www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Psychoacoustic
classification
of
persistent
tinnitus
夽
Flavia
Alencar
de
Barros
Suzuki
∗,
Fabio
Akira
Suzuki,
Ektor
Tsuneo
Onishi,
Norma
Oliveira
Penido
UniversidadeFederaldeSãoPaulo(UNIFESP),EscolaPaulistadeMedicina(EPM),DepartamentodeOtorrinolaringologiae CirurgiaCabec¸aePescoc¸o,SãoPaulo,SP,Brazil
Received18January2017;accepted9July2017 Availableonline1August2017
KEYWORDS Tinni-tus/classification; Audiometry; Psychoacoustic/ characteristics Abstract
Introduction:Tinnitusisadifficulttotreatsymptom,withdifferentresponsesinpatients.Itis classifiedindifferentways,accordingtoitsoriginandassociateddiseases.
Objective: toproposeasingleandmeasurableclassificationofpersistenttinnitus,throughits perceptionassoundsofnatureorofdailylifeanditscomparisonwithpuretoneornoise,of highorlowpitch,presentedtothepatientbyaudiometersound.
Methods:A totalof110adult patients,ofbothgenders,treatedattheTinnitus Outpatient Clinic, wereenrolled accordingtotheinclusionandexclusioncriteria.Otorhinolaryngologic andAudiological,PitchMatchingandLoudness,VisualAnalogScale,TinnitusHandicapInventory andMinimumMaskingLevelassessmentswereperformed.
Results:Inthese110patients,181tinnituscomplaintswereidentifiedaccordinglytotypeand ear,with93(51%)PureTone,and88(49%)Noisetype;19atlowand162athighfrequency;with ameaninthePureToneof5.47intheVisualAnalogScaleand12.31decibelintheLoudnessand ameanintheNoiseof6.66and10.51decibel.ForTinnitusHandicapInventoryandMinimum Masking Level,the110patients were separatedinto threegroups withtinnitus,PureTone, Noiseandmultiple.TinnitusHandicapInventoryhigherinthegroupwithmultipletinnitus,of 61.38.MaskingnoisessuchasWhiteNoiseandNarrowBandwereusedfortheMinimumMasking Levelatthefrequenciesof500and6000Hz.TherewasasimilaritybetweenthePureToneand Multiple groups.IntheNoisegroup,differentresponseswerefound whenNarrowBandwas usedatlowfrequency.
夽 Please citethisarticle as:Suzuki FA, Suzuki FA, OnishiET, PenidoNO. Psychoacoustic classification ofpersistent tinnitus.Braz J
Otorhinolaryngol.2018;84:583---90.
∗Correspondingauthor.
E-mail:flaviafabs@yahoo.com.br(F.A.Suzuki).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2017.07.005
1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Conclusion:Classifyingpersistenttinnitusaspuretoneornoise,presentinhighorlowfrequency andestablishingitsdifferentcharacteristicsallowustoknowitspeculiaritiesandtheeffects ofthissymptominpatients’lives.
© 2017 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 Zumbido/classificac¸ão; Audiometria; Psicoacústicas/ características
Classificac¸ãopsicoacústicadozumbidopersistente Resumo
Introduc¸ão:O zumbido é um sintoma de difícil tratamento, com respostas diferentes nos pacientes.Éclassificadodeformasdiversas,deacordocomaorigemoudoenc¸asassociadas.
Objetivo:Proporumaclassificac¸ãoúnicaemensuráveldozumbidopersistente,pormeioda suapercepc¸ãocomo sonsdanaturezaoudavidacotidianaedasuacomparac¸ãocomotom puroouoruído,depitchaltooubaixo,apresentadosaopacientepelossonsdoaudiômetro.
Método: Participaram110pacientes adultos,de ambos ossexos, atendidos noAmbulatório deZumbido,tendo sidoobservadososcritérios deinclusão eexclusão.Realizada avaliac¸ão otorrinolaringológica, audiológica,Pitch MatchingeLoudness, VisualAnalogScale, Tinnitus HandicapInventoryeMinimumMaskingLevel.
