Braz. j. . vol.81 número2

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Tinnitus

prevalence

in

the

city

of

São

Paulo

夽

,

夽夽

Jeanne

Oiticica

∗

_,

_Roseli

_Saraiva

_Moreira

_Bittar

DepartmentofOtorhynolaryngology,HospitaldasClínicas,FaculdadedeMedicina,UniversidadedeSãoPaulo(USP),SãoPaulo, SP,Brazil

Received16November2013;accepted20July2014 Availableonline27December2014

KEYWORDS

Tinnitus; Epidemiology; Prevalence

Abstract

Introduction:ThepublicandprivatehealthcareinthecityofSãoPaulohasnodataontinnitus prevalence.

Objective: DeterminetinnitusprevalenceinSãoPaulocity.

Studydesign:Seriesstudy.

Methods:Cross-sectionalstudybyfieldquestionnairewith1960interviews.Predictorvariables includedgender,age,tinnitus.

Results:The prevalence oftinnitus was22%. Itaffects more women(26%) thanmen (17%) and increaseswithadvancing age.Approximatelyone thirdofcases (32%)assert thatthey haveconstanttinnitus(i.e.,‘‘ringing’’),whilemostdescribeintermittenttinnitus(68%).The majority(64%) reportedfeeling annoyed,while others(36%)deniedany annoyance.Among women,theoccurrenceofanannoyingtinnituswassignificantlyhigher(73%)thanamongmen (50%).Thepercentageswere:mildlyannoying(11%),moderatelyannoying(55%),andseverely annoying(34%).Tinnitusinterfereswithdailyactivitiesin18%ofthosereportingtobeannoyed.

Conclusion: ThepopulationinthecityofSãoPaulosufferingfromtinnituswasmoreprevalent thanpreviouslyestimated.Generally,itaffectsmorewomenandthosewithoutoccupation, andincreasessignificantlywithage.Mostrespondentsdescribedthetinnitusasannoying,and thiswasmoreprevalentinfemales.ThedegreeofdiscomfortmeasuredbyaVisualAnalogue Scaleshowedmoderatetinnitus,withresponsesaveraging6.3.

夽

Pleasecitethisarticleas:OiticicaJ,BittarRS.TinnitusprevalenceinthecityofSãoPaulo.BrazJOtorhinolaryngol.2015;81:167---76.

夽夽

Institution:EscoladeMedicina,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil.

∗_{Corresponding}_author.

E-mail:[email protected](J.Oiticica).

http://dx.doi.org/10.1016/j.bjorl.2014.12.004

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PALAVRAS-CHAVE

Epidemiologia; Prevalência; Zumbido

PrevalênciadozumbidonacidadedeSãoPaulo

Resumo

Introduc¸ão:AsredespúblicaeprivadadesaúdenacidadedeSãoPaulonão possuemdados sobreaprevalênciadezumbido.

Objetivo:Determinaraprevalênciadozumbidonapopulac¸ãopaulistana.

Desenhodoestudo:EstudodeSérie.

Método: Estudotransversalporquestionáriodecampototalizando1960entrevistas.

Resultados: A prevalênciadezumbido observadafoi de22%.Acomete maismulheres (26%) doquehomens(17%).Observou-secrescimentoprogressivodaprevalênciacomoaumentoda idade.Cercade1/3doscasos(32%)têmzumbidoconstante,enquantoamaioriareferezumbido intermitente(68%).Amaioria(64%)declarousesentirincomodada,osdemais(36%)negaram qualquerincomodo;nestequesitoopercentualdemulheresfoisignificantementemaior(73%) que ode homens (50%).Os percentuais observadosforam: incômodo leve(11%), incômodo moderado(55%),eincomodosevero(34%).Ozumbidointerferenasatividadesdiáriasem18% dossujeitos.

Conclusão:OzumbidonacidadedeSãoPaulomostrou-semaisprevalentedoqueopreviamente estimado.Acometemmaisfrequentementemulhereseindivíduossemocupac¸ão,aumentando significantementecomaidade.Amaioriarefereseincomodarcomozumbido,sendoaqueixa maisprevalentenasmulheres.Oincômodomédioaferidopelaescalavisualanalógicaapontou zumbidomoderadocomnotade6,3.

Introduction

TinnitusisacommonsymptominENToutpatientclinicsand canbedefinedastheperception of soundinthe absence of any external sound stimulus. The presence of tinnitus may indicate that something is wrong somewhere in the auditorysystem.Thissymptom canalsobetheresultofa numberof health conditions,such asnoise-induced hear-ingloss,acoustictrauma,presbycusis,metabolicdisorders, use of medication, ear infections, somatosensory impair-mentand/orchronicco-morbidities.Itmayalsobepresent inindividualswithnormalhearing.1

