European Journal of Cardiovascular Medicine

Tinnitus is defined as an auditory perception of sound in the ear or head with no external source of sound which is a global enigma for physicians, researchers, as well as subjects globally including in India. Few literature data suggest that tinnitus incidence has physical etiology, whereas, it is seen as idiopathic. Cochlear damage usually results from factors including the aging process, ototoxic medication, and noise exposure which are considered the main factors for tinnitus. Cochlear damage causes abnormal neural activity in the central auditory system causing perceptual experience of tinnitus. Also, causative factors have underlying vascular disease, semicircular canal dehiscence, neck injuries, and temporomandibular joint disorders among other causes.¹ 

Global assessments of tinnitus prevalence have reported varying findings based on the subjects assessed. In the United States, a 9.6% prevalence is reported, whereas, a 14.7% prevalence is reported in other 12 European nations. On the contrary, a prevalence of 19.7% is reported in South Korea. Prevalence in South Asia, Africa, and Western Pacific showed variability in prevalence from a range of 5% to 43%.²   

Few individuals perceive tinnitus as an unthreatening auditory sensation, existing literature underestimates its negative effect on the quality of life of affected subjects causing manifestations such as concentration difficulties, headache, sleep difficulties, depression, annoyance, sadness, and/or anxiety. These symptoms pose multifaceted repercussions on the emotional, social, and physical dimensions of the life of affected subjects, hence, affecting social, professional, and personal workspace.³

Not correlating to the high prevalence of tinnitus and its effects on the quality of life, most of the subjects with tinnitus do not seek medical help. The elucidation of the cause for not taking medical help is vital to understand, particularly with consideration of the availability of management approaches capable of mitigation of the tinnitus burden on both society and individuals.⁴

Also, considering the Indian context, existing literature data is scarce for tinnitus-related research with limited accurate data for the prevalence of tinnitus in the daily lives of Indian subjects with a limited sample size. Hence, the present study aimed to assess the prevalence of tinnitus in Indian subjects, to assess its effect on the quality of life, and to evaluate their approach to seeking medical management. 

The present cross-sectional observation study aimed to assess the prevalence of tinnitus in Indian subjects, to assess its effect on the quality of life, and to evaluate their approach to seeking medical management. The study subjects were from the Department of ENT of the Institute. Verbal and written informed consent were taken from all the subjects before participation.

The present study surveyed the subjects aged 18 years or more and residing in India. The study was done in survey mode to assess subjects. The survey comprised three main sections where the first section assessed questions concerning the demographic details and data of study participants. The second section comprised questions concerning characteristics of tinnitus, its duration as <1 year/>1 year, type, laterality (head, left ear, right war, bilateral), and persistence as occasional, intermittent, or continuous. The third part of the survey was the Indian version of THI⁵ was assessed with additional questions concerning the inclination of tinnitus subjects to seek medical care.   

THI questionnaire was initially developed by Newman et al⁶ in 1996 that served as a reliable tool for the evaluation of discerning challenges faced by subjects affected by tinnitus, and hence, provided insight into the overall quality of life. THI comprises 25 questions and is divided into 3 subscales including 11 functional, 9 emotional, and 5 catastrophic questions. The subjects were needed to select one response from each question as yes, sometimes, or no with scores of 4, 2, and 0 respectively.

The total THI scores were in the range of 0-100 with interpretations seen as slight, mild, moderate, severe, and catastrophic with scores ranging from 0-16, 18-36, 38-56, 58-76, and 78-100 respectively. Subscale scores were in the range of 0 to 44 for functional, 0-36 for emotional, and 0-20 for catastrophic.

Incomplete survey data were excluded from the final analysis. The study subjects that affirmed the presence of sound for a duration higher than 5 minutes in their heads or ears during the past two years were categorized as subjects that have tinnitus.

The data gathered were analyzed statistically using SPSS (Statistical Package for the Social Sciences) software version 24.0 (IBM Corp., Armonk. NY, USA) for assessment of descriptive measures, Student t-test, ANOVA (analysis of variance), Turkey post hoc analysis, and Chi-square test. Pearson correlation coefficient was used to assess correlation in various parameters. The results were expressed as mean and standard deviation and frequency and percentages. The p-value of <0.05 was considered.

The present cross-sectional observation study aimed to assess the prevalence of tinnitus in Indian subjects, to assess its effect on the quality of life, and to evaluate their approach to seeking medical management. The present study assessed 8832 subjects following the survey approach. All the assessed subjects were assessed using the Indian version of the THI (Tinnitus Handicap Inventory) questionnaire. There were 52.3% (n=4620) males and 47.7% (n=4212) females in the present study. There were 29.2% (n=2580) subjects in the age range of 41-59 years followed by 28.6% (n=2526) subjects in 18-30, 25.1% (n=2214) subjects in 31-40 years, 10.3% (n=912) in 51-60, and least 6.8% (n=600) subjects in >60 years of age. There were 52.26% (n=4616) subjects from rural and 47.73% (n=4216) subjects from urban residences (Table 1).