Resultados: Nesses110pacientesforamidentificadas181queixasdezumbidoseparadaspor tipoeorelha,sendo93(51%)tipotompuroe88(49%)tiporuído;19debaixafrequênciae162 dealtafrequência;commédiadoVisualAnalogScalenotompurode5,47eruídode6,66; médiadoLoudnessdotompurode12,31dBNSeruídode10,51dBNS.ParaoTinnitusHandicap InventoryeoMinimumMaskingLevelos110pacientesforamseparadosemtrêsgruposcom zumbido,tom puro,ruídoemúltiplo,comamédiadoTinnitusHandicapInventorymaiorno grupocomzumbidomúltiplocom61,38.ParaoMinimumMaskingLevelforamusadososruídos mascaradorestipoWhite NoiseeNarrow Bandnasfrequências de500Hz e 6000Hz. Houve semelhanc¸aentreosgruposcomtompuroemúltiplo.Nogrupoderuídoforamencontradas respostasdiferentesquandousadooNarrowBandemfrequênciabaixa.
Conclusão:Classificar ozumbido persistenteem tompuro ouruído,presentes em frequên-ciaalta oubaixa eestabelecersuas diferentescaracterísticas nospermitem conhecersuas particularidadesearepercussãodessesintomanavidadospacientes.
© 2017 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
The increase in the worldwide population and life
expectancychallenges ourexistenceandmaycausea
cri-sisin thepublicand privatehealth systems inboth, poor
andrichcountries.Researchersaroundtheworldare
look-ingforsolutionstoimprovethepopulation’saccessibilityto
thehealthsystem,usingstandardized,simplifiedand
easy-to-useclassificationsandtreatments.
Regardingtinnitus,thefirststepinthis investigationis
tofind a cause and effectrelationship, seeking the
etio-logical treatment of the underlying disease tobe able to
suppress or inhibit tinnitus. When it persists, the patient
oftenreturnshomewithoutanyassistanceorisreferredto
somepsychologicaltreatmenttolearnhowtolivewiththis
sensation.
Although the current approach to tinnitus is based on
symptomaticapproaches,itsclassificationcontinuestobe
establishedbyitsoriginoretiology.1---3IntheClinicalPractice
GuidelineTinnitus---CPGT,Tunkeletal.(2014)4addressed
the importance of classification to direct the treatment,
considering individuals amenable totreatment thosewith
persistent and uncomfortable tinnitus for more than 6
months.However,theyhavenotshownscientificevidence
ofhowtomanagepatientswithsequeloridiopathic
tinni-tus.Inthesecases,thetreatmentguidancewouldhaveto
bebasedonlyonthesymptom,definedbythepatientsas
the perception of asound when thereis nosound source
present.1,5,6
For this classification, the perception of tinnitus is
observed as being similar to a whistle, a noise or other
soundwithcharacteristicssimilartocertainspecificsound
frequencies. Some studies have shown that these
dis-tinct characteristics of tinnitus perception have different
reactions in the central nervous system (CNS). Vanneste
etal., usingelectroencephalography (EEG), mapped
tinn-itusthroughtheelectricalbrainresponsesobservedatthe
generationofdifferenttypesoftinnitus,andfounddistinct
responsestotinnitussimilartopuretoneandnoise,7which
corroboratestheimportanceofseparatingthesesymptoms.
To determine the loudness and correlate it with the
aspects of the patient’s life, and the possibilityof
mask-ingthem arecrucialto understandthe tinnitussymptom.
The use of tinnitus quantificationquestionnairesand how
itaffectssomeaspectsofpatientslives,suchastheVisual
Analogs Scales --- VAS,8 the Tinnitus Handicap Inventory
---THI9,10,11andpsychoacousticmeasuressuchasPitch
Match-ing, Loudness and Minimum Masking Level --- MML, areof
enormous value,but becausetheyuse different
measure-mentmethods,demandtime,trainingoftheexaminerand
specificexpensiveequipment,12theirtherapeuticindication
becomesimprecise and random. It is therefore important
thatmoreresearchisperformedonhowtoassess,perceive
andclassifytinnitus.
The objective of the present study was to propose a
uniqueandmeasurableclassificationofpersistenttinnitus,
throughitsperceptionassoundsofnatureordailylifeand
itscomparisonwithpuretoneornoise,ofhighorlowpitch,
presentedtothepatientbyaudiometersounds.