Despite itshigh prevalence, in Braziland in São Paulo

there are no epidemiologic studies of the general

popu-lation to determine the frequency of tinnitus. Estimates

of the prevalence of tinnitus vary among different

exist-ingepidemiologicalstudies;butpreviouslypublishedresults

indicateafrequencyofapproximately10---15% ofthe

gen-eraladultpopulation.2---8 _The_difficulties_in_conducting_this

typeofstudyandthesourceofuncertaintyin

epidemiologi-calstudiesarebasedontwokeyfacts:tinnitusseveritycan

onlybeassessedbythepatient,andthereisnoobjective

measureforthesymptom.9

Accordingtotheliterature,mostindividualswith

tinni-tusarenotbotheredbythesymptom,withonly25%ofthose

seekingprofessionalhelp.10 _The_degree _of_discomfort_with

thesymptom often varies over time;and asmall but

sig-nificantnumber ofpatients reportthat tinnitusinterferes

directlyintheirdailyactivities,causeschangesinqualityof

lifeandsubstantialchangesinbehavior,includinganxiety,

frustration,irritability,depressionandsleepdisorders.11_In

1---2%ofcases,tinnitusisbothersomeenoughtosignificantly

affectdailyactivities.12

It is known that the prevalence of tinnitus is directly

relatedtoageandhearingloss;12_however,_the_exposure_to

noiseisalsoawellestablishedandknownriskfactor,andone

ofthemostcommoncausesoftinnitus.Urbancenterslike

SãoPauloemergeasaconcentrationpointfordailyexposure

to noise andenvironmental noise pollution.As examples,

consider the excessive land and air traffic, overcrowded

public spaces, shows, concerts and outdoor recreational

activities, sports activities, and eventhe noise stemming

fromdomesticleisureandsafetyequipmentandhousehold

appliances.Theexpectationisthattheprevalenceof

tinn-ituswillincreaseinthefuture, notonlyamongadultsand

the elderly, asa consequence of increased longevity and

chronic comorbidities;butalsoamongteenagersand

chil-dren, because of the greater noise exposure in schools,

leisure environments, and in particular by the misuse of

personalmusiclisteningdevices.Therefore,itisreasonable

toinferthatauditoryclinicalcomplaints,suchastinnitus,

shouldemergeasapublichealthproblem.

According to the latest census of the IBGE (Instituto

BrasileirodeGeografiaeEstatística),2010,thecityofSão

Paulo has a population of 11,253,503 inhabitants, with a

birthrateof 15.59/1000.13 _The_elderly_represent_12.5% _of

thepopulationandilliteratepersons3.1%.The cityofSão

Paulo hasaper capitaannualincomeofR$39,445.20and

58.4% of the population concluded secondary education.

Thesesocio-demographiccharacteristics ofthecityofSão

Paulo reveal a profile that is similar to that observed in

most Europeancountries.Demographic changesespecially

a decline in fertility and an increase in years of survival

directly influencestheagecompositionofthe population,

andwe havewitnessedatransferof responsibilityfor the

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Knowledgeofinformationaboutthepopulationprofileof

thecityofSãoPauloisofutmostimportance,sinceitis

crit-icaltomakesurethatthefinalsampleobtainedafterfield

collectionandanalysisofourresultsisactuallysufficiently

diversified,representative ofallsocioeconomicstrata and

majoragegroupsandproportionaltopopulationsize,

keep-ingtheequiprobability.

Thesocialdemandsofthosepeoplelivinginthecityof

SãoPaulohavebeen changing,anditisnecessary tohave

abetterunderstandingofthispopulation,sothat

appropri-atehealth policiescan beundertaken.Publicand private

healthcarenetwork in thecity of São Paulo have nodata

on the prevalence of tinnitus; actually, this information

is unknown even for the Brazilian population, becauseof

an absence of specific epidemiological studies. Thus, the

compilation,analysisanddisseminationofsuchinformation

mayhelptodelineatethepreciseprofileofthepopulation.

Ourhypothesisisthattinnitusisaprevalentcomplaintin

thecityofSãoPaulo,withpotentialmorbidityandimpacton

people’shealth,particularlyintheelderly.Thus,additional

informationabout the frequency, intensity of discomfort,

impactondaily activitiesand associatedrisk factors, can

improveprimarycareandthereferralofpatientstotriage

sectors.In addition,thisinformation helpssupportpublic

health policies and prevention campaigns. Moreover, risk

factors collected frompopulation samples may raise new

pathophysiologicalhypothesesandcontributetoadvancesin

tinnitustherapy.Determiningtheprevalenceoftinnituswill

increaseourknowledgeaboutthesymptomprofileforthis

city,favoringtheimplementationofnewpublichealth

poli-cies.Withoutanaccurateestimate,itisimpossibletoplan

anykindofaction,includingobtainingresourcesorsupport

fortheseprojects.

Objectives

Thisepidemiologicalstudyaimedto:

1. Determinetheprevalenceoftinnitusintheadult

popu-lationofthecityofSãoPaulo;

2. Describethemain clinicalcharacteristics oftinnitusin

thispopulation;