Table 1: Demographic data of study subjects at baseline

Table 2: characteristics of tinnitus in the study subjects

Table 3: Tinnitus Handicap Inventory total and subscales scores in study subjects

Table 4: Reason in study subjects for not seeking medical support for tinnitus

Table 5: Association of age, sex, tinnitus duration, laterality, persistence, and type to THI scores in study subjects

On assessing the characteristics of tinnitus in the study subjects, whistle, ocean wave, wind, pulse, buzz, whizzing, and click type tinnitus was seen in 49.8% (n=1656), 0.4% (n=12), 11.9% (n=396), 5.4% (n=180), 6% (n=198), 16.6% (n=552), and 9.9% (n=330) study subjects respectively. Disease duration was <1 and >1 year in 63.9% (n=1200) and 63.1% (n=2124) subjects respectively. For persistence, the disease was occasional, intermittent, and constant in 30.2% (n=1002), 53.2% (n=1770), and 16.6% (n=552) study subjects respectively. Disease laterality was in the head, left ear, right ear, and bilateral in 4.3% (n=144), 20.2% (n=672), 22.7% (n=756), and 52.7% (n=1752) study subjects respectively (Table 2).

The study results showed that for the Tinnitus Handicap Inventory total and subscales scores in study subjects, the mean catastrophic THI was 1.7±0.4 that depicted the THI grade as slight, mean emotion THI was 6.9±7.3 that showed the grade as mild, mean functional THI was 7.5±8.8 that reported the disease grade as mild, and total mean THI score was 16.5±17.0 that also depicted the mild scores (Table 3). 

It was seen that on evaluating the reason for not seeking medical management in subjects with tinnitus, it was seen that the most common cause was the thinking that there is no management of tinnitus seen in 66.7% (n=1266) subjects followed by the reason that subjects thought that they could live with tinnitus as reported in 22.5% (n=426) subjects and that subjects were not aware as what specialty to visit for treatment of tinnitus as reported by 10.8% (n=204) study subjects (Table 4). 

It was also seen that for association of age, sex, tinnitus duration, laterality, persistence, and type to THI scores in study subjects, showed a statistically significant association in age, gender, tinnitus duration, and the emotional subscale of the THI with p=0.01, 0.01, and <0.001 respectively. Also, persistence, type, laterality, tinnitus duration, and age showed a statistically significant association with medical support with p<0.001 (Table 5).

The present study assessed 8832 subjects following the survey approach. All the assessed subjects were assessed using the Indian version of the THI (Tinnitus Handicap Inventory) questionnaire. There were 52.3% (n=4620) males and 47.7% (n=4212) females in the present study. There were 29.2% (n=2580) subjects in the age range of 41-59 years followed by 28.6% (n=2526) subjects in 18-30, 25.1% (n=2214) subjects in 31-40 years, 10.3% (n=912) in 51-60, and least 6.8% (n=600) subjects in >60 years of age. There were 52.26% (n=4616) subjects from rural and 47.73% (n=4216) subjects from urban residences. These data were comparable to the previous studies of Seydel C et al⁷ in 2013 and Baigi A et al⁸ in 2011 where authors assessed tinnitus subjects with demographic and disease data comparable to the present study in their respective studies.

Concerning the assessment of the characteristics of tinnitus in the study subjects, whistle, ocean wave, wind, pulse, buzz, whizzing, and click type tinnitus was seen in 49.8% (n=1656), 0.4% (n=12), 11.9% (n=396), 5.4% (n=180), 6% (n=198), 16.6% (n=552), and 9.9% (n=330) study subjects respectively. Disease duration was <1 and >1 year in 63.9% (n=1200) and 63.1% (n=2124) subjects respectively. For persistence, the disease was occasional, intermittent, and constant in 30.2% (n=1002), 53.2% (n=1770), and 16.6% (n=552) study subjects respectively. Disease laterality was in the head, left ear, right ear, and bilateral in 4.3% (n=144), 20.2% (n=672), 22.7% (n=756), and 52.7% (n=1752) study subjects respectively. These results were consistent with the findings of Fujji K et al⁹ in 2011 and Ciminelli P et al¹⁰ in 2018 where characteristics of tinnitus reported by authors in their studies were comparable to the results of the present study.

It was seen that for the Tinnitus Handicap Inventory total and subscales scores in study subjects, the mean catastrophic THI was 1.7±0.4 depicted the THI grade as slight, mean emotion THI was 6.9±7.3 showed the grade as mild, mean functional THI was 7.5±8.8 that reported the disease grade as mild, and total mean THI score was 16.5±17.0 that also depicted the mild scores. These findings were in agreement with the results of Nascimento ID et al¹¹ in 2019 and Hiller W et al¹² in 2006 where the Tinnitus Handicap Inventory total and subscales score comparable to the present study were also reported by the authors in their respective studies.  

