers wererecruited:15 complainingof
tinni-tus(testgroup)and15withnotinnituscomplaint(control
group),agedbetween 18and40 years.The study
partici-pants were selected at the Tinnitus Service offered at a
schoolclinic,accordingtothefollowingeligibilitycriteria:
havingunilateralorbilateraltinnitusformorethan6months
(chronic);havingnormal(upto25dBHLatallfrequencies)
andsymmetricalhearing.14Thesmallnumberofvolunteers
inthesamplewasduetoashortageofindividualswith
tin-nitusandhearingwithinthenormalityrangeagedbetween
18and40years.
Tomeetthestudyobjectives,theprocedureswere
per-formedaccordingtothestagesdescribedbelow.
StageI:anamnesis,audiologicalandtinnitus
evaluation
Initially, according toResolution 466/2012, the study was
approved by the Research Ethics Committee (protocol n.
0129/12) and the volunteers who accepted to
partici-pate in the study signed the Free and Informed Consent
Form. Subsequently, data collection was started through
theanamnesis,basic audiological evaluation(meatoscopy,
tonal/vocalaudiometryandimmittanceaudiometry),
otoa-coustic emissions and, after that, the application of the
TinnitusHandicapInventory(THI),VisualAnalogScale(VAS)
andpsychoacousticmeasuresfortinnitusevaluation.
0 5 10 15 20 25 250 500 1000 2000 3000 4000 6000 8000 RE SG LE SG RE CG LE CG
Figure1 Meansofhearingthresholdsbyfrequency.RE,right ear;LE,leftear;SG,studygroup;CG,controlgroup.
The anamnesis consisted of seven objective questions
concerning hearing and tinnitus: time of tinnitus, sound
description,location,typeandbeginning.Themeatoscopy
identifiedthepresenceorabsenceofanyimpedimentinthe
externalearthatcouldinterferewiththeauditoryexams.In
casesofimpediment,thepatientswerereferredto
otorhi-nolaryngologicalevaluationand,whentheimpedimentwas
corrected,theyreturnedtoundergotheotherprocedures.
The audiological evaluation was performed using an
Interacoustics® AD229two-channelaudiometerinan
acous-tic booth. Individuals with normal hearing were those
whohadan auditorythreshold ≤25dBHL(decibel Hearing
Level).14 The means areshown in Fig. 1. To perform the
acousticimmittancemeasurements, an Interacoustics® AT
235middle-ear analyzer wasusedto evaluatemiddle-ear
complianceandthe acousticstapedial reflex.Only
indivi-duals with type ‘‘A’’ tympanogram and acoustic reflexes
wereincludedinthesample.
Finally, the following protocols wereapplied: the THI,
consistingofaself-assessmentquestionnaireaimedto
quan-tifythe impact of tinnituson qualityof life.15,16 The THI
consistsof 25 questions, of which answers can be ‘‘yes’’
(4points),‘‘no’’(0point)or‘‘sometimes’’(2points),and
eachquestionisrelatedtooneofthedomains:functional,
emotionalorcatastrophic.Afterthat,theEVAwasapplied,
consisting of a graphic-visual formto determine the
per-ceivedannoyancegeneratedbytinnitus,quantifyingitona
scaleof0---10.14
When performingthe psychoacoustic measures,
accor-dingtothetypeoftinnitusreportedbythepatientduring
theanamnesis,thepuretone(continuous,pulsatileand
Fre-quencyModulated),narrowbandnoiseandthewhitenoise
werepresentedtotheearcontralateraltothetinnitus.In
casesofbilateraltinnitus,thestimuluswaspresentedtothe
earcontralateraltothemostintensetinnitus.
