Impact of tinnitus masking in adults based on its nature and onset Author

Impact of tinnitus masking in adults based on its nature and onset
Author:-Haraprasad Behura, Shubhangi Shree Bhatt, Sujoy Kumar Makar
INTRODUCTION Tinnitus is a perception of an auditory sensation without the presence of an external sound and it affects the quality of life for millions of people around the world. Tinnitus is associated with normal hearing or hearing impairment. It is basically of two types objective type of tinnitus in which the external noise is heard by both the sufferer and the examiner and subjective type of tinnitus is one in which the sufferer only hears noise in the head, or ears. Tinnitus is a heterogeneous disorder that is idiopathic in nature although causes may include aging, hearing loss, ototoxicity, and a history of noise exposure. Tinnitus is concurrent with depression, insomnia, anxiety, and concentration problem. The prevalence of tinnitus range from 6.6% to 18.6% and it increases 30% at age of 55 years and older according to the Environment Health and Life Safety. The severity of tinnitus may range from very less to extreme bothersome, leading to social isolation or suicidal attempts. As tinnitus has a devastating impact on quality of life of sufferers affecting the multiple domains of sufferer, therefore, it requires the use of multidisciplinary approach in interventional procedures to (1) supress the tinnitus and (2) to reduce its impacts. Tinnitus masking treatment is found more effective application to suppress the original tinnitus and thus reduces its impact in long duration.

Aims and Objectives
The study aims to detect and recommend the appropriate candidacy in terms of nature and onset of tinnitus for effective tinnitus masking treatment.
The pathophysiology of tinnitus accompanying the disorder of auditory system is not fully understood, therefore, there is not any particular affective treatment method has been specified till date. To determine appropriate candidacy for effective tinnitus masking treatment this study was required.

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NEED FOR THE STUDY
Impact of tinnitus in Indian population is so high, Makar S K, Biswas A, Shatapathy P, (2014) reported that there was negative correlation between depression, anger and duration of tinnitus (-0.034). The multiple sounds of tinnitus have far more devastating effect on quality of life of tinnitus sufferers than the single nature of tinnitus.
There are approximately 10-15% of general population is affected by tinnitus with the probability of increment in future as there is currently no cure for tinnitus, further, treatment of tinnitus is limited (Husain et. al., in 2018).
Therefore study required to find out appropriate candidacy for masking treatment.

METHOD
Subjects
A total of 40 participants of age range 30 to 60 years with tinnitus including both males & females from audiology department of AYJNISHD (RC). They were divided into two groups: group 1 includes 20 patients with complain of tinnitus for 0-6 months & group 2 includes 20 patients with complain of tinnitus for 6-12 months. Written consent had been taken from patients. Exclusion criteria for selection of participants assure that the participants must not have suffering from any endocrine disorder, neuropsychiatric disorder, ear operation, history of ototoxicity, trauma. Inclusion criteria consist of mild to moderate SN hearing loss with unilateral tinnitus and normal middle ear.
Procedure
Complete case history was taken following appropriate audiometric evaluation. The tests was performed using the calibrated audiometer Resonance r37a, circumaural TDH39 headphone in a sound treated audiometric test room meeting the specifications given by ANSI S3.1, 1996.
Adequate tinnitus matching was done involving pitch matching (125hz-10000hz), loudness matching (0-120dB) , minimum masking level (0-10dB), residual inhibition( full / partial), and loudness discomfort level.
The masking treatment was applied for 30 sessions with duration of 45 minutes per session using matched stimulus (NBN/ WN/PT) ipsilateraly.
The results were compared between pre & post masking treatment using varied subjective tools that were Trans-adapted English version of THI in native language Bengali for determining severity of tinnitus. BDI is used for determining the patient’s depression levels and symptoms affecting the quality of life. VAS used for qualitative analysis of tinnitus severity, frequency, and duration.
Statistical analysis
The data obtained of the study were analysed as mean, standard deviation and statistical analysis such as Kolmogorov-Smirn, Mann-Whitney U Test, Kruskal-Wallis test, Wilcoxon test, Spearman’s rank correlation coefficient test was done using windows SPSS -17 software.

Results and Discussion
A total of 40 patients with tinnitus were included in the study with 24 male and 16 female, with age range 30- 60 years (mean age 45.41) years with( SD ± 9.1) while 35.15% stated left ear and 64.85% stated right ear tinnitus with mild to moderate hearing loss(64%) & moderately severe to profound haring loss(56%)
Among those patients tinnitus frequency matched 17.5% at 500 Hz and 1 KHz – 3 kHz each however, 65% patients matched their tinnitus frequency at 4 KHz to 8 KHz. Similar findings reported by Vernon that major tinnitus frequencies found to be 4 KHz – 8 KHz.
Following the 30 session masking treatment patient were asked to evaluate the amount of suppression of tinnitus, such as 25 % suppression, 50% suppression, 75% suppression and 100% suppression where 100% suppression indicate no tinnitus. Result 40 cases showed 15% reported (6/40) no tinnitus, 57.5% (23/40) informed 50% suppression, 12.5% (5/40) delineate 25% suppression and 15% (6/40) reported no changes indicating 0% suppression. Significant positive correlation (? =0.003) was found between the suppression of tinnitus and shorter onset of tinnitus (0 to 6 months), indicate shorter onset showed better improvement by tinnitus masking treatment. Similar study by Aytac et al. 2017 reported 18% patients had 100% suppression and 43% patients had partial suppression and 39% patients had no suppression.
Acoustic tests such as pitch, loudness & MML of tinnitus was measured before and after masking & found that there was significant difference in pitch(t=9.32) (p=0.001) loudness (t=19.37) (p=0.001) MML(t=18.13) (p=0.001).it was also found that highly significant reduction in pitch louness MML patient with shorter duration (0-6) months of tinnitus.
Psychosomatic questionnaires such as THI, BDI, VAS was used to compare pre post difference in impact of tinnitus and improvement in quality of life. A decrease was obtained in THI scores of patients reporting complete suppression of tinnitus. The mean of post treatment THI scores was 12.45 & pre- treatment THI scores was 38.13 that is at moderate level. A significant correlation was found between the pre- post masking treatment of THI score ( t=9.87, P< 0.05).
A positive moderate significant correlation(r = 0.343, P = 0.001) was found between the two questionnaire scores i.e. THI & BDI in patients with shorter duration tinnitus (0-6 month).
There was a correlation between the patients’ ages and tinnitus parameters a significant difference was found particularly between Tinnitus Handicap Questionnaires, VAS Frequency-Duration Scores, and Control VAS Discomfort Level Scores.
The patients having single tinnitus frequency revealed reduction in THI ; VAS scores after tinnitus masking treatment and also reporting 75-100% suppression of tinnitus.
However, no significant difference was found between the other tinnitus parameters and age, and no correlation was obtained.
Summary ;Conclusion
Although the evidence and reviews for tinnitus care and research have been going on for long, there is lack of conclusive data for determining efficacy of most tinnitus management procedures. The recommendation for effective masking treatment is to administer suitable matching of tinnitus parameters and carry the treatment in a sound treated room without any interruptions for at least 45 minutes. The patients having single tinnitus frequency with less duration, since the complaint of tinnitus, are effectively managed by use of tinnitus masking treatment.