Methods
Thiswasacross-sectionalstudy,withadultpatientsofboth
gendersfromtheTinnitusOutpatientClinic,fromJuly2011
toSeptember 2015, and approved by theResearch Ethics
Committeeoftheinstitutionunderprotocoln.CEP1333/10.
Patientswereinstructedonalltheresearchproceduresand
signedthefreeandinformedconsentform.
Inclusioncriteriawere:adultpatients ofboth genders,
ranging in age from 18 to 80 years, with persistent and
continuous tinnitus for more than 6 months and without
hearinglossorwithmildtomoderatesensorineuralhearing
lossandasymmetry<40decibelhearinglevel(dBHL)among
allfrequenciestoavoidpossibletechnicalbiaswhenusing
masking;noalterations intheexternal and/ormiddle ear
and no decompensated diseases associated with tinnitus.
Thenoisemasking,NarrowBandnoise,wasthesameasthat
usedbythepatienttoclassifythetinnitusasNoise.
AnInteracousticsAudiometer---ModelAC40andan
Inter-acousticsImmittanceAudiometer---modelAZ7wereused,
bothofwhicharecalibratedannually.
Patients were submitted to anamnesis,
otorhinolaryn-gologyevaluation,tonalandvocalaudiometry,immittance
tests with stapedial muscle reflexes, Pitch and Loudness
Matching,VisualAnalogScale(VAS),MinimumMaskingLevel
(MML) and Tinnitus Handicap Inventory (THI). They also
answered a sociodemographic and clinical questionnaire
thatcontaineddataontinnitus:whetherthesymptomonset
wassuddenorgradual,whetheritsperceptionwasofalow
orhighfrequencysound,whichsidewasaffectedandwhat
itsresemblancetodailysoundswas.
Basedonthecomparativeanswersacquiredthroughthe
psychoacousticmeasuresobtainedwiththeaudiometer,the
tinnituscharacteristicswereestablished:thepitch,if
simi-lartoPureTone(PT)orNoise,withahighorlowfrequency,
andtheLoudness,measuredwithattenuationsof5dBSLand
recorded in Decibel Sensation Level (dBSL). The level of
annoyancecausedbythetinnituswasassessedbytheVisual
AnalogScale(VAS).
For thesemeasurements, the responses wereanalyzed
ineachear,ipsilaterallyandbytypeoftinnitus,withsome
patients presenting uptofour responses, beingsimilarto
PTandNoise, in theright andleftears.The resultswere
obtainedbycountingeachresponse,sothatthenumberof
responseswas higherthan the numberof patients. These
responseswere correlated totheresponses regarding the
typeoftinnitusreportedbythepatientinthequestionnaire
andthepsychoacousticcharacteristicsobtainedthroughthe
audiometer.
Subsequently,thesepatientsweredividedaccording to
the type of tinnitus into three groups: Pure Tone Group
(PTG),Noise(NG)andMultipleTinnitus,PureToneandNoise
Group (PTNG). Each patient belonged to a single group,
withthenumberoftotalresponsesequaltothenumberof
patients.Afterbeingseparatedbygender,ageandsideof
thetinnituscomplaint,the THI andMMLprocedureswere
performed, and their characteristics were studied within
eachgroupandbetweengroups.RegardingtheTHI,inorder
toobtainabetterstatisticalevaluation,itwasmeasuredin
valuesfrom0to100,insteadofdegreesfrom1to5.
Toassess theMML,anumerical variablethat evaluates
thepatient’sCNSabilitytosuppressormasktinnitus,three
typesofmaskingnoiseswereused:WhiteNoise(WN),Low
FrequencyNarrowBand(LFNB)atthefrequencyof 500Hz
and the High Frequency Narrow Band (HFNB) at the
fre-quency of 6000Hz. The test was always simultaneous in
bothearsandstartedwiththesameintensityindBSL,with
attenuationsof5dBSL.
Inthestatisticalanalysis,thechi-squaretestwasusedto
evaluatethedistributionbygender,sideoftinnitusandthe
associationofPureToneandNoisetinnituswiththehighand
low frequencies. The non-parametric Mann---Whitney test
wasperformedtoevaluatetheVASandLoudness
measure-ments.Thenon-parametricKruskal---Wallistestswereused
forthemeanageandTHI,andTukey’smultiplecomparisons
wereusedinTHItodetectdifferencesbetweenmeans.The
non-parametricFriedmantestwasusedforMML
measure-ments,withTukey’smultiplecomparisonsasacomplement,
whensignificant.