The study results showed that on evaluating the reason for not seeking medical management in subjects with tinnitus, it was seen that the most common cause was the thinking that there is no management of tinnitus seen in 66.7% (n=1266) subjects followed by the reason that subjects thought that they could live with tinnitus as reported in 22.5% (n=426) subjects and that subjects were not aware as what specialty to visit for treatment of tinnitus as reported by 10.8% (n=204) study subjects. These results were in line with the findings of Meyer C et al¹³ in 2014 and Smith SL et al¹⁴ in 2011 where the reason for not seeking medical management in subjects with tinnitus reported by authors in their studies was comparable to the results of the present study.  

The study results also showed that for association age, sex, tinnitus duration, laterality, persistence, and type to THI scores in study subjects, showed a statistically significant association in age, gender, tinnitus duration, and the emotional subscale of the THI with p=0.01, 0.01, and <0.001 respectively. Also, persistence, type, laterality, tinnitus duration, and age showed a statistically significant association with medical support with p<0.001. These findings correlated with the results of Rhee J et al¹⁵ in 2020 and Hofmann E et al¹⁶ in 2013 where the association of age, sex, tinnitus duration, laterality, persistence, and type to THI scores in study subjects similar results to present study were also reported by the authors in their respective studies.

Within its limitations, the present study concludes that the prevalence of tinnitus in Indian subjects is significantly high with a high occurrence in females and a higher association with advancement in age. While tinnitus has a detrimental effect on the quality of life, a significant proportion is restricted from seeking medical support. In the future, longitudinal studies with larger sample sizes and longer monitoring are needed to reach a definitive conclusion.

1. Langguth B, Kreuzer PM, Kleinjung T, De Ridder D. Tinnitus:Causes and clinical management. Lancet Neurol 2013;12:920–30.
2. Snow JB. Tinnitus: Theory and Management 1^sted United States PMPH USA Ltd 2004.
3. Lockwood AH, Salvi RJ, Burkard RF. Tinnitus. N Engl J Med 2002;347:904–10.
4. Bae SC, Kim DK, Yeo SW, Park SY, Park SN. Single-center 10-year experience in treating patients with vascular tinnitus: Diagnostic approaches and treatment outcomes. Clin Exp Otorhinolaryngol 2015;8:7–12.
5. Singh V, Alakh A, Rajesh A. Standardisation of Tinnitus Handicap Inventory in Hindi. Indian J Otolaryngol Head Neck Surg [Internet]. 2019;71(s2):1515-22.
6. Newman CW, Jacobson GP, Spitzer JB. Development of the tinnitus handicap inventory. Arch Otolaryngol Head Neck Surg 1996;122:143–8.
7. Seydel C, Haupt H, Olze H, Szczepek AJ, Mazurek B. Gender and chronic tinnitus: Differences in tinnitus-related distress depend on age and duration of tinnitus. Ear Hear 2013;34:661–72.
8. Baigi A, Oden A, Almlid-Larsen V, Barrenäs ML, Holgers KM. Tinnitus in the general population with a focus on noise and stress: A public health study. Ear Hear 2011;32:787–9.
9. Fujii K, Nagata C, Nakamura K, Kawachi T, Takatsuka N, Oba S, et al. Prevalence of tinnitus in community-dwelling Japanese adults. J Epidemiol 2011;21:299–304.
10. Ciminelli P, Machado S, Palmeira M, Carta MG, Beirith SC, Nigri ML, et al. Tinnitus: The sound of stress. Clin Pract Epidemiol Ment Health 2018;14:264–9.
11. Nascimento ID, Almeida AA, Diniz J Jr, Martins ML, Freitas TM, Rosa MR. Tinnitus evaluation: Relationship between pitch matching and loudness, visual analog scale, and tinnitus handicap inventory. Braz J Otorhinolaryngol 2019;85:611–6.
12. Hiller W, Goebel G. Factors influencing tinnitus loudness and annoyance. Arch Otolaryngol Head Neck Surg 2006;132:1323–30.
13. Meyer C, Hickson L, Lovelock K, Lampert M, Khan A. An investigation of factors that influence help-seeking for hearing impairment in older adults. Int J Audiol 2014;53:S3–17.
14. Smith SL, Fagelson M. Development of the self-efficacy for tinnitus management questionnaire. J Am Acad Audiol 2011;22:424–40.
15. Rhee J, Lee D, Suh MW, Lee JH, Hong YC, Oh SH, et al. Prevalence, associated factors, and comorbidities of tinnitus in adolescents. PLoS One 2020;15:e0236723.
16. Hofmann E, Behr R, Neumann-Haefelin T, Schwager K. Pulsatile tinnitus:Imaging and differential diagnosis. Dtsch Arztebl Int 2013;110:451–8.