3. Quantifythedegreeoftinnitusinthepopulation.

Methods

Thisobservationalcross-sectionalepidemiologicalstudywas

conductedbetweenAprilandOctober2012inthecityofSão

Paulo.Thepopulation-basedsurveytodeterminethe

preva-lenceoftinnitusinthecityofSãoPaulowasaccomplished

throughtheapplication of afieldsurveyquestionnaire on

thispopulation,previouslydesignedforthisspecificpurpose

and adapted and modified based ontwo original studies:

thefirst,conductedtodeterminetheprevalence of

tinni-tusintheUSpopulation8_and_the_second_to_study_Meniere’s

diseaseinsouthwesternFinlandpopulation14 _In_a_previous

publication, we determined that the prevalence of

dizzi-ness in the city of São Paulo was 42%, with the use of

the same questionnaire.15 _The _project _was _conducted _in

accordancewithnormsandguidelinesestablishedby

ESO-MAR’s International Code of Practice for Social Research

andMarketing, and after approval by the Ethics

Commit-teefor Analysis of ResearchProjects (CAPPesq), Medicine

School,Universidade de São Paulo (USP), research

proto-colNo.0970/09. Theproject wasfundedby Fundac¸ãode

AmparoàPesquisadoEstadodeSãoPaulo(FAPESP/Regular

ResearchSupport/ProcessNo.2011/10343-7).

Sample

Thesamplesizewascalculatedassuminganexpected

preva-lenceoftinnitusof15%inthepopulation,withanaccuracy

of2%,confidenceintervalof95%,designeffectoftwo,and

10%increaseforpossiblelosses.Thesamplesizewasinitially

estimatedasbeing1901inhabitants.Estimating3---4persons

perhousehold,itwascalculatedthat633householdswould

bevisited.It wasestimated that 40of the 13,193 census

sectorsofthecityofSãoPaulowouldbeselected:8ineach

ofthefirstfiveareasofthecity (north,south,east,west

andcenter).Thefiveregionswereincludedtoensuresome

diversitytothesample,thusensuringanestimateinvolving

allmajorsocioeconomicprofilesandagegroups.Thedraw

ofthecensussectorwasproportionaltothepopulationsize

ofthearea,formaintenanceofequiprobability.

Datasampling

Clustersamplingamongthevariouscensussectorswasused.

Fortheselectionofhouseholdstobevisitedfordata

collec-tion,arandomselectionofcensussectorswasperformed.

Insideeach ofthesesectors,one blockandone cornerof

thisblockweredrawn.Fromthisallocatedcorner,thefirst

16homeswerevisitedconsecutively.Everyadaptationand

codificationofourstructuredpopulationquestionnaire,

pre-test conduction, preparation of cards, field manuals and

controlsupplies, stafftraining,censussector draws,

field-work,interviewspersonallyappliedinhouseholdvisitsand

statisticalanalysis ofthe collected resultswere executed

byAnalíticaPesquisasMercadológicas,SociaiseEconômicas

Ltda,a specialized company in field research,with

long-termexperienceinthatbusiness.

Inclusioncriteria

Individualsover18yearsandofbothgenderswereincluded.

Inthepopulation-basedsurveysample,allresidentsineach

selectedhouseholdwereinterviewed.Ifinthesameplace

twoormorefamiliescohabited,eachwasconsidered

sepa-rately.

Exclusioncriteria

Fortheassortedresidences,theexclusioncriteriawere:(1)

residentsabsentatthetimeoftheinterview,andthatafter

threerationalattemptsofvisitationwerenotfound;(2)sick

andconvalescentpeople;(3)peoplenotlivinginthe

house-hold who were being visited, including relatives and/or

friendspassingthroughthehouseanddomesticemployees

notresident inthe household;and(4)commercial houses

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Studyvariables

The measure of occurrence was evaluated by the ratio

between the number of individuals with tinnitus

com-plaintcomparedtothe totalnumber ofrespondents. The

mainpredictorvariablesweregender,age,schooling,race,

occupation, and their relationships with tinnitus,

tinni-tuscharacteristics(constant[notconstant];annoying[not

annoying], interfering [not interfering] with daily

activi-ties),definedasqualitativevariables.Quantitativevariables

includedtimeofoccurrenceoftinnitusandlevelof

discom-fortof tinnitusmeasured by VAS (Visual Analogue Scale).

Thescaleisgraduatedincolorsrangingfromwhite,through

blue,green,yellowandorangetones,endingintheredcolor

andnumberedfrom0to10.Thesubjectwasinstructedto

assign a score from zero to ten for the nuisance caused

by his/her tinnitus, according to Figueiredo16 _and

illus-tratedinFig.1.Therespondentwasrequestedtoposition

him/herselfinrelationtothelevelofdiscomfort,i.e.,the

closertothewhitecolorzone,thelowerthediscomfort;and

theclosertotheredzone,thehigherthediscomfort.Ascore

ofzerocorrespondsto‘‘noannoyanceatall’’andascoreof

tencorrespondstothe‘‘mostuncomfortable’’perception.

Thelevelofdiscomfortwasclassifiedasmild(1---3),

moder-ate(4---7)orsevere(8---10),accordingtothescoregivenby

therespondenttohis/hersymptomonascalefrom0to10.

Statisticalanalysis

The variables investigated were subjected to descriptive

analysis.Thesignificanceoftheassociation between

qual-itativevariablesandthemeasureofoccurrence,presence

orabsenceof tinnituswasdeterminedby thechi-squared

(2)test.Forquantitativevariables,theStudent’st-testwas

applied.Thevariablesshowingasignificantassociationwith

themeasure ofoccurrence (p<0.05) weresubjected toa

logistic regression model to identifypossible confounders

ofthe association and alsoto identifythosefactors most

stronglyassociatedwiththepresenceanddegreeof

annoy-ancecaused bytinnitus.Confidenceintervals of95%were

alsocalculatedfortheestimatesproduced(e.g.,prevalence

oftinnitus).