Results
A sample of 110 patients with continuous and persistent
chronic tinnitus was analyzed. Of these, 66 (60%) were
femalesand44(40%)weremales.These110patientsshowed
181responsesofthetinnituscomplaint,inwhichthe
pres-enceof tinnitus typePT was observedin 93 (51%) of the
responses,andNoisein88(49%),includingallresponsesand
consideringthepresenceoftinnitusontherightsideandon
theleftside.
In relation to low pitch sensation, 19 responses were
obtained at the frequencies of 250Hz, 500Hz or 1000Hz
correspondingtothesoundreportedasbassinthe
sociode-mographicand clinical questionnaire.With the high pitch
sensation,162responseswerefoundthatcorrespondto
fre-quencies of 2000Hz, 3000Hz, 4000Hz, 6000Hz, 8000Hz,
10,000Hzor toWNtype,comparedtothehigh frequency
sound(Table1).
Therewere93responsesofsoundssimilartoPT,4(4.3%)
of Low Pitch and 89 (95.7%) of High Pitch. All patients
whoreported tinnitus perception as the characteristic of
‘‘shiphorn’’wereassociatedwithPT atthe low
Table1 CorrelationofPureToneorNoisetinnituswiththeircharacteristicsandwithlowandhighfrequencies. Subjectivecharacteristics Pitch Highfrequency Lowfrequency Chi-square
test(p)a Total n % n % n % Shiphorn 250Hz/500Hz 0 0% 4 100% p<0.001 4 4.3% Whistle/cicada/insect 2kHz/3kHz/4kHz/6kHz/8 kHz/10kHz 89 100% 0 0% 89 95.7% Carengine/wave/ airplane/waterfall 250Hz/500Hz/1kHz 0 0% 15 100% 15 17% Bee/wheezing/pressure cooker/rain 2kHz/3kHz/4kHz/6kHz/8kHz 73 100% 0 0% 73 83% n 162 100% 19 100% 181 100%
aChi-squaretest.p<0.001.Significance0.05%.
n,numberofresponsestotinnitussimilartoPureTone(PT)orNoise.
‘‘whistle/cicada/insect’’-like sounds had their responses
associatedwithPTatthehighfrequencies.
There were 88 responses of tinnitus similar to Noise,
15 (17%) at low frequency and 73 (83%) at high
fre-quency. All perceptions with the characteristic of ‘‘car
engine/airplane/wave/waterfall’’wereassociatedwiththe
Noisesoundatthelowfrequenciesoftheaudiometerandall
thosewiththecharacteristics of‘‘bee/wheezing/pressure
cooker/rain’’were associated with the sound of noise at
highfrequencies.
Whenthetypeoftinnituswasassociatedtothedegreeof
annoyancemeasuredthroughtheVAS,themeanfortinnitus
similarto PT was 5.47 and, for tinnitus similarto Noise,
of6.66(Table2).Thisresponsewassignificantlyhigherfor
tinnitusperceivedasNoisethanfortheoneperceivedasPT.
When analyzing tinnitusintensity in the 181 responses
obtainedinthisstudy,wefoundthemeanLoudnessfor
tinn-itussimilartoPT of 12.31dBSL andforthe onesimilarto
Noiseof 10.51dBSL(Table 3).Itwasverifiedthat the
val-ues of this intensity were significantly higher for tinnitus
perceivedaspuretone.
These110patientswereseparatedintogroups,according
tothetypeoftinnituspresent.InthePTG,ofthe45(41%)
patients,60%werefemalesand40%males,withameanage
of 54.3years. Ofthese, 25 (55.4%)patients had bilateral
tinnitus.IntheNG,ofthe49patients(45%)found,57%were
femalesand43%weremales,withameanageof53.4years,
withahigherincidenceoftinnitusontheleftside,with22
(45%)patients.InthePTNG,ofthe16(14%)patients,69%
werefemalesand31%weremales,withameanageof52.4
years.Therewasahigherincidenceoftinnitusontheleft
side,with7(43.8%)patients andbilateraltinnitus,with8
(50%)patients.