Subsequently, the tinnitus frequency sensation (pitch)
wasinvestigatedinthecontralateralear.Thefrequenciesof
8000Hzand500Hzwerecompared,and,afterthechoice,
otherfrequenciesweretheninvestigateduntilthepatient
identifiedthetinnitusfrequency.Toinvestigatethetinnitus
intensitysensation(Loudness),atthepreviouslyestimated
tinnitusfrequency andat itsauditorythreshold,thestudy
wasperformed intheipsilateralearof thetinnitus
repor-tedbythepatient,testingevery5dBHL,andthenthrough
the1dBHLscale at thefrequency pre-determinedby the
patient. It was considered the value in dBSL (dB
sensa-tionlevel),thatis,thevalueobtainedsubtractedfromthe
patient’sauditorythresholdatthetinnitusfrequency
Table1 ParametersusedtoobtainP3potential.18 IntelligentHearing System® equipment SmartEPmodule Electrodes:M1, M2,FpzandCz
Electrodeimpedance≤3kohms Intensity75dBPe Stimulationtype:binaural Numberofstimuli: 300(80%frequent and20%rare) Channels:AB Velocity:0.8pps Duration:2.0ms Phase Alternate
Stimulusutilized 1kHz(frequent)4kHz(rare) Transducertype Insertearphones
Stimulusduration 50,000s
Envelope Trapezoid
Individualstatus Alert
kohms,kiloohms;dBHL,decibelinhearinglevel;pps,pulsesper second;ms,milliseconds;kHz,kilohertz;s,microseconds.
StageII---behavioralandelectrophysiological
evaluation
Individualswhometthestudyeligibilitycriteriawere
refer-red to the second stage of the study. At this stage, the
electrophysiological (long-latency auditory evoked
poten-tials---P300)andauditoryprocessingbehavioraltestswere
performed (Dichotic Digits Test --- Integration and
Sepa-ration, Speech-in-Noise Test, and the Sustained Auditory
AttentionAbilityTest ---SAAAT).Each of themwillbe
dis-cussedindetailsbelow.
To evaluatetheabilityof sustainedauditoryattention,
the P300 (Short-Latency Auditory Evoked Potential) was
used,throughthe dual-channelSmartEPequipment,after
cleaningtheskinwith70%alcoholandaftertheelectrodes
werefixedtothesubject’sskinusingtheelectrode
electro-lytepaste,inthepositionsM1(leftmastoid)andM2(right
mastoid),Cz(vertex),withthegroundelectrode(Fpz)being
placedontheforehead.Theacousticstimuluswas
presen-tedthroughinsertearphones,elicitingtheresponses. The
patientswereinstructed topayattentiontothedifferent
stimuli (rare stimulus) that appeared randomly, within a
seriesofequalstimuli(frequentstimulus)(Table1).
Subsequently, the behavioral tests were performed to
evaluatetheselectiveandsustainedattentionofthe
indi-viduals participating in the study. For this purpose, the
followingtestswereused:DichoticDigits(DD)Test
(binau-ralintegration/separation)and monotonicspeech-in-noise
test.
The DD test used a listconsisting of 20 pairs of digits
representingPortugueselanguagedisyllables(4,5,7,8and
9).To evaluate the binaural integrationability, twopairs
of digits were presented at each ear simultaneously,and
thepatientswereaskedtorepeatorallyallthedigitsthey
heard,regardlessoftheorder.19
Then, the speech-in-noise test was performed using a
listconsistingof25mono-syllablesandacompetitive
mes-sage consisting of white noise, at a signal-to-noise ratio
of(+5dB).When applyingthetest, themonosyllablesand
whitenoisewerepresentedsimultaneouslyandipsilaterally,
andthepatientswereaskedtoorallyrepeatthe
monosyl-lablestheyheard.19
Allofthe abovementionedtestswere performed atan
intensity of 50dBSL. The measurementswere obtained in
an acousticbooth,usingproperlycalibratedauditory
pro-cessingequipment(AcústicaOrlandi®,modelPA2004),and
typeTDH39earphones(AcusticaOrlandi®).Thestimuliwere
presented using an Ipod device (AppleTM) coupled to the
auditoryprocessingequipment.