Results

Sample

The company responsible for our field research chose to

expandthesamplesizeoriginallycalculatedatthetimeof

collection, toreduce possible losses. Therefore,our final

sample consisted of 1960 individuals. To obtain this

num-ber, 1008 households, randomly assigned between 63 of

13,193censussectorsofthecityofSãoPaulo,werevisited,

whichaccountedforanaverageof2.2adultsperhousehold

(Table1).

A descriptive analysis of the main predictor variables

evaluated(gender,age,schooling,race)isdiscriminatedin

Table2.

Table1 Samplesize(n)andpercentage(%)ofhouseholds visitedaccordingtocensussectorsinthecityofSãoPaulo.

Regions Total

n %

East 738 38

South 589 30

North 305 16

West 194 10

Center 134 7

Samplebase 1960 100

n,samplesize;%,samplepercentage.

Table 2 Descriptive analysis of the sample profile col-lectedforthecityofSãoPaulo.

n %

Gender

Female 1046 53

Male 914 47

Age(years)

18/25 278 14

26/35 404 21

36/45 349 18

46/55 325 17

56/65 273 14

66and+ 328 17

Refusal 3 *

Schooling

Illiterate/incomplete primaryschool

292 15

Completedprimary school/incompletejunior highschool

484 25

Completedjuniorhigh school/incomplete Secondarystudies

346 18

Completedsecondary studies/incomplete universitystudies

620 32

Completeduniversity studies

218 11

Race(byobservation)

White 1237 63

Black 167 9

Yellow 45 2

Mulatto 507 26

Indian 4 *

Samplebase 1960 100

* _Percent_value_<0.003%.

Prevalenceofsymptomsinthepopulationofthe cityofSãoPaulo

Presenceoftinnitus

The prevalence of the reported symptom ‘‘tinnitus’’ in

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Visual analogue scale - VAS

Figure1 VASforclassificationofannoyancecausedbytinnitus.

respondents), who responded affirmatively to the

ques-tion, ‘‘Do you have ringing in your ears?’’, versus 78%

(1530individuals)whodeniedthiscomplaint.Thesymptom

affectsa higherpercentage of women(26%) comparedto

men(17%),withastatisticallysignificantdifference

(Pear-son’schi-squaredtest,p=0.000).Aprogressivelyincreasing

prevalence with increasing age was also observed.

Appli-cation of Pearson’s chi-squared test revealed statistical

significance (p=0.000) in the evaluation of the presence

of tinnitusby agegroups. From thepoint of viewof age,

the peakof therespondents’ complaintoccursin

individ-ualsover 65yearsofage (36%),andis threetimes higher

than the prevalence (12%) observed among those 18---25

years of age (Table3).There was nodifferencebetween

smokers(23%)andnonsmokers(22%)(Pearson’schi-squared

test,p=0.581). However,havingor nothavingan

occupa-tionawayfromhomeprovedtobeakeydifferentiator;the

prevalence oftinnitusamongindividualswithout an

occu-pationwas29%,comparedwith18%ofthoseworkingaway

fromhome(Pearson’schi-squaredtest,p=0.000).

Durationoftinnitus

Therespondentswhoreportedhavingtinnitus(430

individ-uals,reducedbase),wereasked,‘‘Howlonghaveyoubeen

experiencingthisringinginyourears?’’.Weobservedawide

variationinresponses.Somepeoplelivedwiththesymptom

forashorttime(40%,uptothreeyears)andsomepeople

alongertime(27%,3---10years),whiletheremaininglived

withtinnitusforalmostalifetime(22%between10and30

years).Inoursample,nosignificantdifferenceswerefound

relativetothisparameter,asshowninTable4.

Characteristicsoftinnitus

Consideringtherespondentswhoreportedtinnitus(430

indi-viduals),theywereasked,‘‘Isyourringingconstant,i.e.,do

youperceiveitallthetimeeveryday?’’Approximatelyone

thirdofcases(32%)claimedtohaveaconstantringing,while

the vast majority related an intermittent tinnitus (68%).

Amongmen(38%)constanttinnituswasmoreprevalentthan

amongwomen(28%)(Pearson’schi-squaredtest,p=0.044).

With respect to age, the constant tinnitus increased in

prevalence about three times higher with advancing age

(Table5).

Thosewhoreportedthesymptom(430individuals)were

asked,‘‘Doesitbotheryou?’’Thevastmajority(64%)stated

that they felt uncomfortable, while others (36%) denied

anyannoyance.Amongwomen,thepercentagewas

signifi-cantlyhigher(73%)comparedtomen(50%).Withrespectto

theothervariables,nosignificantdifferencesinprevalence

werefoundinthesample.

Degreeoftinnitusannoyance

Aiming to better understand and measure the degree of

tinnitusannoyanceamongrespondentswhomentioned

hav-ing the symptom (430 individuals), the Visual Analogue

Scale(VAS)wasapplied.Theobservedpercentagesformild,

moderate,andseverediscomfortwere11%, 55%and34%,

Table3 Prevalenceofthereportedsymptom‘‘tinnitus’’accordingtothedifferentagegroupsinthepopulationofthecityof SãoPaulo.