The impactoftinnitus onsomelife aspectsof the110
patientsevaluatedbyTHIwasgreaterinthePTNGwith
mul-tipletinnitus(puretone+noise),withaTHImeanof61.38.
InthePTG,themeanwas37.42andintheNG,itwas46.04
(Table4).Whenanalyzingtheresultsofthemultiple
com-parisons,nosignificantdifferencewasfound betweenthe
PTGandNG,orbetweentheNGandPTNG,buttherewasa
statisticallysignificantdifferencebetweenthePTGandthe
PTNG.
The threegroups weresimilarinrelation tothe
inten-sityrequiredtomasktinnituswhenWNandHFNBmasking
noise were used. In relation to the low frequency
mask-ingnoise, LFNB, the NGrequired smaller valuesthan the
PTG andPTNG groups, withMMLLFNB inPTG=30.4dBSL;
intheNG=23.8dBSLandinPTNG=31.6dBSL(Table5).The
associationofthethreetypesofmaskingnoise,WN,LFNB
andHFNB,wasevaluatedwiththehighpitchandlowpitch
tinnituswithineachgroupalone.
Inpatientswithhigh-frequencytinnitus,42patientswere
fromthePTGgroup,39fromtheNGand14patientsfromthe
PTNG,withthecharacteristicsofhighfrequencyforPTand
Noise(Table6).Thesepatientsshowedthesameassociation
foundinthegroupsasawhole,withthemeanMMLintensity
usingtheLFNBmaskingnoise,beinghigherthantheWNand
HFNBmean(Table6).
Regarding patients with low-frequency tinnitus, three
patientswerefoundinthePTGgroup,10patientsintheNG
andtwopatientsinthePTNG,withdistinctcharacteristics
ofhighfrequencypuretonetinnitusandlowfrequencyNoise
tinnitus(Table7).Patientswithlow-frequencytinnitusfrom
thePTGandPTNGgroupshadthesameintensityassociation
withmaskingnoises,WN=HFNB<LFNB,butstatistical
anal-ysiscouldnotbeperformedbecauseofthelowincidence.
However,itwasobserved thatthosewhohadmultiplePT
tinnituswithhighfrequencysensation associatedwithlow
frequency Noisetinnitushadgreaterdifficultyinmasking,
requiringahighnoisemaskingintensity(MML).Patientswith
low-frequency tinnitus required moreintensity to mask it
withHFNBandWNthanthosewithhigh-frequencytinnitus.
Discussion
Theabsenceofaspecificclassificationtoscorethe
assess-ment criteria for tinnitus characteristics, associated with
the lack of measurement parameters, makes it
impossi-ble to perform a comparative analysis of improvement
or worsening of tinnitus with the several available
ther-apies. Treatments currently reported in the literature,
such as acupuncture, transcranial stimulation and drug
therapies4,13---15 donot have aconsensus,showing benefits
only in selected cases. This is probably due to the lack
of standardization for the selection of different types of
tinnitus,thusbeingnecessarytoadoptanewclassification
criteriontobetterevaluateandtargetthesetreatments.
StoufferandTyler(1990)andShulman(1997)found
sev-eralsubjective descriptions, difficult tobe measured and
compared.2,16 This studywasabletoshowsignificancefor
Table2 Comparisonofthe181responsesoftinnitusperceptionasPureToneorNoiseinrelationtotheVisualAnalogScale (VAS).
VAS PureTone Noise Mann---Whitneytest(p) Result
Mean(0---10) 5.47 6.66 p=0.002a PT<Noise
Standard-deviation 2.47 2.35
n 93 88 Significant
a Mann---Whitneytest.Significance:0.05%.
n,numberofresponsestotinnitussimilartoPureTone(PT)orNoise.
Table3 Comparisonof181responsesoftinnitusperceptionasPureToneorNoiseinrelationtoLoudness.
Loudness PureTone Noise Mann---Whitneytest(p) Result
Mean(dBSL) 12.31 10.51 p=0.016a PT>Noise
Standard-deviation 5.34 5.14
n 93 88 Significant
a Mann---Whitneytest.Significance:0.05%.
n,numberofresponsestotinnitussimilartoPureTone(PT)orNoise.