Inordertoevaluatethesustainedauditoryattention,we
usedtheSustainedAuditoryAttentionAbilityTest---SAAAT,
whichis basedontheACPT---AuditoryContinuous
Perfor-manceTest,clinicallyusedtomeasureauditoryattention.16
The test was presented in a dichotic form, that is, the
sameinformationwaspresentedconcomitantlytobothears,
through earphones. The test consists of the presentation
of a list of 21 monosyllabic words, accessed through the
websiteand coupledtothe Acustica Orlandi® equipment;
thesewordswerepresentedsixtimeswithoutinterruption,
totaling600words throughoutthetest.16 Eachparticipant
received verbal instructions given by the evaluator: they
wouldhearalistofwordsandshouldraisetheirhandevery
timetheyheardtheword‘‘NO’’.The testwasappliedby
theresearcherherselfandlastedapproximately10min.
AsfortheSAAATperformance,itconsidersthetotalscore
oferrorsandthedecreaseofattentiveness.Thetotalerror
scoreisobtainedbyaddingtheInattentionnumber(In)plus
the numberof Impulsivity (I).Inthe SAAAT, Inattention is
anerrorwhentheindividualsdonotraisetheirhandwhen
theyheartheword‘‘NO’’beforethenextwordis
presen-ted,andImpulsivityiswhentheindividualsraisetheirhand
toanotherwordinsteadoftheword‘‘NO’’.Thedecreased
attentiveness,thatis,thedeclineinattentionthatoccurs
overtimeduringtheattentiontask,isobtainedby
calcula-tingthenumberofcorrectanswersfortheword‘‘NO’’at
thefirstpresentationandthenumberofcorrectresponses
forthe6thpresentation.Thedifferencebetweenthesetwo
numbersiswhatiscalleddecreasedattentiveness.20
The data were categorized and added to a digital
spreadsheet.Thevariablesweredescriptively---mean,
stan-darddeviationandfrequencymeasures---andinferentially
analyzed --- tests: t-Student for independent samples and
Spearman’scorrelation.ThestatisticalsoftwareR,version
2.11.0,wasused,withsignificancelevelof5%.
Results
TheStudyGroup(SG)participantshadameanageof25.40
(±7.36)years,andmostweremales(53.3%,n=7)and
stu-dents(53.3%,n=7).Thecontrolgroup(CG)hadameanage
of26.66±7.06years,mostwerefemales(60.0%,n=9)and
students(73.3%,n=11).Thesamplewashomogeneous.
Table2showsdatacharacterizingthevolunteers’
tinni-tus. Therewasa predominance of tinnitusin theleftear
(33.3%;n=5),singletype(60.0%;n=9),withsuddenonset
(60.0%;n=9),constant(73.3%,n=73.3)andwithawhistling
sound(40.0%,n=6).
Itwasobservedthattheindividualsreportedthe
symp-tomoccurrencefor5.04(±6.20)years,onaverage,witha
valueof6.21(±1.84)onthevisual-analogscale.Theyhada
meanscoreof37.78(±27.05)inthetotalTHI,characterizing
a moderate degree, especially in the Functional domain,
withameanscoreof17.85(±12.97)points(Table3).
In the psychoacoustic measures, it was observed that
thetinnitusmeanfrequencysensationintherightearwas
3000Hz(±2576.45)andintheleftear,3000Hz(±3057.29),
with a mean intensity sensation of 13 (±11.96) and 13
Table 2 Tinnitus characterization in study group volunteers.
Variable Studygroup
n % Location RE 4 26.7 LE 5 33.3 R=L 3 20.0 R>L 3 20.0 R<L 0 0.0 Head 0 0.0 Type Single 9 60.0 Multiple 3 20.0 Pulsatile 2 13.3 Singleclick 1 6.7 Start Progressive 6 40.0 Sudden 9 60.0 Perception Constant 11 73.3 Intermittent 4 26.7
Descriptionofthesound
Whistling 9 60.0 Wheezing 4 26.7 Pulsatile 2 13.3 AcuphenometrystimulusRE Continuous 9 60.0 Modulatedfrequency 0 0.0 NB 2 13.3
DidnotreporttinnitusintheRE 4 26.7
AcuphenometrystimulusLE
Continuous 10 66.7 Modulatedfrequency 1 6.7
NB 0 0.0
DidnotreporttinnitusintheLE 4 26.7
Table 4 shows the behavioral and electrophysiological
evaluationofthestudyandcontrolgroups.Differenceswere
observed in thebinaural separation of theDichotic Digits
test,bothintheright(p=0.009)andintheleft(p=0.001)
ears,beingstatisticallysignificant.Therewasalsoa
diffe-rence between the results of the Speech-in-Noise test in
bothears(RE:p=0.044,LE:p=0.019),P300(p=0.049)and
TotalSAAAT(p=0.032).