Doyouhavetinnitus inyourears?

Total Age

n % 18---25years 26---35years 36---45years 46---55years 56---65years >65years

n % n % n % n % n % n %

Yes 430 22 33 12 54 13 60 17 86 26 79 29 117 36 No 1530 78 245 88 350 87 289 83 239 74 194 71 211 64 Samplebase 1960 278 404 349 325 273 328

Qui-squaredtests

Value df p

Pearson’schi-squared 86.416a ₆ _0.000

Likelihoodratio 13.822 6 0.000

LinearbyLinearAssociation 1.275 1 0.000

n,samplesize;%,samplepercentage;df,difference;p,statisticalsignificance(two-tailed).

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Table4 Timeofdurationofreportedtinnitus,accordingtothedifferentagegroupsinthepopulationofthecityofSãoPaulo. Howlonghaveyou

beenexperiencing thisringinginyour ears?

Total Age

n % n % n % n % n % n %

Upto1year 84 20 7 21 19 35 17 28 20 23 13 16 8 7 >1and≤3years 86 20 12 36 11 20 11 18 21 24 9 11 22 19 >3and≤5years 62 14 3 9 9 17 14 23 8 9 11 14 17 15 >5and≤10years 100 23 8 24 9 17 7 12 22 26 22 28 32 27 >10and≤20years 54 13 3 9 3 6 5 8 10 12 13 16 19 16 >20and≤30years 28 7 --- --- 3 6 4 7 1 1 8 10 12 10 >30years 10 2 --- --- --- --- 2 3 4 5 3 4 1 1 Refused 1 * _--- _--- _--- _--- _--- _--- _--- _--- _--- _--- ₁ ₁

Donotknow/donot remember

5 1 --- --- --- --- --- --- --- --- --- --- 5 4

Reducedbase 430 33 54 60 86 79 117

* _Percentage_value_<0.003%.

respectively.Theirresponseswere:mean,6.3±2.3points,

andmedian,6points.

Interferenceoftinnitusindailyactivities

Despitethe high prevalence of respondentswho reported

annoyance with tinnitus when asked, ‘‘Does your ringing

interferewithyourdailyactivities?’’,82%answered‘‘no’’,

while18%answered‘‘yes.’’Withrespecttothose18%who

reportedthattinnitusinterfereswiththeirdailyactivities,

nodifferenceswereobservedbetweenthecategorical

varia-blessurveyed.

Discussion

Our field study wasintended to estimate the prevalence

of thesymptom ‘‘tinnitus’’in theadult populationof the

city ofSãoPaulo. This is thefirststudy ofthiskind tobe

heldinBrazil.Thisisanexpensiveproject,sincethe

inter-views were conductedin person in the households of the

interviewees;andtheexecutionofourstudywasonly

pos-sible becauseof the financialsupportof FAPESP.We used

the field research as a tool --- the investigator went to

theinvestigatedperson’shomeanddirectly addressedthe

questionnaire. Considering that tinnitus is subjective and

Table5 Prevalenceofconstant/intermittenttinnitus,accordingtothedifferentagegroupsinthepopulationofthecityof SãoPaulo.

Isthisringing constant,i.e.,do youperceiveit everyday?

Total Age

n % n % n % n % n % n %

Yes 136 32 5 15 7 13 8 13 34 40 33 42 48 41 No 294 68 28 85 47 87 52 87 52 60 46 58 69 59

Reducedbase* 430 33 54 60 86 79 117

Qui-squaredtests

Value df p

Pearson’schi-squared 35.315a ₆ _0.000

Likelihoodratio 38.621 6 0.000

LinearbyLinearAssociation 25.957 1 0.000

n,samplesize;%,samplepercentage;*,mentionedtinnitusintheirears;df,difference;p,statisticalsignificance(two-tailed).

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a difficult symptom to measure, we insisted onintensive

trainingofallinterviewersontheapplicationofthe

ques-tionnairesothatwecouldcharacterizeasbestaspossible

thesymptommentioned.Therefore,itmustbeconsidered

thatthesubjectivityoftherespondents’judgment,aswell

asthetemporalnatureofthereportedcomplaints,canbe

consideredaspotentialelementsofbias.

An affirmative answer to the question: Heading 3 was

given by 22% (430 individuals) versus 78% (1530

individ-uals) of respondents who denied the complaint. Despite

theclinicalrelevanceofthesymptom, noepidemiological

study determining the prevalence of tinnitus in the

pop-ulation was published in Brazil, and this prevalence was

estimatedbasedontheresultsfrompopulation-based

sur-veysinothercountries.Evenconsideringthesedata,studies

thatestimated theprevalenceof tinnitusin adult

popula-tions(over18yearsold)arelimited,sincetheydifferfrom

eachotherinmanyaspects,makingitdifficulttocompare

our results with those of other authors in the literature.