Table4 ComparisonbetweentheTinnitusHandicapInventoryofthreegroups,PureTone(PTG),Noise(NG)andPureTone+ Noise(PTNG).
PTG NG PTNG Kruskal---Wallistest(p) Tukey’smultiplecomparisons(p) Result Mean(0---100) 37.42 46.04 61.38
p=0.009a
PTG×NG.p=0.229
Standard-deviation 21.56 28.81 23.26 PTG×PTNG.p=0.004a PTG=NG<PTNG
n 45 49 16 NG×PTNG,p=0.093
a Kruskal---WallistestandTukey’smultiplecomparisons.Significanceof0.05%.
n,numberofpatientswithtinnitusinallthreegroups.
Table5 Comparisonofthreegroups,PureTone(PTG),Noise(NG)andPureTone+Noise(PTNG),inrelationtotheintensity usedbytheMinimumMaskingLevelwithWhiteNoise(MMLWN),NarrowBandLowFrequencies(MMLLFNB)andNarrowBand HighFrequencies(MMLHFNB). Mean(dBSL) GPT GN GPTN Kruskal---Wallis test(p) Tukeymultiple comparisons(p) Result MMLWN Mean 14.9 14.8 17.5 PTG=NG=PTNG Standarddeviation 8.8 9.8 8.2 0.300 n 45 49 16 MML LFNBL Mean 30.4 23.8 31.6 PTG×NG.p=0.022a PTG=PTNG>NG Standarddeviation 12.7 11.2 12.2 0.004a PTG×PTNG. p=0.945 NG×PTNG.p=0.066 n 45 49 16 MMLHFNB Mean 14.2 16.6 19.1 PTG=NG=PTNG Standarddeviation 8.6 13.7 10.2 0.255 n 45 49 16
a Kruskal---WallistestandTukey’smultiplecomparisons.Significanceof0.05%.
n,numberofpatientswithtinnitusinallthreegroups.
audiometer,identifiedasPTorNoise,withloworhigh
fre-quency sensation. Unlike Vernon and Meikle (2003), who
found greater presence of low-frequency tinnitus in the
Noise type,17 thisstudy found ahigher presence of
tinni-tusresponsessimilartothehighfrequencysensation,both
forPTandforNoise(Table1).
Formanyyearstinnituswasbelievedtoberelatedonly
to changes in the auditory nerve and cochlea. The use
ofimaging andEEGexams hasdemonstratedthe possible
involvementof central mechanisms in tinnitusgeneration
andperception,withdifferentbrainactivitiesfordifferent
Table6 ComparisonoftheMinimumMaskingLevel(MML)intensityusingWhiteNoise(MMLWN),NarrowBandlowfrequencies (MMLLFNB)andNarrowBandhighfrequencies(MMLHFNB)inrelationtotinnitusperceptionatthehighfrequenciesinthree groups,PureTone(PTG),Noise(NG)andPureTone+Noise(PTNG).
Mean(dBSL) MML WN MMLLFNB MML HFNB Friedman’s test(p) Tukeymultiple comparisons(p) Result High-frequency PTG Mean 15,24 31,07 14,64 WN×LFNBp<0.001a Standarddeviation 8,900 12,761 8,582 <0.001a WN×HFNBp=0.877 WN=HFNB<LFNB HFNB×LFNBp<0.001a n 42 42 42 High-frequencyNG Mean 13,08 24,23 12,05 WN×LFNBp<0.001a Standarddeviation 7,832 10,671 8,006 <0,001a WN×HFNBp=0.485 WN=HFNB<LFNB HFNB×LFNBp<0.001a N 39 39 39 High-frequency PTNG(puretone andnoise) Mean 15,00 29,29 16,79 WN×LFNBp<0.001a Standarddeviation 4,804 11,242 8,684 <0,001a WN×HFNBp=0.718 WN=HFNB<LFNB HFNB×LFNBp<0.001a N 14 14 14
aFriedman’stestandTukey’smultiplecomparisons.Significanceof0.05%.
n,numberofpatientswithtinnitusinallthreegroups.