A positive correlation was observed between totalTHI
scoreswithVAS(p=0.036)andSAAATresponses(p=0.041).
There was also a negative correlation between SAAAT,
decrease in attentiveness and binaural integration in the
right(p=0.044)andleft(p=0.048)ears(Table5).
Discussion
Thehumanearhasarestrictedabilitytoprocessthearrival
of agivenstimulus.21 Therefore,it isconsidered that the
attentionalmechanismsareimportanttolimittheamount
ofprocessedinformation.
Table3 Meanandstandarddeviationoftinnitusvariables inthetestgroupindividuals.
Variables Studygroup Mean SD Timeoftinnitus 5.04 6.20 VAS 6.21 1.84 THI:Functional 17.85 12.97 THI:Emotional 13.35 10.62 THI:Catastrophic 9.14 6.16 TotalTHI 37.78 27.05 Psychoacousticmeasure: frequencyRE 3000 2576.45 Psychoacoustic measurement:intensity RE 13 11.96 Psychoacousticmeasure: frequencyLE 3000 3057.29 Psychoacousticmeasure: intensityLE 13 15.00
SD,standarddeviation;VAS,VisualAnalogScale;RE,rightear; LE,leftear;THI,TinnitusHandicapInventory.
Concerningtinnitusandattentionalissues,more specifi-callyinrelationtoauditoryattention,studieshave shown thatindividuals haveconcentrationand attention difficul-tiesdue totinnitus.7,22 Inthepresentstudy,subjectswith
tinnitusreporteda moderatedegreeof annoyance,afact
that can hinder concentration. Another study that used
theTHIquestionnaire alsoshowedthatmost patientshad
concentrationandsustainedattentiondifficulties.23
Regardingthebinauralseparation ofthedichoticdigits
test,abetterresultwasobservedinboth earsinthe two
testsforthenon-tinnitusgroup.Therewasalsoadifference
betweentheresultsoftheSpeech-in-Noisetestinbothears.
Thesefindingssuggestthattinnitusmaybedisruptingthese
individuals’selectiveattention.Studieshavedirectly
asses-sedtheimpactoftinnitusonselectiveattentionandhave
concludedthatithasaneffectonthecognitiveperformance
bydisruptingselectiveattention.9,22,23
Thepresentstudyshowedapositivecorrelationbetween
the total THI scores with the VAS and SAAAT responses,
suggesting that the greater the impactof tinnitus onthe
individual’slife,thegreatertheannoyanceandinterference
oftinnituswithsustainedattention(concentration).
Todate,nostudyhasbeen foundintheliteraturethat
evaluatedthesustainedattentionabilityusingSAAATin
tin-nituspatients,butconsideringthestudiedpopulation,itcan
beinferredthatindividualswiththesymptomhavegreater
difficultiesinconcentration.Therewasanegative
correla-tionbetweenSAAAT,decreaseinattentivenessandbinaural
integration, and right and left ears; that is, the greater
thenumberoferrorsintheSAAAT(theworsethesustained
attention),thelowerthebinauralintegrationvalue(more
errors).
RegardingthemeanP300latency,astatistically
signifi-cant differencewas observed between both groups. Such
findings corroborate the evaluated literature,24 in which
latencydifferences wereobserved in individualswithand
without tinnitus; that is, in individuals withtinnitus, the
latencyisincreased.
Individuals with tinnitus commonly complain of
diffi-cultiesin concentration and in activities of daily living.25
Table4 Mean,standarddeviationandcomparisonofbehavioralandelectrophysiologicalevaluationbetweenthestudyand controlgroups.