Ingeneral,theseepidemiologicalstudiesestimatethatthe

prevalenceoftinnitusisaround10---15%oftheadultgeneral

population.3,9,12,17,18

The percentage observed in our study is remarkable,

sincethisvalueiswellabovethatestimatedforthenational

population, andis stillhigh comparedtomostother

pub-lished surveys. Axelsson and Ringdahl observed in 1989 a

prevalenceof 14.2%,withtheoccurrencebeingmore

fre-quentinmenversuswomen).12_In_2.4%_of_cases,_tinnitus_was

reportedasadisablingcondition.In1996,inan

epidemio-logical study of adult hearing problems in Italy, Quaranta

etal.foundthattheprevalenceofprolongedspontaneous

tinnituswas14.5%.18 _In_an _{epidemiological}_study _on

hear-inglossintheUnitedStatesassessingindividualsbetween

48and92yearsoldandpublishedin2002, Nondahletal.

notedaprevalenceoftinnitusof8.2%.9_In_2011,_Fujii

con-ducteda Japanese population-basedstudy of adultsaged

45---79 years.3 _The _prevalence _was_11.9%, _occurring _more

frequentlyinmen(13.2%)thanwomen(10.8%);theauthor

also notedthat the frequency of this symptom increased

withage.

Inapopulation-basedfieldstudyconductedinAustralia

bySindhusakeetal.in2003,2015individualsagedbetween

55 and 99 years were included. Similar to our series, to

determine itsprevalence theauthors focused only onthe

presenceoftinnitusbytheirpatients,without focusingon

factors such astime, frequency and/or severity of

symp-toms. The prevalence oftinnitus was30.3%.11 _This _is _one

of thefew publishedstudiesin theliterature indicating a

highprevalenceofthesymptom,andoneofthefewwhose

resultsresemble thoseofoursurvey. Themain difference

isthat,intheiranalysis,Sindhusake etal.consideredonly

elderlyindividuals,whereasinourstudywechosetoinclude

asamplewithanagegroup(18---80years)more

representa-tiveofthepopulation.

Theuseofdifferentcriteriaforthedefinitionoftinnitus

(ringinginthelastyear,persistenttinnitusforatleastthree

months,prolongedtinnitus,tinnitusoftenoralwayspresent,

tinnitusforafewyears,frequentandbothersometinnitusin

recentyears,atleastmoderatetinnitusthatinterfereswith

sleep). Thestudy ofdifferent agegroups (elderly,

adoles-cents), characteristics (workersand non-workers,workers

exposedandunexposedtonoise),andmethodsusedfordata

collection(mailedquestionnaires,a retrospectiveanalysis

ofdatafrompopulation-based studies)amongthevarious

existingstudiesintheliteraturecomplicates the

compari-sonofprevalenceamongpopulations.Thehigherprevalence

inourstudymayhavebeeninfluencedbythefactthatwe

didnotrestrictourquestion toa specifictime,frequency

andseveritypatternsoftinnitusduringtheinterview,when

wesimplyaskedaboutthepresenceofthesymptom.Among

respondents,tinnitusoccurredintermittentlyintwothirds

ofthesamplewhoreportedthesymptom.Thisfindingcanbe

supportedby apopulation-basedfieldresearchconducted

with14,178USadultsbetween1999and2004,withtheaim

todeterminetheprevalenceoftinnitusintheUnitedStates.

ThestudywaspublishedbyShargorodskyetal.in2010,after

ananalysisofthenationaldatabase,andincluded

individ-ualsaged30---80years.8_The_prevalence_of_tinnitus_among_US

adultswas25.3%forthepresenceoftinnitus,regardlessof

frequencyormeasureofoccurrence,afindingverysimilarto

ours;and7.9%whenconsideringonlythecasesoffrequent

tinnitusin the lastyear. That is, the prevalence changes

drasticallydepending onthecriteriausedtoconsiderthe

occurrenceoftinnitus.

With respect to gender, among those who answered

‘‘yes’’tothequestion:‘‘Doyouhaveringinginyourears?’’

(22%---430individuals),ahigherpercentageofwomen(26%)

versusmen(17%)wasobserved,whencomparedto

respon-dents who answered ‘‘no’’ to the same question (78%

---1530 individuals). Populationstudies are discrepant when

considering the gender among individuals who reported

tinnitus. Some studies show a higher prevalence among

menversuswomen,7,19---21_but_not_all_studies.9,11,12,22,23 _Few

articlesintheliteratureweresimilartooursastothe

sam-plechosen (adult individuals in the population). In 2004,

Fujii et al., while investigating the prevalence of

tinni-tusintheJapanesepopulation,observedhigherprevalence

of thiscomplaint in men(13.2%) than in women (10.8%).