Table7 ComparisonoftheMinimumMaskingLevel(MML)intensityusingWhiteNoise(MMLWN),NarrowBandlowfrequencies (MMLLFNB)andNarrowBandhighfrequencies(MMLHFNB)inrelationtotheperceptionoftinnitusatthelowfrequenciesin thePureTone(PTG)andNoise(NG).Inthemultiplegroup(PTNG),thetinnitusatthehighfrequenciesforPureToneandlow frequenciesforNoise.
Mean(dBSL) MML WN MML LFNB MML HFNB Friedman’s test(p) Tukey’smultiple comparisons(p) Result Low-frequency PTG Mean 10.00 21.67 8.33 --- --- ---Standarddeviation 5.000 7.638 7.638 --- --- ---n 3 3 3 Low-frequencyNG Mean 21.50 22.00 34.50 WN×LFNB.p=0.984 Standarddeviation 13.754 13.581 16.907 0.005a WN×HFNB.p<0.001a WNp=LFNB<HFNB HFNB×LFNB. p=0.001a n 10 10 10 Low-frequency (noise)+High-frequency (puretone)PTNG Mean 35.00 47.50 35.00 --- --- ---Standarddeviation 0.000 3.536 0.000 --- --- ---n 2 2 2
aFriedman’stestandTukey’smultiplecomparisons.Significanceof0.05%.
n,numberofpatientswithlowfrequencytinnitusinPTGandNoiseandhighfrequencyforPTandlowfrequencyforNoiseinthePTNG.
ofevaluatingandstudyingthedistinctcharacteristicsofPT
andNoisetinnitus.
WhenanalyzingtheVASinrelationtothetypeof
tinni-tus,itwasobservedthatthemostuncomfortableresembles
atinnitus similartoNoise (Table2), the samefindings of
Vannesteetal.(2010).7
TheNoise tinnitus,becauseitisafrequencyspectrum,
involvesalargerarea,withgreaterEEGactivity7and
con-sistsofaperiodicwaves,ofrandommovementsthatdonot
repeatthemselves.19ThismakesitmoredifficultfortheCNS
togethabituated.ThiswasobservedinthestudybyBarros
Suzukietal.(2016),demonstratingthatPTtinnitus(whistle)
hasabetterresponsetothetreatmentwithsoundtherapy
thantheNoisetype.20
Whentheloudnessresponseswereanalyzed,thePTmean
was statistically significant higher than that of the Noise
tinnitus (Table 3), which may be justified by the greater
presenceofbilateraltinnitusinthePTGgroup.
Vannesteetal.(2010)andBalkenholetal.(2013),when
studying the EEG of patients with tinnitus, observed a
difference in the responses of PT and Noise tinnitus and
foundpatternsofdistinctbrainactivitiesfortinnitus
inten-sityanddiscomfort,7,18whichcanalsojustifythefactthat
we have differentanswers,withtheannoyancemeasured
by the VAS worse in the Noise tinnitus and the intensity
(loudness)worseinthePTtype.
Theimpactoftinnitusonsomeaspectsofpatientlifeas
MMLcannotbeassessedseparatelybyear.Thus,toanalyze
theseexplanationsofthetinnituscharacteristicsinthe110
assessedpatients,thesewereseparatedintothreegroups,
PTG,NGandPTNG.Therewereagreaternumberoffemales
inthesethreegroups.Thegroupsarehomogeneousin
rela-tion to gender and age and heterogeneous in relation to
laterality, withbilateral tinnitusfound moreoften in the
PTG.
TheTHIwaschosenbecauseitiseasilyapplicableandhas
beentranslatedandvalidatedinseverallanguages,
includ-ingPortuguese.10,11,21
Although studies such as the one by Figueiredo et al.
(2009)correlatedTHIwithVAS,8byseparatingpatientsinto
groups, this association was not observed.While VAS was
worseforthosewithNoiseTinnitus,THIdidnotshowa
sig-nificantdifferencebetweenPTGandNGgroups,butshowed
amuchhighermeaninthegroupwithbothtypes of
tinn-itus,PTNG(Table4).Whencomparingthethreegroups,it
isobservedthattheTHI scoreissignificantlyhigherinthe
PTNGgroup.ThesefindingsweresimilartothatofLimetal.