Variable Studygroup Controlgroup p-Value
Mean SD Mean SD
DichoticDigitsTest
BinauralintegrationRE 95.89 6.91 97.66 2.90 0.087 BinauralintegrationLE 98.00 4.83 95.40 5.07 0.508 BinauralseparationRE 96.50 8.18 100.00 0.000 0.009a BinauralseparationLE 94.60 7.29 97.66 3.33 0.001a Speech-in-NoiseTest PSRIRE 95.60 5.25 96.13 3.41 0.262 PSRILE 96.26 3.53 94.00 3.46 0.563 SNRE 82.93 13.13 86.93 9.25 0.044a SNLE 81.33 11.17 85.60 7.97 0.019a P300 305.86 37.68 301.40 23.28 0.049a TotalSAAAT 3.26 5.86 1.00 1.30 0.032a SAAATdecrease 0.86 1.18 0.46 0.74 0.152
SD,standarddeviation;PSRI,PercentageofSpeechRecognitionIndex;SN,Speech-in-Noise;RE,rightear;LE,leftear;SAAAT,Sustained AuditoryAttentionAbilityTest.
aStudent’st-test---independentsamples;p<0.05.
Table5 Correlationbetweenself-assessmentresultsand auditoryaspectsofindividualsinthestudygroup.
Variable Teststatistics p-Valuea
TotalTHI×VAS 0.563 0.036
TotalTHI×SAAAT 0.482 0.041
SAAATAD×binaural integrationRE −0.546 0.044 SAAATAD×binaural integrationLE −0.454 0.048
VAS,VisualAnalogScale; SAAAT,SustainedAuditory Attention AbilityTest;AD,attentivenessdecrease;THI,TinnitusHandicap Inventory;RE,rightear;LE,leftear.
aPearson’sCorrelationTest;p<0.05.
attention to the stimulus. If the stimulus is ignored, the
waveformsareattenuatedandpossiblydelayed.26
Itisalsobelievedthattinnitushasamaskingeffecton
theacousticsignalspresentedtotheseindividuals.27
The-refore,itcanbeinferredthatindividualsinthetestgroup
wereless attentive during the tests, probablydue tothe
presenceoftinnitusand,consequently,thereduced
atten-tioncouldhavebeen acontributingfactor totheincrease
ofP300latency.25
ThealterationsinP300observedinindividualswith
tin-nitusdemonstratetheinvolvementoftheCentralAuditory
System,suggestingtheparticipationoftheauditorycortex
inthetinnitusgenerationand/ormaintenance.28
A study hasshown thatthe reaction timefor therare
stimuluspresented,observedinpatientswithtinnitus,was
significantlyslowerthaninthecontrolgroup(notinnitus).23
Anotherstudy8evaluatedtheselectiveattentionin
indivi-dualswithtinnitususingtheStroopTest,andconcludedthat
thereactiontimeinthetinnitusgroupwasslower(1559ms)
thanintheothergroup.
Other possible factors that can be attributed to the
increasedP300wave latencyin individualscomplainingof
tinnitusarethepossibilityofareductioninthenumberof
functioning neurons, a decrease in neural activity and/or
greaterfiringdesynchronizationintheaffectedneurons.29
In summary, based onthe data fromthis study, it can
be inferredthattinnitus is afactor that can dispersethe
selectiveandsustainedattentionoftheseindividuals.This
factcaninterferewiththeactivitiesofdailylivingandbe
animpedimentfactorforthehabituationmechanism.
Addi-tionally, the behavioral and electrophysiological tests are
importantinidentifyingcognitive(attention)aspectsin
indi-vidualscomplainingoftinnitus.
Conclusion
Tinnituswithamoderatedegree ofannoyancewas
obser-ved. The binaural integration ability performance in
subjects withtinnitus wasworse thanthat of the control
group.Inaddition,selectiveandsustainedauditory
atten-tion was found to be diminished in these subjects when
comparedtocontrolgroup.
Therefore,itisimportanttoconsidertheattentional
pro-cessesduringtheevaluationoftheseindividuals,sincethe
behavioral andelectrophysiological tests areimportant in
theidentification ofcognitiveaspects(attention) inthese
patientsandsuchfactorsmaybeimportanttofacilitatethe
managementoftinnitus.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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