The authorsusedastheir study platform an olddatabase

from31,552 residentsover 35yearsofage inthetownof

Takayama,interviewed in 1992 ondemographicissues. In

2002, after excluding those deceased and those whohad

moved,theauthorssent questionnairesaskingabout

tinn-itus, so that one of three possible answers was marked:

(1)‘‘Ineverhadtinnitus,’’(2)‘‘Ihavetinnitus,’’(3)‘‘I’ve

hadtinnitus.’’Thebiasisthatnewresidentsorthosewho

have completed 35 years old during the gap of 10 years

ofthe studywere notincluded inthe sample.3 _And_when

thosewhoresponded‘‘I’vehadtinnitus’’wereconsidered,

the prevalence was higher among females (5.1%) than in

males(3.1%).Baigietal.(2011)randomlyselected20,100

inhabitantsfromthenationalregistryoftheentireSwedish

population (6,891,560 inhabitants), limited to the age of

18---84years,amongwhich12,166individualsrespondedto

theproposed questionnaire. The question askedwas ‘‘Do

youhaveringinginyourears?’’Withthreepossibleanswers:

(1)‘‘No,’’(2)‘‘Yes,withamilddiscomfort,’’and(3)‘‘Yes,

withan intensediscomfort.’’ Logisticregression was

per-formed to estimate the probability of tinnitus related to

stress and noise level. According to the authors, women

have 40% less risk to develop tinnitus than men (Odds

Ratio=0.60);thischancewasobservedforallagegroups.2_In

2010,intheUnitedStates,afterananalysisofthenational

(8)

Shargorod-skyetal.observedsimilarresults.Thepresenceoftinnitus

wasconsideredbasedonan answer‘‘Yes’’tothequestion

‘‘Inthelast12monthsdidyouhavetinnitusinyourears?’’,

followedbythe question‘‘How often?’’.The tinnituswas

consideredasbeingfrequentwhenthissymptom was

usu-allypresent,oroccurringatleastonceaday.Theprevalence

of tinnitus was higher among men (26.1%) versus women

(24.6%). However, as the national database intentionally

containedan overrepresentation of elderly peopleand of

Mexican-Americanandblacksubjects,thissimplycannotbe

consideredasampleoftheUSpopulation.Aftera

multivari-ateadjustmenttoturnthissampletoarepresentativebasis

forgeneralizingtheresultstothepopulation,itwasfound

thattheprevalenceoftinnituswashigherinwomen,when

onlythepresenceofthissymptomwasconsidered,

irrespec-tiveofwhetherornotthisbeafrequentsymptom(OR1.28).

Thus,afterthisadjustment,womenare28%morelikelyto

havetinnitus than men.8 _In _2005, _Hannaford_et_al., _using

a questionnaire mailed to12,100 households in Scotland,

conductedasurveythatincluded15,788respondentsover

14years.Thepercentageofresponsetothequestionnaires

was64.2%.The prevalenceof tinnitus(lastinglongerthan

5min)was17%.Theauthorsfoundthat,inindividualsunder

45years,theprevalencewashigheramongwomen(13.3%),

reachingavalue almosttwicethatobserved amongmales

(7.1%);andthatagradualreversionofthissituationoccurs

forpeopleover45years.23

Similar to other systematic reports in the literature

describingage asawell-defined riskfactor for the

devel-opment of tinnitus,2,3,8,9 _we _also _observed _a _progressive

increase in the prevalence of thissymptom with

increas-ingage. The peakof the complaint occursat 65 yearsof

age,andisthreetimeshigherthantheprevalenceobserved

in younger subjects. This can be easily explained by the

noise exposure over a lifetime andthe own auditory

sys-temagingprocess,withconsequentincreaseofcomplaints

relatedtotheinnerear.AccordingBaigietal.(2011),with

each additionalyear ofage, the riskof tinnitus increases

by3%,despitetheriskobservedinourstudyisalarmingly

higherthanthatreportedbytheseauthors.2

Anotherimportantfeatureobservedinourstudyrelated

toemployment.Theprevalence oftinnitusamong

individ-uals without an occupation was almost two times higher

thanthatobservedamongthosewithanoccupation.A

sim-ilar result was observed by Hasson et al. in 2010, when

describing the prevalence of communication disorders in

theSwedishgeneralpopulation(bothemployedand

unem-ployed);andcorrelationswithgender,age,socioeconomic

status(SES)andnoise.6_The_authors_demonstrated_a

signif-icant association between SES and prevalence of hearing

problems, including tinnitus. We can infer that

individ-uals withno occupation should be thosewith lower SES;

and,therefore, those moresusceptible tonoise exposure

(mechanical stress tothe inner ear), because these

peo-pleassumeunhealthyhabitsregardinghearingprotectionin

noisyenvironments,orexposethemselvestoexcessivenoise

forlongperiods.Thesepeoplearealsoclinicallymore

vul-nerable,thanks tothe highlevelofstress associatedwith

theircondition (emotional stress). Recently, it wasshown

thatpoorhealthisdirectlyrelatedtohigherprevalenceof

tinnitus;andthattheemotionalstatecanactasamodulator

oftheauditorysystem.5_The _processes_of_emotional_stress

involveboththeactivationofthesympatheticsystemwith

stimulation of ␣-adrenergic receptors in the cochlea,24,25

andtheprimaryneuroendocrine responseaimedat

estab-lishing the hypothalamic---pituitary---adrenal (HPA) axis.26

Current research suggests that acute stress protects the

cochlea,27---29 _while_chronic_stress_is_damaging_to_hearing.30

TheimportanceofHPAaxisinhearingpreservationis

sup-portedbyclinicalstudiesshowingthatpatientswithtinnitus

showsignsofcommitmentassociatedwithahighdegreeof

perceivedstress,comparedtopatientswithouttinnitus.31---33

Onemustkeepinmindthattheelderlycomprisea

signifi-cantsegmentoftheunemployedpopulation,andtinnitusis

threetimesmorecommoninthisagegroup.