(2010).22
The MML analysis with three types of masking noise
wasperformedconsideringthefindingsofFeldmann(1971)
andVernonand Meikle(2003).They concludedthatmany
patientshadtinnitusmaskedbyexternalnoisesof
frequen-ciessimilartotheirtinnitusandthattheuseofMMLwouldbe
betterwhenusedwithfrequencieshigherthanspeech.17,23
Whencomparingthethreetypesofmaskingnoiseused:
WN,LFNBandHFNB,inthethreegroupsofpatients,there
was a homogeneity regarding the proportion of masking
noiseused.TheMMLwithWNandwithHFNBshowedsimilar
andlowermeanvaluesthantheMMLintensitieswithLFNB,
whichrequiredmoreintensitytomaskthetinnitus(Table5).
However, whenthe amount of intensity usedwas
ana-lyzed, a difference was found between the groups when
LFNBwasused.WhilewithWNandHFNBthethreegroups
obtainedsimilarMMLaverages,PTG=NG=PTNG,withlow
frequency maskednoise, LFNB,theproportionwas
differ-ent,PTG=PTNG>NG(Table5).Inthiscasealowerintensity
of lowfrequency masking noisewasrequired tomask the
tinnitusnoisegroup(NG).
TheNGwasthegroupwiththehighestincidenceoflow
pitchtinnitus, which may have contributed tolower that
average,followingthesamepremisethatthemaskingnoise
that requires lessintensity to suppress thetinnitus is the
onethatresemblesthetinnitusitself.
WhenanalyzingtheMMLintensityvariablesusing
mask-ing noise in relation tohigh pitchtinnitus, the ratio was
WN=HFNB<LFNB (Table6). Inthe PTG and PTNGgroups,
the low incidence of patients with low pitch tinnitus did
notallow thestatistical analysis.However,in theNG,for
lowpitchtinnituspatients,theWN=LFNB<HFNBratiowas
found, requiring less intensity to mask the tinnitus when
performingtheMMLwithLFNB(Table7).
In the PTNG,withboth types of tinnitus,twopatients
wererecordedwiththecharacteristicsofPTwithHighPitch
andNoisewithLowPitch,whereastherewere14patients
withPTandNoisetinnituswithHighPitch.Thepresenceof
tinnituswithhigh pitchcaused theWN=HFNB<LFNBratio
tobemaintained.
The two patients with high frequency tinnitus for PT
andlowfrequencyforNoisewerethosewhorequiredmore
intensityofMMLtosuppresstinnituswithalltypesof
mask-ingnoises.Althoughthereareonlytwocases,anditwasnot
possibletoanalyzefromastatisticalpointofview,itmay
beassumedthatmultipletinnitusofdifferent
characteris-ticsisthemostdifficulttomaskandthatthesepatientsmay
presentgreaterdifficultytobetreated.
AllthesefindingsconfirmwhatFeldman(1971)andBarros
Suzukietal.(2016)hadalreadyobserved.Thepatientneeds
lessintensitywhenthenoiseusedtomaskitistheclosestto
thefrequencyofthetinnitustobemasked.20,23Asmostof
themwerefoundatthehighfrequencies,theMML,usinglow
frequencymaskingnoise,wasthemostdifficulttosuppress
thetinnitus.
ToknowthedifferencesbetweenthePTandNoisetypes
oftinnitusandtonoticesomedifferencessuchasthefact
thatthepuretonehasagreatersensationofintensityand
bilateralpresence; Noise tinnitus hasa greater degree of
discomfort;multipletinnitusaffectsmoresomeaspectsof
thepatient’slifeandrequireslessintensitytomaskitwhen
the frequency is similar to the frequency of the masking
noise,isofgreatimportancetodeterminethebest
treat-mentforthepatients,especiallywhenthedataregarding
theassociatedpathologiesarepoorlydefined.
These evaluations can be performed by any
profes-sionaltrained ona single-channel audiometer, except for
MML,which is abinaural test and requires a two-channel
audiometer.
Conclusion
Toclassifypersistenttinnitusaspuretoneornoise,present
athighorlowfrequencyandestablishitsdifferent
charac-teristicsallowsustoknowitspeculiaritiesandtheeffectof
thissymptom onthe patients’lives,leadingustoa
treat-mentdirection.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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