When asked about the characteristics of the symptom

mentioned, ‘‘Is this ringing constant,i.e.,is it perceived

every day?’’; one-third of individuals experienced steady

tinnitus, while the remaining two-thirds had intermittent

tinnitus.Surprisingly,theconstanttinnituswasmore

preva-lentamongmenthaninwomen.Thisfindingwasalsonoted

byShargorodskyetal.in20108_who_observed_the_occurrence

offrequenttinnitus(ringingusuallypresent,oratleastonce

aday)withahigherprevalenceinmenversuswomen(OR

0.92).

Whenasked about theannoyance causedby the

symp-tom, ‘‘Is this ringing bothersome to you?’’, we found

thattwo-thirdsof thepopulationwhomentionedtinnitus,

whetherconstantor not,werebotheredbythesymptom.

Until then, it wasestimated thatthis percentagewas far

lower, because according to Jastreboff, only 25% of

indi-vidualswhohavetinnitusdoseekmedicalattention10 _and

assuch, the percentageobserved in our series(64%) was

totallyunexpected.Thispercentagewassignificantlyhigher

inwomencomparedtomen,indicatinggreatersensitivityin

thefemalegender.

To those who answered ‘‘Yes’’ to the above question,

wetookcaretoquantifythatlevelofdiscomfortusingVAS

(‘‘Pointonthecardhowmuchyourtinnitusisbothersome’’)

---arapidandeasilyunderstoodmethodforthelarge-scale

assessment of subjective symptoms.And it wassurprising

torealizethat thevast majority(89%)had amoderateto

severe degree of discomfort.The mean for the responses

obtained usingVASwas6.3.We arenotawareof another

fieldstudyintheliteraturethathasconductedthistypeof

measurementtocharacterizetinnitusinthepopulation,but

thisseemstousaveryhighvalue,basedonexpectationsand

estimatesforthelevelofdiscomfortofthesymptom.

We also asked, ‘‘Does this ringing interfere with your

daily activities?’’; and almost 20% of the population with

anannoyingtinnitusanswered‘‘Yes’’.Wefoundnostudies

intheliteraturethatsupportthesenumbers.In2011,when

consideringthissymptomintheJapanesepopulation,Fujii

etal.foundthat20---30%reportedtinnitusperception

dur-ingwakinghours,andthatapproximately0.4%ofthetotal

populationrefersthattinnitusseverelyaffectstheirability

toleadanormallife.3_In_2010,_Gopinath_reported_that_the

incidenceoftinnitusduringa5-yearobservationperiodin

theAustralianpopulationwas18%.Tinnituswasmentioned

asslightlyuncomfortablein55.5%ofnewcases,as

moder-atelyuncomfortablein6.5%,andasseverelyuncomfortable

in 1.3%;five yearslater,this profile haschangedin those

individualswithpersistenttinnitus:39.6%mentioneda

(9)

Notwithstandingtheinabilitytodirectlycomparetheresults

ofGopinathin2010,sincethestudydesignsaredifferent,

thesefiguresarewellbelowthoseobservedinourstudy.

Thisstudyassessedtheprevalenceoftinnitusintheadult

population of the city of São Paulo. This is the first and

largeststudyofitskindever doneinBrazil,and

consider-ingthat mostother reports in theinternational literature

werebasedonmailedquestionnaires,webelievethatour

population-based sample is more reliable and

represen-tative. The high prevalence of tinnitus observed in our

patients,togetherwiththealarmingpredictionsofWHO34,35

withrespecttoanincreaseofhearingproblemsintheshort

term, signalsthe seriousness of the problem.Part of this

exponentialgrowthcanbeexplainedbytheaging

popula-tion,aswellasbytheincreasingnoiseexposureincountries

withmiddle and high income,35 _as_is _the _case _of _the_city

ofSãoPaulo. Inordertorevertthis negativetrendin our

community,itisnecessarythatpreventiveinterventionsare

implementedandadjusted,bothattheindividualand

orga-nizationallevel,makingmorepressingthedevelopmentof

strategiesandcampaignstoprevent,delayorminimizeits

currentandfutureimpactonthecommunity.

Conclusion

TinnitusinthepopulationofthecityofSãoPaulowasmore

prevalentthanpreviouslyestimated.Generally,this

symp-tommorefrequentlyaffectswomenandthoseunemployed,

andincreasessignificantlywithadvancingage.Most

respon-dentsmentionedannoyance withtinnitus,andthisfinding

is more prevalent in females. The degree of discomfort

measured by the Visual Analogue Scale showedmoderate

tinnitus,withanaverageof6.3fortheresponses.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

Associac¸ão Brasileira de Otorrinolaringologia e Cirurgia

Cérvico-Facial (ABORL-CCF), under Direction of Prof. Dr.

RicardoFerreiraBento---PublicNoticeforScholarship

Sup-porttoEpidemiologicalProjects;andFundac¸ãodeAmparoa

PesquisadoEstadodeSãoPaulo(FAPESP)/RegularResearch

Support/ProcessNo.2011/10343-7.

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